Addiction Medicine: Closing the Gap between Science and Practice

the most severe form of the illness: chronic
relapsing disease.

There are two leading sources of diagnostic
classifications for addiction (called substance
use disorders): The American Psychiatric
Association’s Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) and the World
Health Organization’s International Statistical
Classification of Disease (ICD). Both reflect the
historical classification of addiction as a mental
disorder based on measures of its behavioral
symptoms rather than the current science
documenting the medical nature of the problem
as an underlying brain disease.^166

Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). The DSM-IV is the main
diagnostic reference of mental health
professionals in the United States and presents
three types of disorders that are drug specific:
(1) alcohol use disorders, (2) drug use disorders
and (3) nicotine dependence. Both alcohol and
drug use disorders involve two levels of
severity--abuse and dependence--while nicotine
only involves dependence. The criteria for
abuse are similar for alcohol and other drugs,
and the criteria for dependence are similar for all
three drug types.^167

The DSM-IV defines substance abuse as “a
maladaptive pattern of substance use leading to
clinically significant impairment or distress.”^168
The term substance abuse, though widely used--
and often used beyond its clinical definition to
describe any kind of risky substance use--has
become controversial due to its negative, value-
laden and pejorative connotation.^169

The term substance dependence is defined in the
DSM-IV as “...a cluster of cognitive, behavioral
and physiological symptoms indicating that the
individual continues use of the substance despite
significant substance-related problems.”^170

DSM-IV Criteria^165

Substance Abuse

To be diagnosed with substance abuse, an individual

must exhibit one or more of the following four

symptoms within a 12-month period:*

 Recurrent use resulting in failure to fulfill major

role obligations at work, school or home;

 Recurrent use in physically hazardous

situations;

 Recurrent use resulting in legal problems; and

 Continued use despite persistent or recurrent

social or interpersonal problems.

Substance Dependence

To be diagnosed with substance dependence, an

individual must exhibit three or more of seven

symptoms within a 12-month period:

 Tolerance--the need for markedly increased

amounts of the substance to achieve intoxication

or the desired effect or a markedly diminished

effect with the continued use of the same

amount of the substance;

 Withdrawal--maladaptive behavioral change

with co-occurring physiological and cognitive

changes that occurs when use of a substance is

reduced or discontinued, or usage of a substance

to relieve or avoid withdrawal symptoms;

 Taking increasing amounts or using the

substance over a longer period than intended;

 A persistent desire or unsuccessful efforts to

reduce or control substance use;

 Spending a significant amount of time in

activities to obtain the drug, use it or recover

from use;

 Neglecting or giving up important social,

occupational or recreational activities because of

use; and

 Continuing use of the substance despite

knowledge of having a persistent or recurring

physical or psychological problem that is caused

or worsened by use.

* The symptoms must never have met criteria for

substance dependence for the class of substances

used.