Preaddiction – A Helpful Term?
by Tom Horvath, Ph.D.
Would the term “preaddiction” be helpful? The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) jointly issued a Request for Information on this term. The details of the Request are at the very bottom. Below is what I sent them (slightly edited):
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What would a better term be?
Addiction (and thereby, preaddiction) is an undesirable term because it is used by many in an all-or-none fashion, or to denote a state of disease (leaving out those who view these disorders as primarily behavioral). Consequently, preaddiction is also undesirable. I believe that eliminating the terms addiction and preaddiction will greatly reduce stigma, because these terms are used to divide people into two groups (addicted, non-addicted). That division is a foundation of stigma.
The addictive behavior spectrum has 6 levels: 1) abstinence, 2) moderation, 3) misuse (subclinical use), 4) mild SUD (or a comparable level if there is no disorder for that behavior or substance), 5) moderate SUD, and 6) severe SUD. Every individual has a standing on this spectrum for each addictive behavior or class of behaviors.
The term “addictive problems” can be applied to levels 3-6. This term is consistent with Broadening the Base of Treatment for Alcohol Problems, published by the National Academy of Sciences in 1990. The term is also consistent with your opening statement:
“Background: Substance misuse and substance use disorders (SUD) continue to have a devastating impact on people in the United States”
Most of us are at “abstinence” on most addictive behaviors. An underlying assumption of this spectrum is that addictive behavior itself is normal human behavior (to include food, sex, getting attention from others). Many of us over the course of our lives reach level 3 or higher for one or more addictive behaviors, so addictive problems are common.
How might a family doctor use the addictive behavior spectrum?
A family doctor might say to a patient:
Level 3) “Your use has gone beyond moderation. You have entered the lower range of addictive problems. We identify 4 levels of addictive problems. You are in #1. Of course, some individuals over time go all the way up to #4. We can think of your situation as being like skin cancer. It is better to address minor skin problems early, rather than waiting until they become major. If I were a dermatologist, I might be telling you that we have some concerning moles to remove. I have suggestions about how you can monitor your use, and changes you might consider. Then we can meet again (in x months). How does that course of action sound to you?”
Level 4) “Your use is in the lower middle range of addictive problems. We identify 4 levels of addictive problems. You are in #2. Of course, some individuals over time go all the way up to #4. We can think of your situation as being like skin cancer. It is better to address skin problems earlier than later. If I were a dermatologist, I might be telling you that I want to do some biopsies. I have suggestions about how you can monitor your use, medications you might consider, and other changes you might consider. Then we can meet again (in x months). How does that course of action sound to you?”
Level 5) “Your use is in the upper middle range of addictive problems. We identify 4 levels of addictive problems. You are in #3. Of course, some individuals over time go all the way up to #4. We can think of your situation as being like skin cancer. It is better to address skin problems earlier than later. If I were a dermatologist, I might be telling you that there is some tissue I want to remove. Other interventions may be needed. I have some suggestions about how you can monitor your use, medications you might consider, and other changes you might consider. Then we can meet again (in x weeks). If you would be willing, I could also refer you to a specialist. How does that course of action sound to you?”
Level 6) “As you may realize, your use is in the upper range of addictive problems. We identify 4 levels of addictive problems. You are in #4, the highest level. [the doctor might then review diagnostic criteria]. Of course, your problems could become even worse. At a minimum I hope we can work together to make sure your situation does not get worse. It’s also time to consider what changes you might be willing to make to bring your level of problems down, all the way down if possible. If you had this level of skin cancer, I would be encouraging you to consider significant medical interventions, because without them you might have very serious consequences or die. Would you be willing to meet with a specialist, who can help you consider your options? You and I will continue to meet, so that I can support positive change as well. How does that course of action sound to you?”
What challenges exist for this suggested approach?
These statements may rely too much on the family doctor knowing enough about motivational interviewing and addictive problems. Alternatively, the referral for evaluation (and the consideration there about options for change) could occur even at level 3. To the extent that we have data (e.g., the percentage who progress from level 3 to levels 4, 5, or 6, for a specific addictive problem) it should be included in the evaluation.
If the busy and non-specialist provider does not have a specific level of addictive problems to diagnose, the statement might be: “It seems to me your use has gone beyond moderation. You have entered the range of addictive problems. We identify 4 levels of addictive problems. Precisely where you are on that range might take some effort to determine. I estimate that you are at least at the first level of problems, and possibly higher. The effort to arrive at a precise diagnosis may not be worthwhile. The important part is that you could keep moving up to higher levels, or we could work on moving you down or off the addictive problems spectrum altogether, by moderating or abstaining. Would you be willing to meet with a specialist, who can help you consider your options? You and I will continue to meet, so that I can support positive change as well. How does that course of action sound to you?”
Unfortunately, there are not enough harm-reduction oriented evaluators and providers to support family doctors who made this kind of referral. It would be jarring for the patient to have the kind of conversation just suggested, and then see an abstinence-only, 12-step oriented, disease-oriented evaluator or treatment provider. Unless the family doctor knew harm reduction-oriented providers, it might be more sensible for the family doctor (or other medical provider) to continue to work directly with the patient, and refer the patient to mutual help groups, such as SMART Recovery, that are harm reduction oriented.
How should NIDA and NIAAA rename themselves?
If you adopted this term, addictive problems, a follow-up step would be to become the National Institute on Addictive Problems, and to include in your work gambling and other non-external-substance addictive problems.
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Last summer I wrote a blog on this topic:
Will the Concept of Preaddiction Improve Care for Addictive Problems?
The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have jointly issued a “Request for Information (RFI): Inviting input on use of a term like “preaddiction” for identifying and intervening in substance misuse and mild/early-stage substance use disorder.” This RFI seeks input from people with lived experience of substance use, medical and scientific research communities, and other interested parties. Responses must be received by April 27, 2023, and submitted electronically to: PreaddictionRFIFeedback@nida.nih.gov
If you or a loved one fall somewhere on the addictive behavior spectrum and are looking for cutting edge that leaves behind labels like addict, preaddiction, and addiction, we might be a good fit for you. Please don’t hesitate to reach out – you don’t have to navigate this alone.