Alcohol & Drug Use in Eating Disorders: Treatment Approaches and Solutions

By Jamie Manwaring, PhD

Substance use disorder (SUD), including alcohol and drug use, is common in individuals with eating disorders. Eating disorders and SUDs share multiple traits, including impulsivity and negative affect. Effective addressing both substance use and eating disorders is important for long-term recovery from both conditions. Treatments include substance withdrawal treatment, refeeding syndrome prevention, dialectical behavior therapy (DBT) and emotion regulation strategies.

Substance Use in Patients with Eating Disorders

Substance use disorders (SUDs) – a problematic pattern of substance use that affects a patient’s health and wellbeing1 –  are the fourth most common co-occurring psychiatric disorder in people with eating disorders. Across diagnoses, up to 22% of individuals with an eating disorder are affected by a SUD.2 Common substances used by patients with eating disorders include:2

  • Alcohol (29%)
  • Tobacco (25%)
  • Cannabis (14%)
  • Stimulants (14%)

Alcohol Use Disorder & Eating Disorders

Co-occurring eating disorders and alcohol use disorder (AUD) are exceptionally common, with a higher prevalence of AUD among patients with eating disorders and a greater rate of eating disorders in patients with AUD.2

The most common co-occurrence of AUD is seen in those with bulimia nervosa, with up to 49% experiencing co-occurring AUD.3 This rate is four times higher than the 6% co-occurrence seen in people with anorexia nervosa.3

Is Binge Eating & Purging Linked to Substance Use?

SUDs are significantly more common in individuals who binge eat or purge.2 25% of individuals with BED report a lifetime history of SUD, while almost half of those with bulimia nervosa have AUD.3,4 A study of patients with anorexia nervosa also found that AN-BP are more than twice as likely (18%) to have substance use disorders compared to those with AN-R (7%). Those with AN-BP are also more likely to experience drug use or dependence.2

Why is Substance Use so Common in Those with Eating Disorders?

Shared risk factors

Both also share a significant amount of common risk factors, including:

Dual-diagnosis

Substance use disorder isn’t the only co-occurring condition. Most people with eating disorders have at least one co-occurring mental health diagnosis (dual diagnosis), and up to 95% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder, such as:5

Impulsivity

Substance use, binge drinking, and eating disorders are linked to impulsivity and sensation-seeking, especially in individuals who binge eat and purge.6-10

Lack of impulse control can lead to acting without thinking about the consequences, especially when experiencing intense emotions, whether positive or negative. Substance use provides a quick way to escape the negative feelings linked to disordered eating – like guilt after a binge or shame after purging – which can reinforce the behavior over time.

Negative affect

Anorexia nervosa, bulimia nervosa, BED and heavy drinking are all associated with negative affect.11-13

Eating disorders and substance use disorders can both develop as patients try to escape feelings of pain, anxiety, depression or stress. Those with eating disorders may also use drugs or alcohol alongside their disordered eating behaviors to cope with difficult emotions.

Appetite suppression

Patients who restrict food may turn to substance use, particularly methamphetamines and cocaine, to lose weight. These drugs can suppress appetite and make restriction easier.

Behavioral substitution

As a patient begins to address their disordered eating, substance use problems can arise if they try to replace their eating disorder with another maladaptive coping mechanism – known as behavioral substitution.

This may explain why those with eating disorders are significantly more likely to receive their SUD diagnosis within a year of being diagnosed with their eating disorder.14

Medical Treatment for an Eating Disorder & Substance Use Disorder

Substance withdrawal treatment

The management of alcohol withdrawal focuses on relieving symptoms and identifying and addressing metabolic imbalances. Benzodiazepines or similar medications are used to manage psychomotor agitation and prevent progression to more severe withdrawal.

Supportive care, including IV fluids, nutritional support, and regular clinical monitoring with vital signs, is essential at this phase in recovery

Refeeding syndrome prevention

Patients who are malnourished and have alcohol use disorder are at a high risk of developing refeeding syndrome. Refeeding syndrome can put patients at risk for a variety of severe medical complications, including heart failure and death. Because of the risks and potential mortality of refeeding syndrome, prevention should be prioritized.

Learn more about preventing refeeding syndrome.

Psychotherapy & Support for Substance Use Disorder & an Eating Disorder

Process model of emotional regulation

Using the process model of emotional regulation, patients can understand how they process their feelings at any moment or in specific situations. This model helps patients recognize when emotional regulation is needed and encourages patients to reevaluate their thoughts about a situation to influence their emotional response.

Using maladaptive emotion regulation skills, such as rumination, suppression, and avoidance, can worsen symptoms of SUD and eating disorders. Improving the ability to regulate emotions helps patients manage and cope with their feelings in appropriate and effective ways.

