8 Assessment & Treatment of Substance Use Disorders

Before someone receives substance use disorder treatment, he or she must be both screened and assessed to determine whether services are needed and what type of treatment best matches the situation. The screening process is generally brief and provides feedback suggesting that someone does or does not have a problem requiring treatment.

Some screening tools can even be self-administered. Among the most-used screening instruments are the short four-question CAGE survey and the Alcohol Use Disorder Identification Test, or AUDIT. These tools provide insight into the presence of a problem and set up the next step of looking for helpful programs or interventions to address the problem.

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In contrast to the screening process, assessment is a longer and more formal process conducted by a trained professional. The assessment helps to clarify the specific problem areas to address in treatment and at what level of intensity the person should be treated. The primary purpose of the information gathered during an assessment is to develop a comprehensive treatment plan for the client.

At the end of this chapter is a chart created by the National Institute on Drug Abuse that highlights several available screening and assessment tools.

Once a substance use problem has been identified and a recommendation for treatment has been made, a person can begin receiving services. There are numerous options when it comes to treating substance use disorder. In the next chapter, we discuss the importance of having several options available and utilizing multiple pathways to recovery. Here we look at the tools of the treatment provider and what a course of treatment might look like.

To start, let’s look at the story of someone who may need treatment services:

Sample Client

Jessica is a 26-year-old woman who recently received her second driving-under-the-influence (DUI) ticket and has been charged with a misdemeanor crime. She got her first DUI at age 21 and lost her license for one year. During that time, she completed a basic risk education DUI course and paid several thousand dollars in fines and attorney’s fees.

Jessica drinks with her friends on weekends, usually having five or six drinks per night. One of Jessica’s best friends growing up (Kaitlin) has started distancing herself from Jessica because she does not like how much their other friends are drinking. Kaitlin still occasionally invites Jessica to hang out, but Jessica refuses because there is no drinking involved.

In addition to alcohol, Jessica has started taking Xanax, a benzodiazepine. Although she has a prescription from her doctor to take Xanax to help treat her anxiety disorder, Jessica often takes more than prescribed, sometimes even mixing the pills with her alcohol consumption.

Jessica works a full-time job as a graphic designer and does most of her work from home. She says that she has little time to socialize during the week, so she looks forward to the weekend when she can see her friends and relax.

Now that she has a second DUI, Jessica has lost her license again, although she is not overly concerned because she can continue working from home and can walk or order a ride wherever she needs to go.

The court has ordered Jessica to have an evaluation done and to complete any treatment recommendations.

Although this is an imaginary client, the story probably applies to many of the clients who seek treatment. A screening of Jessica would reveal that she likely meets the criteria for a substance use disorder and should receive a full assessment. (Note that a screening tool alone never diagnoses a substance use disorder.) 

The exercise below gives you the opportunity to apply the knowledge you have learned in this book to her case.



Consider the story of Jessica in the example above:

  • What stands out about her story?
  • Identify the drug or drugs that might be a problem for Jessica.
  • If you were evaluating Jessica, what are some of the questions you would ask her?
  • List at least three issues that might be addressed in a treatment plan for Jessica.
  • How many of the DSM-5 criteria for Substance Use Disorder (see list below in this chapter) can you identify from the brief description above?
  • How do her legal issues impact treatment?

Treatment services can be performed at several levels of care. These levels are defined by the American Society of Addiction Medicine (ASAM).

ASAM Levels of Care

Level 0.5: Risk Education

Level I: Outpatient

Level II.1: Intensive Outpatient

Level II.5: Partial Hospitalization

Level III.1: Residential Recovery Homes

Level III.5: High-Intensity Residential

Level IV: Medically Managed Inpatient (Hospitalization)

A critical part of the assessment is recommending the appropriate level of care based on the client’s bio-psycho-social needs. The higher the level, the more intense the treatment. Other issues to consider are the client’s level of motivation, payment source, transportation, and child care. If a client requires medical detoxification, that should be completed prior to beginning treatment.

It is also a good idea to involve a client’s physician when possible. With the case of Jessica, she would benefit from an evaluation to determine if she can safely withdraw from two potentially life-threatening drugs, alcohol and Xanax.

Flip through the cards below to review the levels of treatment care.

Principles of Drug Addiction Treatment: A Research-Based Guide (NIDA, 2018)


Drug addiction is a complex illness.

It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. This update of the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment is intended to address addiction to a wide variety of drugs, including nicotine, alcohol, and illicit and prescription drugs. It is designed to serve as a resource for healthcare providers, family members, and other stakeholders trying to address the myriad problems faced by patients in need of treatment for drug abuse or addiction.

Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. That is why addiction is a brain disease. Some individuals are more vulnerable than others to becoming addicted, depending on the interplay between genetic makeup, age of exposure to drugs, and other environmental influences. While a person initially chooses to take drugs, over time the effects of prolonged exposure on brain functioning compromise that ability to choose, and seeking and consuming the drug become compulsive, often eluding a person’s self-control or willpower.

But addiction is more than just compulsive drug taking—it can also produce far-reaching health and social consequences. For example, drug abuse and addiction increase a person’s risk for a variety of other mental and physical illnesses related to a drug-abusing lifestyle or the toxic effects of the drugs themselves. Additionally, the dysfunctional behaviors that result from drug abuse can interfere with a person’s normal functioning in the family, the workplace, and the broader community.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is a disease, most people cannot simply stop using drugs for a few days and be cured. Patients typically require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives. Indeed, scientific research and clinical practice demonstrate the value of continuing care in treating addiction, with a variety of approaches having been tested and integrated in residential and community settings.

As we look toward the future, we will harness new research results on the influence of genetics and environment on gene function and expression (i.e., epigenetics), which are heralding the development of personalized treatment interventions. These findings will be integrated with current evidence supporting the most effective drug abuse and addiction treatments and their implementation, which are reflected in this guide.

Principles of Effective Treatment: Dr. Nora Volkow, Director of the National Institute on Drug Abuse

1.   Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.

2.   No single treatment is appropriate for everyone. Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

3.   Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.

4.   Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.

5.   Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of the patient’s problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

6.   Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment.         Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.

7.   Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate, disulfiram, and naltrexone are medications approved for treating alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (available as patches, gum, lozenges, or nasal spray) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.

8.   An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.

9.   Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.

10.   Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal and can, for some, pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivational enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement.

11.   Treatment does not need to be voluntary to be effective.  Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.

12.   Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.

13.   Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments. Substance abuse treatment facilities should provide onsite, rapid HIV testing rather than referrals to offsite testing—research shows that doing so increases the likelihood that patients will be tested and receive their test results. Treatment providers should also inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug-abusing populations, and help link them to HIV treatment if they test positive.


Frequently Asked Questions

Why do drug-addicted persons keep using drugs?

Nearly all addicted individuals believe at the outset that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences—the defining characteristic of addiction.

Understanding that addiction has such a fundamental biological component may help explain the difficulty of achieving and maintaining abstinence without treatment. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues (such as meeting individuals from one’s drug-using past), or environmental cues (such as encountering streets, objects, or even smells associated with drug abuse) can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder attainment of sustained abstinence and make relapse more likely. Nevertheless, research indicates that active participation in treatment is an essential component for good outcomes and can benefit even the most severely addicted individuals.


What is drug addiction treatment?

Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. For many, treatment is a long-term process that involves multiple interventions and regular monitoring. There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy (such as cognitive-behavioral therapy or contingency management), medications, or their combination. The specific type of treatment or combination of treatments will vary depending on the patient’s individual needs and, often, on the types of drugs they use.

Treatment medications, such as methadone, buprenorphine, and naltrexone (including a new long-acting formulation), are available for individuals addicted to opioids, while nicotine preparations (patches, gum, lozenges, and nasal spray) and the medications varenicline and bupropion are available for individuals addicted to tobacco. Disulfiram, acamprosate, and naltrexone are medications available for treating alcohol dependence, which commonly co-occurs with other drug addictions, including addiction to prescription medications.

Key Takeaways

Drug addiction treatment can include medications, behavioral therapies, or their combination.

Treatments for prescription drug abuse tend to be similar to those for illicit drugs that affect the same brain systems. For example, buprenorphine, used to treat heroin addiction, can also be used to treat addiction to opioid pain medications. Addiction to prescription stimulants, which affect the same brain systems as illicit stimulants like cocaine, can be treated with behavioral therapies, as there are not yet medications for treating addiction to these types of drugs.

Behavioral therapies can help motivate people to participate in drug treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and prevent relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can also help people improve communication, relationship, and parenting skills, as well as family dynamics.

Many treatment programs employ both individual and group therapies. Group therapy can provide social reinforcement and help enforce behavioral contingencies that promote abstinence and a non- drug-using lifestyle. Some of the more established behavioral treatments, such as contingency management and cognitive-behavioral therapy, are also being adapted for group settings to improve efficiency and cost-effectiveness. However, particularly in adolescents, there can also be a danger of unintended harmful (or iatrogenic) effects of group treatment—sometimes group members (especially groups of highly delinquent youth) can reinforce drug use and thereby derail the purpose of the therapy. Thus, trained counselors should be aware of and monitor for such effects.

Because they work on different aspects of addiction, combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach used alone.  Finally, people who are addicted to drugs often suffer from other health (e.g., depression, HIV), occupational, legal, familial, and social problems that should be addressed concurrently. The best programs provide a combination of therapies and other services to meet an individual patient’s needs. Psychoactive medications, such as antidepressants, anti-anxiety agents, mood stabilizers, and antipsychotic medications, may be critical for treatment success when patients have co-occurring mental disorders such as depression, anxiety disorders (including post-traumatic stress disorder), bipolar disorder, or schizophrenia. In addition, most people with severe addiction abuse multiple drugs and require treatment for all substances abused.


Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches.


How effective is drug addiction treatment?

In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient’s problems, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and his or her treatment providers.

Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on the brain and behavior and to regain control of their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also likely, with symptom recurrence rates similar to those for other well-characterized chronic medical illnesses—such as diabetes, hypertension, and asthma (see figure, “Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses”)—that also have both physiological and behavioral components.

Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: Successful treatment for addiction typically requires continual evaluation and modification as appropriate, similar to the approach taken for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted individual, lapses to drug abuse do not indicate failure—rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment is needed (see figure, “Why is Addiction Treatment Evaluated Differently?”).

Is drug addiction treatment worth its cost?

Substance abuse costs our nation over $600 billion annually and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated health and social costs by far more than the cost of the treatment itself. Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person.

According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and to society also stem from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths.

How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum, and some opioid-addicted individuals continue to benefit from methadone maintenance for many years.

Treatment dropout is one of the major problems encountered by treatment programs; therefore, motivational techniques that can keep patients engaged will also improve outcomes. By viewing addiction as a chronic disease and offering continuing care and monitoring, programs can succeed, but this will often require multiple episodes of treatment and readily readmitting patients that have relapsed.

What helps people stay in treatment?

