A few decades ago, waiting until the person hit bottom, or hitting bottom or finding your bottom, was the advice professionals gave when asked about helping a loved one accept treatment. The expression “hit rock bottom” was commonly utilized by 12-step treatment programs and has become part of our understanding of addiction and interventions. Hitting bottom means that a person has reached a point where they have lost everything. They are powerless over drugs and may have nothing left to lose. There is no lower place to fall as you are at absolute rock bottom. When someone struggling with drug abuse “hits rock bottom,” it implies that they have hit their lowest possible point. Perhaps they were discovered using at work, were arrested, hurt someone, had an overdose, call 911, or went to the Emergency Room. Essentially, “hitting rock bottom” in gallows humor means you have hit the point where things cannot get any worse.
While we have called for earlier and earlier interventions and raising the bottom to avoid needs, harm and suffering, published studies have identified “hitting bottom” and tried to quantify what it means and how it could be measured. While hitting bottom may be the result of denial and enabling, it is a concept that has allowed health professionals and even addiction experts to advise letting the disease take its course. Hitting bottom for an impaired physician or health professional may be getting called into the Hospital Chief of Staff’s Office after drugs were found or in response to a co-worker’s accusation or complaint. It is true that when an addict has lost everything, they either ask for help, accept their powerlessness or continue with a vengeance. Hitting bottom as a catalyst to enter treatment is commonly portrayed in the popular media. Still, more often, the addict’s friends, colleagues, and others finally intervene to save their life. Yet, “hitting bottom” has been more of a recovery truism than evidence-based and formally operationalized[i]. Things always seem to come up in the addict’s life, making it seem like they can get treatment later or an evaluation tomorrow. Rarely do they see it as an emergency until they have medical, neurological, infectious, or other consequences and losses of family, friends, and jobs. Waiting for a bottom assumes reversibility. Sometimes along the way to the bottom, an overdose intervenes or a suicide. Once in treatment, the road to the bottom is recalled as where the most damage was done, and often questions arise as to whether it is possible to recover from the trauma of years of numerous painful losses in their lives[1]
One of the definitions of addiction is continued and compulsive use despite adverse health consequences. On the one hand, you want to quit, but on the other, you have the compelling, compulsive use and loss of control over use. This is a helpful definition and suggests that without early intervention and prompt and effective treatment, usage will continue in a chronic and relapsing course until overdose, accident, or death. Treatment changes the person and the risks whenever in the course of the illness it begins or whenever the addict re-engages. It seems like everyone is getting substance abuse treatment, but, most people with a substance use disorder are not treated. In their recent paper, the Directors of the National Institutes on Alcoholism and the National Institute on Drug Abuse suggest that just 10 percent of people who could benefit from treatment get it[ii]. At some point, the patient with SUD has a complete loss of control over the substances, but that does not occur on a particular date or at a specific time. It is a process. The earlier in the use-to-addiction continuum that treatment begins, the more likely treatment can succeed in re-establishing voluntary control. In alcoholism, it is the point where someone with excessive and harmful drinking begins to cut back and limit their use.
Historically, the type 2 diabetes field was focused on the most severely affected and most difficult to treat. They had their groups of T2DM patients with treatment resistance, medication compliance challenges and disease progression. However, in 2001, the American Diabetes Association strategically suggested pre-diabetes, operationally defined by elevated scores on 2 laboratory tests: im- paired glucose tolerance and impaired fasting glucose. The term was purposely chosen to capitalize on public motivation to avoid severe diabetes. Although type 2 diabetes continues to be a serious, pervasive health problem, the strategy has detection, intervention and treatment rates. By reducing the duration of the untreated illness, consequences of the disease were mitigated, and T2DM patients did not necessarily progress to diabetes.
