Day Four

Substance Use Disorders

Definition of Addiction
Compulsive need for and use of a habit-forming substance (such as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly: persistent compulsive use of a substance known by the user to be harmful

Agenda - Day Four

8:30 AM – 9:00


9:00 – 10:00

Introductions, Expectations & Experiential Exercise


10:00 – 11:00

Introduction and Overview of addictions

11:00 – 11:15


11:15 – 12:15 PM

Assessment and Treatment Overview

Experiential Exercise

12:15 – 1:00


1:00 – 2:00

Meditation/Breathing/Grounding/ focusing

Motivational Interviewing

2:00 – 2:30

Discussions and Questions

2:30 – 2:45


2:45 – 3:45

Experiential Seeking Safety group

3:45 – 4:30

Individual check-in

Feedback and a Brief Evaluation of the Day

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

DSM-V or DSM 5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, often called the DSM-V or DSM 5, is the latest version of the American Psychiatric Association’s gold-standard text on the names, symptoms, and diagnostic features of every recognized mental illness—including addictions.

The DSM-V criteria for substance use disorders are based on decades of research and clinical knowledge. This edition was published in May 2013, nearly 20 years after the original publication of the previous edition, the DSM-IV, in 1994.

What Are Substance Use Disorders?

The DSM-V recognizes substance-related disorders resulting from the use of ten separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens (phencyclidine or similarly acting arylcyclohexylamines), other hallucinogens such as LSD, inhalants, opioids, sedatives- hypnotics- or anxiolytics, stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and other or unknown substances. Therefore, while some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.

The activation of the brain’s reward system is central to problems arising from drug use—the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.

While the pharmacological mechanisms for each class of drug is different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”

The DSM-V recognizes that people are not all automatically or equally vulnerable to developing substance-related disorders and that some people have lower levels of self-control that predispose them to develop problems if they're exposed to drugs.

There are two groups of substance-related disorders: substance-use disorders and substance-induced disorders. Substance-use disorders are patterns of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result. Substance-induced disorders, including intoxication, withdrawal, other substance/medication-induced mental disorders, are detailed alongside substance use disorders.

Criteria for Substance Use Disorders

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

  1. Taking the substance in larger amounts or for longer than you're meant to
  2. Wanting to cut down or stop using the substance but not managing to
  3. Spending a lot of time getting, using, or recovering from use of the substance
  4. Cravings and urges to use the substance
  5. Not managing to do what you should at work, home, or school because of substance use
  6. Continuing to use, even when it causes problems in relationships
  7. Giving up important social, occupational, or recreational activities because of substance use
  8. Using substances again and again, even when it puts you in danger
  9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance
  10. Needing more of the substance to get the effect you want (tolerance)
  11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

Severity of Substance Use Disorders

The DSM-V allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder; and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”


The DSM-V allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder; and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”


Substance intoxication, a group of substance-induced disorders, detail the symptoms that people experience when they are "high" from drugs. Disorders of substance intoxication include:

Substance/Medication-Induced Mental Disorders

Substance/medication-induced mental disorders are mental problems that develop in people who did not have mental health problems before using substances, and include:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - DSM 5. American Psychiatric Association. 2013.



 Addiction can develop despite a person's best intentions and in spite of their strength of character. Repeated drug use disrupts complex but well balanced systems in the human brain. Many people are addicted to more than one substance, complicating their efforts to recover.

The human brain is an extraordinarily complex and fine-tuned communications network containing billions of specialized cells (neurons) that give origin to our thoughts,  motions, perceptions and drives. Often, a drug is taken the first time by choice to feel pleasure or to relieve depression or stress. But this notion of choice is short-lived. Why? Because repeated drug use disrupts well-balanced systems in the human brain in ways that persist, eventually replacing a person's normal needs and desires with a one-track mission to seek and use drugs.

At this point, normal desires and motives will have a hard time competing with the desire to take a drug.

How Does the Brain Become Addicted?

