When a person comes to ask for help from a therapist or a mental health service for a addiction problemvery often he has already undergone numerous painful losses in his life.
Nobody who works in this area or who for personal reasons knows the phenomenon, escapes awareness of how literally dependence destroys the work, friends and family of a person.
Still too often, the expectation (of the patient, of his family, of the enlarged society, of the services in charge …) is that someone should “touch the fund” before the treatment can work (Leshner, 1999).
But this is a false myth that can have disastrous consequences: at that point The damage is almost always serious and the way to recovery very difficult. In fact, the best time to get help is as soon as possible.
In a very recent work published in July 2022 on the Journal of American Medical Association (https://nida.nih.gov/about-nida/noras-blog/2022/07/Time-start-alking-bout-predation), Tom McClellan, George Koob, and Nora Volkow, some of the authors of maximum reference on the theme of the topic of the topic of the topic of the topic of the topic of the addictions, argue their proposal to move on to a plan for a better identification and support of those who are in the early stages of a substance use disorder (DUS).
The authors use an interesting parallel in the condition of “prediabetes” in order to illustrate the essential elements characterizing their proposal, which we see summarized below.
From use/abuse to dependence: the possible trajectories
We well know how the altered capacity of control or the total loss of it is the element that unequivocally defines the central nucleus of a dependence disorder.
However, the fact is shown that a DUS is the result of a gradual They give brain circuits that control sensitivity to reward, motivation, self -regulation, negative emotional states and stress tolerance.
In other words, among those who begin alcohol consumption or other drugs, the progression to disturbance from the use of “serious” level substances is not “obvious”. When it occurs, the progression is rarely linear or rapid. Usually the severity of the disorder is determined after years of improper use.
Adolescence is a particularly risky period For the transition from use/abuse to actual dependence disorder, probably due to the greater sensitivity of the cerebral circuits still developing.
The highest risk of transition risk (from use/abuse to dependence) are characterized by risk factors such as: early debut of use, history of traumatic events, family history of consumption of substances and/or mental health problems.
Like the DSM-5 conceptualizes dependence disorder
Recognizing that the transition to Dus severe can be progressive but manifested in a variable way, the DSM-5 uses 11 symptoms of equal weight to define dus along a continuum of gravity with 3 stadiums.
The addiction (understood in common sense) is reserved for serious dus (i.e. with 6 or more symptoms).
Those with mild to moderate dus achieve 2-5 symptoms and according to the authors constitute a much wider percentage of the adult population (13%) than those with severe dus.
So why should therapeutic efforts and public health policies focus almost exclusively on people with serious, usually chronic addictions, “ignoring” the much wider population with Dus in the initial phase?
Why is the study of diabetes also useful for the addiction clinic?
By now we know well that increasingly widespread border condition that is not yet type 2 diabetes, but, if not cared for, it can become it.
The diffusion of diabetes made the use of a strategy that would allow its widespread prevention necessary. This is possible where it is intervened in a phase of the clinical history prior to diabetes and which is therefore called “prediabetes”.
Prediabetes is not, in itself, a defined clinical entity, but a category of risk for the future development of type 2 diabetes and cardiovascular diseases.
This example suggests the potential impact of a parallel strategy to reduce dependence problems through more aggressive efforts for identify the “pre-addiction”.
The diagnosis of Dus proposed by the DSM-5 already identifies this possible “border area” according to precise criteria, is reliable and should be systematically applied in clinical contexts and in the services dedicated to mental health. The criteria that define the mild to moderate to severe dus are an objective and reasonable starting point to operationally define pre-dependence.
In the field of Dus, early screening, brief intervention and any postponement to the actual treatment have enormous potential.
It is important to emphasize that the abuse of substances even at “low level” or occasional is one of the main causes of car accidents, interpersonal attacks and deaths from overdose among young adults.
The identification of “pre-dependent” could motivate greater attention to risks associated with substances use disorder In the initial phase and help to coordinate the policies and health resources that will support prevention and early intervention measures.
Develop the prevention approach
Despite the indisputable awareness that “a gram of prevention is worth a kilo of care”, the health system is objectively established to treat diseases and ailments once they manifest themselves, not to avoid them.
The example of diabetes, however, evidently suggests the implications of making prevention. The same mentality should be applied to substances use disorders.
It is no longer reasonable to support (or even just convey the idea that) people with drug or alcohol problems must “touch the bottom” before a substance use disorder is recognized and faced.
Nor is it necessarily true that people will contemplate the treatment only when their disorder reaches that point.
Instead, it is necessary to begin to spread the idea (and then systematically study) of a problematic consumption profile that may not reach (still) the threshold of dependence. The criteria proposed by the DSM-5 allow us. A diagnosis of pre-addiction could serve as a warning to the individual on a behavioral model with potentially important consequences, but also very preventable, on health and on life.
In conclusion, It is important to think dependence not as a disease that appears from today, but as a condition with a background: a story of growing substances, often exacerbated by environmental and personal factors, historical circumstances and genetic risk factors.
A greater awareness of the potential negative trajectories of the use of substances and opportunities to prevent them will allow those who find themselves in the early stages of a disorder from the use of substances to arrest their escalation.
Bibliography
- McLellan, AT, Koob, GF, Volkow, ND (2022). Preaddiction, A Missing Concept for Treating Substance Use Disorders. Jama Psychiatry, 79 (8).
- Koob, GF, Kandel, D., Baler, RD, Volkow, ND (2015) Pathophysiology of Addiction. In: Tasman, A., Kay, J., Lieberman, Ja, First, MB, Maj, M., Eds. Psychiatry. Vol 1. 4th ed. Wiley; 2015: 359-381.
- Leshner, A. (1999). Addiction Myths & Miths Bustters. The Principles of Drug Addiction Treatment: A Research Based Guide1999.
- Marel, C., Sunderland, M., Mills, KL, Slade, T., Teesson, M., Chapman, C. (2018) Conditional probabilities of substance users and associates and associated risk factors: progression from first use to use on alcohol, cannabis, stimulants, sedatives and opioids. Drug and Alcohol Dependence. 2019; 194: 136-142.
