The Role Of Vitamin Therapy In Drug Rehabilitation

September 2008
F o u n d a t i o n
f o r
A d v a n c e m e n t s
i n
S c i e n c e
a n d
E d u c a t i o n
WHITE PAPER
Are we ignoring effective substance
abuse treatment solutions?
The role of vitamin therapy in drug rehabilitation.
Summary
Introduction
This White Paper is based on the findings from an extensive search
which was undertaken over the past several years to answer the
question of whether there was clinical evidence and biologic
rationale for recommending the use of micronutrient therapy as part
of the management of addicted persons undergoing rehabilitation.
This search has led to two papers now in preparation for submission
for publication. The search, which covered over 50 years of published
literature, is briefly summarized in this White Paper.
The latest national survey estimates that 21.6 million Americans
suffer from substance dependence or abuse of drugs, alcohol or both.
Yet treatment remains unavailable to 1 in 5 persons who seek help.1
For those who do obtain substance abuse treatment, only 1 in
4 persons remains abstinent for over a year following treatment
completion. Reversion rates are high, and often those entering
treatment are doing so for the third time, are using multiple
substances, and have other health and social problems.2
Continuously high failure rates have caused some experts to conclude
that addiction is an incurable disease. However, it is also possible that
treatment models in current use are inadequate.
The authors, while noting the lack of large randomized trials in
this area, identified consistent external clinical evidence that
vitamin, mineral and amino acid therapy in drug withdrawal and
rehabilitation can reduce withdrawal symptoms, increase treatment
retention, improve psychological status, contribute to higher
abstinence rates and improve quality of life. Additionally there was
found to be a wide range of evidence for a strong biologic rationale
which would support such outcomes.
Published outcome studies of programs that included micronutrient
therapy reported greater than 50% long-term sobriety rates. Studies
on safety of micronutient therapies indicated that adverse effects
from short-term use of high-dose vitamin, mineral and/or amino acid
therapy were rare, of minor consequence and occurred at doses or
duration of use far greater than those seen in practical use.
Malnutrition among alcoholics has been well documented. AboveRDA doses of specific vitamins are a standard clinical component of
alcohol withdrawal and treatment regimens. Although malnutrition
among abusers of illicit drugs has also been well characterized,
micronutrient therapy for illicit drug withdrawal and treatment has
not been used as widely.
The typical program that included a micronutrient component had
a social-educational focus; some were entirely drug-free. Available
evidence suggests that such therapies have the potential to mitigate
the failure rates often seen in drug rehabilitation; it could be argued
that above-RDA intake of micronutrients is necessary to fully address
the physical consequences of addiction.
Accessible, cost effective, safe and demonstrated by published studies
to improve treatment effectiveness, micronutrient therapy deserves
much more research attention and broader implementation.
2
Ideally, treatment would restore health as well as rehabilitate
the individual. This paper explores one component essential to
fully managing the adverse physical and mental health effects of
substance abuse – micronutient therapy. Accessible, cost effective,
safe and demonstrated by published studies to improve treatment
effectiveness, micronutrient therapy deserves much more research
attention and broader implementation.
Reconsidering recovery goals
True recovery from addiction could be described as abstinence
without cravings and engagement in productive activities. Factors
that improve retention, treatment completion, and increase time
in treatment lead to better outcomes.3 These include factors that
decrease withdrawal symptoms and cravings.4 Where there are unmet
micronutrient requirements, whether determined by individual
differences or from an unhealthy lifestyle, the body will crave that
which it lacks or similar substitutes.
Inclusion of a micronutrient component as part of a comprehensive
approach to drug rehabilitation appears to be beneficial. Over 50
years of published literature provides consistent evidence that
vitamin, mineral and amino acid therapy in drug withdrawal
and rehabilitation can reduce withdrawal symptoms and cravings,
increase treatment retention, improve psychological status,
contribute to higher abstinence rates and improved quality of life.
