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Are You Really at Risk for Cross Addiction?

“If it’s not one thing it’s another”

If you go to rehab, it’s likely that you’ll be warned about the potential for “cross addiction” to substances that are not your “drug of choice.” For instance, if you’re in treatment for a drinking problem, you’ll likely be warned about the risk for developing an addiction to opioids, even if you never liked the feeling from painkillers. And if you’re addicted to heroin but never had a problem with alcohol, you’ll still be told about your vulnerability for becoming an alcoholic. Sometimes, they’re even warned about the prospect of substituting behaviors like excessive eating, sex, and exercise as a form of cross addiction.

On his blog, Robert Weiss, LCSW and senior vice president of clinical development with Elements Behavioral Health says, “Frankly, battling cross- and co-occurring disorders can feel a bit like playing a game of addiction-related whac-a-mole. One addiction pops up, and while you’re busy pounding it down another problem emerges.” But is it really true that people who overcome one addiction are at increased risk for developing another one down the road? Just how likely are they to substitute another substance when they give up their drug of choice?

New Research Challenges the Cross Addiction Hypothesis

To answer these questions, a team of researchers from Columbia University Medical Center and the New York State Psychiatric Institute analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions, a large nationally representative sample of adults, and published their findings in the September 10, 2014 issue of JAMA Psychiatry.

They compared two groups of people from that study: 1) adults who had a substance use disorder who overcame it and 2) adults who had a substance use disorder who did not overcome it. All participants were interviewed twice, three years apart. After three years, those who overcame their original substance use disorder were about half as likely to develop a new substance disorder (13 percent developed a new addiction) as those who did not overcome their original substance disorder (27 percent developed a new addiction.) One of the researchers, Mark Olfson, M.D., MPH, told me, “Because both groups had around three thousand people in them, we are confident in our results.”

The results overturn an old idea that when people give up an addiction they are at particularly high risk of picking up a new addiction.-Dr. Mark Olfson

He added, “The results overturn an old idea that when people give up an addiction they are at particularly high risk of picking up a new addiction. In fact, the people who are able to give up the first addiction are about half as likely to pick up a new addiction as those who couldn’t give up the first addiction.”

Why is cross addiction less likely in recovered people? Dr. Olfson believes it’s probably because the same factors that helped people give up the first addiction help them resist a new one. The researchers note, “Coping strategies, skills, and motivation of individuals who remit from an SUD may also protect them from the onset of a new SUD.” For instance, they may avoid or better handle triggers for use and avoid drug- and alcohol-using peers (and dealers), which often lead to recurrences.

Can People Recovered from Drug Addiction Ever Drink?
Or Vice Versa?

Another common part of the cross addiction message at treatment programs and at 12-step meetings is that there is no such thing as a “safe” substance for people in recovery. This stems from the notion that if you’re addicted to one substance, you’re likely to be addicted to all of them.

…people addicted to opioids such as heroin or prescription painkillers are commonly told that they can never pick up an alcoholic drink or smoke marijuana.-Anne Fletcher

When visiting facilities across the U.S. while writing Inside Rehab, counselors commonly told me that one of their greatest challenges was getting clients to accept that they have to abstain from all drugs (including alcohol) that might be addictive, even if they’ve never had a problem with substances outside of their drug of choice. For instance, people addicted to opioids such as heroin or prescription painkillers are commonly told that they can never pick up an alcoholic drink or smoke marijuana. And people are often terrified about taking prescribed medications that have addiction potential, even when necessary.

A counselor at a prominent rehab told me, it’s widely believed that “people who continue to use [anything] have a greater risk of relapsing.” When I asked if there are studies supporting this notion, I got no response, which then led me to wonder if such warnings could become a self-fulfilling prophecy.

If you’re repeatedly told that use of any alcohol or drugs will lead you back to ruin, why not throw in the towel the minute you “succumb” to any use?

This appears to be just what happened to Sarah H., who never had any trouble with alcohol, despite serious problems with illicit drugs. After residential treatment for a crystal meth addiction, she said, “They scared me so much about alcohol that I was afraid to go into grocery stores. My dad had to go with me.” Two and a half years into her recovery she drank some alcohol. She then said to herself, “Oh well, I’ve done it now; I’m using, so I may as well use meth and keep using before they make me stop.” This led to a lengthy return to heavy drug use, including eventual heroin use.

(When I last spoke with her, she was off hard drugs, close to getting her doctorate, and occasionally had a glass of wine but was vigilant about her use.)

Interestingly, although the Psychiatry “cross addiction” study data do not support this one way or the other, the researchers warn, “Exposure to other substances, even among individuals who achieve remission from one SUD, may increase the risk of a new-onset SUD or relapse. This pattern highlights the importance of abstaining from any substance use for individuals in remission of an SUD.” I asked Dr. Olfson about this, and he affirmed that he and his colleagues said this because they were concerned that readers might take their data as license to use substances that were not originally their “drug of choice.”

While certainly no one wants to encourage recovered people to start using drugs and alcohol again – and many of us do know someone who switched to a new drug after giving up another one – we don’t want them to be walking on pins and needles about “any use.” It’s certainly well known that there are recovered people, like Sarah, who are able to safely use certain substances. Doing so under professional supervision is recommended. Sarah said, “I still see a psychologist and closely monitor my feelings to pay attention to why I’m drinking. I have to think about my motives and keep myself in check.”

What Happens in the Brain During Addiction?

The neuroadaptations in the brain that result from the combination of genetic vulnerability and environmental triggers are substance-specific.-Dr. Mark Willenbring

In his recent Pro Talk column about the brain and addiction, Mark Willenbring, M.D. stated, “The neuroadaptations in the brain that result from the combination of genetic vulnerability and environmental triggers are substance-specific. That is, the dysregulation of consumption (of the intoxicant) only applies to the specific drug consumed. It does not apply to other drugs… in my practice, I find that opioid addicts seldom like alcohol, and vice versa.” He added in e-mail communication that although the changes in the brain resulting in addiction appear to be substance-specific, there are common traits (especially behavioral under-control, a trait used to define people who tend to be impulsive, aggressive, and seek novel, intense and risky experiences) that increase risk in general. So some people, even though remitted from one substance addiction, might be predisposed to addiction to another. Yet this predisposition is not about addiction per se but a common underlying tendency that can contribute to the risk of many disorders.

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