Because successful outcomes often depend on a person’s staying in treatment long enough to reap its full benefits, strategies for keeping people in treatment are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention typically include motivation to change drug-using behavior; degree of support from family and friends; and, frequently, pressure from the criminal justice system, child protection services, employers, or family. Within a treatment program, successful clinicians can establish a positive, therapeutic relationship with their patients. The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services should also be available.

Key Takeaways

Whether a patient stays in treatment depends on factors associated with both the individual and the program.

Because some problems (such as serious medical or mental illness or criminal involvement) increase the likelihood of patients dropping out of treatment, intensive interventions may be required to retain them. After a course of intensive treatment, the provider should ensure a transition to less intensive continuing care to support and monitor individuals in their ongoing recovery.

How do we get more substance-abusing people into treatment?

It has been known for many years that the “treatment gap” is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2011, 21.6 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 2.3 million received treatment at a specialty substance abuse facility.

Reducing this gap requires a multipronged approach. Strategies include increasing access to effective treatment, achieving insurance parity (now in its earliest phase of implementation), reducing stigma, and raising awareness among both patients and healthcare professionals of the value of addiction treatment. To assist physicians in identifying treatment need in their patients and making appropriate referrals, NIDA is encouraging widespread use of screening, brief intervention, and referral to treatment (SBIRT) tools for use in primary care settings through its NIDAMED initiative. SBIRT, which evidence shows to be effective against tobacco and alcohol use—and, increasingly, against abuse of illicit and prescription drugs—has the potential not only to catch people before serious drug problems develop, but also to identify people in need of treatment and connect them with appropriate treatment providers.

How can family and friends make a difference in the life of someone needing treatment?

Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy can also be important, especially for adolescents. Involvement of a family member or significant other in an individual’s treatment program can strengthen and extend treatment benefits.

How can the workplace play a role in substance abuse treatment?

Many workplaces sponsor Employee Assistance Programs (EAPs) that offer short-term counseling and/or assistance in linking employees with drug or alcohol problems to local treatment resources, including peer support/recovery groups. In addition, therapeutic work environments that provide employment for drug-abusing individuals who can demonstrate abstinence have been shown not only to promote a continued drug-free lifestyle but also to improve job skills, punctuality, and other behaviors necessary for active employment throughout life. Urine testing facilities, trained personnel, and workplace monitors are needed to implement this type of treatment.

What role can the criminal justice system play in addressing drug addiction?

It is estimated that about one-half of State and Federal prisoners abuse or are addicted to drugs, but relatively few receive treatment while incarcerated. Initiating drug abuse treatment in prison and continuing it upon release is vital to both individual recovery and to public health and safety. Various studies have shown that combining prison- and community-based treatment for addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use—which, in turn, nets huge savings in societal costs. A 2009 study in Baltimore, Maryland, for example, found that opioid-addicted prisoners who started methadone treatment (along with counseling) in prison and then continued it after release had better outcomes (reduced drug use and criminal activity) than those who only received counseling while in prison or those who only started methadone treatment after their release.

Key Takeaways

Individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily.

The majority of offenders involved with the criminal justice system are not in prison but are under community supervision. For those with known drug problems, drug addiction treatment may be recommended or mandated as a condition of probation. Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily.

The criminal justice system refers drug offenders into treatment through a variety of mechanisms, such as diverting nonviolent offenders to treatment; stipulating treatment as a condition of incarceration, probation, or pretrial release; and convening specialized courts, or drug courts, that handle drug offense cases. These courts mandate and arrange for treatment as an alternative to incarceration, actively monitor progress in treatment, and arrange for other services for drug-involved offenders.

The most effective models integrate criminal justice and drug treatment systems and services. Treatment and criminal justice personnel work together on treatment planning—including implementation of screening, placement, testing, monitoring, and supervision—as well as on the systematic use of sanctions and rewards. Treatment for incarcerated drug abusers should include continuing care, monitoring, and supervision after incarceration and during parole. Methods to achieve better coordination between parole/probation officers and health providers are being studied to improve offender outcomes.

What are the unique needs of women with substance use disorders?

Gender-related drug abuse treatment should attend not only to biological differences but also to social and environmental factors, all of which can influence the motivations for drug use, the reasons for seeking treatment, the types of environments where treatment is obtained, the treatments that are most effective, and the consequences of not receiving treatment. Many life circumstances predominate in women as a group, which may require a specialized treatment approach. For example, research has shown that physical and sexual trauma followed by post-traumatic stress disorder (PTSD) is more common in drug-abusing women than in men seeking treatment. Other factors unique to women that can influence the treatment process include issues around how they come into treatment (as women are more likely than men to seek the assistance of a general or mental health practitioner), financial independence, and pregnancy and child care.

What are the unique needs of pregnant women with substance use disorders?

Using drugs, alcohol, or tobacco during pregnancy exposes not just the woman but also her developing fetus to the substance and can have potentially deleterious and even long-term effects on exposed children. Smoking during pregnancy can increase risk of stillbirth, infant mortality, sudden infant death syndrome, preterm birth, respiratory problems, slowed fetal growth, and low birth weight. Drinking during pregnancy can lead to the child developing fetal alcohol spectrum disorders, characterized by low birth weight and enduring cognitive and behavioral problems.

Prenatal use of some drugs, including opioids, may cause a withdrawal syndrome in newborns called neonatal abstinence syndrome (NAS). Babies with NAS are at greater risk of seizures, respiratory problems, feeding difficulties, low birth weight, and even death.

Research has established the value of evidence-based treatments for pregnant women (and their babies), including medications. For example, although no medications have been FDA-approved to treat opioid dependence in pregnant women, methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental outcomes associated with untreated heroin abuse. However, newborns exposed to methadone during pregnancy still require treatment for withdrawal symptoms. Recently, another medication option for opioid dependence, buprenorphine, has been shown to produce fewer NAS symptoms in babies than methadone, resulting in shorter infant hospital stays. In general, it is important to closely monitor women who are trying to quit drug use during pregnancy and to provide treatment as needed.

What are the unique needs of adolescents with substance use disorders?

Adolescent drug abusers have unique needs stemming from their immature neurocognitive and psychosocial stage of development. Research has demonstrated that the brain undergoes a prolonged process of development and refinement from birth through early adulthood. Over the course of this developmental period, a young person’s actions go from being more impulsive to being more reasoned and reflective. In fact, the brain areas most closely associated with aspects of behavior such as decision-making, judgment, planning, and self-control undergo a period of rapid development during adolescence and young adulthood.

Adolescent drug abuse is also often associated with other co-occurring mental health problems. These include attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct problems, as well as depressive and anxiety disorders.

Adolescents are also especially sensitive to social cues, with peer groups and families being highly influential during this time. Therefore, treatments that facilitate positive parental involvement, integrate other systems in which the adolescent participates (such as school and athletics), and recognize the importance of prosocial peer relationships are among the most effective. Access to comprehensive assessment, treatment, case management, and family-support services that are developmentally, culturally, and gender-appropriate is also integral when addressing adolescent addiction.

Medications for substance abuse among adolescents may in certain cases be helpful. Currently, the only addiction medications approved by FDA for people under 18 are over-the-counter transdermal nicotine skin patches, chewing gum, and lozenges (physician advice should be sought first).

Buprenorphine, a medication for treating opioid addiction that must be prescribed by specially trained physicians, has not been approved for adolescents, but recent research suggests it could be effective for those as young as 16. Studies are underway to determine the safety and efficacy of this and other medications for opioid-, nicotine-, and alcohol-dependent adolescents and for adolescents with co-occurring disorders.

Are there specific drug addiction treatments for older adults?

With the aging of the baby boomer generation, the composition of the general population is changing dramatically with respect to the number of older adults. Such a change, coupled with a greater history of lifetime drug use (than previous older generations), different cultural norms and general attitudes about drug use, and increases in the availability of psychotherapeutic medications, is already leading to greater drug use by older adults and may increase substance use problems in this population.

While substance abuse in older adults often goes unrecognized and therefore untreated, research indicates that currently available addiction treatment programs can be as effective for them as for younger adults.

Can a person become addicted to medications prescribed by a doctor?

Yes. People who abuse prescription drugs—that is, taking them in a manner or a dose other than prescribed, or taking medications prescribed for another person—risk addiction and other serious health consequences. Such drugs include opioid pain relievers, stimulants used to treat ADHD, and benzodiazepines to treat anxiety or sleep disorders. Indeed, in 2010, an estimated 2.4 million people 12 or older met criteria for abuse of or dependence on prescription drugs, the second most common illicit drug use after marijuana. To minimize these risks, a physician (or other prescribing health provider) should screen patients for prior or current substance abuse problems and assess their family history of substance abuse or addiction before prescribing a psychoactive medication and monitor patients who are prescribed such drugs. Physicians also need to educate patients about the potential risks so that they will follow their physician’s instructions faithfully, safeguard their medications, and dispose of them appropriately.

Is there a difference between physical dependence and addiction?

Yes. Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, for which the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.

How do other mental disorders coexisting with drug addiction affect drug addiction treatment?

Drug addiction is a disease of the brain that frequently occurs with other mental disorders. In fact, as many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs—i.e., tobacco and alcohol. For these individuals, one condition becomes more difficult to treat successfully as an additional condition is intertwined. Thus, people entering treatment either for a substance use disorder or for another mental disorder should be assessed for the co-occurrence of the other condition. Research indicates that treating both (or multiple) illnesses simultaneously in an integrated fashion is generally the best treatment approach for these patients.

Is the use of medications like methadone and buprenorphine simply replacing one addiction with another?

No. Buprenorphine and methadone are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed. They are administered orally or sublingually (i.e., under the tongue) in specified doses, and their effects differ from those of heroin and other abused opioids.

Heroin, for example, is often injected, snorted, or smoked, causing an almost immediate “rush,” or brief period of intense euphoria, that wears off quickly and ends in a “crash.” The individual then experiences an intense craving to use the drug again to stop the crash and reinstate the euphoria.

The cycle of euphoria, crash, and craving—sometimes repeated several times a day—is a hallmark of addiction and results in severe behavioral disruption. These characteristics result from heroin’s rapid onset and short duration of action in the brain.

In contrast, methadone and buprenorphine have gradual onsets of action and produce stable levels of the drug in the brain. As a result, patients maintained on these medications do not experience a rush, while they also markedly reduce their desire to use opioids.

If an individual treated with these medications tries to take an opioid such as heroin, the euphoric effects are usually dampened or suppressed. Patients undergoing maintenance treatment do not experience the physiological or behavioral abnormalities from rapid fluctuations in drug levels associated with heroin use. Maintenance treatments save lives—they help to stabilize individuals, allowing treatment of their medical, psychological, and other problems so they can contribute effectively as members of families and of society.

Where do 12-step or self-help programs fit into drug addiction treatment?

Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. Most drug addiction treatment programs encourage patients to participate in self-help group therapy during and after formal treatment. These groups can be particularly helpful during recovery, offering an added layer of community-level social support to help people achieve and maintain abstinence and other healthy lifestyle behaviors over the course of a lifetime.

