ADVERTISEMENT
Preaddiction: A New Motivational Category Warning of Disease Progression
Addiction care must move further upstream to start helping people before they meet criteria for substance use disorder (SUD). Thought leaders recently proposed “preaddiction” as a new concept for early dangerous use. Analogous to prediabetes, this category hopefully warns people at risk for progressing to addiction.
This appeals to common sense. Yet however sensible early warnings might seem, we must ask which early interventions really make a difference? Study of the stages of change suggests getting people to accept categories and labels may be unproductive. Encouraging people to compare their lives to a disease process tends to be less effective than eliciting a person’s ambivalence about their behavior.
People need to find specific, personal reasons to change. Many who misuse substances or overeat believe they will avoid serious trouble. Give it a technical name if you will, but names are not reasons to change.
Preaddiction further medicalizes the field by expanding the disease model’s scope. The timing is ironic since interest is growing within medicine, especially primary care, to import our psychosocial tools for behavior change. Psychosocial solutions are increasingly being sought due to the limits of medical ones.
Prediabetes is the prototype here, with the goal being to learn from a less stigmatized chronic disease. Of course, addiction lacks biological markers comparable to diabetes (i.e., HbA1c, plasma glucose), but this may not be as critical as one might expect in the process of change.
PCPs share warning signs of diabetes because a percentage of patients are influenced by the knowledge. They should similarly discuss liver function tests that can reflect risky substance use. However, terms like preaddiction envision more than patient care. They are public health tools to improve population health. We must ask if our decades-long diabetes campaigns are meeting goals before we copy them.
The idea of prediabetes was implemented in 2001. A large JAMA study in 2021 undermines hope that diabetes campaigns are working. This national survey found the rates of diabetes increased from 9.8% to 14.3% over a 20-year period. An astounding 24% of young adults (ages 18-44) have prediabetes. These are major public health disappointments.
Pre-disease warnings to promote behavior change are best understood in connection with 2 related questions:
- Is it helpful to self-identify as having a disease (or pre-disease)?
- What is the relative value of different types of support, education, counseling, and therapy?
Our field is divided over the need for people to self-identify as having an addiction. Few practical insights on this are emerging from diabetes care. In fact, disease management (DM) programs tend to be baffled and unprepared for people’s lack of readiness for change. Nurses sometimes call DM patients with documented diabetes and find they are unaware of the diagnosis or unwilling to accept it.
Biological markers may seem like a great advantage for diabetes care, and yet a person’s readiness for change often preempts clinical information. This touches on another historical weakness of DM. These programs are nursing interventions geared to provide education and support (not counseling or therapy) to achieve discreet goals. Leaders are aware of DM’s weak performance and want better tools.
Can the addiction treatment field learn from the extensive efforts to prevent and treat diabetes? More learning may come from the opposite direction. Medical providers are more eager to apply our techniques to a host of conditions driven by behavior. They know behavior change is hard and see our clinicians as best at facilitating progress. Medically driven nursing discussions miss the mark.
Addiction treatment involves powerful interventions (e.g., motivational interviewing, relapse prevention) that are personalized by well-trained clinicians. Despite poor access rates, many are helped. We may do well to move our services where the patients reside—primary care. Moving a segment of our workforce there would be difficult, but physicians are learning that behavioral care is primary care.
The experts promoting the idea of preaddiction strongly support “integration into the rest of mainstream healthcare.” Primary care is the prime location for early interventions. This is where pre-disease states of every type will be found, and yet current medical tools are inadequate. Therapists are increasingly being hired in primary care to take advantage of their individualized psychosocial solutions.
PCPs increasingly see chronic medical conditions as epitomizing the limits of the medical model. Rates of diabetes are increasing, and patients are not achieving clinical goals due partly to maladaptive attitudes and behaviors. Education about the progression of disease is not therapy. Many people with chronic conditions might benefit from adaptation of our counseling and therapy tools.
The preaddiction concept may contribute little to SUD work upstream given the poor record for diabetes, but we definitely must focus on the early years of use. Primary care is the right stage for this. Everyone can agree on one point: More collaboration between medical and behavioral clinicians is essential. This cross-fertilization will hopefully produce ever-improving solutions.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
References
