KolarzykProbl Hig E Epidemiol i wsp. Zinc, 2010, copper 91(2): and 243-247 magnesium intake in a daily diet in -addicted persons before and after ... 243

Zinc, copper and magnesium intake in a daily diet in opiate‑addicted persons before and after 5 years of treatment

Podaż cynku, miedzi i magnezu w diecie osób uzależnionych od opiatów przed rozpoczęciem oraz po 5 latach trwania leczenia substytucyjnego metadonem

Emilia Kolarzyk 1/, Agnieszka Szpanowska-Wohn 1/, Jan Chrostek-Maj 2/

1/ Department of Hygiene and Ecology, Jagiellonian University, Medical College, Krakow 2/ Rydygier Hospital, Center for Dependency Treatment, Krakow

Cel pracy. Oszacowanie podaży cynku, miedzi i magnezu w diecie osób Aim. Estimation of zinc, copper and magnesium intake in the diet of opiate- uzależnionych od opiatów przed rozpoczęciem oraz po 5 latach trwania addicted persons before and after 5 years of methadone maintenance leczenia substytucyjnego metadonem. treatment. Materiał i metoda. Badaniami objęto 35 uzależnionych osób (12 kobiet Material & method. Thirty five opiate-addicted persons were included in i 35 mężczyzn). Sposób żywienia, z uwzględnieniem podaży cynku, miedzi the examination (12 women and 23 men). The nutritional model including i magnezu, był oceniany metodą 24-godzinnego wywiadu. Uzyskane zinc, copper and magnesium intake estimation was analysed on the basis wyniki były odnoszone do norm żywieniowych na bezpiecznym poziomie of a 24-hour nutritional recall. The received values were compared with spożycia. the daily norms of the safe intake level. Wyniki. W badaniu wyjściowym średnia podaż wszystkich ocenianych Results. In the initial examination the mean intake of all analyzed mikroelementów była niższa niż rekomendowana, zarówno w grupie microelements in a daily diet was lower than the recommended both in mężczyzn (59,0-71,5%) jak i w grupie kobiet (43,0-782%). Po 5 latach men (59.0-71.5%) and in women (43.0-78.2%) groups. After 5 years of leczenia substytucyjnego metadonem magnez i cynk był spożywany methadone maintenance treatment in the group of examined women, w zalecanych ilościach przez kobiety, natomiast w grupie mężczyzn spożycie magnesium and zinc were consumed according to the recommended magnezu, cynku i miedzi nie uległo istotnej zmianie i wciąż było niższe values. In the men’s group the magnesium, zinc and copper consumption niż zalecany poziom. did not change and was still lower than the safe consumption level. Wnioski. Badania wykazały nieprawidłowe zachowania żywieniowe osób Conclusions. The quoted results of our examination showed incorrect uzależnionych i były podstawą do podjęcia wysiłków w celu zmotywowania nutritional behaviors and were the reason to motivate addicted patients to badanych do przestrzegania zaleceń żywieniowych, obejmujących respect recommendations concerning the microelements consumption. The również podaż mikroelementów. Powyższe badania były tylko jednym research was one of the elements of multidimensional care over addicted z elementów wielokierunkowej opieki mającej na celu pomóc osobom persons, aimed to help addicted people in recovering and improving their uzależnionym w powrocie do zdrowia, w aspekcie zarówno fizycznym jak physical and mental health. i psychicznym. Key words: magnesium, zinc, copper, 24-hour nutritional recall, opiate Słowa kluczowe: cynk, miedź, magnez, 24-godzinny wywiad żywieniowy, dependence, methadone program. uzależnienie od opiatów, program metadonowy

© Probl Hig Epidemiol 2010, 91(2): 243-247 Adres do korespondencji / Address for correspondence Prof. dr hab. Emilia Kolarzyk www.phie.pl Department of Hygiene and Ecology, Jagiellonian University, Medical Nadesłano: 10.03.2009 College, Krakow, 7 Kopernik Street, Krakow, Zakwalifikowano do druku: 17.05.2010 tel./fax +48-12-422-37-20, e-mail: [email protected]

