Substance use disorder (SUD): symptoms, causes, involved substances, DSM-5 criteria, and treatment

Substance use disorder (SUD) is a medical condition characterized by the compulsive use of substances such as alcohol, drugs, or other addictive substances, despite negative consequences. It involves a combination of behavioral, psychological, and physiological symptoms, including a strong craving for the substance, inability to control its use, and withdrawal symptoms when not using it.

Symptoms of substance use disorder include physical symptoms, psychological symptoms, impaired control, social problems, risky behaviors, and behavioral issues.

Causes of substance use disorder encompass genetic predisposition, trauma, environmental factors, social and cultural factors, co-occurring mental health conditions, and neurobiological changes.

Involved substances in substance use disorder include alcohol, marijuana, opiates, prescription medicines, cocaine, methamphetamine, nicotine, hallucinogens, and inhalants.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for substance use disorder include taking the substance in larger amounts or for longer periods than intended, persistent desire or unsuccessful efforts to cut down or control use, dedicating a significant time obtaining, using, or recovering from the substance, craving or strong desire to use the substance, failure to fulfill major obligations due to substance use, continued use despite social or interpersonal problems, giving up important social, occupational, or recreational activities, recurrent use in physically hazardous situations, continued use despite physical or psychological problems, tolerance, and withdrawal.

Treatment of substance use disorder includes detoxification, medication-assisted treatment (MAT), cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), family therapy, holistic therapy, support groups, outpatient programs, and aftercare planning.

What is substance use disorder (SUD)?

Substance use disorder (SUD) is a complex condition characterized by the uncontrolled use of a substance despite its harmful consequences. SUDs range from mild to severe, involving cravings, tolerance, and withdrawal. It is possible for people to struggle with more than one substance at the same time.

Substance use disorder significantly impacts health, relationships, and overall quality of life. It’s crucial to seek help as soon as signs of SUD develop. The reason behind starting SUD varies among different individuals, often escalating into addiction. The risk of developing substance use disorder depends on various factors such as the type of substance abused, the amount consumed, the frequency of consumption, and the duration of abuse.

Is substance use disorder (SUD) the same as addiction?

No, substance use disorder (SUD) is not the same as addiction, while the terms are often used interchangeably, they both have distinct definitions and implications in clinical contexts.

SUD is a medical diagnosis that refers to a pattern of substance use leading to significant problems in a person’s life such as relationship, occupation, interpersonal and social problems. The SUD is categorized as mild, moderate and severe as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). SUD does not always involve compulsive behaviors. It is not necessary that a person who has SUD has an addiction.

Addiction, on the other hand, is a more severe form of SUD and involves compulsive drug use despite its negative consequences. It occurs when the brain’s reward system dominates, intensifying the compulsion to seek and use substances. Addiction is marked by a loss of control over substance use and intense cravings. Furthermore, addiction does not have a formal diagnosis.

Is substance use disorder (SUD) the same as substance dependence?

No, substance use disorder (SUD) is not the same as substance dependence. SUD is a broader term to refer to the problematic pattern of using substances (like drugs or alcohol) that leads to significant distress or impairment in daily life. In contrast, substance dependence is more specific and refers to the physical or psychological reliance on a substance, often characterized by tolerance and withdrawal symptoms when not using.

However, these terms are sometimes used interchangeably. In other words, substance dependence is a component of SUD. Sustained substance abuse often leads to drug dependence, where the body adapts to the substance and develops tolerance, which is needing more quantity of the substance to achieve the same effect. Over time, the brain adapts itself, creating a need for the substance to function normally. Stopping use triggers withdrawal symptoms, ranging from mild to severe. In certain cases, medical supervision or hospitalization becomes necessary to safely manage its withdrawal.

Is substance use disorder a mental illness?

Yes, substance use disorder is a mental illness. The APA Dictionary of Psychology published by the American Psychological Association, updated on 11/15/2023, defines substance use disorder (SUD) as characterized by a combination of cognitive, behavioral, and physiological symptoms that persist despite causing significant distress or harm.

