Addiction Substitution: Friend or Foe?

drug and alcohol addiction
drug and alcohol addiction
Researchers conducted a systematic review to examine addiction substitution during recovery from substance use or behavioral addictions.

Addiction substitution — the practice of increasing the use of one addictive substance while recovering from another — has both positive and negative connotations. For example, substituting heroin for methadone acts as a form of harm reduction. However, replacing alcohol abuse with gambling has negative implications, according to a systemic review published in Clinical Psychology Review.

Researchers conducted a systematic review to examine addiction substitution during recovery from substance use or behavioral addictions. The review was necessary, the researchers state, because of inconsistent terminology and mixed results from existing research.

Working with a systematic review expert, the researchers used PsycINFO and adapted the search for Medline, CINAHL, and Embase databases. The search included studies published between 1975 and May 2021. After applying inclusion and exclusion criteria, the review included 96 articles.

Of the 29 studies focusing on opioid misuse, 11 mentioned concurrent recovery, noting that alcohol, nicotine, cannabis, and other drug use decreased during opioid recovery. In one study, alcohol use increased in participants recovering from heroin use.

Addiction substitution occurred in 20% of the 20 studies that examined cannabis misuse. Concurrent recovery was reported in 30% of the cannabis misuse studies.

Of the studies that examined predictors for addiction substitution, the tendency towards substitution occurred more often in younger males. Race was not a factor.

Taken together, the results provide “preliminary support for a concurrent model of recovery,” the researchers state. “However, the subgroup of individuals who do engage in substitution is likely to experience worse treatment outcomes. Given that people are more likely to engage in multiple addictions, it would be important to identify and enhance factors that will prevent addiction substitution and facilitate concurrent recovery.”

Limitations include: Inconsistent terminology may have impacted the effectiveness of the review. Most of the studies consisted of individuals seeking treatment; therefore, the review may not generalize to the broader population of people recovering from an addiction.

Overall, while the review revealed general support for a concurrent model of recovery, the number of people that engaged in harmful addiction substitution was “not inconsequential, given that increasing other addictions during recovery was associated with worse treatment outcomes,” the researchers note.

“Further research examining characteristics and processes of addiction substitution as well as concurrent recovery may ultimately aid in the development of more effective treatments for addictions and decrease the likelihood of engaging in addiction substitution.”


Kim HS, Hodgins DC, Garcia X, et al. A systematic review of addiction substitution in recovery: Clinical lore or empirically-based? Clin Psychol Rev. November 2021. doi:10.1016/j.cpr.2021.102083