Shirah Vollmer MD

The Musings of Dr. Vollmer

Substance Abuse, Dependence Becomes Substance Use Disorder

Posted by Dr. Vollmer on January 19, 2016

Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impairment or distress. Although the termsubstance can refer to any physical matter, ‘substance‘ in this context is limited to psychoactive drugs.



DSM 5 changed our language from substance abuse to substance use disorder. Further, the diagnostic system requires that the substances be specified such that the DSM IV diagnosis of “poly substance abuse” has become “opiate use disorder, methamphetamine use disorder, tobacco use disorder and cannabis use disorder.”  More specificity in the diagnosis will help big data analyze “population health,” the new buzzword for focusing on trends and not on individuals. I wonder if there is a difference between “heroin use” and “heroin use disorder”.  Clearly, outlining the nature of the substances that the patient uses helps us understand the chemical feeling they are seeking. Yet, my experience in working in drug rehabilitation centers is that the majority of patients use all substances available to them including opiates, cannabis, alcohol, meth amphetamines and tobacco. I salute Lance Dodes MD who says that substance abuse, like so many behaviors, are about self-sabotage, and not so much about the exact chemical that the patient is drawn to. He states, rightly so, that alcohol abuse is not qualitatively different from opiate abuse, but rather they are the result of self-hatred.This matches my clinical experience. If a patient goes from an alcohol use disorder to a gambling disorder, he does not have a new diagnosis, only a new symptom of an old diagnosis, which, in my mind would be a lost self. Rehabilitation centers need to help people love themselves, and how to do this is up for debate. Being tough, setting limits, or giving them understanding and compassion. Both approaches have successes and failures and both approaches do not know who to target and so most programs use a one-size fits all approach to a problem which uniquely develops in each person. In my mind, the diagnoses should be “escape disorder,” to group people together who need to escape from themselves, such that the major challenge is to find out what they are escaping. If they no longer have to escape, the substance will recede in importance. Is this oversimplifying a complex disorder? I do not think so. It is a hard job to find out what the patient is scared to face, and, of course, the pain they are avoiding is layered and often not obvious. Still, if the focus was on the escape and not the drug, there would be more hope. Our diagnostic system is important since it helps patients understand themselves and their family members. To speak in terms of “use disorders” misses the point.



4 Responses to “Substance Abuse, Dependence Becomes Substance Use Disorder”

  1. Jon said

    “Escape Disorder.” Now that is a succinct and cogent phrasing. This makes sense and seems to get more to the root cause of the problems. Substance disorder or substance abuse is a reaction not a fundamental problem. You are on the right track to a deeper understanding, escape. Thus, the focus needs to be on understanding why there is a need to escape, and what can be done about it. Can one escape in less self-sabotaging methods? Can one change the need or necessity to escape? These are the more basic questions.

    • Yes, symptom substitution is the phrase for using a “better” symptom to deal with the need for escape, hence the crossover to extreme exercise or obsessive or compulsive behaviors which serve as an escape without the harm of the substance. To change the need or necessity to escape, one has to dig into the pain and uproot the issues so that the sting of feeling unlovable is exchanged for a compassionate understanding of the environment that created your existence. In so doing, the patient can learn to love himself and thereby not need to escape into an unfeeling existence. Thanks, as always.

  2. Shelly said

    I agree with Jon and you both: the focus does need to be on understanding why there is a need to escape. However basically any behavior, if it is in excess, can be used to escape, can’t it? Excessive work, excessive spending, excessive eating, excessive yelling, excessive dieting, excessive video gaming. When does it become a disorder? Where do you draw the line? Why is substance abuse considered an act of self-hate, because it is against the law?

    • Absolutely! Anything in excess is a problem and psychiatrists say that when it impairs social or occupational functioning then it is a disorder. All excesses are an act of self-hate, not just substance abuse. The legal issues of substance abuse are fascinating in that when heroin was used by minorities it was criminalized, but now that heroin is used by middle and upper-middle class white folks, there is a greater emphasis on rehabilitation. So, the laws are more political than compassionate. Thanks for chiming in, as always.

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