Summary

Despite much research, there is little evidence upon which to provide clear guidance on the treatment of co-occurring ED and AOD use disorders. Research from single disorder ED suggests that comprehensive assessments conducted by a multidisciplinary team should be followed by psychotherapy as the first line of treatment, with strongest evidence in support of CBT-based approaches [1400]. Although there is some evidence that pharmacotherapy may be a useful adjunct to the treatment of single disorder ED (particularly binge eating disorder), the evidence is not conclusive and Australian clinical guidelines do not recommend its use in the absence of psychotherapy [870].

Box 21 illustrates the continuation of Kai’s case study, following their story after their ED was identified.

Box 21: Case study H: Treating co-occurring ED and AOD use: Kai’s story continued

Case study H: Kai’s story continued

The AOD worker consulted with an ED specialist, who arranged with Kai and their mother to attend an assessment. Kai was moderately underweight (with a BMI of 16) and the specialist arranged for a complete physical assessment, including heart rate, blood pressure, temperature, metabolic tests, assessments for any cognitive changes, and contributing factors. Kai’s family were encouraged to maintain involvement with their ongoing treatment, and the specialist devised a plan with Kai that included their family’s involvement, with a focus on medical stabilisation, psychoeducation with MI, reversal of the cognitive effects of starvation, and psychological treatment.

Kai continued working with the AOD service who provided ongoing support in relation to their goal of reducing their use of alcohol and non-prescribed opioids, but Kai said they were not ready to give up smoking. The AOD worker made a note of this and planned to explore it further using MI in a future appointment. During one follow-up appointment, the AOD worker asked Kai to take a urine test. Kai refused and left the appointment. Assuming Kai had used non-prescribed opioids between appointments and did not want them to show up in a urine test, Kai’s AOD worker called Kai and told them that it was normal to experience lapses and they would work through the process together. The AOD worker asked Kai to please come back so they could discuss Kai’s reasons for leaving, and also so she could give Kai some additional relapse prevention strategies. Kai agreed to come back.

During their next appointment, Kai told the AOD worker that they were sexually assaulted in a public toilet when they were 14, and since that time had experienced a lot of difficulty going into any public toilets, even when accompanied. The AOD worker asked Kai whether their food restriction also started around this time and thinking about it, Kai thought it may have. Kai said they had not used any opioids. The AOD worker organised a case management meeting with everyone involved in Kai’s care to reassess Kai’s treatment plan. The ED specialist was able to start addressing the underlying trauma which was recognised as a contributing factor to the ED. Kai also agreed to an inpatient stay at a specialised ED facility to stabilise their weight gain and was provided with ongoing support from their AOD worker, who was also involved in discharge planning and relapse prevention.

Key Points

It can be difficult to identify ED in people with AOD use disorders.
Once identified, it is vital that a person experiencing ED receives a comprehensive physical assessment by a medical professional. The primary focus is on stabilising the client’s physical health and restoring cognitive function, and then psychotherapy can begin.
The AOD worker should maintain client engagement, even if a referral to an ED specialist is made.