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In contrast to early psychoanalytic theory, which stressed pleasurable/aggressive drives and the symbolic meaning of drugs to explain their appeal, a modern psychodynamic perspective of substance-use disorders (SUDs) places greater emphasis on intolerable painful or confusing affects that make addictive drugs compelling. A psychotherapeutic relationship rooted in a psychodynamic approach yields valuable data on the nature of a person's distress and deficits in psychological (ego/self) structures that predispose individuals to addiction. An evolving psychodynamic perspective, spanning 30 years, is presented wherein addictions have been considered as (1) a special adaptation, (2) an attempt to self-medicate painful or confusing emotions, (3) an overarching problem in self-regulation, and finally (4) a reflection of disorder in personality organization. This evolving perspective more likely than not should and does complement and resonate with other perspectives. A modern psychodynamic perspective of SUDs adds an important dimension to unraveling the biopsychosocial equation involved in understanding addictive vulnerability.