The Spectrum of Substance Use

by Jessica Hulsey

Substance use occurs across a spectrum. This continuum encompasses a wide range of behaviors related to the use of any mood-altering substance, from abstinence to occasional and controlled use, to problematic use and addictive behaviors. Understanding this spectrum is crucial for patients, family members, and clinicians as it helps in assessing and addressing substance use disorders effectively. It’s important to note that not everyone who experiments with substances progresses along this spectrum to addiction.

The spectrum has several stages:

1. Abstinence. Abstinence is on one end of the spectrum when there is no use of the substance. The age when abstinence ends and use begins is important, as an early age of first use is a significant risk factor for the progression of substance use disorder, including the use of nicotine, marijuana and alcohol.

2. Occasional use. This stage includes when individuals begin using a specific substance and participate in occasional use. Most people who experiment with substances do not progress past occasional use, though different types of substances have different levels of harm and addiction risk. For example, in a large study that examined the harms associated with different substances, opioids, tobacco, benzodiazepines, alcohol and amphetamines were categorized as having the highest risk of reliance and craving.^[1]

3. Risky or problematic use. This stage involves an increase in the frequency and quantity of substance use, which leads to negative consequences, such as health issues, conflicts with loved ones, or difficulties at work or school. An individual may continue to use despite recognizing these problems. As problematic use continues, both the symptoms and consequences often worsen, and substance use disorder can develop. The first level of severity is a mild substance use disorder, followed by a moderate SUD, then a severe SUD.

As occasional use begins, harm reduction should also begin. Key harm reduction tactics can include limiting the quantity and frequency of use (such as not drinking before five p.m.), minimizing use to once per week or month or only in social contexts, and limiting the quantity (such as the number of drinks per sitting). Strategies to reduce or moderate use can help prevent further progression.

When an individual transitions to problematic use, when the substance use begins to cause disruption and create consequences, early intervention is important. The earlier the disease is interrupted, the better the outcomes for the patient. For those who develop a substance use disorder, there are specific criteria and symptoms identified to make a diagnosis or connect an individual to treatment if needed.

Citations:

1. Morgan CJ, Noronha LA, Muetzelfeldt M, Fielding A, Curran HV. Harms and benefits associated with psychoactive drugs: findings of an international survey of active drug users. J Psychopharmacol. 2013 Jun;27(6):497-506. doi: 10.1177/0269881113477744. Epub 2013 Feb 25. Erratum in: J Psychopharmacol. 2015 Sep;29(9):NP1. PMID: 23438502; PMCID: PMC4107777.

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Excerpts from Understanding Addiction: A Guide for Families by Jessica Hulsey © 2025