Can exercise play a role in the treatment process?

Yes. Exercise is increasingly becoming a component of many treatment programs and has proven effective, when combined with cognitive-behavioral therapy, at helping people quit smoking. Exercise may exert beneficial effects by addressing psychosocial and physiological needs that nicotine replacement alone does not, by reducing negative feelings and stress, and by helping prevent weight gain following cessation. Research to determine if and how exercise programs can play a similar role in the treatment of other forms of drug abuse is under way.

How does drug addiction treatment help reduce the spread of HIV/AIDS, Hepatitis C (HCV), and other infectious diseases?

Drug-abusing individuals, including injecting and non-injecting drug users, are at increased risk of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and other infectious diseases. These diseases are transmitted by sharing contaminated drug injection equipment and by engaging in risky sexual behavior sometimes associated with drug use. Effective drug abuse treatment is HIV/HCV prevention because it reduces activities that can spread disease, such as sharing injection equipment and engaging in unprotected sexual activity. Counseling that targets a range of HIV/HCV risk behaviors provides an added level of disease prevention.

Drug abuse treatment is HIV and HCV prevention.

Injection drug users who do not enter treatment are up to six times more likely to become infected with HIV than those who enter and remain in treatment. Participation in treatment also presents opportunities for HIV screening and referral to early HIV treatment. In fact, recent research from NIDA’s National Drug Abuse Treatment Clinical Trials Network showed that providing rapid onsite HIV testing in substance abuse treatment facilities increased patients’ likelihood of being tested and of receiving their test results. HIV counseling and testing are key aspects of superior drug abuse treatment programs and should be offered to all individuals entering treatment. Greater availability of inexpensive and unobtrusive rapid HIV tests should increase access to these important aspects of HIV prevention and treatment.

Drug addiction is a complex disorder that can involve virtually every aspect of an individual’s functioning—in the family, at work and school, and in the community.

Because of addiction’s complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual’s drug use; others, like employment training, focus on restoring the addicted individual to productive membership in the family and society (See diagram “Components of Comprehensive Drug Abuse Treatment“), enabling him or her to experience the rewards associated with abstinence.

Treatment for drug abuse and addiction is delivered in many different settings using a variety of behavioral and pharmacological approaches. In the United States, more than 14,500 specialized drug treatment facilities provide counseling, behavioral therapy, medication, case management, and other types of services to persons with substance use disorders.

Along with specialized drug treatment facilities, drug abuse and addiction are treated in physicians’ offices and mental health clinics by a variety of providers, including counselors, physicians, psychiatrists, psychologists, nurses, and social workers. Treatment is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.

Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of addiction and its medical consequences. Unfortunately, managed care has resulted in shorter average stays, while a historical lack of or insufficient coverage for substance abuse treatment has curtailed the number of operational programs. The recent passage of parity for insurance coverage of mental health and substance abuse problems will hopefully improve this state of affairs. Health Care Reform (i.e., the Patient Protection and Affordable Care Act of 2010, “ACA”) also stands to increase the demand for drug abuse treatment services and presents an opportunity to study how innovations in service delivery, organization, and financing can improve access to and use of them.

Types of Treatment Programs

Research studies on addiction treatment typically have classified programs into several general types or modalities. Treatment approaches and individual programs continue to evolve and diversify, and many programs today do not fit neatly into traditional drug addiction treatment classifications.

Most, however, start with detoxification and medically managed withdrawal, often considered the first stage of treatment. Detoxification, the process by which the body clears itself of drugs, is designed to manage the acute and potentially dangerous physiological effects of stopping drug use. As stated previously, detoxification alone does not address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification should thus be followed by a formal assessment and referral to drug addiction treatment.

Because it is often accompanied by unpleasant and potentially fatal side effects stemming from withdrawal, detoxification is often managed with medications administered by a physician in an inpatient or outpatient setting; therefore, it is referred to as “medically managed withdrawal.” Medications are available to assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives.

Long-Term Residential Treatment

Long-term residential treatment provides care 24 hours a day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), with planned lengths of stay of between 6 and 12 months. TCs focus on the “resocialization” of the individual and use the program’s entire community—including other residents, staff, and the social context—as active components of treatment. Addiction is viewed in the context of an individual’s social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured and can be confrontational at times, with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others.

Many TCs offer comprehensive services, which can include employment training and other support services, onsite. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, homeless individuals, people with severe mental disorders, and individuals in the criminal justice system.

Short-Term Residential Treatment

Short-term residential programs provide intensive but relatively brief treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat other types of substance use disorders. The original residential treatment model consisted of a 3- to 6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as AA. Following stays in residential treatment programs, it is important for individuals to remain engaged in outpatient treatment programs and/or aftercare programs. These programs help to reduce the risk of relapse once a patient leaves the residential setting.

Outpatient Treatment Programs

Outpatient treatment varies in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social supports. It should be noted, however, that low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient’s characteristics and needs. In many outpatient programs, group counseling can be a major component. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders.

Individualized Drug Counseling

Individualized drug counseling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioning—such as employment status, illegal activity, and family/social relations—as well as the content and structure of the patient’s recovery program.

Through its emphasis on short-term behavioral goals, individualized counseling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counselor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services.

Group Counseling

Many therapeutic settings use group therapy to capitalize on the social reinforcement offered by peer discussion and to help promote drug-free lifestyles. Research has shown that when group therapy either is offered in conjunction with individualized drug counseling or is formatted to reflect the principles of cognitive-behavioral therapy or contingency management, positive outcomes are achieved. Currently, researchers are testing conditions in which group therapy can be standardized and made more community-friendly.

Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals

Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, presenting opportunities for intervention and treatment prior to, during, after, or in lieu of incarceration. Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug abuse and related crime. Individuals under legal coercion tend to stay in treatment longer and do as well as or better than those not under legal pressure. Studies show that for incarcerated individuals with drug problems, starting drug abuse treatment in prison and continuing the same treatment upon release—in other words, a seamless continuum of services—results in better outcomes: less drug use and less criminal behavior. More information on how the criminal justice system can address the problem of drug addiction can be found in Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (National Institute on Drug Abuse, revised 2012).

Key Takeaways

  • Drug addiction can be treated, but it’s not simple. Addiction treatment must help the person do the following:
    • stop using drugs
    • stay drug-free
    • be productive in the family, at work, and in society
  • Successful treatment has several steps:
    • detoxification
    • behavioral counseling
    • medication (for opioid, tobacco, or alcohol addiction)
    • evaluation and treatment for co-occurring mental health issues such as depression and anxiety
    • long-term follow-up to prevent relapse
  • Medications and devices can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions.
  • Behavioral therapies help patients
    • modify their attitudes and behaviors related to drug use
    • increase healthy life skills
    • persist with other forms of treatment, such as medication
  • People within the criminal justice system may need additional treatment services to treat drug use disorders effectively. However, many offenders don’t have access to the types of services they need.

SAMHSA Guide to MAT Medications, Counseling, and Related Conditions

Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. It is also important to address other health conditions during treatment.

MAT Medications

The Food and Drug Administration (FDA) has approved several different medications to treat alcohol and opioid use disorders MAT medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. Medications used for MAT are evidence-based treatment options and do not just substitute one drug for another.

Methadone used to treat those with a confirmed diagnosis of Opioid Use Disorder can only be dispensed through a SAMHSA certified OTP. Some of the medications used in MAT are controlled substances due to their potential for misuse. Drugs, substances, and certain chemicals used to make drugs are classified by the Drug Enforcement Administration (DEA) into five distinct categories, or schedules, depending upon a drug’s acceptable medical use and potential for misuse. Learn more about DEA drug schedules.

Alcohol Use Disorder Medications – Acamprosate, disulfiram, and naltrexone are the most common drugs used to treat alcohol use disorder. They do not provide a cure for the disorder but are most effective in people who participate in a MAT program.

  • Acamprosate – is for people in recovery, who are no longer drinking alcohol and want to avoid drinking. It works to prevent people from drinking alcohol, but it does not prevent withdrawal symptoms after people drink alcohol. It has not been shown to work in people who continue drinking alcohol, consume illicit drugs, and/or engage in prescription drug misuse and abuse. The use of acamprosate typically begins on the fifth day of abstinence, reaching full effectiveness in five to eight days. It is offered in tablet form and taken three times a day, preferably at the same time every day. The medication’s side effects may include diarrhea, upset stomach, appetite loss, anxiety, dizziness, and difficulty sleeping.
  • Disulfiram – treats chronic alcoholism and is most effective in people who have already gone through detoxification or are in the initial stage of abstinence. Offered in a tablet form and taken once a day, disulfiram should never be taken while intoxicated and it should not be taken for at least 12 hours after drinking alcohol. Unpleasant side effects (nausea, headache, vomiting, chest pains, difficulty breathing) can occur as soon as ten minutes after drinking even a small amount of alcohol and can last for an hour or more.
  • Naltrexone – blocks the euphoric effects and feelings of intoxication and allows people with alcohol use disorders to reduce alcohol use and to remain motivated to continue to take the medication, stay in treatment, and avoid relapses.

To learn more about MAT for alcohol use disorders view Medication for the Treatment of Alcohol Use Disorder: A Brief Guide – 2015 and TIP 49: Incorporating Alcohol Pharmacotherapies Into Medical Practice.

Opioid Dependency Medications – Buprenorphine, methadone, and naltrexone are used to treat opioid use disorders to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone. These MAT medications are safe to use for months, years, or even a lifetime. As with any medication, consult your doctor before discontinuing use.

  • Buprenorphine – suppresses and reduces cravings for opioids. Learn more about buprenorphine.
  • Methadone – reduces opioid cravings and withdrawal and blunts or blocks the effects of opioids. Learn more about methadone.
  • Naltrexone – blocks the euphoric and sedative effects of opioids and prevents feelings of euphoria. Learn more about naltrexone.

Learn more about MAT for opioid use disorders or download TIP 63: Medications for Opioid Use Disorder – Introduction to Medications for Opioid Use Disorder Treatment (Part 1 of 5) – 2020.

Opioid Overdose Prevention Medication – Naloxone saves lives by reversing the toxic effects of overdose. According to the World Health Organization (WHO), naloxone is one of a number of medications considered essential to a functioning health care system.

  • Naloxone – used to prevent opioid overdose, naloxone reverses the toxic effects of the overdose. Learn more about Naloxone.

Counseling and Behavioral Therapies

Under federal law 42.CFR 8.12, MAT patients receiving treatment in OTPs must receive counseling, which may include different forms of behavioral therapy. These services are required along with medical, vocational, educational, and other assessment and treatment services. Learn more about these treatments for substance use disorders.

Regardless of what setting MAT is provided in, it is more effective when counseling and other behavioral health therapies are included to provide patients with a whole-person approach.

Co-Occurring Disorders and Other Health Conditions

The coexistence of both a substance use disorder and a mental illness, known as a co-occurring disorder, is common among people in MAT. In addition, individuals may have other health-related conditions such as hepatitis, HIV and AIDS. Learn more about co-occurring disorders and other health conditions.

