Cross Addiction Isn’t a Myth

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© vlue 123RF.com

Last year there was a study published in JAMA Psychiatry that concluded there was a lower risk of developing a new SUD (substance use disorder, the new DSM-5 lingo) if the individual had “remitted” from a SUD in the past. The results indicated that remitters had “less than half the risk of developing a new SUD.” So contrary to “clinical lore,” achieving remission does not lead to drug substitution, but rather to a lower risk of new SUDs.

There was a Reuters article, “Former Addicts May be at Lower Risk of New Addictions,” that discussed the study’s results. Mark Olfson, the senior author of the study, was quoted by Reuters as saying the results “cut against conventional clinical lore” that suggests people who stop one addiction are at risk of starting a new one. “The results challenge the old stereotype that people switch or substitute addictions but never truly overcome them.” He went on to say:

While it would be foolish to assume that people who quit one drug have no risk of becoming addicted to another drug, the new results should give encouragement to people who succeed in overcoming an addiction.

Commenting on the study to Reuters, Olaya García-Rodríguez, who was not one of the study’s researchers, said: “To achieve remission, most individuals need to make changes in their lifestyle and learn strategies to avoid substance use that will eventually protect against the onset of new addictions.” They learn to avoid substance-related people, place and things. They develop more behavioral coping strategies. Improved family relationships, better health and financial stability can also contributed to their ability to maintain abstinence. She suggested that we should rethink the perception that SUDs are chronic illnesses as the study indicated that remission was possible.

There was also an article on The Fix, titled: “New Study Disproves So-Called ‘Cross-Addiction’ Myth. The author began her article by saying that it is often believed that people who have a substance use disorder are at increased risk for developing another. However, the JAMA Psychiatry study debunked this so-called “cross-addiction” myth. When comparing the two articles, it seemed to me that they both reported much of the same information. Both even quoted the above block quote by Mark Olfson. And yet The Fix article concluded the study had debunked the cross-addiction myth, while the Reuters article was suggesting that there was little support for the hypothesis that conquering one addiction leaves you vulnerable to substituting another substance.

It does seem that Mark Olfson sees his work as challenging the notion of switching or substituting addictions, but even he said it would be foolish to assume people who quit one drug have no risk of becoming addicted to another drug.  Not only would it be foolish to conclude the study disproved cross-addiction, but to simply stop where The Fix author did with her understanding of its implications would be dangerous for some people with a SUD. So I decided to look at the study myself, “Testing the Drug Substitution Switching-Addictions Hypothesis.” You can review the article abstract here.

There were two “waves” to the data gathering that occurred an average of 36 months apart. Individuals were considered to have remitted from an SUD (abuse or dependence) if by the wave 2 assessment they did not meet the DSM-IV criteria for that disorder in wave 2, but had met the criteria in wave 1.

Individuals who met the criteria for abuse at wave 1, but later met the criteria for dependence (a more serious diagnosis) at wave 2, were seen as having a new-onset SUD. Individuals who met the criteria for dependence at wave 1 (which meant they also met the criteria for the less serious diagnosis of abuse), were not counted as in remission at wave 2 if they still met the abuse criteria, but no longer met the dependence criteria.

Having a new SUD was defined as having an SUD at wave 2, but no lifetime history of that SUD at wave 1. Relapse was a new episode of an SUD at wave 2 among individuals with a lifetime history of the SUD that was in remission at wave 1. So far, so good. The diagnostic distinctions and operational definitions for remission, relapse and a new SUD made sense. Now let’s look at the results. Remember that there was a 36-month average time period between wave 1 and wave 2.

Individuals who did not remit an SUD were more likely to have a new SUD at wave 2 than individuals who did remit (43.3% for non-remitters versus 8.7% for remitters). This makes sense. People with an SUD who continued active substance use had a greater likelihood of “catching” a second one in 3 years. Remitters with only one SUD at wave 1 were less likely to have a new SUD at wave 2 than non-remitters (10.0% versus 24.3%). Remitters with two or more SUDs at wave 1 were also less likely to have a new SUD at wave 2 than non-remitters (21.4% versus 46.3%).

