Medications, Pharmacology: What are the four main diagnostic criteria of a substance use disorder?

October 11, 2025 •

4 min read

According to the National Survey on Drug Use and Health, approximately 48.7 million people in the U.S. met the criteria for a substance use disorder (SUD) in 2022. A proper diagnosis is the first step toward effective treatment, and understanding what are the four main diagnostic criteria of a substance use disorder is crucial for this process.

Quick Summary

The four main diagnostic clusters for a substance use disorder are impaired control, social impairment, risky use, and pharmacological effects (tolerance and withdrawal). Diagnosis is made based on meeting a specific number of 11 individual criteria across these four areas, as defined by the DSM-5.

Key Points

Impaired Control: This cluster includes criteria that reflect a loss of control over substance use, such as using more than intended, experiencing cravings, and failing to cut down use.
Social Impairment: A person with an SUD often fails to meet major life obligations at work, school, or home and continues use despite relationship problems.
Risky Use: This includes repeated use in physically dangerous situations or continuing use despite a known physical or psychological problem caused or worsened by the substance.
Pharmacological Effects: The physiological adaptations of tolerance (needing more for the same effect) and withdrawal (symptoms when use is stopped) are included in the diagnostic criteria.
Severity Spectrum: The DSM-5 assesses SUD severity based on the number of criteria met, from mild (2-3) to moderate (4-5) to severe (6 or more).
Pharmacological Treatment: Medications are often used in conjunction with therapy to address cravings, withdrawal, and normalize brain chemistry during recovery.
Neurobiological Basis: Addiction involves complex neuroadaptations in the brain's reward, stress, and executive function circuits, which can be addressed through combined treatment approaches.

A substance use disorder (SUD) is a complex and treatable medical condition characterized by a loss of control over substance use despite harmful consequences. A correct diagnosis is essential for determining the appropriate course of action, which often includes a combination of behavioral therapies and pharmacological interventions. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), provides a comprehensive framework for diagnosing SUDs across 11 specific criteria that fall into four major diagnostic clusters. This framework helps clinicians understand the severity and nature of the disorder, moving past the outdated distinction between 'abuse' and 'dependence'.

The Four Pillars of SUD Diagnosis (DSM-5)

1. Impaired Control

This cluster includes symptoms that reflect the individual's difficulty in controlling their substance use, despite a desire to do so. It highlights the compulsive nature of the disorder. The criteria in this category are:

The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time is spent in activities necessary to obtain, use, or recover from the substance's effects.
An intense craving or strong desire or urge to use the substance is experienced.

2. Social Impairment

This cluster focuses on the social and interpersonal consequences of substance use, where an individual's use takes precedence over their responsibilities and relationships. Symptoms include:

Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued substance use despite having persistent or recurrent social or interpersonal problems caused or worsened by its effects.
Important social, occupational, or recreational activities are given up or reduced because of substance use.

3. Risky Use

This category involves the continued use of a substance in situations that are physically hazardous, or despite knowledge of a negative health impact. The criteria reflect a disregard for personal safety and well-being. They are:

Recurrent substance use in situations in which it is physically hazardous.
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance.

4. Pharmacological Effects (Tolerance and Withdrawal)

This cluster includes the physiological adaptations that occur with repeated substance exposure. These are key indicators of physical dependence, which often drives continued use. The two criteria are:

Tolerance: A need for markedly increased amounts of the substance to achieve intoxication or a desired effect, or a markedly diminished effect with continued use of the same amount of the substance.
Withdrawal: The characteristic withdrawal syndrome for the specific substance, or the substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Determining the Severity of a Substance Use Disorder

Under the DSM-5, the number of criteria met by an individual determines the severity of the SUD. This is crucial for guiding treatment intensity and setting appropriate goals.


Severity Level	Number of Criteria Met	Characteristics
Mild	2-3 criteria	Substance use is causing some level of impairment or distress, but the number of issues is relatively low.
Moderate	4-5 criteria	More extensive issues related to control, social life, and risky behavior indicate a more entrenched problem.
Severe	6 or more criteria	The individual is experiencing a significant loss of control, and multiple life areas are being negatively impacted.

