Substance use disorder

What this diagnosis means

A substance use disorder means a person keeps using alcohol or drugs even though the use is causing harm. The harm may be to their health, work, school, family, or safety.² One term covers both alcohol and drugs. You may also hear the word addiction, which usually refers to the more severe forms of the disorder.¹¹

This is a medical condition. It is not a weakness of character. It is not a failure of faith, and it is not bad parenting. SAMHSA describes it as a long-term illness that changes the brain, much as asthma or diabetes are long-term illnesses.² Repeated use changes the parts of the brain that handle judgment, memory, stress, and self-control. That can make quitting very hard, even for someone who badly wants to stop.¹³ Genes account for about half of a person’s risk. Stress, trauma, and starting to use at a young age raise the risk further.¹¹

It is common. SAMHSA reports that in 2023, more than 1 in 10 U.S. adults said they had ever had a substance use problem. Of those, more than 7 in 10 said they were in recovery.¹ SAMHSA’s message to families is that recovery is possible.⁴

Many people with a substance use disorder also have another mental health condition. Depression and anxiety are common examples.¹² Another is post-traumatic stress disorder, a lasting reaction to a frightening event. Another is bipolar disorder, which brings large swings in mood and energy. Having both is called co-occurring disorders, sometimes called dual diagnosis. NAMI cites a national survey that found 17 million U.S. adults had both in 2020.⁹ Either condition can come first. Some people use substances to cope with symptoms. For others, substance use makes a second condition more likely.¹²

Diagnosis can take time. The psychiatrist looks at how much control the person has over their use, and how much it affects their life. The disorder can be mild, moderate, or severe.² Treatment can help at any severity.³ The symptoms of a substance use disorder and of another mental health condition can overlap, so a diagnosis may be revised as the picture becomes clearer.¹²

What you may notice at home

Every family’s story is different. Families often notice some of these.⁹¹³ They are not a test. Only a clinician can say what they mean for your family member.

• Continuing to drink or use after it has cost a job, a relationship, or their health.
• Needing more of the substance to get the same effect. This is called tolerance.
• Feeling sick, shaky, sweaty, or very anxious when the substance wears off. This is called withdrawal.
• Strong urges to use, called craving, that crowd out other interests.
• Using more, or more often, than they meant to. Trying to cut down and failing.
• Missing work or school. Sudden money problems. Things going missing from the house.
• Secretive behavior, new friends, or pulling away from family.
• Neglecting appearance or hygiene. Changes in sleep or appetite.
• Getting angry or defensive when the subject comes up. Blaming other people for problems the use is causing. SAMHSA calls this denial, and it is part of the illness.⁷

For teens, AACAP lists added signs. These include red or glazed eyes, a lasting cough, and repeated health complaints. Others are mood swings, a drop in grades, skipping school, breaking rules at home, and new friends who care less about school.¹⁴ AACAP notes that many of these signs can point to other problems.¹⁴ A child and adolescent psychiatrist can sort out what is really going on.

What treatment usually involves

Treatment is tailored to the person. No single approach fits everyone, and the psychiatrist and treatment team decide with the person.³ Plans change as needs change. That is normal.

Treatment begins with a full assessment of substance use, physical health, mental health, family, work, and past attempts to quit.³ Family members are sometimes invited to share what they have seen.⁷

Some people first need detoxification, often called detox. This means stopping the substance safely while medical staff manage withdrawal. For alcohol and some other substances, stopping suddenly can be dangerous without medical help. Detox is a first step, not treatment by itself.³

For some substances, treatment includes medicines. There are approved medicines for alcohol use disorder and for opioid use disorder. They ease craving and withdrawal and lower the chance of returning to use. Some are taken for months or years.³ SAMHSA is clear that these medicines are real treatment, not trading one drug for another.³ There are also medicines that can reverse an opioid overdose, which means taking enough of a substance to become dangerously ill.¹ Families can ask the treatment team whether having one at home makes sense. Medicines for a co-occurring condition, such as antidepressants, may be part of the plan too. The psychiatrist chooses and adjusts any medicine with the person.

Counseling is part of nearly every plan. One common approach is cognitive behavioral therapy, which teaches new ways to handle the thoughts and situations that lead to use. Another is motivational interviewing, which helps a person find their own reasons to change. Group, family, and life-skills sessions are common.³ When there is a co-occurring condition, the best results come from integrated treatment. That means one coordinated team treats both conditions together.¹²

Peer support means help from people who have been through recovery themselves. This includes peer support workers on treatment teams and mutual-help groups. Some groups are faith-based and some are not. They are free and widely available.⁴ They add to treatment but do not replace it.

Care can be outpatient, where the person lives at home and attends sessions. Or it can be residential, where the person lives at the program for a time. After the main program ends, follow-up care usually continues for a year or more. Staying connected to care over time is an important part of the plan.³

Relapse means returning to use after a period of stopping. It is common, especially early on. SAMHSA states plainly that relapse does not mean treatment failed. It is a signal to get back to the team quickly and adjust the plan.⁴ Returning fast is a sign of health, not shame.

How to support without taking over

Your family member has their own choices. Lasting change has to come from them. What you can do is make it easier to say yes to help, and harder for the illness to stay hidden.

With the person’s permission, go to appointments or family sessions. Privacy laws are strict here. Substance use treatment records get even stronger protection than other medical records. Staff usually cannot confirm your family member is in a program until the person signs a release.⁷ But privacy rules only limit what the team can tell you. You can always give information to the team, such as changes you have seen or worries about safety. If your family member is willing, ask them to sign a release so the team can talk with you.

For teens, parents are usually closely involved in treatment planning and follow-up. Family counseling is a core part of adolescent care.³ Families are also often advised to keep any prescription medicines in the home locked up and to get rid of ones no longer in use.

Learn about the condition. NAMI Family-to-Family is a free eight-session class for relatives and friends of people with mental health conditions.¹⁰ Al-Anon, Nar-Anon, and Alateen are free groups for families and teens affected by a loved one’s use.⁷ Many treatment programs offer family education as well.⁶

Take care of yourself. Sleep, eat, and talk to people you trust. Your church, mosque, temple, or other faith community can be a real source of strength. SAMHSA’s family booklet says something families need to hear. You did not cause this. You cannot control it. You cannot cure it.⁷ Your family member’s recovery does not depend on you. Your own well-being does not have to wait for theirs.

If you are not sure where to start, call SAMHSA’s National Helpline at 1-800-662-4357. It is free, confidential, and open 24 hours a day in English and Spanish. Family members can call. It gives referrals to local treatment and support groups.⁵ FindTreatment.gov is SAMHSA’s confidential, anonymous search for licensed treatment near you.⁸

Questions worth asking the psychiatrist

With the person’s consent, these can be asked together at the next visit.

• Which substances are involved, and how severe is the disorder right now?
• Is there another mental health condition here too? How will both be treated together?
• Does my family member need medically supervised withdrawal? Is stopping suddenly dangerous?
• Are there medicines that could help for this substance? What do they do, and for how long?
• Should we have an overdose-reversal medicine at home? How would we get it and learn to use it?
• What kind of counseling is planned, and how often?
• What level of care do you recommend, outpatient or residential, and why?
• How can the family be involved? Is there family counseling or education?
• What paperwork lets you share information with us?
• What should we do if there is a relapse? Who do we call?
• What support groups do you recommend for the person, and for us?