Substance use disorder

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Substance use disorder
Other namesDrug use disorder
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Specialty Psychiatry

A substance use disorder (SUD), also known as a drug use disorder, is a medical condition in which the use of one or more substances leads to a clinically significant impairment or distress. [1] Substance use disorders are characterized by an array of mental, physical, and behavioral symptoms that may cause problems related to loss of control, strain to one's interpersonal life, hazardous use, tolerance, and withdrawal. [2] Drug classes that are involved in SUD include alcohol, phencyclidine, inhalants, stimulants, cannabis, "other hallucinogens", opioids, tobacco, and sedatives, hypnotics, and anxiolytics . [2] [3]

Alcohol (drug) active ingredient in alcoholic beverages

Alcohol, also known by its chemical name ethanol, is a psychoactive substance that is the active ingredient in drinks such as beer, wine, and distilled spirits. It is one of the oldest and most common recreational substances, causing the characteristic effects of alcohol intoxication ("drunkenness"). Among other effects, alcohol produces a mood lift and euphoria, decreased anxiety, increased sociability, sedation, impairment of cognitive, memory, motor, and sensory function, and generalized depression of central nervous system function. Ethanol is a type of chemical compound known as an alcohol, and is the only type of alcohol that is found in alcoholic beverages or is commonly used for recreational purposes; other alcohols such as methanol and isopropyl alcohol are toxic.

Phencyclidine chemical compound

Phencyclidine (PCP), also known as angel dust among other names, is a drug used for its mind-altering effects. PCP may cause hallucinations, distorted perceptions of sounds, and violent behavior. As a recreational drug, it is typically smoked, but may be taken by mouth, snorted, or injected. It may also be mixed with cannabis or tobacco.

Cannabis (drug) A psychoactive drug from the Cannabis plant used for medical or recreational purposes

Cannabis, also known as marijuana among other names, is a psychoactive drug from the Cannabis plant used for medical or recreational purposes. The main psychoactive part of cannabis is tetrahydrocannabinol (THC), one of 483 known compounds in the plant, including at least 65 other cannabinoids. Cannabis can be used by smoking, vaporizing, within food, or as an extract.


Drug addiction and drug dependence are distinct components of substance use disorders. The severity of substance use disorders can vary widely; in the diagnosis of a SUD, the severity of an individual's SUD is qualified as mild, moderate, or severe on the basis of how many of the 11 diagnostic criteria are met. In the DSM-5, the term drug addiction is synonymous with severe substance use disorder. [4] [5]

Worldwide 275 million people were estimated to have used an illicit drug in 2016. [6] Of these, 27 million have high-risk drug use otherwise known as recurrent drug use causing harm to their health, psychological problems, or social problems or puts them at risk of those dangers. [7] [8] In 2015 substance use disorders resulted in 307,400 deaths, up from 165,000 deaths in 1990. [9] [10] Of these, the highest numbers are from alcohol use disorders at 137,500, opioid use disorders at 122,100 deaths, amphetamine use disorders at 12,200 deaths, and cocaine use disorders at 11,100. [9] The number of deaths directly caused by drug use has increased over 60 percent from 2000 to 2015. [11]

Opioid use disorder substance abuse that involves the recurring use of opioid drugs despite negative consequences

Opioid use disorder is a problematic pattern of opioid use that causes significant impairment or distress. Symptoms of the disorder include a strong desire to use opioids, increased tolerance to opioids, failure to fulfill obligations, trouble reducing use, and withdrawal syndrome with discontinuation. Opioid withdrawal symptoms may include nausea, muscle aches, diarrhea, trouble sleeping, or a low mood. Addiction and dependence are components of a substance use disorder. Complications may include opioid overdose, suicide, HIV/AIDS, hepatitis C, marriage problems, or unemployment.


Addiction and dependence glossary [12] [13] [14] [4]
  • addiction – a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences
  • addictive behavior – a behavior that is both rewarding and reinforcing
  • addictive drug – a drug that is both rewarding and reinforcing
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Substance abuse may lead to addiction, substance dependence, or both, depending upon the substance. Medically, physiologic dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence often implies abuse, but abuse frequently occurs without dependence, particularly when an individual first begins to abuse a substance. Dependence involves physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society. [15]

Substance dependence, also known as drug dependence, is an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral addiction and drug addictions, but not dependence.

Drug withdrawal is the group of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications or recreational drugs.

Addiction state characterized by compulsive engagement in rewarding stimuli despite adverse consequences

Addiction is a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences. Despite the involvement of a number of psychosocial factors, a biological process – one which is induced by repeated exposure to an addictive stimulus – is the core pathology that drives the development and maintenance of an addiction. The two properties that characterize all addictive stimuli are that they are reinforcing and intrinsically rewarding.

