What is the recommended approach for diagnosing and treating Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

Diagnosing and Treating Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD) According to DSM-5

The recommended approach for diagnosing AUD and SUD requires using the DSM-5 criteria, with at least 2 out of 11 criteria needed for diagnosis, followed by integrated treatment combining pharmacotherapy and cognitive behavioral therapy for optimal outcomes. 1

Diagnostic Approach

DSM-5 Diagnostic Criteria

The DSM-5 defines both AUD and SUD as problematic patterns of substance use leading to clinically significant impairment or distress, with severity levels based on the number of criteria met:

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

For AUD, the 11 diagnostic criteria include:

1. Alcohol consumed in larger amounts or over longer periods than intended
2. Persistent desire or unsuccessful efforts to cut down
3. Significant time spent obtaining, using, or recovering from alcohol
4. Craving or strong urge to use alcohol
5. Recurrent use resulting in failure to fulfill major role obligations
6. Continued use despite social/interpersonal problems
7. Important activities given up or reduced due to alcohol use
8. Recurrent use in physically hazardous situations
9. Continued use despite physical/psychological problems
10. Tolerance
11. Withdrawal symptoms 1

Similar criteria apply to other SUDs, with substance-specific manifestations.

Screening Tools

For AUD:

• AUDIT (Alcohol Use Disorders Identification Test): Gold standard screening tool developed by WHO with high sensitivity and specificity 1
• AUDIT-C: Shortened 3-question version focusing on consumption patterns 1

For Adolescents:

• NIAAA's two age-specific questions about personal and peer alcohol use
• S2BI (Screening to Brief Intervention): Frequency-of-use questions for multiple substances
• CRAFFT: Car, Relax, Alone, Forget, Friends, Trouble screening tool 1

Biomarkers (when applicable)

• PEth (Phosphatidylethanol): Highest sensitivity (100%) and specificity (96%) for detecting recent alcohol use 1
• Hair EtG (Ethyl Glucuronide): Detects alcohol use over longer periods 1
• Urine EtG: Good sensitivity (71-89%) and specificity (98-99%) 1

Treatment Approach

Integrated Treatment Model

Combined pharmacotherapy and cognitive behavioral therapy (CBT) is the most effective approach for treating AUD/SUD, with significantly better outcomes than either modality alone 1. Integration of SUD screening, diagnosis, and treatment into mental health services is strongly recommended 1.

Pharmacotherapy Options

For AUD:

• FDA-approved medications:
  • Naltrexone (oral or injectable)
  • Acamprosate
  • Disulfiram 1

For Opioid Use Disorder:

• FDA-approved medications:
  • Buprenorphine (requires supervised initiation, then can progress to unsupervised administration)
  • Methadone
  • Extended-release naltrexone 1, 2

Behavioral Interventions

• Cognitive Behavioral Therapy (CBT): First-line behavioral approach targeting cognitive, affective, and environmental risks 1
• Motivational Interviewing: Particularly helpful for patients ambivalent about substance cessation 1
• Contingency Management: Most efficacious form of treatment for stimulant use disorders 1
• Mutual Aid Societies (e.g., Alcoholics Anonymous) 1

Treatment Monitoring and Adjustment

For patients on medication:

• Initial phase: Weekly visits during first month
• Stabilization phase: Less frequent follow-up once stable dosage achieved and assessment indicates no illicit drug use
• Maintenance phase: Monthly visits may be appropriate for stable patients 2

Monitor for:

1. Absence of medication toxicity
2. Absence of adverse effects
3. Responsible medication handling
4. Compliance with treatment plan
5. Abstinence from illicit drug use 2

Special Considerations

Severity-Based Approach

Treatment intensity should match the severity of the disorder:

• Mild AUD/SUD: Brief intervention, motivational interviewing
• Moderate to Severe AUD/SUD: Comprehensive treatment with pharmacotherapy and behavioral interventions 1

Comorbidity Management

AUD/SUD frequently co-occur with other psychiatric disorders, particularly:

• Major depressive disorder
• Bipolar disorder
• Antisocial and borderline personality disorders 3

The severity of personality pathology is a significant risk factor for co-occurring substance use disorders in AUD patients 4. Therefore, comprehensive assessment and treatment of comorbid conditions is essential.

Treatment Gap Considerations

Only about 19.8% of individuals with lifetime AUD ever receive treatment 3, and individuals with AUDs are more likely to receive mental health treatment (11-20%) than specific AUD treatment (8%) 5. This highlights the importance of integrating AUD/SUD treatment with mental health services.

Harm Reduction

For those unable to achieve abstinence, harm reduction services should be offered, including:

• Naloxone distribution
• Safe injection education
• Fentanyl and xylazine test strips
• Referral to syringe service programs 1

By following this structured diagnostic and treatment approach, clinicians can effectively identify and manage AUD and SUD according to DSM-5 guidelines, improving patient outcomes and quality of life.