Substance Abuse

The Opioid Crisis- Getting Vulnerable

The Opioid Crisis- Getting Vulnerable 

I gave an academic talk the other day where I shared some personal experience with the opioid crisis. I don’t normally open up this way because my anecdote can bias my research, however my story can also bring my work to life in some meaningful ways. Thus, I am selective about what I share in certain non-recovery settings. I told the story of my friend Brad who I grew up who was my first close friend to die from an overdose, in 2005. I had lost a few other friends prior to that, but Brad’s death really struck me because I had gotten high with him shortly before it happened. I shared that since getting sober in 2006 I have lost about 20 friends to drug-related overdose. I shared that my brain has started to block those memories out and I probably couldn’t even list off the names. At some point I stopped going to memorials. And at some point, I even stopped making friends. People were shocked. Was this true? I did say it. In reflection I have realized that it takes a while for me to become close to someone these days, particularly if they are in recovery. I have wounds. And complex trauma wounds can be so subtle that we sometimes don’t even know we have them. And the truth is, I have been to many memorials, just not all of them. 

Why Are So Many People Dying?

I’m a big city kid. I live in West Los Angeles. But the opioid crisis has swept the entire nation. Overdose is more common in rural areas compared with urban settings1with higher prevalence among whites compared to nonwhites2and is a growing risk among adolescents.3Prescription opioid injection misuse is higher among males4but some data suggests that non-medical opioid use is higher among female adolescents.5Female adolescents? There is something going on here. This is about more than just “peer pressure” or growing up in socially disadvantaged settings. Of course, environment factors matter. Of course, it has to do with the pharmaceutical industry and with irresponsible prescribers, but where does all the pain come from in the first place? Why do these opioids feel so darn good? Why are so many people dying? This fentanyl thing is out of hand. The opioid crisis has gone too far.

Pain Management 

Pain management is the medical specialty that treats a variety of conditions including cancer, traumatic pain, postsurgical pain, and end of life issues. By far the most common opioid analgesics are codeine, hydrocodone, oxycodone, morphine, and fentanyl. OxyContin sales went from $48 million in 1996 to $1.1 billion in 2000. I am guessing you have seen the news about Purdue Pharma and the Sackler family. It’s quite disheartening but also exciting to see shifts happening. There are lots of new policies and procedures for opioid prescribing, as well as efforts to move patients toward non-opioid approaches to pain management, such as yoga, acupuncture, etc. Meanwhile, adoption and implementation of new policies and procedures in emergency departments (e.g. better screening) have been slow and not without administrative challenges.6

A Veterans Health Administration study found high opioid prescription rates among veterans with unexplained gastrointestinal (GI) symptoms (e.g. irritable bowel syndrome) where opioids have no clear role.7The authors identified psychiatric comorbidity as a mediator of unexplained GI symptoms, potentially driving opioid misuse. While opioids may provide some short-term relief of GI-related issues, these benefits are likely to fade as tolerance increases, and can leave patients with opioid-induced bowel dysfunction. Mental health screening before prescribing has also been recognized as an important risk mitigation strategy during the crisis8but has not been widely implemented. As a nutritionist, I am very much interested in the link between opioids and gastrointestinal function. I do think there will be some exciting findings in the next few years. However, nutrition never gets the attention it deserves on the medical stage, and sometimes I am even offended by the idea that nutrition is “alternative medicine.” It makes a big difference- it is just slow and therefore difficult to measure. But it matters. Nutrition matters. 