Substance abuse is sometimes used as a synonym for drug abuse, drug addiction, and chemical dependency, but actually refers to the use of substances in a manner outside sociocultural conventions. All use of controlled drugs and all use of other drugs in a manner not dictated by convention (e.g. according to physician's orders or societal norms) is abuse according to this definition; however there is no universally accepted definition of substance abuse.

The physical harm for twenty drugs was compared in an article in the Lancet (see diagram, above right)[ citation needed ]. Physical harm was assigned a value from 0 to 3 for acute harm, chronic harm and intravenous harm. Shown is the mean physical harm. Not shown, but also evaluated, was the social harm.

Substance use may be better understood as occurring on a spectrum from beneficial to problematic use. This conceptualization moves away from the ill-defined binary antonyms of "use" vs. "abuse" (see diagram, lower right) towards a more nuanced, public health-based understanding of substance use.

Signs and symptoms

The DSM definition of addiction can be boiled down to compulsive use of a substance (or engagement in an activity) despite ongoing negative consequences. The medical community makes a distinction between physical dependence (characterized by symptoms of physical withdrawal symptoms, like tremors and sweating) and psychological dependence (emotional-motivational withdrawal symptoms) [ citation needed ]. Physical dependence is simply needing a substance to function. Humans are all physically dependent upon oxygen, food and water. A drug can cause physical dependence and not psychological dependence (for example, some blood pressure medications, which can produce fatal withdrawal symptoms if not tapered) and some can cause psychological dependence without physical dependence (the withdrawal symptoms associated with cocaine are all psychological, there is no associated vomiting or diarrhea as there is with opiate withdrawal).


There are many known risk factors associated with an increased chance of developing a substance use disorder. Children born to parents with SUDs have roughly a two-fold increased risk in developing a SUD compared to children born to parents without any SUDs. [16] Taking highly addictive drugs, and those who develop SUDs in their teens are more likely to have continued symptoms into adulthood. [16] Other common risk factors are being male, being under 25, having other mental health problems, and lack of familial support and supervision. [16]


Individuals whose drug or alcohol use cause significant impairment or distress may have a substance use disorder (SUD). [2] Diagnosis usually involves an in-depth examination, typically by psychiatrist, psychologist, or drug and alcohol counselor. [17] The most commonly used guidelines are published in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). [17] There are 11 diagnostic criteria which can be broadly categorized into issues arising from substance use related to loss of control, strain to one's interpersonal life, hazardous use, and pharmacologic effects. [2]

DSM-5 guidelines for the diagnosis of a substance use disorder requires that the individual have significant impairment or distress from their pattern of drug use, and at least two of the symptoms listed below in a given year. [2]

  1. Using more of a substance than planned, or using a substance for a longer interval than desired
  2. Inability to cut down despite desire to do so
  3. Spending substantial amount of the day obtaining, using, or recovering from substance use
  4. Cravings or intense urges to use
  5. Repeated usage causes or contributes to an inability to meet important social, or professional obligations
  6. Persistent usage despite user's knowledge that it is causing frequent problems at work, school, or home
  7. Giving up or cutting back on important social, professional, or leisure activities because of use
  8. Using in physically hazardous situations, or usage causing physical or mental harm
  9. Persistent use despite the user's awareness that the substance is causing or at least worsening a physical or mental problem
  10. Tolerance: needing to use increasing amounts of a substance to obtain its desired effects
  11. Withdrawal: characteristic group of physical effects or symptoms that emerge as amount of substance in the body decreases

There are additional qualifiers and exceptions outlined in the DSM. For instance, if an individual is taking opiates as prescribed, they may experience physiologic effects of tolerance and withdrawal, but this would not cause an individual to meet criteria for a SUD without additional symptoms also being present. [2] A medical professional trained to evaluate and treat substance use disorders will take these nuances into account during a diagnostic evaluation.


