Will an individual who initially uses a substance with lower addictive potential subsequently revert to it after using a substance with higher addictive potential?

From the Guidelines

When a person transitions from a less addictive substance to a more addictive one, they typically will not voluntarily return to the less addictive substance, as the more addictive substance produces stronger euphoric effects, more intense cravings, and more severe withdrawal symptoms, creating a powerful neurochemical dependency. This pattern occurs because the brain's reward pathways become significantly altered by the more potent substance, making the effects of the less addictive substance seem inadequate by comparison. The phenomenon is sometimes called "cross-tolerance" where the body becomes tolerant to similar substances, requiring increasingly potent options to achieve the desired effect. For example, someone who progresses from prescription opioids to heroin rarely returns to prescription medications voluntarily because heroin produces more intense effects, as discussed in the context of opioid addiction 1.

Key Factors Influencing Substance Use

• The development of addiction to opioids involves several neurobiological processes, including learning mechanisms that consolidate automatic behaviors in response to the drug and stimuli associated with it, as well as the release of dopamine in the nucleus accumbens, a key reward region 1.
• The use of medication-assisted treatment, such as methadone, buprenorphine, and naltrexone, can significantly improve outcomes in opioid addiction, including reducing relapse, preventing overdoses, and preventing HIV 1.
• Individual responses to substance use can vary based on personal circumstances, availability of substances, social factors, and whether the person receives treatment, highlighting the importance of tailored treatment approaches 1.

Clinical Implications

In addiction treatment settings, clinicians sometimes use the principle of cross-tolerance in reverse through medication-assisted treatment, gradually transitioning patients to less addictive substances to manage withdrawal and recovery. This approach is supported by studies on the effectiveness of medication-assisted treatment in managing opioid addiction, including the use of buprenorphine and naltrexone, as discussed in the context of adolescent opioid use disorders 1. The most recent and highest quality study on this topic, published in 2019, highlights the potential of neuroimaging to combat the opioid epidemic by identifying novel treatment targets and individual difference factors conferring vulnerability for relapse 1.

Recommendations for Practice

Clinicians should prioritize the use of evidence-based treatments, such as medication-assisted therapy, and consider individual factors that may influence treatment response, including personal circumstances, availability of substances, and social factors. By taking a comprehensive and tailored approach to treatment, clinicians can help individuals overcome addiction and improve their overall quality of life, as supported by the latest research on opioid addiction and treatment outcomes 1.

From the FDA Drug Label

Abuse of and addiction to opioids in some individuals may not be accompanied by concurrent tolerance and symptoms of physical dependence. "Drug-seeking" behavior is very common in persons with substance use disorders Dependence Both tolerance and physical dependence can develop during use of opioid therapy

The person may or may not go back to the less addictive thing. Addiction and substance use disorders can lead to drug-seeking behavior, but the FDA drug label does not provide direct information on whether a person will return to a less addictive substance after using a more addictive one 2.

From the Research

Addictive Substance Use

• The provided studies do not directly address the question of whether a person will go back to a less addictive substance after taking a more addictive one 3, 4, 5, 6, 7.
• However, research on opioid use disorder suggests that treatment with medications like buprenorphine or methadone can reduce the risk of relapse and improve patient outcomes 3, 4, 5.
• Studies also highlight the importance of addressing craving and negative affect in individuals with opioid use disorder, as these factors can contribute to relapse 3.
• The use of non-pharmacological approaches, such as cognitive behavioral therapy and mindfulness-based interventions, may also be beneficial in reducing relapse risk 3.

Treatment and Relapse

• Research on treatment pathways for opioid use disorder suggests that medication-based treatments, such as buprenorphine or methadone, are associated with reduced risk of overdose and serious opioid-related acute care use 5.
• The length of time a person is treated with medications like buprenorphine or methadone is also associated with decreased odds of nonprescribed opioid use 4.
• However, the provided studies do not specifically examine the phenomenon of switching between substances with different levels of addictiveness.

Help-Seeking Behavior

• Studies on help-seeking behavior among individuals who self-harm suggest that adolescents who self-harm often turn to friends and family for support, rather than seeking professional help 7.
• Barriers to help-seeking, such as fear of negative reactions and stigma, may also play a role in an individual's decision to seek treatment for substance use disorders 7.