Diagnostic Criteria for Substance Use Disorders

Substance use disorders (SUDs) don’t always begin with reckless choices or visible consequences. Sometimes they start quietly, growing from occasional use into something more challenging to control. Diagnostic SUD criteria help bring that hidden struggle into focus, offering clear markers to identify when substance use has crossed the line into something more serious. With this clarity, however, also comes hope and a starting point for recovery.

What is a Substance Use Disorder?

Going beyond occasional or experimental misuse, an SUD is defined as repeated use despite harmful consequences, such as damaged relationships, job loss, health problems, and legal trouble ^[1]. Within this definition, severity varies considerably. While some people experience subtle signs that interfere with emotional health or relationships, others face more severe disruptions to their ability to function. Additionally, substances of misuse vary from alcohol and prescription medications to illegal drugs and inhalants. 

Despite the variables, the negative impact on daily life is often similar and, unfortunately, widespread. According to the 2023 National Survey on Drug Use and Health, approximately 48.5 million people aged 12 or older (more than 17% of the population) had an SUD within the past year ^[2]. 

Complicating matters further, SUDs can have lasting effects on the brain that can exacerbate the condition. As substance misuse becomes more frequent, it can begin to alter the brain’s natural reward system, making it harder to experience pleasure or make decisions without the influence of the substance. These changes can affect impulse control, motivation, and judgment, making it even more challenging to stop using despite the harm it causes ^[1]. 

Indeed, SUDs are complex and often have life-altering outcomes. However, an SUD diagnosis can be a powerful turning point that opens the door to support, treatment, and lifelong recovery.

What is the DSM-5-TR?

Diagnosing an SUD isn’t based on guesswork or opinion. Instead, it follows a set of criteria outlined in a comprehensive manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This guide, developed by the American Psychiatric Association, is widely considered the gold standard for diagnosing mental health conditions, including those related to substance use.

Mental health professionals, including therapists, psychiatrists, and addiction specialists, rely on the DSM-5-TR to ensure that diagnoses are accurate, consistent, and rooted in clinical research. When someone is evaluated for a possible substance abuse diagnosis, clinicians use this manual to assess patterns of behavior, emotional responses, and physical effects that align with an SUD.

What makes the DSM-5-TR especially important is its role in shaping both diagnosis and treatment. It not only helps clinicians determine whether someone meets the SUD criteria, but also informs which treatment approaches might be most effective. 

Diagnosing an SUD 

According to the DSM-5-TR, an SUD diagnosis is made when at least two of the following criteria are met within 12 months ^[3]: 

• Taking the substance for long periods or in larger amounts than intended
• Being unable to cut down or stop substance use despite a desire to do so
• Spending a lot of time obtaining, using, and recovering from the effects of the substance
• Experiencing cravings, intense desires, or urges for the substance
• Failing to fulfill obligations at home, work, or school due to substance use
• Continuing substance use despite having interpersonal or social problems that are caused or worsened by substance use
• Giving up social, recreational, or occupational activities due to substance use
• Using a substance even when it’s physically dangerous to do so
• Continuing substance use despite having a physical or mental issue that is probably due to substance use
• Developing tolerance, so it’s necessary to take more of the substance to achieve the same desired effect
• Experiencing withdrawal symptoms when substance use stops

Please note that only healthcare professionals are authorized to make formal diagnoses. However, the criteria above can help people recognize when a formal assessment might be warranted.  

Screening and Assessment Tools

Identifying an SUD doesn’t rely on instinct or surface-level observation. Instead, clinicians use validated screening and assessment tools to evaluate the presence and severity of symptoms. 

Screening tools are often used early in the process, such as during routine doctor visits or mental health check-ins. They are typically brief and designed to flag risky behaviors or patterns that may require a closer look. Meanwhile, assessment tools dig deeper. They evaluate not only the frequency and quantity of use but also the physical, emotional, and functional impact of that use. Plus, some tools like the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) combine screening with assessment ^[4].  

None of these tools is meant to label or judge. Instead, they offer a structured, evidence-based approach to guide diagnoses and support treatment planning.

Misuse vs. Addiction

While substance misuse and addiction are often interconnected, they represent different points on the spectrum of problematic substance use. Substance misuse refers to using a drug in a way that deviates from medical instructions or legal requirements. This might include taking higher doses than prescribed, using an illegal substance, using someone else’s prescription, or taking medication for reasons other than prescribed ^[5]. 

For example, a person might occasionally take extra doses of prescribed pain medication after surgery or borrow a family member’s sleep medication. While these behaviors carry serious health risks, they’re labeled as misuse and don’t necessarily indicate an addiction. However, regular misuse can lead to the development of an SUD.

An SUD, by contrast, involves a pattern of continued use despite negative consequences, along with symptoms such as cravings, tolerance, and withdrawal ^[3]. The distinction matters because treatment approaches may differ. Someone who misuses substances might benefit from education and brief intervention, while a person with an SUD typically requires more comprehensive treatment. 

