by Mark Gold M.D. –  Reviewed by Michelle Quirk – November 3, 2025 –

The mistaken belief that people with substance use disorders (SUDs) must “hit rock bottom” has shaped addiction care for decades. This model contrasts with how medicine manages chronic illnesses, where early detection and proactive treatment are normal. The “bottom” in addiction is a moment of maximum despair and hopelessness. It also may be a life-changing event like getting fired, losing a relationship, or facing legal charges. It could mean a moment between considering changing one’s life or suicide.

For more than 30 years, I have proposed that addiction treatment must “move up the bottom” to reduce harm and have a better chance of working. Applying preaddiction logic holds promise for lowering SUD-related suffering, illness, and mortality. Denying early diagnosis and treatment may primarily stem from addiction stigma.

“Let them hit bottom” was (and is) the refrain in addiction care; suffering supposedly must crescendo before people with an SUD accept the need to stop using drugs. Whether arising from fear of people gaming the system and seeking opioids for fake injuries or the inherent austerity of public institutions, this belief still shapes policy and practice.

In the early 1970s, I encountered this idea as a medical student. People who came to the emergency room with overdoses were not admitted. Medicine had little to offer and might undermine a person’s journey toward readiness; a person might feel ready for treatment, but someone else decided they’d not hit bottom. How ridiculous is this?

But when physicians misuse substances, then early intervention, long-term monitoring, and structured support are considered necessary. These practices, codified in physicians’ health programs (PHPs) across the United States, help most physicians, yielding an excellent return-to-work rate and resumed function. The message is clear: The “rock bottom” model is neither ethical nor clinically efficient.

National Institute on Drug Abuse Director Nora Volkow has called the belief that someone must “hit rock bottom” before treatment “a myth that can have dire consequences.” While the rock-bottom narrative offers psychological neatness—drama, surrender, catharsis—it lacks scientific grounding. Substance use disorders rarely emerge overnight; they evolve with “use,” then “risky use,” often in adolescence or early adulthood. By the time someone meets all criteria for severe SUD, the hijacked brain is adept at finding and using drugs, and not getting caught or sent to treatment. The longer SUD continues, the more complex and complicated the reversal is.

Ethically, “waiting” is untenable. Delayed intervention amplifies harm, entrenches bad behavior, and puts family, friends, and others at risk of harm. An earlier intervention and treatment might prevent loss of friends, family, and job, as well as halt the addiction from becoming entrenched.

We don’t withhold antihypertensives until catastrophic bleeds occur. We don’t wait for myocardial infarction to begin statins. Medicine emphasizes upstream prevention and treatment. While many perceive addiction as a choice, impaired MDs will tell you they wish someone had intervened and helped them earlier.

The directors of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism proposed, in 2022, earlier identification and intervention for substance use and its consequences. Volkow, Koob, and McLellan introduced this preaddiction concept by paralleling prediabetes. These researchers used mild to moderate Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, SUD criteria to help define pre-addiction, allowing early detection, brief treatment, or intervention before addiction-related neurobehavioral and psychosocial collapses occurred.

Research shows that at mild to moderate levels of SUD severity, patients often retain executive function, can reassert control over drugs, and may still re-engage and preserve intact relationships, work roles, and decision-making. At this preaddiction point, brief interventions, outpatient treatment, or educational measures have great potential to resolve the preaddiction. Sometimes, treatment might comprise advice and education rather than weeks in a treatment facility. In addition, early interventions may not require anti-craving medications, detoxification, opioid treatment medications, hospitalization, or extensive monitoring.

Preaddiction thinking supports early engagement, attacks denial, and normalizes a preventive mindset. Preaddiction communicates risk while preserving agency, as with prediabetes. It gives clinicians a structured rationale to screen, counsel, and refer before severe illness.

Early Intervention Works

Nowhere is “raising the bottom” more visible than in PHPs. These state-based programs often identify impaired doctors from anonymous reports of patients, staff, or other providers. They protect patients from impaired physicians by managing them through structured evaluation, mandated treatment, regular toxicology testing, workplace monitoring, and ongoing recovery support—often for five or more years.

This model is widely celebrated, even though its success depends partly on external leverage: Physicians are often told noncompliance may result in license suspension and loss of professional status. In a five-year, multi-state study, DuPont and colleagues found that more than 70 percent of the doctors returned to practice, sustaining functional recovery. The model used early identification, accountability, structured care, serial urine testing, and long-term follow-up. It’s preventive, continuous, and outcome-driven.

The PHP system contradicts the “hitting bottom” mantra. It’s a real-life demonstration of what addiction care could be: long-term, hopeful, and outcome-driven, but with accountability. The limited application of such systems beyond professional circles reflects a profound inequity—not a clinical limitation.

Physician colleagues have moral, ethical, and legal obligations to report coworkers whose impairment threatens patients. Avoiding “punishment” and promoting sharing, shame reduction, and physicians helping each other in camaraderie while in treatment is critical to the success of physician programs.

When structured and ethical, coercion may paradoxically enhance autonomy by restoring capacity. Treat coercion as a clinical tool—not punishment. Integrate preaddiction into medical education, focusing on prevention, brain changes, and ethical duties.

“Bottom” need not be the destination just before treatment. Waiting or delaying intervention until full disorder or voluntary self-referral risks disease progression, more entrenched brain/behavior changes, worse prognosis, and higher costs.

Summary

To align addiction with other chronic medical conditions, SUD screening must be routine for every healthcare, clinic, or emergency department visit. Duration, age of initiation at use, and severity should be assessed. The preaddiction concept provides a teachable inflection point rather than the binary “normal vs addicted,” and intervention may change the trajectory. Brief interventions may be the only treatment needed if interventions start early enough.

Medicine should abandon the myth that people with SUDs must earn the right to be helped by suffering “enough.” Medicine has shown numerous benefits of early screening, intervention, and assisting patients in changing. If we can intervene early for hypertension, for type 2 diabetes, and for breast and colon cancer, we can do the same for addiction. What’s holding us back?

Source: https://www.psychologytoday.com/us/blog/addiction-outlook/202511/preaddiction-intervention-could-save-lives