Written by [AUTHOR NAME, CREDS] — [one-sentence credential summary] Clinically reviewed by EDS Clinical Team on 2026-05-29 Last Reviewed: 2026-05-29
About one in five people with an eating disorder also meets criteria for a substance use disorder at some point in their life, according to a 2019 systematic review and meta-analysis of 43 studies [1]. That overlap is not a coincidence — the two conditions share risk factors, brain pathways, and behaviors — and when they appear together, the medical and psychiatric risks rise. This guide explains why the two conditions co-occur, what makes the combination dangerous, and what an integrated assessment looks like.
How often the two conditions occur together
A 2019 meta-analysis pooling 43 studies estimated the lifetime prevalence of a comorbid substance use disorder among people with an eating disorder at roughly 22 percent — about three to four times higher than rates in the general population [1]. A more recent 2023 narrative review confirmed that substance use disorder is the third-most-common psychiatric comorbidity in eating disorders, after anxiety and depression [2].
The overlap is not evenly distributed. Comorbid substance use is more common in the binge/purge subtype of anorexia and in bulimia nervosa than in restricting-type anorexia [1][3]. For anorexia specifically, a 2022 meta-analysis found pooled substance use disorder prevalence around 16 percent overall, with the binge/purge subtype showing roughly 18 percent versus about 7 percent in the restricting subtype [3].
Why these numbers matter
Co-occurring eating disorders and substance use are associated with more medical complications, higher relapse rates, and higher all-cause mortality than either condition alone [2]. Both conditions independently elevate suicide risk, and people with anorexia nervosa have one of the highest mortality rates of any psychiatric illness [4]. When the two appear together, screening for both becomes essential — if a clinician treats only the substance use, the eating disorder may worsen unrecognized, and vice versa.
Why the two conditions are linked
Research suggests several overlapping pathways rather than a single shared cause.
Shared neurobiology
Both eating disorders and substance use disorders involve reward circuitry — dopamine, serotonin, and the brain regions that process reinforcement and craving [2]. Restriction, bingeing, purging, and substance use all act on overlapping circuits, which is one proposed reason that one behavior can substitute for or escalate alongside another. This is a research-supported framework, not a settled mechanism — be cautious of any source that claims a single specific cause.
Shared psychological vulnerability
People with both conditions often share underlying features: impulsivity (especially in binge/purge subtypes), emotion dysregulation, perfectionism, and a history of trauma [1][2]. Co-occurring depression, anxiety, OCD, and PTSD are common in both groups and may drive the use of food restriction, bingeing, purging, or substances as attempts at emotional self-regulation.
Family history and genetics
Family studies suggest moderate heritability for both eating disorders and substance use disorders, with shared genetic risk that increases vulnerability when other factors are present [2]. Genetics does not determine outcome — environment, stress, trauma, and access to care all matter — but a family history of either condition is a meaningful risk signal.
Important: not a “helpful tool”
You may read content online that frames stimulants, alcohol, or cannabis as a way to manage hunger, anxiety, or eating-related distress. That framing is harmful. Stimulants (including misused prescription medications such as Adderall, as well as cocaine and methamphetamine) suppress appetite at the cost of cardiac strain, sleep disruption, and dependence — and they intensify restriction in ways that increase the risk of arrhythmia and cardiac arrest [5]. Alcohol used to reduce anxiety around eating worsens nutritional status, depresses the central nervous system, and complicates withdrawal management later. If you find yourself using a substance to manage eating-related distress, that is a sign to get evaluated, not a strategy to refine.
How specific substances interact with specific eating disorders
The pattern of which substances are used differs by eating disorder type. None of the patterns below should be read as “what to expect” — they are clinical observations from the literature, not predictions about any individual.
Stimulants and restriction
Misused stimulants are most commonly reported in restricting-type anorexia and in some presentations of bulimia [1][2]. Because stimulants suppress appetite and increase energy expenditure, they can intensify the restrictive cycle. Cardiac risks include tachycardia, arrhythmia, and — in the setting of pre-existing bradycardia from malnutrition — sudden cardiac events [5]. Stimulant misuse in a person with restrictive eating is a medical emergency-adjacent presentation, not a manageable habit.
