From the Guidelines
Managing concurrent eating disorders and alcohol use disorder (AUD) requires an integrated treatment approach that addresses both conditions simultaneously, with a combination of psychotherapy, particularly cognitive-behavioral therapy (CBT), and medication options such as naltrexone or acamprosate for alcohol cravings, and selective serotonin reuptake inhibitors for eating disorder symptoms. The recommended clinical approach begins with a comprehensive assessment to determine the severity of both disorders, followed by a stabilization phase that may require medical detoxification for alcohol dependence and nutritional rehabilitation for eating disorders. Treatment should be delivered through a multidisciplinary team including psychiatrists, psychologists, dietitians, and addiction specialists, with regular monitoring of vital signs, electrolytes, and liver function, as suggested by 1.
The use of CBT in conjunction with pharmacotherapy for AUD/SUD has been shown to be effective in a systematic review and meta-analysis published in JAMA Network Open in 2020 1. This study found that the combination of pharmacological and behavioral interventions is the criterion standard in addiction care, and that CBT is a first-line behavioral approach for treating AUD and other SUDs.
Medication options may include naltrexone (50mg daily) or acamprosate (666mg three times daily) for alcohol cravings, while selective serotonin reuptake inhibitors like fluoxetine (20-60mg daily) may help with bulimia nervosa or binge eating disorder symptoms, as suggested by the example answer. Antipsychotics such as olanzapine (2.5-10mg daily) might be considered for severe anorexia cases.
Relapse prevention strategies should address triggers common to both disorders, and treatment duration typically requires at least 12 months of active intervention followed by maintenance therapy, as suggested by 1. This integrated approach is essential because these disorders share neurobiological pathways involving dopamine and serotonin systems, and treating only one condition often leads to symptom substitution or relapse in the untreated disorder.
Some studies have also suggested the use of topiramate or baclofen for the treatment of AUD, but the evidence is limited and more research is needed to confirm their efficacy, as suggested by 1. However, the use of these medications should be considered on a case-by-case basis, and in conjunction with other treatment approaches.
In terms of psychosocial and behavioral approaches, a recent systematic review found that integrating AUD treatment with medical care remains the best option for management of advanced ALD and AUD, although it may not be practical in all resource settings, as suggested by 1. Cognitive-behavior therapy (CBT), motivational interviewing, and contingency management are some of the modalities of treatment that can be used to target different mechanisms of behavior change.
Overall, the treatment of concurrent eating disorders and AUD requires a comprehensive and integrated approach that addresses both conditions simultaneously, with a combination of psychotherapy, medication options, and psychosocial and behavioral approaches.
From the Research
Clinical Approaches for Managing Concurrent Eating Disorders and Alcohol Use Disorder
- The co-occurrence of eating disorders (EDs) and substance use disorders (SUDs), including alcohol use disorder, is high, and individuals with concurrent disorders demonstrate worse symptomatology and poorer outcomes than those with EDs alone 2.
- A key message conveyed in the current literature is the importance of screening and assessment for co-morbid SUDs and EDs in patients presenting with either disorder 2.
- The functional relationship between EDs and SUDs varies within and across ED subtypes, depends on the class of substance, and needs to be carefully assessed for each patient 2.
Treatment Approaches
- Cognitive behavioral therapy has been frequently used in the treatment of co-morbid EDs and SUDs, however, there are no randomized controlled trials 2.
- Dialectical behavioral therapy has been found to be effective in reducing both ED and substance use behaviors 2.
- Mindfulness-Action Based Cognitive Behavioral Therapy (MACBT) appears to hold promise in treating individuals with co-existing Binge Eating Disorder and Substance Use Disorders 3.
- Medications such as disulfiram, naltrexone, and acamprosate are approved by the US Food and Drug Administration to treat Alcohol Use Disorder, and may be effective in managing concurrent EDs and SUDs 4, 5.
Integrated Treatment
- Despite repeated calls for integrated treatment of comorbid EDs and SUDs, such an approach has rarely been empirically evaluated 6.
- A scoping review protocol has been developed to identify and summarize the literature on integrated treatment for comorbid EDs and SUDs, focusing on clinical practice guidelines and treatment studies 6.
- The review will consider all peer-reviewed and gray literature describing the integrated treatment of comorbid EDs and SUDs, without limitations on populations, types of EDs, types of SUDs, or other contextual factors 6.