Commentary: Similarities and Differences Between Harm-Reduction and Substitute Addiction-- Implications for the Health Professions

Abstract

“Substitute addiction” refers to the process of achieving abstinence or resolution of one addictive behavior and subsequently engaging in one or more additional addictive behaviors in its place. Substitute addiction, a concept in the abstinence-based recovery field for decades, is viewed as a cause for concern because resolving one addictive behavior might not fully remove harm or ensure recovery. Conversely, “harm-reduction treatment” refers to a counseling orientation that focuses on helping service users reduce substance-related harm and improve their quality of life without necessarily requiring abstinence or use reduction. Harm-reduction treatment assesses a constellation of addictive behaviors in the larger context of a person’s life to holistically reduce harm in that constellation. In this commentary, we define and compare both constructs and point out their implications for addictions treatment.

Introduction

In 2021, 44 million people in the United States (US) met the criteria for a substance use disorder (SUD) (Center for Behavioral Health Statistics and Quality, 2022). There may be different pathways to the successful resolution of substance-related consequences among people who use alcohol, tobacco, and other drugs. Most behavioral SUD treatments worldwide tend to be abstinence-focused, with legal or stigmatizing consequences for people who may not be ready, willing, or able to stop using substances. Over the past few decades, there has been an increasing interest in non-abstinence-based treatment approaches to reach this population (Bischof et al., 2021; Marlatt et al., 2011). One recent development is behavioral health treatments that focus on reducing the harms of substance use, which may involve a focus other than abstinence (e.g., Collins & Clifasefi, 2023; Denning & Little, 2012).

In considering the differences between abstinence-based and harm-reduction treatment approaches, it is important to consider the targeted outcome. In abstinence-based treatment, the aim is attaining and maintaining abstinence from all substances indefinitely. However, even after recovery has been attained for the target behavior(s), there remains a risk that service users displace their behavior to a new behavior, called a “substitute addiction.” With the rise of harm-reduction approaches, including harm-reduction treatment, it is unclear how abstinence-based treatment concepts, such as substitute addiction, might apply. It has been suggested that substitute addiction might overlap with harm-reduction outcomes (e.g., see Sussman & Black, 2008); however, the two concepts may also reflect different perspectives on ongoing substance use or engagement in addictive behaviors and different ways of defining “recovery.” In this commentary, we describe these two concepts, and how they may or may not overlap, to provide more clarity on when they may be relevant in treatment.

Defining Substitute Addictions

One seldom researched area, particularly relevant to abstinence-based approaches is the potential occurrence of “substitute addictions” (e.g., Sussman, 2017; Sussman et al., 2023), also referred to as cross addiction, replacement addiction, switching addictions, and addiction hopping (Blume, 1994; Buga et al., 2017; Shaffer et al., 2004; Sinclair, Sussman, Savahl, et al., 2021, Sinclair, Sussman, De Schryver, et al., 2021). Substitute addiction generally pertains to the experience of quitting or cutting down on a particular addictive behavior but replacing it with another addictive behavior, that had begun, resumed, or increased in frequency and/or intensity after addressing the targeted addiction. Substitute addictions may continue to elicit negative social, legal, medical, or emotional lifestyle consequences which also lowers one’s quality of life (QofL). For example, someone may abstain from alcohol use but then develop a gambling disorder, leading to financial debt, social complaints from family, and emotional distress (Sussman, 2017). One should note that a substitute addiction is not merely a substitute behavior. That is, to qualify as an addiction the substitute behavior will (a) elicit an appetitive motivation effect (satiation) on which one relies (experienced as improvement in cognition, affect, or level of arousal), and with which one (b) is preoccupied (particularly when not engaged in that behavior), (c) experiences a loss of control over when the behavior begins or its duration, and (d) suffers negative, undesired consequences (Sinclair, Sussman, Savahl, et al., 2021; Sussman, 2017).

A substitute addiction may occur if it serves a similar function as the addiction targeted for treatment; for example, to cope with negative affect or achieve similar sensations (Kim et al., 2021), or for time-spending, self-medication, or craving management (Sinclair et al., 2023). Individuals may or may not select substitutes (e.g., such as work, food, exercise, shopping, video gaming) that result in less harm than the preceding addiction (generally SUD) which also maintains a lower than potential QofL, but a higher QofL than the initially targeted addiction. However, substitute addictions may indicate continued lifestyle unmanageability and deficits in adaptive coping skills, heightening the risk of relapse (Chiauzzi, 1991; Selby, 1993; Sussman & Black, 2008). Consequently, service providers in abstinence-based treatment services emphasize relapse prevention, detection of potential relapse warning signs, and family education (Sinclair et al., 2023). On the other hand, by highlighting triggers and early warning signs for relapse, particularly during early recovery, substitute addictions provide an opportunity to adapt and individualize one’s recovery plan. Additionally, substitute addictions may potentially serve as stepping-stones toward abstinence (Pentz et al., 1997), or represent a level of recovery without a sense of generalized abstinence.