As highlighted in the DSM-5 published by American Psychiatric Association in 2013, SUD causes long-lasting changes in brain circuits, especially in severe cases, even after detoxification. These changes lead to strong cravings and repeated relapses, resulting in problematic behaviors like difficulty controlling substance use, social problems, dangerous actions, and tolerance or withdrawal. The mental and behavioral aspects of SUD, such as difficulty controlling substance use, risky use, social problems, match the criteria for a mental disorder. The ongoing nature of these changes and their effects on behavior, decision-making, and physiological responses confirm SUD as a mental illness requiring medical and therapeutic treatment.

Mental illness and substance abuse often go parallel to each other. People with substance use disorder are more likely to have a mental illness, and vice versa. Treating addiction is important for these patients, as it helps improve their overall mental health. Both inpatient and outpatient rehab programs are effective in treating addiction.

What are the symptoms of substance use disorder?

The symptoms of substance use disorder are listed below.

• Physical symptoms: Physical symptoms of SUD include noticeable changes in physical appearance and health. Common signs are bloodshot eyes, abnormal pupil sizes, sudden weight fluctuations, and a decline in personal hygiene. Individuals exhibit unusual odors in their breath or disheveled clothing, along with tremors, slurred speech, or impaired coordination.
• Psychological symptoms: Psychological symptoms reflect significant changes in mental and emotional states. These include paranoia, anxiety, or unexplained fear, along with abrupt changes in personality and a sense of being “spaced out.” A lack of motivation, extreme fatigue, mood swings, irritability, and confusion are prominent, indicating substance use issues.
• Impaired control: Impaired control in substance use disorder is characterized by a person’s inability to regulate their consumption despite wanting to stop. Individuals experience intense cravings or urges to use the substance, making it difficult to focus on anything else. They often try to cut down but fail, leading to frustration and helplessness. This loss of control results in using larger amounts than intended and spending significant time obtaining, using, or recovering from the substance, which further disrupts their daily life.
• Social problems: Substance use disorders typically interfere with the ability to meet obligations at work, school, or home, leading to absenteeism, poor performance, or conflicts. These disorders strain relationships with family members, friends, or colleagues, often leading to isolation and social withdrawal.
• Risky behavior: Substance use disorders often involve risky behavior. People with SUDs use substances in dangerous situations, like driving while intoxicated, which leads to accidents and injuries. They continue using substances even when they know it’s harmful.
• Behavioral issues: Substance use disorders lead to changes in behavior. People with SUDs become secretive, have trouble with relationships, neglect their responsibilities, and get into legal trouble. They change their habits, engage in risky behaviors, and have financial problems. Despite the negative consequences, they often continue to use substances.

What are the causes of substance use disorder?

The causes of substance use disorder are listed below.

• Genetic predisposition: Genetic predisposition plays a significant role in the risk of developing substance use disorder (SUD). The research article titled “Multivariate genome-wide association meta-analysis of over 1 million subjects identifies loci underlying multiple substance use disorders“ byAlexander S. Hatoumet al. published in the journal Nature Mental Health in 2023, identified 19 genetic variations known as single-nucleotide polymorphisms (SNPs) linked to a general risk factor (addiction-rf) for addiction. These variations were highly spread across different genes. One key gene, PDE4B, was significant across different ancestries, suggesting that dopamine regulation plays a role in making people vulnerable to various substance use disorders.
• Trauma: In the 2023 research article “Adverse Childhood Events, Mood and Anxiety Disorders, and Substance Dependence: Gene X Environment Effects and Moderated Mediation” by Henry R. Kranzler et al., published on medRxiv, adverse childhood events (ACEs)—such as experiences of childhood sexual abuse, exposure to violence or parental substance abuse and physical abuse, have been shown to lead to the development of substance use disorders.
• Environmental factors: An individual’s environment strongly impacts their risk of substance use by influencing access to drugs, social attitudes, and exposure to stressors. Easy availability and prevalent drug use increase the likelihood of experimentation and addiction. Stressors from the environment, such as unemployment or poverty, additionally make someone more susceptible to drug addiction. These pressures cause people to turn to drugs or alcohol as a means of escape from difficult situations.
• Social and cultural factors: Social and cultural factors play a significant role in substance use disorder. Factors such as peer pressure, media influence, societal norms, and easy access contribute to the development of substance use disorder.
• Co-occurring mental health conditions: According to a research “Common Comorbidities with Substance Use Disorders Research Report Part 1: The Connection Between Substance Use Disorders and Mental Illness”published by the National Institute on Drug Abuse in 2018, people with SUD often have underlying mental health conditions, such as generalized anxiety disorder, bipolar disorder, post-traumatic stress disorder (PTSD), depression, panic disorder, attention deficit hyperactivity disorder (ADHD), and personality disorders.
• Neurobiological changes: Drugs stimulate the brain’s reward system by releasing dopamine, leading to reinforcing behaviors such as cravings, tolerance, and withdrawal symptoms. Over time, desensitization occurs, leading to higher doses to achieve the same effect. In a 2011research article “Dysfunction of the Prefrontal Cortex in Addiction: Neuroimaging Findings and Clinical Implications” by Rita Z. Goldstein and Nora D. Volkow, published in the journal Nature Reviews Neuroscience, shows that hyperactivity in the prefrontal cortex (PFC) plays a significant role in the development of substance use disorders. The authors suggest that long-term hyperactivity of this brain region impairs impulse control and heightens emotional dysregulation, both of which contribute to an increased risk of substance abuse.

