Substance Use Disorders

Core Concepts

The 11 criteria and 4 domains

The DSM-5-TR SUD criteria cluster into four domains: (1) impaired control — using more or longer than intended, persistent desire or unsuccessful efforts to cut down, great time spent obtaining/using/recovering, and craving; (2) social impairment — failure to fulfill major role obligations, continued use despite interpersonal problems, and giving up important activities; (3) risky use — recurrent use in hazardous situations and continued use despite knowing it causes physical or psychological problems; (4) pharmacological — tolerance (needing more for the same effect, or reduced effect at the same dose) and withdrawal (the characteristic syndrome when use stops or is reduced). Two or more criteria within 12 months indicate mild severity; 4–5 moderate; 6+ severe. The old DSM-IV split ("abuse" vs. "dependence") was dropped because research showed the categories did not map cleanly onto severity.

Tolerance, withdrawal, and "not all dependence is addiction"

Tolerance and withdrawal are physiological adaptations that can occur with prescribed medications taken exactly as ordered — for example, opioids for pain or benzodiazepines for anxiety. Someone with physical dependence on a prescribed medication does not necessarily have a substance use disorder. The diagnosis requires the behavioral criteria (impaired control, social impairment, risky use), not just physical adaptation. This matters in care: clinicians must not assume that a person taking opioids for pain is "addicted," and must not undertreat pain out of fear. Withdrawal syndromes vary by substance and can be dangerous (alcohol and benzodiazepine withdrawal especially); monitoring and management follow provider orders and facility protocols (including standardized withdrawal scales where used) — never improvisation.

Biopsychosocial models and the "brain disease" debate

Research on reward circuitry (dopamine pathways such as the mesolimbic system) shows that substances hijack motivation and learning systems, and the influential National Institute on Drug Abuse "brain disease" framework (associated with Volkow and colleagues) describes addiction as a chronic brain disorder. The framework is contested: critics argue it overemphasizes biology, underplays choice and social context, and may not reduce stigma as promised. Historical studies illustrate the social dimension — for example, the 1970s "Rat Park" experiments found that rats housed in enriched environments consumed far less morphine solution than isolated rats (small samples; heavily debated), and a landmark 1974 study of Vietnam veterans found that most soldiers who used heroin in Vietnam did not continue use after returning home. Takeaway: addiction is biopsychosocial — biology, psychology, and environment all matter, and no single model is complete.

Co-occurring disorders and dual diagnosis

People with SUD commonly meet criteria for mood, anxiety, trauma-related, and psychotic disorders, and vice versa. Each condition can worsen the other: untreated mental illness drives relapse just as untreated SUD worsens mental illness. Integrated treatment — addressing both together — is the standard of care in most settings; nurses coordinate, educate, and refer.

The nursing role

Nurses: (1) screen — validated tools like the CAGE or AUDIT (alcohol) and DAST (drugs) are administered per facility policy; a positive screen triggers further assessment by qualified clinicians, not a diagnosis; (2) communicate — use nonjudgmental, person-first language and motivational interviewing principles (rolling with resistance, exploring ambivalence); (3) monitor withdrawal and intoxication per orders, and escalate emergencies (for example, suspected overdose, seizures, severe agitation) immediately — call for help, notify the provider, follow facility protocol; (4) teach about treatment options (psychosocial treatment, mutual support groups, and medication-assisted treatment where indicated and ordered) and refer; (5) support harm-reduction approaches where facility policy and jurisdiction allow (for example, naloxone education, safer-use information) — noting that harm-reduction availability varies widely by jurisdiction and institution; and (6) document objectively, avoiding judgmental language. Scope of practice, policies, and legal frameworks vary by jurisdiction and facility.

Common Confusions