Substance Use

Substance Use is the contemporary, less-stigmatizing terminology used by national and international health bodies (SAMHSA, NIDA, WHO) for what was historically called "substance abuse." Substance Use Disorder is the formal DSM-5-TR diagnosis covering problematic use of alcohol, drugs, and other psychoactive substances.

Overview

“Substance use” is the contemporary clinical and public-health terminology for engagement with psychoactive substances; Substance Use Disorder (SUD) is the formal DSM-5-TR diagnosis covering problematic use that meets diagnostic threshold. This terminology has been adopted by SAMHSA, NIDA, the WHO, and most national health bodies in place of the older “abuse” terminology, reflecting recognition that stigmatizing language reduces help-seeking and worsens outcomes.

The shift from “abuse” to “use” is more than semantic. Research consistently shows that stigmatizing terminology in clinical settings is associated with lower treatment-seeking, lower treatment retention, and worse clinical outcomes. Person-first language (e.g., “person with substance use disorder” rather than “addict” or “abuser”) and recovery-oriented framing produce better engagement. Major guidelines and clinical training programs now use the contemporary terminology.

Substance Use Disorders affect approximately 20% of Canadian adults at some point in their lifetime. SUDs are recognized as chronic, relapsing brain disorders with documented neurobiological changes in reward, motivation, executive control, and stress regulation circuits. The “chronic disease” model — comparable to type 2 diabetes or hypertension — is the contemporary clinical framework. This model is associated with reduced stigma, improved treatment engagement, and better outcomes.

The DSM-5 (2013) consolidated the previous “Substance Abuse” and “Substance Dependence” diagnoses into a single Substance Use Disorder diagnosis with severity specifiers. The DSM-5-TR (2022) maintains this framework. Substance-specific diagnoses exist for alcohol, cannabis, hallucinogens, inhalants, opioids, sedative-hypnotics, stimulants, tobacco, and others; the diagnostic criteria are largely consistent across substances.

Comorbidity with mental-health conditions is the rule rather than the exception. Trauma history, mood disorders, anxiety disorders, ADHD, and personality disorders all elevate SUD risk and complicate treatment. Integrated, trauma-informed, person-centered care produces the best outcomes.

Signs and symptoms

Loss of control over use — Use of the substance in larger amounts or over a longer period than intended; repeated unsuccessful efforts to cut down or stop.
Significant time on substance-related activities — Substantial time obtaining, using, or recovering from the substance.
Craving — Persistent strong desire or urge to use the substance.
Failure to fulfill obligations — Recurrent use resulting in failure to fulfill major obligations at work, school, or home.
Continued use despite social or interpersonal problems — Continued use despite persistent social or interpersonal problems caused or exacerbated by use.
Important activities given up — Important social, occupational, or recreational activities given up or reduced because of use.
Use in physically hazardous situations — Recurrent use in situations in which it is physically hazardous.
Continued use despite physical or psychological harm — Continued use despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance.
Tolerance — Need for markedly increased amounts to achieve effect, or markedly diminished effect with same amount.
Withdrawal — Substance-specific withdrawal syndrome on cessation, or use of the substance to relieve or avoid withdrawal.

Diagnostic context

Substance Use Disorder diagnostic criteria, severity specifiers, and clinical evaluation framework are described in detail on the substance-abuse page. The DSM-5-TR uses the same 11 criteria across substance classes (alcohol, cannabis, opioids, stimulants, sedatives, etc.) with substance-specific modifiers for tolerance and withdrawal patterns.

Severity specifiers: mild (2-3 criteria), moderate (4-5), severe (6+). Specify if in early remission (3-12 months), sustained remission (12+ months), in a controlled environment, or on maintenance therapy.

This page is provided as a contemporary-terminology entry point; the clinical content is the same as the substance-abuse page and the substance-specific pages (alcohol-abuse, drug-abuse, gambling-addiction, etc.).

Causes and risk factors

SUDs develop through interaction of biological, psychological, and social factors:

Genetic factors: heritability of SUDs ranges from approximately 40% to 60% across substances. Genetic vulnerability overlaps substantially across substance classes and with comorbid mental-health conditions.

Neurobiological factors: repeated substance use produces neuroplastic changes in mesolimbic dopamine reward circuits, prefrontal executive control, amygdala stress response, and habenula aversion circuits.

Developmental factors: early initiation (before age 15) substantially elevates lifetime SUD risk. Childhood ACE exposure, family history of SUD, ADHD, conduct disorder, and early peer use are all robust predictors.

Psychological factors: co-occurring mental-health conditions, particularly trauma history, depression, anxiety disorders, PTSD, ADHD, and personality disorders.

Social and environmental factors: peer use, family use, accessibility, neighbourhood disorder, poverty, discrimination, housing instability, and trauma exposure.

Substance-specific factors: route of administration, pharmacokinetics, accessibility, and supply contamination (fentanyl in opioids).

Comorbidity: approximately 50-60% of SUD has comorbid mental-health condition. Co-occurring tobacco use disorder is extremely common across SUD populations.