Which substances are commonly involved in substance use disorder (SUD)?

Substances commonly involved in substance use disorder (SUD) are listed below.

• Alcohol: Alcohol is the most widely used legal substance linked to substance use disorder. Alcohol addiction is characterized by compulsive drinking, inability to regulate its consumption, and negative emotions when alcohol is not available.Alcohol acts as a depressant on the central nervous system, slowing down the brain functions, impacting mood, behavior, and self-regulation. It impairs memory and cognitive clarity, as well as hinders coordination and physical control.
• Marijuana: Marijuana addiction is characterized by the persistent use of marijuana despite facing serious negative consequences. The psychoactive component of marijuana, tetrahydrocannabinol (THC), is responsible for its physical and mental effects. Marijuana, known as cannabis, is frequently used for both medical and recreational purposes. Individuals addicted to marijuana experience an overwhelming and compulsive urge to use the drug, regardless of the harm it causes to their health or social relationships.
• Opiates: Opioid addiction is characterized by a person’s failure to reduce or cease opioid use. Opiates are a class of drugs derived from the opium poppy plant and are commonly used for pain relief. This group includes substances like heroin, morphine, and codeine. Those suffering from opioid addiction typically experience physical dependence, where their body adjusts to the drug’s presence, resulting in tolerance (the need for increased amounts to achieve the same effect) and withdrawal symptoms when the drug use is decreased or discontinued. Symptoms of opioid addiction include poor decision-making, mood swings, irritability, depression, lowered motivation, anxiety, and withdrawal symptoms.
• Prescription medicines: Prescription medicines are pharmaceutical drugs that require a doctor’s prescription and cannot be bought over the counter. Prescription medicines addiction often begins unintentionally, following a doctor’s prescription for a legitimate health issue. Over time, misuse leads to tolerance, dependence, and prescription drug addiction. Common addictive prescription drugs include opioids and tranquilizers, with hydrocodone, codeine, fentanyl, morphine, and oxycodone being among the most frequently abused.
• Cocaine: Cocaine is a powerful stimulant that elevates dopamine levels in the brain, producing intense euphoria. Its long-term use leads to cardiovascular issues, neurological damage, paranoia, and hallucinations. Cocaine addiction is marked by uncontrollable use despite its harmful effects, causing cravings and loss of self-control. Signs include rapid weight loss, dilated pupils, nosebleeds, anxiety, irritability, compulsive drug-seeking, neglect of responsibilities, financial struggles, and strained relationships.
• Methamphetamine: Methamphetamine is a highly addictive stimulant that affects the central nervous system, boosting energy and alertness. Its addiction is a form of substance use disorder marked by compulsive use despite harmful effects. Methamphetamine addiction manifests as physical deterioration, mental health problems, and risky behaviors to maintain euphoria, along with severe withdrawal symptoms during attempts to quit.
• Nicotine: Nicotine is a stimulant found in tobacco products like cigarettes and cigars. Despite its prevalence and normalization, nicotine addiction poses significant health risks. Symptoms include the inability to quit, withdrawal symptoms upon stopping, continued use despite health issues, and persistent smoking even when it negatively affects daily life.
• Hallucinogens: Hallucinogenic drugs are a class of psychoactive drugs that alter consciousness, mood, perception, and thought. While not physically addictive, they lead to psychological issues like changes in perception and psychosis. Hallucinogens addiction involves the compulsive use of these substances despite their harmful effects. Hallucinogenic drugs are categorized into classic types such as d-lysergic acid diethylamide (LSD), peyote, and dissociative types phencyclidine (PCP), and ketamine.
• Inhalants: Inhalant addiction, or inhalant use disorder, is a form of SUD characterized by a compulsive urge to use inhalants despite their harmful effects. Inhalants are psychoactive substances typically consumed through inhalation. This type of addiction is more common among adolescents and young adults than older individuals.

