Earlier this month, Dr. Thomas McLellan, Dr George Koob, and Dr Nora Volkow published a viewpoint article at JAMA titled Preaddiction—A Missing Concept for Treating Substance Use Disorders. It is an important piece. The concept of preaddiction could dramatically expand our intervention strategies and better help us address the horrific consequences of harmful substance use across our society. As substance misuse and addiction are a leading if not the leading public health challenge we face, this is a welcomed articulation of these complex conditions. Preaddiction and its relationship to addiction as a parallel of prediabetes to diabetes could change what we do to help people heal from SUDs and save lives. This is a timely statement of a vital conceptual model we need to consider widely adopting.
The piece calls to reconceptualize substance use on a spectrum from harmful misuse to addiction and to focus our attention on preaddiction as it presents in early-stage misuse. As a decades long clinician, this fits with how I would work with people who were grappling with substance misuse in my work over the years. For persons experiencing problematic use, we need to consider if such persons are experiencing either an early-stage severe SUD or their substance use issues are a less severe from that can be addressed by lifestyle modifications that does not necessarily include cessation of substance use. Impaired control over use is central to how we explore this with those we serve. As noted in their article:
“Scientific findings now suggest impaired control as the core defining diagnostic construct, hypothesized to be the result of gradual use-related damage to brain circuits controlling reward sensitivity, motivation, self-regulation, negative emotional states, and stress tolerance”
As with diabetes, people with substance use disorders are experiencing a complex condition that includes a myriad of genetic and environmental factors. Impaired control is the core defining issue I would sit and discuss with persons I was working with in respect to exploring harmful substance use. Not everyone I worked with was addicted. As an aside, we do not see people in our care in these earlier stages as often as we should. We must expand and fund services for persons examining their risk factors. Persons in a preaddiction phase could address trauma, develop better coping mechanisms and reduce reliance on substance use as a coping strategy. Others will likely continue to experience impaired control as their use would progress into our classic understanding of addiction in which cessation of the use of substances became a more central facet in our treatment focus. Some people (like me) with early onset severe forms of the condition end up moving very swiftly from misuse, through preaddiction into addiction. This model could also help identify persons like me who are at the highest risk for a severe SUD earlier in life because of the genetic and environmental influences that make addiction a likely outcome.
Three areas were adopting a model that includes preaddiction could help us improve care for persons experiencing harmful substance use:
- Normalizing Substance Use Monitoring in Routine Medical Care – Articulating preaddiction can move these types of discussions more centrally into general medical practice settings. Getting people assistance to identify ways to understand their risks and change their lifestyles in routine medical care is paramount. It would support wellness strategies that can help people avoid addiction before they cross this threshold into loss of control. These discussions should be routine and occur when you have an annual medical checkup, just as it would if your blood sugars indicate you are moving into prediabetes. Every American should know their risk factors in relation to harmful substance use and understand what resources are available to help them maintain wellness.
This would also serve to help us expand how the public understands early-stage substance misuse and its progression. Like diabetes, there are complex genetic and environmental factors that influence its development. Medical communities and the public understand this paradigm in respect to diabetes. Moving conversations about substance use into general medical care using preaddiction as part of our model to explore and monitor risk factors and potential interventions would help normalize this highly stigmatized condition. This would save lives and normalize these types of medical conversations in ways we have failed to achieve to date.
- Early Interventions – As the authors note, we have focused nearly all of our interventions on later stage addiction. Addiction often, but not always is a condition that presents in early life, yet we tend to ignore it until it reaches high severity in later years. We ignore it and let it run its course until it gets harder to address! Here in my home state of Pennsylvania, I worked a few years back to hold a hearing in our General Assembly on the loss of our care structure for young people. We have actually lost ground on our young person’s SUD care infrastructure, and not just here in PA, but nationally. If this was any other public health crisis, we would focus on early intervention! Let’s do that.
Substance misuse can be conceptualized as a communicable condition, it spreads primarily among young people. Wellness works the same way when we normalize and support healing strategies to help people who are experiencing substance use issues heal. We ignore the signs until they reach elephant on coffee table dimensions. In contrast, we stop talking with people about prevention when they turn 18 years old, which makes no sense in a public health model. As the saying goes, we need to stop pulling people out of the water and go upstream to stop them from falling in. Preaddiction as part of our model in understanding and articulating to continuum of harmful substance use can help us focus on earlier interventions, which may well reduce the number of people who become addicted. More resources to help people heal earlier in the continuum means fewer people falling into the river. Deploying a preaddiction model could reduce the time that people are progressing through a substance use condition. We can save lives and help more people flourish in this way.
- Developing a more nuanced understanding of wellness and recovery. There have been a myriad of attempts to develop all-encompassing definitions for recovery over the years. As the article notes, most people who initiate substance use do not progress to full addiction. Healing and wellness from a substance use condition is also not a one size fits all process. The common understanding of recovery centers on the cessation of substance use and changed lifestyle as central pillars of recovery. Loss of control through damaged brain circuits defines addiction. Healing from a process of harmful substance misuse for those in a preaddiction phase is different in both degree and type than recovery for a person with a severe substance use disorder who experience the impaired control over use as highlighted by the authors. Articulating healing in a preaddiction model can help develop more nuanced definitions of recovery across the substance use healing and recovery spectrum that include persons who do not experience the severe form of the condition.
It is readily apparent to anyone who is even casually observing that harmful substance use is dramatically increasing across our society. Increased access to mood altering substances, increased social stress and greater social isolation are significant environmental factors that lead to people using substances to cope with challenges they face. We also know that addiction is influenced by a myriad of factors. Researchers are examining the complex genetic and epigenetic influences of how people use substances. Like diabetes, some are protective, and others increase risk for substance related conditions. The preaddiction model fits with what is occurring in respect to the continuum of harmful substance use to addiction and provides us additional off ramps to help save lives and heal communities.
There has never been a time in which we need to develop unifying concepts and systematize earlier stage interventions for harmful substance use issues in ways that can be readily understood in front line medical practice and by the public.
I hope we can embrace it as an important way to improve our care system.