Concept of 'Preaddiction' Could Lead to Early Intervention for Possible Substance Use Disorder

About 20 years ago, diabetes care changed when an organized effort was made to identify patients at risk of diabetes earlier and connect them with treatment. A similar strategy could be used within the substance use disorder (SUD) field by using the term “preaddiction,” advised A. Thomas McLellan, Ph.D., George F. Koob, Ph.D., and Nora D. Volkow, M.D., in a Viewpoint piece published yesterday in JAMA Psychiatry.

“Addiction is the most severe form of a full spectrum of substance use disorders,” the authors wrote. “It has been the almost exclusive focus of U.S. clinical and policy efforts. However, serious addiction only results after years of unhealthy substance misuse that could be identified and managed much earlier.”

McLellan is the co-founder of the Treatment Research Institute, Koob is the director of the National Institute on Alcohol Abuse and Alcoholism, and Volkow is the director of the National Institute on Drug Abuse.

The transition from using a substance to developing a substance use disorder is usually slow and variable, the authors wrote. “[T]he DSM-5 uses 11 equally weighted symptoms of impaired control to define SUDs along a three-stage severity continuum,” they continued. Severe SUDs, commonly referred to as addiction, are defined by six or more symptoms and found in only 4% to 5% of adults, while mild to moderate SUDs are defined by two to five symptoms and found in about 13% of adults. “However, treatment efforts and public health policies have focused almost exclusively on those with serious, usually chronic addictions, virtually ignoring the much larger population with early stage SUDs,” the authors wrote.

When faced with a similar problem, the American Diabetes Association suggested the term prediabetes in 2001, defined by elevated scores on two laboratory tests (impaired glucose tolerance and impaired fasting glucose). Advertising campaigns that followed to raise public awareness and partnerships with insurers led to the creation of new medications, testing, and interventions. If a similar approach were taken in the SUD field using the term preaddiction, McLellan, Koob, and Volkow wrote, it would require a similarly integrated effort in three areas, including the following:

• Establish measures to define and detect preaddiction: DSM-5 diagnoses are reliable and could be implemented in clinical settings to define preaddiction.
• Identify effective interventions: Screening, brief interventions, referrals to treatment, and a computerized version of cognitive-behavioral therapy could potentially be used as preaddiction interventions. However, the authors also pointed out the need for a broader range of medication treatments and social support.
• Advocate and educate: Few in the public or even in medical practice know how to recognize or what to do when an individual begins to transition to an SUD, and procedures for screening and tracking early stage SUDs must be taught in medical or nursing schools and properly reimbursed.

The authors acknowledged that some may be concerned that the term preaddiction could intensify stigma, yet they contend that it is exactly the right term to use for two reasons. First, preaddiction refers to the disease, not the individual. “Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided,” the authors wrote. “Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”

For more information, see the Psychiatric News article “The Perils of a Pandemic: Challenges Faced by Addiction Services.”

(Image: iStock/monkeybusinessimages)

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Innovative Solutions for Expanding MH Care and More From APA’s 2017 Annual Meeting Day Two

Day two of APA’s Annual Meeting included an announcement of the results of a national poll on Americans’ views on access to mental health care, an address by the director of NIAAA, and discussion about ways to strengthen the therapeutic alliance with a patient after a suicide attempt.

From now through May 24, Psychiatric News will deliver an evening digest of some of the day’s highlights—from the lecture halls to the exhibit floor. Whether you are here in San Diego or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Oquendo Recounts Victory of 21st Cures Act, APA’s Ongoing Efforts on AHCA

“We are at the threshold of a wonderful era for psychiatry,” said APA President Maria A. Oquendo, M.D., Ph.D., recapping an eventful presidential year highlighted by her presence at the White House for the signing of the 21st Century Cures Act.
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Everett to Center Presidency on Innovative Solutions to Expanding Care, Increasing Support to Members

During the Opening Session, APA President-elect Anita Everett, M.D., said the development of innovative systems for improving access to care, team-based care for first-episode psychosis, and initiatives regarding physician wellness and burnout would be key goals for her presidency. Read More >

Large Majority of Americans Say MH Care Should Be Covered by Insurance

Mental health is important to Americans, and they think it should be important to their elected representatives as well, according to the results of a national poll released today by APA. Read More >

NIAAA Director Describes ‘Dark Side of Addiction,’ Hope for Future Treatments

The negative emotional states experienced by people with substance use disorders are an integral part of the addictive process, according to George F. Koob, Ph.D. Read More >

Winners of Assembly Election Announced

At their meeting held yesterday in conjunction with the Annual Meeting, members of the APA Assembly chose James R. Batterson, M.D., of Kansas City, Mo. (right), as the group’s next speaker-elect. He is the Area 4 representative and is concluding his term as recorder. Steven Daviss, M.D., a representative from the Maryland Psychiatric Society, was elected recorder. The new officers begin their terms at the close of the Annual Meeting, at which time Theresa Miskimen, M.D., of Piscataway, N.J., will become the speaker of the Assembly.

Asking Patients About Suicide Narrative May Improve Long-Term Outcomes

Placing greater emphasis on a patient’s narrative of the feelings leading up to a suicide attempt may not only strengthen the therapeutic alliance, but create a foundation from which safety planning and long-term outreach can be maintained. Read More >

What Can Children’s Books Teach You About Your Patients?

All literature is born from the human need to tell stories that help us understand ourselves and others. Children’s books—which allow young readers to experience love, loss, and betrayal through the lives of characters—can lead to cognitive and emotional growth in young people. Read More >

Psychiatrists Have Tools Needed to Help Patients in Pain

Physicians today appreciate that chronic pain involves vicious cycles of both physical and psychological feedback. Read More >

Historical Survival Traits May Be to Blame for Some Mental Health Disorders

Depression and anxiety are, paradoxically, directly linked to the same genetic traits that evolved to help our ancestors survive, said Lee Goldman, M.D., author of Too Much of a Good Thing: How Four Key Survival Traits Are Now Killing Us. Read More >

Brain Stress Systems May Be Key Piece of the Addiction Puzzle

The brain’s stress systems appear to play a key role in the transition to addiction and maintaining addiction once it is initiated. People addicted to drugs take those substances not to feel good, but to avoid the anxiety, stress, irritability, or dysphoria of drug withdrawal, said George Koob, Ph.D., of the Scripps Research Institute in La Jolla, Calif., in a talk at the Society of Neuroscience meeting today in San Diego.

Excessive use of drugs triggers negative emotional states that activate the stress systems within areas of the brain known to mediate emotions, including the amygdala and basal ganglia, said Koob, who will become director of the National Institute on Alcohol Abuse and Alcoholism in January.

Two neurotransmitters—corticotropin-releasing factor (CRF) in the amygdala and the dynorphin-κ opioid system in the basal ganglia—are in those brain areas and mediate anxiety-like behavior, fear conditioning, and dysphoria-like behavior in animal models, Koob noted. He hypothesized that brain stress response systems are activated by excessive drug intake, then activated again during repeated withdrawals, and continue during abstinence.

 “A role of the brain stress systems in addiction not only provides insight into the neurobiology of the emotional misery of addiction but also provides novel targets for the treatment of addiction,” he concluded.

For more in Psychiatric News about George Koob's research on addiction, see "People With Addiction Exhaust Brain’s Limited Reward System."

(Image: Aaron Levin/Psychiatric News)