When someone gets off opioids and manages to stay off them for long enough that deprivation, withdrawal, and craving gradually diminish, the great grassroots consensus is that they’re clean. There isn’t a box for “stopped injecting heroin, now drinks every day” the way there is for “quit drinking, now hits the bong the second their feet hit the floor in the morning.” No one sees similar behavior changes in someone and says in almost an accusing tone, “They’re clearly shifting their addictive process to alcohol or benzodiazepines. They’re not sober. Still just a junkie.” But they do that all the time if someone replaces opioids with marijuana or alcohol, or even psych meds.
What cross-addiction actually is
When it comes to treatment, cross-addiction is potentially very threatening. It’s one of the reasons why abstinence is still a valid and valuable approach. If you’re someone who has a similar compulsive reaction to more than one substance or behavior, it’s safer to swear off everything addictive than to convince yourself that you can switch between them. However, if we’re ever going to get to a better understanding of addiction, we need to recognize cross-addiction phenomenon for the message it’s sending: that the drug or behavior being abused is not really the problem.
The brain doesn’t just want the drug back – it wants the reward
Long-term use of substances changes how the dopamine motivation pathway works. Eventually, the brain becomes accustomed to unnaturally high amounts of dopamine by generating less of it naturally and diminishing the quantity of receptors available for accepting it. It’s one component of the so-called reward deficiency syndrome – a concept proposing that some individuals already have a less active reward pathway, which partially made them more predisposed to addiction.
When an individual becomes clean, this pathway does not return to its normal state. It remains flat for a while, sometimes over the course of several months, during a stretch referred to as post-acute withdrawal syndrome or PAWS. Throughout PAWS, individuals regularly feel emotionally disconnected, cranky, and lacking in drive. Their brain nearly has a void of wants to be filled. This is the specific time any new supply of dopamine – a substance, an action, a pattern – can glide in and commence filling the emptiness left by the previous substance.
Add genetic susceptibility into the equation, like the various forms of the DRD2 gene linked with dopamine receptor activity, and you have a much clearer concept of why a subset of individuals in recovery will pick up a new compulsive practice even when they can help with different addictions they don’t desire to include their initial substance of choice in that.
The substitution patterns we see most often
Cross-addiction doesn’t always look dramatic. Some of the most common patterns are almost mundane:
Alcohol gives way to cannabis or benzodiazepines, both of which get framed as “calmer” alternatives. Opioid recovery sometimes shifts into heavy drinking, since alcohol is legal, cheap, and doesn’t carry the same stigma. Stimulant users sometimes trade one dopamine rush for another through gambling, online shopping, or gaming. Nicotine and sugar addictions frequently show up after someone gets sober from something else entirely, often dismissed as harmless because “at least it’s not drugs.”
There’s also cross-tolerance to consider. If someone’s brain and body have already adapted to one class of substances, a newly adopted one can escalate faster than it might in someone without that history. A person who builds a benzodiazepine habit after years of heavy drinking may find their tolerance climbing at a pace that catches everyone off guard, including them.
Why it hides in plain sight
It is difficult to recognize cross-addiction because it is generally experienced through a socially acceptable behavior. It is unusual that someone enters an intervention program because they’re drinking three cans of soda a day or that they are spending several hours at the gym. What’s more, relatives and friends often feel glad that the “real” addiction is over, so they support and even encourage the new habits. 12-step programs and peer support groups that are based on AA and focus on a single substance, may overlook it as well since the discussion in the meeting room is about the dangers of staying away from a specific drug and not on a general viewpoint of compulsory reward-seeking activities.
The real driver is usually untreated dual diagnosis
In most cases of cross-addiction, what was left unresolved and drove the addiction in the first place was some mental health issue: anxiety, depression, PTSD, unprocessed trauma. And it was these mental health issues that, in many cases, sent the person down the path of their drug of choice to begin with. If you look at the real numbers, you’ll find that about 25% of people with alcohol use disorder also have a disorder around an illicit drug, and those numbers go up significantly for individuals in treatment for a primary substance. Odds are that whatever drove your addiction the first time is still doing push-ups in the parking lot while you’re in rehab, waiting for you to come out.
