Substance use disorder criteria & severity

Substance use questions on case exams frequently hinge on counting criteria, assigning severity, and separating disorder from experimentation or appropriate medical use. One framework covers alcohol, cannabis, opioids, stimulants, sedatives, tobacco and others.

Criteria at exam depth (paraphrased). A problematic pattern with at least 2 of 11 criteria within a 12-month period, in four groups:

• Impaired control: using more or longer than intended; persistent desire or unsuccessful efforts to cut down; much time spent obtaining, using or recovering; craving.
• Social impairment: failing major role obligations at work, school or home; continued use despite social or interpersonal problems; giving up important activities.
• Risky use: recurrent use in physically hazardous situations (e.g., driving impaired); continued use despite a known physical or psychological problem made worse by it.
• Pharmacological: tolerance and withdrawal.

Severity: mild 2–3, moderate 4–5, severe 6 or more. Medical-use rule: tolerance and withdrawal do not count when they occur only with medications (such as opioids, sedatives or stimulants) taken appropriately under medical supervision. Remission specifiers: early remission = after full criteria were met, none met (except craving) for at least 3 but less than 12 months; sustained remission = none met (except craving) for 12 months or longer. Add in a controlled environment when access is restricted (e.g., locked unit, jail), and on maintenance therapy for opioids or tobacco when applicable. Substance-specific notes: cannabis withdrawal exists (irritability, anxiety, sleep problems, decreased appetite, restlessness); hallucinogens and inhalants have no withdrawal criterion.

Hinge differentials.

• Nonproblematic use or experimentation: use without impaired control, consequences or physiological dependence.
• Appropriate medical use: tolerance/withdrawal on prescribed medication alone; misuse, escalation or illicit sources signal a disorder.
• Substance-induced disorders: symptoms (depression, anxiety, psychosis) that arise during intoxication or withdrawal and resolve with abstinence.
• Independent mental disorder: symptoms that precede use or persist well into abstinence.

On the NCMHCE. Count criteria from the vignette and match the severity specifier. Screen for withdrawal risk (alcohol, benzodiazepines), overdose, impaired driving, suicide risk and co-occurring disorders. Use standardized screens and collateral, refer for medical evaluation when physiological dependence appears, and match level of care to need. Use motivational interviewing, person-first language ("person with a substance use disorder"), and describe criteria as behavior patterns rather than labels. Adolescents need the same criteria, not a separate threshold.

Clinical Pearl: 2 of 11 in 12 months: 2–3 mild, 4–5 moderate, 6+ severe. Prescribed-as-directed tolerance and withdrawal never count.