{"id":20280,"date":"2025-11-16T18:00:59","date_gmt":"2025-11-16T17:00:59","guid":{"rendered":"https:\/\/drugprevent.org.uk\/ppp\/?p=20280"},"modified":"2025-12-07T18:08:44","modified_gmt":"2025-12-07T17:08:44","slug":"pre-addiction-intervention-could-save-lives","status":"publish","type":"post","link":"https:\/\/drugprevent.org.uk\/ppp\/2025\/11\/pre-addiction-intervention-could-save-lives\/","title":{"rendered":"Pre-addiction Intervention Could Save Lives"},"content":{"rendered":"
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by Mark Gold M.D. – <\/span>\u00a0Reviewed by Michelle Quirk – <\/span><\/span>November 3, 2025<\/span>\u00a0–<\/span><\/span><\/h1>\n

Key points<\/span><\/h3>\n
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  • We screen and intervene early for hypertension, type 2 diabetes, and cancer; we can do the same for addiction.<\/span><\/li>\n
  • Preaddiction thinking supports early engagement, attacks denial, and normalizes a harm-reducing mindset.<\/span><\/li>\n
  • Delaying treatment increases risks and harms, contradicting outcomes research and ethical medical practice.<\/span><\/li>\n<\/ul>\n

    Raising \u201crock bottom\u201d\u00a0<\/span>with early diagnosis and intervention in substance use.<\/span><\/h2>\n<\/div>\n<\/div>\n
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    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 \u201cbottom\u201d 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\u2019s life or\u00a0suicide.<\/span><\/p>\n

    For more than 30 years, I have proposed that addiction treatment must \u201cmove up the bottom\u201d 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\u00a0stigma.<\/span><\/p>\n

    “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\u00a0fear\u00a0of people gaming the system and seeking opioids for fake injuries or the inherent austerity of public institutions, this belief still shapes policy and practice.<\/span><\/p>\n

    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\u2019s journey toward readiness; a person might feel ready for\u00a0<\/strong>treatment, but someone else decided they\u2019d not\u00a0<\/strong>hit bottom. How ridiculous is this?<\/span><\/p>\n

    But when physicians misuse substances, then early intervention, long-term monitoring, and structured support are considered necessary. These practices, codified in physicians\u2019 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 \u201crock bottom\u201d model is neither ethical nor clinically efficient.<\/span><\/p>\n

    National Institute on\u00a0Drug Abuse\u00a0Director Nora Volkow has called the belief that someone must \u201chit rock bottom\u201d before treatment \u201ca myth that can have dire consequences.\u201d While the rock-bottom narrative offers psychological neatness\u2014drama, surrender, catharsis\u2014it lacks scientific grounding. Substance use disorders rarely emerge overnight; they evolve with \u201cuse,\u201d then \u201crisky use,” often in\u00a0adolescence\u00a0or 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.<\/span><\/p>\n

    Ethically, \u201cwaiting\u201d 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.<\/span><\/p>\n

    We don\u2019t withhold antihypertensives until catastrophic bleeds occur. We don\u2019t 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.<\/span><\/p>\n

    The directors of the National Institute on Drug Abuse and the National Institute on\u00a0Alcohol Abuse\u00a0and 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\u00a0Diagnostic and Statistical Manual of Mental Disorders, 5th Edition,<\/em> SUD criteria to help define pre-addiction, allowing early detection, brief treatment, or intervention before addiction-related neurobehavioral and psychosocial collapses occurred.<\/span><\/p>\n

    Research shows that at mild to moderate levels of SUD severity, patients often retain\u00a0executive function, can reassert control over drugs, and may still re-engage and preserve intact relationships, work roles, and\u00a0decision-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\u00a0education\u00a0rather than weeks in a treatment facility. In addition, early interventions may not require anti-craving medications, detoxification, opioid treatment medications, hospitalization, or extensive monitoring.<\/span><\/p>\n

    Preaddiction thinking supports early engagement, attacks\u00a0denial, 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.<\/span><\/p>\n

    Early Intervention Works<\/span><\/h2>\n

    Nowhere is \u201craising the bottom\u201d 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\u2014often for five or more years.<\/span><\/p>\n

    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\u2019s preventive, continuous, and outcome-driven.<\/span><\/p>\n

    The PHP system contradicts the \u201chitting bottom\u201d mantra. It\u2019s 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\u2014not a clinical limitation.<\/span><\/p>\n

    Physician colleagues have moral, ethical, and legal obligations to report coworkers whose impairment threatens patients. Avoiding \u201cpunishment\u201d and promoting sharing,\u00a0shame\u00a0reduction, and physicians helping each other in camaraderie while in treatment is critical to the success of physician programs.<\/span><\/p>\n

    When structured and ethical, coercion may paradoxically enhance autonomy by restoring capacity. Treat coercion as a clinical tool\u2014not punishment. Integrate preaddiction into medical education, focusing on prevention, brain changes, and ethical duties.<\/span><\/p>\n

    \u201cBottom\u201d 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.<\/span><\/p>\n

    Summary<\/span><\/h2>\n

    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 \u201cnormal vs addicted,\u201d and intervention may change the trajectory. Brief interventions may be the only treatment needed if interventions start early enough.<\/span><\/p>\n

    Medicine should abandon the myth that people with SUDs must earn the right to be helped by suffering \u201cenough.\u201d 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\u2019s holding us back?<\/span><\/p>\n

    Source: https:\/\/www.psychologytoday.com\/us\/blog\/addiction-outlook\/202511\/preaddiction-intervention-could-save-lives<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

    by Mark Gold M.D. – \u00a0Reviewed by Michelle Quirk – November 3, 2025\u00a0– Key points We screen and intervene early for hypertension, type 2 diabetes, and cancer; we can do the same for addiction. Preaddiction thinking supports early engagement, attacks denial, and normalizes a harm-reducing mindset. Delaying treatment increases risks and harms, contradicting outcomes research […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[73,63,68,40,36,19],"tags":[],"class_list":["post-20280","post","type-post","status-publish","format-standard","hentry","category-addiction","category-brain-and-behaviour","category-drug-use-various-effects","category-prevention-research","category-treatment-addiction","category-usa"],"_links":{"self":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/20280","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/comments?post=20280"}],"version-history":[{"count":2,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/20280\/revisions"}],"predecessor-version":[{"id":20282,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/20280\/revisions\/20282"}],"wp:attachment":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/media?parent=20280"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/categories?post=20280"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/tags?post=20280"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}