This post has been adapted from a blog series originally published by the Obesity Action Coalition.
Cross-addiction is a term used to describe when one compulsive behavior is exchanged for another compulsive behavior. This is also sometimes referred to as addiction transfer. Cross-addiction is a phenomenon that has been unofficially observed for some time and has been recognized by participants of 12-step programs, such Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous for years. The concept of cross-addiction has also been discussed in the popular media. The Wall Street Journal featured an article noting a trend of cross-addictions in former bariatric surgery patients, who seemed to replace food with other compulsive substances or behaviors following surgery. Oprah also aired an episode, “Suddenly Skinny,” which cautioned that some individuals who undergo bariatric surgery might transfer from “food addiction” to alcohol addiction. Despite recognition in the media, the existence of cross-addiction has remained a controversial issue among healthcare professionals, researchers and patients.
Though still somewhat controversial, the theory of cross-addiction is gaining more traction as research into the subject expands. Recent research has shown similar disruptions in the brain reward systems of those with substance abuse/dependence disorders and those with obesity. This may represent a common mechanism underlying both food addiction* and drug addiction, which would make the concept of addiction transfer more likely than once thought.
Possible Risk Factors for Cross-Addictions
Addictive behaviors are sometimes engaged in to handle stress or unpleasant emotional states. In fact, 10-25% of adult alcohol drinkers report drinking in response to negative affect. Similarly, low distress tolerance, or difficulty withstanding negative emotions, has been linked to relapse following smoking cessation and is hypothesized to be correlated with addictive behaviors. A 2011 study found that distress tolerance is inversely correlated with emotional overeating, meaning that people with low distress tolerance are more likely to overeat in response to negative emotional states. Let’s take, for example, someone with low distress tolerance who may be used to turning to food to cope with stress or difficult emotions but has undergone bariatric surgery and is now physically unable to overeat. He or she may be more likely to turn to destructive addictive or compulsive behaviors, such as excessive use of alcohol or prescription pain medications. This might help to explain why a recent study found increased substance use in bariatric surgery patients two years after surgery compared to before.
Another possible explanation for this finding comes from a study that reported an association between pre-surgery food addiction and a greater likelihood of problematic substance use post-surgery. One group of researchers interested in better understanding the relationship between weight loss surgery and drug addiction asked former bariatric surgery patients receiving inpatient treatment for substance abuse to consider why they thought they may have developed substance problems. The results of this study showed that 83% of patients attributed their drug issues to addiction transfer and 75% cited unresolved conflicts. Other factors, like faster or greater drug effects and increased access to pain medications, were also cited, though less often.
As with many things in life, the first step to preventing or addressing a cross-addiction is awareness. Once aware, you can find healthy ways to replace the reward that may have once been experienced from eating or overeating. One example of substituting an unhealthy source of reward with a healthy alternative comes from the story of a 55-year-old man who underwent gastric bypass surgery and lost 243 lbs. He maintained this weight loss by adopting an intense exercise regimen. He runs and works out five times a week without fail. He has seemingly substituted overeating with an activity that may have been difficult for him to enjoy when he was extremely overweight, but like overeating, is reinforcing. Exercise causes a release of the neurotransmitter dopamine in reward-related areas of the brain, just like excess consumption of cookies or cake can do, as well as endorphins. For those who aren’t avid exercisers, it can be difficult at first, and its reward value may be tempered by the aches and pain we feel from being out of shape. With time, however, our body adapts, and physical activity feels good! Other ideas for finding alternative sources of reward include participating in scheduled social and service activities, as is encouraged by Alcoholics Anonymous, or taking up a new hobby that you’ve always wanted to try, whether it be gardening, playing tennis, learning a new language, playing an instrument - the list goes on and on. Of course, it is important to be aware that, as with all substances and behaviors, there can be drawbacks to these substitutes if they too are taken to the extreme.
People who intend to undergo bariatric surgery may benefit from planning healthy, alternative sources of reward prior to undergoing surgery. Support groups are in place for bariatric surgery patients. These may offer some of the benefits conferred by groups like AA, such as emotional support, external supervision by the therapist involved, and new relationships with other group members. These groups may also provide helpful therapy for participants and may help to prevent a lapse into more dangerous methods for obtaining reward.
In the past few years, the concept of cross-addiction has received increasing support from research studies. In light of the findings mentioned here, it may be beneficial to assess bariatric surgery candidates for characteristics of low distress tolerance and food addiction prior to undergoing surgery. Additionally, patients should be informed of the psychological risks that may accompany bariatric surgery and be provided therapeutic support to prevent or properly address cross-addictions if they develop. Also, although much of this article is focused on cross-addiction with respect to bariatric surgery, this process is not limited to those who undergo surgery. Transferring an addiction from food to other destructive substances and/or behaviors may apply to individuals with many different circumstances but, fortunately, so can the suggestions discussed above!
*It is important to note that while certainly not all individuals with obesity have food addiction, food addiction diagnoses are generally greatest among samples of obese participants.
Appreciation is extended to Ms. Nisa Beceriklisoy and Ms. Susan Murray for their assistance with the writing and development of this post.
Dr. Nicole Avena is a research neuroscientist/psychologist and expert in the fields of nutrition, diet and addiction. She has published over 60 scholarly journal articles, as well as several book chapters on topics related to food, addiction, obesity and eating disorders. She recently edited the book, Animal Models of Eating Disorders (Springer/Humana Press, 2013), and she has a book Why Diets Fail (Ten Speed/Crown) available for preorder now and to be released Dec. 31, 2013. Her research achievements have been honored by awards from several groups including the New York Academy of Sciences, the American Psychological Association, the National Institute on Drug Abuse, and her research has been funded by the National Institutes of Health (NIH) and National Eating Disorders Association.