Diagnostic Criteria for Substance Use Disorders

Medical professionals frequently rely on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to guide the diagnosis and treatment of mental health conditions, including substance use disorders (SUDs). The DSM-5 provides a standardized framework that helps clinicians identify specific patterns of substance misuse, assess severity, and determine appropriate interventions. This unified diagnostic system allows healthcare providers to offer more accurate diagnoses, deliver targeted treatments, and support patients more effectively in their recovery journey.

What are Substance Use Disorders?

Substance use disorders (SUDs) involve the repeated use of substances despite negative consequences that impair an individual’s mental or physical health ^[1]. Over time, substances alter brain function, particularly by stimulating the release of dopamine, a neurotransmitter associated with pleasure and reward. As dopamine levels drop, the brain and body begin to crave that feeling again, leading to compulsive substance-seeking behavior.

Common substances associated with substance use disorders include alcohol, cannabis, cocaine, methamphetamine, tobacco, and opioids. It is also not uncommon for individuals to experience multiple SUDs simultaneously, for example, having both alcohol use disorder and cannabis use disorder ^[2].

SUDs are highly prevalent in the United States. According to the U.S. Department of Health and Human Services, in 2021, approximately 46.3 million people (16.5% of the population aged 12 or older) met the DSM-5 criteria for a substance use disorder. This includes 29.5 million with alcohol use disorder and 24 million with drug use disorder ^[3].

The DSM-5 Definition of Substance Use Disorders

The American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. Since then, the manual has undergone multiple revisions to reflect advances in mental health research and clinical understanding. The current edition, DSM-5, was released in 2013 and introduced significant changes, especially in how substance use disorders (SUDs) are diagnosed ^[3].

In the DSM-IV, substance-related conditions were divided into two separate categories: substance abuse and substance dependence. The DSM-5 eliminated this distinction, combining both into a single, unified diagnosis of substance use disorder, measured on a continuum from mild to severe based on the number of criteria met.

The DSM-5 also removed “legal problems” as a diagnostic criterion and replaced it with “craving or a strong desire or urge to use a substance,” reflecting a more behaviorally and clinically relevant symptom.

Under the new model, every substance is classified as a specific disorder (e.g., alcohol use disorder, opioid use disorder, stimulant use disorder). Still, all are evaluated using the same 11 diagnostic criteria. Significantly, the diagnostic threshold also changed: whereas DSM-IV required only one symptom to diagnose substance abuse, DSM-5 requires at least two symptoms to qualify for a mild diagnosis.

These updates allow for a more nuanced and accurate assessment of substance use, reflecting both the severity and functional impact of the disorder.

The 11 Diagnostic Criteria

The DSM-5 outlines 11 diagnostic criteria for identifying a substance use disorder (SUD). Meeting two or more of these criteria within 12 months may indicate the presence of a diagnosable condition, with severity classified as mild (2–3 symptoms), moderate (4–5), or severe (6 or more) ^[4].

The criteria are as follows:

1. Using the substance in larger amounts or for longer than intended.
   
2. Persistent desire or unsuccessful efforts to cut down or control use.
   
3. Spending a significant amount of time obtaining, using, or recovering from substance use.
   
4. Experiencing intense cravings or urges to use the substance.
   
5. Failure to fulfill significant obligations at work, school, or home due to substance use.
   
6. Continued use despite persistent or recurrent social or interpersonal problems caused or worsened by use.
   
7. Giving up or reducing important social, occupational, or recreational activities because of substance use.
   
8. Using the substance in physically hazardous situations (e.g., driving under the influence).
   
9. Continued use despite knowledge of physical or psychological problems likely caused or exacerbated by the substance.
   
10. Developing tolerance and needing more of the substance to achieve the same effect or experiencing diminished effect with the same amount.
    
11. Experiencing withdrawal symptoms, which are relieved by taking more of the substance.
    

These criteria provide a comprehensive framework for clinicians to assess substance use severity and guide appropriate treatment planning.

Severity Levels of Substance Use Disorders

The DSM-5 recognizes three levels of substance use: mild, moderate, and severe. Healthcare professionals use these levels to determine levels of severity.

Those with two to three symptoms are considered to have a mild substance disorder. Those with four to five symptoms are said to have a moderate substance disorder. Finally, those with six or more symptoms are considered to have a severe substance disorder ^[5].

When diagnosing patients, healthcare professionals can also add “in early remission (3 to 12 months without meeting DSM-5 criteria)” and “in sustained remission (more than 12 months).” They can also add “on maintenance therapy” for certain substances and “in a controlled environment” ^[6]. 

