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. Author manuscript; available in PMC: 2025 Apr 25.
Published in final edited form as: J Soc Work Pract Addict. 2023 Feb 20;24(4):339–349. doi: 10.1080/1533256x.2023.2181294

Examining substitution behaviors in a non-treatment sample of current drinkers: an exploratory study

Christina S Lee a, Corrine A Beaugard a, Lidia Meshesha b, Ana M Abrantes c
PMCID: PMC12031640  NIHMSID: NIHMS1892000  PMID: 40291125

Abstract

In a sample of adults who reported cutting down on their alcohol use in the past 3 months, study goals were to Identify how many increased consumption of licit substances (called ‘substituters’); and analyze the psychological profiles of substituters compared to non-substituters. Participants (25.6% Latinx, 46.2% female) were recruited using Amazon’s Mturk and completed questionnaires on substance use substitution (i.e. any increased use of a substance while cutting down on another substance) and stress, depression, and anxiety. Among those reporting decreases in alcohol use (N = 78), 78% substituted (N = 61), defined as concomitant increases in food, cannabis, or nicotine. Substituters had higher levels of pysychological distress, reported greater polysubstance use and significantly higher levels of problems related to use than non-substituters. All of the Latinx participants (n = 20) reported substitution and reported significantly higher psychological distress than non-Latinx substituters. Latinxs who reported substitution had more serious psychological profiles and problems related to substance use. The findings provide evidence for a clinical phenomenon involving substitution in a non-treatment sample. Future studies should examine this phenomenon among people in addiction treatment and among Latinxs.

Keywords: Alcohol, anxiety, cannabis, depression, stress

Unhealthy alcohol use includes a range of alcohol use, from risky drinking to alcohol use disorder. Risky drinking is defined as a level of drinking that exceeds the recommended guidelines for drinking (4/5+ drinks per day, women and men, respectively, or >7 drinks/week for women, >14 drinks/week for men, NIAAA, n.d.). Approximately 1 in 3 U.S. adults have risky alcohol use and 25.8% of the U.S. population reported binge drinking in the past 30 days (NIAAA, 2022; Patel & Balasanova, 2021). Unhealthy alcohol use increases the risk for injury, liver failure, chronic diseases, and deaths due to alcohol-related causes have more than doubled in the past decade (White et al., 2020). Alcohol use disorder (AUD) encompasses a pattern of drinking ranging from mild to severe depending on the number of criteria met.

People in recovery from AUD and other substance use disorders may subsequently increase use of other substances (e.g., cannabis). This behavior, noted clinically (Kim et al., 2021), has been termed ‘addiction substitution’ (Kim et al., 2021; Sinclair et al., 2021; Sussman & Black, 2008). Substitution refers to the shift from the use of one substance to another (see Sinclair et al., 2021 for a scoping review) and has been defined as the ‘consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions,’ (Shapira et al., 2020, p. 1). Studies investigating addiction substitution have investigated licit, more easily procurable substances like alcohol, cigarettes, coffee, high-sugar food, and cannabis, as well as illicit substances: amphetamines, barbiturates, or cocaine (Allsop et al., 2014; Peters & Hughes, 2010; Rabin et al., 2018; Sinclair et al., 2021). For example, several studies have reported that reductions in drug or alcohol use were followed by an increase in the consumption of sweet snacks (Alarcon et al., 2021; Friend & Pagano, 2004; James et al., 2004; Kleiner et al., 2004).