Case Management in Addiction

Case management is a coordinated, intentional approach to delivering quality services (SAMHSA, 2015). It requires cooperation among multiple agencies and professionals, awareness of the multifaceted needs of clients, and purposeful collaboration between counselor and client.

In many ways, all addiction professionals take on the role of case manager. This includes doctors, nurses, social workers, licensed counselors, and certified addictions counselors. The reason for this distinction is because of the range of “whole-person” issues discussed throughout this book. Substance use disorder is a primary diagnosis, but it is not an isolated one.

SAMHSA developed a series of treatment improvement protocol manuals (TIPs) designed to provide professionals with expert guidance, and they devoted an entire manual to the importance of case management services (TIP 27). Included in the manual is an overview of the skills that case managers in substance abuse treatment settings need to have:

  • Understanding various models and theories of addiction and other problems related to substance abuse
  • Ability to describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems
  • Ability to recognize the importance of family, social networks, community systems, and self-help groups in the treatment and recovery process
  • Understanding the variety of insurance and health maintenance options available and the importance of helping clients access those benefits
  • Understanding diverse cultures and incorporating the relevant needs of culturally diverse groups, as well as people with disabilities, into clinical practice
  • Understanding the value of an interdisciplinary approach to addiction treatment


Assessment & Treatment Quiz

Screening and Assessment Tools Chart

Tool Substance type Patient age How tool is administered
Alcohol Drugs Adults Adolescents Self-
Screening to Brief Intervention (S2BI) X X X X X
Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD) X X X X X
Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) X X X X X
NIDA Drug Use Screening Tool: Quick Screen (NMASSIST) X X X X
Alcohol Use Disorders Identification Test-C (AUDIT-C (PDF, 41KB)) X X X X
Alcohol Use Disorders Identification Test (AUDIT (PDF, 233KB)) X X X
Opioid Risk Tool (PDF, 168KB) X X X
CAGE (PDF, 14KB)(link is external) X X X
Helping Patients Who Drink Too Much: A Clinician’s Guide (NIAAA) X X X
Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide (NIAAA) X X X
Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) X X X X X
CRAFFT(link is external) X X X X X
Drug Abuse Screen Test (DAST-10)*
For use of this tool – please contact Dr. Harvey Skinner(link sends email)
Drug Abuse Screen Test (DAST-20: Adolescent version)*
For use of this tool – please contact Dr. Harvey Skinner(link sends email)
NIDA Drug Use Screening Tool (NMASSIST) X X X X
Helping Patients Who Drink Too Much: A Clinician’s Guide (NIAAA) X X X
Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide (NIAAA) X X X

DSM-5 Criteria for Substance Use Disorder

  1. The substance is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
  3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  4. Craving, or a strong desire or urge to use the substance, occurs.
  5. Recurrent use of the substance results in a failure to fulfill major role obligations at work, school, or home.
  6. Use of the substance continues despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
  7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
  8. Use of the substance is recurrent in situations in which it is physically hazardous.
  9. Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve intoxication or desired effect
    2. A markedly diminished effect with continued use of the same amount of the substance.
  11. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for that substance (as specified in the DSM-5 for each substance).
    2. The use of a substance (or a closely related substance) to relieve or avoid withdrawal symptoms.

The Classification of Substance Use Disorders: Historical, Contextual, and Conceptual Considerations

Sean M. Robinson and Bryon Adinoff

Behav. Sci. 2016, 6, 18; doi:10.3390/bs6030018
Published August 2016


Abstract: This article provides an overview of the history of substance use and misuse and chronicles the long shared history humans have had with psychoactive substances, including alcohol. The practical and personal functions of substances and the prevailing views of society towards substance users are described for selected historical periods and within certain cultural contexts. This article portrays how the changing historical and cultural milieu influences the prevailing medical, moral, and legal conceptualizations of substance use as reflected both in popular opinion and the consensus of the scientific community and represented by the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM). Finally, this article discusses the efforts to classify substance use disorders (SUDs) and associated psychopathology in the APA compendium. Controversies both lingering and resolved in the field are discussed, and implications for the future of SUD diagnoses are identified.

1.    Introduction

Today, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is regarded as the defining standard for mental health diagnoses (including substance use disorders (SUDs)) in America and increasingly abroad. While the fact that the DSM identifies SUDs as primary mental health disorders may be taken for granted today, it is noteworthy that SUDs were, prior to the third publication of the DSM (1980), largely conceptualized as manifestations of underlying primary psychopathology [1]. Thus, a large paradigm shift in SUD nosology is apparent in less than half a century’s time. Taking an even longer perspective reveals that, although psychoactive substances (including alcohol) have been around for nearly as long as recorded history, the scientific classification of SUDs only began in the early 19th century. Taken together, these observations suggest that the complex relationships human societies have had with substances over time may provide a rich and valuable backdrop of contextual and conceptual considerations for the eventual rise of nosological science. While it is beyond the scope of this article to provide a well-rounded historical account of the complex history of substance use in its entirety, the general purpose is to provide a historical framework by which the reader can contextualize and therefore better understand those influences which have shaped development of the DSM nosology of SUDs. Because the development of the DSM is singularly tied to cultural and historical developments in both Europe and the United States of America (i.e., “US”, “American”), this review takes a decidedly Western-oriented outlook on modern nosology and focuses almost exclusively on the American classification system (i.e., that which is associated with the American Psychiatric Association [APA]). Also of note: consistent with the most recent DSM, this manuscript generally uses the terminology “substance use disorder(s)” to refer to a superordinate category which is comprised of a number of singular disorders (e.g., alcohol use disorder (AUD), cannabis use disorder, etc.). In order to most effectively contrast this modern diagnostic label with earlier conceptualizations, this term is often used alongside and in comparison to earlier terms and labels.

First, a relatively brief historical overview of the long and complicated relationships humans have had with substances is provided, including the historical context of both medical and non-medical use preceding the advent of the modern diagnostic system. In order to provide a detailed yet bounded overview, this review focuses on a number of substances (including their pharmacological progenitors and/or descendants), which have, arguably, played more prominent historical roles (i.e., opium, cannabis, alcohol, cocaine). Second, this article provides demonstrative historical examples of the top-down impact that societal factors have had on substance use and substance use conceptualization and also discusses a number of influences (i.e., cultural, industrial, socio-political) which have impacted the development of the APA compendium. Third, the impact of substance use on society today is discussed in terms of substance use-related costs. Finally, following an account of the development of each version of the DSM, a few of the lingering controversies in the field are identified, and future considerations are discussed for SUD diagnoses specifically and for the addiction field as a whole.

2.    Historical Considerations: A Long History of Psychoactive Substances

2.1.  Opioids

The history of psychoactive drugs is closely entwined with the lives and histories of the humans that cultivated and used them. Likely one of the first drugs known to humans, opium and its derivatives, have been associated with its human cultivators for millennia (for an in-depth review of the history of opium/narcotics, the reader is referred to Davenport-Hines [2] and Booth [3]). Opium itself (which contains the active opioid alkaloids morphine and codeine) is derived from a species of poppy flower, Papaver somniferum (Latin for “sleep inducing poppy”). Knowledge of the effects of opium in the ancient world most likely originated in Egypt, the Balkans, or the Black Sea, and the substance was obtained through relatively simple harvesting and preparation methods. The promulgation of opium throughout Persia, India, China, North Africa, and Spain by Arab traders allowed for the quick spread of the drug throughout the ancient world, leaving behind well-known written records of is properties and uses. One written account believed to reference an opium concoction, known as nepenthe, takes place in Homer’s The Odyssey, where he gives an account of “a drug that had the power of robbing grief and anger of their sting and banishing all painful memories.” This mixture may refer to opium and alcohol, a mixture later known as laudanum. Figure 1 provides additional points of historical reference. Advancing to more recent times, it was in the 19th century that experimentation with morphine for non-nonmedicinal purposes by Europeans increased while physicians concurrently came to recognize the negative effects of the drug—especially with regards to prolonged medical use.



2.2.  Cannabis

Evidence of cannabis (a.k.a. marijuana, hemp) use dates back tens of thousands of years in both Europe and Taiwan. For detailed reviews on the history of cannabis, the reader is referred to Abel [24],  Earleywine [5],  Grinspoon and Bakalar [7],  and Lee [9].  Although cannabis originated in Afghanistan, it was cultivated in in Europe, Arabia, France, Asia, and North and South Africa, and its use was common in the cultures comprising the modern day nations of China, Japan, India, and others. The widespread cultivation of the plant was largely due to its ability to make rope and textiles and its fibers,  and was purportedly used in the creation of paper in China and Japan in     the 2nd and 5th centuries A.D., respectively [25,26]. The popularity of the plant was also due to its use as a medicine; its pain-relieving properties were well known in ancient China and recorded in pharmacopeias dating back to the 1st century A.D. The historical use of cannabis in the treatment of medical illness has also been documented by the ancient people of India, who used cannabis preparations to treat headaches, dysentery, and venereal disease [2]. In ancient China cannabis was used to ease the pain associated with surgery, in Japan it was used to drive away the evil spirits believed to be the cause of illness, and among the ancient Greeks it was believed to be a cure for earaches and to reduce sexual desires [24]. In 17th and 18th century Europe the use of cannabis for its purported antibiotic and analgesic effects became common and it was recognized as a sedative/hallucinogen. In India, cannabis preparations in a variety of forms were used recreationally, including bhang, ganja, and charas (i.e., hashish). As seen in Figure 1, the use of cannabis continued over time,  partly as a  folk remedy for a number of ailments. While its use as a recreational drug eventually became more widespread, it was not until the mid-19th century that interest in the medicinal properties of the drug once again became popular. In the US around this time, exposure to recreational use of the drug was limited to a relatively small number of individuals [5].

2.3.  Cocaine

Although the history of cocaine itself is relatively short compared to the coca plant from which it is derived, both substances have a longstanding place in history (for reviews on the topic, the reader is referred to Davenport-Hines [2] and Karch [27]). Cocaine is one of the alkaloids contained in the leaves of the coca plant (Erythroxylum coca), which has grown wild for thousands of years in what currently comprises the countries Colombia and Bolivia. The alkaloids were used by native peoples in modern-day Peru for thousands of years to reduce hunger and thirst and to increase energy through the chewing of coca leaves. In addition to the functional utility of the leaves, they were also considered sacred by the Peruvian Incas and were used ritualistically in worship of the divine. Because the plant is cultivated under hot and humid tropical climates, it was not grown in Europe until the 1700’s, when heated greenhouses became available. In the mid-19th century, cocaine was isolated as the active ingredient in the coca leaf in Europe and cocaine was extolled by both American pharmaceutical companies as well as some notable figures in the medical community for its non-addictive qualities and its potential usefulness in weaning people off the dangerous “morphine habit” (see Figure 1 for additional selected historical events). Although cocaine is famously known for being included in popular beverages in the late 19th century, the idea of cocaine as a non-addictive panacea-like wonder-drug was short-lived and since then cocaine has been employed with increasing rarity in medicine. Today, it is most commonly used by otolaryngologists as a local anesthetic with vasoconstrictive properties [28,29].

