Wednesday, September 17, 2014

The Myth of "Cross-Addiction" Debunked

For decades, the conventional wisdom and clinical lore in rehab facilities and recovery communities has warned against the risks of so-called "cross-addiction". "Be careful," they say, "you're at-risk of picking up a new addiction now that you've kicked one habit." Heroin addicts are warned against developing an addiction to alcohol, and cocaine addicts are warned against developing an addiction to opiates, Cross-addiction can even occur to things like exercise or sugar, according to pamphlets and even therapists who have worked in the field for years and years.

But is it even true? Is the notion of cross-addiction supported by empirical evidence - or does it fall on its face under scientific scrutiny?

According to a new report, published September 10 in JAMA Psychiatry, the answer is a resounding, "No."

The study, "Testing the Drug Substitution Switching-Addictions Hypothesis," analyzed data from the National Epidemiological Study on Alcohol and Related Conditions (NESARC) to investigate whether participants developed new-onset substance use disorders (SUD) after remission from a previous SUD. These data were then compared against people with a SUD who did not achieve remission but also developed a new-onset SUD.

The authors discovered that, "As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets."

This is probably the best evidence to-date that addresses the concept of cross-addiction. Will counselors and agencies begin to pull back from this concept - or will clients still be subjected to homework assignments and lectures warning against it?

Here's the abstract from JAMA Psychiatry (found here:

Importance  Adults who remit from a substance use disorder (SUD) are often thought to be at increased risk for developing another SUD. A greater understanding of the prevalence and risk factors for drug substitution would inform clinical monitoring and management.
Objective  To determine whether remission from an SUD increases the risk of onset of a new SUD after a 3-year follow-up compared with lack of remission from an SUD and whether sociodemographic characteristics and psychiatric disorders, including personality disorders, independently predict a new-onset SUD.
Design, Setting, and Participants  A prospective cohort study where data were drawn from a nationally representative sample of 34 653 adults from the National Epidemiologic Survey on Alcohol and Related Conditions. Participants were interviewed twice, 3 years apart (wave 1, 2001–2002; wave 2, 2004–2005).
Main Outcomes and Measures  We compared new-onset SUDs among individuals with at least 1 current SUD at wave 1 who did not remit from any SUDs at wave 2 (n = 3275) and among individuals with at least 1 current SUD at wave 1 who remitted at wave 2 (n = 2741).
Results  Approximately one-fifth (n = 2741) of the total sample had developed a new-onset SUD at the wave 2 assessment. Individuals who remitted from 1 SUD during this period were significantly less likely than those who did not remit to develop a new SUD (13.1% vs 27.2%, P < .001). Results were robust to sample specification. An exception was that remission from a drug use disorder increased the odds of a new SUD (odds ratio [OR] = 1.46; 95% CI, 1.11-1.92). However, after adjusting for the number of SUDs at baseline, remission from drug use disorders decreased the odds of a new-onset SUD (OR = 0.66; 95% CI, 0.46-0.95) whereas the number of baseline SUDs increased those odds (OR=1.68; 95% CI, 1.43-1.98). Being male, younger in age, never married, having an earlier age at substance use onset, and psychiatric comorbidity significantly increased the odds of a new-onset SUD during the follow-up period.
Conclusions and Relevance  As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets.


  1. “Cross Addictions,” are always an issue in that humans have a tendency to do the wrong thing. We aren’t powerless over our decisions (free will) but we do have a tendency to make poor decisions.
    When individuals have not faced their core issues in facing stressful circumstances in life, then we often continue to respond with Quick Fixes and Mood Changers that are attempts to regain control of our helpless issues.

  2. Thanks for bringing this to my attention Ian. I haven't read this yet, but I would say that this aligns with my experiences with patients. Although I do believe in the syndromal model where multiple manifestations are possible, I also believe that once the addictive disorder is resolved then the manifestations will not switch to new drugs or activity. Where I have my doubts is when remission is regarded purely as abstinence from the substance of choice without considering other life dimensions. For me abstinence is one of the least reliable indicators of recovery from an addictive disorder, rather quality of relationships and social integration are the true indicators, in my opinion. Will read the study over the weekend.

  3. In visiting rehabs for my book, Inside Rehab, a prominent 12-step-based rehab insisted use of ANY substances was problematic and basically considered a relapse. I asked its research dept several times for supporting evidence and received no reply. Sad that patients keep being fed unsupported information that can become a self-fulfilling prophecy. E.g., wine was never a problem for someone who recovered from opioid dependence but he has a drink and figures he blew it (relapsed) and may as well use drugs again.

    1. I wonder if the wine drinker relapsed from believing in a shame fueled ideology of a disease over which they have no control (AA), or the wine drinker's cognitive immunity was decreased and they lost control and drank to much......?

    2. Correct me if I can't read, but it seems this study is comparing those who remitted from those who did not and found that those who remitted had a 50% chance of developing a new SUD. I think a 50/50 chance of developing a new addiction is far above the national average for drug addiction for those who have not had an SUD. This article is saying that the chances are statistically high (50% vs say 7-9% for nat avg) for a drug user to develop a new addiction after remittance. An absitent addict faces 50/50 odds when deciding to use substances outside of their original class of drug addiction. Those sound like roulette odds, Russian roulette would have a lower chance of impairing ones life significantly...according to the evidence presented here. Not sure it would be worth the risk to experiment with different drugs for the remitted.

    3. Actually, the total proportion of the sample who developed a new SUD was about 20%. In those who remitted, it was only 13%, compared to 26% in those who did not.

    4. I do get a little confused by numbers, thanks for trying to clear it up for me. So those who overcame one addiction had less than half the chance of developing a new SUD as compared to those who never remitted from their initial SUD?
      Is that correct? If so, it would speak more to the person learning from their experience and perhaps not being willing to try new substances, rather than their actually experimenting with new substances and finding out that lo and behold they didn't get addicted to that (italicized). People with SUD's who never remit are obviously more likely to try other substances to the point of possible addiction as they have never achieved recovery from their first SUD and do not have the requisite coping skills, medication, support, etc that would be protective. If anything, this study speaks to the higher likelihood of cross-addiction in the abscence of prior remission, rather than any kind of disproof of the old cross-addiction theory. I think there is meaningful data in the study, but the manner in which it is presented seems to be slanted towards beating the dead horse of an old argument that nobody gives a shit about anyways. You ask anybody with any amount of sobriety if it would be foolish to try a substance if they were never addicted to it, and they would most likely tell you and your interpretation of the data to take a proverbial hike. Most people who have remitted are not scared so much as developing a new SUD as they are by any alteration in consciousness with any drug will increase the odds they will return to that one substance they did have a problem with in the past. Have there been any studies on what has happened to 'remitters' who have tried novel substances to see if they returned to their original SUD. That is perhaps the most prevalent and realistic fear among 12-step abstinence-based programs. Let's not use data to win old arguments but rather think about what it does or does not say and what possibly more meaningful questions can be asked in the future. What do you think?