It seemed the presence of multiple SUDs at wave 1 was a significant factor in remission. The proportion of individuals with 1 SUD at wave 1 who remitted was 41.1%. “Among individuals with 2 or more SUDs, 17.1% remitted from all of them, 46.9% from at least 1 of them, and 36.6% did not remit from any of them.”

Taken together, our findings indicate that remission of an SUD is not associated with an increase but rather with a dramatic decrease in the risk of a new-onset SUD or relapse onto a previously remitted SUD.

Some observations need to be made about the study. First, as the study noted, there were several likely mechanisms that contributed to “the protective effects of SUD remission from new-onset SUDs.” The avoidance of drug-related cues and drug-using peers (avoiding people, places and things associated with addiction) would not only assist in blocking SUD remission, but also in inhibiting new-onset SUDs. The lifestyle changes made by successful remitters would make it less likely they could “catch” a new SUD.

The study also did not include any information on whether other substances were used during the time of remission. For example, someone with an opioid SUD remission in the study could have used and even been drunk on alcohol off and on during their remission time without meeting the criteria for an alcohol use disorder diagnosis. Alcohol use disorders will typically take a longer period of time to progress from initial use to meeting the criteria for an SUD diagnosis.

In addition, the assessment of what the researchers referred to in their study title as “switching-addictions hypothesis” was limited to assessing the risk of developing another SUD. “Adults who recover from an SUD are often thought to be at increased risk for developing another SUD.” Ironically, the study cited in support of this statement, “Substitute Addiction: A Concern for Researchers and Practitioners,” had a broader understanding of what a substitute addiction could be. In addition to substance addictions, they also looked at how process addictions and food could become “substitute addictions.”

Sussman and Black, the authors of the study, described process addictions as “a series of pathological behaviors that exposes one to ‘mood-altering events’ on which one achieves pleasure and becomes dependent.”  They said process addictions involved a relatively indirect manipulation of pleasure through situational and physical activity. Examples of process addictions they said were identified in the literature included: video game playing, gambling, Internet use, sex, work, exercise, compulsive spending, and religion.

That there may be a wide variety of behaviors that one can become dependent on, repeat excessively, and suffer consequences from, suggests the opportunity for someone to participate in these behaviors sequentially; one replacing functions of the other. In the recovery movement, substitute addictions have been addressed as an issue about which persons in recovery should be vigilant.

So I don’t think the study goes against conventional clinical lore that people who stop one addiction are at risk to develop a new one. It does not debunk the so-called “cross-addiction” myth. It does indicate that individuals who successfully establish a lifestyle that is not full of drug-related cues and drug-using peers will have a decreased chance of developing a new SUD.

In closing, I thought the following results, while not directly related to the purpose of the study, were particularly interesting. Individuals who sought treatment between wave 1 and wave 2 “were significantly more likely to remit than those who did not (36.8% versus 19.2%).” After adjusting for remission status (remission versus non-remission), individuals who sought treatment had the lower odds of a new-onset SUD at wave 2. “The probability of a new-onset SUD was lowest for abstinent remitters (12.4%), intermediate for nonabstinent remitters (15.2%), and highest for nonremitters (27.2%).”

I’d say the “cross-addiction myth” is very much alive and well. And it isn’t just a myth.


Stinkin’ Thinkin’ Addiction

© Gennadiy Kravchenko | 123RF.com

© Gennadiy Kravchenko | 123RF.com

“Most Substance-addicted people are also addicted to thinking, meaning they have a compulsive and unhealthy relationship with their own thinking.” (David Foster Wallace, Infinite Jest)

Once a person becomes dependent upon a drug there is a tendency to transfer that addiction to other mood-altering substances. This is what is meant by cross addiction. If an individual becomes addicted to one drug, they can rapidly develop an addiction to another drug in that class of drugs. The reason is mostly physical. The body becomes accustomed to the effects of one kind of drug and will have an affinity to drugs that are similar. “Cross addiction occurs because all addictions work in the same part of the brain.” For an in-depth examination of the neurobiological factors underlying drug addiction and relapse, read “Neuroplasticity in Drug Addiction” on “Terry Gorski’s Blog.”