The Biopsychosocial Perspective 

In order to truly understand the opioid crisis, it is critical to examine it from all perspectives, including social and environmental factors, psychosocial factors such as stress, trauma/PTSD, and childhood adversity. And biological factors: genetics, epigenetics, microbiome, nutrition, etc. A biopsychosocial approach looks at all possibilities and more importantly at the interactions between influencing forces, from the microscopic to the planetary level. Some experts believe that the biopsychosocial approach lacks foundation and does not identify specific quantifiable mechanisms that demonstrate a causal chain of events.9The biopsychosocial model has also been criticized as being anti-medicine, but it has also been argued that it may improve psychiatric intervention.10

In my opinion, this perspective is exactly what we need to combat the opioid crisis, as reductionistic approaches such as new medications to treat opioid addiction can only address parts of the issue. We need a systems approach. For example, a biopsychosocial perspective on pain suggests an interaction with psychological factors such as depression and anxiety which lead to psychosocial interventions (e.g. behavioral and cognitive therapies) based on an individual assessment in addition to psychopharmacology.11

Furthermore, the “nature vs. nurture” controversy related to addiction has decreased in the past two decades given strong evidence for both, as well as the emerging field of epigenetics representing convergence between genetic and environmental factors. There is so much new information related to the intersection of social and biological factors, and we need to embrace multidisciplinary efforts in order to fully understand them. Multi-modal = multiple modalities. 

Psychosocial Factors 

The role of trauma and chronic stress have been identified as important vulnerability factors in the development of addiction. In some cases, a trauma history may serve as a proxy measure for addiction severity. The self-medication hypothesis describes one’s tendency to find ways to anesthetize unresolved pain. This perspective of underlying risk factors for opioid use disorder can include negative childhood experiences that are psychological/emotional (e.g. leading to depressive symptoms) or physical (e.g. pain). Advocates of this theory suggest that individuals self-medicate in response to physical and psychological experiences of pain, such as victimization.12Adverse Childhood Experiences, also known as ACE scores, are a major part of my current work and research. I can’t wait to share more about this with you soon. The original ACE study showed that individuals who had 4 or more ACEs were at a 12-fold increase in risk of drug addiction.13We need to start screening for ACEs and intervening early on. 

Policy and Environmental Interventions

The environmental theory of the opioid epidemic is impossible to deny. Legal action against Purdue Pharma have implicated the role of the pharmaceutical industry in disseminating misleading claims about the addictive potential of OxyContin. Irresponsible prescribing is another important part of the supply side theory, as countless “pill mills” have been raided in the last ten years across the US. Finally, increased accessibility of illicit opioids such as heroin have continued to plague communities across the nation. Policy interventions targeting all three of these problems are essential. Environmental enrichment has shown promise in reducing opioid administration.14But we obviously need to go much further. Where to?

Psychosocial Interventions

Painful life experiences increase vulnerability to addiction. It is well established that early life adversity can compromise adult mental health through multiple stress-related pathways,15including transmission of atypical HPA axis regulation.16The psychosocial theory describes the stress, trauma, and ACEs that are often influenced by socioeconomic status, and which appear to modify reward pathways in the brain. One solution is trauma-informed mental health services, and the other is to improve the social factors in susceptible populations. So much work that needs to be done here. Trauma-informed therapy is the key. But sadly, only those with financial resources are likely to access this. We need high quality trauma-informed care in underserved communities. 

Nutrition Interventions?

YES. This is where my current efforts are headed. I don’t want to spill the beans, but I do want to get you excited about work that is being done. My recent book chapter can be found HERE and I assure you a very exciting publication is coming soon. 

Future Directions

There is a need for more research on how stress, trauma, and ACEs impact reward functioning in the brain. Given what is known about the link between psychosocial factors and the opioid crisis, it would be helpful to further elucidate the neurobiological underpinnings. This direction has recently been described as a “syndemic” approach, examining the pathways from socioenvironmental conditions to biological states, and the drivers behind disease clustering,17which has been observed in the opioid crisis. Given that opioid use disorder is also prevalent in socially advantaged groups, it may be useful to examine how socioeconomic status impacts treatment outcomes in all directions. There is a vast array of social issues that still need to be resolved, particularly on the supply-side of the opioid demand, where new prescribing policies are underway. And there is so much we need to know about opioids and the microbiome, particularly how opioid use can affect mental health through the gut-brain axis. Stay tuned! 