Each decade since 1970 has included a major national outcome
study of substance abuse treatment in the U.S. In 1995, a large study
was also published in England. Comparing these outcome studies
to treatment results for programs that included a micronutrient
component shows that the latter were consistently better than the
national averages (Figure 1). Appendix 1 summarizes findings of
relevant micronutrient treatment studies. In light of this apparent
outcome benefit, it would be shortsighted to continue to rely solely
on the use of additional or substitute drugs to abate withdrawal
symptoms or manage cravings.
of these building blocks can limit the rate of formation of many life
molecules and can adversely affect health. For example, drug and
alcohol consumption creates demand for niacin used in degrading and
eliminating foreign chemicals. Should niacin levels drop the body will
convert tryptophan to niacin. This leaves insufficient tryptophan to
produce the neurotransmitter serotonin. Low levels of serotonin are
associated with depression, suicide and substance abuse.41-43 Further,
depleted niacin as well as depleted vitamin E increase the “leakiness” of
the intestinal wall and alter absorption.44
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
DARP 1969-73
TOPS 1979-81
SROS* 1989-90
NTIES 1995
NTORS 1995
Smith - 1974
Guenther‡ - Larson† - Beasley 1982
1981-84
1991
1 year abstinence rates except: *SROS gives 5 year outcome, ‡Guenther gives 6 month outcome,
†Larson gives 1-4 year outcome
Figure 1. Long term abstinence rates measured in large national outcome studies
(red) vs. programs with high dose vitamin component (blue).
Joseph D. Beasley MD, while Director of Comprehensive Medical
Care, Amityville, NY, argued that failure to address the nutritional
biochemistry and metabolic realities of the addicted individual was
an inadequate standard of practice.5 This viewpoint is shared by
the American Dietetic Association in their position statement that
improved nutritional status can make treatment more effective while
reducing drug and alcohol craving, thereby preventing relapse.6
High doses of nutrients are needed to reverse depletion
and provide therapeutic value
Recommended daily allowances (RDAs) are amounts set by
committee to meet the needs of most healthy people. There are
circumstances where above-RDA intakes may be needed. In addiction
therapy the need is based on several concepts:
a) To address deficiencies from poor diet, impaired absorption,
increased excretion, caused by drug use;
b) To repair altered neurotransmitter function caused by drug use;
c) To supply increased requirements needed to metabolize and
eliminate drugs as a chronic toxic exposure;
d) To address unmet individually determined requirements.
The lifestyle of addiction includes notorious neglect of diet including
a tendency to consume foods high in sugars and low in proteins,
vitamins and iron.7;8. Chronic alcohol and other drug consumption
impair absorption, metabolism and storage of many micronutrients,
particularly water-soluble vitamins and minerals.7;9-19 Numerous
papers describe the profound effects of alcohol and illicit drugs on
nutritional status, whether due to displaced nutrients or increased
demand by metabolic processes.20-40
Vitamins, minerals, amino acids, and essential fatty acids are constantly
required to maintain body tissues and health, are interdependent,
and cannot be properly understood in isolation. Lowering just one
Breakdown and removal of foreign chemicals depletes
certain nutrients
Substance abuse is also a form of chronic chemical exposure that
places additional demands on the body’s detoxification systems.
Vitamins and minerals, particularly the antioxidants including vitamin
C and vitamin E and niacin are expended in an effort to detoxify
foreign chemicals.27;46;47 Alcohol and other drugs including cocaine,
phenobarbital, anesthetics, and solvents such as inhalants increase the
generation of reactive free radicals45, further increasing oxidative stress.
Further, ethanol impairs the conversion of beta-carotene to vitamin A
and depletes vitamin A levels in the liver.48
Drugs such as morphine, oxycodone, methadone, amitryptiline,
benzoylecgonine49, cocaine50-52, marijuana53-55 diazepam56, LSD57,
PCP58;59 and their metabolites are among the many foreign chemicals
that have been identified in fat analysis and other tissues and add
to an individual’s total contaminant body burden. During periods
of fasting, exercise, and stress fat is burned and stored toxins may
be released back into the blood stream. Particularly where there
is inadequate micronutrient support for detoxification pathways,
this toxin mobilization can result in non-specific symptoms such as
fatigue, headaches, pain, poor memory or depression, commonly
cited reasons a person seeks relief by using drugs.60
Drugs alter normal levels of chemicals involved in the
sensations of pleasure
All drugs of abuse, including alcohol, activate a region of the brain
referred to as the “reward pathway.” How drugs accomplish this varies:
They may masquerade as natural neurotransmitters – directly causing
an effect; they may block chemicals that would normally limit “reward
pathway” activity – increasing the effect; they may enhance chemicals
that in turn increase release of “pleasure” neurotransmitters – greatly
increasing activity; or block chemicals that normally remove these
neurotransmitters from their site of activity – prolonging their effect.