Addiction substitution has been investigated more commonly with people in treatment for substance use disorders. In one study, individuals in treatment for AUD reported that they initiated tobacco use and their increased cannabis use following reductions in alcohol use (Friend & Pagano, 2004; Karoly et al., 2021). A second qualitative study of men in recovery from SUD showed increased consumption of sweet and junk foods to regulate mood. People reported eating more frequently when sad, depressed, anxious, or upset, particularly when they experienced cravings for their primary substance (Cowan & Devine, 2008). In the first systematic review of the addiction substitution concept (Kim et al., 2021), the presence of co-occurring mental health problems such as depression (Kohn et al., 2003; Kosten et al., 1987) was found to predict substitution. Moreover, the co-occurrence of mood and anxiety disorders with substance use disorders has been well established (Grant et al., 2004; Lai et al., 2015; Turner et al., 2018). There are several theories to explain addiction substitution. One, consistent with the notion of ‘functional equivalence’ (Adler, 1966) proposes that addiction substitution occurs when a new substance is used to achieve the same effects (e.g., relaxation) (Cowan & Devine, 2008; Sussman & Black, 2008) or to manage the feelings of dysphoria or low mood associated with the reduced use of alcohol (Shaffer et al., 2004; Sussman & Black, 2008). In a similar vein, the self-medication hypothesis proposes that people use substances to cope with the mental health symptoms (Khantzian, 1997).

A surprising finding from the systematic lit review was that the risk of substitution was significantly more likely to occur among individuals recruited from the community (i.e., not seeking treatment) than among treatment samples (Kim et al., 2021). In the community-based samples, two studies found that among individuals reporting smoking cessation, alcohol use increased (Carmelli et al., 1993; Perkins et al., 1990). In another community-based longitudinal study, individuals who abstained from cannabis reported increases in alcohol and nicotine use (Allsop et al., 2014). Similarly, a survey given to patients at a medical cannabis dispensary revealed that 40% reported using cannabis as a substitute for alcohol and 66% as a substitute for prescription drugs (Reiman, 2009). Given the proportion of the population who meets criteria for unhealthy alcohol use and who may not be receiving any intervention, examining substitution behaviors in a non-clinical sample is of importance. The current study explores the concept of substitution in a non-clinical population by developing and administering a short self-report survey. Surprisingly, despite the clinical pervasiveness of the concept (Kim et al., 2021), to date there are no self-report measures of whether patients increase their use of one substance when attempting to cut down on another. The study team assembled questions assessing substitution behavior, specifically whether the use of licit substances increased following a reported reduction in alcohol use. These questions were administered to the general population.

This study’s goals were twofold: 1. To explore the prevalence of increases in alternative substance use (i.e., ‘substituters’) within a sample of adults who reported trying to cut down or stop using alcohol in the past 3 months, and 2. To compare individuals who substituted with non-substituters on measures of substance-related problems and symptoms of stress, anxiety, and depression. Because ethnicity was also found to predict substitution behavior in non-clinical samples (Kim et al., 2021) we also explored differences by Hispanic ethnicity.

Materials and methods

Recruitment and consent

Participants were recruited as part of a larger study on Amazon’s Mechanical Turk (MTurk) in July 2020. The larger study surveyed US adults on the impact of COVID-19 on substance consumption, mood, and engagement in rewarding activities unrelated to alcohol or drug use. Participants were study eligible if they were 18 years of age or older, used alcohol or cannabis in the past week, were designated by Amazon as having completed 100 or more Human Intelligence Tasks with an acceptance rate of at least 99% for those tasks and were in the US. These criteria verify respondents have successfully submitted at least 100 high-quality submissions, eliminating bots or users with a history of invalid submissions. Using Amazon’s designations for inclusion criteria is common practice in MTurk studies (Morris et al., 2017). Crowdsourcing platforms like MTurk have generated valid and replicable results and are especially appropriate for research involving hard-to-reach populations, including individuals in the process of changing substance use behaviors (Mellis & Bickel, 2020).

Potential participants who responded to the MTurk study posting were forwarded to Qualtrics to complete the screening consent form. After providing consent electronically, eligible persons completed assessments. Participants were compensated for their time via funds placed in their Amazon MTurk account. Human Subjects approval was obtained through Butler Hospital.

Measures

Participants completed a demographics questionnaire including questions on race, ethnicity, household income, gender, age, and education.

