Key takeaway
SAMHSA's TIP 42 describes anorexia nervosa, bulimia nervosa, and binge-eating disorder as the eating disorders most linked with substance use. A meta-analysis it cites found a substance use disorder in about 25 percent of people with an eating disorder over a lifetime. Diagnosis of either condition belongs with clinicians.
Last updated: Mon Oct 05 2026 00:00:00 GMT+0000 (Coordinated Universal Time)
You are hiding both the food and the drinking, and you are afraid a program will treat only the one you admit first. An eating disorder and a substance use disorder can be two names for one stretch of harm, or two conditions that make each other harder to treat. SAMHSA's TIP 42, updated in 2020, puts feeding and eating disorders in its chapter on mental disorders that show up with substance use. The core it names is a persistent disturbance of eating, or of behavior tied to eating, that changes how food is taken in or absorbed and that seriously harms physical health or day-to-day life. The eating disorders it links most closely to substance use are anorexia nervosa, bulimia nervosa, and binge-eating disorder.
Meals, deficiencies, and why a treatment program may not have a dietitian are the nutrition guide. A different SAMHSA advisory, noted on the women's treatment guide, says over one quarter of women with an eating disorder also have a substance use disorder, and that the two should be addressed together. The wider map is the dual-diagnosis guide. None of those is a diagnosis.
If you might act on thoughts of suicide, call or text 988. If someone will not wake, cannot breathe, or is seizing, call 911. Do not use alcohol, laxatives, or another drug to manage weight or a feeling tonight. After a long stretch of heavy drinking, quitting all at once can be dangerous, and so can stopping a benzodiazepine suddenly.
Three disorders, not one look
TIP 42 says anorexia nervosa is the most visible of the three, and that the name is misleading. "Nervous loss of appetite" is not what is happening until the body is severely starved. The pattern it describes is a refusal to keep weight above the minimum for age and height, driven by an intense fear of gaining. Some people restrict food, exercise heavily, and fast. Others binge and then purge with vomiting, laxatives, diuretics, or enemas. Fear of weight gain, plus a distorted sense of body shape, is the reinforcement the protocol names. Believing you are "fat" at an extremely low weight is the example it gives. That is a clinical picture. It is not a mirror test you run alone.
Bulimia nervosa, in the same chapter, is bingeing and purging. A binge is eating an unusually large amount, by social standards, in a discrete period such as two hours, with a feeling of being out of control. It is not ordinary overeating. The binge may stop only when someone is interrupted, the food is gone, or the person is exhausted or physically unable to continue. Purging is the compensation. TIP 42 says 90 percent of people with bulimia nervosa self-induce vomiting or misuse laxatives. Other methods it lists include diuretics, emetics, saunas, excessive exercise, fasting, and single-food diets people believe will cause weight loss. It says many of those methods are dangerous and ineffective because they mainly drop water and electrolytes. To meet criteria, bingeing and purging occur, on average, at least once a week for three months, and shape and weight carry undue weight in the person's identity.
Binge-eating disorder is recurring episodes of eating much more than most people would in a short time, with a lack of control, often quickly and when not hungry, sometimes alone because of guilt, embarrassment, or disgust. The protocol says it causes marked distress and occurs, on average, at least weekly for three months. Unlike bulimia nervosa, the binge is not followed by behavior meant to get rid of the food.
Twelve-month prevalence in the general population, from a study TIP 42 cites, is about 0.05 percent for anorexia nervosa, 0.14 percent for bulimia nervosa, and 0.44 percent for binge-eating disorder. Lifetime figures in that same citation are about 0.80 percent, 0.28 percent, and 0.85 percent. Women had 12 times the odds of anorexia nervosa, 5.8 times the odds of bulimia nervosa, and about 3 times the odds of binge-eating disorder. Rare in the whole population does not mean rare in a treatment program, and it does not mean a man cannot have one of these disorders.
How substance use fits
TIP 42 says feeding and eating disorders coincide often with substance misuse, and that most studies find rates above those for women of similar age in the general population. A meta-analysis it cites found a lifetime substance use disorder in 25 percent of people with an eating disorder. About 20 percent had an alcohol use disorder. About 20 percent had an illicit drug use disorder. Cocaine and cannabis use disorders were each almost 14 percent. Opioid use disorder was 6 percent. Even short of a disorder, substance use is higher in people with eating disorders, especially when bulimic features are present.
In a sample of almost 3,000 people that the protocol cites, 80 percent of those with bulimia nervosa reported using alcohol and 50 percent used other substances. For binge-eating disorder the figures were 65 percent and nearly 24 percent. For the binge-purge subtype of anorexia nervosa they were 60 percent and 44 percent. Women seeking substance use treatment have higher rates of bulimia nervosa than of the other eating disorders, and substance use disorders are more common with bulimia nervosa, or with anorexia that includes bulimic features, than with restricting anorexia alone. Some researchers the protocol cites treat bulimia nervosa, or anorexia with those features, plus alcohol use disorder as the most common pairing. "Some have suggested" is the protocol's wording. It is not a rule that every person with one has the other.
