Substance Use Disorders

Substance Abuse

Substance abuse is diagnosed when substance use leads to significant problems in one or more of the following four domains within a 12-month period: (1) legal, (2) interpersonal, (3) work or school, or (4) hazardous behaviors. Individuals with a substance abuse diagnosis may exhibit a failure to fulfill major role obligations, repeatedly use substances in situations where it is dangerous to do so, and experience recurrent interpersonal problems despite these problems being exacerbated by the substance use. Substance abuse thus constitutes a pattern of recurrent negative consequences associated with the substance use, but does not include tolerance, withdrawal, or a pattern of compulsive use, which are characteristic of substance dependence. Substance abuse is more likely to be diagnosed in individuals who have recently started using the substance; many of these individuals will progress to substance dependence.

Substance Dependence

The diagnosis of substance dependence is made when substance use is persistent, leading to the development of three or more cognitive, behavioral, or physiological symptoms within a 12-month period. These symptoms may include failed attempts to decrease use of the substance; tolerance; withdrawal; or impairment in social, occupational, or recreational functioning as a direct result of substance use or behaviors involving pursuit of the substance. Tolerance is defined as either needing a substantially increased amount of the substance to achieve intoxication effects than what was previously necessary or having a substantially decreased intoxication effect from the substance with continued use of the same amount of the substance. Withdrawal includes physiological changes that occur when a substance has been used over a prolonged period of time and then the substance use is either stopped or reduced. Withdrawal is defined as either experiencing a characteristic withdrawal for the substance or if the same (or a similar) substance is taken to reduce withdrawal symptoms. Withdrawal syndromes for particular substances include symptoms that are typically the opposite of the effects of the substance itself.

The diagnosis of substance dependence may include, but does not require, physical dependence on [Page 882]the substance, as would be evidenced by the presence of increased tolerance or withdrawal symptoms. However, a primary distinction between the diagnoses of substance abuse and substance dependence is that, with substance abuse, the criteria do not include withdrawal, tolerance, or symptoms of compulsive use. If an individual meets criteria for substance dependence, then it is important to specify whether or not physiological dependence is associated with tolerance or withdrawal symptoms. This is indicated with the specifiers "with physiological dependence" and "without physiological dependence." If tolerance or withdrawal symptoms are present, then the specifier "with physiological dependence" is used. If there is no evidence of either tolerance or withdrawal symptoms, then the specifier "without physiological dependence" is used. Substance dependence criteria have a total of six course specifiers, four of which specify different states of remission; the other two indicate whether the individual is on agonist therapy or in a controlled environment. An individual is considered to be in remission from substance dependence only after the criteria for substance dependence or abuse have been absent for 1 month or longer. There are four qualifiers for remission, which are determined by the period of time that has elapsed since the cessation of dependence (early or sustained remission) as well as by the continued presence or complete absence of one or more of the substance dependence or abuse criteria (partial or full remission). The four remission specifiers are "early full remission," "early partial remission," "sustained full remission," and "sustained partial remission." Early full remission is specified if an individual has not met criteria for dependence or abuse for at least 1 month but less than 12 months. Early partial remission occurs when an individual has not met criteria for dependence or abuse for at least 1 month but less than 12 months. Additionally, for the specifier "early partial remission," following at least a 1-month period of sobriety, the individual meets one or more criteria for dependence or abuse but does not meet full criteria for dependence. The specifier "sustained full remission" is obtained when an individual has not met any criteria for dependence or abuse at any time in the past 12 months or longer. "Sustained partial remission" is a specifier used to describe individuals who have not met full criteria for dependence for a period of 12 months or longer but have met one or more criteria for dependence or abuse. Two other course specifiers are whether the individual is on agonist therapy or whether he or she is in a controlled environment. The specifier "on agonist therapy" applies to individuals who are prescribed an agonist medication, such as methadone for an opioid addiction, and who have not met criteria for dependence or abuse in the past month. This excludes the development of tolerance to or withdrawal due to the agonist medication. The course specifier "in a controlled environment" is used when an individual is currently living in a controlled environment with no access to any substances of abuse (e.g., incarceration) and has not exhibited symptoms of dependence or abuse for at least the past month.

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