The National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism recently proposed a new addition to the addiction vernacular: “preaddiction.” The idea is that the word will help identify and intervene on harmful substance use earlier and more effectively.
While it’s an admirable goal, the term fails to align with the evidence. Worse, adopting it could have potentially disastrous consequences for people with substance use disorders — an already marginalized group.
The term “preaddiction” was proposed by federal agencies to raise awareness about harmful substance use, increase screening and brief interventions in clinical settings, prevent overdose, and support the development of new interventions for harmful substance use and early-stage substance use disorders. Adopting such a label is unlikely to support these goals and, instead, likely carries with it additional stigma.
Critically, there already exist several terms to capture harmful substance use and early-stage substance use disorders. For example, the Diagnostic and Statistical Manual of Disorders (DSM), Fifth Edition uses a count of substance use disorder criteria to indicate how severe one’s substance use disorder is. This includes designations of “mild” (meeting at least two criteria) and “moderate” (at least four criteria) substance use disorder. The proposal from the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism would, among under things, replace the terms “problematic substance use,” “mild substance use disorder,” and “moderate substance use disorder” with “preaddiction.”
Even the existing mild and moderate categories are on shaky ground. My research shows that DSM criteria for substance use disorder are in themselves flawed and relying on a criterion count as an indicator of substance use severity has several limitations. For instance, not all substance use disorder criteria count equally toward a diagnosis in terms of their severity. The criteria include experiences like craving (which is a strong desire or urge to use), withdrawal, using substances in larger amounts or longer than intended, and having failed attempts to quit or cut down. Someone who has only the first two is quite different from someone who is experiencing the final two, yet both count as having “mild” substance use disorder. 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. Attaching new labels to those already not-terribly-helpful DSM criteria and criteria counts would be a serious misstep.
Furthermore, 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.
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.”
Treating substance use and substance-related problems as existing along a continuum of harm is associated with greater problem recognition among harmful drinkers and reduced public- and self-stigma. Viewing use and problems as existing along a continuum may also encourage a greater focus on public health and prevention approaches, which seems to be in line with the goals of introducing the term “preaddiction” minus the additional pitfalls of being assigned such a label.
I’m particularly concerned that “preaddiction” will be used to empower exploitative addiction treatment industries and force people into involuntary treatment. For example, the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism 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.
I also worry that this label will be misused by people in power to further punish and control people who use substances and worsen other existing inequities for people who use substances or have substance use disorders —particularly those with other marginalized identities. This would serve to further deter intervention, including early intervention. If I knew a provider might label me as “preaddicted” — a label that would live in my medical record and be available to other providers long-term — I doubt I would seek care for my substance use.
Some compare adopting “preaddiction” to “prediabetes,” a label intended to capture those at risk for type 2 diabetes with the goal of intervening earlier. But addiction is not akin to diabetes. Addiction, unlike diabetes, is contested as a medical disease and lacks biological markers comparable to those available for diabetes, such as hemoglobin A1C. Viewing addiction as a medical disease also has the consequence of “othering” people with addiction. The disease perspective is associated with decreased societal and personal optimism about the likelihood of addiction recovery as well as reduced clinician empathy. Further, there is little evidence to support that taking an equivalent approach with addiction would be effective. The perspective that preaddiction is similar to prediabetes also serves to medicalize addiction, reinforcing narrow conceptualizations of what addiction is and pulling attention away from other sociopolitical and environmental causes that also drive risk for substance use disorders.
Instead of wasting time considering adopting the term “preaddiction,” federal agencies should focus their attention on social determinants of health and other systemic issues that contribute to addiction, overdose, and other related problems such as food security and housing. Our efforts are best spent advocating for continuum-based models of substance-related harm that avoid arbitrary categories like “preaddiction.”
Cassandra L. Boness is a licensed clinical psychologist and research assistant professor at the University of New Mexico Center on Alcohol, Substance use, And Addictions.
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