If a service provider, you are likely used to seeing people present wired, worn out, and running on empty. While the drugs they’re using might be your immediate concern, also of importance is what’s going on under the surface – nutritional deficiencies that are often overlooked but deeply intertwined with health and drug use. This can be a particular concern for people who use stimulants such as crack cocaine.
Right now, there are limited interventions tailored for people who use stimulants, and that’s a problem. Stimulant use is common, but support around basic needs like safe paraphernalia, drug use advice, and pharmacological interventions has not caught up or is limited by legislation. One overlooked challenge that can be addressed in the current context, however, is poor nutrition – something that’s often rooted in a perfect storm of social marginalisation, limited financial resources, and the appetite-suppressing effects of the drugs themselves.
ESSENTIAL NUTRIENTS
And this isn’t just about being a bit peckish. Nutritional deficiency is a serious issue that can worsen both physical and mental health. Broadly, there are two main nutritional issues – eating poorly and therefore lacking essential vitamins and minerals, or having limited calorific intake, which compounded by a lack of essential nutrients can lead to malnutrition. Malnutrition can damage vital organs, and people suffering from it are at real risk of significant harm or death. If someone is malnourished, they should be referred to a GP.
Not consuming enough food can also make comedowns and withdrawals much worse. There’s a reason for the expression hangry – hunger levels have been shown to impact mental health and can manifest in impulsivity, anger and irritability. If a skipped lunch can turn the average person into a grump, imagine how challenging navigating day-to-day life can be for someone who is chronically undernourished. Stimulant use can be a coping strategy in these circumstances, providing energy to push through – particularly for people who need to stay awake at night to stay safe on the streets.
So, let’s dig into the problem and, more importantly, what we can do about it. Research shows that people who use drugs, especially stimulants, often have diets low in calories, protein, and essential nutrients. This isn’t just about skipping a few meals – it’s a sustained broader issue of food insecurity, poverty, unstable living situations, and disrupted eating patterns.
FOOD INSECURITY
Data from the Safe Inhalation Pipe Provision (SIPP) study suggests that a significant proportion of people who use crack cocaine in England face food insecurity. This is no surprise, given the day-to-day realities many people experience. But even when food is accessible, appetite suppression can kick in. And here’s where it gets interesting. It’s not just about eating less – stimulants may actually dysregulate hunger hormones, leading people to eat at odd hours and making imbalanced dietary choices (think high fat and sugar, low protein).
These patterns may result from a combination of limited access to high-quality food and disruptions in key appetite-regulating hormones, such as leptin and ghrelin, which affect energy sensing and hunger signalling, ultimately shifting eating behaviour towards high-reward foods. Together, these factors can lead to a lack of key nutrients like essential amino acids, vitamins, and minerals.
We know good nutrition is important. But for people who use stimulants, it can be particularly significant in supporting mental and physical health, even when it comes to respiratory conditions.
RESPIRATORY HEALTH
Take vitamin C, for example. Studies have shown that it plays a role in respiratory function, and high doses can reduce incidence and mortality of pneumonia – albeit marginally. Research suggests that 400mg/day (ten times higher than the recommended daily amount) can benefit lung function in people with COPD. Offering vitamin C (in multivitamins or dissolvable tablets) can be a simple way for drug services to assist people to care for their physical and respiratory health – and to engage in vital further respiratory and physical support pathways.
Protein is another big one. Not only is it crucial for tissue repair and immunity, it also helps synthesise neurotransmitters like dopamine and serotonin which can be depleted by sustained stimulant use. Plus, protein helps wounds heal faster, which is important for people dealing with injuries sustained while living on the streets and/or in relation to use of unsafe drug equipment such as blunt needles or improvised pipes.
We are living in a protein-obsessed world. What used to be the territory of gym bros and fitness fanatics is now widely available, though they can be expensive – think chocolatey protein bars, protein coffee drinks, grab-and-go shakes. It’s never been easier to sneak in some protein without needing to cook or refrigerate anything, but this isn’t the case for people on low – or no – incomes. Drug services can help here, if they’re able to obtain the funding to do so.
Meal replacement shakes are also an option if they’re available. They’re quick, may be better tolerated than solid food when someone’s high or coming down, and contain balanced amounts of calories, protein, vitamins, and minerals.
Good nutrition doesn’t have to mean expensive ingredients or fully equipped kitchens. Practically supporting people to eat a wide range of food, even if it’s in small quantities, can help people get the mix of nutrients they need. Tinned fruits and vegetables are a good source of vitamins and minerals, while tinned fish or beans are good for protein. They are generally cheap (especially own-brand tins), have a long shelf life, and don’t require a fridge or cookers to store and eat. Where possible, linking people up with the local food banks or having a small food stock available within the service can make a difference.
But it doesn’t need to stop there. Services might consider seeking funding to bring in local dietic support, even on a part-time or consultancy basis. A dietician could offer training alongside practical support, develop simple nutrition resources, or run occasional drop-in sessions – including for staff. This kind of support doesn’t necessarily need to be intensive to be impactful, but it could help build capacity within services to recognise nutrition as a core part of care.
PRACTICAL CHANGE
We talk a lot about harm reduction, but we sometimes forget that harm includes poor nutrition. If we’re serious about supporting people who use stimulants we need to start asking them how easy they find it to access food and what they’re able to eat, with an eye toward practical, positive change.
There’s no need for gourmet intervention. Providing multiÂvitamins, protein snacks, meal shakes, and nutrition advice at little or no cost can go a long way. And it sends a powerful message – we care about more than just drug use, we care about health, dignity, and meeting people where they’re at (even if where they’re at is in need of a sandwich).
So next time you’re stocking up supplies at your service, consider adding some protein bars, canned fruit, and vitamins alongside the naloxone kits and syringes. Because sometimes, reducing harm starts with something as simple as a snack.
Alexandre Piot is research fellow at the London School of Hygiene and Tropical Medicine
Professor Magdalena Harris is professor of inclusion health sociology at the London School of Hygiene and Tropical Medicine
Dr Jenny Scott is senior lecturer at Bristol Medical School
Philippe Bonnet is overdose prevention lead at Cranstoun