Alcohol and purging
Alcohol use disorder is more frequently observed in bulimia nervosa and the binge/purge subtype of anorexia [1][3]. Both heavy alcohol use and purging deplete electrolytes (especially potassium and magnesium), and combined depletion meaningfully raises the risk of cardiac arrhythmia and torsades de pointes [5]. Alcohol withdrawal in someone who is malnourished can also progress more severely and unpredictably; medical evaluation is required.
Sedatives, opioids, and cannabis
Sedative-hypnotic and opioid use are reported across eating disorder subtypes, often in the context of co-occurring anxiety, trauma, or chronic pain [1]. Cannabis is sometimes used for the opposite effect — appetite stimulation — which can complicate binge-eating disorder presentations. Polysubstance use is common when an eating disorder co-occurs with a substance use disorder, and it raises the complexity of medical detoxification.
Caffeine, nicotine, and “diet” products
These are easily overlooked. Heavy caffeine intake, nicotine use, and over-the-counter “diet aids” or laxatives can all interact with restrictive or purging behaviors, contribute to electrolyte disturbance, and complicate the medical picture. Anyone screening for substance use in an eating disorder context should ask about these specifically.
How ARFID and body dysmorphic disorder fit in
Avoidant Restrictive Food Intake Disorder (ARFID) is a DSM-5-TR diagnosis distinct from anorexia. People with ARFID restrict intake based on sensory characteristics of food, fear of aversive consequences (such as choking or vomiting), or low interest in eating — not because of body image or weight goals. Substance use in ARFID is less studied than in anorexia or bulimia, but co-occurring anxiety is common, and any substance use should be evaluated by a clinician familiar with both ARFID and substance use disorders.
Body Dysmorphic Disorder (BDD) is also separate from eating disorders, though it can co-occur. Substance use in BDD often relates to underlying anxiety and depression. Treating one condition without addressing the other tends to leave both partially treated.
What integrated assessment looks like
When eating disorder and substance use behaviors appear together, a single assessment that covers both is more useful than separate evaluations months apart. A thorough assessment typically includes:
- A medical evaluation — vitals, ECG, comprehensive metabolic panel, magnesium and phosphate, complete blood count, and a substance use history with timing of last use
- A psychiatric evaluation — current and past diagnoses, suicidality, history of trauma, and a medication review
- An eating disorder evaluation — behaviors (restriction, bingeing, purging, exercise compulsion, laxative use), duration, prior treatment, current weight history, and body image
- A substance use evaluation — substances used, frequency, route, last use, prior withdrawal experience, and prior treatment
Level of care — outpatient, intensive outpatient, partial hospitalization, residential, or inpatient — is determined by this assessment using clinical criteria such as the APA practice guideline for eating disorders [6] and ASAM criteria for substance use [7]. It is not determined by a single number, by weight alone, or by a marketing page. If a program tells you the right level of care for you without seeing your labs, vitals, or substance use history, get a second opinion.
Special safety note: withdrawal in the context of an eating disorder
Withdrawal severity depends on the substance, the person’s medical history, and a clinical assessment. Alcohol and benzodiazepine withdrawal can be medically dangerous on their own — and in a person who is malnourished, dehydrated, or experiencing electrolyte derangement from purging, the medical risks compound. Opioid withdrawal is usually not life-threatening in healthy adults but can become so in the setting of severe medical compromise. Stimulant withdrawal is primarily psychiatric (depression, suicidality, fatigue) but psychiatric risk should never be minimized in someone with an eating disorder.
Do not attempt unsupervised withdrawal from alcohol, benzodiazepines, or opioids when an eating disorder is active. Get a medical evaluation first.
Practical Next Steps
If you are reading this because you or someone close to you is using substances alongside an eating disorder, these are reasonable next steps in order:
- If there is any safety concern right now — suicidality, severe restriction, severe purging, signs of withdrawal, or chest pain — call 988, 911, or the Alliance helpline at 1-866-662-1235. Do not wait for an appointment.
- Schedule a medical evaluation with a primary care provider or an emergency department. Ask for vitals, an ECG, and a basic metabolic panel including magnesium and phosphate.
- Schedule a behavioral health evaluation with a provider who can assess both eating disorder and substance use — not one or the other. A psychiatrist, a Certified Eating Disorder Specialist (CEDS), or an addiction medicine physician are the closest fits.
