Substance use disorders (SUD) are quite common. In 2014, 20.2 million adults in the USA aged 18 years or older reported a substance abuse disorder. The majority (16.2 million) had an alcohol use disorder, while 6.2 million had an illicit drug use disorder (https://www.samhsa.gov/data/sites/default/files/report_2790/ShortReport-2790.html). According to the National Institute on Drug Abuse, the annual cost of substance abuse is more than $740 billion when considering expenses related to crime, lost work productivity, and health care. (https://www.drugabuse.gov/related-topics/trends-statistics)

Given the high prevalence of SUDs and its co-occurrence with other mental disorders I have always wondered why there have been only a few reports focusing on drug addiction and autism. Indeed, a recent study that examined the Swedish based population registry found 26,986 individuals with an ASD diagnosis.  According to this study, the risk for substance use disorder in ASD doubled that of the control population (Butwicka et al., 2017). Furthermore, higher prevalence rates, ranging from 19-30%, have been reported in the clinical setting (Hofvander et al., 2009; Sizoo et al., 2010).  Risk appears to be highest during times of transition in children’s lives: when they leave the security of the home to enter school or upon entering high school and facing additional social, emotional and educational challenges.  If left unattended, substance abuse in adolescents can lead to increased risk of sexually transmitted infections, vehicular fatalities and juvenile delinquency.

Despite some studies showing lower prevalence rates of SUDs in ASD (Ramos et al., 2013), there seems to be cause for concern. Some studies have found increased risk of substance-use related problems among relatives of ASD individuals (Miles et al., 2003).  This is of importance as proximal social factors exert a strong influence on substance use behaviors. In addition, I have always found it noteworthy that there is a higher risk for ASD among the children of parents with alcohol abuse problems (Sundquist et al., 2014).  Alcohol consumption is associated with an increased rate of de novo mutations in germ cells (sperms and eggs) that have been implicated in the pathogenesis of autism and attention-deficit/hyperactivity disorder.

Researchers and caregivers have questioned the putative correlation between autism and SUD.  After all, ASD individuals do not seek to engage in the same social patterns that procreate substance abuse. Still, individuals in the autism spectrum may use drugs or consume alcohol either as a way of self-medicating for stress, or as a result of an impulse control problem (ADHD subgroup), or due to their obsessive-compulsive nature.  Furthermore, ASD individuals may also have to deal with other mental disorders (e.g., depression) that make them easier prey for drug abuse or for relapse after treatment.

When talking about SUD, autistic individuals have specific requirements that need to be addressed. How do your report problems when you have difficulties in communication?  How can you perform group sessions when an individual has problems interacting within social gatherings? Keep in mind that many therapeutic attempts at SUD will use group sessions to address the emotional or substance use burden of family members or friends.

Some suggestions for therapeutic endeavors include the following:

• Incorporate visual learning tools.
• Treatment should address, when appropriate, comorbid conditions like anxiety or depression.
• Cognitive Behavioral Therapy, has proven efficacy as monotherapy and combination treatment. It should be considered in higher functioning ASD individuals.
• In many cases there is a need to address avoidance or for minimizing contact with high-risk people as well as to develop a recovery network of supportive people.
• In order to resist the social pressure to use drugs, we need to improve communication and assertiveness skills.
• Always remember that an important risk factor for SUDs is lack of parental supervision- therefore, as parents, it is important to monitor and institute preventive strategies when appropriate.
• Because risks appear at every life transition, prevention planners need to choose programs that strengthen protective factors at each stage of development.

A new book entitled, “Drinking, Drug Use, and Addiction in the Autism Community” by Elizabeth Kunreuther (Jessica Kingsley Publishers) explores why addiction appears to be more common in this patient population, describes how substance use affects people on the spectrum, and provides helpful suggestions as to how to screen and modify treatment to accommodate the characteristics of ASD.

Other resources:

Alcohol and Drug Addiction Happens in the Best of Families https://store.samhsa.gov/product/Alcohol-and-Drug-Addiction-Happens-in-the-Best-of-Families/SMA12-4159

It Feels so Bad: It doesn’t Have to https://store.samhsa.gov/product/It-Feels-So-Bad/SMA12-4160

References

Butwicka A, Langstrom N, Larsson H, et al., Increased risk for substance use-related problems in autism spectrum disorders; a population-based cohort study. J Autism Dev Disord 47(1):80-89, 2017.

Hofvabder B, Delorme R, Chaste P, et al. Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders. BMC Psychiatry 9:35, 2009.

Miles JH, Takahashi TN, Haber A. Hadden L. Autism families with a high incidence of alcoholism. Journal of Autism and Developmental Disorders 33(4):403-415, 2003.

Ramos M, Boada L, Moreno C, LLorente C, Romo J, Parellada M. Attitude and risk of substance  use in adolexcents diagnosed with Asperger syndrome. Drug and Alcohol Dependence 133(2):535-540, 2013.

Sizoo B, van den Brink W, Koeter M, Gorissen van Eenige M, van Wijngaarden-Cremers P, van der Gaag RJ. Treatment seeking adults with autism or ADHD and co-morbid substance use disorder: Prevalence, risk factors and functional disability. Drug and Alcohol Dependence, 107(1):44–50, 2010.

Sundquist J, Sundquist K, Ji J. Autism and attention-deficit/hyperactivity disorder among individuals with a family history of alcohol use disorder. Elife 3:e02917, 2014.