Drug experts are normalizing the idea that you can be "pre-addicted." Is that really a thing?

"I don't know if this is a helpful term": experts torn on a concept invented to help treat drug addiction

By Troy Farah

Science & Health Editor

Published May 12, 2023 8:00AM (EDT)

Man standing on the edge of syringe needle (Getty Images/Boris Zhitkov)
Man standing on the edge of syringe needle (Getty Images/Boris Zhitkov)

The word "addiction" is probably over-used in our culture. Clinically, it means compulsive use of drugs; colloquially, we stretch its use to refer to addiction to things that probably don't fit the clinical definition, like when we speak of addiction to screens or kombucha.

Now, as the opioid crisis has precipitated a huge investment in a public health apparatus devoted to treating addiction, public health experts have coined a new term: pre-addiction. The idea behind the label is that it could be a useful concept for ascertaining one's risk of developing a drug addiction. Indeed, some organizations that use the term, such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA), hope that it can be useful in intervening in addiction before it even starts. Yet as the term gains more prominence, experts in the field are torn over whether or not it's a worthy concept.

One of its most prominent proponents is Dr. Nora Volkow, a psychiatrist who has served as the director at the National Institutes of Drug Abuse (NIDA) for the last two decades. In an opinion piece published last summer in the journal JAMA Psychiatry, Volkow describes pre-addiction as a "missing concept" in the realm of addiction treatment. 

Critics of pre-addiction warn that it could burden individuals with a stigmatizing label that could actually make it harder to navigate the healthcare system.

Addiction, known formally as substance use disorder, is defined as compulsive use of drugs and alcohol, even when it leads to significant distress or impairment in one's personal life. It's distinct from dependence, which is when using drugs over time increases tolerance and generates withdrawals. It's possible for someone to be physically dependent on a substance without having a substance use disorder, such as with certain prescription medications, but illicit drugs as well.

The hallmark of addiction is chaotic use coupled with the inability to control or reduce it, despite harmful consequences. Preaddiction, on the other hand, is still a somewhat nebulous concept that may or may not be useful for determining someone's risk of developing a serious issue with drug use. In March, NIDA and NIAAA put out a joint request for information, petitioning physicians and addiction specialists to comment on whether such a concept would help — and some drug policy experts are already expressing concern that a preaddiction label may backfire or deepen America's struggle with fatal overdoses.

"What we are aiming for is a recognition of identifying individuals that may be at risk from the use of opioids. You can predict in many instances who is at risk, and if you intervene, you may prevent them from escalating," Volkow told Salon in a call. "The aim of the concept of preaddiction was to generate that awareness and to generate a model that clinicians can agree [on], so that people can be screened in a systematic fashion … At this point, the illicit drug market is so dangerous, that even occasional drug taking can be dangerous."

In other words, you don't need to be addicted to a substance like fentanyl to die from it. Not all drug use equals addiction. Some people only use cocaine, meth or even opioids occasionally and it doesn't disrupt their work or relationships. But the increased volatility of drug markets can make even intermittent drug use a roll of the dice, underscoring the importance of drug testing tools to know what you're taking. Everyone should also have naloxone on hand, a drug that reverses opioid overdoses, even if fentanyl or related drugs aren't something you use.

The debate comes at a pivotal moment in the drug war and in an overdose crisis driven in large part by opioids like fentanyl. The latest fatality stats from the Centers for Disease Control and Prevention (CDC) paint a stark picture: more than 108,000 died from overdose in 2021, and the CDC reported this month that drug overdose deaths involving fentanyl increased by 279 percent between 2016 and 2021. Deaths involving methamphetamine and cocaine also rose over that period.

The drug supply is getting steadily more unpredictable, as more substances are found to contain fentanyl and animal tranquilizers like xylazine that can generate horrific necrotic injuries. For years, some public health experts have argued people who use drugs need regulated alternatives, a harm reduction strategy known as safe supply. It's essentially the kind of regulatory structure that already exists for alcohol, tobacco, prescription drugs and cannabis in some areas.

"Safe supply programs are built on the premise that prescribing pharmaceutical-grade opioids such as hydromorphone and diacetylmorphine to people at high risk of fatal overdose will reduce their use of fentanyl-adulterated opioids obtained from the illicit drug market, and subsequently prevent overdose events and reduce overdose mortality," a group of drug policy experts wrote in the International Journal of Drug Policy in 2020. But safe supply remains a hard sell at the federal level.

One of the most stubborn myths of addiction is that taking a drug once will instantly hook someone for life. Not only does true addiction require persistent use of a substance over time, the vast majority of people recover from substance use disorders without any formal treatment. Numerous studies support the idea of natural recovery, with one federally-funded survey of 43,000 people concluding that over 72 percent of all people who recovered from alcohol dependence managed to do it without formal intervention. Most people who have problematic drug use actually grow out of it, a relationship that remains stable over time. Treatment can still help many people, of course, and the rapid shifts in the underground drug market still make things unpredictable and deadly.

