09 Substance-Related and Addictive Disorders
Learn how substance-related and behavioral addictive disorders are identified, assessed, managed safely, and supported through individualized treatment and recovery.
Understanding substance-related disorders
Substance-related and addictive disorders involve patterns of substance use or behavior that cause significant distress, health risks, or difficulty managing important parts of life. They are treatable health conditions, not evidence of weak character. Risk and are shaped by interacting biological, psychological, social, and environmental factors.
A may involve alcohol, cannabis, opioids, stimulants, sedatives, tobacco, hallucinogens, inhalants, or other substances. Clinicians assess the pattern and consequences of use rather than relying on a single sign.
Criteria and clinical assessment
Under DSM-5 criteria, at least of symptoms within a -month period indicate a substance use disorder. Severity is classified as mild with – symptoms, moderate with –, or severe with or more.
Symptoms include using more or for longer than intended, unsuccessful efforts to cut down, craving, neglecting responsibilities, hazardous use, and continuing despite harm. Tolerance or alone does not automatically establish a substance use disorder, particularly when either occurs during appropriate medical treatment.
For example, a person who repeatedly drinks more than planned, has tried unsuccessfully to cut down, and continues despite worsening health may warrant a clinical assessment. Screening can identify risk, but diagnosis requires a fuller assessment that considers health, medications, functioning, and the person’s circumstances.
Behavioral addictive disorders
Not every frequent or intense activity is an addiction. A involves impaired control, increasing priority given to the behavior, persistence despite harm, and meaningful disruption to daily functioning.
is recognized as an addictive disorder in the DSM. Warning signs can include repeated unsuccessful attempts to stop, chasing losses, and jeopardizing relationships or work.
is included in the World Health Organization’s ICD-11. Diagnosis requires impaired control and substantial functional impairment; the pattern is normally evident for at least months. In the DSM-5-TR, Internet remains a condition for further study, not a diagnosis in the manual’s main diagnostic section.
Other potentially harmful patterns, such as compulsive shopping or excessive social-media use, should be assessed for distress and impairment without assuming they are formally recognized addictive disorders.
Respectful communication and assessment
Assessment should be collaborative, private, and nonjudgmental. Ask what substances or behaviors are involved, how often and how much, what the person values or worries about, and how use affects health, relationships, sleep, work, school, and safety. Explore history, prescribed medications, other mental or physical health conditions, trauma, housing, and social supports. Use validated screening tools when appropriate, then arrange a diagnostic assessment and medical evaluation as indicated.
reduces stigma: say “person with a substance use disorder” rather than defining someone as an addict or abuser. Ask open-ended questions, listen reflectively, recognize strengths, and support the person’s autonomy. One example is, “What do you like about using, and what concerns you about it?”
helps explore ambivalence and identify the person’s own reasons and next steps for change.
Crisis care and immediate safety
Address immediate medical and behavioral safety first. Seek emergency help for suspected overdose, severe confusion, seizure, loss of consciousness, breathing difficulty, or risk of harm to self or others.
An opioid overdose may involve unresponsiveness, slow or absent breathing, and pinpoint pupils. Give if available, call 911, and follow dispatcher instructions. may need to be given again.
can also be dangerous. Abruptly stopping alcohol after prolonged heavy drinking can cause life-threatening , including seizures or delirium. Encourage urgent medical assessment and medically supervised management rather than advising a person to stop suddenly without support.
If a person expresses suicidal thoughts or appears unable to stay safe, ask directly about immediate danger, stay with them when safe to do so, and connect them with emergency or crisis services. Do not promise secrecy about an imminent safety risk.
Integrated treatment and support
Care is most useful when it matches the person’s needs, preferences, culture, and goals. With consent, coordinate medical care, mental health treatment, substance-use services, and practical supports. People with co-occurring mental health and substance use conditions benefit from coordinated or integrated assessment and treatment rather than having one condition ignored while the other is treated.
Treatment and support may include:
Medication and therapy: Medications are available for opioid, alcohol, and tobacco use disorders. For opioid use disorder, a qualified clinician may consider methadone, buprenorphine, or naltrexone. Medication can be combined with counseling, but treatment should be individualized rather than withheld because someone declines counseling. For other substances, behavioral treatment and supportive care are important; medication availability differs by disorder.
Behavioral and psychosocial support: Options may include cognitive-behavioral therapy, motivational approaches, contingency management where appropriate, family involvement with the person’s agreement, and peer or mutual-support groups. No single pathway fits everyone.
and practical supports: Reduce immediate health risks while maintaining connection to care. Supports may address overdose prevention, infectious-disease screening when relevant, stable housing, food, transportation, education, work, and social connection.
Ongoing support: is a process of improving health and wellness and building a self-directed life. It can include reduced use or abstinence, treatment engagement, coping skills, supportive relationships, and renewed roles and interests. A return to use is a signal to reassess safety and adjust the plan, not a reason to withdraw care.
For example, a patient with opioid use disorder, depression, and unstable housing might receive medication for opioid use disorder, depression assessment and treatment, , peer support, and help connecting to housing services. The team can check in, revise the plan with the patient, and continue care if setbacks occur.