Substance use substitution questions

Participants were asked, ‘In the past 3 months, have you made an effort to cut down or stop using alcohol?’ Those who answered affirmatively were asked if they increased sweet snacks, savory snacks, nicotine, or cannabis since they had cut down or stopped using alcohol. Participants who indicated increased consumption of at least one of the following: sweet snacks, savory snacks, cannabis, and nicotine while trying to cut down or discontinue their alcohol use were referred to as ‘substituters’ and those who reported no increased consumption of the same items were referred to as ‘non-substituters.’

Depression Anxiety Stress Scale (DASS)

Stress, depressive, and anxiety symptoms were measured using the Depression, Anxiety and Stress Scale (DASS-21) (Lovibond & Lovibond, 1995). The DASS-21 is a self-report instrument that consisted of three, 7-item subscales: stress, anxiety, and depression. Participants indicated on a 4-point scale how much each item applied to them over the past week. A higher score indicated greater symptoms. The DASS-21 has shown reliability (Cronbach’s alpha >= .82 for each subscale) and predictive validity (Beaufort, 2017). The Cronbach’s alpha for this sample was .97.

Substance Use

The Daily Drinking Questionnaire (DDQ, Collins et al., 1985) was used to measure participants’ alcohol consumption. On the DDQ, participants estimated the total number of standard drinks they consumed on each day during a typical week in the past month. The DDQ is a widely used measure of drinking and has been shown to have good reliability and construct validity (Collins et al., 1985). Participants also reported their cigarette and drug consumption. Individuals were asked to report on the number of cigarettes smoked per day in the past 3 months. They were also asked about how frequently they used cannabis, cocaine, designer drugs, hallucinogens, heroin, methamphetamine, synthetic drugs, or vaporized nicotine in the past 3 months.

Marijuana Problem Scale (MPS)

The MPS is a 19-item measurement that assessed for consequences of cannabis use in the past 3 months on a 3-point scale (0 = No Problem, 1 = Minor Problem, 2 = Serious Problem) (Hodgins & Stea, 2018). Domains assessed included social relationships, self-esteem, motivation and productivity, psychological and physical health, and cognitive functioning. Higher scores suggested more perceived consequences related to cannabis consumption. It has demonstrated reliability (Cronbach’s alpha = 0.85) (Stephens et al., 2004) and construct validity (Hodgins & Stea, 2018). The Cronbach’s alpha for this sample was .97.

Short Inventory of Problems (SIP)

The Short Inventory of Problems (SIP) is a 15-item validated measure for negative consequences of alcohol use in the past 3 months, derived from the Drinker Inventory of Consequences (Feinn et al., 2003). Higher scores indicated a higher frequency of consequences. The SIP had demonstrated reliability (Cronbach’s alpha=.74) and construct validity across age and gender groups. The Cronbach’s alpha for this sample was .96.

Analysis

Descriptive statistics means, standard deviations (SD), medians and interquartile ranges (IQR) were calculated using SPSS. We compared substituters and non-substituters on all mental health and substance use variables. A second set of analyses compared Latinx and non-Latinx respondents. For bivariate analyses, we calculated chi-square tests for independence and Welch’s t-test for categorical and continuous variables, respectively. Welch’s t-test was chosen because of the difference in sample size between comparison groups. The Type I error rate was set at .05.

Results

Participants

A total of 344 respondents who used alcohol or cannabis in the past week completed valid MTurk surveys and 319 reported past-week alcohol use. Of these respondents, n = 78/319 (24.5%) reported trying to cut down or stop using alcohol in the last 3 months. Of the n = 78, most (74.4%, n = 58) were white, one-quarter were Latinx (n = 20), the average age was 36.3 (SD = 9.65) years, and approximately half (46.2%, n = 36) were female. Most (78.2%, n = 61) of participants had at least a college degree and half (n = 39) reported household earnings between $50,000 and $100,000.

