Adequate and balanced nutrition is commonly overlooked in well-meaning detoxification and recovery programs. This is especially true in programs (low or non-funded) that treat the lower economic status clients [1] While most programs encourage recovering alcoholics to eat and take basic vitamins and supplements, what is lacking is a clear understanding by most mono-therapeutic treatment programs of the depths of physiological changes caused by alcoholism. Furthermore, most programs have little ability to assess whether the patient can adequately absorb nutrients taken orally.
Time is needed to bring the alcoholic back to an acceptable state of health so that body functions (both physical and mental) can be assessed at baseline conditions. Furthermore, what is missing in many programs is the ability to provide quality nutrients in sufficient quantities (or provide accessibility to these nutrients) to assist the client’ s recovery through the healing of tissue damage and neurotransmitter dysfunction. The means to deliver these nutrients, especially in the detoxification stages or early in recovery, need to be considered. Furthermore, many alcoholics and drug addicts, having suffered through years of malnourishment, suffer profound and possibly irreversible physiological changes which intensify discomfort in recovery and, for many, lead to relapse. Embedded in the multi-disciplinary approach is an intense focus on nutritional deficits and the profound long-term effects of chronic malnutrition and alcohol intoxication.
The fact that nutrition has been often overlooked in the past in the areas of pharmacology, standard medical practices, and treatment of addiction is not surprising. More than two-thirds of the medical schools in the United States still do not have a specific nutrition course in their curriculum [2] This ongoing failure to teach nutrition and practice nutritional medicine is embedded in the idea that we get our recommended daily allowance (RDA) of nutrients if we eat within certain defined parameters. There is a clear understanding now that even RDA’s of these nutrients, established by the Food and Nutrition Board of the National Academy of Sciences (NAS) in 1941, may keep subclinical disease states subclinical. Because the RDA’ s for vitamins are minimum amounts that will only prevent the signs and symptoms of deficiency diseases, the daily intake should often be higher than recommended. This is especially true for treatment of alcoholism. Furthermore, however well RDA’ s work as a guideline, for any given person, they may be an underestimate or overestimate of the amounts actually needed for any specific health problem. The fact that alcoholics have impaired utilization of the basic nutrients is unquestioned, but the level of deficiency is unique to each alcoholic [3]. In fact, these subclinical states may exist before active alcoholism because of poor nutrition. Furthermore, de facto nutritional deficits must exist in a subclinical state before they become clinically apparent [3-6].
All chronic alcoholics suffer from some level of nutritional deficiencies [5, 7-10] The alcoholic obtains most, if not all, his/her daily energy requirements from ethanol, which although not a nutrient, contains approximately 7 calories per gram and represents about 3% to 5% of the daily energy intake of the adult American population As the most widely abused drug of our society, ethanol contributes dramatically to the development of disease states of several organ systems, especially the liver [12] and gastrointestinal tract [13]. For many, the result is diminished utilization of oral nutrients that are necessary for normal health which leads to the subsequent state of malnutrition [14, 15].
Treating alcoholic malnutrition and end organ injury is a complex problem. Damage to vital organ function via the toxic effects of alcohol is just one of the many issues that need to be addressed. Absorption, assimilation, and elimination are all impaired to some degree. Unfortunately, the efficacy of intestinal absorption in a given patient cannot be predicted adequately [3, 11]. Inadequate diet, digestion, and malabsorption contribute to secondary malnutrition [13, 16] Alcohol causes changes in protein digestion and metabolism [51], absorption, metabolism, and utilization of vitamins [52, 53], and deficiencies of minerals [54].
Lack of quality oral nutrition, impaired utilization of these nutrients, and excessive loss and reduced storage of these nutrients all impede movement back to mental and physical health and recovery. In fact, the central paradox in treating chronic alcoholism is getting enough nutrients into the alcoholic for organ repair so that the organ itself can utilize the nutrients in the most efficient manner possible. This is one reason that some treatment programs have begun to supply vital nutrients in much higher quantities to recovering alcoholics than one would supply a person in reasonably good health [17] Nutritional supplementation and the correction of subclinical deficiencies are not only vital for improvement of general physiological health during detoxification and treatment [18], but also absolutely necessary for relapse prevention. Improving nutritional status is not only paramount in the detoxification stages and early treatment, it has also been shown, at least in the long-term, to decrease the over-all relapse rate [19, 20].