Internal Medicine has done an excellent job of identifying problems and treating them before a full-blown catastrophe like a heart attack or stroke occurs. Evidence-based approaches have made it a routine to take blood and monitor risk factors like cholesterol during routine checkups. We also expect our pulse, blood pressure, and weight to be taken each time we see a health provider. With these data risks and BMI are calculated during routine checkups. With these data, we can suggest lifestyle, diet, and exercise changes and start medication management to mitigate heart attacks or stroke risks . Unfortunately, behavioral healthcare is far behind and addiction medicine healthcare is further behind. In Psychiatry we know that if you are depressed every winter you might do better moving to Florida, exercising, getting an indoor seasonal affective illness light and so on. In addiction medicine, we are debating intervention and early treatment vs. waiting for the addict to audition for treatment by hitting bottom. Prevention is addiction medicine is often ridiculed as naïve. Just Say No or DARE or other programs prevent use and addiction in some people but not most people. Using drugs is seen as something everyone tries, and this nihilism has helped shift resources from prevention efforts even though prevention is the only absolutely safe and effective treatment. Without prevention, experimental use interacts with host risk factors, from genes to trauma, so abusers develop. Sadly, waiting for an abuser of substances to come to treatment may take years, cause irreversible consequences and result in lost decades. Addiction causes depression, anxiety, cravings, and panic attacks and use by itself de-prioritizes jobs, friends and family. Everyone seems to be waiting and expecting the user to get the bright idea that they will die if they don’t stop and get treatment. Everyone seems to be waiting for the t “rock bottom” before treatment can work. But , if our experiences with physician addicts are a guide, you can and should raise the bottom and not assume it is good medical care to wait until the patient has hit their bottom. [iii]
Drs Tom McLellan of the Treatment Research Institute, National Institute on Alcohol Abuse and Alcoholism Director Dr. George Koob, and Nora Volkow MD suggest in a recent JAMA paper that rather than make the person with a SUD wait until a bottom arrives, treatment should begin. Bravo, and about time! The evidence that early detection, intervention, and treatment even at the earliest stages of substance use disorder is extensive and compelling. Early preaddiction diagnosis and treatment can avert the development of addiction or many drug consequences. .[2] They suggest addiction is after all a chronic diseases like heart disease or diabetes and effective early interventions have been crafted for these diseases. Why not for addictions ?
Increased blood alcohol testing, concerns about DUIs and growing awareness of binge drinking even outside of a diagnosed alcohol use disorder, has re-focused the disease continuum on unhealthy drinking and loss of control. A diagnosis of pre-addiction could help us focus attention and treatment efforts earlier on the misuse of opioids to the intravenous self-administration continuum.
The diabetes field already had easy-to-use, insurance-reimbursed laboratory tests to define and detect pre-diabetes. No such objective tests are yet available in the SUD field, but DSM-5 diagnoses are reliable and could be implemented right away and save lives. Even occasional or low-level substance misuse is a significant cause of motor vehicle accidents, school and work failures, fights and arguments, and overdose deaths among young adults.
The American Psychiatric Association’s DSM criteria for mild to moderate substance use disorder are a starting point, as are questionnaires, screening tools, drug and alcohol testing, and medical testing. Once identified, we would need evidence-based and reimbursable treatments for individuals meeting pre-addiction criteria. As McLellan, Koob, and Volkow emphasize, just pre-addiction will not have the same impact as pre-diabetes until all physicians and other providers are motivated to learn about addictions and the continuum from experimental or low-severity substance use disorder to a SUD. That occasional use is nevertheless a risk for overdose, polysubstance abuse, anhedonia, or use begetting more use and becoming more severe. We must stop pretending that addiction appears overnight. Rather than an infection or accident, it is a chronic, progressive disease that begins with use but is often exacerbated by genes, intrauterine and early life exposures, psychiatric illness, trauma, and environmental and personal historical circumstances.
References
[1] https://nida.nih.gov/about-nida/noras-blog/2022/07/time-to-start-talking-about-pre-addiction
[2] McLellan AT, Koob GF, Volkow ND. Preaddiction-A Missing Concept for Treating Substance Use Disorders. JAMA Psychiatry. 2022 Jul 6. doi: 10.1001/jamapsychiatry.2022.1652. Epub ahead of print. PMID: 35793096.
[3] Hill KP, Gold MS, Nemeroff CB, McDonald W, Grzenda A, Widge AS, Rodriguez C, Kraguljac NV, Krystal JH, Carpenter LL. Risks and Benefits of Cannabis and Cannabinoids in Psychiatry. Am J Psychiatry. 2022 Feb;179(2):98-109. doi: 10.1176/appi.ajp.2021.21030320. Epub 2021 Dec 8. PMID: 34875873.
[4] Balachandran P, Elsohly M, Hill KP. Cannabidiol Interactions with Medications, Illicit Substances, and Alcohol: a Comprehensive Review. J Gen Intern Med. 2021 Jul;36(7):2074-2084. doi: 10.1007/s11606-020-06504-8. Epub 2021 Jan 29. PMID: 33515191; PMCID: PMC8298645.
[i] Megan Kirouac & Katie Witkiewitz (2017) Identifying “Hitting Bottom” Among Individuals with Alcohol Problems: Development and Evaluation of the Noteworthy Aspects of Drinking Important to Recovery (NADIR), Substance Use & Misuse, 52:12, 1602-1615, DOI: 10.1080/10826084.2017.1293104
[ii] McLellan AT, Koob GF, Volkow ND. Preaddiction-A Missing Concept for Treating Substance Use Disorders. JAMA Psychiatry. 2022 Jul 6. doi: 10.1001/jamapsychiatry.2022.1652. Epub ahead of print. PMID: 35793096.
[iii] DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009 Mar;36(2):159-71. doi: 10.1016/j.jsat.2008.01.004. PMID: 19161896.
