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DRiNK TWO 6 PACK clarifies substance use

Some patients can have substance-related adverse social consequences for a long time without developing dependence

Vol. 8, No. 5 / May 2009

Substance dependence is defined by physiologic and behavioral symptoms, and substance abuse is described in terms of adverse social consequences of substance use. Dependence involves physiologic processes whereas abuse reflects a complex interaction between the individual, the abused substance, and society.

Diagnostic criteria for substance use disorders allow clinicians to:

  • plan treatment and monitor progress
  • provide patients access to health insurance coverage.

Following the mnemonic DRiNK TWO 6 PACK can help you determine if your patient’s symptoms meet diagnostic criteria for substance abuse or substance dependence, which then allows you develop an appropriate treatment plan. The mnemonic suggests alcohol abuse and dependence, but it can be applied to any substance.

Substance abuse

DSM-IV-TR1 defines substance abuse as a maladaptive pattern of use leading to clinically significant impairment or distress as evidenced by ≥1 of 4 symptom criteria within a 12-month period. The mnemonic DRiNK aids recall of the 4 symptoms:

  • Dangerously driving a vehicle or machine when impaired by substances
  • Ri: Role failure in home, school, or work because of recurrent substance use
  • No respect for the law, leading to legal problems
  • Keeps using a substance despite persistent or recurrent social or interpersonal problems.

Finally, the patient must not have met criteria for substance dependence. Although a substance abuse diagnosis is more likely in individuals who recently started using the substance,2 some individuals can have substance-related adverse social consequences for a long time without developing dependence.

Substance dependence

Physiologic dependence is development of tolerance leading to withdrawal symptoms. According to DSM-IV-TR, substance dependence is a maladaptive pattern of substance use leading to clinically significant impairment or distress identified by ≥3 of the 7 symptoms at any time in the same 12-month period. These symptoms can be recalled with the mnemonic TWO 6 PACK:

  • Tolerance
  • Withdrawal
  • Occupational, social, or recreational activities given up or reduced
  • 6
  • Persistent desire or unsuccessful efforts to cut down or control substance use
  • Amount of use is excessive
  • Continues substance use despite having persistent or recurrent physical or psychological problems
  • Keeps spending a lot of time in search, use, or recovery from the substance.


1. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

2. Hasin DS, Grant B, Endicott J. The natural history of alcohol abuse: implications for definitions of alcohol use disorders. Am J Psychiatry. 1990;147(11):1537-1541.

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