1. Dunn, K. E.et al.Opioid overdose experience, risk behaviors, and knowledge in drug users from a rural versus an urban setting. Journal of Substance Abuse Treatment71,1–7 (2016). 

2. Martins, S. S. et al.Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry74,445–455 (2017). 

3. Sheridan, D. C. et al.Association of Overall Opioid Prescriptions on Adolescent Opioid Abuse. The Journal of Emergency Medicine51,485–490 (2016). 

4. Jones, C. M. Trends and key correlates of prescription opioid injection misuse in the United States. Addictive Behaviors78,145–152 (2018). 

5. Vaughn, M. G., Nelson, E. J., Salas-Wright, C. P., Qian, Z. & Schootman, M. Racial and ethnic trends and correlates of non-medical use of prescription opioids among adolescents in the United States 2004–2013. Journal of Psychiatric Research73,17–24 (2016). 

6. Weiner, S. G. et al.Opioid‐related Policies in New England Emergency Departments.Academic Emergency Medicine23,1086–1090 (2016). 

7. Sayuk, G. et al.Opioid medication use in patients with gastrointestinal diagnoses vs unexplained gastrointestinal symptoms in the US Veterans Health Administration. Alimentary Pharmacology & Therapeutics47,784–791 (2018). 

8. Brady, K. T., McCauley, J. L. & Back, S. E. Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update. American Journal of Psychiatry173,18–26 (2016). 

9. Lane, R. D. Is it possible to bridge the Biopsychosocial and Biomedical models? BioPsychoSocial Medicine8,1–3 (2014). 

10. Pilgrim, D. The biopsychosocial model in Anglo-American psychiatry: Past, present and future? Journal of Mental Health11,585–594 (2009). 

11. Campbell, L. C., Clauw, D. J. & Keefe, F. J. Persistent pain and depression: a biopsychosocial perspective. Biological Psychiatry54,399–409 (2003). 

12. Young, A., McCabe, S., Cranford, J. A., Ross-Durow, P. & Boyd, C. J. Nonmedical Use of Prescription Opioids Among Adolescents: Subtypes Based on Motivation for Use. Journal of Addictive Diseases31,332–341 (2012). 

13. Felitti, V. J. et al.Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine14,245–258 (1998). 

14. Eitan, S., Emery, M. A., Bates, M. L. S. & Horrax, C. Opioid addiction: Who are your real friends? Neurosci Biobehav Rev83,697–712 (2017). 

15. Jones, T. M., Nurius, P., Song, C. & Fleming, C. M. Modeling life course pathways from adverse childhood experiences to adult mental health. Child abuse & neglect80,32–40 (2018). 

16. Scorza, P.et al.Research Review: Intergenerational transmission of disadvantage: epigenetics and parent’s childhoods as the first exposure. Journal of Child Psychology and Psychiatry(2018). doi:10.1111/jcpp.12877 

17. Singer, M., Bulled, N., Ostrach, B. & Mendenhall, E. Syndemics and the biosocial conception of health. The Lancet389,941–950 (2017). 

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Eating Disorders and Substance Use Podcast 1

Eating Disorders and Substance Use Podcast

Eating Disorders and Substance Use Podcast – Interview with Tabitha Farrar

In this excellent conversation Tabitha and David Wiss discuss the co-occurrence of eating disorders and substance use disorders, and the challenges faced by treatment providers. David discusses how many people with EDs can “hide out” in addiction treatment.

Eating Disorders and Substance Use
LINK HERE

Tabita Farrar is an eating disorder recovery coach with lived experience. She was a pleasure to chat with and has a fantastic podcast.

