Addiction, recovery, & autism

Introduction

Until the last few years, research on autism and addiction has been fairly unreliable. Initially, addiction was considered to be rare among autistic individuals.^[1]High functioning autistic spectrum disorders, offending and other law-breaking: findings from a community sample (Woodbury-Smith et al. 2006) One reason for this theory stemmed from the belief that some of our autistic traits, like our differences in social interactions, may “protect” us against developing an addiction because we aren’t being exposed to abused substances as often in our social contexts.^[2]Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome (Ramos et al., 2013^[3]Treatment seeking adults with autism or ADHD and co-morbid Substance Use Disorder: Prevalence, risk factors and functional disability (Sizoo et al., 2010)

This theory is surprising since autistics are statistically more prone to mental health conditions such as anxiety and depression, and these conditions are known to be associated with substance use disorders. So why did research assume that addiction was uncommon in autism?

In most cases, researchers didn’t used to screen for substance use disorders in autistic populations, and when they did, the screening wasn’t specific to autistic patterns of behaviour.^[4]Autism Spectrum Disorder and Co-occurring Substance Use Disorder – A Systematic Review (Arnevik et al., 2016^[5]The Critical Lack of Data on Alcohol and Marijuana Use by Adolescents on the Autism Spectrum (Adhia et al., 2020 Looking back, we now know that those with autism are indeed more likely to develop substance use disorders than those without autism.^[6]Risk of Substance Use Disorder and Its Associations With Comorbidities and Psychotropic Agents in Patients With Autism (Huang et al., 2021)

Prevalence

We still don’t have reliable statistics on how many autistic people struggle with addiction, and we are likely still underestimating the prevalence rate.^[7]The Critical Lack of Data on Alcohol and Marijuana Use by Adolescents on the Autism Spectrum (Adhia et al., 2020)^[8]Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders (Ressel et al., 2020) One recent study suggests that up to 36% of individuals with autism may have co-occurring substance abuse struggles.^[9]Prevalence and correlates of autism in a state psychiatric hospital (Mandell et al., 2012) At 36%, this (under)estimate is higher than the prevalence rate in the Canadian general population at 21.6%.^[10]Mental and substance use disorders in Canada | Statistics Canada

To further emphasize that addiction may be underestimated in the autistic population, one study suggested that 20% of people seeking treatment for addiction may have undiagnosed autistic traits.^[11]Characterizing autistic traits in treatment-seeking young adults with substance use disorders (McKowen, 2022) Therefore, we may be undercounting how many autistic people struggle with substance abuse because many of these individuals may not know they are autistic.

Risks

Co-occurring mental health conditions

It is well documented that depression, anxiety, and other mental health conditions increase a person’s likelihood of substance use.^[12]The interrelationship between alcoholism, depression, and anxiety (Tindle et al., 2021) This is relevant since many autistics struggle with depression and anxiety and use substances as a coping mechanism. Using substances may help to alleviate stress by disengaging from stressful situations.^[13]Coping styles in substance use disorder (SUD) patients with and without co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) (Kronenberg, et al., 2015)

Substance use has been found to relieve psychological distress associated with difficulties regulating overwhelming thoughts and emotions. For example, substances can help dampen strong emotions and distract from negative thoughts.^[14]Personal Recovery in Individuals Diagnosed with Substance use Disorder (SUD) and Co-Occurring Attention Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) (Kronenberg, et al., 2015)^[15]Substance use disorder in Asperger syndrome: An investigation into the development and maintenance of substance use disorder by individuals with a diagnosis of Asperger syndrome (Clarke et al., 2016)

Late Diagnosis

Late diagnosis is an important factor to consider when evaluating the overall well-being of autistic individuals. Research shows that adult-diagnosed autistics are more likely to experience mental health conditions than childhood-diagnosed autistics.^[16]Associations between co-occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research (Jadev & Bal, 2022) Some late-diagnosed individuals report that if they had known about their autism sooner in life, they would have been able to seek out appropriate support and would not have needed to turn to substance use as a coping mechanism.^[17]Personal Recovery in Individuals Diagnosed with Substance use Disorder (SUD) and Co-Occurring Attention Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) (Kronenberg, et al., 2015)