The complexity of the “reward pathway” is one reason why substitute
drugs have failed more often than not to offer a solution.
Addictive drugs are thought to exert their effects by influencing
dopamine directly or altering other neurotransmitters that modulate
dopamine levels such as GABA (gamma-aminobutyric acid – a
neurotransmitter whose deficiency is linked to anxiety, irritability,
insomnia and depression), endogenous opioids, serotonin,
3
acetylcholine and noradrenalin.61;62 The resulting unnaturally high
levels of the neurotransmitter dopamine then modulates other
neurotransmitters.63 While the person is feeling “pleasure”, normal
brain chemistry is being disturbed in long-lasting ways. Continued
use of the drug ultimately depletes the neurotransmitters, while the
cells on the receiving end reduce their numbers of active receptors.
Recovery from addiction must include a model which provides
for adequate supplies of amino acid neurotransmitter precursors,
vitamins and minerals found to be essential to restoration of a healthy
“reward pathway”.64;65
Table 2
Number of Deaths From Various Causes
in the U.S. in 200279
Cardiovascular Disease
927,448
Cancer
539,628
Tobacco
175,483
Poor Diet & Physical Inactivity
170,323
Properly Prescribed & Used Drugs75
126,426
Alcohol
109,587
Microbial Agents
75,000
Toxic Agents
55,000
Avoidable Medical Misadventure
40,000
Suicide
30,622
Incidents Involving Firearms
29,000
Motor Vehicle Crashes
26,347
Homicide
20,308
Sexual Behaviors
20,000
Illicit Use of Drugs
17,000
Some gene variations correlate with increased risk of addictive,
impulsive and compulsive behaviors70;71 and craving72.
Anti-Inflammatory Drugs (including Aspirin)
7,600
Adverse Reaction to Dietary Supplements*
5
Researchers have argued that if gene alterations such as these
predispose to substance abuse and other antisocial behaviors, then
corrective nutrition may be the best prevention.73
*Dietary supplements have averaged less than 5 confirmed deaths per year
over the past 25 years in the USA. Most of those relate to a single batch of
contaminated tryptophan introduced in the late 1980’s. (Source, CDC/FDA)
What is “normal” metabolism anyway?
Today’s understanding of the human genome helps to explain why
certain individually-determined nutrient requirements, if left unmet,
could predispose a person to addiction. It may also partially explain
the increases in long-term sobriety rates when these nutritional needs
are met. There are at least 50 diseases caused by genetic variations
that lead to known metabolic inefficiencies that can be remedied
by feeding high dose B vitamins, raising levels of the corresponding
coenzyme..46 Genetic variability of certain genes associated with
cancer66-69, is another example in which disease may be addressed
through high-dose supplementation.
A long-established therapy
Over half a century of research has provided a strong biologic
rationale for nutrient inclusion in substance abuse treatment.
Appendix 2 provides a summary of micronutrients that have
commonly been used in treatment programs, and brief descriptions
of relevant biologic roles and benefits.
Safety of high dose nutrient combinations
Safety studies indicate that adverse effects from short-term use of
high dose vitamin, mineral and/or amino acid combinations, such as
are used during withdrawal or rehabilitation, are negligible. (Table
2). With the exception of vitamin A, it is most likely that rarely
reported adverse events associated with high doses of a single vitamin
were actually caused by other unidentified nutrient imbalances;
therefore useful therapies should include well-balanced regimens of
key vitamins, minerals and amino acids with relevant biologic roles.
4
Successful treatment programs include a nutrient component
A number of well-respected treatment programs – some of
which have been entirely drug free – have included high doses
of micronutrients with results exceeding the typical long term
abstinence rates (Appendix 1). Abstinence and quality of life
measures were most enhanced when providing nutrient support
in combination with psychosocial/educational treatment models.
The largest and most established groups to systematically include
nutrient based interventions over the past few decades have been
the Narconon™ drug rehabilitation program, the protocols of Joseph
Beasley MD, Joan Matthews Larson, Ph.D., Julia Ross, M.A., and Ken
Blum, Ph.D./Howard Trachtenberg, Ph.D.