Defining Harm-Reduction

The abstinence-based approach and its subsequent potential to precipitate associated substitute addictions may be contrasted with a harm-reduction approach to addressing SUD or substance-related harm. The limited reach of abstinence-based treatment -- 9% of persons with SUDs in the US attended treatment in 2021 -- has been attributed to the belief by potential service users that treatment was not needed or desired, or that they do not want to stop using substances (Center for Behavioral Health Statistics and Quality, 2022). These findings have been consistent over the past decade and indicate that most people in the US, and possibly worldwide, who are impacted by SUD are not interested in abstinence-based approaches. However, many people, even those who experience greater marginalization in their substance use, do want to learn how to live healthier and with safety from harm, which may take many forms (Fentress et al., 2021; Grazioli et al., 2015).

Harm-reduction strategies explored with service users may include their engaging in substance use at the same level but adopting ways to buffer the effects of the substances (e.g., taking thiamine to reduce cognitive damage from heavy drinking) or changing how they use to be safer (e.g., using at home to avoid driving while intoxicated). Reducing the frequency or intensity of substance use or attaining abstinence are also viable means of harm reduction (Collins et al., 2016; Fentress et al., 2021). In one empirically supported harm-reduction treatment approach that was co-developed by clinical researchers and people with lived experience of homelessness and alcohol use disorder, counselors adopted a compassionate and pragmatic approach that embraced service users’ own goals and safer-use strategies to reduce harm (Collins & Clifasefi, 2023). The three components of this model include a) measurement and tracking of substance-related harm and other service user-preferred substance use metrics, b) setting and tracking harm-reduction and other QofL goals, and c) discussion of safer-use strategies. Given its service user-driven approach, harm-reduction treatment does not require or prioritize abstinence or use reduction, but it also does not preclude abstinence as a viable pathway to recovery. Rather, if a service user has a goal to stop, it is on one’s own terms and timelines, which may lead to a more sustainable change.

The harm-reduction field does not usually directly address the construct of substitute addictions, and we are unaware of any empirical data on the impact of harm-reduction interventions on the experience of substitute addictions. However, we posit that harm-reduction treatment could help address the potential development of harmful substitute addictions for at least two reasons. First, in harm-reduction treatment, as applied to substance use, providers conceptualize substance use as a set of complex behaviors within the larger context of service users’ lives. They assess the larger constellation of substance use and other addictive behaviors by eliciting complex service user narratives around drug, physiological and mental set, and setting. They address the substance-related goal setting, broadly, and they bring more awareness to the potential risks and perceived benefits of (poly)substance use (Collins & Clifasefi, 2023). This more holistic approach to substance use treatment may help address concurrent addictive behaviors simultaneously and early on in treatment, boosting the ability to detect concurrent constellations of harm, such as engagement in potentially harmful substitute addictions. Second, the focus in harm-reduction treatment on increasing engagement with other QofL goals, such as engaging in meaningful activities and relationships, can encourage more adaptive and prosocial behavior generally and thereby hamper the development of more harmful substitute addictions.

Considering this holistic approach, harm-reduction treatment, if optimally implemented, could reduce the possibility of a substitute addiction creeping into one’s appetitive motive profile and effectively rid that pathway preventively (Sussman, 2017). There may remain some desired or desirable level of appetitive effect, a reduction of which through treatment-related adjustment in one’s addictive behavior, could lead to a search for substitute addictive behaviors and their associated risks for harm (Sussman, 2017). Although that might be considered a negative development from a substitute addictions perspective, a harm-reduction perspective would view such behaviors neutrally. Instead, harm-reduction providers would assess the substitute addictive behaviors’ role in the larger behavioral constellation as well as the net harm. Harm reduction providers would then seek to limit net harm on an ongoing basis, with the service user leading those efforts. Future clinical research is needed to learn more about how substitute addictions may manifest in harm reduction treatments.

Substitute Addiction and Harm-Reduction: An Emphasis on Behavior Versus Harm

Taken together, substitute addiction and its abstinence-emphasis views behavior and harm as aspects of the same conceptual entity. A displacement of one addictive behavior to another perpetuates harm. In contrast, a harm-reduction treatment approach emphasizes behavior and harm as separate conceptual entities. A focus on harm takes precedence. One instance where the two perspectives diverge is whether the substitute addiction is the outcome in and of itself. That is, a service user may decide that the reduced harm elicited by the substitute behavior or addiction is sufficient and that no further change is needed. For example, the service user may wish to mesh the substitute addiction with safer substance use, such as using marijuana along with using buprenorphine to address opiate addiction (Sussman, 2017). While not leading to an optimal or ideal QofL, as might be described by an observer (but also involving careful guidance by a well-seasoned provider), it would be up to the service user to decide and indicate sufficient satisfaction with the choices made.