These DSM-5 addiction criteria help reduce the “all-or-nothing” thinking that was previously used to diagnose addiction. This framing is also essential for doctors diagnosing patients. Knowing their SUD level helps them provide the appropriate treatment plan.

Diagnosing Substance Use Disorders

To diagnose a substance use disorder (SUD), healthcare professionals typically begin with a comprehensive evaluation of the individual’s medical history, often followed by laboratory testing to detect the presence of specific substances in the body ^[7].

In addition to medical evaluation, several standardized screening tools are commonly used to assess substance use patterns and severity. Two widely used assessments include:

• Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool (TAPS): The TAPS is a flexible screening tool that can be self-administered online or completed with the help of a clinician ^[8]. It consists of two components:
  • TAPS-1: A brief, four-item screener for tobacco, alcohol, illicit substances, and prescription medication misuse.
  • TAPS-2: Administered if the first screen is positive, this component identifies specific substances used and determines the individual’s risk level.
• Drug Abuse Screening Test (DAST-10): The DAST-10 includes 10 yes/no questions assessing drug use behavior. Example questions include:
  • “Have you used drugs other than those required for medical reasons?”
  • “Are you always able to stop using drugs when you want to?”
  • “Have you ever experienced withdrawal symptoms (felt sick) when you stopped?”

Scoring is based on the number of “yes” responses:

• 0: No problems reported
• 1–2: Low level of problems
• 3–5: Moderate level
• 6–8: Substantial level
• 9–10: Severe substance use concerns ^[9]

These tools, when used alongside clinical interviews and diagnostic criteria from the DSM-5, help providers make accurate, evidence-based diagnoses and tailor effective treatment plans for individuals struggling with substance use.

Challenges in Diagnosing Substance Use Disorders

Diagnosing substance use disorders (SUDs) can be complex due to several overlapping factors. One significant challenge is the presence of co-occurring mental or physical health conditions, where an individual experiences multiple disorders at the same time ^[2].

Healthcare providers frequently observe that individuals with SUDs also struggle with other mental health disorders. According to the 2023 National Survey on Drug Use and Health, 35% of adults aged 18 and older with a mental health condition also have a substance use disorder, highlighting the high rate of comorbidity.

Another barrier is underreporting. Many individuals hesitate to disclose their substance use due to fear of stigma, legal consequences, or judgment from others. This lack of transparency can delay accurate diagnosis and appropriate care.

To support those hesitant to seek help, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers a free, confidential national helpline, available 24/7, year-round. This service connects individuals to local treatment centers, support groups, and community resources, helping them access the care they need in a safe and nonjudgmental environment.

DSM-5 Criteria vs. Other Diagnostic Systems

The DSM-5 isn’t the only system used to diagnose substance use disorders. One of the other major diagnostic systems for SUDs is the ICD-11, revised in 2022, and includes significant changes related to SUDs ^[10].

Efforts have been made to synchronize the DSM-5 and ICD-11, but the two diagnostic systems still have differences and different aims.

While the American Psychiatric Association produces the DSM-5, the ICD-11 is produced by the World Health Organization, and it therefore includes some psychoactive substances that have global importance, such as synthetic cannabinoids.

The ICD-11 also uses different categories to diagnose substance use disorders: “substance dependence,” “harmful pattern of psychoactive substance use,” and “episode of harmful psychoactive substance use.”

Overall, the DSM-5 and the ICD-11 have the same goal: to help diagnose SUDs so individuals can get the right help. 

Key Takeaways 

Substance use disorder (SUD) is a complex and multifaceted condition shaped by genetic, psychological, and environmental factors. Thanks to advancements in research and diagnostic frameworks like the DSM-5, healthcare professionals now have more accurate tools to assess and treat SUDs. The shift from categorizing substance abuse and dependence separately to a unified diagnosis reflects a more comprehensive understanding of how addiction manifests. 

With standardized diagnostic criteria, screening tools like TAPS and DAST-10, and growing awareness of co-occurring mental health disorders, early detection and intervention are increasingly possible. However, challenges remain, especially in encouraging individuals to seek help amid stigma and fear of judgment. Support systems like SAMHSA’s confidential helpline, evidence-based therapies, and integrated treatment approaches are crucial in recovery. By recognizing the signs and understanding how SUDs are diagnosed, individuals and families can take informed steps toward healing, prevention, and long-term wellness.