2.4.  Alcohol

Alcohol, along with opium, is probably one of the first psychoactive substances used by man and remains one of the most widely used recreational substances. Today, the non-pathological use of alcohol today is typically associated with festivity, leisure, and recreational activities, and history is replete with examples of practical and functional uses of alcohol dating back to antiquity (for detailed explications of this history see Sournia [6], Davenport-Hines [2], and White [8]). Beer and wine, for example, are believed to have been important resources for the Ancient Egyptians, with pictographs from around 4000 BCE depicting Egyptians using the substance for medicine and nutrition as well as for religious and other cultural practices. Consumption of alcohol was also pervasive throughout all segments of ancient Chinese society and its sale also provided major sources of revenue for the empire. The use of alcohol became widespread in a number of religious and cultural practices such that an imperial edict was issued stating that “moderate consumption was a religious obligation” [4]. The word alcohol (from the Arabic word al-kuhl) came to mean an essential property or spirit of something, and the mysterious properties of the substance became associated with transcendental and therefore religious experiences in a number of cultures [6,8]. The association of alcohol with religion and the divine was also common among the ancient Babylonians and the area that is now Greece. With the exception of all but a few Native American and Australian native tribes (for whom alcohol was largely non-existent prior to the arrival of Europeans), alcohol was continually consumed in large quantities throughout much of the known world. In 13th century England, as knowledge of the brewing process spread, ale became both a dietary staple for children and adults alike as well as a commodity for commerce. Alcohol use was also prominent during the renaissance and in beer was a staple of the early economy in America [2].

Along with its functional uses, alcohol was used in the ancient world, as it is today, as an intoxicant. One early account of excessive alcohol intoxication is found in the cult of Dionysus, a religious sect, which held to the idea that intoxication brought worshippers closer to their god. Indeed, consumption of alcohol, particularly wine, was so central to Greek culture that abstinence was frowned upon and wine consumption was considered a civic duty in Athens [2]. Despite the central role of alcohol in Greek society, Greeks promoted moderate drinking and reproached intoxication, with some exceptions. Similar to the Greeks, the Romans also considered wine to be central to their society and placed a high value on moderation. The decline of moderation and the rise of excessive consumption, however, began after the third century BCE, as the Roman Empire continued to spread and eventually began its period of decline [2]. As the influence of the Romans declined, so did the influence of the Christian religion rise. The growing power of the Church would exert an influence over attitudes towards drinking and intoxication for nearly two thousand years. See Figure 1 for additional selected historical events involving alcohol.

3.    Cultural and Contextual Considerations

3.1.  Societal Influences on Attitudes and Perceptions of Substance Use

Over time, a number of influences (i.e., religious, cultural, industrial,  and sociopolitical) can be seen to impact attitudes and perceptions of substance use among both professionals and the laity alike.   These attitudes and perceptions,  enmeshed with the prevailing cultural zeitgeist of the time, have considerable impact across a number of domains, including interest in and funding towards treatment, the legal status/criminalization of substance users, substance use itself, as well as professional conceptualization and psychiatric nosology. A selected few of these influences are described below.

3.1.1.  Religious Influences

Historically speaking, the beliefs and practices of the Christian religion, for one, provided both support for the consumption of wine and also warned against excessive use [4]. Indeed, while the church held largely favorable views regarding the consumption of alcohol in moderation, it also considered over-indulgence to be a sin. According to Hanson [4],

Paul the apostle considered wine to be a creation of God and therefore inherently good and recommended its use for medicinal purposes but condemned intoxication and recommended abstinence for those who could not control their drinking [4] (p. 3).

The Bible itself contains nearly two thousand references to vineyards and wine, and numerous references to drinking that both condemn its use in excess and extoll its virtues in moderation [6].  As alcohol consumption remained high in colonial America, the abuse of alcohol came to be considered a sin by the church and was increasingly condemned by society [8]. The temperance movement of the late 19th century, which [30] describes as one of evangelical “moral absolutes”, left little room for consideration of moderation [30]. The movement sought to cement its cause in morality and set forth a number of arguments designed to reconcile the absolutist beliefs of the temperance movement with a number of positive references to wine in the bible (e.g., wine’s association with Jesus at the Marriage at Cana, the transfiguration of wine at communion). Although prohibition was enacted and eventually repealed, the characterological and moral problems believed to be associated with the sinful vice of excessive alcohol consumption remained. One sign, perhaps, of the perseverance of such beliefs was the groundswell of the post-prohibition grass-roots self-help group, Alcoholics Anonymous,  founded in 1935 on the belief that alcoholism represented a medical disease worthy of professional attention and not societal enmity. The group simultaneously upheld the beliefs that alcoholism was both (a) a medical disease; and (b) that treatment for this disease was best accomplished through a “moral inventory, confession of personality defects, restitution of those harmed, and the necessity of belief in and dependence upon God” [31,32]. Today, the organization boasts more than 2 million members worldwide [33].

3.1.2.  Cultural Influences

As the field of mental health has come to recognize that the process of human development is inexorably linked to and fundamentally shaped by the environment in which we are enmeshed, so, too, is the ever-unfolding process of conceptualizing substance use shaped by the habits, beliefs, and traditions of the larger society. Top-down cultural influences can be seen to exert notable effects on substance use and perceptions of substance use, particularly in the 19th century. The culturally bound perception of morphine addiction of the Victorian age,  for example,  was enmeshed with the highly restrictive sexual attitudes towards women characteristic of the era (the same era in which psychoanalysis rose to prominence). Due to the drugs well-known effect on decreasing libido, for example, opium was often prescribed to women for the treatment of neuroses, hysteria, and hypochondriacal disorders; all of which were linked to sexual desires and frustrations among women [34,35]. Thus, the integration of societal standards regarding female sexuality into the mental health profession and diagnostic nomenclature is representative of the way in which the cultural zeitgeist at any given time can influence, if not directly promote, the misuse of substances. With the decline of the Victorian-era, cultural norms shifted, psychiatric diagnoses were re-conceptualized, and female sexuality became less restrained/is no longer treated in a ubiquitously pathological manner.

3.1.3.  Industrialization

The influence of industrialization upon the attitudes and perceptions of substance users is readily apparent as America progressed into the industrial revolution. The rapid change from an agricultural to an industrial economy during this time was largely a result from the establishment of the factory system, where labor was carried out by individuals in a centralized location on a large scale [36]. The already negative view of excessive consumption became magnified as society came to rely heavily upon individual personal characteristics incompatible with intoxication—namely productivity, reliability, and punctuality [4]. This was coupled with a shift in the national zeitgeist towards values consistent with the engine of the new economy, including the accumulation of materials and personal wealth. The growing antipathy surrounding the use of alcohol and substances fueled the conceptualization of the “addict” as an unproductive social outcast. Such views were only strengthened by the concomitant rise of problems typically associated with industrialization and urbanization such as increased crime, poverty, and infant mortality rates [2,4]. Furthermore, the already negative perception of “addicts” became enmeshed with moral judgment; “Addicts were represented as self-tormenting devils lost in eternal damnation . . . plagued by a ‘diseased soul’” [2] (p. 63). The near inexorable link between criminal behavior and substance use had thus been influenced by the economic concerns and industrial needs of the world’s largest burgeoning economy.

The effects of industrialization on substance use were not limited solely to alcohol, wherein excessive consumption was antagonistic to the zeitgeist of the times. Harkening back to the provision of coca leaves by the Spanish Conquistadors to the Peruvian slaves in order to increase mining of silver, the modern day equivalent of the coca leaf, cocaine, was supplied by American industrialists and plantation owners to black construction and plantation workers to increase productivity (see Figure 1). Nonetheless, the association of the drug with racial minorities resulted in racialized, zealous accounts of minorities (i.e., “negro cocaine fiends”) driven mad by the drug, whose use resulted in acts of murder and/or sexual depravity; not surprisingly, public disapproval of the drugs soon followed [2,37].  The propagation of such attitudes of disapproval across various strata of society would play a principal role in criminalization of substance use (including, most notably, the Temperance Movement and Prohibition). The socio-political American Temperance Movement (1817) coincided with the increasing religious and moral condemnation of alcohol use as detrimental to religious ideals and values related to family and society [4].

4.    Legality and MoralityRecreational drug use began to be stigmatized as “socially offensive” with records referencing opium as “the pernicious drug” around 1814, and drug users were depicted in medical case studies and referenced as being “incapable of self-control” from a “self-inflicted, self-purchased curse” with “no happy earthly end” [2] (p. 62). Due to the widespread use of narcotic medications to treat wartime injuries, societies around the world found a rise in the number of addicted individuals following the American Civil War (1861–1865), the Austro-Prussian War (1866), and the Franco-Prussian War (1870–1871). Despite the growing moral intolerance of substance users, with the exception of a few US cities in the 1870’s, the possession of drugs for non-medicinal use was not a criminal offense until the early 20th century [5]. Like cocaine, cannabis became highly stigmatized in America due to its association with racial minorities and impoverished workers and, by the mid 1890’s these substances became relegated to the category of “vice” associated with criminals and the lower class. A series of laws were enacted starting in the early 20th century which criminalized the distribution of cocaine [27]. As motor vehicles became increasingly common in American early 20th century, research into the metabolic effects of alcohol on driving impairments increased,  and the newfound dangers posed   by alcohol intoxication took on additional costs to society [15]. As the temperance movement drew strength in industrialized America, so too did it influence attitudes abroad, with prohibition enacted in Russia (1916–1917), Hungary (1919), Norway (1919–1927), Finland (1919–1932) and the United States (1920–1933), among others [4]. Attitudes towards drug use and the increasing costs to a  newly industrialized society resulted in widespread legislation designed to restrict their possession and distribution which in turn resulted in the criminalization of substance use and the entrenched association of addiction with crime, an association which has persisted (even within the mental health field). For over 30 years until its most recent iteration, the DSM has included references to legal problems as part of the criteria for SUDs (see Section 7.2).

5.    Modern Developments

5.1.  Opioids

In the last several decades, substantial advances in pharmacology have led to the identification of endogenous G-protein coupled opioid receptors and the use of synthetic opioids (e.g., methadone, fentanyl) and opiates (e.g., heroin, oxycodone) has proliferated, greatly increasing the amount of drugs manufactured and distributed in the United States and also abroad [38,39]. Due to their potent analgesic effect, opiate drugs have been increasingly used over the past 20 years by physicians in the treatment of chronic pain. There is a growing acceptance, however, that the long term benefits  of opiates for the treatment of chronic pain are limited by analgesic tolerance, worsening of pain,  the development of an opioid use disorder in those in whom the opiates were initially prescribed for chronic pain. Additionally, the diversion of prescription opioid medication is believed to have resulted in increased illicit use stemming from the subjective reduction in anxiety, mild sedation, and sense of well-being or euphoria induced by consumption of these drugs [38,39]. In 2010, about 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers during the past year, with nearly a million emergency department visits associated with prescription painkillers with an associated cost to health insurers of 72.5 billion dollars a year [40]. In 2014, over 18,000 deaths have been attributed to overdose from prescription opioid pain relievers, in addition to those associated with their illicit counterpart, heroin [41]. Today, there is increasing recognition on a national level in the U.S. of the problems associated with overuse of opioids.