Introduction drug-addicts are the persons from the risk groups of AIDS and sexually transmitted diseases. The The opiate addiction is a severe, chronic disease treatment of addicted persons is very difficult because of central nervous system and addicted persons the drug addiction is connected with neurobiological are the group of patients who may develop, more mechanisms and depends on some psychological, frequently than others, such diseases as: dermatitis, social and economic factors [1,2]. phlebitis (followed by clots in venal system), hepatitis, pancreatitis, osteitis, and in some cases sepsis. The Presently, an important way of help for opiate- (-, -) addicted persons are 244 Probl Hig Epidemiol 2010, 91(2): 243-247 substitutional programs. The most helpful drug The nutritional model of addicted persons was used in long-term treatment of opiate-addiction is assessed by the specialists from the Department of methadone [3,4]. Hygiene and Ecology, Medical College of Jagiellonian Methadone is a synthetic agonist of opioid University, Krakow, on the basis of a 24-hour receptors. It may be administered orally and it is active nutritional recall. The nutritional recall was performed in organisms for 24 hours. Since January 2000 the twice: just before the treatment was started (the initial methadone therapy for opiate-addicted persons has examination – Exam 1) and after 5 years of methadone started in Krakow. Interprofessional collaboration maintenance treatment (the final examination between different specialists is realized – the patients – Exam 2). The nutritional recall was performed during are given the complex psychological, psychiatric and 3 non-consecutive days for every person both in the medical care [5]. A lot of attention is being paid to initial and in the final examination. The “Album of their consumption pattern, their nutritional status products and meal portions” was used in the recall. and dietetic recommendations. It is very important for The obtained quantitative nutritional analyses were addicted persons because a well-balanced diet in the processed with the use of specialized nutrition software aspect of main nutritional products (carbohydrates, calculating nutritional values of a daily diet. proteins and fats) and a proper intake of vitamins and In the present study the analysis concerned the microelements may effectively support the medical main nutritional components (proteins, fats and treatment [6,7]. carbohydrates) and such microelements as: zinc, The research data show that such microelements copper and magnesium. The received data were set as zinc, copper and magnesium play a role in the against the consumption standards for the Polish normalization of physiological and biochemical population on the safe intake level (N) [13]. The functions that had changed because of used drugs normal range was established at ±10% of the safe level [2]. Currently some investigators have been reporting (N±10%). a change in serum trace element contents in drug- The statistical significance of differences between addicted individuals and the different levels of the results obtained in particular examinations were these elements in the blood of addicted persons in calculated by the Mann-Whitney U test. comparison with healthy people were shown [8,9,10]. All subjects gave informed consent prior to their Nevertheless the estimation of the intake of zinc, recruitment in the study. The Ethics Committee for copper and magnesium in the diet of addicted persons Human Research of Jagiellonian University, Medical treated for a long time with methadone has not yet College approved the study. been performed. Results Aim The length of the period of opiate addiction, Estimation of the intake of zinc, copper and age, gender, body mass, body height and BMI values magnesium in the diet of opiate-addicted persons for all examined men and women were presented in before and after 5 years of methadone maintenance particular examinations in Tab. I. treatment. Table I. General and anthropometric characteristics of drug-addicted women and men in the initial (1) and final (2) examinations Materials and Methods Women (N=12) Men (N=23) The studied group included 35 persons (12 Variable X SD Min Max X SD Min Max women and 23 men) treated with methadone Duration of opiate- 8.8 3.5 5.0 15.0 12.0 5.8 6.0 28.0 continuously for at least 5 years. All of them used the addiction [exam.1] so-called „” (literally this Polish word could (years) be translated as English “compote”– stewed fruits), Age at the initial 27.4* 5.8 21.0 37.0 30.4* 5.1 25.0 45.0 “Polish heroin” (heroin, morphine, in small exam [years] amounts, and some amount of 6-monoacetylmo, Age at the final 33.2 5.9 25.0 40.0 36.3 6.2 30.0 49.0 morphine) [11] parenterally, and some of them also exam [years] used amphetamine, THS, LSD or benzodiazepines Height [cm] 168.7 6.1 160.0 177.0 177.8 6.2 163.0 190.0 orally. An individual oral methadone dose adequate Body weight 1[kg] 57.7 4.9 54.0 66.0 73.7* 16.9 51.0 136.0 for blocking the drug craving and hunger was Body weight 2 [kg] 56.0 9.1 50.0 76.0 82.5 25.0 60.0 145.0 established for each patient. An adequate effective BMI 1 [ kg/m2 ] 20.3 1.5 17.6 22.6 23.3* 5.3 17.1 44.9 dose of methadone was administrated daily and serum BMI 2 [ kg/m2 ] 19.8 2.7 17.2 25.4 25.9 7.9 19.0 55.1 methadone concentration was monitored. Urine X – arithmetic mean SD – standard deviation samples were taken regularly to control the patients’ * p – 1:2 < 0.05 abstinence from opiates [12]. Kolarzyk E i wsp. Zinc, copper and magnesium intake in a daily diet in opiate-addicted persons before and after ... 245