Substance use disorders range can range widely in severity, and there are numerous methods to monitor and qualify the severity of an individual's SUD. The DSM-5 includes specifiers for severity of a SUD. [2] Individuals who meet only 2 or 3 criteria are often deemed to have mild SUD. [2] Substance users who meet 4 or 5 criteria may have their SUD described as moderate, and persons meeting 6 or more criteria as severe. [2] In the DSM-5, the term drug addiction is synonymous with severe substance use disorder. [4] [5] The quantity of criteria met offer a rough gauge on the severity of illness, but licensed professionals will also take into account a more holistic view when assessing severity which includes specific consequences and behavioral patterns related to an individual's substance use. [2] They will also typically follow frequency of use over time, and assess for substance-specific consequences, such as the occurrence of blackouts, or arrests for driving under the influence of alcohol, when evaluating someone for an alcohol use disorder. [2] There are additional qualifiers for stages of remission that are based on the amount of time an individual with a diagnosis of a SUD has not met any of the 11 criteria except craving. [2] Some medical systems refer to an Addiction Severity Index to assess the severity of problems related to substance use. [18] The index assesses potential problems in seven categories: medical, employment/support, alcohol, other drug use, legal, family/social, and psychiatric. [19]

Screening tests

There are several different screening tools that have been validated for use with adolescents such as the CRAFFT and adults such as CAGE.




Depending on the severity of use, and the given substance, early treatment of acute withdrawal may include medical detoxification. Of note, acute withdrawal from heavy alcohol use should be done under medical supervision to prevent a potentially deadly withdrawal syndrome known as delirium tremens. See also Alcohol detoxification.


Therapists often classify people with chemical dependencies as either interested or not interested in changing. About 11% of Americans with substance use disorder seek treatment, and 40–60% of those people relapse within a year. [20] Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.

Behavioral patternInterventionGoals
Low self-esteem, anxiety, verbal hostilityRelationship therapy, client centered approachIncrease self-esteem, reduce hostility and anxiety
Defective personal constructs, ignorance of interpersonal means Cognitive restructuring including directive and group therapiesInsight
Focal anxiety such as fear of crowdsDesensitizationChange response to same cue
Undesirable behaviors, lacking appropriate behaviorsAversive conditioning, operant conditioning, counter conditioningEliminate or replace behavior
Lack of informationProvide informationHave client act on information
Difficult social circumstancesOrganizational intervention, environmental manipulation, family counselingRemove cause of social difficulty
Poor social performance, rigid interpersonal behaviorSensitivity training, communication training, group therapyIncrease interpersonal repertoire, desensitization to group functioning
Grossly bizarre behaviorMedical referralProtect from society, prepare for further treatment
Adapted from: Essentials of Clinical Dependency Counseling, Aspen Publishers

From the applied behavior analysis literature and the behavioral psychology literature, several evidenced-based intervention programs have emerged (1) behavioral marital therapy (2) community reinforcement approach (3) cue exposure therapy and (4) contingency management strategies. [21] [22] In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.


The disability-adjusted life year, a measure of overall disease burden (number of years lost due to ill-health, disability or early death), from drug use disorders per 100,000 inhabitants in 2004
no data
>440 Drug use disorders world map - DALY - WHO2004.svg
The disability-adjusted life year, a measure of overall disease burden (number of years lost due to ill-health, disability or early death), from drug use disorders per 100,000 inhabitants in 2004
  no data

Rates of substance use disorders vary by nation and by substance, but the overall prevalence is high. [23] On a global level, men are affected at a much higher rate than women. [23] Younger individuals are also more likely to be affected than older adults. [23]

United States

In 2017, roughly 7% of Americans aged 12 or older had a SUD in the past year. [24] Rates of alcohol use disorder in the past year was just over 5%. Approximately 3% of people aged 12 or older had an illicit drug use disorder. [24] The highest rates of illicit drug use disorder was among those aged 18 to 25 years old, at roughly 7%. [24] [23]

The were over 72,000 deaths from drug overdose in the United States in 2017. [25] This represents a 3-fold increase in mortality from overdose from 2002 to 2017. [25] Overdose fatalities from synthetic opioids, which typically involve fentanyl, have risen sharply in the past several years to contribute to nearly 30,000 deaths per year. [25] Death rates from synthetic opioids like fentanyl have increased 22-fold in the period from 2002 to 2017. [25] Heroin and other natural and semi-synthetic opioids combined to contribute to roughly 31,000 overdose fatalities. [25] Cocaine contributed to roughly 15,000 overdose deaths, while methamphetamine and benzodiazepines each contributed to roughly 11,000 deaths. [25] Of note, the mortality from each individual drug listed above cannot be summed because many of these deaths involved combinations of drugs, such as overdosing on a combination of cocaine and an opioid. [25]

Deaths from alcohol consumption account for the loss of over 88,000 lives per year. [26] Tobacco remains the leading cause of preventable death, responsible for greater than 480,000 deaths in the United States each year. [27]

Related Research Articles

Substance abuse a patterned use of a drug in which the user consumes the psychoactive/chemical substance substances in amounts or with methods which are harmful to themselves or others

Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behaviour occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.

