A current patient is a 20+ year old male who is trying to recover from a heroin addiction.
Having been on the methadone program for the last 7 months and only having ‘used’ once or twice during this time, he is doing well. He has managed to get down to just 25mg/d of methadone which is typically the final dose before stopping altogether.
He is keen to get off the methadone but also apprehensive about making this transition.
He presents as if he is always sedated or ‘under the influence’ – in spite of seeing him before his daily methadone dose. He has a desire for excessive sleep and struggles with energy and motivation. He reports that initially when stopping the heroin he had marked anhedonia (especially in relation to things that previously gave him pleasure such as surfing) but there is some slow resurfacing over the last few months of an improved capacity for pleasure, laughter and happiness.
With the fabulous ongoing support of his family and some minor non-taxing work – he assures me that he is not experiencing any particular high level stress. Just some apprehension about getting off methadone. I know this to be his genuine belief.
When we organise his baseline pathology testing, it reveals an a.m. cortisol value at the highest end of the range – over 600. This, at first glance, would seem at odds with both his ‘sedated appearance’, his lack of drive, motivation, his flailing energy and his limited stressors but his body is under enormous stress just by virtue of undergoing drug withdrawal and I explain this to the patient.
Drug withdrawal is a significant stressor, stimulating the release of large amounts of cortisol overall and exaggerated cortisol spikes as drug levels in the body decline and the body rapidly tries to adjust to the removal of a substance it has become dependent upon for ‘normal functioning’.
In addition to this, it is well established that arguably the biggest driver behind relapse in drug addiction is ‘stress’. During attempts to recover from addiction we need to minimise cortisol release and excessive cortisol effects as much as possible – this includes not just psychologically perceived stresses but any physical stimulus that evokes a cortisol release such periods of low blood sugar, environmental stressors in the form of excessive noise and temperature extremes etc.
This patient has been a life-long vegetarian and over the last few years has developed a dietary habit of not eating until 5 or 6pm when he is ‘starving’. His bloods reveal, as expected, a relative protein inadequacy (U:C 55), significant acidity (Anion gap 14) and poor magnesium status (Low serum Calcium & Magnesium). These present as obvious first places to begin the nutritional support.