A Look at the Comorbidity of Eating Disorders and Addiction

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CLINICAL CONVERSATIONS

Psychiatric Times® sat down with Elizabeth Wassenaar, MD, MS, CEDS-S, DFAPA, regional medical director of the Eating Recovery Center in Denver, Colorado, to discuss the comorbidity of eating disorders and addiction, as well as the effects of semaglutide and other GLP-1 agonists on patients with eating disorders.

Psychiatric Times: How common is the comorbidity of eating disorders and addiction? How might the neurobiological pathways implicated in eating disorders intersect with those involved in addiction, and what implications does this have for the use of medications like semaglutide in managing these overlapping conditions?

Elizabeth Wassenaar: The lifetime co-occurrence of eating disorders and substance use disorders was reported to be 21.9% in 2019,¹ and some studies report that up to 50% of individuals with an eating disorder will abuse substances. The most commonly misused substances were tobacco, caffeine, and alcohol, and female-identifying patients with binge-purge eating disorders were most commonly affected.

There are common neurobiological pathways implicated in eating disorders and substance use disorders, especially dopamine and endogenous opiate pathways. There is evidence that GLP-1 receptors also exist in reward areas of the brain and decrease rewards related to eating, including anticipation of food. GLP-1 receptor agonists' impact on dopamine may also have implications for addictive processes in the brain.

PT: Research suggests that semaglutide and other GLP-1 agonists may influence appetite regulation and weight management, which are significant components of eating disorder pathology. How does the mechanism of action of these drugs impact individuals with eating disorders or addiction, considering the potential for weight loss and its effect on appetite regulation?

Wassenaar: GLP-1 receptor agonists work in the brain to suppress appetite and increase feelings of fullness, which is how they act for individuals who take them to manage their type 2 diabetes. We are beginning to notice patients who are vulnerable to disordered eating and/or relapse of their eating disorder following the initiation of GLP-1 receptor agonist medications.

PT: There is potentially a link between addiction-related neurobiological changes and disordered eating behaviors. How do you navigate the complexities of treating patients with both addiction and eating disorders, particularly concerning medications like semaglutide and other GLP-1s that may influence these underlying neural pathways?

Wassenaar: The impact of drugs like semaglutide on mental health is not yet well understood. We do not yet understand which patients are vulnerable to the negative impact of these medications versus which patients may find mental health benefits.

PT: How do you assess the risk of addiction or misuse associated with semaglutide and other GLP-1 agonists when considering their use in treatment plans for patients with eating disorders?

Wassenaar: The biggest risk that I have seen is precipitating a severe eating disorder and medical complications of malnutrition. Eating disorders are one of the most fatal mental illnesses, and prescribing a medication that has the potential to trigger this is very concerning.

With the opiate crisis, many practitioners thought they were being helpful and addressing pain in ways that provided better care. It was not until years and decades later we learned the tragic dark side of prescription opiate pain medications and how they could trigger the mental illness of addiction, and now we are dealing with the fallout of this prescribing practice.

I worry that GLP-1 RAs could have a similar impact on eating disorders, in that we will not know the true harm for many years, and by then, countless individuals will have suffered from preventable mental illness.

Dr Wassenaar is the regional medical director of the Eating Recovery Center in Denver, Colorado.

Reference

1. Bahji A, Mazhar MN, Hudson CC, et al. Prevalence of substance use disorder comorbidity among individuals with eating disorders: a systematic review and meta-analysis. Psychiatry Res. 2019;273:58-66.