Dialectical behavioral therapy

Dialectical behavior therapy (DBT) is a type of psychotherapy that emphasizes mindfulness, interpersonal skills, distress tolerance and emotional regulation. It is especially effective for people who experience intense emotions. It can be a helpful treatment for patients with both an eating disorder and SUD, who may use disordered eating behaviors and substance use to manage overwhelming feelings.

Trauma therapies

For substance abuse disorders that partially stem from trauma history, trauma therapies such as Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy (CPT), or Prolonged Exposure (PE) may be beneficial.

Getting Help for Substance Use & an Eating Disorder

Both substance use disorder and an eating disorder can significantly impact your physical health, mental functioning and overall quality of life. Prioritizing withdrawal treatment and preventing refeeding syndrome are essential to ensure you can recover safely during eating disorder treatment.

References

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
  2. Devoe, D. J., Dimitropoulos, G., Anderson, A., Bahji, A., Flanagan, J., Soumbasis, A., Patten, S. B., Lange, T., & Paslakis, G. (2021). The prevalence of substance use disorders and substance use in anorexia nervosa: a systematic review and meta-analysis. Journal of Eating Disorders, 9(1). https://doi.org/10.1186/s40337-021-00516-3
  3. Lilenfeld, L. R., & Kaye, W. H. (1996). The link between alcoholism and eating disorders. PubMed, 20(2), 94–99. https://pubmed.ncbi.nlm.nih.gov/31798142
  4. Schreiber, L. R. N., Odlaug, B. L., & Grant, J. E. (2013). The overlap between binge eating disorder and substance use disorders: Diagnosis and neurobiology. Journal of Behavioral Addictions, 2(4), 191–198. https://doi.org/10.1556/jba.2.2013.015
  5. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S. M., Caldwell, B., Calvert, S., Carroll, B., Castle, D. J., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
  6. Rosval, L., Steiger, H., Bruce, K., Israël, M., Richardson, J., & Aubut, M. (2006). Impulsivity in women with eating disorders: Problem of response inhibition, planning, or attention? International Journal of Eating Disorders, 39(7), 590–593. https://doi.org/10.1002/eat.20296
  7. Lee, R. S. C., Hoppenbrouwers, S., & Franken, I. (2019). A Systematic Meta-Review of Impulsivity and Compulsivity in Addictive Behaviors. Neuropsychology Review, 29(1), 14–26. https://doi.org/10.1007/s11065-019-09402-x
  8. Doumas, D. M., Miller, R., & Esp, S. (2016). Impulsive sensation seeking, binge drinking, and alcohol-related consequences: Do protective behavioral strategies help high risk adolescents? Addictive Behaviors, 64, 6–12. https://doi.org/10.1016/j.addbeh.2016.08.003
  9. Hirvelä, L., Sipilä, P. N., & Keski-Rahkonen, A. (2021). Relationship between sensation seeking, alcohol problems and bulimic symptoms: a community-based, longitudinal study. Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity, 27(2), 589–595. https://doi.org/10.1007/s40519-021-01193-6
  10. Bø, R., Billieux, J., & Landrø, N. I. (2016). Which facets of impulsivity predict binge drinking? Addictive Behaviors Reports, 3, 43–47. https://doi.org/10.1016/j.abrep.2016.03.001
  11. Brunborg, G. S. (2016). Positive and negative affectivity as risk factors for heavy drinking in the second half of life: a prospective cohort study. Addiction, 112(5), 801–807. https://doi.org/10.1111/add.13718
  12. Peterson, C. B., Thuras, P., Ackard, D. M., Mitchell, J. E., Berg, K., Sandager, N., Wonderlich, S. A., Pederson, M. W., & Crow, S. J. (2009). Personality dimensions in bulimia nervosa, binge eating disorder, and obesity. Comprehensive Psychiatry, 51(1), 31–36. https://doi.org/10.1016/j.comppsych.2009.03.003
  13. Williams-Kerver, G. A., Wonderlich, S. A., Crosby, R. D., Cao, L., Smith, K. E., Engel, S. G., Crow, S. J., Peterson, C. B., Mitchell, J. E., & Grange, D. L. (2020). Differences in affective dynamics among Eating-Disorder Diagnostic Groups. Clinical Psychological Science, 8(5), 857–871. https://doi.org/10.1177/2167702620917196
  14. Skøt, L., Mejldal, A., Guala, M. M., Støving, R. K., Ascone, L., Stenager, E., Lichtenstein, M. B., & Mellentin, A. I. (2022). Eating disorders and subsequent risk of substance use disorders involving illicit drugs: a Danish nationwide register-based cohort study. Social Psychiatry and Psychiatric Epidemiology, 57(4), 695–708. https://doi.org/10.1007/s00127-021-02201-x

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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