Substitution prevalence

Substituters and non-substituters did not significantly differ on demographics (gender, age, race, household income, or education) and on levels of alcohol or cannabis consumption. There were no significant differences in average number of drinking days/week between substituters and non-substituters (M = 3.69, SD = 2.03 vs M = 2.82, SD = 1.63, t(30.43) = 2.41, p = .131) or on number of drinks/week (M = 11.7, SD=10.1, vs. M = 11.7, SD=10.25, t(24.56)=.03 p = .856). All (100%) of the Latinx participants (n = 20) reported substitution, while 69% (n = 40) of the non-Latinx participants reported substitution (X2 (1) = 7.5, p = .006).

Of those who reported trying to cut down or stop using alcohol (n = 78), more than three-quarters (78.2%, n = 61) reported increased consumption of sweet snacks (62.8%, n = 49), savory snacks (51.3%, n = 40), nicotine (35.9%, n = 28), and cannabis (28.2%, n = 22). With regard to the number of substances used, n = 22 (36.07%) reported increased use of one substance, n = 14 (22.95%) reported using two substances, n = 11 (18.0%) reported using three substances, and n = 14 (22.95%) reported increased use of four substances.

Substituters and non-substituters: drug use and substance-related problems

Demographics for those who cut down or stopped drinking alcohol are listed in Table 1. Substituters reported illicit drug use, whereas non-substituters reported no illicit drug use. Of the 61 participants who identified substitution, 32.2% (n = 19) used heroin, 27.1% (n = 19) used hallucinogens, 24.1% (n = 19) used synthetic drugs, 22% (n = 16) used methamphetamine and designer drugs, and 18.6% (n = 11) used cocaine. Both substituters and non-substituters reported nicotine use, though substituters had significantly higher rates of both vaping (52.5% vs. 16.7%; p = .007) and cigarette use (66.7% vs. 33.3%; p = .011). Comparisons between substituters and non-substituters on substance-related problems are reported in Table 2.

Table 1.

Descriptive statistics of people who cut down or stopped drinking alcohol (N = 78).

Mean (SD)/Median
(Q1, Q3)		 Substituters
(n = 61)		 Non Substituters
(n = 17)		 Statistics p value
Age 36.3(9.65) 36.87 (9.68) 34.29 (9.59) t(25.81)=.96 .338
Gender Female 36 (46.2%) 29 (47.5%) 7 (41.2%) X2 (1, N = 78)= .22 .642
Race Asian 4 (5.1%) 1 (5.9%) 3 (4.9%) X2 (4, N = 78) = 1.71 .788
 Black 12 (15.4%) 2 (11.8%) 10 (16.4%)
 Multiracial 2 (2.6%) 0 (0%) 2 (3.3%)
 Native Hawaiian/Pacific 2 (2.6%) 1 (5.9%) 1 (1.6%)
 Islander 58 (74.4%) 13 (76.5%) 45 (73.8%)
 White
Ethnicity Latinx 20 (25.64%) 20 (32.8%) 0 (0%) X2 (1, N = 78) = 7.50 .006
Household income <$50,000 33 (21.8%) 7 (41.18%) 26 (42.62%) X2 (2, N = 78)=.14 .934
 $50,000-$100,000 39 (50%) 9 (52.94%) 30 (49.18%)
 >$100,000 6 (7.7%) 1 (5.88%) 5 (8.2%)
High school degree 17 (21.8%) 12 (20.69%) 5 (29.41%) X2 (2, N = 78) = 1.61 .448
 College degree 44 (56.4%) 34 (55.7%) 10 (58.8%)
 Master’s degree 17 (21.8%) 15 (24.6%) 2 (11.8%)
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Table 2.

Mental health and substance use characteristics (N = 78).

