The Problem with Treating "Pre-Addiction"

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Addiction tends to develop over time, emerging in adolescence and young adulthood. There are a host of reasons for this tendency, some of them biological and some of them social or environmental. But, whatever the reasons, there is a certain shape to addiction, such that it commonly manifests itself as a person matures.

If this is right, then the following idea naturally suggests itself: If addiction emerges over time, it is plausible that there is a transitional phase where one passes from not being addicted to being addicted. Furthermore, if we could intervene with people in this transitional phase, we might change the course of addiction and perhaps prevent or moderate its more destructive forms before they even begin. This is an idea proposed in a recent article by three leading figures in addiction research: Nora D. Volkow, A. Thomas McLellan, and George F. Koob. The authors propose that this transitional phase be called "preaddiction."

Both the phrase and the idea of preaddiction draw inspiration from the concept of "prediabetes." A person is prediabetic when their blood glucose level and glucose tolerance are impaired, such that one is at risk of—but has not yet met the criteria for—type 2 diabetes. The introduction of the concept of prediabetes more than 20 years ago proved an important step in enabling early and effective intervention for people at risk of developing type 2 diabetes. Volkow and her co-authors suggest that preaddiction may play a similar role.

Asymmetries Between Addiction and Diabetes

There are, however, some notable asymmetries between addiction and diabetes. For one thing, there are clear biomarkers for diabetes, such that blood testing can diagnose prediabetes. There is no such biomarker for addiction, and the diagnosis of preaddiction will have to be much less straightforward.

The natural history of diabetes is also unlike that of addiction. If left untreated, diabetes will not get better on its own. On the other hand, it is common for people who are addicted to "age out" of addiction without any medical or clinical intervention at all. Diabetes is a biologically well-defined and generally progressive condition, while addiction is neither. This makes the demarcation of preaddiction a considerably more fraught project.

Even if we can successfully demarcate preaddiction, there are concerns about the effect the concept itself will have on addiction treatment. The psychologist Cassandra L. Boness observes that addiction is a stigmatized category and that expanding this category by adding preaddiction risks simply extending this stigma into an earlier stage of development. What is worse, Boness observes, the labeling risks imperiling treatment, by making stigmatizing diagnoses and even involuntary treatment more likely, which will, in turn, make young people with substance use concerns less likely to seek out treatment in the first place.

Addiction as a Disability

I want to raise a separate but related concern about the concept of preaddiction. I have argued that addiction is a disability—this is true under U.S. law, and in many other countries—and that recognizing that addiction is a disability should alter our view of the proper response to addiction. When we reflect on a physical disability such as blindness or deafness, we attend to the social nature of these conditions and aim to construct an environment that provides appropriate accommodations for people who are blind or deaf. So, too, I argue, should we think about addiction. The first priority of addiction policy should be making the environment more accommodating to people with addictions, instead of the discrimination and exploitation to which people with addictions are often subject.

The concept of preaddiction fits uneasily with such an approach. The notion of preaddiction does not have an obvious analog in the case of physical disabilities. It is true that, in some cases, certain people are more likely to develop certain physical disabilities later in life. But we do not typically think of the identification and treatment of these individuals as a central priority of disability policy. Rather, the priority of disability policy should be the construction and protection of a social environment that is accessible to everyone, disabled and nondisabled alike. Early intervention with "at-risk" individuals is not central to this approach.

Nor should it be central to addiction policy. What then is the alternative? Does rejecting the concept of preaddiction imply a sanguine attitude toward substance use in adolescents and young adults? Not at all. If anything, what the disability model of addiction suggests is what is sometimes called a "public-health approach" to addiction (something that Boness endorses as well). With this kind of approach, we focus on social and environmental aspects of addiction, and, in particular, on how to counteract forces of discrimination and exploitation.

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Consider, to take one example, the prohibition of flavored cigarettes. In 2009, the U.S. Food and Drug Administration banned the sale of flavored (nonmenthol) cigarettes. The impact of this ban on youth smoking rates was significant and immediate. One study holds that the ban was responsible for reducing youth smoking rates by 30 to 40 percent while having no effect on adult smoking rates.

On the disability approach, this is precisely the kind of approach to youth substance use that makes sense. If addiction is a social and environmental phenomenon, then we want to shape the environment to make it as accessible as possible to everyone—for example, by banning the sale of products that are specifically targeted toward encouraging substance use among youths.

There is no need, on this approach, to identify those who are "preaddicted." We might choose to deploy this concept for certain special purposes, but, as an approach to addiction, it directs our attention to precisely the wrong place, namely on individuals, rather than on social structures. The best approaches to addiction focus not on intervening on supposed problems of a special subclass of individuals but, rather, on changing the environment for everyone.

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