Episode 20 – The Reality Of Relapse
Dr. Ashish Bhatt ❘
Relapse is oftentimes part of the recovery process. Dr. Bhatt, MD explains why it happens and what you should do if it does.
Read More ⟶
The podcast and articles by Dr. Bhatt are intended to be strictly informative, and will not provide any diagnosis, treatment recommendation, or directed medical advice. Unfortunately, not all messages can be addressed, and no message is guaranteed a response. Information provided by Dr. Bhatt in articles and podcasts is intended to address common questions of general applicability, and may not apply to your unique situation. As a result, please do not use the advice or conclusions found in any articles and podcasts on this site as a substitute for professional personal medical advice. If you are looking for treatment, please call
Hayley: Hi, everyone. My name is Hayley and I am your host for Straight Talk With The Doc: the podcast that breaks down topics on addiction, mental health, and treatment with addiction medicine specialist, Dr. Bhatt.
Dr. Bhatt: How are you doing, Hayley?
Hayley: I’m great; thanks for asking. Today is our 30th episode of Straight Talk With The Doc. We’ve covered so many interesting topics from social media addiction to getting a full understanding of drugs like Hallucinogens, Cocaine, and Fentanyl. And some of our listeners may have a personal experience with addiction while others do not. But we all have experience with what we’re going to be talking about today, and that is food. You need food to live, but it goes far beyond that. What we eat and how we eat plays a role not only in our nutrition, but in our mental health as well, and that’s even more true for those in recovery. Abusing drugs or alcohol can seriously affect the user’s relationship with nutrition, making it even more important when they begin their recovery journey. Dr. Bhatt is going to help me cover all of that today, but Dr., can you start by explaining: how does food play a role in our mental health?
Dr. Bhatt: Well, our food is basically the building blocks. It’s providing us with the fuel and the nutrition to help us grow and be healthy. Food also affects a lot of things in our body that regulate our hormones that help us feel and function- anything from serotonin to dopamine, things that make us feel pleasure or help us sleep, and affect our mood. Similarly, food helps to control and regulate bacteria and gut flora. It really controls a lot, everything from our physical well-being and our psychological well-being. How we eat definitely reigns true.
Hayley: Okay, I want to talk about how we eat. I think growing up we’ve all heard advice- families should eat dinner together; don’t eat in front of the T.V. Do all those other pieces of advice actually make a difference?
Dr. Bhatt: Definitely. I think we take food for granted. I think many people think what we eat or a meal is just something to get over with. There are people that do now take nutrition seriously, though, but I don’t think it’s a pervasive thing as much as it should be. Here in America, we suffer with a lot of obesity. We suffer with a lot of people who have malnutrition and we definitely see our fair share of issues especially with nutrition when it comes to those who suffer with addiction and substance use. Creating healthy habits as they are from when we grow up, within our family, definitely can help us put the focus on nutrition and not being distracted while we are in front of the television. Not only can it help us concentrate on the quality of our food so we know what we’re eating, we ensure we’re getting the right balance of proteins and carbohydrates and proper fats. But that also can serve as a time where we can socialize and have psychological well-being. I think we’ve lost that whole concept of sitting together as a family just because everybody’s doing their own thing. And I think it’s important for our emotional well-being that it’s not only what we put in our body, but for our minds that we’re having healthy dialogue. And eating together or eating while not being distracted with some sort of electronic device, I think it’s super important and really can help us especially because we’re a stressed out and often isolated society. Using the dinner table as a place to connect again definitely can contribute to our overall well-being.
Hayley: It’s important to practice mindfulness with food with what’s going into your body.
Dr. Bhatt: Definitely. We do see that, right, but where is this being taught to us? We do have nutrition classes in school, but what does that really mean? How many kids are really taking this seriously? I go back to it being important at home. At home, I know we have busy lives. Moms and dads are working and it’s often just getting it done. But food should have a purpose other than just putting something in our mouth. And definitely, being mindful- I love what you just said. Being mindful of our food is super important.