5.2.  Cannabis

Relatively recent advances in our understanding of the pharmacology of cannabis has led to the identification of its active ingredient, chemicals collectively termed cannabinoids, including tetrahydrocannabinol (THC), the chemical most associated with psychotropic effects [42]. Federal Drug Administration (FDA) approved synthetic cannabinoids are now available for the treatment  of nausea/vomiting associated with chemotherapy and weight loss/loss of appetite associated with cancer and HIV/AIDS. The last several decades have also seen an unprecedented rise in physician approved marijuana use for the treatment of medical conditions in a growing number of American states [42]. Despite these advances, in 2014, it is estimated that 22.2 million Americans aged 12 or over were current users of marijuana, with 4.2 million meeting criteria for a marijuana use disorder [43].

5.3.  Cocaine

The pharmacological properties of cocaine and related drugs are now well known and its effects on behavior are primarily attributable its effect on the neurotransmitter dopamine [28,44]. Cocaine, coca leaves, and ecgonine are presently listed as Schedule II substances by the Drug Enforcement Administration [45]. In 2014, it is estimated that 1.5 million Americans age 12 or older were current uses of cocaine (including crack cocaine), with 913,000 meeting criteria for a cocaine use disorder [43].

5.4.  Alcohol

Alcohol is now largely used as a ritualistic and recreational intoxicant.  In contrast to most  illicit psychoactive substances, the health consequences of alcohol use are recognized as occurring on a continuum in which the level of potential harm is relative to the amount and pattern of an individual’s consumption. For example, while excessive use of alcohol remains the third preventable leading cause of death in the United States and contributes to over 200 diseases and health related conditions, there is also a growing recognition of the potential benefits of moderate drinking, including decreased risk of diabetes, ischemic stroke, risk heart disease and related mortality [21,46]. In 2014, slightly more than half (52.7 percent) of Americans reported current use of alcohol, with 6.4 percent of people age 12 or older having a past-year AUD [43].

6.    Modern Classification of Substance Use Disorders: The DSM 

6.1. DSM-I: 1952

After World War II, following the decline of German influence on psychiatric nosology, the center of psychiatry shifted to the United States and the APA commissioned its constituents to create its own psychiatric nosology [11,47]. In 1952 the first DSM (DSM-I) [14] was based upon an expanded nosology used by the United States Army created by psychoanalyst William Menninger (brother    to Karl Menninger) [47,48]. Evidence of the influence of psychoanalysis and the psychosocial model in the DSM-I are evident with its observable emphasis on psychoneurosis and functional reactions to environmental stressors [11,47]. The first DSM conceptualized substance use disorder (i.e., “drug addiction” and “alcoholism”) as most commonly arising from a primary personality disorder (see Table 1) [14]. Although DSM-I conceptualized the etiology of substance use disorder as a symptom of a broader underlying disturbance, it did leave some room for exceptions—at least in coding. For example, in the case of alcoholism, the DSM did allow for a primary diagnosis of SUD when “there is a well-established addiction to alcohol without recognizable underlying disorder” [14]. Similarly, for drug addiction, the diagnostic label could be given “while the individual is actually addicted” with the “proper personality classification to be given as an additional diagnosis” [14]. That these exceptions were noteworthy exemptions, and not the rule, however, speaks to the strength of the etiological conceptualization of SUD as being secondary to, or arising from a primary personality disorder.

6.2. DSM-II: 1968

In 1959, only seven years after the publication of DSM-I, major advances in the treatment of mental disorders (i.e., the introduction of effective pharmacologic treatments) occurred in the field and, following the lead of the World Health Organization (1951), the American Medical Association (1965) recognized the severity of alcoholism and declared it to be a medical disorder. This further emphasized the need for a classification system based on the medical model [11,47,49]. The publication of the DSM-II [16] however, did little to change the influence of psychoanalysis and its characteristic descriptions of disorders described in the DSM-I. Interestingly, while the DSM-I and DSM-II did not employ diagnostic criteria as we understand them today, the DSM-II did encourage separate diagnoses for alcoholism and drug addiction “even when it begins as a symptomatic expression of another disorder” [40]. As seen in Table 1, three recognized types of alcoholism were recognized in DSM-II: (a) episodic excessive drinking (intoxication four times per year); (b) habitual excessive drinking (given to alcoholic persons who become intoxicated more than 12 times a year or are recognizably under the influence of alcohol more than once a week, even though not intoxicated); and (c) alcohol addiction (defined in terms of dependency, suggested by withdrawal which may be evidenced by inability to abstain for one day or heavy drinking for three months or more) [16]. Although withdrawal was emphasized for Drug Addiction, it was also recognized that dependence could occur without withdrawal (a point  of semantic confusion which would follow the DSM until its most recent publication). Medically prescribed drugs were excluded in that they were taken in proportion “to the medical need” [16].

6.3. DSM-III: 1980

In keeping with the growing need for a valid and reliable diagnostic compendium for clinicians and researchers alike, the third edition of the DSM (DSM-III) [1] broke with psychoanalytic tradition and instituted consensus based diagnoses and diagnostic criteria [47]. These criteria, including those for SUDs, were based on the Research Diagnostic Criteria (1978) which were, in turn, influenced by the Feighner criteria (1972) [50] and earlier diagnostic attempts by Jellinek [15] to classify alcoholism. The DSM-III also saw the addition of new diagnoses (e.g., Post-traumatic Stress Disorder, Attention Deficit Disorder) and the use of consensus-based diagnoses and diagnostic criteria which, although unremarkable today, were novel concepts at the time [51]. The DSM-III is thus considered a major milestone in the field, reflecting a reemergence of the medical model and the rise of research investigators as the most prominent voices within the field [35,36].

In terms of SUDs, it is notable that the new iteration appeared devoid of the term “alcoholic” and continued the trend of separately diagnosing SUDs by now setting them apart from other mental health conditions (see Table 1). While, for the first time, this version of the DSM explicitly acknowledged differences in cultural perspectives on the acceptability of substance use, it also attempted to anchor the diagnostic criteria in terms of behavioral changes “almost all subcultures would view as extremely undesirable” [1]. Starting in DSM-III, the categories of Substance Abuse and Substance Dependence were adopted, and, although little explicit explanation is offered within the manual as to the basis for adopting this distinction, it seems that the former was equated with pathological use (e.g., social or occupational consequences, including legal problems which may arise from car accidents due to intoxication) and the later with physiological dependence (i.e., tolerance or withdrawal) [51]. While the rationale behind the DSM-III’s creation of these two categories was not described in the manual, there are a number of criticisms of this paradigm by individuals ultimately tasked with subsequent DSM revisions. Among other things, they stated that the distinction between “abuse” and “dependence” is made entirely on the basis of evidence for the presence of physiological tolerance or withdrawal . . . [which leaves the current system] vulnerable to powerful, swiftly changing social forces such as the tightening of laws restricting alcohol use while driving.  Thus, for example, actions of a legislature in  a particular state can determine the number of residents who met DSM-III criteria for a mental disorder (i.e., alcohol abuse) [52].

Such criticisms would form the basis for recommendations to alter these categories in the next iteration. Interestingly, some notable irregularities existed within the DSM-III. For example, the manual made the explicit additional requirements of a pathological use criterion for Alcohol and Cannabis Dependence diagnoses in addition to the main physiological criterion; the manual also stated that data was lacking in support of the main physiological criterion necessary for a Cannabis Dependence diagnosis, i.e., “the existence and significance of tolerance with regular heavy use of cannabis are controversial” [1] (p. 176). Furthermore, while Cocaine Abuse was a recognized diagnosis, Cocaine Dependence was not included “since only transitory withdrawal symptoms occur after cessation of or reduction in prolonged use” [1] (p. 173).

6.4. DSM-III-R (1987)

While the third edition of the DSM reflected,  up to this point,  the most profound changes      in conceptualization of psychiatric nosology since its inception, its successor, the DSM-III-R also evidenced important changes. One such change was DSM-III-R’s inclusion of criterion items formerly associated with Abuse (i.e., aspects of pathological use) in the Dependence category. By grouping (pathological) behavioral dysfunctions with physiological processes in a polythetic diagnostic set, the conceptualization of the new Dependence category stood in contrast to earlier view that physiological symptoms were both necessary and sufficient for a dependence diagnosis. The DSM-III-R goes even further in separating physiological dependence from the diagnosis of Dependence, explicitly stating that “surgical patients [who] develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of impaired control over their use of opioids” are not considered to fall in the category of Substance Dependence [17,53].

In examining the question of how such a change came about, the reader is referred back to the conceptual validity critiques of the Abuse/Dependence diagnostic sets described in the previous section. In light of these and other conceptual validity problems, recommended revisions to the DSM-III-R included elimination of the Abuse category and incorporation of elements into a newly expanded Dependence category [52]. Such a large conceptual change, they argued, would be consistent with the influential model of a dependence syndrome set forth in 1976 by Edwards and Gross which described a clinical syndrome of alcohol dependence that was comprised of physiological dependence on one axis and pathological use/behavioral consequences on the other axis of a singular disorder [54]. The recommendation to expand the Dependence criteria while removing the Abuse category offers some justification for the integration of the pathological use criterion into the Dependence category and the reversal of the DSM-III stance that physiological use was, in most cases, the hallmark of the disorder. As the DSM-III-R ultimately retained the Abuse category, this re-conceptualization of the mental health disorder never fully took shape. One admitted disadvantage to the re-conceptualized single disorder model was the potential for diagnostic abandonment of individuals with lower level problems who did not meet the criterion for the would-be expanded Dependence category [52]. Although possible coding schemes were set forth to circumvent this potential problem with the removal of the Abuse diagnosis [52], some suspect the pragmatic fears of diagnostic abandonment superseded validity concerns and ultimately left the Abuse category intact while at the same time advancing the dependence syndrome’s biaxial concept . . . albeit solely within the Dependence diagnosis [55].

6.5. DSM-IV (1994), DSM-IV-TR (2000)

As the science of mental health continued to progress, the Abuse and Dependence categories were shown to have significant limitations, including: differences in reliability and external validity, incorrect assumptions about the relationship between abuse and dependence, and the problem of “diagnostic orphans” (individuals with symptoms for whom neither diagnosis was met) [56]. The DSM-IV attempted to clarify earlier inconsistencies regarding the distinction between physiological dependence and Substance Dependence by specifying that “Neither tolerance or withdrawal is necessary or sufficient for a diagnosis of Substance Dependence” and added specifiers “With” and “Without Physiological Dependence” [19]. The DSM-IV-TR makes a number of other relatively minor revisions to the Substance Use Disorders and highlights that, compared to Substance Dependence, “the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead only the harmful consequences of repeated use” [20].

