Substance Use Disorders

Related Terms

• Moderate to severe substance use disorders are often described as addiction. 
• Older terms that may still be used are substance abuse or substance dependence.

Overview

Substance use disorders are complex, chronic conditions in which a person continues to use drugs or alcohol despite significant harmful consequences to their health, relationships, and daily functioning. Effective treatments for substance use disorders exist, and people can and do recover.

A person may have a substance use disorder involving one substance, such as alcohol, opioids, cannabis, nicotine, or stimulants, or people may have more than one substance use disorder at the same time.

Substance use disorders are common. However, most people with substance use disorders do not receive treatment. Stigma, limited awareness, and challenges with access or insurance keep many people from getting the care they need. Behavioral therapies, medicines, and mutual-support groups can be effective. While relapse (return to drug or alcohol use after a period of abstinence) is common, many people do achieve lasting recovery with the right treatment and support.

Addiction in the Brain

Different addictive substances act on the brain in different ways and produce different pleasurable sensations. However, they all cause bursts of the chemical dopamine in a brain region called the nucleus accumbens.

Dopamine bursts tell the brain whether to expect that a behavior (like using alcohol or other drugs) is rewarding and worth repeating. This triggers brain rewiring that makes it easier to repeat that activity automatically. The brain links this rewarding activity to cues; for example, the first use of a drug might be linked to feelings of relief from a stressful event. Encountering that stress again can trigger craving and use of the drug, and this cycle can continue to repeat itself.

Some habits can be helpful or even vital for survival, such as eating when you’re hungry. But alcohol and other drugs can produce much stronger dopamine surges than everyday rewards. This can make it hard to stop seeking and using drugs and alcohol.

With regular substance use, the brain also compensates by reducing activity in the reward circuit, like turning down the volume on a loud radio. Over time, a person becomes less able to experience pleasure from daily life and needs more of the substance to get the same effect (this is called tolerance). Meanwhile, drugs weaken the brain circuits responsible for self-control and stress management. These brain changes may last a long time after a person stops taking drugs or drinking alcohol.

This can make cravings stronger and a return to use during recovery from a substance use disorder more likely.

Related Health Effects

Substance use disorders and addiction are a serious public health problem.

People who misuse substances or have substance use disorders are more likely to experience:

• Overdoses
• Accidents, injuries
• Chronic health conditions across all body systems
• Certain cancers
• Infections such as hepatitis and HIV due to sharing needles and inhalation devices or engaging in unprotected sex while intoxicated

Mental Disorders

Many people who develop substance use disorders are also diagnosed with other mental health disorders, and vice versa. Mental health disorders that commonly co-occur with substance use disorders include anxiety, depression, post-traumatic stress disorder (PTSD), bipolar disorder, disorders of psychosis, and borderline and antisocial personality disorders.

Substance use can contribute to the development of mental health disorders and make them worse. For example, evidence suggests that cocaine use may worsen the symptoms of bipolar disorder. Some evidence has linked cannabis use to earlier onset of psychosis in people with genetic risk factors for psychotic disorders, including schizophrenia.

Causes and Risk Factors

No single factor determines whether a person will develop a substance use disorder. A combination of factors influence risk, and the more risk factors a person has, the greater the chance that drug use will lead to addiction.

Biological factors

The genes that people are born with account for about half of a person’s risk for addiction. Scientists estimate that genes, including the effects environmental factors have on gene expression (epigenetics), account for between 40% and 60% of a person’s risk. In one study, researchers analyzed genomic data from over 1 million people and found nearly 20 gene variants associated with substance use disorders.

Environmental factors

A person’s environment includes many influences, from family and friends to economic status and quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress, and lack of parental guidance can greatly affect a person’s likelihood of drug use and addiction. Common risk factors, including inherited characteristics, adverse social environments, trauma, and stress, can contribute to both substance use disorders and other mental disorders.

Childhood Trauma

Childhood trauma increases the risk for substance use, other mental disorders, suicidal thoughts and behaviors, and physical health conditions.

Early Use

Research shows that the earlier people begin to use drugs, the more likely they are to develop a substance use disorder. This may be due to the harmful effect that drugs can have on the developing brain. There is also evidence that preexisting differences in brain structure can increase the risk of earlier substance use.

Mental Disorders

People with mental illnesses like depression, anxiety, PTSD, and many other psychiatric conditions are more likely to use substances and to develop substance use disorders. People who experience anxiety, stress, depression, or pain may use drugs to try to feel better, especially if mental healthcare is not accessible.

Older Adults

Older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs. Chronic health conditions tend to develop as part of aging, and older adults are often prescribed more medicines than other age groups, leading to a higher rate of exposure to potentially addictive medicines.

Prevention Guidance

Preventing or delaying substance use in young people is particularly important. Teachers, parents, and healthcare providers have crucial roles in educating young people and preventing drug use and addiction. Research shows that active, supportive involvement by parents and guardians can help teens avoid drug and alcohol use.

