What are the diagnostic criteria and treatment approaches for Substance Use Disorder (SUD) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)?

DSM-5 Diagnostic Criteria for Substance Use Disorder

According to the DSM-5, Substance Use Disorder (SUD) is diagnosed when a patient meets at least two out of eleven criteria within a 12-month period, with severity classified as mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria). 1

Diagnostic Criteria

The DSM-5 combines the previously separate DSM-IV diagnoses of substance abuse and substance dependence into a single disorder measured on a continuum of severity. The eleven criteria for SUD include:

1. Impaired control:

   • Taking the substance in larger amounts or over longer periods than intended
   • Persistent desire or unsuccessful efforts to cut down or control use
   • Spending a great deal of time obtaining, using, or recovering from substance use
   • Craving or strong desire to use the substance

2. Social impairment:

   • Recurrent use resulting in failure to fulfill major role obligations
   • Continued use despite persistent social or interpersonal problems caused by use
   • Important social, occupational, or recreational activities given up because of use

3. Risky use:

   • Recurrent use in physically hazardous situations
   • Continued use despite knowledge of physical or psychological problems likely caused by the substance

4. Pharmacological criteria:

   • Tolerance (needing increased amounts for same effect)
   • Withdrawal symptoms when not using

Severity Classification

• Mild: 2-3 criteria met
• Moderate: 4-5 criteria met
• Severe: 6 or more criteria met 1

Important Diagnostic Considerations

• Medical use exception: When substances are used appropriately under medical supervision (e.g., opioids for pain), tolerance and withdrawal alone do not qualify for an SUD diagnosis 1

• Craving criterion: The addition of craving as a criterion in DSM-5 helps identify cases but doesn't substantially affect overall diagnosis rates 2

• Diagnostic orphans: DSM-5's lower threshold (2+ criteria) captures individuals who previously fell between diagnostic categories in DSM-IV 3

Course Specifiers

DSM-5 includes important course specifiers:

• Early remission: 3-12 months without meeting SUD criteria (except craving)
• Sustained remission: 12+ months without meeting SUD criteria (except craving)
• In a controlled environment: When access to substances is restricted
• On maintenance therapy: For patients on medications like methadone, buprenorphine, naltrexone, or tobacco cessation medications 1

Screening Tools

For initial screening, clinicians can use:

1. Single-question screen: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (90-100% sensitivity) 1

2. Drug Abuse Screening Test (DAST-10): 10-item questionnaire with excellent sensitivity (90-100%) for identifying substance abuse or dependence 1

Treatment Approaches

Treatment should be matched to the severity of the disorder:

For Mild SUD (2-3 criteria):

• Brief counseling using motivational interviewing techniques
• Ongoing assessment and monitoring 1

For Moderate SUD (4-5 criteria):

• Brief counseling with a negotiated treatment plan
• Close follow-up
• Referral for more intensive treatment if symptoms persist 1

For Severe SUD (6+ criteria):

• Brief counseling with referral for specialized treatment
• Consider medication-assisted treatment when appropriate
• Ongoing assessment and support 1

Medication-Assisted Treatment

For opioid use disorder specifically, evidence-based treatment typically includes:

• Buprenorphine or methadone maintenance therapy
• Behavioral therapies in combination with medications
• Regular monitoring and follow-up 1, 4

Clinical Pearls and Pitfalls

• Avoid diagnostic errors: Don't diagnose SUD based solely on tolerance and withdrawal in patients appropriately using prescribed medications 1

• Recognize comorbidities: SUDs frequently co-occur with other mental health disorders, requiring comprehensive assessment 5

• Monitor treatment progress: Assess for abstinence from illicit substances, medication compliance, and engagement in recovery activities 4

• Prevent relapse: When discontinuing treatment, implement a gradual taper and comprehensive relapse prevention plan 4

• Screening implementation: The Substance Use Symptom Checklist has been validated for assessing DSM-5 SUD symptoms in primary care settings 6

By understanding and applying these DSM-5 criteria systematically, clinicians can more accurately diagnose SUDs and implement appropriate evidence-based treatments to improve patient outcomes.