What are the DSM-5 criteria for substance use disorder (SUD)?

The DSM-5 criteria for substance use disorder (SUD) are listed below.

• Taking the substance in larger amounts or for longer periods than intended: Individuals find themselves using a substance in greater quantities or over a longer period than they initially planned, indicating impaired control over their use.
• Persistent desire or unsuccessful efforts to cut down or control use: Despite a desire to reduce or regulate their substance use, individuals are unable to do so, even after repeated attempts, which is a key DSM-5 symptom.
• Spending a significant amount of time obtaining, using, or recovering from the substance: A significant amount of time is devoted to activities related to obtaining the substance, using it, or recovering from its effects, which dominate a person’s daily life.
• Craving or strong desire to use the substance: Individuals experience intense cravings or urges to use the substance, particularly in environments or situations associated with prior use.
• Failure to fulfill major obligations due to substance use: Substance use interferes with an individual’s ability to meet responsibilities at work, school, or home, leading to neglect of important duties.
• Continued use despite social or interpersonal problems: Individuals persist in using the substance despite recurrent social or relationship problems exacerbated by its use.
• Giving up important social, occupational, or recreational activities: Substance use causes individuals to abandon previously enjoyed activities, including hobbies, work, or family time, in favor of using the substance.
• Recurrent use in physically hazardous situations: Individuals use the substance in dangerous situations, such as driving under the influence or operating machinery, putting themselves or others at risk.
• Continued use despite physical or psychological problems: Even when individuals are aware that substance use is causing or worsening physical or mental health problems, they continue to use the substance.
• Tolerance: Tolerance occurs when individuals need increasingly larger amounts of the substance to achieve the same effect, or when the same amount produces diminished impacts over time.
• Withdrawal: Withdrawal refers to the physical and psychological symptoms that occur when substance use is abruptly reduced or stopped after prolonged heavy use. These symptoms drive individuals to continue using the substance to relieve discomfort.

How is substance use disorder diagnosed?

Substance use disorder is diagnosed through comprehensive evaluation by qualified medical professionals, such as psychiatrists, psychologists, or licensed counselors who specialize in drug and alcohol addictions. This evaluation involves a formal assessment that considers the individual’s symptoms, medical history, social circumstances, and psychiatric concerns, ensuring a comprehensive understanding of their condition.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), provides standardized criteria for diagnosing SUD, which include 11 symptoms grouped into categories as mentioned above. An individual is diagnosed with SUD if they meet at least two of these criteria within a 12-month period, as outlined in the research article “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale” by Deborah S. Hasin et al. published in the American Journal of Psychiatry in 2013. The article further explains that the DSM-5 task force decided to use a straightforward criteria count to indicate the severity of SUDs. The number of criteria met determines the severity such as mild if 2-3 criteria are met, moderate if 4-5 criteria are met, and severe if 6 or more criteria are met.

Each substance presents unique patterns of addiction and effects on the individual, recognizing that substance abuse manifests differently depending on the drug involved. Therefore, the DSM-5 identifies 10 different types of substance-related disorders. These include drugs like alcohol, opioids, inhalants, sedatives, hypnotics, cannabis, caffeine, hallucinogens, stimulants, and tobacco.

