Diagnosis, Screening, and Assessment
DSM-5-TR substance use disorder
A diagnosis requires at least 2 of 11 criteria within 12 months, grouped as impaired control (using more or longer, unsuccessful cutting down, time spent, craving), social impairment (role failure, interpersonal problems, giving up activities), risky use (hazardous situations, continued use despite harm), and pharmacological criteria (tolerance, withdrawal). Severity is mild (2–3), moderate (4–5), or severe (6 or more). Early remission is 3–12 months without criteria (except craving); sustained remission exceeds 12 months.
Screening tools
AUDIT (10 items; 8 or more suggests hazardous use), AUDIT-C (3 items), CAGE (brief but insensitive), DAST-10, ASSIST, and CRAFFT for adolescents. CIWA-Ar and COWS measure withdrawal severity, not diagnosis. Screening is not diagnosis; a positive screen requires a criterion-based interview.
Assessment
Take a biopsychosocial history: quantity, frequency, route, last use, prior withdrawal seizures or delirium, overdose history, psychiatric comorbidity, suicide risk, pregnancy, legal and social consequences, and motivation. Use collateral information when possible, and obtain urine drug testing or breath alcohol with consent and chain-of-custody awareness.
Traps
“Legal problems” was removed from DSM-5; craving was added. Tolerance and withdrawal are not criteria for stimulant use disorder, and hallucinogens and inhalants have no withdrawal syndrome. Cannabis withdrawal and caffeine withdrawal are recognized. Do not diagnose a mild disorder from a single binge, and do not count withdrawal from a different drug.
Worked example
A 45-year-old drinks five beers nightly, has tried to cut down twice, misses work occasionally, and has no withdrawal. That is 3 criteria (using more than intended, unsuccessful control, role failure)-moderate disorder, not severe.