Substance Use & Addictions
Substance-Related and Addictive Disorders (DSM-5-TR)
Compulsive use despite consequences, tolerance, withdrawal, and functional impairment. Includes alcohol, opioids, stimulants, cannabis, and behavioral addictions. MI, CBT, contingency management, and 12-step facilitation have strong evidence.
Prevalence: ~17% for any SUD in past year (US)
Clinical Picture
Substance use disorders sit at the intersection of neurobiology, psychology, social context, and meaning. The field has moved substantially from the moral model ('addiction as character flaw') and even from the pure disease model toward a more integrated understanding that includes developmental trauma, affect dysregulation, social determinants, and the genuine (if destructive) function that substances serve. Motivational Interviewing's foundational insight — that ambivalence about change is normal, not pathological — has transformed how clinicians across all modalities approach substance use.
Treatment Considerations
Motivational Interviewing is the entry point for many clients who are ambivalent about change. CBT-based approaches (including relapse prevention) address the cognitive and behavioral patterns that maintain use. Contingency Management has some of the strongest effect sizes in the addiction literature but remains underused due to implementation challenges. For clients whose substance use is intertwined with trauma history (which is the majority), integrated treatment that addresses both simultaneously outperforms sequential treatment. 12-step facilitation remains widely available and effective for many, though its spiritual framework isn't a fit for everyone.
29 Therapeutic Approaches
Sorted by evidence tier: guideline-recommended first, then RCT-supported, then emerging/limited evidence.
Related Clinical Vignettes
Sources & References
Prevalence data from NIMH, WHO, and DSM-5-TR field trial publications. Evidence tiers reflect guideline status (APA, NICE, VA/DoD, WHO) and meta-analytic findings as of early 2025. Individual modality citations are listed on each modality page. Full bibliography available on the Sources page.