Outcomes are worse when both are present. TIP 42 cites higher odds of early death, of other physical and mental illness, and of delayed recovery. People in substance use treatment who also have eating-disorder symptoms have a higher risk of dropping out and of leaving against medical advice. Alcohol misuse more than doubles the risk of death in anorexia nervosa, in a study the protocol cites. Those are risk statements from research summaries. They are not a forecast with your name on it.
The protocol also tells counselors to ask about more than alcohol and the usual drugs. People with eating disorders, it says, may misuse diet pills, laxatives, diuretics, and emetics for weight loss, appetite suppression, or purging, and nicotine and caffeine belong in that history too. That is a screening warning. It is not a list of methods. Alcohol and cannabis, it says, can loosen restraints on appetite and raise the risk of binge eating and of relapse in bulimia nervosa.
What care is supposed to look like
Only 51 percent of substance use treatment programs, in a figure TIP 42 cites, report screening for feeding and eating disorders. Counselors are told not to look only for someone who "looks like" they have an eating disorder, because symptoms are often hidden and because most people with bulimia nervosa are not extremely thin.
Medical and weight stabilization come first, so a person is physically and mentally able to use therapy. Some people with anorexia nervosa or bulimia nervosa need inpatient care or partial hospitalization to stabilize weight. A facility may not be set up to treat substance use at the same time. Heightened mortality is why TIP 42 says the team should include primary care and nutrition professionals, not only substance use counselors and mental health clinicians.
Randomized trials for the combination, the protocol says, are not there yet. The general recommendation is concurrent treatment. Treating one and waiting on the other can raise relapse in the condition left aside. If integrated care is impossible, substance use treatment should proceed first so active use stops and the person can take part in the rest. Do not use that sentence as permission to ignore the eating disorder, and do not use it as a home plan to get sober first without medical care for starvation, purging, or withdrawal.
Psychosocial treatment is primary: individual, group, family, or a mix. Cognitive behavioral therapy can help eating disorders and has not been researched thoroughly when addiction is also present. The substance use version of that therapy is the CBT guide. Dialectical behavior therapy can help with mindfulness, difficult emotions, and self-regulation in each disorder separately, and has not been studied much when both are present at once. That boundary stays on the DBT guide. Pharmacotherapy may be warranted for bulimia nervosa and binge-eating disorder and is not first-line. A drug name and a dose belong with the prescriber.
SmarterRecovery is a referral helpline. SMART Recovery is a separate mutual-help program. Call or text (800) 653-9376 if you need help finding a program, and say both problems. FindTreatment.gov lists substance use and mental health treatment. Ask whether the program screens for eating disorders and whether medical care for weight and purging is in the building or by referral.
Additional Resources
Sources cited on this page:
- SAMHSA TIP 42, Chapter 4: Feeding and Eating Disorders (NCBI Bookshelf, updated 2020)
- SAMHSA FindTreatment.gov
- 988 Suicide & Crisis Lifeline
Common Questions
Are anorexia, bulimia, and binge eating the same problem?
No. TIP 42 says feeding and eating disorders share a persistent disturbance of eating that harms health or functioning. Anorexia nervosa involves keeping weight extremely low out of fear of gaining, by restricting or by bingeing and purging. Bulimia nervosa is bingeing plus compensating, such as vomiting or laxatives, at least weekly for three months. Binge-eating disorder is repeated out-of-control eating without those compensatory behaviors. A clinician applies the criteria.
How often do eating disorders and substance use disorders occur together?
TIP 42 cites a meta-analysis that found a lifetime substance use disorder in 25 percent of people with an eating disorder. Within that, about 20 percent had an alcohol use disorder, about 20 percent any illicit drug use disorder, almost 14 percent cocaine use disorder, almost 14 percent cannabis use disorder, and 6 percent opioid use disorder. Those are study summaries the protocol reports. They are not a diagnosis for one person.
If I am not extremely thin, can this still apply?
Yes. TIP 42 tells counselors that people often hide these symptoms, and that many people with feeding and eating disorders are not extremely thin. It says most people with bulimia nervosa are at a normal weight or are overweight. Looking only for someone who matches a stereotype misses people. A comment about weight is not an assessment.
Should one disorder be treated before the other?
TIP 42 says concurrent care is the general recommendation, because treating only one can raise the chance of relapse in the other. If integrated care is not available, it says substance use treatment should come first so the person can take part in further care. Medical and weight stabilization come before therapy that assumes someone is well enough to participate. Do not sequence this yourself at home.
Is there a medicine I should start from a general description?
No. TIP 42 says pharmacotherapy may be warranted for bulimia nervosa and binge-eating disorder and is not a first-line treatment. It does not give a drug, a dose, or a start date. Cognitive behavioral therapy can help eating disorders and has not been studied thoroughly when addiction is also present. Dialectical behavior therapy has been useful for each disorder separately and has not been studied much when both are present. A prescriber and a therapist make those calls.