Substance use disorder
Criteria span impaired control, social impairment, risky use and pharmacologic features. Two or three criteria indicate mild, four or five moderate, and six or more severe disorder, with substance-specific exceptions.
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Brooke Harbor Health System
PMHNP Clinical Learning Environment
Condition Guide
Condition GuideAssessment, differential, treatment, and monitoring guidance.
Substance-Related and Addictive Disorders
Substance-related care combines nonjudgmental assessment, immediate attention to intoxication, withdrawal and overdose, evidence-based treatment, harm reduction, co-occurring psychiatric and medical care, and sustained support for recovery goals.
Clinical application
Using this resource
Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.
Use this when
- Substance use, a behavioral addiction, or a possible intoxication, withdrawal, overdose, or substance-induced presentation could affect assessment, safety, or treatment planning.
Clarify first
- Ask nonjudgmentally about actual substances, medications and products used, amount, route, source, pattern, timing of last use, recent change, prior complications, and current symptoms.
- Assess medical stability, overdose and withdrawal concern, co-occurring psychiatric symptoms, patient goals, supports, and readiness for change.
Act now
- Address the highest-priority safety or medical question, then match harm-reduction, treatment, monitoring, and coordination options to the person’s goals and current setting.
Document and communicate
- Record reported and observed use, timing and sources, current findings, risk and diagnostic formulation, patient goals, agreed actions, monitoring, and ownership of follow-up.
Escalate or consult when
- There is overdose concern, severe intoxication or withdrawal, delirium, seizures, impaired consciousness, significant physiologic instability, acute safety risk, or inability to manage safely in the current setting.
Diagnostic Features
Separate use, disorder, intoxication, withdrawal and induced syndromes
DSM-5-TR substance-use diagnosis is based on a maladaptive pattern and consequences—not a toxicology result, tolerance alone or moral judgment.
Intoxication
A clinically significant behavioral or psychological change develops during or shortly after exposure with substance-specific signs, after competing medical, psychiatric and polysubstance explanations are considered.
Withdrawal
A substance-specific syndrome follows cessation or reduction after prolonged or heavy use and causes distress or impairment; alcohol and sedative withdrawal can be life-threatening.
Substance/medication-induced disorders
Mood, psychotic, anxiety, sleep, sexual, neurocognitive and other syndromes require evidence that the exposure produced the symptoms, and that they are not better explained by an independent disorder or by delirium.
Gambling disorder
Persistent, recurrent problematic gambling causes impairment or distress, with at least four specified features in twelve months and behavior not better explained by a manic episode.
Remission and controlled environment
Early and sustained remission specifiers depend on how long criteria other than craving have been absent; a controlled-environment specifier does not itself establish remission.
Rating Scales & Screening
Use validated tools without turning a screen into a diagnosis
Choose age- and substance-appropriate tools, follow positive results with assessment, and use withdrawal scales only in suitable clinical settings.
AUDIT and AUDIT-C
WHO alcohol-risk screening and brief consumption screen; positive findings require diagnostic and safety assessment.
Open WHO AUDIT manual ↗ASSIST
WHO instrument covering tobacco, alcohol and multiple drug classes with risk-linked brief-intervention guidance.
Open WHO ASSIST manual ↗TAPS
NIDA-supported adult tobacco, alcohol, prescription medication and other substance screening tool.
Open TAPS ↗CRAFFT
Validated adolescent substance-use screening framework; use the current age-appropriate version and follow-up questions.
Open CRAFFT ↗CIWA-Ar
Alcohol-withdrawal severity scale used to guide monitoring in appropriate settings; do not use it to diagnose alcohol use disorder.
Open ASAM withdrawal guideline ↗Clinical Opiate Withdrawal Scale
Clinician-rated opioid-withdrawal severity tool used with examination and treatment context; it does not diagnose opioid use disorder.
Open COWS PDF ↗Assessment
Ask about actual use and immediate risk
Use specific, neutral language and distinguish screening, diagnosis, physiologic dependence, intoxication, withdrawal, and the patient’s own goals.
