Substance-Related and Addictive Disorders
Substance Use Disorders
Diagnosis is based on criteria applicable to the specific substance class within a 12-month period.
Tolerance and withdrawal are not required for the diagnosis, and the diagnosis is not a moral judgement nor does it imply criminality. Treatment is most effective when tailored to the individual's substance, severity, physical and mental health, and goals, with a combination of therapy, medications where available, harm reduction, and social support.
What Are Substance Use Disorders?
DSM-5-TR describes use disorders for alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other or unknown substances. Age of onset and course vary significantly: use may begin in adolescence, later, or after medical exposure to a prescription drug. There is no single "addiction profile" for all substances or all people.
Key Features and Signs
The 11 criteria are commonly grouped into impaired control, social impairment, risky use, and pharmacological criteria:
- Use in larger amounts or for longer than intended and repeated unsuccessful attempts to cut down or control use.
- Spending a great deal of time obtaining or using the substance or recovering from its effects; craving or a strong urge to use it.
- Failure to fulfil important obligations and continuing despite social or interpersonal problems.
- Giving up or reducing important social, work or recreational activities.
- Recurrent use in hazardous situations; continued use despite knowing that a physical or psychological problem is likely to have been caused or worsened by the substance.
- Tolerance, i.e. the need for a larger amount or a smaller effect with the same amount, when applicable to the specific substance.
- Withdrawal, or using the substance to avoid withdrawal, when a recognized withdrawal syndrome exists for that substance.
How It Is Diagnosed
Assessment is confidential and non-judgemental and considers each substance separately, including dose, route of administration, overdose history, withdrawal, medications, mental health, and social needs.
- Diagnosis requires at least two criteria applicable to the specific substance class within the same 12-month period, with clinically significant impairment or distress. The general framework contains up to 11 criteria, but not all apply to every substance. Withdrawal is not a criterion for inhalant, phencyclidine or other hallucinogen use disorders. Caffeine use disorder is not an established diagnosis in the main diagnostic section of DSM-5-TR.
- Current severity is determined by the number of criteria: mild 2–3, moderate 4–5, and severe 6 or more.
- Tolerance and withdrawal are not mandatory. They do not count when they result solely from appropriate medical use of certain supervised prescription drugs.
- Use alone, frequency without consequences, or a positive toxicology test are not sufficient for a diagnosis; the full functional pattern is considered.
- DSM-5-TR records current severity and, when applicable, early remission, sustained remission, and in a controlled environment. For certain substance classes, an applicable maintenance-therapy specifier is also recorded.
How It Can Affect Daily Life
Use can affect memory, sleep, physical health, finances, work, relationships and parenting. Risk depends on substance, purity, dose, route, combinations and reduced tolerance after abstinence. Stigma often delays help. Person-centred language—“person with a use disorder” instead of derogatory terms—supports access and does not diminish severity.
Causes and Risk Factors
The paths to disorder are different. Substance properties and availability, genetic and medical vulnerability, pain, mental distress or other disorder, trauma, housing, poverty, discrimination, social network, and treatment exposure interact. There is no single age or causative pattern, and the diagnosis does not prove "emotional emptiness," lack of will, or criminality.
Similar or Co-occurring Conditions
Use disorder itself, acute conditions, and independent diagnoses need to be distinguished:
- Intoxication and withdrawal are specific syndromes that may exist with or without a use disorder.
- A substance-induced depressive, anxiety, psychotic, or bipolar and related disorder is diagnosed only when the substance is capable of producing the syndrome and the causal relationship is supported by the clinical evidence.
- Independent mental disorders may precede, co-occur or worsen and should not be ignored.
- Medically supervised use with expected tolerance or withdrawal does not by itself amount to a use disorder.
- Delirium, head injury, infection, metabolic disorders, and overdose can be confusing and are urgent.
Treatment and Support
Treatment is substance-specific and may aim for abstinence, harm reduction, or gradual change, depending on the individual's risk and choices.
- Psychosocial interventions, such as motivational interviewing, cognitive-behavioural therapy, contingency management, and family support, are selected as needed.
- For opioid use disorder, methadone or buprenorphine are evidence-based treatments; access to naloxone reduces the risk of overdose death.
- For alcohol use disorder there are medication options for some people, after a medical evaluation and together with psychosocial care.
- Withdrawal from alcohol or sedatives may require medical supervision. Detoxification is only a first step and is not a complete cure for the disorder.
- Harm reduction includes avoiding dangerous combinations, access to sterile equipment where available, infection control and an overdose prevention plan.
- Housing, work, legal needs, pain, and co-occurring mental or physical illness are addressed as part of care.
When to Seek Help
Seek assessment if use is difficult to control or continues despite harm, or if there are withdrawal symptoms, dangerous substance combinations or a history of overdose.
Frequently Asked Questions
Is tolerance or withdrawal needed for diagnosis?
No. At least two of the eleven criteria within twelve months are sufficient. Tolerance and withdrawal are only two possible criteria and do not occur with all substances.
Does prescribed use mean there can be no disorder?
No, but expected tolerance or withdrawal during appropriate medical treatment does not automatically count. The full pattern of use, impaired control, harm, and functioning is assessed.
Is detoxification the whole treatment?
No. Detoxification addresses acute withdrawal; it is not the whole treatment. Long-term care may include medication, psychotherapy, harm reduction, relapse prevention, and social support.
Why is naloxone still necessary after abstinence?
Tolerance to opioids decreases after abstinence, so a previously tolerated dose can become fatal. Naloxone can temporarily reverse an overdose, but emergency help is always needed.