By Tom Horvath, PhD, ABPP
On 7/6/22 JAMA (the Journal of the American Medical Association) published “Preaddiction—A Missing Concept for Treating Substance Use Disorders.” Written by three of the most well-respected scientists in the field (McLellan, Koob, and Volkow), the article reminds us of the value of early detection and treatment of addictive problems, rather than waiting until these problems are severe. Because there is also a much larger number of individuals at lower levels of severity, there is substantial societal benefit from addressing that larger group. That group may generate more negative impact than the severe group.
The article also reminds us that less than 20% of those who might benefit from treatment seek it, a situation that frustrates the authors. When diabetic care faced a similar situation, providers began to focus on “pre-diabetes,” with positive results. The rates of addictive problems remain high in the US (and may indeed be rising). A fresh approach and fresh language, modeled on pre-diabetes, might be helpful. Their frustration appears to arise regarding clients themselves, for not seeking treatment, and our healthcare system, which is not well-organized for identifying and responding to lower levels of addictive problems (even though how to identify and respond to them is well enough understood).
The term prediabetes had motivational value because the average person would be motivated to avoid advancing to diabetes. For the individual with addictive problems, would preaddiction be a more motivating term, or might it arouse just as much negative reaction as “addiction” itself? Would the individual react negatively when they discover that in many cases treatment for preaddiction would be quite similar to treatment for addiction, and would often involve the same medications, psychosocial treatments, and mutual help groups (even though treatment setting and length of treatment or recovery support might change)? Or would they react negatively when they discover that most with preaddiction do not progress to addiction? If there were specific preaddiction treatments, how might they be different other than a high tolerance for moderation outcomes?
Perhaps for an insurer preaddiction would be motivating (although does not insurance already reimburse for a mild or moderate substance use disorder)? Perhaps the new term would allow our healthcare system to organize itself better? The authors of this paper are suggesting high level systemic change. As a clinician involved with individual clients and their families, and one who operates somewhat outside our healthcare system, I have little sense of how their suggestion might play out.
All healthcare and behavioral healthcare providers should screen for a wide range of disorders (and lower levels of these disorders) and then involve other providers or services as needed. There would be substantial benefit from a continuously updated “universal comprehensive screening” process for behavioral health problems, accessible to every provider and individual in the nation, especially if the screening were accompanied with resources for appropriate responses (e.g., further assessment, basic intervention, referral). Of course, having a genuine national healthcare system would facilitate the deployment of such a screening. Decreasing the emphasis on “addiction” and considering the entire continuum of addictive problems would also be beneficial.
Any level of addictive problems, even those that fall below a mild substance use disorder but are still higher than moderation, are worth addressing. Once specific problems are identified, we could let the client decide what to call them. Until such screening and treatment are commonplace, it is worthwhile, as these authors have done, to consider the systemic changes that might bring about that change.
Preaddiction—A Missing Concept for Treating Substance Use Disorders
