Substance Use Disorder — Recognition + Diagnosis
Module 2 of 11 · 45 min
DSM-5 criteria, screening tools (CAGE-AID, AUDIT, DAST-10), behavioral red flags, addressing in clinical encounter.
Learning objectives
- •Apply DSM-5 SUD criteria to a clinical scenario
- •Choose appropriate validated screening tool by population
- •Recognize behavioral, physical, social red flags for SUD
- •Conduct a non-stigmatizing screening conversation
DSM-5 — 11 criteria, severity by count
Substance use disorder diagnosis requires 2+ of: (1) using more/longer than intended, (2) unable to cut down, (3) significant time spent obtaining/using/recovering, (4) cravings, (5) failure to fulfill role obligations, (6) continued use despite social/interpersonal problems, (7) social/recreational/occupational activities given up, (8) recurrent use in physically hazardous situations, (9) continued use despite physical/psychological problems, (10) tolerance, (11) withdrawal. Severity: mild (2-3), moderate (4-5), severe (6+). Remission = absence of criteria for 3+ months (early), 12+ months (sustained).
Screening tools
CAGE-AID (4 questions, modified for drugs + alcohol): C-cut down, A-annoyed, G-guilty, E-eye opener. ≥ 2 positives = high likelihood. AUDIT (10 questions, alcohol-specific): scores 8+ in men, 6+ in women warrant further evaluation. DAST-10 (drugs other than alcohol). NIDA Quick Screen (1 question per substance class). For pain patients: ORT (Opioid Risk Tool), SOAPP-R. None replace clinical judgment; all reduce miss rate.
Red flags in clinical encounter
Behavioral: doctor shopping, requesting specific opioid by name, lost prescription stories, escalating dose without anatomical basis, seen in ED frequently for pain. Physical: track marks, dental decay (meth), nasal septum perforation (cocaine), unexplained weight changes. Social: family conflict, work problems, legal issues, frequent moves. PDMP (Prescription Drug Monitoring Program) check is mandatory in most states before opioid prescribing — pulls multi-state data, shows pattern of fills.
How to ask
Open with universal screening: 'I ask everyone about substance use because it affects how I care for you.' Use specific quantifiable questions: 'How many drinks per week on average?' not 'Do you drink?' Avoid loaded language: 'addict,' 'abuser,' 'clean/dirty urine.' Use: 'person with OUD,' 'has used,' 'positive/negative for X.' Stigma reduces disclosure → reduces care quality. Build rapport before probing.
References
- · DSM-5
- · SAMHSA TIP 67 (Clinical Tools)
- · ASAM Criteria 4th Ed