Statistically significant elevation in body In the initial examination it was found that weight and BMI values of males were noted in average intake of all 3 analyzed minerals in DNR the final examination in comparison to the initial was lower than the recommended intake on the safe examination. level: 59.0% – Cu, 69.1% – Zn, 71.5% – Mg in men Figure 1 shows the basic nutritional components group and 43.0 – Cu, 76.2% – Zn, 74.2% – Mg in the intake in the diet of examined persons expressed as the women’s group (Fig. 2) . percentage participation of these components in the energy intake in a daily nutritional ratio (DNR). Copper Zinc Magnesium 110 100% Safe level (±10%) 90% 90 35,16 36,58 80% 45 70% % 60% 20,13 16,48 50% 10 40% 30% 30 28,31 31,54 20% Men Women Men Women Men Women 10% 15 13,90 14,51 0% Exam. I Exam. II Norm Exam. I Exam. II

% E from polysaccharides Fig. 2. The daily intake of copper, zinc and magnesium in relation to % E from mono- and disaccharides normal range (±10% of the safe level) % E from fat % E from proteins

Fig. 1. The contribution of different nutrients in the energy intake in After 5 years of the substitution treatment with comparison to recommendations methadone a statistically insignificant increase of zinc and copper and a statistically significant increase of The daily diet of an adult is considered adequate magnesium intake was found in the examined women when proteins provide 10-15% of whole energy intake, (Table II). Despite of that increase, the level of copper fats – maximum 30%, carbohydrates about 55-60%, intake was still below the lower limit of the safety level but monosaccharides no more than 10% of energy. In (62.5 %) but zinc and magnesium were consumed on the diet of examined persons, these proportions were a little higher level than the upper safe level (N+10%) distorted. The contribution of proteins in the energy amounts (111.0% and 112.9%) (Fig. 2). intake was too low, mainly in the initial examination In the men’s group the increase of intake (13.5%) of the daily intake of energy, whereas in the (insignificant) was observed for magnesium. The final examination fats provided slightly more energy. zinc intake was the same and the copper intake was Monosaccharide provided much more than the slightly lower (Table II). The consumption of all 3 recommended ratio – 20.1% in the initial examination elements was lower than the safety level. The norm and 16.5% in the final examination. Fats provided realization was 53.5% (copper), 67.8% (zinc) and slightly more energy than the recommended 30% of 78.9% (magnesium) (Fig. 2). energy expenditure in the final examination.

Table II. Statistical characteristics of the mineral content in a daily diet in women and men in the initial (exam. 1) and final examinations (exam. 2)

Women (N=12) Men (N=23) Minerals X SD Med Min Max p X SD Med Min Max p Copper 1 [mg] 0.9 0.4 0.9 0.3 1.4 ns 1.2 0.7 1.3 0.0 3.1 ns Copper 2 1.3 0.9 1.4 0.2 3.0 1.1 0.6 1.2 0.2 3.0 Zinc 1 [mg] 7.9 3.1 8.3 4.1 12.3 ns 9.5 4.9 8.9 0.0 22.1 ns Zinc 2 11.1 6.4 11.3 2.0 20.8 9.5 4.1 9.4 2.9 19.6 Magnesium 1 [mg] 207.8 63.8 199.1 103.2 310.6 0.05 250.5 85.0 244.2 47.0 317.8 ns Magnesium 2 316.0 89.5 328.5 183.9 349.1 276.3 75.8 257.4 84.0 367.3 X – arithmetic mean SD – standard deviation Med – median P – 1:2 (U-test ) ns – not statistically significant 246 Probl Hig Epidemiol 2010, 91(2): 243-247

