Substance Use Disorder or Addiction?
In a recent podcast our friend and Governor called for a return to plain speaking. One example he cited was the recent use of substance use disorder where we previously, commonly, used the term addiction. Governor Beshear is a sophisticated man and if he is concerned about expanding and confusing language it is reasonable to assume that others are as well. Is there a difference between these two terms? Does it make a difference?
A 2025 article in Healthline details that Substance Use Disorder can range from mild to severe, depending on the number of criteria a person meets. Those levels include:
Mild substance use disorder: Two or three criteria
Moderate substance use disorder: Four or five criteria
Severe substance use disorder: Six or more criteria which may signal addiction to that substance
The Diagnostics and Statistical Manual Version-5 criteria for substance use disorder include:
Substance is taken in larger amounts or over a longer period than was intended
Persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time is spent on activities necessary to obtain the substance, use the substance, or recover from its effects
Important social, occupational, or recreational activities are given up or reduced because of substance use
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use
Increasing tolerance, as defined by a need for markedly increased amounts of substance to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of the substance
Withdrawal as manifested by either the characteristic withdrawal syndrome for the substance or the substance is taken to relieve or avoid withdrawal symptoms.
The report clarifies that it is possible to have mild to severe substance use disorder while using more than one substance.
An article published by Urban Recovery in 2023 reviews these criteria and then discusses a definition of addiction. Addiction is a term that is often used to describe a severe form of SUD. It is a complex brain disease that involves compulsive drug seeking and use, despite the harmful consequences. Addiction is characterized by a number of symptoms, including:
Loss of control over drug use
Continued use of the drug despite negative consequences
Cravings for the drug
Inability to stop using the drug, even when wanting to
Using the drug in larger amounts or for longer periods of time than intended
Giving up important activities or social events in order to use the drug
Spending a lot of time using or obtaining the drug
Using the drug even when not in a safe environment
Developing a tolerance to the drug, meaning that higher doses are needed to achieve the same effect
Experiencing withdrawal symptoms when the drug is not used
Obviously, the described criteria are extensively overlapping. The Healthline article suggests that addiction is a severe case of substance use disorder characterized by an increasing number of these behaviors. SUD can range from mild to severe and may not always involve compulsive drug seeking and use that is characteristic of addiction. In other words, someone can have SUD without crossing the line to addiction. This report suggests that this chronic, persistent use still has a significant impact on a person's life, but it may not be as severe as addiction.
Addiction is a severe form of SUD that involves compulsive drug seeking and use, despite the harmful consequences. The significant difference is that addiction is characterized by a physical, chemical brain linkage that becomes a physical dependence driving cravings. That linkage in the brain creates far greater difficulty for most people to quit the drug. Further, and as we have reported previously, long term, chronic use appears to create further changes in the reasoning functions of the brain that creates further, severe difficulty in accepting and achieving recovery. Addiction is often characterized by a loss of control over drug use, and an intense focus on obtaining and using the substance, even when it causes problems in other areas of life, like work, relationships, and health.
As we have discussed previously, there are at least 50 million Americans who abuse alcohol who may not fit the definition of addiction. The United States Census Bureau estimates that there are 258.3 million adult Americans. The National Institutes for Health estimates that 70% use alcohol at least on occasion leaving us 180.8 million Americans who use alcohol at least occasionally. Among these the Centers for Disease Control (CDC) estimates that there are 43 million binge drinkers who consume toxic amounts in one sitting and do so four times a month. CDC also estimates that there are, separately, 13 million heavy drinkers who drink beyond moderation every week. The NIH estimates that there are 40 million Americans with a substance use disorder. If we remove these three groups, then we are talking about 84 million Americans who might use alcohol in moderation. Certainly, there is overlap in the three categories calculated by two different agencies that may not coordinate their studies. Regardless, these numbers tell us that there are 50 million Americans who abuse alcohol but may not be addicted by the medical definition. Defining Substance Use Disorder as a treatable, behavioral health condition suggests that abusive yet not addictive behavior is damaging to the abuser and perhaps others and can be corrected perhaps with support from treatment.
One may ask if abusive behavior can continue indefinitely without crossing the line to addiction. The Prevention Research Institute (PRI) presents a model that suggests that for most people the answer is no. They report, “These findings suggest that each person has a biological threshold for addiction, conceptualized in our programs as a range of distances from a "trigger point.” Persons with increased biological risk start out at a shorter distance from their trigger point, meaning it will take less time and less use to reach it than people born with standard risk. In addition, some people have greatly increased biological risk, and they can develop addiction even more rapidly.” PRI claims that addiction is 50% biologic and 50% behavioral. While PRI does not discuss people with very low or non-zero predisposition, it is reasonable to assume that if there are genetic variation that create great predisposition then the opposite would also be true.
Does this all make a difference? On the one hand, this discussion does not make the Governor wrong that too often scientific language is imposed on everyday conversation that does not, necessarily, add value. Most Americans today likely still think of alcohol and other drug abuse as addiction. To the extent that most Americans include binge drinking and heavy drinking in their consideration of abuse, and do not limit their thinking to the poor soul who has progressed to public drunkenness and street behavior, then little harm is done. If, on the other hand, the consideration is focused solely on the very end stages of alcoholism and other drug addiction, and in doing so glosses over binge drinking and heavy drinking as not being a problem, then harm is done by not allowing terms like substance use disorder to expand our consideration of our national problem.
From the point of view of the health care provider the use of the term substance use disorder is an important distinction. We must not focus solely on the end stages of addiction but address the damage being done every day from heavy use or binge use of alcohol and other drugs.
Gene Gilchrist
September 2025