 Typically it happens like this:

 A person takes a drug of abuse, be it marijuana or cocaine or even alcohol, activating the same brain circuits as do behaviors linked to survival, such as eating, bonding and sex. The drug causes a surge in levels of a brain chemical called dopamine, which results in feelings of pleasure. The brain remembers this pleasure and wants it repeated. Just as food is linked to survival in day-to-day living, drugs begin to take on the same significance for the addict. The need to obtain and take drugs becomes more important than any other need, including truly vital behaviors like eating. The addict no longer seeks the drug for pleasure, but for relieving distress. Eventually, the drive to seek and use the drug is all that matters, despite devastating consequences. Finally, control and choice and everything that once held value in a person's life, such as family, job and community, are lost to the disease of addiction. What brain changes are responsible for such a dramatic shift? Research on addiction is helping us find out just how drugs change the way the brain works.

These changes include the following:

  • Reduced dopamine activity. We depend on our brain's ability to release dopamine in order to experience pleasure and to motivate our responses to the natural rewards of everyday life, such as the sight or smell of food. Drugs produce very large and rapid dopamine surges and the brain responds by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the addict incapable of feeling any pleasure even from the drugs they seek to feed their addiction.

  • Altered brain regions that control decision-making and judgment. Drugs of abuse affect the regions of the brain that help us control our desires and emotions. The resulting lack of control leads addicted people to compulsively pursue drugs, even   when the drugs have lost their power to reward. 

  • The disease of addiction can develop in people despite their best intentions or strength of character. Drug addiction is insidious because it affects the very brain areas that people need to "think straight," apply good judgment and make good decisions for their lives. No one wants to grow up to be a drug addict, after all.
Co-occurring Addictions: Compounding Complexities

It is not unusual for an addicted person to be addicted to alcohol, nicotine and illicit drugs at the same time. Addiction to multiple substances raises the level of individual suffering and magnifies the associated costs to society. No matter what the addictive substance, they all have at least one thing in common - they disrupt the brain's reward pathway, the route to pleasure.

What is the best way to treat people who are addicted to more than one drug?


 In some cases, medications developed for one addiction have proven useful for another. For example, naltrexone, which can help former heroin users remain abstinent by blocking the "high" associated with heroin, has been found to be effective in treating alcoholism.

Behavioral therapy or other psychotherapy

 Behavioral therapies do not need to be specific to one drug and can be adapted to address use of multiple or different drugs. It is the disease of addiction that the therapy addresses.

Combined medications and behavioral therapy

Research shows that this combination, when available, works best.

Multipronged approach.

Treatment for multiple addictions should be delivered at the same time. This is especially true because there are always triggers, such as trauma, depression, or exposure to one drug or another, that can put the recovering addict at risk for relapse. In addition, treatment must consider all aspects of a person – their age, gender, and life experiences - in order to best treat their drug addiction. Although the type of treatment may differ, it should always strive to address the entire person through a multipronged approach that tackles all co-occurring conditions at once.

Relapse: Part of Addiction as a Chronic Disease

Despite the availability of many forms of effective treatment for addiction, the problem of relapse remains the major challenge to achieving sustained recovery. People trying to recover from drug abuse and addiction are often doing so with altered brains, strong drug-related memories and diminished impulse control. Accompanied by intense drug cravings, these brain changes can leave people vulnerable to relapse even after years of being abstinent. Relapse happens at rates similar to the relapse rates for other well-known chronic medical illnesses like diabetes, hypertension and asthma.

How is relapse to substance use similar to what happens with other chronic diseases?
  • Just as an asthma attack can be triggered by smoke, or a person with diabetes can have a reaction if they eat too much sugar, a drug addict can be triggered to return to drug abuse.

  • With other chronic diseases, relapse serves as a signal for returning to treatment. The same response is just as necessary with drug addiction.

  • As a chronic, recurring illness, addiction may require repeated treatments until abstinence is achieved. Like other diseases, drug addiction can be effectively treated and managed, leading to a healthy and productive life.

To achieve long-term recovery, treatment must address specific, individual patient needs and must take the whole person into account. For it is not enough simply to get a person off drugs; rather, the many changes that have occurred - physical, social, and psychological - must also be addressed to help people stay off drugs, for good.