Pattern and consequences
Assess substance, amount, route, frequency, last use, tolerance, control, craving, consequences, prior change attempts, treatment, overdose, withdrawal, and periods of remission.
Immediate syndromes
Identify intoxication, withdrawal, delirium, psychosis, agitation, sedation, respiratory depression, seizures, dehydration, hyperthermia, chest pain, and other medical emergencies.
Co-occurring conditions
Assess suicide risk, trauma, mood and psychotic symptoms, pain, sleep, pregnancy, infection risk, cognition, housing, violence or victimization, and prescribed medication exposure.
Screening and testing
Use validated tools such as AUDIT-C, DAST-10 or substance-specific screens when appropriate. Toxicology testing answers a limited question and requires consent, interpretation, and context.
Treatment
Offer evidence-based treatment without unnecessary delay
Match intervention intensity to risk, diagnosis, goals, access, prior response, and the care setting.
Alcohol use disorder
Consider naltrexone, acamprosate, disulfiram, and other evidence-informed options as appropriate; address withdrawal separately and account for hepatic, renal, opioid, and adherence considerations.
Opioid use disorder
Buprenorphine, methadone, and extended-release naltrexone are evidence-based medications. Withdrawal management alone is not treatment and can increase post-withdrawal overdose risk.
Tobacco and stimulant disorders
Offer evidence-based tobacco pharmacotherapy and counseling. For stimulant use disorder, contingency management and other behavioral treatment are central; treat acute complications and co-occurring illness.
Behavioral care
Use motivational interviewing, contingency management, CBT, relapse-prevention approaches, peer support, mutual-help options, and family involvement according to goals and preference.
Harm Reduction
Reduce preventable harm at every stage of change
Harm reduction and recovery-oriented treatment are complementary, not competing, approaches.
Overdose prevention
Provide naloxone access and education, discuss reduced tolerance, mixing sedatives, fentanyl exposure, using alone, and response steps. Include family or supports when the patient agrees.
Safer use and infection prevention
Discuss sterile supplies, wound care, HIV and hepatitis testing or prevention, vaccination, sexual health, and local low-barrier services without making abstinence a prerequisite.
Medication continuity
Avoid unnecessary interruption of methadone, buprenorphine, benzodiazepines, or other physiologically relevant medications; verify the regimen and manage changes safely.
Transitions
Overdose and suicide risk may rise after detoxification, hospitalization, incarceration, residential treatment, or medication disruption. Make follow-up, medication, transportation, and crisis plans concrete.
Longitudinal Care
Treat recurrence as clinical information
Recovery trajectories vary; continue reassessment and engagement after return to use.
Measurement
Track patient-defined goals, use pattern, craving, overdose, withdrawal, function, health outcomes, treatment participation, medication response, and quality of life.
Reassess the plan
After return to use, review triggers, treatment intensity, medication adequacy, barriers, pain, psychiatric symptoms, housing, supports, and overdose risk rather than automatically discharging the patient.
Integrated treatment
Coordinate psychiatric, addiction, primary, infectious-disease, obstetric, pain, social, and peer services. Avoid requiring one condition to be resolved before another receives care.
Recovery supports
Offer multiple pathways, including medications, therapy, peer support, mutual-help groups, recovery coaching, housing and vocational assistance, and culturally responsive community resources.
Clinical Sources
Use current guidance and patient-specific evidence
These sources support clinical reasoning but do not replace a complete assessment, current prescribing information, local policy, consultation, or individualized shared decision-making.
ASAM Clinical Guidelines
Current guidelines for opioid, alcohol-withdrawal, stimulant, and other substance-related care.
Open source ↗ASAM Opioid Use Disorder Guideline
Evidence-based medication treatment and overdose-prevention recommendations.
Open source ↗ASAM Stimulant Use Disorder Guideline
Assessment, acute management, behavioral treatment, and recovery guidance.
Open source ↗Last updated September 1, 2026