Recovery and substitute addictions

Substitute addictions (replacement behaviours or addictions for terminated Substance Use Disorders, and distinct from Opioid Substitution Treatment) have been implicated in relapse and recovery for decades, but remain poorly understood, particularly in low- and middle-income contexts. While the literature suggests a multifactorial aetiology, research is needed to elucidate the risk factors, motives and mechanisms by which substitute addictions may arise.

We report on a prospective cohort follow-up study of the prevalence and associated factors of substitute addictions among substance use treatment service users (n= 137), and in-depth interviews on perceptions and experiences of substitute addictions with Narcotics Anonymous (NA) attendees (n= 23) in the Western Cape province of South Africa. The respective data sources were analysed descriptively, inferentially, and thematically.

At follow-up 40% (n= 55) of service users had maintained abstinence, while 23% (n= 32) had relapsed. Substitute behaviours were reported by 36% (n= 50) and a higher probability of substituting was linked to precarious post-treatment employment and moderate scores on the Brief Assessment of Recovery Capital. Among NA attendees, substitute behaviours were primarily behaviour-based (binge-watching; cigarettes/vaping; coffee; exercise; food; gambling; sex, relationships and pornography; shopping; stealing and work) and developed across recovery stages to endure temporarily or long term. Across samples, mechanisms of substitute addictions included escalation of secondary addictive behaviours and addiction cycles that alternate, necessitating self-monitoring and vigilance. The leading substitute motives included relapse prevention; harm reduction; coping; managing cravings; time-spending, availability and accessibility.

Substitute behaviours are not uncommon during recovery, may be a source of concern to some, and follow diverse trajectories. The desired goals and parameters of recovery (e.g. abstinence; harm reduction or moderation management) should be considered alongside the role and relative harm of substitute behaviours. Though risk profiles may differ, targeted interventions can decrease risk. Recommendations for prevention, practice and policy are proposed.