The Role of Medications and Pharmacology

Pharmacology, the study of drugs and their effects, plays a critical role in treating substance use disorders, particularly by addressing the physiological symptoms within the pharmacological criteria cluster. Medication-assisted treatment (MAT) helps normalize brain chemistry, alleviate withdrawal symptoms, and reduce cravings, allowing patients to focus on behavioral therapies.

Addressing Withdrawal: Medications can ease the physical discomfort and emotional distress of withdrawal, reducing the powerful motivation to use again for relief.
Mitigating Cravings: Certain pharmacological agents can help control cravings, which are a key component of the impaired control cluster. For example, naltrexone and buprenorphine are used for opioid use disorder to reduce cravings.
Blocking Effects: Antagonist medications, like naltrexone, can block the rewarding effects of a substance, making it less appealing and helping to prevent relapse.
Supporting Recovery: In combination with counseling and behavioral therapies, medication provides a comprehensive, 'whole-patient' approach to treatment that has been shown to improve survival rates and increase treatment retention.

The Neurobiological Context of SUD

Understanding the underlying neurobiology of addiction helps explain why individuals develop a substance use disorder. Repeated substance use profoundly alters specific brain circuits:

Reward Circuitry (Basal Ganglia): Substances hijack the brain's reward system, leading to a surge of dopamine that reinforces use. Over time, the brain becomes less responsive to natural rewards, leading to anhedonia and an increased need for the substance.
Stress Circuitry (Extended Amygdala): Chronic use leads to an overactive stress response system. The unpleasant emotional state of withdrawal is driven by this 'anti-reward' system, motivating the individual to seek the substance for relief.
Executive Functioning (Prefrontal Cortex): The prefrontal cortex, responsible for impulse control and decision-making, becomes impaired. This weakening of 'executive control' contributes to compulsive substance seeking, particularly when triggered by drug-related cues.

Conclusion

Understanding what are the four main diagnostic criteria of a substance use disorder provides the essential framework for clinicians to make an accurate diagnosis. The DSM-5 clusters of impaired control, social impairment, risky use, and pharmacological effects offer a detailed view of the multi-faceted nature of SUD. This medical condition, rooted in significant neurobiological changes, can be effectively treated through a combination of pharmacological interventions and psychosocial therapies. Continued research, particularly in areas like pharmacogenetics and novel drug development, offers promising avenues for more personalized and effective treatment strategies. Resources from organizations like the National Institute on Drug Abuse (NIDA) can offer further insight into addiction research and treatment options.

Frequently Asked Questions

The 11 individual diagnostic criteria for SUD, as outlined in the DSM-5, are grouped into the four main clusters: impaired control, social impairment, risky use, and pharmacological effects. A diagnosis is made when an individual meets at least two of these 11 criteria within a 12-month period.

Substance use refers to any use or misuse of a substance, while a substance use disorder is a diagnosable medical condition. An SUD diagnosis requires meeting specific criteria that show a pattern of problematic use and significant impairment or distress.

Yes. An individual only needs to meet two of the 11 total criteria for a diagnosis. It is possible to meet criteria in the other three clusters (impaired control, social impairment, risky use) without showing evidence of tolerance or withdrawal.

The pharmacological effects criteria, which include tolerance and withdrawal, signify that a person's body has adapted physically to the substance. This can make quitting more difficult and is often addressed with medication-assisted treatment to manage physiological symptoms.

SUDs frequently co-occur with mental health disorders like depression, anxiety, or PTSD. Both conditions should be diagnosed and treated simultaneously, as they can interact and worsen each other's symptoms, making diagnosis and recovery more complex.

MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a 'whole-patient' approach to treating SUDs. Medications can reduce cravings, lessen withdrawal symptoms, and block the euphoric effects of substances, improving patient outcomes.

While SUD is considered a chronic, relapsing disorder with long-lasting brain changes, it is treatable. Recovery is possible and sustainable with proper, ongoing treatment, though the risk of relapse can persist for years.