Understanding Cross, Co-Occurring, and Paired Addictions

By David Fawcett PhD, LCSW

Over the years in my therapy practice, I have learned that my clients are rarely dealing with a single, standalone issue. They may think they have only one problem when they walk in the door of my office, but after a small amount of assessment and conversation it’s fairly easy to see that what they’re reporting – usually something like depression, anxiety, an out-of-control sex life, or an inability to quit drinking and/or drugging – is part of a larger, interrelated picture.

This is especially likely when the clients are in some way addicted, regardless of whether they have acknowledged their addiction (or addictions). In fact, almost every single addicted client I’ve treated has also needed help with a secondary disorder, be it another addiction or a mental health issue such as depression, bipolar disorder, or posttraumatic stress disorder (PTSD).

For purposes of this blog, I will limit my discussion of secondary issues to other addictions. Generally, these fall into one of three categories:

  1. Cross Addictions
  2. Co-Occurring Addictions
  3. Paired Addictions

Individuals who are cross-addicted switch from one addiction to another. Those with co-occurring addictions engage in multiple addictions simultaneously. Individuals with a paired addiction have, over time, fused multiple addictive behaviors into a single-co-occurring disorder so that when they’re engaging in one part of the addiction, they’re also engaging in the other.

Typically, people with cross, co-occurring, and paired addictions move seamlessly from one addictive substance to another, from one addictive behavior to another, and back and forth between addictive substances and addictive behaviors.


  • Alice, after leaving treatment for alcohol addiction, gains 35 pounds in three months, the first time in her life she’s struggled with her weight. She also finds herself compulsively cruising social media sites, looking for men who want to engage in romantic or sexual chat.
  • James binge-watches porn after work and on weekends. These behaviors continue for days or even weeks at a time – until he feels remorse and shame about his porn use and stops. But then he begins to drink heavily. After a few days or weeks of this, when he feels bad enough about his drinking, he stops and goes back to porn.

Co-Occurring Addiction:

  • Michelle uses alcohol and meth to disinhibit herself sexually. She is unable to engage in the sexual behaviors that turn her on unless she is drunk and high. She needs booze and meth to overcome the fears and shame she has about her sexual desires, and to overcome her low self-worth.
  • Allen, a pharmaceutical sales rep, continually spends his evenings in hotel bars, searching for women (and sometimes men) who want to drink and hook up. He has repeatedly promised himself that he will stop cheating on his wife, but then he has a cocktail – just to relax after work – and can’t stop himself.

Paired/Fused Addiction:

  • Katy spends most of her free time online, cruising dating sites and apps, engaging in sexualized web chat, and viewing porn. The entire time she does this, she smokes marijuana. If she’s not in ‘sex mode,’ she has no interest in pot; similarly, if she’s not smoking pot, she has no interest in sex.
  • Diego pairs cocaine with pornography, strip clubs, and prostitutes. If he is high, he’s also chasing sex. If he’s chasing sex, he’s also high. Typically, he ‘loses’ three to five days at a time when he is on a cocaine/sex binge. Often, he misses work without even calling in sick.

Manifestations of Cross, Co-Occurring, and Paired Addictions

Patrick Carnes, Robert Murray, and Louis Charpentier list 11 ways in which cross, co-occurring, and paired addictions occur.[i]

  1. Alternating Cycles: Switching back and forth from one addiction to another, often for years on end (i.e., flipping between binge drinking and sexual acting out)
  2. Combining: Combining various addictive substances/behaviors in search of the perfect high (i.e., mixing meth with porn and then cybersex)
  3. Cross-Tolerance: Using one addiction as a way to tolerate another (i.e., getting drunk or smoking cigarettes to self-soothe shame about sexual behaviors)
  4. Disinhibiting: Using one addiction to reduce inhibitions related to a second addiction (i.e., getting high before having sex with a stranger or a prostitute)
  5. Fusing (also known as Stacking): Using one addiction to amplify another (i.e., using cocaine or methamphetamine to heighten the pleasure of orgasm)
  6. Inhibiting: Viewing one addiction as the lesser of two evils (i.e., smoking cigarettes instead of looking at porn all night)
  7. Masking: Using one addiction to hide another (i.e., going to AA for alcoholism but never looking at one’s compulsive sexual activity)
  8. Numbing: Using one addiction to numb the shame of another (i.e., getting drunk or high after cheating on your spouse)
  9. Replacement: Replacing one addiction with another (i.e., cutting down on the use of hookup apps by gambling for hours on end)
  10. Rituals: Incorporating one addiction into the ritual phase of another (i.e., buying cocaine or methamphetamine before beginning the search for a prostitute)
  11. Withdrawal Mediation: Using one addiction to stop another (i.e., shopping compulsively as a way to stay out of sex clubs)

