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© Copyright 2023 National Eating Disorders Association. All rights reserved.
As has been highlighted during the drug overdose epidemic in the U.S., substance use disorders (SUD) are well known to increase the risk of premature death, with a large body of research documenting mortality related to tobacco, alcohol, and other drugs. Eating disorders (ED) are also associated with high premature mortality rates and are among the most lethal of all the psychiatric disorders. Death rates for those with both ED and SUD are addictive, leaving those with co-occurring illness at a substantially elevated risk of premature death. Despite the increase in morbidity and mortality of comorbid ED and addiction, patients with this unique co-occurrence have been infrequently studied, leaving them often undiagnosed, untreated and underserved. According to a 2021 study published in the American Journal of Psychiatry, “A major driver of mortality in patients with eating disorders is substance use disorders…eating disorders and substance use disorders are each shown to be associated with high rates of mortality, but the combination of anorexia nervosa, bulimia nervosa, or unspecified eating disorders with a substance use disorder is particularly lethal because the risks of death from one are added to the other.”1
Up to 50% of individuals with eating disorders use alcohol or illicit drugs, a rate five times higher than the general population.2 Up to 35% of individuals who were dependent on alcohol or other drugs also have eating disorders, a rate 11 times greater than the general population.3 Despite the substantial overlap between these two illnesses, there remains a gap between eating disorders and addiction professionals, which impacts training, research and clinical care for those with co-occurring disorders. NEDA is invested in bridging this gap and advocating for the unique needs of this complex patient population.
People who have eating disorders may begin using substances before, at the same time or after eating disorder symptoms appear.2 Less frequently, people first use substances in a problematic way after achieving full recovery from their eating disorder. Those struggling with co-occurring substance use and disordered eating should speak with a trained professional who can understand, diagnose, and treat both disorders. It can be difficult to find providers who have in-depth understanding and experience with treating both diseases, but people who have both are best served by these professionals. Finding a clinician who understands both of these illnesses as brain diseases, with significant genetic underpinnings and bio-psycho-social-spiritual manifestations is critical. Clinicians with this understanding are equipped to provide you care that is free from shame or stigma, which is commonly (even if unintentionally) heaped on by providers who don’t understand one or the other of these illnesses.
The substances most commonly used by individuals with eating disorders are alcohol and nicotine.2 Other substances include cannabis, caffeine, laxatives, emetics, diuretics, stimulants, amphetamines, cocaine, sedatives and opioids, including heroin. Prescription medications for conditions like ADHD, pain, anxiety, migraines, low thyroid, diabetes and even depression can be misused by people with eating disorders alone or by those co-occurring with SUD.2
Eating disorders and substance use share a number of common risk factors, including genetic risks, brain chemistry, family history, trauma, low self-esteem, depression, anxiety, and social pressures. Other shared characteristics include compulsive behavior, impulsivity, loss of control/over-control cycles, social isolation and inability to stop the behavior without help.2
One of the most important reasons to seek help if you have an eating disorder plus addiction is that each of these illnesses alone significantly increases mortality rates.1 When the two occur together, medical problems occur earlier and tend to be more severe, suicide rates are higher, co-occurring mental health and trauma related disorders tend to be more severe, and treatment needs become greater.1,4
As with eating disorders, early intervention of substance use and including families in treatment is essential. Despite the bleak increases in morbidity and mortality for those with co-occurring illness, treatment works and recovery is possible!
Drunkorexia is a colloquial term that refers to altering eating behaviors to either offset planned caloric intake from alcohol or to increase/speed the effects of alcohol. Not a clinical diagnosis and not necessarily indicative of a substance use disorder, the term is often used in the context of college campuses to describe disordered eating and binge drinking occurring together.6
Regardless of whether the behaviors become diagnosable conditions, the relationship between food restriction, purging behaviors and high levels of alcohol use puts individuals at risk for significant medical complications, up to and including sudden death.1 It’s important that these dangerous behaviors be identified and treated as soon as possible.7,8
 Mellentin, A. I., Mejldal, A., Guala, M. M., Støving, R. K., Eriksen, L. S., Stenager, E., & Skøt, L. (2022). The Impact of Alcohol and Other Substance Use Disorders on Mortality in Patients With Eating Disorders: A Nationwide Register-Based Retrospective Cohort Study. The American journal of psychiatry, 179(1), 46–57. https://doi.org/10.1176/appi.ajp.2021.21030274
 Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry research, 273, 58–66. https://doi.org/10.1016/j.psychres.2019.01.007
 Hudson, J. I., Hiripi, E., Pope, H. G., Jr, & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348–358. https://doi.org/10.1016/j.biopsych.2006.03.040
 Brewerton, T.D., Brady, K. (2014). The Role of Stress, Trauma, and PTSD in the Etiology and Treatment of Eating Disorders, Addictions, and Substance Use Disorders. In: Brewerton, T., Baker Dennis, A. (eds) Eating Disorders, Addictions and Substance Use Disorders. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-45378-6_17
 American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
 Szynal, K., Górski, M., Grajek, M., Ciechowska, K., & Polaniak, R. (2022). Drunkorexia – knowledge review. Alkoreksja – przegląd wiedzy. Psychiatria polska, 56(5), 1131–1141. https://doi.org/10.12740/PP/OnlineFirst/134748
 Choquette, E. M., Ordaz, D. L., Melioli, T., Delage, B., Chabrol, H., Rodgers, R., & Thompson, J. K. (2018). Food and Alcohol Disturbance (FAD) in the U.S. and France: Nationality and gender effects and relations to drive for thinness and alcohol use. Eating behaviors, 31, 113–119. https://doi.org/10.1016/j.eatbeh.2018.09.002
 Rahal, C. J., Bryant, J. B., Darkes, J., Menzel, J. E., & Thompson, J. K. (2012). Development and validation of the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS). Eating behaviors, 13(2), 83–87. https://doi.org/10.1016/j.eatbeh.2011.11.001