6.6. DSM-5: 2013 (See Also Section 7)

The fifth and most recent iteration of DSM (DSM-5) [22] represented the most dramatic modifications since DSM-III with the removal of the Abuse-Dependence paradigm and important revisions to the diagnostic criteria themselves. Most notably, DSM-5 combines Abuse and Dependence into a single unified category and measures severity on a continuous scale from mild (2–3 symptoms endorsed), moderate (4–5 symptoms endorsed) and severe (6 or more symptoms endorsed) out of 11 total symptoms (versus the previous 7) (see Table 1). The shift to a unified category measured along a dimension of severity represents a notable change from the post-hoc categorical severity specifiers   in the previous version and also further cements the difference between the now defunct DSM diagnosis of Dependence and the medical concept of physiological dependence, a distinction which had been increasingly emphasized over time. As reported in Hasin, et al. [57], a number of empirical considerations supported this change, including psychometric studies reporting the uni-dimensionality of the biaxial abuse/dependence paradigm across a number of populations. These empirical findings suggests that, contrary to the categorization of abuse and dependence as more-or-less distinct entities with different severity levels, the criterion items actuality represent a single continuum-of-severity construct. The integration of dimensional elements of classification seen here in SUD also mirrors the call for such an approach among a number of other categorical diagnostic classifications [5860].

Other noteworthy changes in the DSM-5 were the addition of the craving criterion, the removal of the legal problems criterion, and the title of the chapter, which now reads “Substance-Related and Addictive Disorders” (despite the use of the term addiction in the title, the text reveals that “ . . . the word [addiction] is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation” [22]). The chapter also, for the first time, includes a behavioral addiction (i.e., Gambling Disorder), suggesting that a behavioral addiction has a shared underlying neurological reward systems and a compatible symptom set with SUDs [22]. These changes (i.e., craving criterion addition, legal problems criterion elimination, and the introduction of behavioral addictions) are further discussed in the section below.

7.    Discussion

7.1.  Potential Practical Implications of Atheoretical Nosology

While the departure from psychoanalytic etiology and adoption of atheoretical consensus based diagnostic entities in the DSM-III is regarded as one of the greatest advances in the field over the last century, the fact that the definitive manual for the diagnosis of mental disorders provides no known etiology or pathophysiology and relies, instead, on defining a disorder by its symptoms may pose a challenge not only for the field in general but for the treatment of SUDs more specifically. One way in which atheoretical classification may prove problematic is the actual clinical usage of the diagnostic criteria themselves. While in vivo studies of clinician usage of DSM-5 for substance use disorder have yet to be carried out beyond the routine clinical practice field trials, past research comparing clinical psychiatric diagnosis versus vs. structured clinical interviews revealed significant disparities in diagnoses among providers for the same patient [61]. According to a review by First et al. [61] these and other results suggest that clinicians “were most likely making DSM diagnoses using a method other than by evaluating each of the diagnostic criteria in sequence” [61] (p. 842). This observation raises several points of consideration. First, while there are substantial benefits in utilizing consensus-driven standardized diagnostic criteria (e.g., increased reliability and validity of diagnoses, communication between providers) these benefits are significantly curtailed if clinicians do not actually adequately employ the criteria as intended. Second, while more research is needed in order to determine precisely how clinicians are arriving at diagnoses if not utilizing full diagnostic criteria, cognitive research into the clinical reasoning of clinical psychologists suggests that experienced practitioners still rely on their own particular causal theoretical conceptualizations despite the atheoretical diagnostic criteria that have been in place for well over thirty years [62]. Thus, the same lack of universally recognized etiology that was the impetus to move beyond the early psychoanalytic influence and advance to a more valid and reliable model may run contrary to innate mechanisms for conceptualizing diagnostic entities among individual providers.

Given the necessity of the diagnostic agnosticism of the DSM and the substantial benefits this model provides to both clinicians and researchers when used correctly, the question arises as to what contributions does the particular state of psychiatric nosology today have on the field as a whole and for SUD specifically? The adoption of a consensus-based symptomological approach might represent the lack of a shared etiology among professionals. Indeed, some of the major controversies (e.g., natural recovery and the disease model, abstinence and moderation/harm reduction approaches) in the field of substance use over the last several decades have inspired protracted debate [6365] and may very well epitomize this lack of etiological consensus. Today, while the DSM continues to retain its etiological neutrality, the field of substance use has undoubtedly moved in the direction of explicitly emphasizing biological and disease model conceptualizations of addictive behaviors. While advocates of a strict disease model of pathology underlying SUDs point out important achievements including improved recognition of the neurobiological process involved in addiction as well as new pharmacotherapies for treating addiction [66], this conceptualization is still, today, not without its detractors [67,68].

One potential manifestation of this lack of unified etiology or conceptually-driven nosology is the “scientist-practitioner gap”, noted in the field as a whole [6972] and in the treatment of  SUDs. Within SUD treatment, this gap is exemplified in the hesitancy among some practitioners and training programs to readily adopt and promote Evidence-Based Practices (EBPs) in favor of empirically unsupported alternative approaches. Differences in support for and knowledge of the effectiveness of EBPs has been shown to be related to provider level of education, institutional culture, provider type, training, academic affiliation [7376] and, despite the effectiveness of both psychosocial and pharmacological EBPs, research has shown that their widespread adoption has remained challenging, if not controversial, in some arenas [61]. Specifically, despite increasing availability of effective pharmacologic agents and reductions in cost associated with prescription medication for SUDs, adoption of these practices are slow [77], with considerable variation in adoption across publicly funded non-profit, government-owned, privately funded non-profit, and for-profit treatment centers[78] (p. 164). In addition to such macro-influences, individual provider attitudes and beliefs may be another link between conceptualization of SUDs and use of EBPs, with providers with higher responsibility-focused conceptualizations of addiction holding more negative views of the use of naltrexone in the treatment of AUD [79]. Interestingly, the use of pharmacotherapies is particularly low for SUDs (i.e., AUDs) when compared to substantially higher rates of prescribing for other comorbid mental health conditions (e.g., schizophrenia, bipolar, post-traumatic stress disorder) [80], a phenomenon which might suggest larger conceptual differences among SUD providers when compared to other mental health conditions.

7.2.  Removal of Legal Problems Criterion

One of the significant DSM-5 changes identified above (Section 6.6) is the removal of the legal problems criterion for Substance Use Disorders. The removal of the legal problems criterion was reported to reflect the low prevalence for endorsement of this item in the general population, as well as poor fit with other criteria, and little added information based on item response theory (IRT) and differential item functioning analyses [8183]. In contrast to simple summations of items endorsed by an individual in determining an outcome (i.e., level of severity), IRT is used to estimate the level of information provided by a particular item and its utility in predicting that outcome [84]. The data gathered from these models suggests that legal problems were the least associated with the overarching construct when compared to the other items and model fit was actually improved when the legal problems criterion was omitted [82]. Thus, while the removal of this criterion was accomplished through the impartiality of advanced empirical models, as described above, the significance of the departure of the tradition of using the legal problems criterion as a diagnostic criterion reveals the ways in which even a purportedly atheoretical nosology can be influenced by specific contexts and cultural changes. This point becomes particularly salient when we consider the original contextual factors (e.g., racism, industrialization) which came together in the 19th century to make the use of certain substances illegal, thereby forming the nearly inexorable link between criminality and substance use which has persisted over time despite its questionable utility in describing SUD. The historical example of the use of opium-based drugs on women from the not-so-distant Victorian age past illustrates the powerful enmeshment of legality, medical acceptance, and cultural norms that remain so saturated in the culture of the time that they remain effectively invisible. Only with the benefit of time do these cultural factors reveal themselves, and, while the example of the influence of Victorian-era cultural factors on the diagnosis and treatment of mental health in women may seem part of psychiatry’s remote past, the influence of culture on nosology can be readily witnessed even in modern times.

Although not substance-related, perhaps the most salient example of social norms affecting diagnosis in recent history is the diagnostic evolution of homosexuality in the DSM which was, much like early conceptualization of SUD, considered a symptom of a real psychological illness  (i.e., sociopathic personality disturbance) [85,86]. Following the advent of the LGBT rights movement in the 1960s and subsequent research into the condition, the APA eventually reversed its stance on the issue and today it is recognized that the pathology of sexual behavior (which was, in part, justified by the subjective level of disturbance it caused) is related not to an underlying pathology but rather to socially accepted norms and stigmatization. Consequently, homosexuality is no longer considered a disease or a representation of underlying personality disturbance and is conceptualized from a non-pathological viewpoint (and indeed labeled differently in order to avoid the long-held stigma associated with the term homosexual [87]. Thus, history provides clear examples of how even an atheoretical psychiatric nosology such as the DSM is vulnerable to pathologizing behavior based on socially accepted norms- norms which only come to be revealed as reflecting large scale societal biases as they change over time though shifts in generational perspectives.

In terms of legality of substance use today, we are, perhaps, in the midst of another cultural shift; along with the government’s acknowledgment of disparate racial sentencing in drug crimes, there is an increased recognition today among professionals of the dissociation between legal status of drugs with their relative dangerousness to individuals and society as well as the calls for a scientifically informed drug policy [8892]. Cannabis and its derivations, for example, hold the distinction of being classified as both a Schedule I (no currently accepted medical use and lack of safety) and its active ingredient, THC, in pill-form, as Schedule II (accepted medical use and high potential for abuse) [45]. Disparities can also be seen in the legal status of alcohol use which, despite its non-illicit standing, has been recognized to provide a relatively greater level of harm to individuals and society compared to illicit drugs (i.e., heroin, crack cocaine) [90]. The removal of the legal problems criterion may be reflective of a larger cultural change of increased recognition of the somewhat arbitrary division between legal status and levels of harm of substances. The removal of the legal problems criterion underscores the larger philosophical issue of relying on a fluctuating socially-constructed criterion with arguable racial and socio-economic disparity in defining an ostensibly biological disorder in an atheoretical symptom- based diagnostic manual.

