Risk Factors for Cross-Addiction

In the previous blog post, I discussed the concept of cross-addiction, also termed “addiction-transfer,” particularly as it might relate to patients who have undergone bariatric surgery. Alcohol and drug addictions, as well as other compulsive behaviors, are contraindications for bariatric surgery in patient eligibility screenings.

While the concept of food addiction has been widely accepted by the public, only recently has it been evidenced by scientific research. One study designed to assess food addiction found that many women with Binge Eating Disorder (BED) can be considered “dependent” when questions that typically ask about addiction replaced the word “substance” with “binge eating.” This concept has been further supported by studies investigating how animals behave when they are fed diets rich in fats and sugars. For example, our laboratory has found that when rats are fed a high sugar diet intermittently, they exhibit behaviors that resemble binge eating seen in humans; consuming large amounts of the diet during a limited span of time. Additionally, when sugar is taken away, the rats show symptoms of withdrawal. Together with other recent evidence in both humans and animals, food addiction has gained support as a true addiction.

Addiction to food, like addiction to any substance, is subject to replacement by other forms of addiction or compulsive behaviors. For instance, studies have shown that rodents that are considered to be addicted to sugar also tend to consume greater amounts of drugs of abuse, like alcohol, and vice-versa. Further, a study from 2011 found that food-addicted individuals (as determined by the Yale Food Addiction Scale) had greater instances of comorbidity with depression and attention deficit/hyperactivity disorder than their weight- and age-matched counterparts. This is especially relevant as both depression and ADD/ADHD are often associated with addictive behaviors.

Addictive behaviors are sometimes engaged in to handle stress or unpleasant emotional states. In fact, 10-25 percent 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 also inversely correlated with emotional overeating. In other words, people with low distress tolerance are more likely to overeat in response to negative emotional states.

Low distress tolerance and food addiction are of particular concern when considering those who undergo bariatric surgery, as individuals with these characteristics may be at a greater risk for substituting overeating with substances of abuse post-surgery. For instance, when faced with tension, stress, depression, or any type of emotional challenge, those with low distress tolerance may be more likely to turn to addictive or compulsive behaviors in an effort to feel a sense of comfort similar to what they may have experienced by overeating prior to surgery. This might help to explain why a recent study found increased substance use in bariatric surgery patients two years following surgery compared to before.

Another possible explanation for this finding comes from a study that reported an association between food addiction pre-surgery and a greater likelihood of substance use disorder post-surgery. One group of researchers interested in better understanding the relationship between weight loss surgery and drug addiction asked bariatric surgery patients receiving inpatient treatment for substance abuse to consider why they thought they may have developed substance use disorder. The results of this study showed that 75 percent of patients attributed their drug issues to unresolved conflicts and 83 percent cited addiction transfer. Other factors, like faster or greater drug effects and increased access to pain medications, were also cited, though less often.

In light of these findings, 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 can accompany bariatric surgery and should be provided therapeutic support to prevent or properly address cross-addictions that may develop throughout time. Further research examining the possible relationships between bariatric surgery and other compulsive behaviors, such as gambling, may provide greater insight into our understanding of cross-addiction.

*Appreciation is extended to Ms. Susan Murray for her assistance with developing this post.

*Thanks for Nisa Beceriklisoy for her assistance with the writing and development of this post.

About the Author:
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 in January, 2014. 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. You can learn more about her research at her website (www.DrNicoleAvena.com), or follow her on Facebook and Twitter.

Disclaimer: This blog post does not reflect the views of the OAC, the National Board of Directors or staff. Scientific information contained in this blog post has not been reviewed by the OAC National Board of Directors.



6 Comments for this Post
  • Jill Williams
    November 24, 2013 at 2:00 pm

    I agree that cross addiction is not only possible but also probable if the patient/client is not aware of the possibility and creates a strong after care program that includes the opportunity to open emotional channels instead of burying them in any addictive substance. Support groups, individual coaching/counseling, movement and understanding what creates “fulness” for them will be new additions to their life after the surgery (I know it was for me)! It took some time to develop my village of support; and I am glad that I did. Over 15 years later I am living a great life! Thank for you for blogs – great information!


  • Yvonne McCarthy
    November 24, 2013 at 4:42 pm

    Thank you for writing this blog. I’m almost 13 years out from RNY. It is absolutely what I’m most passionate about and it inspired me to do my own post so that I could share this link and add some additional thoughts. Additionally I am a proponent of adding education regarding addiction for the WLS patient instead of denying someone surgery whose life will be cut short by obesity. I so appreciate this being discussed because I hear from people every day who are in need. My post can be seen here: http://goo.gl/EKb07I Thank you so much Dr. Avena.


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  • Nicole Avena, Ph.D.
    December 3, 2013 at 9:11 am

    Jill and Yvonne,
    I agree that incorporating education about addiction can be useful for patients. Now that this concept is gaining more traction in the literature, hopefully we will see it in practice.
    Dr. Avena


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