Since 1971, the Narconon™ drug rehabilitation program has utilized
high doses of vitamins and minerals in its withdrawal regimen to
assist in reducing depression76, physical symptoms and cravings77.
In a later step, vitamins, minerals and essential fatty acids are used
adjunctive to a sauna regimen78 aimed at enhancing the mobilization
and excretion of stored drugs and other toxins. Withdrawal has
been reported to be accomplished with minimal discomfort and
no adverse events attributable to micronutrient supplements. Based
on a social-educational model developed from the works of L. Ron
Hubbard, the Narconon program is presently delivered at over 100
centers in 37 countries. Over the past three decades, Narconon has
completed treatment of more than 10,000 individuals addicted to
heroin, amphetamines, barbiturates, alcohol, cocaine and other drugs.
The Health Recovery Center in Minneapolis has been utilizing a
nutrient repair protocol developed by Joan Mathews Larson, Ph.D. to
resolve cravings and restore alcoholic individuals to good health. In
conjunction with counseling services, an individualized supplement
program based on laboratory testing has been provided to address
underlying biochemical abnormalities, including hypoglycemia.
Several thousand individuals have now completed this program. A
study published in 1987 reported a success rate of 74 percent or more
in alcoholics.79
treatment outcomes in a variety of treatment settings compared with
those utilizing conventional pharmacologic approaches.
The available observational, experimental and biologic data
supporting the use of high dose vitamin/mineral therapy as a
beneficial component of substance abuse treatment, the long history
of such use without significant adverse effects, and the low cost,
argue for wider use of such therapies, as well as increased research
regarding their place in the substance abuse treatment field. In
view of the considerable financial burden that untreated addiction
places on the healthcare system, and its often-devastating social and
personal consequences, this work should be a public health priority.
Acknowledgements
Kathleen Kerr MD, FASE Senior Research Associate, and Marie
Cecchini MS, are the authors of this white paper. Carl Smith, FASE
Senior Editor, is acknowledged for his review and editing.
The use of amino acid supplementation is another approach to
biochemical restoration. In 1988 Julia Ross, M.A., founded Recovery
Systems in Mill Valley, CA, an outpatient alcohol and other drug
rehabilitation clinic that has been incorporating amino acids and
nutrient therapy with conventional counseling and education and has
reported an 85 percent recovery rate.80
The neuronutrient research of Ken Blum, Ph.D., and Howard
Trachtenberg, Ph.D. has been applied to alcohol, cocaine and
opiate addiction. Preliminary withdrawal and treatment studies of
specific amino acid, vitamin and mineral combinations (SAAVE™ for
treatment of alcoholism and Tropamine™ for opiates and cocaine)
showed improved outcomes.64;81
Conclusions: Nutritional approaches reduce withdrawal symptoms,
enhance program retention, and improve long term outcomes
Despite the modern prevalence of pharmaceutical approaches
to withdrawal, drug therapy has unwanted, adverse effects and is
not effective in all types of drug withdrawal; cocaine addiction,
for example, lacks an effective drug treatment.82 However, there is
consistent evidence that withdrawal protocols incorporating a range
of micronutrients provide safe and beneficial interventions.
Basic multivitamins are recommended in the recovery phase of many
addiction treatment programs. The literature includes numerous case
reports and pilot studies, alongside a group of cohort and controlled
studies, suggesting that high dose micronutrient intervention can
improve rehabilitation outcomes such as drug reversion, craving
and quality of life measures. Longer-term use of micronutrient
supplements by recovering addicts is likely to also be important,
and may help to prevent reversion. This is a particularly important
area to explore to gain information that could lead to cost-effective,
improved treatment outcomes. Additional studies are warranted
to measure the specific effect size of micronutrient support on
5
APPENDIX 1. RESULTS OF NUTRIENT THERAPY IN SUBSTANCE ABUSE TREATMENT
Reference
Population studied
Substance
Nutrient intervention
Outcome
Smith, 1974
5 year study of 507 males, 239
with organic brain syndrome
Alcohol
nicotinic acid (niacin), high
(“massive”) doses amount not
specified
Multiple symptom improveMethodological problems but
ment
impressive results especially in
reduced drinking
more severe group.
reduced recidivism
over 50% of organic alcoholics
showed improvement
Scher, 197684
3 year study of 615 of narcotic
withdrawal and methadone
maintained patients
Narcotics
Vitamin C 5000 mg per day
or more
Vitamin E and
Multiple vitamin and
Minerals 3-4x/day.
