Truly Trading One Drug for Another”

Truly Trading One Drug for Another

‘You are just trading one drug for another’ is a common refrain in the world of substance use disorders. And frequently there is truth to it. Let’s take a look at what and why this is.

First, remember that addiction is not defined by WHAT you use but HOW you use and what the use does to your life and the life of your loved ones. Some persons come to realize that they have a problem with a certain substance- maybe an opioid, maybe alcohol, maybe cocaine. Somehow it has gone from being something they enjoyed and felt in control of to something that just keeps pulling them away from the person they want to be, life they want to have, and their loved ones.

So a sneaky thought appears: what if we stop using THIS thing and try to use this OTHER thing, which we DON’T have a problem with, INSTEAD? Won’t that fix the problem?

This makes sense at first glance- it is someone trying to regain control by moving from something they recognize as a problem to something that they perceive to be less dangerous and less addictive. But there are problems with this approach. First, remember, addiction is a biopsychosocial disease. A person’s biology, psychology, and environment are all likely the same when they move from one substance to another. Biology DEFINITELY is. By virtue of already having one substance use disorder they clearly have the genes that predispose to addiction. And while SOME genes seem to make persons more inclined to have issues for a SPECIFIC substance, a LOT of the genes seem to make one prone to addiction to ANY of the substances—all the different substance share the same common addiction problem genes¹. In addition all the drugs of abuse have a common end pathway: they give that dopamine rush.

So all we are doing is getting to the same ends by a different means; what we still want, NEED, is that dopamine. The brain of one with a substance use disorder now processes rewards and negative consequences in a way that keeps the substance use and craving going. So: same person, same situation, same genes, now already have a brain wired to let something get out of control…this does not sound like it will go well. I tend think of this as having built a racetrack in your brain and now it doesn’t care what kind of horse is brought in to run on it: it is going to let it RUN.

Along with all that biology and brain wiring, we have also had a lot of time using a drug to manage our emotions and moods. The more severe an addiction becomes, the more an automatic loop develops:

That behavioral loop has now become wired into our brain pathways as well. It is automatic- it happens without even having to think about, faster than the speed of conscious thought, and sometimes without even realizing it. You just all of a sudden notice you are craving more. So now even if we change what the substance is we are reaching for, we are still going to end up reaching for it to fill the same holes the old substance filled. The substance is still being used as the main coping strategy. It is how we feel better after a hard day, how we celebrate good things, how we feel/share connection with people in our social circle. It is still filling an outsized role in our life.
And it is preventing us from doing the work to figure out what healthy behaviors and relationships could be used to fill those gaps instead.

Because of all of these things, the new substance becomes a problem over time-it tends to escalate. Even worse, its use increases the chances that we fall back to the OLD substance…and now we have problems with that old substance AND this new substance! After all, mood altering substance like meth, cocaine, opioids, and alcohol all tend to lower a person’s inhibitions and prevent making clear/rational choices. They make that little voice shouting ‘No! Stop! Don’t Use That! You Know it Doesn’t Go Well!’ quieter and the voice saying ‘Just this once it is ok’ to get louder.

I frequently see persons who have tried to switch from heroin/fentanyl to the stimulants meth/cocaine. They believe these drugs will be safer and won’t be a problem for them since it is a different drug type. Other people switch from the drug cocaine to meth. Or stop all drugs but then notice they seem to be drinking more (or gambling more or online shopping more or binge eating sugar more-dopamine is dopamine). The intentions can be good. The realization and admitting a certain substance is a problem is good. It is just that trying to trade one dangerous and addictive substance for another dangerous and highly addictive substance is doomed to fail. Cross addiction is sort of wanting to have your cake and eat it too: we want to continue to be able to use a substance to help us cope, not seek care, not have to change our friends/living situations/way of thinking about the world, not have to face some hard truths and harder choices…but we want to be back in control. It just doesn’t work.

This cross addiction concept explains the interesting fact that persons who continue to smoke are more likely to relapse back to things like heroin!!!!!²

Those things seem on the surface to have _nothing to do with each other. BUT. The nicotine molecule is keeping some of those addictive brain circuits open and active while also providing extra slugs of dopamine. Let’s also think about when people smoke- when it is a certain time of day or event (like mealtimes or morning coffee) or when they are stressed out or when others around them smoke. The link of increased craving and reaching for a cigarette automatically when certain things/situations/feelings occur- using a chemical to control our emotions and selves- is the same behavioral link to ‘worse’ substances. It is a little toe sticking into a door we are trying to slam shut.

Historically, and still in some clinics, this understanding of how cross addiction sabotages people and its dangers is why persons would be kicked out of treatment for having urine tests positive for anything (including marijuana). This was done even if someone was engaging in and improving in care and/or staying away from the substance that originally brought them to treatment. It was done because of this understanding that one drug changes to another which places you at risk to fall back to the original drug AND the new drug. The medical field has increasingly moved away from this punitive type of treatment as we come to better realize that being engaged in care and helping people take small steps towards health on their own timeline is a better strategy to improve lives and health than suddenly cutting people off from care and leaving them on their own.

Please read the previous blog posts (here and here) about how prescribed addiction treatment medications affect the brain differently than these other substances of abuse and occur in a different environment than substances of abuse and thus are NOT the same as cross addiction.

In summary it is easy to accidentally or intentionally start using more of one substance when trying to stop using a DIFFERENT substance to which one is addicted. In the end, though, it doesn’t work and can frequently make things worse. Staying vigilant against slipping into cross addiction is important at all stages of recovery.