Mean (SD)/Median (Q1,Q3)
Total (N = 78) Substituters (n = 61) Non Substituters (n = 17) Statistics p value
Depression (DASS) 26.0 (12.29) 31.37 (12.02) 20.94 (9.72) t(32.0) = 13.43 .001
Anxiety (DASS) 24.0 (11.47) 29.41(11.34) 17.06(4.90) t(63.2) = 43.3 .000
Stress (DASS) 28.0 (10.44) 31.25(9.83) 19.76(7.24) t(34.26) = 28.23 .000
Alcohol problems (SIP) 15 (2, 25.25) 18.54(11.17) 2.76(3.47) t(75.0) = 90.33 .000
Cannabis problems (MPS) 2 (0, 16) 10.34 (9.98) .71 (1.49) t(68.35) = 52.72 .000
Drinking days/week 3.47(1.96) 3.66(2.02) 2.87 (1.67) t(30.43) = 2.41 .131
Drinks/week 11.71 (10.06) 11.58(10.05) 12.13(10.42) t(24.56)= .03 .856
Cannabis use/past 3 months 33 (42.3%) 27 (44.3%) 6 (35.3%) X2(1)= .438 .508
Days cannabis use/past month 6.2 (9.79) 6.17(9.74) 6.38 (10.76) t(9.32)= .003 .960
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Substituters and non-substituters: depression, anxiety, and stress

Substituters reported significantly higher scores on measures of depression, anxiety, and stress compared to non-substituters. Depression scores for substituters were on average 10.43 points higher (M = 31.37, SD = 12.02 vs. M = 20.94, SD = 9.72, t(32.0) = 13.43, p = .001) than depression scores for non-substituters. Anxiety scores for substituters were on average 12.85 points higher (M = 29.41, SD = 11.34 vs. M = 17.06, SD = 4.90, t(63.2) = 43.3, p = .000) than non-substituters. Stress scores for substituters were on average 14.19 points higher (M = 31.25, SD = 9.83 vs M = 17.06, SD = 4.90, t(34.26) = 28.23, p = .000) than non-substituters.

Post-hoc analysis: Latinx Participants

Because we found ethnic differences on rates of substitution, we compared Latinx and non-Latinx groups on the same variables. When compared on demographic variables, non-Latinx and Latinx participants did not differ in sex, age, or household income; but Latinx participants were more likely to have attained at least a college degree (100% versus 70.7%) X2 (1, N = 78) = 7.5, P = .006. Full comparisons for mental health and substance use variables are presented in Table 3.

Table 3.

Mental health and substance use by ethnicity: Latinx vs. not Latinx (N = 78).

Mean (SD)/n(%)
Latinx (n = 20) Not Latinx (n = 58) Statistics p value
Depression (DASS) 37.18 (9.19) 26.43 (12.09) t(34.17) = 15.05 .000
Anxiety (DASS) 37.3 (8.76) 23.07 (9.96) t(37.26) = 36.50 .000
Stress (DASS) 36.6 (6.68) 26.03 (10.16) t(50.63) = 27.81 .000
Alcohol problems (SIP) 24.3 (8.06) 11.46 (15.10) t(47.08) = 27.76 .000
Cannabis problems (MPS) 14.60 (9.66) 6.05 (8.77) t(30.51) = 12.20 .001
Drinking days/week 3.5 (1.98) 3.46 (1.98) t(14.58)=.05 .836
Drinks/week 11.08 (11.73) 11.85 (9.77) t(14.58)=.05 .836
Cannabis use/past 3 months 13 (65%) 20 (35.48%) X2(1) = 5.67 .017
Days cannabis use/past month 4 (6.71) 7.55 (11.16) t(48) = 1.97 .167
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Discussion

In this general population study of people trying to cut down on their alcohol use, we found that over three-quarters (78.2%) increased use of another substance during the same 3-month period. Substituters were significantly more likely to use other drugs and to report higher levels of depression, anxiety, and alcohol and cannabis-related problems than non-substituters. We also found significant differences by ethnicity: all the Latinx respondents reported substituting other substances compared to respondents who were not Latinx.