Prevention programs are aimed at reducing risk factors for substance use and bolstering protective factors. For example, some programs teach young people how to resist peer pressure to drink or use drugs, support alternative drug-free recreational activities, or build social, emotional, and cognitive skills that can help manage stress and bolster resilience. Prevention programs may be geared at building warm, supportive environments and improving communication within families.. Prevention may be delivered at various levels, including to individuals; within schools, families, and healthcare settings; or to entire communities.  Policy-level interventions can also support substance use prevention; for example, under federal law, states must set the minimum legal drinking age to 21 years or lose a portion of their federal highway funds.

Screening youth and adults for drug and alcohol use can help detect early problems and prevent development of substance use disorders. Screening by a primary care provider or other health practitioner provides an opportunity to identify problems early and address them before they escalate. It also allows people to ask questions.

Identifying Signs of Addiction

If you are concerned that a loved one might have a substance use problem or addiction, look out for the signs.

One important sign of addiction is that a person continues to use drugs even though it harms their life — their physical health, performance at school or work, or relationships. Additional signs that someone may have a substance use disorder include:

• Hanging out with different friends than usual
• Not caring about their appearance
• Getting lower grades in school or missing classes
• Losing interest in favorite activities
• Getting in trouble in school or with the law
• Having different eating or sleeping habits
• Having more problems with family members and friends

Diagnosis

Substance use disorders are chronic, treatable medical conditions that involve compulsive seeking and use of alcohol or other drugs, despite harmful consequences. Doctors and other healthcare providers use the Diagnostic and Statistical Manual of Mental Disorders, Version 5 criteria to assess whether a person has a substance use disorder and to determine its severity. Severity is based on the number of criteria met.

These criteria are:

• Using more of the substance than planned
• Finding it difficult to stop
• Continuing to use despite knowing it causes harm
• Being preoccupied with thoughts of using the substance
• Taking risks while using, like driving under the influence
• Developing tolerance: Needing more of the substance to feel the same effects
• Experiencing withdrawal symptoms when stopping, such as stress, anxiety, depression, and sometimes physical symptoms such as sweating, vomiting, and pain

Substance use disorder often co-occur with mental and physical health conditions. Accurate diagnosis is key for treating co-occurring substance use and mental health disorders, since symptoms may overlap. Healthcare providers with experience in both substance use disorders and mental disorders can use comprehensive assessment tools to reduce the chance of a missed diagnosis and create an effective treatment plan.

Treatment and Management

Substance use disorders are treatable. Treatments can help a person stop or reduce their drug use, help prevent a return to use, alleviate negative consequences, and help them regain the ability to function successfully at work, in their family, and in their community.

Treatment approaches should be tailored to each patient’s drug and alcohol use patterns and any co-occurring medical, mental, and social problems. Many people with substance use disorders benefit from treatment that may include behavioral therapies, medications when available and appropriate, and recovery supports.

Withdrawal

People with substance use disorders may need medical help to avoid withdrawal. Withdrawal from alcohol and drugs such as opioids and benzodiazepines is potentially life threatening. It can occur when someone who has used these drugs or alcohol heavily for a prolonged period of time suddenly stops. For example, sudden alcohol cessation after heavy, prolonged use can be life threatening and cause seizures and delirium tremens. Doctors can prescribe medicines to address these symptoms and make the process safer and less distressing

Treatment Settings

There are multiple settings in which a person can receive treatment for substance use disorders:

• Outpatient care may include regular office or telehealth visits for counseling, medicine support, or both, delivered by primary care providers or specialists.
• Intensive outpatient care consists of intensive, coordinated care with dedicated hours of treatment services each week.
• Inpatient care means staying in a hospital or clinic overnight for a few days or weeks, usually for people who need 24-hour care.
• Residential care programs provide extended care, usually for a few weeks to a few months, and may include individual and group counseling, medicines, access to mutual support groups, and referrals to continuing care.
• Opioid treatment programs provide specific care for opioid use disorder, including treatment with safe and effective opioid-based medications, like methadone or buprenorphine." People with opioid use disorder generally do not misuse these medications; most cases of non-Rx use involve self-medication due to limited Rx access. Also, buprenorphine can be prescribed for home use, as can methadone after a stabilization period.

Addiction treatment can also be initiated in emergency departments and in criminal justice settings.

Psychosocial Treatment

Various types of individual, group, and family counseling or psychotherapy, sometimes called psychosocial or behavioral treatment, are the most common treatments for substance use disorders. These therapies are delivered by a licensed mental health professional and may:

• Alter negative thought processes that lead to substance use: Cognitive behavioral therapy (CBT) can help a person gain control of stressful emotions and thoughts that lead them to want to take drugs.
• Replace drugs with healthy, non-drug rewards: Contingency management uses small incentives to help patients stop using drugs and has been shown to be especially effective in treating addiction to stimulants like cocaine and methamphetamine.
• Bolster motivation to change: Motivational enhancement therapy (also called motivational interviewing) helps people build their resolve to quit using drugs or alcohol and assists them in setting and sticking with their goals.
• Encourage participation in mutual-aid groups: 12-Step Facilitation is designed to link to and encourage participation in 12-Step mutual support organizations.
• Family-based interventions: Interventions such as Multisystemic Therapy and Functional Family Therapy focus on improving family dynamics and communication and addressing environmental factors, can be particularly effective for addressing substance use disorders as well as co-occurring mental disorders.