- Ask about integrated treatment specifically. Programs that treat eating disorders without screening for substance use, or vice versa, leave half the picture.
- Bring a family member or friend to the first appointment if possible. Both conditions are difficult to describe accurately alone.
Frequently Asked Questions
How common is it for someone with an eating disorder to also have a substance use disorder?
A 2019 meta-analysis of 43 studies found that roughly 22 percent of people with an eating disorder also meet criteria for a substance use disorder at some point in their life — about three to four times the rate in the general population [1]. Rates are higher in bulimia nervosa and the binge/purge subtype of anorexia than in restricting-type anorexia [1][3].
Can you treat the eating disorder and the substance use disorder at the same time?
In most cases, yes — and current clinical thinking favors integrated treatment over sequential treatment, because untreated symptoms of either condition tend to drive relapse in the other [2]. The specifics depend on medical stability, the severity of each condition, and a clinical assessment.
Is it safe to detox at home when you have an eating disorder?
Withdrawal severity depends on the substance, your medical history, and a clinical assessment. Alcohol and benzodiazepine withdrawal can be medically dangerous and require professional evaluation [7]. When an active eating disorder is present — especially with restriction, purging, or electrolyte disturbance — the risks compound, and a medical evaluation is essential before any attempt to stop or taper. Opioid withdrawal is generally less life-threatening but should still be medically supervised when an eating disorder is active.
What level of care is right for someone with both an eating disorder and a substance use disorder?
The right level of care depends on a clinical assessment using criteria such as the APA practice guideline for eating disorders [6] and the ASAM criteria for substance use [7]. Factors that matter include medical stability, psychiatric stability, suicidality, severity of restriction/purging/use, prior treatment history, and support system. A program that recommends a level of care without an assessment is not giving you a clinical recommendation.
Can stimulants like Adderall make anorexia worse?
Misused stimulants — including prescription stimulants taken outside a prescriber’s plan as well as cocaine and methamphetamine — suppress appetite and can intensify restriction. They also place strain on the cardiovascular system, and in someone with the bradycardia and electrolyte changes that accompany restrictive eating, that strain can precipitate arrhythmia or sudden cardiac events [5]. If you are using a stimulant and you have an eating disorder, talk to a clinician — do not stop a prescribed medication without medical guidance, but do not continue misuse either.
Where can I find a provider who treats both?
The National Alliance for Eating Disorders runs a free helpline at 1-866-662-1235 staffed by licensed eating disorder therapists who can help locate integrated providers. The SAMHSA treatment locator at findtreatment.gov can help locate substance use programs that screen for co-occurring conditions. Asking a primary care provider, psychiatrist, or local hospital for a referral is also reasonable.
Sources
- 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. https://pubmed.ncbi.nlm.nih.gov/30640052/
- Devoe, D. J., et al. (2023). Substance use in patients with eating disorders — a review of the current evidence. Frontiers in Psychiatry / PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10479164/
- Mellentin, A. I., et al. (2022). The prevalence of substance use disorders and substance use in anorexia nervosa: a systematic review and meta-analysis. Journal of Eating Disorders. https://pubmed.ncbi.nlm.nih.gov/34895358/
- National Institute of Mental Health. (2024). Eating Disorders. NIMH. https://www.nimh.nih.gov/health/topics/eating-disorders
- Sachs, K. V., Harnke, B., Mehler, P. S., & Krantz, M. J. (2023). Assessment and management of cardiovascular complications in eating disorders. Journal of Eating Disorders / PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9886215/
- American Psychiatric Association. (2023). Practice Guideline for the Treatment of Patients With Eating Disorders, Fourth Edition. APA. https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
- American Society of Addiction Medicine. (2023). The ASAM Criteria, Fourth Edition. ASAM. https://www.asam.org/asam-criteria
About Eating Disorder Solutions
Eating Disorder Solutions provides specialized eating disorder care in the Dallas-Fort Worth area, with facilities in Dallas, Weatherford, and Ennis, Texas. The clinical team includes psychiatrists, therapists, registered dietitians, and nurses who work together on individualized treatment plans. For specific questions about admissions, levels of care offered, insurance coverage, and co-occurring substance use, call 844-807-0458 or visit our contact page.