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Nutrition for Mental Health Webinar

Nutrition for Mental Health Webinar

Hot Topic: Nutrition for Mental Health

David Wiss MS RDN presents to students at California State University Northridge about the connection between nutrition and mental health. This presentation covers the microbiome, substance use disorders, disordered eating, depression, recovery, and more. It’s just over 50 minutes long, but worth every second! Why? Because nutrition for mental health is the future! Read more about this topic and check out some recent references HERE

Nutrition for Mental Health 53:34 #GutBrainAxis
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Dope Wisdom Podcast

The Dope Wisdom Podcast with Yeshaia Blakeney from Recovery Integrity – Interview with David Wiss.

David and Yeshaia discuss addiction, recovery, nutrition, gut health, microbiome, research, and intellectual spiritualism.

Yeshaia Blakeney, host of the Dope Wisdom Podcast and co-founder of Recover Integrity, a Los Angeles addiction treatment program he opened in 2015, is an addiction expert with 15 years of experience working in substance abuse and mental health.

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Los Angeles Conference April 6, 2019

“Dialectics in Dietetics: Multiple Truths in Nutrition Science” Conference April 6, 2019

History of the Conference

At the Los Angeles District of the California Academy of Nutrition and Dietetics annual transition meeting in the summer of 2016, we had a big idea. What if we could throw our own conference?

In 2017 we actually did it and it was epic! Our first conference was called “Public Health and Private Profits: A Dialogue about Critical Topics Shaping the Future of the Dietetic Profession”

Our 2018 conference was called “One Size Does Not Fit All: Promoting Diverse Perspectives in Dietetics” and was also SOLD OUT.

Our April, 6 2019 conference should be the best one yet! “Dialectics in Dietetics: Multiple Truths in Nutrition Science.” We are so thrilled to have such a star-studded line-up this year! The conference is held at Children’s Hospital Los Angeles and is not to be missed!

April 6, 2019
http://www.ladannualconference.org

We have special pricing for students, RDNs, and LAD members!

Register for the conference HERE

April 6 will be here before we know it!

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Does Alcohol Affect HbA1c? Video

How does alcohol affect HbA1c?

David Wiss MS RDN describes the relationship between alcohol and glycohemoglobin (HbA1c) from a biospsychosocial perspective. Alcohol lowers HbA1c levels significantly and many researchers have concluded that alcohol is protective against T2DM. Sounds strange doesn’t it? What are the mechanisms? Is it the alcohol itself or is it people who drink alcohol? Are group differences in this relationship due to social or biological factors? Until more research is done, we have more questions than answers. Find out what we do know here and next time someone asks “does alcohol affect HbA1c?” you will be ready to chime in!

Nutrition in Recovery is a group practice of Registered Dietitian Nutritionists and other health professionals who specialize in the treatment of addictions, eating disorders, body image, mental health, as well as general wellness.

We send out a monthly Newsletter summarizing the latest research linking nutrition and mental health. Each newsletter will include a short video with some helpful hints and actions you can implement to improve mental, spiritual, and physical wellbeing for yourself and for your clients. You will be among the first to hear the findings and insights from cutting-edge data, and we are providing references so you can do your own research if interested.

Within the next year you can look forward to the following topics being covered:

Bariatric Surgery

Child Nutrition

Circadian Rhythms

Men and Eating Disorders

View last month’s video on Vaping and Disordered Eating

Does Alcohol Affect HbA1c?
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Nutrition Interventions Amidst an Opioid Crisis

Nutrition Interventions Amidst an Opioid Crisis

“Nutrition Interventions Amidst and Opioid Crisis: The Emerging Role of the RDN” by David Wiss MS RDN

The opioid crisis has reached epidemic proportions. The time to include nutrition into the treatment paradigm has arrived. David Wiss is not afraid to take the lead, and is doing research on this topic at the University of California, Los Angeles. 

This presentation was given at the Food and Nutrition Conference and Expo (FNCE) on Sunday October 21, 2018 in Chicago which was an invited presentation in response to the opioid crisis. Here David Wiss describes the impact of opioids on nutritional status and gastrointestinal health, identifies common disordered and dysfunctional eating patterns common to opioid-addicted populations, and describes nutrition therapy protocols for specific substances including opioids and for poly-substance abuse.