Substance Use Disorder Categories

While the criteria as mentioned above, cover all substances of misuse, SUDs don’t come in one form. Instead, a wide range of substances fall under this umbrella, each one of which can affect the brain and body in unique ways. As such, the DSM-5-TR organizes SUDs into 10 substance-specific categories, each of which can help clinicians better understand what someone is using and how it may be impacting their health, behaviors, and risk of long-term complications ^[3].

Some of the more common SUD categories defined by the DSM-5-TR include ^[3]: 

• Alcohol Use Disorder: Beer, wine, liquor, and other alcoholic drinks
• Cannabis Use Disorder: Marijuana, hashish, and THC concentrates
• Hallucinogen Use Disorder: Lysergic acid diethylamide (LSD), psilocybin (aka magic mushrooms), phencyclidine (PCP), and other perception-altering substances 
• Inhalant Use Disorder: Solvents, aerosols, gases, and nitrites 
• Opioid Use Disorder: Prescription pain relievers (e.g., oxycodone and hydrocodone), heroin, synthetic opioids (e.g., fentanyl), etc.
• Sedatives, Hypnotics, or Anxiolytic Use Disorder: Benzodiazepines (e.g., Xanax, Ativan), barbiturates, and sleep aids
• Stimulant Use Disorder: Amphetamines, cocaine, and prescription medications (e.g., Adderall, Ritalin)

These categories are more than just labels. Rather, they help clinicians tailor care more precisely and provide interventions that meet the unique needs of each person’s experience.

Co-Occurring Disorders

Many people who struggle with substance use are also living with mental health conditions such as depression, anxiety, bipolar disorder, and posttraumatic stress disorder (PTSD). When both are present at the same time, they’re referred to as co-occurring disorders (aka dual diagnoses) ^[6]. 

This overlap isn’t a coincidence. Mental health symptoms can increase the likelihood of substance use, especially when someone turns to drugs or alcohol to numb emotional pain or cope with stress. At the same time, substance use can worsen or even trigger mental health symptoms, making it harder to find emotional stability or respond to treatment. In some cases, the two conditions can feed off one another, creating a cycle that’s difficult to break ^[6]. 

Proper diagnosis of all conditions is essential, as treatment for one condition without addressing the other can leave people stuck in a loop of recurring symptoms. Co-occurring disorders often require integrated care, an approach that addresses both the substance use and the mental health condition together ^[6]. Spotting the signs of dual diagnosis can be challenging, but it’s a critical step toward effective care. With the proper support, healing both the mind and body is possible.

Importance of Early Intervention

The faster an SUD is identified, the sooner the person can enter treatment. As such, early identification can alter the trajectory of an SUD, potentially preventing the progression of the disease to more severe forms, reducing the risk of developing co-occurring mental health conditions, and minimizing potential physical health complications. Plus, in milder cases, early intervention can lead to better treatment outcomes, as patterns of use have not yet become deeply entrenched ^[7].

The benefits of early intervention extend beyond immediate health concerns. Quick action can help preserve relationships, maintain employment, and protect financial stability. Most significantly, early treatment can decrease the risk of overdose deaths and other life-threatening complications. Plus, when SUDs are caught early, medical professionals can often address substance use problems more effectively with outpatient care, potentially avoiding the need for more intensive and costly residential treatment programs.

Substance Use Disorder Treatment

While recovery from an SUD is possible, treatment plays a central role. Some of the most effective approaches combine various options, such as medical, psychological, and behavioral health strategies, and they’re highly tailored to each person’s specific needs, including the type of substance used, the severity of the disorder, co-occurring conditions, and personal goals.

Despite this personalized approach, treatment often begins with detoxification. In some cases, patients detox under medical guidance at home. However, many patients enter a medical detox facility where they receive 24/7 care and monitoring to ensure their safety and provide comfort and support as needed. From there, options typically include inpatient treatment or various forms of outpatient care, such as partial hospitalization programs (PHPs), intensive outpatient programs (IOPs), and traditional outpatient programming. 

Within these levels of care, evidence-based therapies such as cognitive behavioral therapy (CBT), contingency management, and motivational interviewing are frequently used to help people change thought patterns and develop coping skills. In addition, medication plays a vital role for many people, but particularly for those recovering from opioid or alcohol use disorders. Medication-assisted treatment (MAT) combines Food and Drug Administration (FDA) approved medications with counseling and behavioral therapies to reduce cravings, ease withdrawal, and support recovery. 

Following formalized care, ongoing support is often a key factor in success. Peer recovery groups, aftercare planning, and long-term case management help people stay connected, accountable, and supported as they rebuild their lives. 

Clarity Leads to Recovery

For many individuals and families, understanding what qualifies as an SUD is a crucial first step in making sense of confusing or overwhelming behavior. After all, knowing the diagnostic criteria for SUDs can bring relief, answers, and a starting point for change. With tools like the DSM-5-TR, validated screening methods, and personalized treatment options, it becomes possible not only to identify the problem but also to treat it effectively.

Granted, SUDs are complex, but recovery is possible. Whether someone is dealing with early signs of misuse or navigating the challenges of a long-term addiction, help is available. Healing may not happen all at once, but with the proper support, progress is possible one step, one decision, and one day at a time.