CASAA professor spotlights warning label with its own warning label

December 20, 2023 - By Savannah Peat

Labels aren’t everything. From something as trivial as a relationship status to something as important as a medical diagnosis, an identification is not the end all to what makes a person. 

In fact, previous studies have shown labels affect performance, stereotypes and create a self-fulfilling prophecy for behaviors. That’s why Center on Alcohol, Substance Use and Addictions (CASAA) Research Assistant Professor Cassandra Boness is cracking down on one: preaddiction

_v5a8779.jpg“I've started advocating against it. A lot of my research to date speaks directly to this issue. There is a need to capture people who are at risk for later developing a substance use disorder but not necessarily with this label,” Boness said. 

Boness published her analysis of this term in the publication Neuropsychopharmacology. She’s also been featured in Salon and Stat defending her position.  

“At best, it's irresponsible. At worst, it's really, really harmful,” she said. “I have community partners who are not necessarily trained as scientists, but have lived experience with substance use or addiction. Unanimously they were all like, ‘this is a terrible idea.’”  

It began with a call from the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) who invited input on use of a term like “preaddiction” for identifying and intervening upon harmful substance use and mild/early-stage substance use disorder (SUD.)   

“JAMA authors came out with this publication saying that there's a missing concept – preaddiction - that we really need to improve prevention of substance use disorders and make all these improvements related to substance use,” Boness said.  

Boness says it is a dangerous term with a dangerous precedent. 

“Honestly, my biggest concern was that it's dangerous. We know that people who use substances and have substance use disorders are already very highly stigmatized, and with that comes a lot of very negative outcomes.” she said. 

While the NIAAA and NIDA believe this label would help target those in the realm of preaddiction through preventative interventions, Boness believes it is redundant with already existing labels. The label is proposed to replace the current manual’s current mild and moderate categories of SUD making it unclear how relabeling already existing categories would be more effective in intervening upon at-risk substance use.  

“'They're proposing to relabel what are already existing diagnostic categories. We have substance use disorders but based on how many criteria a person endorses, that substance use disorder gets a mild, moderate or severe classification,” Boness said. “The way that they framed preaddiction is like being a replacement term for some of those categories.” 

Boness argues the terms mild, moderate and severe should also be taken with a grain of salt. Many of those diagnosed with a SUD are vastly different from one another and may not even have any overlapping symptoms, making the labels less informative for prevention and treatment. 

“Substance use itself is not inherently pathological so you really can't consider substance use as the sole indicator of whether somebody is at risk of developing a substance use disorder or not because it's so much more complex than that,” she said. 

With such a complicated issue, it’s clear simply slapping a new label on an expired product wouldn’t typically draw in a swell of new responses.    

She notes this preaddiction classification is not the same as classifying someone as pre-diabetic, despite that being an analogy offered by the JAMA authors. Preaddiction, on the other hand, isn’t as objective. 

“Pre-diabetes is a prognosis which has objective physical markers, such as hemoglobin A1C. We have some sort of threshold where it goes from being pre-diabetes to diabetes,” Boness said. “The challenging thing is that addiction does not have these same objective markers.”

The NIAAA and NIDA also propose that preaddiction could be used to describe substance use by adolescents. That’s another red flag for Boness.

“This term would have us start labeling adolescents, for whom this is a normal developmental experience, as preaddicted,” Boness said. “An adolescent could be just experimenting, but by adding ‘preaddicted’ into their medical record we could impact their trajectory in a negative way. We already know how stigmatized substance use and addiction are generally in society, so do we really want to put a label on kids who are experimenting? That can come with punitive measures such as forced treatment and that is also associated with increases in overdose.” 

In a realm beyond substance use disorders, if you tell a child they’re below average intelligence, or create a term like pre-stupid for example, this child will age and study with the confidence of someone who has already been written off. This preaddiction classification is just as dangerous. 

“This is science, right? This is what we do as scientists. We try to improve things. We disagree with each other. We like to be constructive. We challenge one another. None of this is personal.” – CASAA Research Assistant Professor Cassandra Boness 

Adding the term preaddiction to those experiencing SUDs further marginalizes them as a group with a negative connotation, or with an equally negative trajectory in life. Those who may be classified as preaddicted may feel less safe to seek care for this issue or any other related issue with a medical provider in fear of being further denigrated.  

While the solution–much like addiction– is not clear cut, Boness believes the answer lies in the fact that addiction is a spectrum.  

“In my opinion, there is a continuum of risk and arbitrary thresholds like ‘addicted or not addicted’ are not necessarily useful for actually addressing most of the challenges related to substance use and SUDs,” Boness said. “By taking this continuum perspective, it reduces the stigma that labels like ‘preaddicted’ carry with them.” 

It’s most important, above all, to not approach addiction as a one-size-fits-all approach. Each person deserves not to be reduced to preaddiction. 

“Part of the reason why I don't like this preaddiction term is that there's so many differences between people with respect to what causes them to use and maintain their use,” Boness said. “Broad labels are just really, unfortunately not very useful. They're just not descriptive. They don't tell us a lot of information about a person or how to help them.”