The manifest goals of abstinence-based treatment are to improve QofL and bring the service user back in compliance with the law or with other social units (family, coworkers). Again, this involves a focus on behavior with the assumption that behavior and harm are part of the same entity. Conversely, the aim of harm-reduction treatment is oriented toward improving one’s QofL and reducing harm. Behavior change is in service of reducing harm. External forces on treatment may favor an abstinence approach, whereas intrapersonal forces may favor a focus on harm reduction. Thus, external mandates may increase the likelihood of a search for and the occurrence of substitute addictions, whereas intrinsic motivation aimed at proactive planning leading to harm reduction may minimize the likelihood of the occurrence of substitute addiction.

With a harm reduction aftercare goal, continued safer use may be emphasized or eventual abstinence may occur. As a caveat, at any point where there is a change in behavioral focus, a substitute addiction may occur. Thus, the service user, in reducing harm, may need to consider avoiding negatively consequential substitutes. Horvath (2006) contends that instrumental and temporary use of a substitute can “reduce the process of change to one of smaller, more manageable, steps” (p. 1) towards abstinence. A “good substitute” enables one to relieve cravings for the terminated addiction while reducing harm, and gradually, those cravings will dissipate (Horvath, 2006, p. 2).

Limitations on Integrating the Constructs of Substitute Addiction and Harm-Reduction

Some researchers argue that there are people who may benefit less from harm reduction treatment. For example, Heather (2006) suggested that relatively severe alcohol, tobacco, and other drug use disorder sufferers are relatively likely to fail to benefit and may need an abstinence-based approach. For example, continued use may lead to continuing proximal medical consequences (e.g., alcoholic liver disease, respiratory disorders, cardiac arrest, death).

That said, quantitative and qualitative research has indicated that many of these sufferers will simply not present for abstinence-based treatment, even when facing external coercion (Center for Behavioral Health Statistics and Quality, 2022; SAMHSA, 2019). Alternatively, they may attend but are turned away by providers due to intoxication, or can’t engage authentically in treatment programming that requires commitment to abstinence, will leave treatment early, and/or complete treatment but relapse shortly thereafter (Collins et al., 2012, 2016; Crabtree et al., 2018; Nelson et al., 2023; Orwin et al., 1999), compounding medical risks such as the worsening “kindling effect” observed in the case of alcohol withdrawal (Becker, 1998). In contrast, for those providers who work primarily with nontreatment-seekers who are severely impacted by substance-related harm (e.g., people experiencing homelessness in community-based settings such as shelters), only 5% of whom are interested in abstinence (Fentress et al., 2021), providers must partner with these potential service users (“meet them where they are at”) if they hope to be helpful. In harm-reduction treatment, service users receive more direct psychoeducation on how substances are impacting their health and QofL and actively work on ways to reduce these harms in personalized and sustainable ways.

Harm-reduction treatment studies have shown very high engagement, with greater than 95% of nontreatment-seeking individuals accepting participation and showing statistically significant and clinically meaningful reductions in alcohol use and alcohol-related harm, as well as reduced hospitalizations and arrests, despite abstinence and use reduction not being required (Collins et al., 2019, 2021). Again, a key to success in harm reduction programs is being able to work with people who would not present for abstinence-based treatment.

To discern whether negatively consequential substitute addictions may occur within abstinence or some applications of harm-reduction treatment, one may consider how the service user entered treatment, what treatment is offered (and what is expected), who decides on the goals of treatment, and how the service user is followed up in treatment. The service user may have entered treatment through the social welfare or criminal justice systems (with possible threats of being removed from family contact, or incarceration), through coercion from family members, or may have sought treatment voluntarily due to desiring to reduce social complaints, medical issues, or emotional remorse concerns (Rivera, 2022). The parameters of systemic forces may facilitate the search for substitute addictions if the emphasis is on compliance with authorities rather than on the reduction of personal harm.

Current Clinical Implications

In considering the constructs of substitute addiction and harm reduction, arguably, clinicians have learned that they may provide different yet complementary insights into service users’ behaviors and ways that they, regardless of orientation, may more optimally support recovery efforts. Within abstinence-based treatment, the current best practices for addressing substitute addition have been more comprehensively addressed (Chiauzzi, 1991; Selby, 1993; Sussman, 2017) relative to harm reduction. Recommendations to clinicians often include the need for vigilance to changing presentations of addiction, awareness of relapse risk, and rendering preventive counseling (e.g., Blume, 1994; Selby, 1993). In a harm-reduction treatment framework, substitute addiction has not been considered as a key construct, if at all. Future research may shed light on its presentation in this treatment context and, as necessary, establish evidence-based practices to address it.

