Intervention before addiction can save lives

The misconception that people with substance use disorders (SUDs) must “hit rock bottom” has shaped addiction care for decades. This model contrasts with the way medicine manages chronic diseases, where early detection and proactive treatment are the norm. The “bottom” in addiction is the moment of maximum despair and hopelessness. It may also be a life-changing event such as being fired, losing a relationship, or facing legal charges. This may mean a moment between thinking about changing one’s life or suicide.

For more than thirty years, I have been suggesting that addiction treatment should “move up” to reduce harm and have a better chance of success. Applying preaddiction logic holds promise for reducing the suffering, morbidity, and mortality associated with SUD. Refusing early diagnosis and treatment may stem primarily from addiction Stigma.

“Let them hit bottom” was (and still is) the refrain in addiction care; It is assumed that suffering must reach a peak before people with SUD accept the need to stop using drugs. Whether arising from He is afraid From people gaming the system and seeking opioids to fake injuries or the austerity inherent in public institutions, this belief continues to shape 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 it could undermine a person’s journey toward readiness; The person may feel ready to treatment, but someone else decided they wouldn’t do it Hit the bottom. How ridiculous is this?

But when doctors misuse substances, early intervention, long-term monitoring and structured support are essential. These practices, codified in Physician Health Programs (PHPs) throughout the United States, help most physicians, resulting in an excellent return to work and job resumption rate. The message is clear: the “rock bottom” model is neither ethical nor clinically efficient.

National Institute on drug Filmmaker Nora Volkow has described the belief that a person must “hit rock bottom” before treatment as “a myth that can have dire consequences.” While the extreme narrative offers psychological accuracy—drama, surrender, and catharsis—it lacks a scientific basis. Substance use disorders rarely appear overnight; They evolve with ‘use’, then ‘risky use’, more often than not Adolescence Or early puberty. By the time someone meets all the criteria for severe SUD, the hijacked brain is skilled at finding and using drugs, and they are not arrested or sent for treatment. The longer the SUD persists, the more complex and complicated the reversal becomes.

Ethically speaking, “waiting” is untenable. Delayed intervention magnifies harm, reinforces bad behavior, and puts family, friends, and others at risk of harm. Early intervention and treatment may prevent the loss of friends, family, and job, as well as stop the addiction from getting worse.

We do not withhold antihypertensive medications until catastrophic bleeding occurs. We do not wait for myocardial infarction to start statins. Medicine emphasizes prevention and treatment in the early stages. While many view addiction as a choice, doctors with disabilities will tell you that they wish someone had stepped in and helped them sooner.

Directors of the National Institute on Drug Abuse and the National Institute on Drug Abuse Alcohol abuse Alcoholism proposed, in 2022, the early identification and intervention of drug abuse and its consequences. Volkow, Cope, and McClellan introduced this concept of preaddiction by counterbalancing diabetes. These researchers used mild to moderate Diagnostic and Statistical Manual of Mental Disordersfifth edition, SUD criteria to help identify pre-addiction, allowing early detection, brief treatment, or intervention before addiction-related neurobehavioral and psychosocial breakdowns occur.

Research shows that at mild to moderate levels of SUD severity, patients often retain it Executive functioncan reassert drug control, and may continue to re-engage and maintain healthy relationships, work roles, and decision making. At this pre-addiction point, brief interventions, outpatient treatment, or educational measures have great potential to resolve the pre-addiction problem. Sometimes, treatment may include advice and guidance education Instead of weeks in a treatment facility. In addition, early interventions may not require anti-craving medications, detoxification, opioid treatment medications, hospitalization, or intensive monitoring.

Pre-addiction supports early involvement and attacks denialand normalize the preventive mentality. Addiction mail conveys risks while maintaining effectiveness, as is the case with diabetes. It gives clinicians a structured rationale for screening, consultation and referral before severe illness.

Early intervention work

Nowhere is “lifting the bottom” more apparent than in PHPs. These state-approved programs often identify physicians with disabilities through anonymous reports of patients, staff, or other providers. They protect patients from vulnerable doctors by managing them through structured assessment, mandatory treatment, regular toxicology testing, workplace monitoring and ongoing recovery support – often for five years or more.

This model is widely celebrated, although its success depends in part on outside influence: doctors are often told that non-compliance could lead to suspension of license and loss of professional status. In a five-year, multi-state study, DuPont and colleagues found that more than 70% of doctors returned to practice, maintaining functional recovery. The model used early identification, accountability, structured care, serial urine testing, and long-term follow-up. It is preventative, persistent and results-oriented.

PHP goes against the mantra of “getting to the bottom”. It’s a realistic demonstration of what addiction care can be: long-term, hopeful, results-oriented, but with accountability. The limited application of such systems outside professional circles reflects deep heterogeneity, not clinical limitations.

Physician colleagues have moral, ethical, and legal obligations to report coworkers whose disability threatens patients. to avoid “Punishment“And to enhance participation, shame Discounting and having physicians help each other with camaraderie during treatment is critical to the success of physician programs.

When coercion is structured and moral, it may paradoxically enhance autonomy through the restoration of agency. Treat coercion as a clinical tool, not as a punishment. Integrating pre-addiction into medical education, with an emphasis on prevention, brain changes, and ethical imperatives.

The “bottom” does not need to be the destination immediately before treatment. Waiting or delaying intervention until complete disarray or voluntary self-referral risks disease progression, more permanent brain/behavior changes, poor prognosis, and higher costs.

summary

To align addiction with other chronic medical conditions, SUD screening should be routine for every health care, clinic, or emergency department visit. The duration, age of onset and severity of use should be evaluated. The concept of pre-addiction provides a teachable inflection point rather than the “normal vs. addict” binary, and intervention may change the course. Brief interventions may be the only treatment needed if interventions are started early enough.

Medicine must abandon the myth that people with these disorders must earn the right to help by suffering “enough.” Medicine has shown many benefits of early screening, intervention, and helping patients change. If we can intervene early to treat high blood pressure, type 2 diabetes, and breast and colon cancer, we can do the same for addiction. What’s holding us back?