3.5 Recognizing Indicators of Substance Use and Co-Occurring Disorders for Referral
Key Takeaways
Identifying indicators of substance use and co-occurring disorders for referral is a required NCPRSS education area; the peer notices, asks, and connects but never diagnoses.
The DSM-5-TR defines a substance use disorder by at least 2 of 11 criteria within 12 months: mild is 2 to 3, moderate 4 to 5, and severe 6 or more.
Tolerance and withdrawal do not count toward a substance use disorder diagnosis when they occur only with medication taken as prescribed.
Signs of mania, psychosis, suicidal thinking, severe withdrawal, or pregnancy with opioid use call for urgent or emergency referral.
Effective referrals involve permission, choice, consent before sharing information, a warm handoff, and follow-up within a day or two.
3.5 Recognizing Indicators of Substance Use and Co-Occurring Disorders for Referral
Note
Quick Answer: NCC AP's required NCPRSS education includes "identification of indicators of substance use and/or co-occurring disorders for referral." The peer's job is to notice, ask, and connect, never to diagnose. Knowing how clinicians define substance use disorders (the DSM-5-TR's 11 criteria in four groups) and the common signs of mental health conditions helps a peer recognize when someone needs a professional evaluation, how urgent it is, and how to make a warm referral with the person's consent.
Why Peers Need to Recognize Indicators
People with substance use problems frequently also live with depression, anxiety, trauma-related conditions, bipolar disorder, or psychotic disorders. When both are present, they are co-occurring disorders, and outcomes are better when both are addressed together (integrated care). A peer may be the first person someone trusts enough to describe symptoms they have never told a clinician. Recognizing those indicators, and knowing what to do next, is part of the role.
Important
Recognizing is not diagnosing. A peer can say, "What you're describing sounds really hard, and a doctor or counselor could help figure out what's going on. Would you like help setting that up?" A peer does not say, "You have bipolar disorder."
How Clinicians Define Substance Use Disorder (for Recognition, Not Diagnosis)
The DSM-5-TR defines a substance use disorder as a problematic pattern of use causing clinically significant impairment or distress, shown by at least 2 of 11 criteria within 12 months. The criteria fall into four groups:
| Group | Criteria (paraphrased) |
|---|---|
| Impaired control | Using more or longer than intended; wanting or failing to cut down; spending a lot of time getting, using, or recovering; craving |
| Social impairment | Failing major obligations at work, school, or home; continuing despite social or relationship problems; giving up important activities |
| Risky use | Use in physically hazardous situations; continuing despite knowing it causes or worsens a physical or psychological problem |
| Pharmacological | Tolerance; withdrawal |
Severity is mild (2 to 3 criteria), moderate (4 to 5), or severe (6 or more). Tolerance and withdrawal do not count toward the diagnosis when they occur only with medications taken as prescribed under medical supervision, such as buprenorphine or a prescribed opioid for pain.
Indicators a Peer Might Notice
| Area | Possible indicators |
|---|---|
| Statements | "I always end up drinking more than I planned," "I've tried to quit three times," "I need more to feel anything now" |
| Behavior | Missed appointments, borrowing money, secrecy, new friends tied to use, loss of interest in old activities |
| Physical | Signs of intoxication or withdrawal (see Chapter 10), injection marks or abscesses, weight loss, frequent illness |
| Consequences | Job loss, legal problems, housing instability, relationship breakdown linked to use |
Indicators of Mental Health Conditions
| Possible condition | Indicators to notice | Typical referral urgency |
|---|---|---|
| Depression | Persistent low mood, loss of interest, sleep or appetite changes, hopelessness, slowed thinking | Routine to urgent; emergency if suicidal thoughts with a plan |
| Anxiety and panic | Constant worry, panic attacks, avoidance that limits daily life | Routine |
| Trauma-related conditions | Nightmares, flashbacks, hypervigilance, avoiding reminders | Routine to urgent |
| Bipolar disorder (mania) | Days of little sleep without tiredness, racing thoughts, grandiosity, risky spending or sex | Urgent |
| Psychosis | Hearing or seeing things others do not, fixed false beliefs, disorganized speech | Urgent; emergency if danger to self or others |
| Cognitive changes | New confusion, memory loss, disorientation | Urgent medical evaluation (can signal intoxication, withdrawal, infection, or brain injury) |
Many of these symptoms can be caused or worsened by substances, by withdrawal, or by medical problems. Sorting out whether symptoms are substance-induced or independent is a clinical task; the peer's task is to notice and connect.