Discussion process the zinc concentration increased a little, the copper concentration was lower and the magnesium The change of the diet during the 5-year period of concentration remained at the same level. The methadone maintenance treatment may be influenced detoxification process lasted from 3 to 20 days by many factors: socio-economical factors, health (15,16). It was also shown that the maintenance of status, change of food preferences, natural senescence the correct magnesium blood level in heroin-addicted and many others. As mentioned in the introduction, persons may be connected with the releasing of this the data concerning the control of carbohydrates, mineral from tissues [14]. proteins, fats, vitamin and mineral intake in the diet in the aspect of the long-lasting methadone treatment The data concerning blood concentrations of the were not found. above-mentioned elements during the methadone treatment of 5 years and longer were not found in the As far as microelements such as zinc, copper and literature. magnesium, the results of this study indicate that before the methadone treatment the mean intake of The changes of minerals eaten by addicted all 3 analyzed elements in a daily nutritional ratio was persons during the methadone treatment do not have lower than the recommended safe level both in men to parallel with the changes of their concentration and in women. After 5 years of methadone therapy in blood (abnormal expenditure/requirement in the group of examined women the consumption for nutrients and energy, malabsorption, limited of magnesium and zinc was even higher than the absorption surface) but clinical observations indicate recommended values, however in the men’s group, that it is necessary to deliver individual dietetic care to the magnesium, zinc and copper consumption still addicted persons. It has been documented that use of was lower than the safe consumption level. drugs (heroin, phensedyl, cannabis) induces multiple nutrient deficiencies or malnutrition, which is the The zinc, copper and magnesium shortages most common cause of immunodeficiency. [17]. The in a daily diet before the methadone treatment use of these drugs undermines appetite and affects (duration of opiate-addiction: 8.8+3.5 years) were dietary habits [18] making those who are drug- not corresponding with the described by other authors dependent crave empty-calorie nutrient-deficient concentrations of these elements in blood or urine of foods [20]. This may cause micronutrient deficiencies opiate-addicted persons [9], and showed an increased (zinc, copper and magnesium), which may lead to blood concentration of copper and a decreased level immunosuppressive complications and other problems of zinc in heroin-addicted persons in comparison in general health status of addicted persons. to healthy people. The examinations conducted by Iyengar at al. [8] showed an increased excretion of zinc Zinc determines to some degree the mental and copper with urine in comparison to the control condition and is also very important for the immunity group, however this excretion was still within normal level. Big shortages of this mineral worsen the values. functions of basic cells of the immunological system. The zinc shortage influences lymphopoesis – it lowers Previous research conducted in Poland did not the lymphocyte number [9]. Its metalloenzymes give unequivocal results in the range of the selected are involved in cognitive functioning, reproductive elements concentrations in serum of drug-addicts maturation and physiological growth [19]. [14], observed higher mean concentrations of magnesium in the addicted group [14], showed that Copper can impact the nervous system enzymes – using opioids for a long time may be connected with such as dopamine beta-hydroxylase, monoaminoxidase the decrease of magnesium concentration in blood or galactotransferase – as well as tyrosinase, the serum and that the interrelations between magnesium enzyme taking part in the melatonin synthesis. concentration in blood serum, HIV infection and Similarly to zinc, copper has a key function in a free methadone treatment were not found. radical inactivation [21]. The examinations conducted in The Clinic Magnesium plays an important role not only in of Toxicology, Jagiellonian University Collegium metabolic changes of proteins and fatty acids but also Medicum in Krakow, Poland [15,16] showed that in the proper functioning of nervous, muscular and before starting the treatment in the Detoxification circulatory systems [10]. Department the average concentration of zinc in the Deficiency of any of the above-mentioned blood of addicted people was lower, of copper – higher, elements badly affects normal functions of the human and of magnesium – similar to concentrations of these body [22,23]. elements in the control group. After the detoxification Kolarzyk E i wsp. Zinc, copper and magnesium intake in a daily diet in opiate-addicted persons before and after ... 247

Conclusions 3. In magnesium, the pattern of changes connected 1. The copper intake was much below the norm (safe with gender and methadone treatment was the level – 10%) both in addicted men and addicted same as for zinc. women, though in the women after 5 years of 4. The examination results showed incorrect nutri- methadone treatment the increase of this element tional behaviors and were the reason to motivate intake was clearly seen. addicted patients to respect recommendations 2. The zinc consumption was lower than the norm concerning the microelements consumption. The (safe level – 10%) before and after treatment, examinations were one of the elements of multi- whereas in women after 5 years of methadone dimensional care over addicted persons, aiming treatment the intake of this element was a little to help addicted people in recovery. higher than the safe level +10%.

