About 2.2 million American adults have obsessive-compulsive disorder (OCD). This mental illness is characterized by intrusive thoughts (like feeling contaminated) to which the person responds with ritualistic behaviors (like repetitive hand washing). Substances can help to calm the anxiety of patients with OCD and as a result, comorbid substance use disorders (SUD), can develop.
The prevalence of SUD among patients with OCD varies: One study suggested about 6% of people with OCD within a population of veterans misused substances, including opioids. Another study estimated that up to 25% of people with OCD will develop a substance use problem during their lives.
Programs that address mental health and substance misuse at the same time offer the best path toward recovery. When both issues are addressed together, sustained recovery on both fronts is more likely.
Why Do OCD & OUD Commonly Occur Together?
OCD is a condition that creates extreme anxiety: You’re convinced that your family members will die if you don’t keep the front door locked. You’re certain that your hands carry germs that could harm your baby and won’t touch him/her as a result. You think your home might burn with your dogs inside if you leave the stove burners on. These kinds of illogical, intrusive thoughts often plague individuals with OCD. 
Substances can help to relieve anxiety associated with these intrusive thoughts, and experts suggest this as one reason why individuals with OCD, and other anxiety related disorders, might have higher rates of SUD. In studies of people with OCD, 70% said they had OCD symptoms prior to the development of their substance misuse, which supports the hypothesis that the substance use is a way of soothing or managing the symptoms of OCD.
People with OCD have behaviors that they cannot seem to control: For example, turning the lights on and off many times before leaving the house, or locking the door over and over again to ensure safety. In some ways, these are similar to the compulsive behaviors exhibited by people with OUD, including compulsive use of opioids even when ones intention is not to use. Thus, these compulsive behaviors seem to overlap and may be another reason why OCD and SUD can often occur together.
Mental Health Impact of OCD & OUD
People may believe substances make life with OCD easier by alleviating the anxiety associated with this condition. But the drugs may actually exacerbate the problem, creating greater feelings of loneliness as individuals substitute drugs for social support.  Some substances may even increase the frequency of compulsive thoughts and behaviors, creating a vicious cycle. Ongoing substance misuse changes dopamine levels inside the brain. People with SUD can develop deep depression, which can also exacerbate OCD symptoms.
OCD is a difficult disease to treat, and while substances may temporarily alleviate symptoms, using substances is really putting a bandaid on a wound instead of truly focusing on more evidence based treatment for OCD, including behavioral and psychological therapies.
Treatment Options for OCD and SUD
Anyone with both a diagnosis of OCD and concurrent SUD should ideally receive treatment that addresses both of these conditions. Programs that address addiction and mental health simultaneously are called dual diagnosis programs. It’s critical to use a program like this to address both your obsessive-compulsive disorder and your opioid use disorder simultaneously.  Treating both mental health and SUD at the same time results in fewer OCD symptoms along with higher abstinence rates.
Medications For OCD and SUD
One of the medications that are often used first line to treat OCD are selective serotonin reuptake inhibitors (SSRIs). Most of these medications can be extremely helpful for OCD, but often require up to 12 weeks before you notice significant changes or improvements in symptoms.
Likewise, there are many SUD, depending on the substance in question, that have very good pharmacologic treatments. For example, for patients misusing opioids, Suboxone and Methadone are both well established, efficacious pharmacological treatments.
Exposure Response Prevention Therapy (ERP) for OCD
OCD symptoms begin with an intrusive thought. In ERP sessions, you’re exposed to triggers or stimuli while a therapist helps you avoid your typical compulsive response. You might look at a dirty sock, for example, and then resist washing your hands.
Cognitive Behavioral Therapy
Your counselor might also use Cognitive Behavioral Therapy (CBT) to help you understand your drug misuse and build your relapse prevention skills. In time, you’ll be able to handle drug triggers without relapsing. CBT is similar to ERP in some ways, but involves identifying intrusive thought and then developing concrete strategies to how to respond with behaviors that are less maladaptive.
OCD and SUD: What to do next?
If you or a loved one suffer from OCD, it is helpful to be aware of the concurrent risk for development of SUD. If you have concerns that you may suffer from one or both of these conditions, help is available! Reach out to a medical professional.
By Elena Hill, MD, MPH
Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where ... Read More
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