While laboratory tests, such as blood or urine tests, confirm recent substance use, they cannot diagnose substance use disorder on their own. Hence, a comprehensive approach, including both clinical evaluations and supportive evidence from laboratory tests, is essential for an accurate diagnosis and the development of an effective, personalized treatment plan.

What are the consequences of substance use disorder?

The consequences of substance use disorder are listed below.

• Impaired physical health: Substance use disorders have significant physical health implications, as the use of various substances leads to severe and chronic health conditions as outlined in the research article “Systematic review of guidelines for managing physical health during treatment for substance use disorders: Implications for the alcohol and other drug workforce” authored by Briony Osborne et al. published in the journal Drug and Alcohol Review in 2022. These effects range from cardiovascular disease and liver damage to respiratory issues and increased susceptibility to infections.
• Mental health effects: Substance use disorders often co-occur with mental health disorders, creating a complex interplay between substance use and mental well-being. The research article “Substance use disorders: a comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention” authored by Nora D. Volkow and Carlos Blanco published in the World psychiatry : official journal of the World Psychiatric Association (WPA) in 2023, highlights the co-occurrence of substance use disorders and psychiatric disorders. The article suggests that individuals with substance use disorders are more likely to develop mental health conditions like anxiety disorders, mood disorders, personality disorders, psychotic disorders, and attention-deficit hyperactivity disorder (ADHD) and vice-versa.
• Social and economic consequences: The social and economic burdens of SUD are profound, affecting individuals and society at large. Socially, SUD leads to withdrawal from social activities and support networks, resulting in increased isolation and loneliness. Economically, it contributes to decreased productivity, higher healthcare costs, and legal expenses.
• Negative impact on family and relationships: Substance use disorders severely disrupt family dynamics and relationships, leading to increased conflict, emotional stress, and changes in family roles. These disruptions affect the overall well-being of family members and complicate the process of recovery.
• Legal and occupational effects: Individuals with SUDs face significant legal and occupational challenges, including increased risk of legal issues and job-related problems such as job loss, and diminished work performance. These consequences include arrests for driving under the influence (DUI) or possession of illegal substances and legal disputes.

What are the treatments for substance use disorder?

Treating substance use disorder involves a multifaceted approach that combines medical, psychological, and behavioral interventions. The treatments for substance use disorder are listed below.