A chemically dependent person who comes to rely on a particular drug may, for various reasons, decide to abstain from that drug. If they substitute something else, it may not be as effective as the original drug of choice was for them. This can lead to thinking about or craving the original drug. Intoxication with the substitute drug that results in impaired thinking could lead them to use their primary drug again. You don’t have to be incredibly intoxicated either. You just have to be high enough to want your drug of choice and be willing to act on the impulse.

Alisha celebrated a years worth of clean time since she stopped using cocaine. She went out to dinner with a guy on a first date. He must have wanted to impress her, because he’d taken her to a very nice restaurant. He didn’t know about her history and ordered a bottle of wine. Alisha didn’t see the harm in having a glass or two of wine; alcohol had never been her thing. In the middle of the dinner she excused herself and called her cocaine dealer from the bathroom.

In The Science of Addiction, Carleton Erickson said that cross-dependence or cross-tolerance occurs between drugs within the same class. So when a person becomes dependent upon one benzodiazepine, they are dependent upon other benzodiazepines. “It is also possible for a person to be cross-tolerant to drugs of different classes.” One example could be benzodiazepines and alcohol.

Cross-dependence between classes occurs as well. “Reports suggest that such cross-dependence occurs between alcohol and cocaine, alcohol and nicotine, alcohol and benzodiazepines, and heroin and cocaine.” Terence Gorski suggested that this cross-dependency is likely to develop gradually. Early in my professional career I referred a heroin addict to an inpatient detox and rehab program, expecting that the individual would be referred back once the inpatient treatment was completed. In their infinite wisdom, the treatment staff referred the man to a methadone clinic. Two or three years later, he came back to my outpatient program, but not for heroin. He never resumed using heroin. Now he had a serious alcohol problem. What started out as a few drinks to take the edge off became a full-blown alcohol dependency problem.

Substance use disorders cannot be effectively treated as if each one is a discrete disease entity. Stable, long term sobriety is only possible if the person lays a foundation of abstinence from all addictive drugs and then works through the personal and social dysfunction that inhabited their life concurrently with their substance use. Sobriety is not simply whether or not you are drinking or using drugs. A relapse begins sometime before the individual resumes active drinking or drug use. Terence Gorski has said:

Sobriety is abstinence from addictive drugs plus abstinence from compulsive behaviors plus improvements in bio-psycho-social health. Sobriety includes all three things. To the extent that you have accomplished those three things you are sober; to the extent that you have not accomplished those three things you are not sober.

The grey area between initial abstinence and sobriety is where cross-addictions develop. These substitutes can be other chemicals or compulsive behaviors—what Gorski referred to as “process addictions.” These compulsive behaviors/process addictions will typically fall into eight types: 1) eating/dieting; 2) gambling; 3) working/achieving; 4) exercising; 5) sex; 6) thrill seeking; 7) escape; 8) spending.

Compulsive behaviors are actions that can produce excitement or emotional release, what Gorski called an addictive brain response. “This means that the brain is flooded with pleasure chemicals that create a unique sense of euphoria while being inhibiting from producing warning chemicals which cause the feelings of stress, anxiety, fear, and panic.” So these triggers initiate a neurochemical reaction that reinforces the person to keep pulling the addictive trigger.

Evidence supportive of this view is found in the treatment of pathological gambling with the opiate antagonist, naltrexone (here). Piz et al. published a case report where a patient with a compulsive gambling problem avoided a resumption of gambling for three years while taking naltrexone.

Many people begin with a chemical addiction and in sobriety “crossover” or “migrate” into a process addiction. In his book, Staying Sober, Terence Gorski noted how the same behaviors could be compulsive, process addictions or positive outlets. “Every behavior that can be used compulsively, can be productive if used in a way that does not result in long-term pain or dysfunction.” A behavior that is used compulsively is used as some people use drugs—to alter mood, turn off mind and evade reality. Behaviors are positive outlets when they enhance reality and help a person to cope more effectively with reality.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.