Eating disorders and substance use disorders share many similar characteristics, including that both are chronic, long-term diseases with high rates of relapse, and often involve compulsive secretive behavior that is continued despite negative adverse consequences. In fact, up to 50 percent of individuals who seek treatment for eating disorders also abuse drugs or alcohol, more than five times the rate observed in the general population, according to the National Center on Addiction and Substance Abuse.[1. The National Center on Addiction and Substance Abuse. Food for Thought: Substance Abuse and Eating Disorders. December 2003. Available at: http://bit.ly/1LURs8P.] Among those in treatment for substance abuse, more than one-third suffer from eating disorders, compared to about 3 percent of the general population. The presentations and chronology may differ. A patient with anorexia nervosa may abuse stimulants such as cocaine or methamphetamines to lose weight. A binge eater may also binge drink, which then allows him to purge. In addition to alcohol and illicit substances such as cannabis, cocaine, crack, methamphetamine, hallucinogens, Ecstasy, individuals with eating disorders can abuse prescribed medications such as stimulants including Ritalin, Adderall, Vyvanse, or Concerta, or tranquilizers such as Xanax, clonazepam, Valium, and Ativan. Individuals with eating disorders can even abuse over the counter medications such as diet pills, laxatives, or diuretics. Despite the high degree of overlap, some treatment centers still do not regularly screen for both. It’s important to conduct a detailed history and perform a comprehensive screen to identify patients who have co-occurring substance use disorders. Often, patients are in denial and will minimize the severity of their alcohol and drug use. They cannot recognize the negative influence using has on their lives and may not want treatment for substance use. Sometimes, the screen does not recognize substance abuse, but withdrawal symptoms emerge quickly because the residential unit provides no access to drugs or alcohol. In the partial hospitalization program, if patients have off-campus privileges, conduct random drug screens. Others may present for substance use disorder at the insistence of family, employers or courts and will not disclose — or acknowledge — an eating disorder. Once treatment begins, the team may notice the patient regularly leaves group sessions or meals early to purge. Or they lose weight rapidly because they stop eating. Surprisingly, relatively few treatment programs employ specialized teams that effectively treat both disorders. That puts patients at much higher risk for relapse because the core issues that drive both disorders — trauma, stress, poor self-worth — remain unaddressed. Treatment for only one disorder may exacerbate the other. The need for dual expertise is evident at the beginning of treatment. Safely detox patients in an inpatient setting. Detox is never pretty, and for some drugs or alcohol, the side effects of withdrawal can be very serious, even deadly. At the same time, it’s crucial to maintain facilities that monitor patients with anorexia nervosa for refeeding syndrome. That potentially fatal side effect of restoring nutrition to someone who has a body mass index (BMI) below 16 can happen in the first week of treatment. Those patients need close monitoring and medical stabilization. The team must have expertise in this area to ensure they are treating the patient appropriately and preventing serious problems. Because of the potential to transfer or intensify addictions, the best approach to treatment is to tackle both the eating disorder and the substance use disorder virtually simultaneously and in an integrated program. Medically stabilize the patient first, whether that’s to restart nutrition and increase base weight in a patient with anorexia nervosa or to support an alcoholic through withdrawal. The next best option is to treat disorders in rapid sequence. The challenge lies in preventing the patient from engaging in one destructive behavior while treating the other. It takes an individualized approach with a focus on containing both disorders from the start. Some patients may not have the resources to go to a program that addresses both disorders. Work with these patients to strike the best balance. That may be residential treatment for a number of weeks to establish sobriety and improve eating behaviors. Then, step down to partial hospitalization for the substance use disorder combined with outpatient therapy for the eating disorder and consultation with a dietician. For any program to succeed, the patient must acknowledge she has both an eating disorder and substance use disorder. If a patient does that, he will generally connect with 12-step programs that will continue to provide support through their recovery. If patients don’t recognize both disorders, they will likely relapse. REFERENCE