Warning signs worth taking seriously
Cross-addiction doesn’t usually make an entrance by shouting “Ta-da! Here I am!” It’s more like a guest that sneaks in quietly, sometimes settling in for months or longer before people realize it’s come to stay.
In recovery communities, you often hear people share that they’re drinking 10 Red Bulls a day, chain-smoking, taking up to six hours of extra-strength Tylenol a day, or having a double espresso at 9 p.m. every night. They don’t consider it a violation of abstinence as long as it’s not “The Drug,” but they sound desperate in a way they usually didn’t when they were using a new medicine or beverage in their first weeks of recovery. They sound like the addiction has already taken root in them, but they’re still telling themselves they have control.
We need a way to talk about this, though. A new addiction. An addiction to something else. Cross-addiction’s too charming a phrase for what it is.
Behavioral addictions deserve equal attention
Programs that focus exclusively on substance use, too, can leave patients ill-equipped to handle a behavioral addiction. A lot of addiction treatment is about coping skills, stress management, and lifestyle changes – things that can help you avoid the substance you’re addicted to. After all, you can live your life without needing a drink every time you feel anxious or going to the bathroom during a party to sneak a few hits off a joint.
For someone who’s addicted to a behavior, though, abstinence isn’t the solution. You can’t just never eat again if you have an eating disorder or never use the internet or go shopping if that’s where you’re struggling. So if all you’ve learned in treatment is how to avoid the thing you’re addicted to, you’re set up to fail.
What actually helps prevent it
Prevention is broader than most models currently allow – for example, at any peer-support or 12-Step meeting, the most common question asked is still, “Have you used?” The first item on a classic relapse prevention plan is “I will use X” (the original drug). It’s time to change that script. A successful recovery plan is designed around the question, “What are you replacing this with?” If you’re not asked that at every check-in, not just once at the start of a treatment episode, the plan isn’t strong enough yet. Co-occurring disorders must be treated concurrently, and cognitive behavioral therapy remains your best double-edged sword (for helping patients identify and manage the thought patterns and emotional clues that lead to problematic substance use, no program is more effective).
Structured daily routines, practiced carefully in treatment episodes, are important. When do new habits slip in? During unstructured time. Be aware and be accountable. Sponsors, therapists, and sometimes even sober roommates can notice the new behavior and tell you its name before your conscious self catches on. Medication-assisted treatment (MAT), using naltrexone, buprenorphine, or methadone to manage craving or to substitute in an agonist’s place, is absolutely part of the plan for many – if dosed and monitored properly to avoid undertreatment. Undertreated, a patient is likely to seek relief elsewhere, which often looks like experimenting with a new (or old) drug.
More broadly, relapse prevention planning, already based on Marlatt’s model of cognitive-behavioral cue awareness teaching, must be updated to take into consideration current research on how cue reactivity doesn’t stay in its lane either. The conditioned response that used to fire for opioids, for instance, can just as easily march you to the bank, the pawnshop, or the bar for a hit of a very different kind. What they didn’t know in the 20th century that has become glaringly obvious one decade later is that relapse often involves not a return to a certain place but a deepening of the addictive process with a new fix.
Choosing treatment that sees the whole picture
A focus on abstinence alone without considering cross-addiction is not a complete recovery approach but a limited one. The more effective way to manage recovery is through treatment centers that offer a broad view of the substances and activities to which a person may be predisposed. Programs with this approach tend to ask tough questions from the outset, assess co-occurring mental health issues, and remain vigilant about emerging behaviors long after the patient has completed detoxification.
Achieving sobriety from one substance is a major milestone, and it needs to be seen as such. However, the program doesn’t end there. The same brain mechanisms will pursue a reward no matter what substance turns up to be the desired target. If that root problem isn’t settled, the brain will direct an individual towards something else. The candle needs to be targeted directly if the plan is to succeed on a longer-term basis and not spontaneously fall apart years down the road.