The Four-Quadrant Model of Co-Occurring Disorders
Planners use the four-quadrant model (developed by national mental health and substance use program directors' associations) to match people with services by the severity of each condition:
| Lower substance use severity | Higher substance use severity | |
|---|---|---|
| Higher mental health severity | Quadrant II: usually served in mental health settings | Quadrant IV: needs intensive integrated care |
| Lower mental health severity | Quadrant I: often served in primary care | Quadrant III: usually served in addiction treatment settings |
The model reminds peers that "where to refer" depends on both conditions, and that people in Quadrant IV are the most likely to fall between systems without active coordination.
Matching Urgency to the Situation
| Level | Examples | Peer action |
|---|---|---|
| Emergency (now) | Suicide plan or attempt, overdose, severe withdrawal, violent psychosis, medical emergency | 911 or 988 and the agency crisis protocol; stay with the person |
| Urgent (same day to 24 hours) | Pregnancy with opioid use, mania, new psychosis without immediate danger, worsening depression | Same-day clinician contact or walk-in services |
| Routine | Ongoing anxiety, untreated depression without safety concerns, wanting an SUD assessment | Scheduled referral with follow-up |
Making the Referral Count
- Ask permission and explain why. "Would you be open to talking with someone who can look at this more closely?"
- Offer choices of providers, times, and formats, including telehealth.
- Get consent before sharing information with an outside provider (42 CFR Part 2; Code II-22).
- Use a warm handoff (Section 3.3): call together, introduce the person, or go with them.
- Follow up within a day or two to see whether the connection happened and what is next.
Tip
On exam scenarios, look for the answer that recognizes, asks, and connects with consent. Eliminate answers that diagnose, ignore clear warning signs, or share information without permission outside an emergency.
Over two weeks, a participant tells a peer specialist that they have barely slept but feel full of energy, have started three businesses, and spent their rent money on equipment. They deny any thoughts of harming themselves. What is the most appropriate peer response?
Tell the participant that these symptoms show bipolar I disorder and that they need to start a mood stabilizer as soon as possible.
Treat the change as positive motivation in recovery and help the participant write a business plan for the new ventures.
Share concern about the changes and help them see a clinician the same day.
Wait to see whether the energy fades on its own before mentioning anything, so the participant does not feel judged or labeled.
A participant who takes buprenorphine as prescribed says they get withdrawal symptoms if they miss a dose and needed a higher dose at first. They worry this means they "still have an active addiction." Which statement is accurate?
Tolerance and withdrawal from a medication taken as prescribed do not count toward an SUD diagnosis.
Any withdrawal symptoms prove that the person still meets criteria for a severe opioid use disorder and should stop the medication.
Withdrawal counts toward the diagnosis, but tolerance does not, so the participant meets at least one active criterion of opioid use disorder.
Only a urine drug screen, not symptoms, can tell whether a person on buprenorphine still has an opioid use disorder.
A participant who is about 10 weeks pregnant tells a peer specialist she is using fentanyl daily and is afraid to tell her doctor. How should the peer respond?
Advise her to stop fentanyl immediately on her own, because any opioid exposure during pregnancy is more dangerous than withdrawal.
Promise to keep the information secret and avoid mentioning treatment until she feels ready to bring it up again on her own.
Report her to child protective services right away, since substance use during pregnancy is always a mandatory report everywhere.
Acknowledge her fear, explain that treatment with medication is recommended in pregnancy, and offer a same-day warm referral.
Sections you finish are checked off in the contents.