How Common Are Cross, Co-Occurring, and Paired Addictions?

Individuals who struggle with compulsive sexual and romantic behaviors tend to also struggle with cross, co-occurring, and paired addictions. A survey of more than 1,600 self-identified sex addicts found that 69% of heterosexual men, 79% of heterosexual women, and 80% of homosexual men admitted to a cross, co-occurring, or paired addiction.[ii] Another study found that sex addicts frequently report secondary or paired issues with drug addiction (58%), compulsive spending (49%), eating disorders (47%), compulsive video gaming (37%), alcoholism (31%), and compulsive gambling (29%).[iii]

Why Are Cross, Co-Occurring, and Paired Addictions So Common?

Individuals who struggle with compulsive sexual behavior are not the only addicts susceptible to cross, co-occurring, and paired addictions. This is because addictions of all types are driven by the same basic factor – a desire to avoid, numb, or otherwise control stress and other forms of emotional discomfort. Addictions are not about feeling good, they’re about feeling less. And addictive substances and behaviors all happily oblige by altering brain chemistry (more on this in future blogs) in ways that temporarily distract people from feelings of stress, loneliness, boredom, depression, anxiety, and the like. Most addicts will seek and use this emotional escape however they can get it – alcohol, drugs, food, video games, spending, gambling, sex, porn, romance, etc.

Sure, a small percentage of addicts in today’s world are purists, relying exclusively on their substance or behavior of choice no matter what. For most addicts, however, a primary addiction is just one element in a larger tapestry of emotional escape. If their primary addiction isn’t available to them for some reason, or if they’re feeling too much shame and remorse about engaging in their primary addiction, they’ll turn to some other addictive substance or behavior. Anything that helps them escape their emotional and psychological discomfort will do just fine.

Ultimately, regardless of the nature of the addiction, the result is always the same:

  • A compelling craving for the substance(s)/behavior(s)
  • A negative impact on self-esteem, family, relationships, finances, career, health, etc.
  • An inability to stop using the substance(s)/behavior(s) despite adverse consequences

As if that’s not bad enough, addicts with cross, co-occurring, and paired addictions are more susceptible to relapse – if for no other reason than they have more than the usual number of potential triggers. For example, a paired meth/sex addict has triggers toward meth, triggers toward sex, and the general triggers toward any addiction that life puts in the addict’s path on a regular basis. Any and all of those impulses to act can send the addict spinning into the abyss of active addiction.

Recognizing this, it is important for individuals with cross, co-occurring, and paired addictions to seek specialized help for each facet of their addiction. Getting treatment for one part of an addiction (like substance abuse) will not help with the other part of the addiction (like compulsive sex). Without the entirety of the addict’s addictive pattern being addressed in a holistic way, relapse is almost inevitable. The untreated portion of the addiction will eventually drag the addict back out, and all parts of the addictive behavior pattern will once again be activated.


[i] Carnes, P. J., Murray, R. E., & Charpentier, L. (2005). Bargains with chaos: Sex addicts and addiction interaction disorder. Sexual Addiction & Compulsivity, 12(2-3), 79-120.

[ii] Carnes, P. J., Murray, R. E., & Charpentier, L. (2005). Bargains with chaos: Sex addicts and addiction interaction disorder. Sexual Addiction & Compulsivity, 12(2-3), 79-120.

[iii] Hall, P. (2013). Understanding and treating sex addiction: A comprehensive guide for people who struggle with sex addiction and those who want to help them, p 186. London: Routledge.