With an acknowledgment that more research is needed, we do have some initial thoughts about the clinical implications of the integration of these constructs. First, service providers must be familiar with the concepts of substitute addictions and harm reduction. These may be important constructs that service users already espouse as an aspect of their recovery, and as such, should be approached competently with care and respect. Substitute addiction may also be a particularly salient and clinically helpful construct for service users to understand in the context of abstinence-based treatment. That is, a narrower focus on abstinence from a specific substance might otherwise overshadow a broader examination of other health-related behaviors that likewise impact QofL (e.g., smoking, overeating). Further, when there is stronger extrinsic pressure to achieve immediate abstinence (e.g., court-mandated treatment), there might be increased pressure to find alternatives to manage the psychological or physiological aspects of withdrawal or functionality of an addiction. In harm-reduction treatment, it might theoretically be easier to monitor for and manage substitute addictions given the broader focus on constellations of use behaviors and health-related QofL; however, the assessment of substitute addictions as such may require more focused clinical attention.

In all cases, comprehensive initial and then ongoing clinical assessment should be conducted to seek to monitor service users’ substance use, addictive behaviors, and medical and behavioral health history (Buga et al., 2017; Chiauzzi, 1991) and establish their extant recovery capital. Further, we recommend that clinicians tailor treatment offerings to match service users’ unique constellations of biological, psychological, and social risk and protective factors as well as to consider individualized recovery goals (Chiauzzi, 1991). What may be harmful to one person may be a means of harm reduction for another person. As appropriate, providers can offer psychoeducation on the development of substitute addictions and encourage and offer guidance on self-monitoring of various health-related behaviors (Sinclair, Sussman, Savahl, et al., 2021). Ongoing assessment of how helpful versus harmful various substitute behaviors are should be undertaken in a nonjudgmental way, with the recognition that these are dynamic factors. Service providers should also be open to the potential for substitute behaviors as a legitimate path to self-defined recovery. That said, reliance on the substitute behaviors to experience a subjective sense of calm, intense preoccupation with that substitute, loss of control, and negative consequences such as remorse or distancing from significant others, could indicate a substitute addiction that could stymie recovery.

Summary and Conclusions

Greater conceptual “crispness” has been needed to appreciate how substitute addiction might manifest and be optimally addressed in the context of harm-reduction treatment. This commentary represents an attempt to clarify the use of these two concepts and show their potential to inform better treatment service provision as it increasingly embraces harm reduction.

A substitute addiction has been defined in abstinence-based recovery as a replacement substance or behavior that arises after the resolution of the presenting addictive behavior. Substitute addictions cause negative consequences and, at best produce mixed results, still injuring one’s QofL and leading to relapse. When assessing potential harm, the nature of and motive for the substitute are important to consider; substitutes may be “a mutation of the existing problem” leading to similar or greater harm (White & Kurtz, 2006, p. 5). Given that most treatments are abstinence-based, substitute addiction will remain a problem. It is a problem that is seldom treated (e.g., Sussman et al., 2023).

In contrast to abstinence-based treatment, harm-reduction treatment may be applied to service users who may be unwilling or do not desire to achieve abstinence (Collins & Clifasefi, 2023). Similarly, persons seeking treatment-assisted recovery may be unable to achieve abstinence (McKeganey et al., 2004). Negatively consequential substitute addictions may not occur or may be openly addressed in well-implemented, holistic-oriented harm-reduction treatment. With harm-reduction, if that switch does occur, the provider and the service user would work together to address the negative consequences of the switchover behavior and formulate a plan to maximize the positives while minimizing harm. Thus, there is always a focus on safety and improved QofL no matter what substances or behaviors the service user is or isn’t choosing to engage with. A harm-reduction approach would assess the alternative behaviors with the individual ahead of time and develop a plan to avoid more negative consequences through a substitute addiction.

This commentary provides an initial, novel comparison of two constructs rarely considered in the same recovery circles: substitute addiction and harm-reduction. In considering these two approaches in tandem, we contend that they may provide different yet complementary insights into service users’ behaviors and ways to optimally support recovery. Recognizing the potential for substitute addictions to occur is a critical first step toward providing individualized, responsive treatment. More research and clinical observations are needed to best understand how these constructs may be used to improve both abstinence-based and harm-reduction approaches to treating substance use disorder. We look forward to these developments.