Leading researchers from prominent addiction and alcoholism institutes are spearheading a campaign to officially recognize a new term: preaddiction. Advocates argue that such a categorization would expedite and increase treatment access, fundamentally changing the treatment penetration landscape. However, the proposal is not without detractors, who caution that it may inadvertently augment societal stigma and propagate involuntary treatments.
Current data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Addiction (NIDA) reveal that merely 20% of those requiring addiction treatment are actually receiving it. To increase this rate, the heads of these two institutions, George F. Koob and Nora Volkow, alongside A. Thomas McClellan, a psychiatrist from Penn, advocate for a new framework. They suggest modifying DSM-5’s “mild to moderate Substance Use Disorder” (SUD) to “preaddiction,” hoping this will stimulate earlier treatment initiatives. By paralleling the concept to prediabetes, they argue the following:
“There may be concern that our suggested term preaddiction is ill advised because it is pejorative and will simply intensify stigma. We contend that preaddiction is exactly the right term for 2 reasons. First, the terms addict, schizophrenic, and diabetic are certainly pejorative because they describe a person by their disease state. In contrast, addiction, schizophrenia, and diabetes are simply descriptions of diseases. Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided. Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”
The article initially explores the evolving understanding of “addiction”, which was formerly seen as a personality disorder and later as the result of tolerance and withdrawal from hard drug use. However, recent scientific evidence indicates impaired control, caused by gradual damage to brain circuits responsible for reward sensitivity, motivation, self-regulation, negative emotional states, and stress tolerance, as the key diagnostic construct.
Interestingly, not all individuals who use drugs and alcohol end up developing an addiction. There is a gap between the initial use and addiction, which the authors believe provides an opportunity for early intervention to prevent addiction, thus potentially reducing public health issues.
“The long latency from use to disorder offers a significant window of opportunity for clinical interventions to stop progression,” they write.
The authors suggest that the success of the “prediabetes” concept could provide a roadmap for the implementation and acceptance of the preaddiction term while also forming a basis for the creation of interventions for the condition. They believe that a diagnosis of preaddiction could motivate individuals to take the necessary steps to avoid developing a full-blown addiction.
For the successful implementation of the preaddiction concept, the authors identify three critical areas that need to be addressed: defining and detecting preaddiction, creating effective interventions, and promoting clinical advocacy.
Measures to define and detect preaddiction
The implementation of “prediabetes” relied on easy-to-use, insurance-reimbursed lab tests in combination with specific, validated measures. In contrast, preaddiction lacks an equivalent objective and measurable test beyond the DSM-5.
The authors also discuss potential criticisms of the term “preaddiction”, particularly the concern that such a label could increase stigmatization:
“First, the terms addict, schizophrenic, and diabetic are certainly pejorative because they describe a person by their disease state. In contrast, addiction, schizophrenia, and diabetes are simply descriptions of diseases. Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided. Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”
Engaging, effective interventions for preaddiction
To counter the progression of prediabetes, specific medications, and behavioral interventions have been developed. Similar strategies, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT) and digitized Cognitive Behavioral Therapy (CBT) tools, could be adapted to target preaddiction.
Public and clinical advocacy
To encourage medical professionals to identify substance use issues or “preaddiction”, the authors suggest that screening tools should be incorporated more broadly into medical and nursing curricula. They also propose that insurance reimbursements for these screenings could promote their adoption by mainstream medical providers.
Critiques of “preaddiction”
While the authors anticipate and address potential criticisms of their proposal, some questions remain about the effectiveness of such a diagnosis and the potential issues that could arise from its usage.
Addiction psychologist Cassandra Boness is particularly concerned about the stigmatization and detrimental outcomes associated with the label “preaddiction”:
“Addiction and using substances are highly stigmatized by society, which leads to detrimental outcomes such as being less likely to seek treatment and being less likely to receive quality treatment. Labeling individuals as having ‘preaddiction’ runs the risk of implying that individuals experiencing harms from substance use are on a one-way path to addiction. Yet many people with harmful substance use and even substance use disorders recover, even without formal treatment. In fact, an estimated 70% of people with alcohol use disorder and alcohol problems experience ‘natural recovery.’ If someone is given the label ‘preaddiction,’ it may be very difficult to escape even if they are no longer using substances in a harmful way.”
Boness also points to difficulties with the existing DSM criteria for substance use disorders (SUD) upon which preaddiction would be based. Boness says that many of the symptoms listed for SUD are more severe than others, and lumping “mild”, “moderate”, and “problematic” SUD into a single category would make it harder to help people suffering from substance use issues.
“Giving the same label to people with very different problems can impair progress in treatment by making it difficult to figure out what will work best for them.”
Boness is also “particularly concerned that ‘preaddiction’ will be used to empower exploitative addiction treatment industries and force people into involuntary treatment. For example, [NIDA and NIAAA] propose “preaddiction” might also be used to describe ‘…any problematic substance use prior to meeting criteria for [substance use disorder] per the DSM-5, such as substance use by adolescents, driving under the influence of drugs, or other potentially risky behaviors.’ Forcing an adolescent into treatment under the premise that any substance use is ‘preaddiction’ is much more likely to cause harm than lead to meaningful change.”
Instead of the current model, Boness and other public health practitioners say viewing substance use and addiction as existing on a spectrum could help deliver the results NIDA and NIAAA are looking for while avoiding the possible pratfalls from the term preaddiction:
“Instead of creating new labels, it would be more effective to take a public health approach to conceptualizing addiction, one in which the harms resulting from substance use are viewed on a continuum without specific thresholds or cutoffs like ‘preaddiction’.”
McLellan, A. T., Koob, G. F., & Volkow, N. D. (2022). Preaddiction—a missing concept for treating substance use disorders. JAMA psychiatry, 79(8), 749-751. (Link)