Substance abuse, also known as drug abuse, is a patterned use of a substance (drug) in which the user consumes the substance in amounts or with methods which are harmful to themselves or others. The drugs used are often associated with levels of intoxication that alter judgment, perception, attention and physical control, not related with medical effects. It is often thought that the main abused substances are illegal drugs and alcohol; however it is becoming more common that prescription drugs and tobacco are a prevalent problem.

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as marijuana, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol.

Physical dependence is a physical condition caused by chronic use of a tolerance forming drug, in which abrupt or gradual drug withdrawal causes unpleasant physical symptoms. Physical dependence can develop from low-dose therapeutic use of certain medications such as benzodiazepines, opioids, antiepileptics and antidepressants, as well as the recreational misuse of drugs such as alcohol, opioids, and benzodiazepines. The higher the dose used, the greater the duration of use, and the earlier age use began are predictive of worsened physical dependence and thus more severe withdrawal syndromes. Acute withdrawal syndromes can last days, weeks or months. Protracted withdrawal syndrome, also known as post-acute-withdrawal syndrome or "PAWS", is a low-grade continuation of some of the symptoms of acute withdrawal, typically in a remitting-relapsing pattern, often resulting in relapse and prolonged disability of a degree to preclude the possibility of lawful employment. Protracted withdrawal syndrome can last for months, years, or depending on individual factors, indefinitely. Protracted withdrawal syndrome is noted to be most often caused by benzodiazepines. To dispel the popular misassociation with addiction, physical dependence to medications is sometimes compared to dependence on insulin by persons with diabetes.

Problem gambling urge to continuously gamble despite harmful negative consequences or a desire to stop

Problem gambling is an urge to gamble continuously despite harmful negative consequences or a desire to stop. Problem gambling is often defined by whether harm is experienced by the gambler or others, rather than by the gambler's behaviour. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria. Pathological gambling is a common disorder that is associated with both social and family costs.

Sexual addiction, also known as sex addiction, is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences.

The modern disease theory of alcoholism states that problem drinking is sometimes caused by a disease of the brain, characterized by altered brain structure and function.

An addictive behavior is a behavior, or a stimulus related to a behavior, that is both rewarding and reinforcing, and is associated with the development of an addiction. Addictions involving addictive behaviors are normally referred to as behavioral addictions.

Psychological dependence is a state that involves emotional–motivational withdrawal symptoms, e.g. anxiety and anhedonia, upon cessation of drug use or certain behaviours. It develops through frequent exposure to a psychoactive substance or behaviour, though behavioural dependence is less talked about. The specific mechanism involves a neuronal counter-adaption, which could be mediated through changes in neurotransmittor activity or altered receptor expression. Withdrawal symptoms can be attenuated by environmental enrichment and physical activity. Psychological dependence is not to be confused with physical dependence, which induces physical withdrawal symptoms upon discontinuation of use. However they are not mutually exclusive.

Behavioral addiction is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behavior – sometimes called a natural reward – despite any negative consequences to the person's physical, mental, social or financial well-being. A gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioral and drug addictions, which are associated with the same set of neural adaptations in the reward system.

Polysubstance dependence

A person with polysubstance dependence is psychologically addicted to being in an intoxicated state without a preference for one particular substance. Although any combination of three drugs can be used, studies have shown that alcohol is commonly used with another substance. This is supported by one study on polysubstance use that separated participants who used multiple substances into groups based on their preferred drug. The three substances were cocaine, alcohol, and heroin, which implies that those three are very popular. Other studies have found that opiates, cannabis, amphetamines, hallucinogens, inhalants and benzodiazepines are often used in combination as well. The results of a long-term or longitudinal study on substance use led the researchers to observe that excessively using or relying on one drug increased the probability of excessively using or relying on another drug.

Opioid overdose acute condition due to excessive opioids

An opioid overdose is toxicity due to excessive opioids. Examples of opioids include morphine, heroin, fentanyl, tramadol, and methadone. Symptoms include insufficient breathing, small pupils, and unconsciousness. Onset of symptoms depends in part on the route opioids are taken. Among those who initially survive, complications can include rhabdomyolysis, pulmonary edema, compartment syndrome, and permanent brain damage.

Cannabis use disorder (CUD), also known as cannabis addiction or marijuana addiction, is defined in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and ICD-10 as the continued use of cannabis despite clinically significant impairment.

Exercise addiction is a state characterized by a compulsive engagement in any form of physical exercise, despite negative consequences. While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury. It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise. Differentiating between addictive and healthy exercise behaviors is difficult but there are key factors in determining which category a person may fall into. Exercise addiction shows a high comorbidity with eating disorders.

Posttraumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.


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