Substance use and addictive disorders

AI-narrated overview made with Google NotebookLM. The written lesson below is by Dr. Andrew Wichterman.

Substance use appears in every domain, but the clinical focus items ask about the disorder itself: how it is diagnosed, what withdrawal looks like, which models explain it, and how treatment is staged.

Diagnosis in the DSM-5-TR

The DSM-5 collapsed abuse and dependence into a single substance use disorder graded by the number of criteria met in twelve months: two to three is mild, four to five moderate, six or more severe. The eleven criteria fall into four groups: impaired control, taking more or longer than intended, wanting to cut down, spending time obtaining and using, craving; social impairment, failing role obligations, continued use despite interpersonal problems, giving up activities; risky use, hazardous situations, continued use despite physical or psychological problems; and pharmacological criteria, tolerance and withdrawal. Tolerance and withdrawal do not count when a medication is taken as prescribed. Remission is early, three to twelve months, or sustained, over twelve months, with a specifier for a controlled environment or maintenance therapy. Gambling disorder is the only behavioral addiction in the chapter; internet gaming disorder is under study.

Intoxication and withdrawal

Alcohol, sedative and benzodiazepine withdrawal can be fatal: tremor, sweating, agitation, hallucinations, and seizures peak within one to three days, and delirium tremens is a medical emergency; detoxification from these substances is medically supervised. Opioid withdrawal is miserable but rarely dangerous: yawning, tearing, runny nose, goosebumps, cramps, diarrhea, dilated pupils; overdose, by contrast, kills through respiratory depression and pinpoint pupils, reversed by naloxone. Stimulant withdrawal brings crash, depression and hypersomnia. Cannabis withdrawal, recognized since DSM-5, brings irritability, insomnia and appetite loss. Wernicke-Korsakoff syndrome is the thiamine-deficiency brain damage of chronic alcohol use, with confusion, ataxia and permanent memory loss. Fetal alcohol spectrum disorders are the leading preventable cause of intellectual disability.

Models of addiction

The moral model treats addiction as a failure of will and underlies punitive policy. The disease model, from Jellinek and adopted by Alcoholics Anonymous and the American Society of Addiction Medicine, treats it as a chronic, progressive, relapsing brain disease; abstinence is the goal. The learning or behavioral model treats use as a reinforced habit shaped by cues and consequences. The biopsychosocial model integrates genetic vulnerability, which accounts for about half of risk, with psychological and environmental factors. Harm reduction, from public health, accepts that some use will continue and works to reduce its damage: needle exchange, naloxone distribution, medication-assisted treatment. The exam expects you to know that the current professional consensus is biopsychosocial and that harm reduction and abstinence are both legitimate goals depending on the client.

Assessment and levels of care

Screening uses the AUDIT, CAGE, DAST and CRAFFT; assessment uses a structured interview and often the Addiction Severity Index. The ASAM criteria place a client in one of five levels: early intervention, outpatient, intensive outpatient or partial hospitalization, residential, and medically managed intensive inpatient, based on six dimensions including withdrawal risk, medical and psychiatric conditions, readiness to change, relapse potential and recovery environment. Co-occurring disorders, a substance use disorder alongside another mental disorder, are the norm rather than the exception and are treated in an integrated way, not sequentially. The exam's standard answer for a client with depression and heavy drinking is to assess and address both, and to remember that substance use can produce, mimic and mask other disorders.

Treatment

Motivational interviewing, built on the stages of change, is the entry point for the ambivalent client: express empathy, develop discrepancy, roll with resistance, support self-efficacy. Cognitive behavioral relapse prevention teaches recognition of triggers and coping. Contingency management rewards verified abstinence and has strong evidence for stimulant use. Twelve-step facilitation connects clients to AA or NA, whose model is spiritual, peer-led, abstinence-based and anonymous; SMART Recovery is the secular, CBT-based alternative. Medication-assisted treatment is standard of care for opioid use disorder: methadone, buprenorphine and naltrexone; for alcohol, naltrexone, acamprosate and disulfiram. Family involvement through the CRAFT approach or family therapy improves engagement. Relapse is expected and treated as information, and the counselor never discharges a client for the symptom that brought them in.