Piśmiennictwo / References

1. Szpanowska-Wohn A, Kolarzyk E, Pach D. General health 13. Ziemlański S. Norms in human nutrition, physiological basis. condition of opiate dependent persons before and during PZWL, Warszawa 2001. methadone maintenance treatment. Pol J Environ Stud 2004, 14. Pasternak K, Florianczyk B, Chmielewska M, Marzec Z. 13, Supl II: 556-561. Magnesium concentration in serum of drug addicts (in 2. Vetulani J. Drug addiction. Part III. Pharmacotherapy of Polish). Biul Magnezol 1997, 2 (3): 178-181. addiction. Pol J Pharmacol 2001, 53: 415‑434. 15. Sadlik J, Pach J, Winnik L, Piekoszewski W. Concentration 3. Habrat B, Chmielewska K, Baran-Furga H, et al. Subjective of zinc, copper and magnesium in the serum of drug addicts quality of life in opiate dependent patients before admission, (in Polish). Med Rev 2000, 57: 563-574. after six months and one year participation in methadone 16. Piekoszewski W, Pach J, Sadlik K, Winnik L. Changes in program (in Polish). Med Rev 2002, 9: 351-354. serum copper during detoxification of acutely poisoned drug 4. Vetulani, J. Psychoactive substances in the past and presence. addicts. Biological Trace Element Research 2000, 78: 1-6. Pol J Pharmacol 2001, 53: 201-214. 17. Varela P, Marcos A, Santacruz I, Ripoll S, Requejo AM. 5. Kamenczak A, Chrostek-Maj J, Kroch S, et al. The initial Human immunodeficiency virus infection and nutritional evaluation of methadone programme in Krakow. Med Rev status in female drug addicts undergoing detoxification: 2000, 57: 525-530. anthropometric and immunologic assessments. Am 6. Szpanowska-Wohn A, Dłużniewska K, Groszek B. Nutritional J ClinNutr 1997, 66: 504S–508. problems of persons classified to the methadone maintenance 18. Mohs ME, Watson RR, Leonard-Green T. Nutritional effects treatment (in Polish). Med Rev 2000, 57: 544-548. of marijuana, heroin, cocaine and nicotine. J Am Dietetic Ass 7. Kolarzyk E, Pach D, Szpanowska-Wohn A, Jenner B. Changes 1990, 90: 1261-1267. in the diet of patients during 5 years of methadone treatment. 19. Shankar AH, Prasad AS. Zinc and immune function: the Pol J Environ Stud 2007, 16(6D): 425‑429. biological basis of altered resistance to infection. Am J Clin 8. Iyengar V, Chou PP, Constantino A. et al. Excessive urinary Nutr 1998, 68: 447S-463. excretion of zinc in drug addicts a preliminary study during 20. Himmelgreen DA, Perez-Escamilla R, Segura-Millan S et methadone detoxification. J Trace Elements Electrolytes al. Comparison of the nutritional status and food security Health Dis 1994 , 8: 213-215. of drug-using and non-drug-using Hispanic women in 9. Elnimir T, Hashem A, Assar R. Heroin dependence effects Hartford, Connecticut. Am J Physical Anthropol 1998, 107: on some major and trace elements. Biol Trace Element Res 351-361. 1996, 54: 153-155. 21. Uauy R, Olivares M, Gonzalez M. Essentiality of copper in 10. Karakiewicz B, Kozielec T, Brodowski J, et al. Serum humans. Am J Clin Nutr 1998, 67: 952S‑59. magnesium concentration in drug-addicted patients. 22. Kazi JH, Mustafa K, Monira A. Serum antioxidant Magnesium Research; Official Organ oh the International micromineral (Cu, Zn, Fe) status of drug dependent subjects: Society for the Development of Research of Magnesium Influence of illicit drugs and lifestyle. Substance Abuse 2007, 20: 53- 57. Treatment Prevention and Policy 2007, 2: 12-23. 11. Kała M, Lechowicz W, Stanaszek R. Kompot – the Polish 23. Diaz-Flores JF, Safudo RI, Rodriguez EM, Romero CD. Serum source of . Problems of Forensic Science 1998, concentration of macro and trace elements in heroin addicts 37: 45-47. of the Canary Islands. J Trace Elements Med Biol 2004, 17: 12. Pach J, Kamenczak A, Chrostek-Maj J et al. Heath status 4, 235-242. evaluation of opiate dependent patients after one year of methadone maintenance treatment program in Krakow. Med Rev 2001, 58: 240-244.