Loneliness

Many autistics feel a lack of belonging among groups and report having smaller social networks. Thus, many autistics are particularly motivated to engage in strategies that may facilitate social interactions.^[18]Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders (Ressel et al., 2020)^[19]Personality characteristics of adults with autism spectrum disorders or attention deficit hyperactivity disorder with and without substance use disorders (Sizoo et al., 2009) For example, drinking alcohol may alleviate anxiety in social situations.^[20]Substance-use disorder in high-functioning autism: clinical and neurocognitive insights from two case reports (Lalanne et al., 2015)^[21]Everyday life consequences of substance use in adult patients with a substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD): a patient’s perspective (Kronenberg, et al., 2014)

These feelings of loneliness and lack of belonging are exacerbated by efforts made to camouflage and mask our autistic traits in social situations.^[22]Understanding the Reasons, Contexts and Costs of Camouflaging for Autistic Adults (Cage & Troxell-Whitman, 2019) Some individuals may find themselves in a cycle of feeling lonely resulting in poorer mental health, camouflaging to compensate in social situations to try and fit in, and then using substances to help cope with the loneliness, social anxiety, and efforts put into hiding autistic traits.

Familial substance abuse

Just like in the general population, there is an association between familial history of addiction and addiction in autistic individuals. One study found that being autistic doubles your risk of substance use problems and your family members were also at elevated risk. This suggests that there is some shared genetic and environmental vulnerability.^[23]Increased Risk for Substance Use-Related Problems in Autism Spectrum Disorders: A Population-Based Cohort Study (Butwicka, et al., 2017) In this case, environmental factors include adverse childhood experiences, like abuse experienced at home.^[24]Treatment seeking adults with autism or ADHD and co-morbid Substance Use Disorder: Prevalence, risk factors and functional disability (Sizoo et al., 2010)

Protective factors

My (Debra’s) theory is that stability may be an important factor that protects us from struggling with substance use. One common autistic trait is the preference for structure, routine, and predictability. If we are privileged enough to understand our autistic needs and be in an environment that supports these needs, we may be less likely to cope with volatility by using substances.

This theory comes from findings that autistics use substances to cope with a lack of stability related to stress and anxiety, changes in mood, and emotional dysregulation. I imagine that substances may also help relieve and numb the feelings associated with a lack of stability from sensory overwhelm, navigating complicated social situations, and experiencing meltdowns. One study supports this theory by finding that substance use was lower among autistics who were taking psychotropic medication such as anti-depressants, anti-psychotics, and mood stabilizers.^[25]Risk of Substance Use Disorder and Its Associations With Comorbidities and Psychotropic Agents in Patients With Autism (Huang et al., 2021)

This suggests that seeking support for our mental health struggles and for meeting our environmental and social needs is crucial for treating and protecting against addiction.

Natalie also theorizes that autistics may be more successful at recovering from substance use due to our increased likelihood to seek treatment. It is possible that the higher we score on psychometrics such as the AQ, the more likely we are to seek treatment. This may be in part due to autistics displaying higher levels of honesty and thus a higher propensity to recognize and admit that we are struggling with addiction.

Evidence to support this theory comes from findings that autistics in treatment tend to already recognize that their substance use is a means to cope with stress and that their stress originates from living in a neurotypical-dominated world.^[26]Personal Recovery in Individuals Diagnosed with Substance use Disorder (SUD) and Co-Occurring Attention Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) (Kronenberg, et al., 2015)

Treatment

In order to support successful treatment for autistic individuals, mental health professionals must receive autism training. It is clear that a large part of supporting autistic adults is to provide adequate mental healthcare for coexisting psychiatric conditions. These supports need to include psychoeducation around coping with stresses commonly experienced by autistics, such as sensory sensitivities and social challenges.

In addition, research on treatments for substance use problems need to be developed with the unique needs of autistic individuals in mind. Thus far, autistic-informed treatments are lacking and traditional addiction treatments don’t seem to be as effective in autistic populations. Clinical findings from newly developed autistic-focused treatment approaches are promising and we hope to see more autistic-focsued treatments in the near future!^[27]Patients With Autism Spectrum Disorder and Cooccurring Substance Use Disorder: A Clinical Intervention Study (Walhout et al., 2022)

If you are an Ontario resident, Natalie recommends accessing the Renascent Centre. This addiction treatment centre has a variety of programs available free of charge. Most of all, the Renascent Centre is focused on gaining more knowledge about autism.