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Substance Use & the DSM-5: How to Differentiate Problematic Use

Substance use is not an uncommon phenomenon. According to the CDC research from 2019, around 50 percent of the population over the age of 12 have tried alcohol in the last month, 13 percent have used an “illicit drug”, and 12 percent have used marijuana.  This trend is relatively consistent throughout the years. For good and bad, substance use is part of American culture. The commonality of substance use can often make determining when there are problematic issues with substance use difficult to determine. The lines between normal use and problematic use can become fuzzy. 

In 2013, the DSM 5 was released and made the switch from diagnosing Substance Abuse or Substance Dependence to diagnosing substance use on a continuum known as Substance Use Disorder. A person meeting criteria from this continuum will either fall into a category of mild, moderate, or severe substance use disorder (SUD). The following 11 Criteria are paraphrased for clarity:

  1. Hazardous use: Driving while under the influence, using in dangerous locations, etc.
  2. Social or interpersonal problems related to use:Getting into fights while using, others expressing concern about the substance use, interpersonal conflict related to the use, etc.
  3. Neglected major responsibilities or roles to use: Failure to complete work tasks, not meeting deadlines, not meeting family obligations, etc.
  4. Withdrawal: Symptoms of withdrawal such as; sleep disturbance, anxiety, irritability, shakes, tremors, nausea, tremors, seizures, etc. emerge when the substance(s) is cut back or ceased.
  5. Tolerance:Have to use increasing amounts of the substance to get the same effect.
  6. Used larger amounts/longer:Using more of a substance without having breaks between the substance use.
  7. Repeated attempts to control use or quit:Attempting to decrease the amount that is being used, inability to stop once a substance has been consumed, inability to follow the rules of using a substance one establishes for oneself (“I won’t drink during the week”, “I only smoke on the weekend”, “ I won’t use when I am alone”, etc)
  8. Much time spent using: Increased time to recover from the use (hangovers), having to plan out acquiring substances, preoccupation with obtaining the substances, etc.
  9. Physical or psychological problems related to use:Experiencing increased anxiety, depression, sleep disturbance, etc. 
  10. Activities given up to use:Not participating in hobbies or pursuits due to the use of substances, etc.
  11. Craving:You have experienced cravings for the substance, preoccupation with thinking of the substance, etc. 

What does the DSM-5 11 different criteria mean?

  • If in the last 12 months someone meets two (2) or three (3) of the criteria that person falls into the Mild SUD category.
  • If it’s four to five criteria then it’s the Moderate SUD category, and if it’s six (6) or more that person falls into the Severe SUD category

BUT WAIT, there is more there is research to suggest that not all of these criteria carry the same weight. Meaning, not every criteria is as important as the other.

When looking at SUD, even independent of the substances used, there is evidence to suggest that withdrawal, sacrificing activities, failure to fulfill role obligations, and compulsion/cravings are almost exclusively found in those with the severe designation (Marisa Malone & Norman Hoffmann (2016) A Comparison of DSM-IV Versus DSM-5 Substance Use Disorder Diagnoses in Adolescent Populations).

Why might this be significant?

There may be many reasons this is significant, but one of the most apparent is that their presence potentially captures different therapeutic needs and considerations. As referenced in this  writing, by Brian Coon, the presence of cravings/compulsions, failure to meet obligations, withdrawal, and giving up activities potentially indicate someone that may need a course of treatment that is longer and more intense. Additionally, the presence of two or more of these criteria may indicate a greater need for abstinence from substances. In treating substance use disorders, it is not uncommon that clients fall into different places along the continuum of use. Given how common it is for adolescents and young adults to use substances at different points and to grow out of problematic use, it may not be appropriate to approach each substance use case with an intensive and potentially intrusive treatment plan. Arguably, without the presence of the aforementioned criteria, it may be better to opt for a plan that involves local therapeutic services, moderation techniques, or periods of sobriety sampling. These sorts of interventions are often far less expensive and are, typically, more in line with the needs of a client.

The presence of two or more of these criteria likely suggest the need for more intensive treatment that may also indicate an inability to effectively moderate use for extended periods of time. This is especially true when withdrawal symptoms are present. Afterall, it’s really difficult to moderate use when reducing use may result in serious medical symptoms. With the presence of two or more of the four criteria listed above, it is a likely indicator that a person will need something more in line with the American Society of Addiction Medicine ( ASAM ) level 3 or 4 continuum of care.

These levels are typically referred to as “rehabs” and/or “inpatient” programs. A hallmark of these is that they are more heavily staffed and often include medical services as part of their programs. This can provide a level of support that is consistent with the severity of the illness. This is not unlike other treatments for medical issues. For example, not all cancer is treated with invasive and intensive chemotherapy. When the symptoms of the cancer are sufficient enough to warrant the most intense course of treatment, the tradeoffs (hair loss, nausea, pain, etc) may be worth it to go into remission. SUDs are not dissimilar.

Problematic use is not a clear indication of the need for intensive and invasive treatments that may remove someone from their home and require more of that person than is necessary. Doing so can often lead a client to feel out of place, frustrated, and difficulty engaging in the treatment model.

Conversely, undertreating when those criteria (cravings, giving up activities, withdrawal, and failure to meet obligations) are present may result in a person not being able to engage in a level of treatment that could radically improve that person’s life. It is important that we consider a person’s symptoms as objectively as possible towards pairing them with the most appropriate treatment course.

About the Author

Marcus Shumate, LCMCH, LCAS has worked in Substance Use and Mental Health Treatment for over 10 years and with a diverse population ranging from adults, impaired professionals, to young adults. He was drawn to therapeutic work from his appreciation of philosophy and a desire to make it more readily applicable to people’s lives towards helping others ease their suffering. After a number of years in direct clinical service, Marcus enthusiastically joined the team at Green Hill Recovery to function in the role of Clinical Outreach Director. He did so after having many positive experiences as a referring therapist to Green Hill and found that he could not resist the opportunity to join an organization that has so much alignment with his values and guiding philosophies.