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"You may be a cocaine user and you just take it over the weekend. There are many cocaine users that do that. Right now, cocaine is being mixed with fentanyl," Volkow said, describing a possible scenario where a preaddiction diagnosis may be useful. "An intervention may be as simple as saying, are you aware that cocaine frequently now could be laced? There are ways that you could protect yourself and that protection may be a fentanyl test strip. But you're doing an intervention that could save that person's life."

But right now, there's no evidence that such a label would do what Volkow and others hope it will accomplish, which is the motivation behind researching it. Critics of pre-addiction warn that it could burden individuals with a stigmatizing label that could actually make it harder to navigate the healthcare system.

"I'm generally all for turning our concept of addiction into a spectrum instead of a yes or no. I don't know if this is a helpful term though." 

"It has been hard enough to get the term and diagnostic criteria of substance use disorder used, despite 10 years of effort, so introducing a new concept that is even less clear seems like it risks muddying the water even more," Dr. Sarah Wakeman, an associate professor of medicine at Massachusetts General Hospital, told Salon in an email.

"Volkow has been promoting the medicalization of addiction in part because she believes it will help destigmatize addiction. But that's clearly not working. Spend five minutes in any emergency department to see how much stigma still flourishes," Dr. Jennifer Carroll, a medical anthropologist, research scientist and substance use expert, told Salon in an email. "Why would piling more complexity onto that medical model be a net benefit for people who use drugs? That model is, at best, not well accepted and, at worst, distorted to present addiction as the absence of free will, justifying all sorts of rights violations against people who use drugs."

In their opinion article, Volkow and her co-authors Thomas McLellan of the Treatment Research Institute (also on the board of Indivior, which makes the addiction treatment drug Suboxone) and George Koob, the director of NIAAA, often compare pre-addiction to prediabetes. They write that "pre-addiction has inherent motivational properties that convey the need for clinical action and patient change — just as pre-diabetes and precancerous currently do." Prediabetes is a term introduced in 1997 by the American Diabetes Association to describe a metabolic syndrome that can turn into type 2 diabetes mellitus.

"We are proposing the term 'pre-addiction' because it gives a readily understandable name to a vulnerable period of time in which preventive care could help avert serious consequences of drug use and severe substance use disorders," Volkow wrote in a blog accompanying the JAMA opinion article.

"I'm generally all for turning our concept of addiction into a spectrum instead of a yes or no. I don't know if this is a helpful term though," Dr. Adam Lake, a family physician at Lancaster General Hospital, told Salon in an email. "Even prediabetes is turning out to be of questionable predictive value, but it has allowed us to get more people access to dietitians and we don't have so much stigma."

There's also the issue that diabetes is a disease that can be objectively measured. Prediabetes is diagnosed based on blood sugar levels. However, there is a growing consensus among drug policy experts that addiction is not a disease but more of a compulsive, behavioral learning disorder.

Substance use disorder is also an incredibly subjective experience that doesn't arise from one, predictable source. It doesn't necessarily relate to a specific substance so much as one's life circumstances. In other words, struggling with housing, healthcare or otherwise navigating capitalist society often has more to do with the disorder than a mental imbalance. This is on par with research showing that depression stems more from societal issues than the brain.

The disease model of addiction is a "very narrow conceptualization that doesn't understand social, environmental and systemic causes to addiction," Dr. Cassandra Boness told Salon in a call. Boness is a psychologist and research assistant professor at the University of New Mexico whose primary area of focus is around issues of classification and diagnosis of substance use disorders.

"It allows people to make it feel more addressable. Like, if we could just call it a brain disease and we can identify this part of the brain, we can fix this," Boness said. "And it also allows the pushing aside of other larger issues in our society that we know are at play here. It allows them to like tune out some of the other systemic issues that we're facing as a society."

Preaddiction is more in line with this model of thinking, Boness said, arguing that the disease model has made stigma against addiction worse, not better.

"Focusing on these more biogenetic causes of addiction has not actually done all that much for us. We're still in the middle of an obvious crisis," Boness said. "The sentiment that I've heard echoed from most other people with any kind of lived experience themselves is [preaddiction] is going to disproportionately impact people who are already stigmatized and discriminated against, oppressed and marginalized, particularly Communities of Color, who, with the drug war, have already been disproportionately impacted by some of these things. It's frustrating. It feels like we're not being listened to."

By Troy Farah

Troy Farah is a science and public health journalist whose reporting has appeared in Scientific American, STAT News, Undark, VICE, and others. He co-hosts the drug policy and science podcast Narcotica. His website is troyfarah.com and can be found on Twitter at @filth_filler

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