60-70% relief of withdrawal
symptoms. Improvement in
mood, sleep and constipation
in methadone maintained
patients given high dose
vitamins.
Libby, 1977[Libby 1977
30 addicts in medical setting
Narcotics
Free, 197985
227 addicts during 21 day
withdrawal
Narcotics
Vitamin C 24 gm/day or more,
tapering to 8-12 gm/day
Multivitamins, calcium, magnesium, liquid protein. Dose
varied with symptoms.
Vitamin treatment: Alleviation Controlled, non randomized,
of withdrawal symptoms in
study.
4-6 days and increased energy.
Case reports that vitamin C
blocked effects if subjects
reused narcotics.
Medication:
Withdrawal symptoms reduced
somewhat after 17 days of
treatment.
Guenther, 198386
105 males VA Medical Center
enrolled in 12-step, hospitalbased program
Alcohol
High dose multivitamins and
minerals
Restricted dietary sugar
Nutrition education
Sobriety 6 months post dischar- Controlled, non randomized,
ge 81.3% nutrition group vs.
field trial.
37.8% control.
No medications given.
Mathews-Larson, 198779
100 clients in 6 wk withdrawal
and outpatient treatment
program
Alcohol
Vitamin C 25 grams/day
Individualized nutrient corrections – see Table 1
Eliminated dietary sugar
Allergy correction
At 6 wks: 89% anxiety free,
94% without sleep problems,
95% depression free.
81% were abstinent at 12 - 42
month follow-up.
Descriptive cohort study with
long (42 mo) follow-up. A
model of highest standard
of care.
Blum 198881
62 alcoholics and polydrug
abusers
Multiple illicit drugs and
Alcohol
SAAVE™ (see Table 1)
Double-blind, placebo-controlled, randomized study.
Replogle, 198987
63 clients in 30 day residential
program based on 12-step
model
Alcohol
Vitamin C 3 grams/day
Niacin 3 grams/day
Vitamin B6 590 mg/day
Vitamin E 590 IU/day
Significant reduction in withdrawal symptoms, significantly
improved physical, behavioral
and emotional scores. Patients
able to more quickly focus
on behavioral component of
treatment.
Vitamin group showed significant reductions in anxiety
before 21 days of nutrient
compared with controls
Brown 199065
60 clients
Cocaine or Alcohol
Tropamine™ or SAAVE™ (see
Table 1)
Controlled, randomized trial
Beasley 199125
111 clients in social-educational residential program
Alcohol
See Table 1
Evangelou, 200088
40 patients in a medical setting Heroin
Vitamin C 20 grams/day
Vitamin E 330 mg/day
Ambrose 200144
107 patients in detoxification
Vitamin B1 (thiamine) at
varying doses during withdrawal
73 % of alcoholics and 53% of
cocaine abusers abstinent at 10
month follow-up
60.4 percent abstinent after 12
months, most were also free
from extensive physical pathology that had been measured
at enrollment
Major withdrawal symptoms in
16 percent of vitamin groups
vs 56 percent of diazepam +
analgesic group
Memory improvement increased with increasing doses of
thiamine
83
Alcohol
Comments
Authors were from the National Council on Drug Abuse and
the Methadone Maintenance
Institute, Chicago. Used blinded placebo controls early on
but dropped this due to clear
benefit in Vitamin C groups.
Vitamin C 25 gm/day (or more No withdrawal symptoms
Open clinical trial
with heavy prior narcotic dose) within 4-6 days, rapid improve- 100% success reported in
Multivitamins, minerals &
ment in well being.
alleviation of withdrawal
liquid amino acids
symptoms.
Controlled, randomized trial.
No medication allowed.
Longitudinal trial, some medication to address withdrawal
symptoms
Blinded, controlled trial. 3
groups, vitamins only, vitamins + medication, medication only.
Randomized, double-blind,
multi-dose study
7
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