Hayley: Like you mentioned, even if a kid takes a nutrition class in school it really does matter what’s going on at home. Because at the end of the day, it’s what their parents are teaching them that they’re probably going to follow. They’re going to follow their parents’ lead.
Dr. Bhatt: Obesity, let’s just talk about that. It’s such a big problem here in the United States of America. And especially with access to fast foods. When we are busy in our lives it’s easier just to grab something from a fast food restaurant. But, we all know the nutrition value of that and what that could do to our bodies and to our minds. When we go into refined and processed foods and steer clear of healthier products, it does take its toll on our physical well-being. And when we are physically not going well, psychologically you’re not doing well either. So, definitely bringing it back to the basics, having that prototypical type of environment, although it’s not ideal and often difficult to achieve. I think we need to strive for that and I think parents need to make an emphasis of this, and it’s good. I think being in the pandemic might’ve taught us how to reconnect again a little bit. It forced people to be at home. Hopefully this was an opportunity to talk about it and eat well and sit down at the dinner table together. It’s a time to connect. There’s a lot of learning that could go on while sitting at the dinner table.
Hayley: Yeah, absolutely. I’m glad that you mentioned obesity. I wanted to talk about that a little bit. Based on numbers from 2018, over 36% of American adults are obese and over 32% are overweight. It’s common knowledge now that eating processed and refined food without moderation, it’s going to lead to weight gain and all the associated health problems. But, many people feel unable to change their eating habits. Are people addicted to the food itself?
Dr. Bhatt: Let’s just be straight- sugar and refined products and things we can see that get to our body very quickly, especially through fast food, yes, they deliver a robust sensation of feeling good, and that happens a lot. We talk about kids and sweets and candy. And when you get sugar that goes straight to your body, it does activate certain neurochemicals in your body and your brain and it is gratifying. It stimulates pleasure and reward. It creates this cycle, but unfortunately, it’s a lot of bad calories that are going into it. There’s not a lot of good nutrients in any of this food. When you eat it on a constant basis and a ritual basis, you’re creating this cycle where you feel this lack of gratification when you don’t have that. The need to compulsively search it out again and it can create that cycle which you can call addiction. I don’t want to say most people who are eating fast food or going through a cycle of doing it are addicted to it. But, my point is it can create a cycle of malnourished eating, and maladaptive eating and it does have to do with the poor nutritional content, simple sugars, refined products that are there in processed foods that can contribute to this cycle.
Hayley: How do you differentiate between the people that are addicted to these processed refined foods, and then somebody who is suffering from say a binge eating disorder?
Dr. Bhatt: Well, a binge eating disorder is an actual medical condition. It’s classified under an eating disorder where there are a lot of calories consumed in a short amount of time and there’s a lot of guilt that goes along with it. There’s a lot of emotions that go along with it, and it is serving a psychological purpose. That’s different from somebody who just has bad nutritional habits. One is a clinical syndrome. It’s a clinical issue and it definitely has a relationship with how we feel, what we put in, and often has compensatory mechanisms behind it and emotional dysregulation. The other one could just be the result of I never learned what to eat correctly or this is just the lifestyle that I’ve been exposed to, or this is just the food I’ve just adapted to eat. But binge eating is distinct. It’s eating a large quantity of calories in a very short amount of time and it meets that specific criteria.
Hayley: On the topic of addiction, when someone has a severe drug or alcohol addiction, the drug becomes their priority. It’s often more important than their family, their job, and, of course, their health. I want to talk about that. How does substance use affect appetite?