Stigma as a contributor to outcomes: stigma toward people who use substances is itself a contributor to SUD severity and treatment outcomes. Stigmatizing language and attitudes (in healthcare settings, in families, in workplaces) reduce help-seeking, treatment retention, and recovery rates. Reducing stigma is a public-health priority.

Typical treatments

Evidence-based treatment combines pharmacotherapy (where available), psychotherapy, peer support, harm-reduction services, and treatment of comorbid mental-health conditions. Detailed treatment information is provided on the substance-specific specialty pages and on the substance-abuse hub page.

Person-centered, trauma-informed, recovery-oriented care is the contemporary clinical standard. Key features:

Engagement begins where the person is, including ongoing use; abstinence is one option among several recovery goals.
Trauma-informed practices recognize the high prevalence of trauma in SUD populations and avoid practices that retraumatize.
Person-first, non-stigmatizing language is used throughout.
Cultural competence and recognition of intersectional identity (race, sexuality, gender, disability, immigration status) shape care.
Harm reduction is integrated with abstinence-oriented options.
Lived-experience peer support is integrated into clinical care.
Recovery is supported across multiple life domains (housing, employment, relationships, meaning) — not only substance use.

Pharmacotherapy (MAT) for alcohol, opioid, and tobacco use disorders has substantial evidence and is significantly underused in clinical practice. Expansion of access is a public-health priority.

Psychotherapy: CBT, motivational interviewing, contingency management, mindfulness-based relapse prevention, trauma-focused therapies. Strong evidence base; specific approach matched to substance, severity, and patient preferences.

Peer support: 12-step (AA, NA, GA), SMART Recovery, Refuge Recovery, LifeRing. Sustained engagement correlates with better outcomes.

Harm reduction: naloxone distribution, supervised consumption sites, drug-checking, syringe services, low-barrier MAT access. Reduces mortality and morbidity.

Integrated dual-diagnosis treatment for co-occurring mental-health conditions.

When to seek help

Professional support is indicated when:

You have been unable to control substance use despite repeated efforts.
Use is producing significant consequences in relationships, work, finances, health, or legal status.
You experience cravings, tolerance, or withdrawal symptoms.
You are using to manage emotions, cope with stress, or avoid withdrawal.
Co-occurring mental-health conditions are present.
You are concealing use from family, partners, or healthcare providers.
You are using opioids from illicit sources (high overdose risk).
You are physically dependent on alcohol or sedative-hypnotics — withdrawal can be life-threatening; medical supervision is needed.

Free 24-hour crisis and addictions support: 1-866-332-2322 (Alberta Health Services Addiction Helpline, 24/7), 1-866-531-2600 (ConnexOntario, 24/7), 1-866-585-0445 (Drug & Alcohol Helpline of Ontario), 9-8-8 (Suicide Crisis Helpline), 1-833-456-4566 (Talk Suicide Canada). For Indigenous-led culturally-competent crisis support: 1-855-242-3310 (Hope for Wellness Helpline, 24/7).

Frequently asked questions

Why is "substance use" preferred over "substance abuse"?

Research consistently shows that stigmatizing terminology reduces treatment-seeking, treatment retention, and clinical outcomes. Major health bodies (SAMHSA, NIDA, WHO) have adopted "substance use" and person-first language as evidence-based reductions of clinical stigma.

Is "substance use" different from substance use disorder?

Yes. "Substance use" describes the behaviour of using a substance; "Substance Use Disorder" is the formal diagnosis when the use meets specific clinical criteria. Most substance use is not pathological; SUD applies when the behaviour produces clinically significant impairment.

Can someone use substances without having SUD?

Yes. Most adults use psychoactive substances at some point (alcohol, caffeine, prescribed medications) without developing SUD. The distinction is whether the use meets diagnostic criteria — primarily whether there is loss of control, social impairment, risky use, and tolerance/withdrawal.

Is harm reduction "enabling"?

No. Harm reduction (naloxone, supervised consumption, drug-checking) reduces mortality and disease transmission for individuals not yet engaging in abstinence-oriented treatment. Harm-reduction approaches are evidence-based and are increasingly integrated with abstinence-oriented care. The framing of harm reduction as "enabling" is contradicted by the research.

How is recovery defined?

Recovery is now defined broadly by SAMHSA as "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential." Recovery is not synonymous with abstinence; it includes improvements across multiple life domains (housing, employment, relationships, meaning) and may or may not involve abstinence.

What is medication-assisted treatment?

MAT uses FDA-approved medications (methadone, buprenorphine, naltrexone, varenicline, disulfiram, acamprosate) combined with counselling and behavioural therapies to treat substance use disorders. MAT for opioid use disorder substantially reduces mortality and is the international standard of care. The terminology is shifting toward "medications for opioid use disorder" (MOUD) and "medications for substance use disorders" (MSUD).

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Substance Abuse and Mental Health Services Administration. (2023). SAMHSA's Working Definition of Recovery.
Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with substance-related conditions? International Journal of Drug Policy, 21(3), 202–207.
National Institute on Drug Abuse. (2021). Words Matter: Preferred Language for Talking About Addiction.
Marlatt, G. A., Larimer, M. E., & Witkiewitz, K. (Eds.). (2011). Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors (2nd ed.). Guilford Press.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.