7.3.  Removal of the Abuse/Dependence Paradigm

Another significant change to the latest iteration of the DSM identified above (Section 6.4) is the removal of the Abuse/Dependence paradigm for Substance Use Disorders, a paradigm that has been present since the adoption of the DSM-III (1980). Within this paradigm Substance Abuse has been considered a “milder” form of Substance Dependence and often construed as a prodrome. Thus, while the two categories were intended to be diagnostically distinct, they were often interpreted as being related- a conceptualization which was argued in the 1970s and resurrected, albeit in a different form, in the new millennium. In making the case for the changes to the DSM-5, empirical findings derived from modern statistical models of the dimensionality of these categories was used, which found that the criteria aligned themselves on a single dimension, a single underlying construct [83,84,9395]. Thus, the issue of validity was again brought into the spotlight. Similar to the socially constructed legal criterion described in the previous section, research into the validity of the Abuse category revealed a disproportionate number of cases of Abuse being diagnosed by a criterion item (i.e., hazardous drinking) which was, itself, socially biased and mediated by political factors. One study, for example, reported that out of 1385 individuals diagnosed with current alcohol abuse, 83.6% met the criteria based solely on hazardous use, with the majority (69.3%) meeting criteria through drinking and driving alone [96]. The same study found a positive relationship between socio-economic status and DSM-IV Alcohol Abuse diagnosis, which may be explained by higher-income drinkers having greater access to vehicles which, in turn, may lead to higher rates of hazardous drinking and, subsequently, Alcohol Abuse [9698]. Such findings recall the recommendations described earlier [52] warning of the socially constructed and therefore problematic nature of the Abuse diagnosis.

Such findings resulted in the shift to the continuum model espoused in the DSM-5, a trend which was evident in  the  severity  specifiers  of  previous  versions  (in  fact,  the  DSM-IV  and  IV-TR contain a disclaimer, titled “Issues in the Use of DSM-IV: Limitations of the Categorical Approach” [19]; [20] (pp. xxii, xxxi). Although the DSM-5 has been criticized by some for retooling the longstanding dichotomy, this change may be viewed,  in a larger sense,  as finally addressing the conceptual validity problems underlying this distinction. For example, if Abuse was best conceptualized not a standalone mental disorder but rather as one dimension of the larger construct of the dependence syndrome as described by Edwards and Gross (1976) [54], then the amalgamation of the two diagnostic entities in the DSM-5 has increased not only the empirical but the conceptual validity of this underlying construct.

While the categorical classification of substance users in the DSM was done from an etiologically agnostic standpoint, is it plausible that, because the format is consensus (vs. theoretically) driven, and because individuals are pre-disposed to cause and effect thinking [62], the DSM will always retain elements of theory (albeit indirectly) and these will likely change as culture and thinking shift over time. As once (in) famously pointed out, symptoms of mental illness are directly tied to the social and ethical culture in which they take place [99]. While the advancement of empirical inductive reasoning which prompted the shift to the current model is a step forward in the science of classification, it is not without its limitations; some disagreements exist about relying on mathematical models to disprove clinically entrenched concepts [55] while others have raised concerns about the validity of diagnostic thresholds (i.e., mild, moderate, severe) and the arbitrariness of diagnostic cut-offs among SUD and other diagnoses [100102]. Looking forward, it remains to be seen what effect this continuum of severity conceptualization has on clinical work and reliability and validity of diagnoses.

7.4.  Addition of Craving Criterion

Another significant change in the DSM-5 identified above (Section 6.5) is the addition of the craving criterion. While craving has been noted in previous versions as a feature of the disorder, DSM-5 marks the first use of the symptom as an actual criterion item. According to Hasin, Fenton, Beseler, Park and Wall [57], the inclusion of craving was supported on several fronts, including its theoretical centrality in accurately describing a clinical feature of SUD, its association with cued self-administration and relapse,  its well-studied role in human and animal models of substance  use, its inclusion in the ICD-10, as well as the potential for pharmacotherapeutic intervention for craving and its neural substrates. Indeed, craving is often associated with increased likelihood of relapse to alcohol use, and therefore it is thought that managing craving may improve treatment outcomes. As such, a number of pharmacologic interventions have been investigated in the last several decades which target craving reduction as a mechanism to reduce substance use including acamprosate, naltrexone, disulfiram, varenicline, lamotrigine and others [103]. To date, the results of clinical studies on reducing craving have been promising although somewhat inconsistent and await future developments (e.g., the elucidation of underlying neurobiological circuits). Current hypotheses on the neurobiology of craving (i.e., Incentive-Sensitization Theory) posit that long term substance use leads to neuroadaptations which increase the incentive salience around stimuli associated with that substance which may occur independently of the changes that mediate the subjective euphoric effects as well as withdrawal, thereby resulting in subjective experience of craving even in circumstances which highly disincentivize substance use (i.e., social, occupational, recreational impairment) [104]. As craving is then, perhaps, the only criterion which may persist following protracted abstinence, future questions may arise about how to treat and code for craving and what role craving plays in identifying remission.

7.5.  Inclusion of “Behavioral Addictions”

Since the DSM-III-R, the field has defined addictive behaviors as relating to compulsive substance use despite adverse consequences with physiological changes often present. The inclusion of behavioral addictions as psychiatric disorders likely marks the next large paradigm shift in the field of addictions and, not surprisingly, has already garnered some debate. Although the future of behavioral addictions may lack certitude as of yet, what does seem clear, from a nosological standpoint, is the eventual expansion of the conceptualization of the broader category of addictions.   This is evidenced by     the chapter title “Substance-Related and Addictive Disorders” and the inclusion of a behavioral addiction in the form of Gambling Disorder and discussion of Internet Gaming Disorder as an area of future research. Gambling Disorder had previously been included in Impulse Disorders Not Elsewhere Classified since the DSM-III (originally “Pathological Gambling”). That routine ingestion of a psychopharmacologic substance is not needed in conceptualizing addictive pathology may point to the growing conceptualization of addiction as the sum of a host of neuroadaptations related to dysregulation of endogenous neurotransmitters (as well as behavioral, genetic, and pyscho-social factors) of which exogenous chemicals play a historically important but potentially diminishing   part as the field progresses. Indeed, the rationale presented in the DSM-5 (i.e., that Gambling Disorder has a shared underlying neurological reward systems and some “behavioral symptoms that appear comparable to those produced by the substance use disorders” [22] appears to clearly lay the groundwork for the inclusion of other behavioral addictions. In fact, the text reports that other “excessive behavioral patterns” (i.e., internet gaming, “sex addiction”, “exercise addiction”, “shopping addiction”) are not yet included with the rationale cited that there has not been enough peer reviewed evidence to support diagnostic criteria “needed to identify these behaviors as mental disorders” [22]. While concern has been expressed about over-pathologizing human behavior, decreasing individual responsibility, and allowing for a deluge of un- or under-supported diagnoses to saturate and hence weaken the credibility of the field [105107], future research into the neurobiological substrates of impulse-related disorders and addictions may lay a more solid framework for the behavioral addictions. Epidemiological and cultural factors of behavioral addictions will likely be an area of future research, as well as identifying behavioral and pharmacological treatment targets, creating validated and reliable measures, and measuring treatment outcomes.

8.    Conclusions

The history of psychoactive substance use is remarkably long, dating as far back, in some cases, as the recorded history of human civilization allows. Compared to the length and complexity of human interactions with psychoactive substances over millennia, the involvement of mental health in regulating the extremes associated with over-use of psychoactive substances is a relatively recent phenomenon. The official nosology of the American mental health system, the DSM, was itself a significant advancement to the field, which lacked a unified classification system. Through its early iterations, the DSM continued to mature and shed its psychoanalytic roots in the name of the development of a unified nosology. By moving to atheoretical, consensus-based diagnostic entities, the DSM-III made a much needed and significant advancements in diagnostic reliability and validity, which supported the scientific development of the field of mental health. The observation that, despite the DSM’s agnostic approach, most providers today do not conceptualize from a strictly atheoretical standpoint suggests the possibility that the greatest advancement in psychiatric in the last century may have the unintended effect of allowing room for unscientific, idiosyncratic, or disparate etiological interpretations in a field already beleaguered by lack of consensus. Despite the atheoretical nature of the DSM clinicians retain their own conceptualizations of causal etiologies of SUDs and such lack of consensus may hinder the adoption of EBPs as the field progresses.

One of the most recent developments in the DSM-5 is the removal of the legal problems criterion, a change, which may be not only driven by empirical findings but may also represent a cultural shift away from criminalizing substance users. Philosophically, such changes may signify a coming-to-terms with the socially constructed and therefore variable nature of criminal behavior, which has long been regarded as one of the characteristic descriptors of an ostensibly biological disorder. Such a change speaks to the observation that, contrary to the popular assumption that the path of social sciences is entirely objective and linear, the iterations of the DSM reveal, in fact, a progression that is susceptible to political and social influences [11]. As Kawa and Giordano [108] state,

The evolution of the DSM illustrates that what is considered to be “medical” and “scientific” is often not an immutable standard, but rather, may be variable across time and culture, and in this way contingent upon changes in dominant schools of thought [108] (p. 7).

While mental health disorders have characteristically lacked clearly demarcated boundaries and have so far largely defied attempts to elucidate and categorize their exclusive etiologies, an increasing  number of individuals have, over time, connected such concerns to the descriptive vs. etiological nature of psychiatric nosology and the limitations inherent in maintaining such a model [107,108].

Today, the mental health field continues to defy its atheoretical nosology by developing, for example, concrete guidelines and research funding priorities to promote cross-diagnostic advancements in the etiology of mental health disorders  based  on  translational  neuroscience.  This endeavor, known as Research Domain Criteria Initiative (RDoC), is bold in its unambiguously transdiagnostic approach and was developed by the National Institute of Mental Health as a direct challenge to the diagnostically agnostic categorizational approach of the DSM [109]. While RDoC has, of yet, failed to gain significant traction in the area of SUD research, it has the potential to impact the identity of the field of mental health, including the future of diagnostic classification, research priorities, and practitioner training [110]. If more readily adopted in SUD research, RDoC may be useful in expanding existing pre-clinical, and human translational approaches and could, potentially, impact the development of a new generation of SUD pharmacotherapies [111]. While such innovations might lend much needed support to a causation-based nosological system, other advancements (e.g., in statistical modeling and classification, including latent class analysis, latent profile analysis, etc.) may provide meaningful ways of understanding and classifying groups of individuals with SUDs without the need to forgo the descriptive approach. As such advances continue to develop, questions of epidemiology and, indeed, epistemology will no doubt continue to challenge the increasingly inter-connected fields of psychology, psychiatry, and neurology. In the meantime, the continued examination and quantification of objective characterological traits (e.g., impulsivity, affect dysregulation) and their neurobiological underpinnings [112114] as well as the expanding field of epigenetics [115] may continue to deconstruct the historical debate of monism vs. dualism (i.e., “the mind-body problem”) which has long beleaguered epidemiology (and therefore nosology) in mental health.

Despite, then, the growing promise and increasing allure of a truly causation-based nosology in SUD/mental health, the realization of such an undertaking may yet prove elusive for decades to come. For now, little choice remains but to continue to refine the current classification strategy in a stepwise fashion while continuously promoting a deeper understanding and appreciation of its origins and influences.

© 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open-access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).

Acknowledgments: This material is based upon work supported by the Office of Academic Affiliations, Department of Veterans Affairs and resources and the use of facilities at the North Texas Veteran’s Affairs Healthcare System, Dallas, Texas. The views expressed in this article do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Author Contributions: Sean M. Robinson developed most of the original content for this manuscript with guidance, direction, and content editing provided by Bryon Adinoff.


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