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Why Recognizing Pre-Addiction Could Save Lives

Earlier treatment with a greater chance of success.

Key points

  • Some addiction-treatment leaders propose the use of the term “pre-addiction” to describe mild-to-moderate substance use disorder.
  • The pre-addiction designation could enable interventions at an earlier stage, when it is easier and less expensive to treat people.
  • Research is needed to identify the behaviors and risk factors that would raise concern for future problems with addiction.

I’ve written here before that our understanding of addiction and addiction treatment has come a long way in the last two decades. As an addiction psychiatrist and chief medical officer at a large treatment center based in Jacksonville, Florida, it’s been incredibly gratifying to see how those changes have benefitted our patients.

For example, we know so much more about the brain chemistry of addiction now, which has profoundly changed how we treat patients. Also, the therapies and medications we use are more effective and evidence-based. We’re also much more aware of, and are better able to treat, the mental conditions that often accompany addiction—from depression and trauma to eating disorders and ADHD.

Out of this much-improved landscape comes another potentially game-changing development I’m very excited about: a group of experts has recently coined the term “pre-addiction” as a new way of understanding and treating an earlier stage of addiction. As you’ll see, this has far-reaching implications.

The Basics of Pre-Addiction

Nora Volkow, director of the National Institute on Drug Abuse, and two other prominent thinkers in the addiction treatment field recently proposed the term “pre-addiction” to describe mild-to-moderate substance use disorder (SUD).

The term consciously mimics “prediabetes,” a now-accepted term to describe people with higher-than-normal blood sugar levels and who are at high risk of developing diabetes. The “prediabetes” designation has allowed resources and interventions to be targeted to this earlier stage of the condition, when it is easier and less expensive to treat.

That’s exactly the goal that Volkow & Co. have in mind with pre-addiction. Here’s how she explains it in a recent commentary in JAMA Psychiatry: “The term ‘pre-addiction’ gives a readily understandable name to a vulnerable period of time in which preventive care could help avert serious consequences of drug use and severe substance use disorders.”

Volkow compares this to other conditions: “It is now standard to monitor risk factors like cholesterol, blood pressure, and BMI during routine checkups, so that steps can be taken to avert heart attacks or stroke through some combination of lifestyle changes and medications.”

The point is that we can do the same thing with addiction. Why do people with alcohol and drug addiction need to “hit rock bottom,” as the saying goes, before their condition is recognized and treated?

If this designation takes hold, it will hopefully force the healthcare establishment (including insurers) to recognize and target resources for the pre-addiction stage. Also, people with pre-addiction will be better able to recognize it and seek treatment for it.

Again, the idea is that the condition will be caught early, when it’s easier to get a handle on, and before serious interventions like detox or inpatient treatment become necessary.

A key point to keep in mind: By the time a person hits full-blown addiction to drugs or alcohol, their brain chemistry and structure have been reconfigured. Those changes can be reversed over time, but that takes months of sobriety. Meanwhile, the altered brain chemistry makes it more difficult to stay on track with recovery.

The beauty of intervening at the pre-addiction stage is that in most cases, those addiction-associated brain changes won’t have happened yet. Consequently, the path back to a healthy mental state is less arduous.

To recap, here’s why targeting treatment at the pre-addiction stage makes so much sense:

  • You have a better chance of arresting the progression of the disease.
  • You are better able to make your own lifestyle changes and other important course corrections to head off addiction.
  • Your available treatments and therapies are less expensive and easier to obtain.
  • Your prognosis for long-term recovery is significantly better.

Identifying and Treating Pre-Addiction

To treat pre-addiction, you first have to identify it. This means screening and intervention during routine checkups in the primary-care setting, among other places. That sounds obvious enough, but we’re not there yet in terms of what those screens look like. The goal of intervention is clear, though: As Volkow puts it in her JAMA Psychiatry commentary, we want “to alert people to problematic patterns of drug or alcohol use that do not (yet) meet the threshold of addiction.”

Further, we need to “define and detect substance use that is clinically significant and amenable for early intervention. Existing DSM criteria for mild to moderate substance use disorder are a starting point, as are existing screening tools used in primary care that ask about frequency of substance use. But research is needed to better characterize the kinds of substance use and the kinds of individual risk factors that would raise concern for future addiction and other health problems.” [Italics added because it’s such a key point. That research is needed as soon as possible.]

As for self-treating pre-addiction, the beauty is that this can be done at all, unlike when people have full-blown addiction. Following are the sorts of adjustments that someone diagnosed with pre-addiction would be able to make if they’re worried about their problem drinking or drug use:

  • Don’t drink or use drugs alone.
  • Eat food and take in water when you drink.
  • Know that in the “upsized” world of bar and restaurant portions, the alcohol content of beer, wine, or mixed drinks can be higher than the average, so be careful and conscious of that.
  • Assess all areas of your life—your job, relationships, finances, the amount you exercise, and so on—to see if drugs or alcohol are having a negative effect on any.
  • Make a conscious effort to replace unhealthy habits like drinking or drug taking with healthy habits. These include daily exercise (maybe at the end of the workday, when you would normally have a drink), fun hobbies, or regular self-care such as meditation, reading, yoga, or a weekly massage.

We still have a long way to go in our understanding of addiction and addiction treatment. This country’s recent, tragic increase in drug overdoses shows we’re not there yet. But we are making progress on several fronts. This new thinking about pre-addiction is a significant example of that. It could lead to a new way of diagnosing, treating, and paying for addiction and addiction care.

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McLellan, Koob & Volkow. (2022). Pre-Addiction: A Missing Concept for Treating Substance Use Disorders. JAMA Psychiatry.

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