Diagnosing Addiction (Substance Use Disorders)

How are substance use disorders diagnosed?

Substance use disorders are diagnosed by a physician, using diagnostic criteria that ascertain the severity of substance use and the impact it has on the individual’s life.

Sometimes, a person’s family members or friends may become worried about their substance use and seek professional advice on how to help them. Other times, the individual themselves will recognize that their substance use and associated behaviors are harming themselves or others and that they need help to make positive changes to their lifestyle.

In either case, it will often be the primary care physician (usually a family doctor) who will assess and diagnose the individual. This assessment will involve asking questions about the individual’s substance use, such as the type of substance used, the frequency and duration of substance use, and the impact that substance use has on the individual’s social, professional, or personal functioning.^[1]

They will also likely conduct physical and mental health assessments, to help gain a better understanding of the individual’s risk factors and underlying conditions, as this can help inform diagnosis and treatment.^[2]

During the assessment, the doctor will utilize diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These criteria can also help determine the severity of the individual’s substance use disorder.^[3]

In previous editions of the DSM, substance use was categorized as two conditions: substance abuse and substance dependence. In the most recent edition, the DSM-5, these conditions have been combined to create one diagnosis of substance use disorder.^[4]

Diagnosing addiction criteria according to the DSM-5

The DSM-5 lists several specific types of substance use disorders, including alcohol, opioid, and stimulant use disorders. The criteria for each are based on the same list of symptoms and behaviors. Still, each diagnosis recognizes the differences in the effects, addictive properties, and withdrawal symptoms of each substance.^[3][4]

A diagnosis of substance use disorder can be made if an individual experiences at least two of the following criteria within a period of 12 months:^[3]

• The individual has stated a desire or made attempts to reduce or stop their substance use with little success.
• The individual uses substances in a larger amount or for a longer time than they had intended to in one sitting.
• The individual neglects their professional, social, or familial responsibilities because of their substance use.
• The individual spends a lot of time seeking, using, or recovering from substance use.
• The individual regularly experiences cravings for the substance.
• The individual regularly avoids social events, hobbies, or activities due to their substance use.
• The individual uses the substance despite awareness of the impairments it causes to social or professional functioning.
• The individual continues to use the substance despite knowledge of the physical or psychological harm it causes.
• The individual uses the substance in risky situations or puts themselves in potentially harmful situations because of their substance use.
• The individual experiences an increase in tolerance, requiring larger amounts of the substance to achieve the desired effects.
• The individual experiences withdrawal symptoms when reducing or not using the substance.

Someone who meets two or three of these criteria could be diagnosed with a mild substance use disorder. Meeting four or five of these criteria may be a moderate substance use disorder and six or more criteria could be classified as a severe substance use disorder.^[3]

The diagnosing process

To make a diagnosis of substance use disorder, the doctor will complete a full assessment of the individual, utilizing diagnostic criteria to determine the level and severity of use and the impact of substance use.^[1][2]

Medical history

The doctor will gather a full medical history of the individual and their family members. This will help determine whether the individual has any underlying conditions or genetic risk factors that may have impacted their substance use.^[5]

They will assess the individual’s mental and physical health history, gathering information about their current health, historical and current drug and alcohol use, and any medical issues that may be associated with substance use.^[1][2]

Drug tests

The doctor may wish to perform certain drug tests, such as a blood, urine, or saliva test. This can help determine the type of substances used and the current level of substance in the individual’s body. These tests can also provide information about the individual’s physical health.^[6]

Questions

The doctor will want to gather as much information as possible about the individual's substance use, including the amount, frequency, and duration of use, and the level of impact this has on their life and functioning. This will help determine the severity of the individual’s condition and the effects of their substance use.^[4]

These questions may be in the form of a structured interview, such as:^[1]

• Addiction Severity Index (ASI)
• Composite International Diagnostic Interview (CIDI)
• Psychiatric Research Interview for Substance Use and Mental Disorders (PRISM)
• Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA)

Alternatively, the doctor may choose to utilize an unstructured approach to these questions, although this will likely also involve assessing the individual compared to the DSM-5 diagnostic criteria.^[1]

What happens once you have been diagnosed?

Once a person has been given a diagnosis of substance use disorder, they will likely be referred to an addiction specialist or specialist services for appropriate treatment. They will be given the necessary information to understand the available treatments and which would be suitable or beneficial to them.^[5]

Various treatment options are available and determining the best option will depend on the symptoms and severity of an individual’s disorder. Someone with a severe substance use disorder may require inpatient services, where they can be supported with medically assisted detox and close monitoring throughout their treatment.^[7]

Someone who can manage their withdrawal process without continuous professional support may benefit from outpatient services. This will involve many of the same interventions that are available with inpatient services while continuing to live at home.^[8]

Treatments for substance use disorders can include:^[7][8]

• Medications to reduce withdrawal symptoms or help with maintaining abstinence
• Psychotherapy, such as cognitive behavioral therapy (CBT) to help reduce addictive behaviors and manage cravings and triggers
• Group therapy and support groups, such as 12-step programs, Narcotics Anonymous, or Alcoholics Anonymous 
• Family therapy or interventions
• Psychosocial interventions, to help with additional difficulties, such as finances, housing, or career skills
• Holistic therapies, such as exercise, nutrition, mindfulness, and acupuncture

Final thoughts

• The first step to receiving treatment for a substance use disorder is to recognize problematic and harmful behaviors and ask for help.
• The diagnostic process will be informed by diagnostic criteria listed in the DSM-5.
• The assessing doctor will take a full medical history and may perform tests to inform their diagnosis.
• Once a diagnosis of substance use disorder has been made, the individual may be referred to a specialist service for treatment.
• Treatments and interventions for substance use disorder can include medications, psychotherapy, and psychosocial interventions, and can be provided through inpatient or outpatient services.