Not only do nutritional deficiencies increase alcohol cravings, they also promote complications in alcoholics such as heart disease, liver disease, high blood pressure, diabetes, osteoporosis, and increased cancer risk [21] Additionally, the chronic use of alcohol has been shown to promote the development of depression [13, 21-28] Nutritional therapies have been shown to not only reduce hepatotoxicity, reduce withdrawal syndromes and cravings, they also alleviate depression and anxiety [32, 33].
In the common type of 28-day treatment program where nutritional support is not the foundation of withdrawal and recovery, residual symptoms such as ongoing anxiety, insomnia, tremors and shakiness, dizziness, depression, and impaired cognitive function are not uncommon for up to 4-8 weeks after discharge [17, 36] It is for this reason that the current understanding of the mechanisms of withdrawal and detoxification, especially in treating alcoholism, must be redefined. Withdrawal encompasses more than just clinical phases where the alcohol disappears from the human system. For example, it has been recognized, especially in opiate dependency, that the withdrawal syndrome does not end in 5-7 days Subtle signs and symptoms existing past the currently “accepted” withdrawal phase, termed the “protracted withdrawal syndrome” [37] , may last up to six months. This is one of the reasons that maintenance programs such as methadone treatment, along with other psychotropics such as benzodiazepines, are utilized for extended periods of the opiate withdrawal [38, 39] In comparison to alcohol, opiates by themselves may be one of the least toxic drugs on human physiologic functions and tissues while the long-term effects of alcohol on liver function, gastrointestinal function, and brain neurochemistry have been well documented [13, 22-25, 27, 28] The long-term effects of alcohol on organ system function contribute greatly to the high relapse rates among recovering alcoholics. Repair of affected organs requires a strong nutritional foundation during treatment and ongoing recovery. This primary focus on a “nutritional foundation” is lacking in almost all alcoholic treatment protocols at this time.
Since all chronic alcoholics suffer from some level of nutrient deficiencies, the best treatment protocols appear to involve designing balanced nutritional protocols, especially utilizing intravenous vitamins and minerals, which will assist the patient in recovery and detoxification. The goal with comprehensive IV nutritional therapy is to provide necessary nutritional support at the cellular level in the individual alcoholic whose gastrointestinal tract is compromised. Ultimately, this therapy will assist the individual back to a state of health so that oral nutrition will suffice in their ongoing health. Initial physical measurements such as body weight, height, and percent body fat would allow the clinician a point from which to measure therapeutic efficacy of the treatment.
The successful treatment for the disease of alcoholism requires knowledge of cellular and biochemical events. Functional medicine recognizes that nutrition is the necessary cornerstone for all good health, which includes adequate detoxification and continued recovery in alcoholism. Through the utilization of nutritional therapy, the patient can be brought back to health quickly so that his body and mind functions can be utilized at the fullest extent It has become apparent that mono-therapies, of any nature, have low success ratios in the treatment of alcoholism. It is time that health professionals of all disciplines come together, with open minds, to utilize holistic treatment regimes that improve the success of treatment. In the few programs where this has occurred success ratios for continued recovery have risen dynamically.