The presentation is 1:29:01 and was moderated by my dear friend and colleague Tammy Beasley, RDN. If you want to skip the video, and go straight to the slides, you can do so HERE. 

In summary, nutrition interventions have not yet been standardized or widely implemented as a treatment modality for substance use disorder (SUDs). Emphasis should be placed on gastrointestinal health, and reintroduction of foods high in fiber and antioxidants such as fruits, vegetables, whole grains, beans, nuts, and seeds. Adequate intake of protein and omega-3 essential fatty acids should be consumed daily. Regular meal patterns can help to stabilize blood sugar. Water should replace sweetened beverages. Caffeine and nicotine intake should be monitored. Dietary supplements can be very helpful in the recovery process, but should not supplant whole foods. Once nutrition behavior has improved, use of dietary supplements should be reevaluated. Lab tests and stool samples assessing gut function should provide valuable insights in upcoming years. In addition to expertise with the interaction between specific substances and nutritional status, RDNs working in treatment settings should specialize in gastrointestinal health, eating disorders, and should be current with food addiction research. There is a timely need for specialized nutrition expertise in SUD treatment settings, including outpatient clinics and “sober living” environments. Public health campaigns and specialized training programs targeting primary care physicians, mental health professionals, and other SUD treatment professionals are warranted. 

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Private Practice

Nutrition in Recovery is a private practice founded by David Wiss MS RDN, who recounts:

The vision was born in 2006 ago when I got sober and used nutrition and exercise as part of my personal recovery. I had made attempts at getting sober previously, but never felt comfortable in my skin, mostly plagued by lethargy and anxiety, which left me pessimistic about sobriety. I had always assumed nutrition was about fitness and weight, which is how it is presented by society. But when I began to exercise and eat a wide range of plant foods, something dramatic happened to my mental health. There were dramatic changes in my body which served as positive reinforcement, but the real outcome was that I became optimistic and found some inner-peace. My thoughts cleared up and so did my skin. My bowel movements became regular, and my heartburn went away. I woke up feeling refreshed in the morning, and when I read recovery-related literature, it was actually sinking in. Previously it seemed as though my eyes were just skimming the page. At that point I knew that nutrition is important for recovery from addiction and wondered why no one ever told me so. From there I was able to quit smoking and became a non-competitive athlete. I can remember being extremely excited to go to the grocery store and buy fresh food to experiment with in the kitchen.

After working as a personal trainer for a few years, I was accepted into a master’s program in nutrition where I completed training to become a Registered Dietitian Nutritionist. I worked at UCLA Medical Center and gained experience with eating disorders. The field of nutrition for addiction recovery was unchartered and I started a private practice immediately after passing my exam. I have not had a slow week since. I have run groups at many different treatment facilities and have trained other dietitians to do the same. I fell in love with academic research and began publishing scientific articles. I taught myself the basics of neuroscience, nutrition-related hormones, and gastrointestinal health. With this information I was able to conceptualize eating behavior in order to create real change in the people I work with. Most of my referrals come from previous clients, and mental health professionals who have seen my work transform people. Currently I am working on my PhD in Public Health from UCLA.

I am not attached to any particular food philosophy. I do not try to convert people to eat the way I eat, although I do eat strategically without much effort. I am a believer in using whole foods and developing life skills to cook and prepare food when possible. Supplements can be helpful, but they are designed to support behavior change. I specialize in helping people to make gradual and stepwise changes in their food choices. I am an expert in nutrition but can serve the role of a coach. I look at the entire dimension of wellness: food, beverage, exercise, supplements, sleep, sunlight, etc. I am recovered, and love to help other people become the same. I spend the first hour collecting information about you and from there will have a better picture of the direction we are headed. Some people need structure, other people just need a safe place to talk about food and body. Some people need tips for grocery shopping, other people just need some accountability for their recovery. I try to find the intersection between giving my clients what they want and giving them what they need. Let’s take a journey together and see where it goes!