Dr. Bhatt: It’s interesting because many different substances affect your appetite differently. A lot of Stimulants, like Cocaine or Methamphetamine, are an appetite suppressant. And we get so sped up, and they effect the reward mechanism and dopamine and the pleasure receptors so quickly and reduce the hormones that promote appetite at that time. You will see people often not eat and become anorexic. And I don’t mean anorexic by eating disorder diagnosis, I mean anorexia meaning loss of appetite, and we do see that. On the opposite, we often see people who use cannabis, for example. After they’ve used it or are consuming it, we do see them often have an increased stimulation of appetite and then they’ll go and eat, often seeking out foods in large quantities. And that has to do with cannabis and tetrahydrocannabinol, an active ingredient in cannabis and its ability to actually enhance smell and taste. If things taste better and smell better after smoking marijuana, your body can get conditioned to maybe eating more after using, and not only that, now even while you’re using to feel like you have the need to eat. Depending on the drug, you will see a lot of altered or dysregulated eating. And I know I talked about cocaine and cannabis, but alcohol is a huge one. Often when people are drinking to the point where they’re addicted and they’re drinking drink after drink, they’re not eating anything. They’re becoming significantly malnourished. They are losing significant vitamins and minerals, and this can cause devastating effects on the body as a whole. Not only is the alcohol or the drug doing the damage, but then you’re not eating so you’re getting a double whammy. You’re being malnourished and you’re getting the insult from the devastation that the drugs or alcohol are doing, so we definitely see a lot of harm done. Again, depending on the drug or alcohol there’s a lot of dysregulated eating there.
Hayley: Okay. Besides losing or gaining weight, what other symptoms of malnourishment can present in people with a substance use disorder?
Dr. Bhatt: Let’s just talk about a big one, alcohol. Alcohol causes a pretty significant syndrome called Korsakoff syndrome and Wernicke’s encephalopathy. These are basically deficiencies in thiamine and we see that often in the clinical population. These people can be confused. These people can be delirious. These people have significant memory loss. These people have issues with their eyes. I mean these people have a lot of cardiac, neurological and physical problems, and this is significantly related to alcohol consumption. And, of course, I’m talking about this as a later aspect of people who consume heavy amounts for long periods of time, but that is one that we do see a lot in the clinical population. And it’s not just about not eating thiamine; it’s also because alcohol alters the lining of the stomach and the intestines where certain nutrients are absorbed. We don’t just see thiamine; there’s a global nutritional decompensation when we’re drinking. And similarly, with other drugs we see a lot of constitutional signs and symptoms meaning if you’re not eating a well-rounded diet- a lot of times, for example, when we see people who use Heroin and Opiates, they’re shooting. They’re injecting. They’re snorting and they’re nodding out, passing out, falling out. There’s no time and no place for food. Then, often, when they go to eat they’re eating carbohydrates or sweets, or drinking. After the fact, they’re filling themselves with poor empty calories or calories that don’t provide a significant subsistence or long-term nutritional value. There are relationships that we do see, like I said, with alcohol, with Heroin, again, with Cocaine. We see a lot of people after using cocaine eating a meal at night. And it might be high in fats or high in carbohydrates, and again, this is not a balanced meal. Drug addiction, the reward is seeking the pleasure from using the drug. The motivational hierarchy, the things that are basic to our survival- food, shelter, relationships, they’re thrown out the window. We’re pursuing the drug and that’s our main state. Food is often neglected considerably, and that’s why we see so many people with substance use disorders with devastating conditions and often devastating nutritional situations with their body.
Hayley: What about something like meth mouth? How would that affect nutrition?
Dr. Bhatt: Oh wow, yeah. With methamphetamines, we see a lot of people when they’re using it get a lot of alterations with their saliva. We need saliva in order to process our foods, to digest, to do a lot of things, to eat and also maintain proper oral hygiene. People who use methamphetamines- I’m glad you brought this question up because it’s almost indirect. And at the same time, not only do methamphetamines alter your appetite and the way we eat and then the hormones behind how we eat and if we feel full or not, but the whole dysregulation with our mouth. It can cause a lot of poor dentition. We get a lot of cavities. We get a lot of oral decaying, and people lose teeth. Many people who are listening, or who know people who have used methamphetamines, they know that their mouth is probably bad. With that bad mouth, it’s difficult to eat. Theirs is almost indirect, too, that there’s that, “I can’t eat because I don’t want to eat and appetite is low.” But then, “Now when I want to eat, my mouth hurts. I don’t have proper tools- the mechanical tools to chew my food properly.” There is an irony there. It’s multifactorial that we see that the meth mouth is unable to chew and eat properly and is often in pain.