Our findings extend the literature by providing information about the clinical profile of individuals not in treatment who substitute other substances when cutting down on another (Karoly et al., 2021). Evidence indicated that substituters had more serious psychological issues than non-substituters. They reported significantly higher levels of stress, depression, and anxiety than non-substituters. While the evidence is very preliminary, it is consistent with the idea that substances may be used to cope with mental health symptoms (Khantzian, 1997; Sussman & Black, 2008) or to regulate affect. These findings suggest the need to focus on co-occurring mental health concerns among individuals trying to decrease or stop their alcohol use (Castillo-Carniglia et al., 2019; Turner et al., 2018). Second, individuals who reported substituting also reported significantly more substance-related issues. Substituters drank more heavily, experienced greater negative social and medical consequences related to alcohol and cannabis use and used more drugs than those who did not substitute. This finding is consistent with the profile of ‘risky alcohol use’ whereby increased consequences are experienced that pose increased harm to the user. This can lead to a spiraling down effect whereby these consequences become risk factors in themselves for increased use. In a study of substitution behavior among people with past years of cannabis disorder, the authors speculated that people not in treatment may be less focused on resolving underlying factors such as depression or anxiety that may lead to addiction than individuals in treatment (Hodgins et al., 2017).

This phenomenon is important to understand in non-treatment seeking samples as well because left unchecked, substitution may confer greater and unanticipated health risks among individuals who are trying to cut down on a primary substance (Lehman et al., 1990; Stephens et al., 1994; Wiseman & McMillan, 1998). For example, the increased consumption of sweet and savory snack foods, and their long-term or excessive use, could contribute to additional health problems such as increased risk for diabetes. The increased use of nicotine and cannabis may also increase the risk for poor cardiovascular health or increase the risk for nicotine or cannabis dependency. More research is needed to explore the etiology of substitution, and in the clinical setting, patients could be encouraged to discuss the potential risks and benefits of substitution when attempting to cut back or stop using a primary substance.

Our preliminary finding, based on a smaller sample of Latinx participants (n = 60), is consistent with prior research documenting an association between ethnicity and substitution behaviors (Blanco et al., 2014). The first systematic review on substitution similarly revealed that co-occurring mental health disorders and race/ethnicity are areas for further exploration, including the mental health needs of those who substitute (Kim et al., 2021). In our sample,

Latinxs who substituted reported more symptoms of stress, anxiety, and depression than non-Latinxs. Further investigation using larger sample sizes, of substitution behaviors among Latinxs who report substance use and psychological distress is warranted.

Limitations

This is an exploratory survey study with a small convenience non-clinical sample. While the study was intended for a general sample, we did not screen for the current treatment status. Future studies should examine these relationships in a larger sample and collect data at multiple time points to establish baseline level of alcohol use and the extent of alcohol reduction. Likewise, the magnitude of any increase in substituted substances was unknown. The significant finding for Latinxs might be a function of the small sample size and is a limitation. Future research should study substitution among Latinx adults to determine if the findings from this study are replicated in a larger sample. Because this is a cross-sectional report, the direction of effect of substitution on psychological outcomes and polysubstance use could not be determined. All measures were within a 3-month window, thus the potential for recall bias may have been minimized. (Most of the assessments asked participants to report back 3 months, one assessment (DASS) asked for only the past week and another (DASS) asked for past month reports). However, given that the time frames for recall are less precise if they have a longer time window than for more recent events, the variable time frames for assessment remains a potential limitation.

Conclusion

Individuals who reported substitution when attempting to cut down on alcohol were more psychologically distressed, reported higher levels of alcohol and drug use, and experienced more substance-related consequences compared to non-substituters. This pattern suggests that people may resort to the use of commonly available substances to help them cope with low mood, cravings for alcohol, and stress, while they are trying to cut down on their alcohol use. Latinx individuals appear to be at risk for substance use substitution. Future studies should examine this phenomenon in studies with larger samples and in clinically diverse samples, such individuals in treatment for substance use disorders.

Funding

This project was supported by the National Institute of Alcohol Abuse and Alcoholism (NIAAA), K23 AA028269 (Meshesha).

Footnotes

Disclosure statement

No potential conflict of interest was reported by the authors.

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