We typically think of withdrawal as attached to the use of street drugs and alcohol. There is no doubt that street drugs cause changes in brain neurochemistry, or frankly, people would not do them. All street drugs, and alcohol, increase the release of a neurotransmitter called dopamine. This is the feel good neurotransmitter…the more that is released the better we feel. Increased levels are seen also with exercise…such as the runners high. This increase in dopamine is also coupled with an increase in the natural bodies opiates—enkephlins and endorphins. However, long term use of any street drug or alcohol leads to what is called tolerance…this is simply the body/mind self-regulation that does several things…1) it cuts back on the production of the neurotransmitter; 2) reduces the number of receptors the transmitter has to act on; or, 3) increases the production of monoamine oxidase to break down the excessive neurotransmitter--thereby trying to bring an abnormal condition back into some level of balance. Unfortunately, the increased release of dopamine also affects levels of other neurotransmitters. When the brain senses too much of the dopamine it increases monoamine oxidase which also breaks down other monoamines (neurotransmitters) such as serotonin. And since dopamine goes on to produce epinephrine (adrenalin) and nor-epinephrine it down regulates these two essential neurotransmitters as well.
In addiction, other factors play into the decrease production of these essential neurotransmitters. Poor diet and dehydration are the most common factors in the decreased availability of these transmitters. Other factors which can affect the production, release, and availability of neurotransmitters is stress; whether that stress is generated through our actions, or by chronic disease states—which all addictions are now considered. Adrenal fatigue is common because the adrenal gland releases epinephrine, nor-epinephrine, cortisol (our natural body steroid) in response to the increased level of stress…after all these are known as the “stress hormones”. If stress is prolonged the adrenal glands eventually “fatigue”…releasing less and less over time. This creates tiredness and feelings of malaise. Once again these are common symptoms in the first year of sobriety. It is not uncommon for the adrenals to take up to a year to come back to normal functioning.
It is clear that psychotropic drugs affect the production, release, and utilization of brain neurotransmitters. Although the mechanism of action of these medications is commonly different than that of street drugs and alcohol, they still affect the same neurotransmitters leading to prolong dysfunction of brain neurochemistry. So the primary question that needs clarification--if prescription drugs cannot enable us to return to some sense of normalcy…what can? Quite simply…nutrition. Nutrition is the foundation of all body biochemistry, including that of neurochemistry. Nutrition supplies us with the basic repair supplies which include proteins (amino acids from proteins are the building materials for neurotransmitters), carbohydrates and fats. Also essential are the vitamins and minerals which act as the co-enzymes and co-factors which facilitate the movement of the human biological system back to normal function. In fact, many vitamins and minerals serve as co-factors and co-enzymes for the production of neurotransmitters from amino acids. How important amino acids are in body/mind health is apparent by the numerous roles they play in the health of any individual. Some of the more important essential roles they serve are:
DNA, the blueprint, serving as the master control for proper biochemical processes in the body consist of amino acids; RNA consist of amino acid chains
All enzymes necessary for the conversion of amino acids to essential processes and products in the body are formed from amino acids
All receptors, that enzymes and neurotransmitters bind to, are amino acid complexes
All neurotransmitters are formed from amino acids
Amino acids may be converted to Glucose during times of starvation…glucose is the only form of energy that brain cells can utilize
Branch chain amino acids are essential for proper immune system function
So it’s easy to see why supplementing amino acids in the treatment of drug and alcohol detoxification and recovery is essential. It is also critical in the treatment of those who have been on anti-depressants and wish to discontinue the medication. Yet amino acids are not enough. The co-enzymes (vitamins and minerals) are essential in increasing the efficiency of the enzymes that convert amino acids to neurotransmitters among other products. Without these essential co-enzymes nothing can happen in biochemistry, or neurochemistry.
Two things must be understood before starting…1) Keep it simple…movement from the simple therapy to the complex therapy will allow the physician, or patient, to move to the level of complexity needed in any particular case without overwhelming the patient, 2) Stay the course…many get discouraged because they want to be “well” now. Ask yourself, “how long did it take me to get here…” and more importantly, “how long am I willing to commit to this process of healing and recovery?” I have my patients commit to 6-weeks of intensive nutritional therapy…we assess every two weeks and change what is necessary. At 6-weeks, I ask for another commitment of 6-months to one year. 65-80% of those who make the initial 6-weeks make the longer commitments. Remember, it takes time to re-establish and heal adequate neurotransmitter function…one day at a time.
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