Hayley: You really have to treat it as a whole. You have to get the dental work as well after recovery to get them back and be able to just eat normally. I want to talk about nutrition plans in recovery. For those who don’t know, can you explain the typical types of nutrition plans that are put together for people while they’re in treatment?
Dr. Bhatt: What we see, often, is that when we’re using drugs or alcohol, like I said, what’s our reward? What’s our motivation? It’s drugs. We’re not thinking about whether we are eating correctly. There are many people who are using other illicit substances, are using testosterone or other things they might be vain or physically fit in one superficial way. And they might worry about what they’re eating in terms of carbs or proteins and stuff like that, but that’s usually an exception. Most people who are significantly addicted to the major classes of drugs are not really worried about or not taking care of themselves from a food consumption perspective. You’ll often see nutritionists on board as part of a team, especially in inpatient rehabilitation. We should have people bring a nutritionist or at least have nutritional assessments done by the practitioner, the physician, that talks about proper eating habits, because it’s like your body has to get re-acclimated with food again. There’s not only a physical relationship that needs to be assessed- what’s your nutritional content? We have to get proper blood counts and check your electrolytes and ensure that your vitamin and mineral levels are appropriate. But at the same time, we often have to teach people how to eat properly and healthy again. So, a balance when we talk about macronutrients and we talk about the big 3 food classes of fats, carbohydrates, and proteins. Many people are going to go back to simple sweets and sugars and carbohydrates initially in their plan, we see that. People in early recovery, they’re pursuing sweets. They’re pursuing carbs, and that often lasts up through 6 months. The education goes through letting them know what they need to do, creating balanced diets for them, showing them even how to cook and showing them even how to prepare a healthy meal. It can go so far as that. One thing is getting a baseline assessment. Another thing is educating them about eating healthy, recognizing that difficulty that they’re going to have or they might be having in early recovery pursuing, like I said, carbohydrates and simple sugars. That’s often where our mind and our brain and our body goes in those cravings and urges to kind of replace the substances that are no longer there. And then teach them how to eat balanced, healthy meals. Many people will often have co-occurring medical conditions like diabetes, hypertension, so then the diet has to even evolve further to ensure that proper salt content, proper fat content, sugars or carbohydrates are counted properly in those people that have diabetes. It’s a pretty complex thing, but you start from general nutrition, to more specific tailored needs during the course of recovery. But it often takes many periods of months into years to get mastery of this. And there are many people who don’t have substance use problems but don’t know how to eat correctly, so it becomes a little bit more complex when we’re talking about people who do have an issue with substances.
Hayley: How do you try to help people? How do you ensure that people continue receiving proper nutrition after they leave treatment?
Dr. Bhatt: Well, it goes back to that previous question. You have to build people up. We cannot expect somebody who has been used to shooting Heroin and snorting Cocaine to just go into eating healthy. And so it goes back to, again, getting proper baseline nutritional analysis by doing blood work, doing body composition, but understanding that there is going to be a period there where they’re not going to be well. Training them on basic fundamental principles or just even eating 3 meals a day or whatever meal frequency that they need to meet their nutritional or caloric intake, again, based on underlying general medical conditions. You have to train them and educate them on basic fundamentals first, because- just think about it. Some people are just used to eating that one meal at night. If I’m on a run, it’s not just the fact that the drugs have made me lose my appetite, but then there’s the psychological conditioning of when I’m eating or how I’m eating. There’s not just a physical component; there’s that psychological component there. Fundamentals, training and educating on breakfast, lunch, and dinner, what are the main macronutrients that you need to have, eating a balanced meal, caloric intake being of a certain value that’s proper for them and if they have gained weight or lost weight here they need to go, and having them practice this. Again, not to go back to talking about people who are in inpatient or other types of treatment, but if you’re in a properly structured rehabilitation program this should be part of the components that should be provided by the treatment team that they go along. And if you’re in treatment for a matter of months, well, at least you can get that practice going. If you’re in supportive housing, hopefully you can get connected with a nutritionist that can help you practice and do these things. And, oftentimes, you’ll see in recovery, people are helping one another out. There’s often people that do try and shift gears now into, “Hey I want to undo all of the bad things I’ve done to my body.” And they often compensate by doing healthier, but maybe compulsive behaviors. But if you had to pick which one to do, they would hopefully prefer to actually be focused and compulsive on eating well. You can often hook them up with people that are practicing proper nutritional habits and have them hopefully take that along for the rest of their life.