• Detoxification: Detoxification is a process that helps people stop using drugs safely and manage the physical symptoms that come with quitting. It focuses on removing harmful substances from the body and minimizing the risks associated with withdrawal. Chapter 1 “Overview, Essential Concepts, and Definitions in Detoxification” of theresearch manual Detoxification and Substance Abuse Treatment: A Treatment Improvement Protocol TIP 45 by the U.S. Department of Health and Human Services,Substance Abuse and Mental Health Services Administration (SAMHSA), last revised in 2015, outlines detoxification as a structured three-step process. The first step involves a thorough evaluation of the patient’s situation and specific needs. The second step focuses on stabilizing the patient through managed withdrawal, ensuring their safety and comfort. The third step emphasizes the importance of facilitating continued treatment and support after detoxification. Throughout the detoxification process, treating patients with kindness and respect is crucial to their overall recovery and well-being.
• Medication-assisted treatment (MAT): MAT is a comprehensive method for addressing substance use disorders that combines medications with psychotherapeutic behavioral therapies and counseling. It is particularly effective for treating addictions to opioids, alcohol, and nicotine. The medications used in this approach are approved by the Food and Drug Administration (FDA) and are carefully chosen and individualized to the needs of each individual. Additionally, MAT along with other therapies helps lower the risk of relapse.
• Cognitive-behavioral therapy (CBT): Cognitive-behavioral therapy is a form of psychotherapy designed to address and modify problematic behaviors, thoughts, and emotions. It aims to identify and reshape automatic negative thoughts that exacerbate mental health issues. CBT integrates principles from both cognitive therapy, which focuses on changing maladaptive thinking patterns, and behavioral therapy, which targets altering harmful behaviors. This combination helps individuals develop healthier thought processes and coping strategies to improve their overall mental well-being.
• Motivational enhancement therapy (MET): Motivational enhancement therapy (MET) is a psychotherapy approach designed to boost a patient’s motivation to change harmful behaviors such as substance abuse. It addresses the ambivalence and lack of motivation that individuals feel about altering self-destructive habits. MET uses motivational interviewing techniques and structured feedback from behavioral assessments to foster commitment and encourage positive behavioral changes.
• Family therapy: Family therapy is a form of psychotherapy aimed at enhancing relationships and behavioral patterns within the family. It operates on the principle that families function as interconnected systems, where changes in one member affect the entire unit. By involving both the therapist and the family, this approach aims to strengthen relationships, resolve conflicts, and improve communication. Through open emotional expression, it fosters healthier family dynamics, making the family a vital support system.
• Holistic therapy: Holistic therapy is a psychotherapy approach that addresses the mental, emotional, physical, and spiritual aspects of an individual. It focuses on the whole person, promoting self-awareness and self-acceptance by exploring how emotions, thoughts, physical experiences, and spiritual beliefs are interconnected. This comprehensive approach includes techniques like breathwork, biofeedback, reiki, hypnosis, mindfulness meditation, and yoga. In the 2018 article titled “Role of Yoga in Management of Substance-use Disorders: A Narrative Review” by Pooja Patnaik Kuppili et al., published in the Journal of Neurosciences in Rural Practice, yoga therapy is highlighted as promising intervention for managing substance use disorders. The article regarded yoga as a comprehensive intervention that helps regulate dopamine levels, that has its long-term benefits in managing addictive behaviors.
• Support groups: Support groups are vital in recovery from substance use disorders, providing a compassionate community where individuals share their experiences and challenges. These groups, led by trained facilitators or peers in recovery, help reduce feelings of isolation and offer encouragement, practical advice, and a sense of belonging. Examples like Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery demonstrate how support groups foster motivation, accountability, and community through shared experiences and mutual support.
• Outpatient programs: Outpatient programs offer a flexible path to recovery by providing structured therapy and support without interrupting daily life. These programs allow individuals to attend counseling sessions, support groups, and educational meetings while managing work or family responsibilities. Their adaptability helps individuals reintegrate into daily routines, handle triggers, and develop effective coping mechanisms.
• Aftercare planning: Aftercare planning involves strategies designed to support ongoing well-being after formal treatment. It includes personalized elements such as continued counseling, support groups, and relapse prevention techniques. This planning facilitates a smooth transition to independent living and enhances long-term recovery by addressing potential challenges and providing ongoing support.

What are the ways to prevent substance use disorder?

The ways to prevent substance use disorder are listed below.

• Comprehensive education: Implementing thorough education programs in schools and communities provides individuals, particularly young people, with crucial knowledge about the risks and consequences of substance use. This education helps them make informed decisions and resist peer pressure.
• Creating awareness: Public awareness campaigns highlight the dangers of substance abuse and promote healthy lifestyle choices. These campaigns, through various media platforms, reach a broad audience and reinforce educational messages.
• Enforcing strict laws: Enforcing stricter laws and regulations on the availability and distribution of substances limits access. This includes regulations on alcohol and tobacco sales, as well as measures to prevent illegal drug trafficking.
• Ease to treatment access: Ensuring that effective treatment and prevention services are available helps support individuals struggling with or at risk of substance use. Accessible treatment options facilitate early intervention and aid in recovery.
• Building healthy communities: Fostering communities with robust social support networks and opportunities for positive engagement reduces substance use. Community involvement, recreational programs, and safe environments contribute to healthier lifestyles.
• Addressing social issues: Tackling underlying social issues such as poverty, inequality, and lack of opportunities is required to prevent substance use. Addressing these root causes reduces the likelihood of individuals turning to substances as a coping mechanism.
• Building strong family bonds: Cultivating strong family relationships offers vital support and guidance. Open communication, clear expectations, and emotional support from families significantly reduce the risk of substance use.
• Evidence-based interventions: Utilizing evidence-based prevention and treatment programs, such as cognitive-behavioral therapy (CBT) and motivational enhancement therapy (MET), help individuals develop healthy coping skills and reduce the risk of relapse.
• Early intervention: Identifying and addressing behavioral problems or mental health concerns early on is important to prevent the development of substance use disorders.