Problems with DSM 5 Substance Use Disorder

DSM 5 classifies all mental health problems as “behavioral disorders”, hence, everything becomes a checklist about behavior with little focus on thinking and feeling issues, with no connection to the brain. Even the brain research that is done for mental health issues is backwards i.e. A DSM 5 diagnosis is taken as fact, then the brain is looked at in terms of those patients rather than looking at the brain first in context of symptoms and signs that constitute a disease, which has anatomic and physiological basis, consistently across the board in people who have it. What creates the confusion is that similar behaviors can be classified as different disorders under DSM 5, hence, the common observation that a DSM 5 diagnosis is in the eyes/brain of the psychologist (non-physicians) or psychiatrist (specialist physicians, who can prescribe) – with other physicians blindly following DSM 5 and prescribing psychotropic medications that they have little understanding off. Sadly, even psychiatrists don’t learn much pharmacology and are often in-bed with pharma to tie up specific drugs with specific DSM 5 diagnoses that then becomes their “specialization”. Sadly, social workers, journalists and the public have been hood-winked into adopting DSM 5 as being an “anti-stigma” document when it reinforces dependence on a new nomenclature that assigns more stigmatizing labels that some even consider fashionable and justification for going on medications and ongoing dysfunction… e.g., “bipolar disorder” or “social anxiety disorder” or “borderline personality disorder”.

The current “behavioral disorders” idea started with DSM III in 1980. American Psychiatric Association used I, II, III and IV but then changed to 5 in 2013. So, the ignorance is visible immediately if someone says, “DSM V”! Before DSM 5, the classification was “Substance-related disorders” that were divided into “Substance-induced Disorders” and “Substance Use Disorders”. The caveat that most clinicians have ignored for decades has been that you cannot make any DSM diagnosis if the individual has ongoing substance use. Most clinicians don’t ask, minimize or sympathize – thinking that substance abuse is “self-medication” for some underlying psychiatric problem or now it has become fashionable to focus on trauma; hence, justification of ongoing use, especially alcohol and cannabis. There has never been a shred of evidence that treating a DSM diagnosis makes substance-related problems go away and the evidence that once someone gets into recovery (abstinence-based), most if not all, “psychiatric disorders” go into remission is never talked about because it is not “mainstream”, which is dominated by the American Psychiatric Association (APA) with complicit support from the American Psychological Association, which is even bigger!

Addiction is a primary chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief with substance use and other behaviors.

Addiction is characterized by inability to consistently abstain (A), impairment in behavioral control (B), craving (C), diminished recognition of significant problems with one’s behaviors and interpersonal relationships (D), and a dysfunctional emotional response (E). Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

This basically recognized the fundamental neurobiology/genetics that is the foundation of the disease of Addiction with behavior being a consequence of the disease, not the disease nor the cause of the disease. We clearly said that a “behavior disorder” and Addiction are not synonyms, yet DSMologists shy away from disease and call it “Addictions” or “Addictive Disorders”, in the vein of “Substance Use Disorder(s)”, even though no one uses one substance alone; and further, they attach a whole bunch of other DSM “disorders” to justify medicating people under the guise of “co-morbidities”. Even DSM 5 classifies “substance use disorder” as mild, moderate or severe to sort of say that moderate or severe are more chronic. Unfortunately, “mild” that can be hazardous use, which for alcohol, may allow for moderation; yet, it is thereafter translated to other substances abuse to help “control” or “moderate” use of opioids, cannabis, club drugs or psychedelics, despite there being no evidence for that “controlled” use of any substances other than alcohol or caffeine, where “low-risk” use is defined, not “safe use”. Anyways, if you do an internet search for terminology, confusion reigns because many people have invented many interpretations, including ASAM, which is so sad. Many Addiction Physicians have quit ASAM as a result.


ASAM also quietly shelved the 2011 definition in 2019 and brought in a “new definition” more in line with DSM 5 that basically only talks about Addiction as compulsion and continued use despite adverse consequences, which is basically old “substance abuse”. Substance Dependence has craving and impaired control, which is included in DSM 5 as criteria for “substance use disorder”!


I still endorse the 2011 definition as the “gold standard” and try to educate people that the core disease is thinking and feeling problems (the D and the E), which is backed by neuroscience related to the pre-frontal cortex, amygdala, insula, hippocampus etc. – collectively often called the “limbic system”. DSM and even WHO (ICD – International Classification of Diseases) remain stuck in A, B and C, while ASAM has gone backwards in endorsing only A and B tangentially and sticking to the old criteria for “substance abuse”, which was continued use despite adverse consequences. The establishment of AA in 1935 was to help “alcoholics” live alcohol-free… aim for “progress, not perfection”, while recognizing the chronicity and complexity “cunning, baffling and powerful… obsession of the mind…” of “alcoholism”. Even through the 1960s and 1970s, “alcoholism” was called a three-headed dragon – drinking, thinking and feeling.


Treating “opioid use disorder” with naloxone to reverse overdoses; and putting people on maintenance medications – buprenorphine or methadone – perpetuates the myth of “opioid deficiency” akin to Type 1 Diabetes (insulin deficiency) – that means opioid substitution (OST) or replacement (ORT) or agonist treatment (OAT) or agonist maintenance (OAM) for life! Further, ASAM has further changed MAR (medication assisted recovery) to MAT (medication for addiction treatment) for “opioid use disorder” and naltrexone for “alcohol use disorder”. This has resulted in many prominent ASAM members to say, MAT = Medications as Addiction Treatment, with no recognition of psycho-social-spiritual elements for recovery!

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