Hayley: It’s really just about that education- giving them that education.
Dr. Bhatt: Education, practice. Like I said, you don’t have to just tell them that. A lot of people when they go into other levels of care, they’re now living in structured homes and they’re getting to cook on their own. They’re learning to prepare meals. And they’re often doing it together. And if they do it together with people who can be introduced into that group, who know how to eat healthy, that can often be that practice that they need.
Hayley: Because if you grew up and were never taught about nutrition, it can seem a little bit overwhelming.
Dr. Bhatt: And if you’ve been addicted to something which has been your nutrition, your insight into it has been totally thrown out of whack. Your brain’s been hijacked. You’re not looking at food as a nutritional thing. You’re looking at food as some other replacement for some other emotional or physical deficiency. And we want to retrain the relationship between food and your body and your mind, and that takes time. It takes a lot of time.
Hayley: Absolutely. There’s so much information out there. For somebody that doesn’t have all the resources that treatment provides, where can they go to learn about nutrition? Because if you just look it up on the internet, like I said, there is just so much information and a lot of it contradicts itself.
Dr. Bhatt: I don’t mean to put the burden back on primary care, but that’s why we call them primary care. They’re here to deal with your primary situation, and people who do go to get wellness checks and often people who are now first entering early recovery, they’re starting to take care of themselves for the first time in their lives. And that means going to doctors and going to take care of their physical well-being. And those are opportunities to talk to them about, “Hey, how am I doing?” Because a lot of times in our examinations, by the way we look physically, our physical examinations, the way our heart sounds, the way our blood levels are, we can tell, believe it or not, what our nutritional construct is like. But also, our doctor should be prepared to give us advice on how to eat healthy, too. And we have doctors managing our cholesterol and managing our blood sugars. They should be able to provide you with basic education. And I bring this up because I can’t say should a person just go and get a private- that’s not realistic. And like you mentioned, going on the internet, I mean I don’t know how to vet everything that’s available on the world-wide web. But hopefully, as a standard, your doctor can guide you. But then there’s also support groups. And if you start to refine and get involved with people who are there who’s focus might be on nutrition without me advocating there, you can find legitimate people and legitimate support groups that are there to help work and support one another about eating healthy. And so those are some resources I would suggest people look at, which they can find online.
Hayley: Okay, perfect. Dr. Bhatt, is there anything else on this topic that you think people should know?
Dr. Bhatt: Well, definitely, I think that we have to realize that eating healthy is not just a one day thing. It’s a life-long process, and again, it has to start early. As it relates to those who suffer from substance use disorders, I mean it’s definitely not high on their priority, but when they are seeking recovery, they do need to get that support. And if they’re not getting that support as individuals, those who suffer need to ask for that help. If they’re in a treatment center, if they’re in a facility, if they’re entering into any organized therapeutic environment, they need to reach out to whoever’s providing them with treatment and ask to get their nutrition and health assessed. Because it’s super important. And I hope to see that more and more centers or facilities or organizations that do provide treatment for substance use disordered individuals do understand that it’s a comprehensive approach at healing and wellness. It’s a mind and body and spirituality. It’s all involved together, and definitely what we put into our bodies needs to be included in that bio-psychosocial approach and how we treat individuals. Not only the therapeutic environment, but people have to look out for themselves and ask for that guidance.
Hayley: Great, thank you for explaining, Dr. Bhatt. And thank you to our listeners who have tuned into our 30th episode. I’ve learned a lot while working on this podcast, and I hope our listeners have as well. We have episodes available on addictioncenter.com, Apple Podcasts, Spotify, and Google Podcasts, so it’s available free wherever you listen. We’ll see you next time for another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.