About Nutrition in Recovery 1

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Journal Articles by David Wiss

Peer-Reviewed Journal Articles by David A. Wiss MS RDN

(ORCID Link Takes You Directly To The Articles)

Wiss, D. A., Avena, N., & Rada, P. (2018). Sugar addiction: From evolution to revolution. Frontiers in Psychiatry, 9(545). doi:10.3389/fpsyt.2018.00545

Wiss, D. A., Schellenberger, M., & Prelip, M. L. (2018). Rapid assessment of nutrition services in Los Angeles substance use disorder treatment centers. Journal of Community Health. https://doi.org/10.1007/s10900-018-0557-2

Wiss, D. A., Schellenberger, M., & Prelip, M. L. (In Press). Registered dietitian nutritionists in substance use disorder treatment centers. Journal of the Academy of Nutrition and Dietetics. doi:10.1016/j.jand.2017.08.113

Wiss, D. A., Criscitelli, K., Gold, M., & Avena, N. (2017). Preclinical evidence for the addiction potential of highly palatable foods: Current developments related to maternal influence. Appetite.doi:10.1016/j.appet.2016.12.019

Wiss, D. A., & Brewerton, T. B. (2016). Incorporating food addiction into disordered eating: The disordered eating and food addiction nutrition guide (DEFANG). Eating and Weight Disorders. doi:10.1007/s40519-016-0344-y

Wiss, D. A., & Waterhous, T. S. (2014). Nutrition therapy for eating disorders, substance use disorders, and addictions. In Brewerton, T. D., & Dennis, A. B., Eating disorders, substance use disorders, and addictions (pp. 509-532). Heidelberg, Germany: Springer Publishing.

Specter, S. E., & Wiss, D. A. (2014). Muscle dysmorphia: Where body image obsession, compulsive exercise, disordered eating, and substance abuse intersect in susceptible males. In Brewerton, T. D., & Dennis, A. B., Eating disorders, substance use disorders, and addictions (pp. 439-457). Heidelberg, Germany:Springer Publishing.

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Is There Science to Sugar Addiction?

Is There Science to Sugar Addiction???

I know, I know, I know…food addiction and sugar addiction are controversial topics, especially in the eating disorder community, where any kind of “diet” beliefs or behaviors are viewed as harmful. I agree that many of the proponents of sugar addiction and food addiction carry a very punitive “food negative” message. Is there a way to accept the science of food addiction AND be “eating disorder friendly” at the same time??? That takes skill. One has to be able to hold multiple things true at the same time, and separate emotions and personal bias from their work. But it can be done!!! In fact, it HAS TO be done!
The revolution is now.

Our latest publication: “Sugar Addiction: From Evolution to Revolution” has been recently published in the prestigious Frontiers in Psychiatry. I will say this was the hardest peer-review I have ever gotten through! It is published OPEN ACCESS so download it HERE. For those who work with eating disorders, there is a special section to address the controversies! Enjoy! Feedback always welcomed.

Is There Science to Sugar Addiction?

Want to learn more about Food Addiction? Check out our FAQ page on it.

Want to learn more about Eating Disorders? We got that too.

Nutrition in Recovery specializes in the nutritional management of addictions, eating disorders, body image, mental health, and weight management. We offer group education and individual counseling. We love to help people finally make peace with food and exercise. Nutrition in Recovery also offers general wellness services, sports nutrition, and medical nutrition therapy for various chronic diseases, including gastrointestinal issues. Whatever brings you into our office, we are prepared to help you on your journey to recovery.

We pride ourselves on being flexible with different food philosophies. We do not believe that any single food philosophy works for all people. In fact, we think that only having one food philosophy is not scientific. We are skilled in making an individual assessment in order to figure out the best treatment approach for you. We have a team of experts at Nutrition in Recovery and can therefore get you in touch with the best person for your specific needs.

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