Medicines

There are FDA-approved medicines to treat alcohol, opioid, and tobacco use disorders. Treatment with methadone, buprenorphine, or naltrexone is standard of care for opioid use disorder. Naltrexone, disulfiram, and acamprosate are approved for the treatment of alcohol use disorder. Nicotine replacement therapy, varenicline, and bupropion are approved to help people quit smoking.

When taken as prescribed, these medicines can control withdrawal symptoms and cravings and, over time, help restore balance to brain circuits affected by addiction.

Naloxone is a medicine that rapidly reverses an opioid overdose. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. Nalmefene is another overdose reversal medicine.

Telehealth Options

If you or a loved one needs help with an alcohol or drug problem, you have several options beyond in-person care. You can access professional telehealth care by phone or video chat, take self-guided online programs to reduce or quit substance use, and attend online mutual-support groups.

Treatment for Adolescents

Adolescents who have substance use problems benefit from treatment programs tailored to their needs. This may include some of the same behavioral treatments as adults, such as CBT and contingency management. There are also several behavioral treatment approaches designed specifically for adolescents, many of which involve family members or other caregivers in the treatment process. One medicine, buprenorphine, is also approved for adolescents 16 and over who have opioid use disorder.

Treatment for Older Adults

Many behavioral therapies and medicines have been successful in treating substance use disorders in older adults. Research shows that older patients have better results with longer durations of care. Ideal models include diagnosis and management of other chronic conditions, rebuilding support networks, improving access to medical services, improved case management, and staff training in evidence-based strategies for this age group. It is never too late to quit using substances — quitting can improve quality of life and future health.

Integrated Treatment for Co-Occurring Disorders

The high rate of co-occurring substance use and other mental disorders shows the need for an integrated approach to identify and treat these disorders at the same time. Research shows that integrated treatment leads to better health outcomes for people with substance use and other mental disorders. Such treatments may include medicines, psychosocial interventions, or a combination, depending on the needs of the individual and the substance or substances involved.

Living With Substance Use Disorders

Recovery is a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential. Even people with severe and chronic substance use disorders can, with help, overcome their illness and regain health and social function. This is called remission.

Substance use disorders are chronic illnesses, and as with many other chronic illnesses, relapse — or return to drug use after a period of abstinence — is often part of the treatment and recovery process. A return to drug use is an indication that a person should speak to their healthcare provider about resuming or modifying their treatment plan.

Mutual aid groups are a common type of recovery support in which peers help each other stop or reduce their substance use. These groups include 12-step programs such as Alcoholics Anonymous and Narcotics Anonymous, as well as others such as SMART Recovery, Women in Sobriety, and Life Ring. Studies show that mutual aid groups can be very effective at supporting long-term recovery. They are free, not time-limited, and many people find them useful on their own or in addition to professional care.

Other recovery support services include recovery coaching, recovery management checkups, drug- and alcohol-free housing (recovery housing), and social-recreational programs designed for people in recovery. These services are offered at many college recovery programs and at dedicated recovery high schools. Some states have recovery-oriented systems of care to integrate recovery support services with assistance for employment, education, childcare, and other social services.

Mutual-Support Groups

Mutual-support groups provide peer support for stopping or reducing substance use. These include 12-step programs such as Alcoholics Anonymous and Narcotics Anonymous, as well as others such as SMART Recovery, Women in Sobriety, and Life Ring. These programs are free, not time-limited, and many people find them useful on their own or in addition to professional care. Studies show that these programs can be very effective at supporting people’s long-term recovery.

Group meetings are run by people who have lived experience, and are available in most communities at low or no cost, and at convenient times and locations — including an increasing presence online.

For Families and Caregivers

About one out of every four children in the United States ages 17 or younger — about 19 million young people — live in households with at least one parent or caregiver who is coping with a substance use disorder. Research shows that children in this type of environment are more likely to develop depression or anxiety in adolescence and to use alcohol or other drugs early on.

Supporting a loved one through a struggle with substance use can be difficult for adults and teens alike. If you are concerned about a loved one’s substance use, support is available. You do not need to wait for a crisis to seek help.

If you feel unsafe at home:

• Call 911 if you or other family members are in immediate physical danger.
• Identify a place you would feel safe to go while things cool off.
• Identify another adult you trust who you can call — a grandparent, an adult sibling, a coach, a teacher, or a faith advisor.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on substance use disorders.

Find Treatment

If you have concerns about substance use or mental health, talk to a primary care provider. They can talk to you about your use pattern and any health consequences. If needed, they can refer you to a qualified mental health professional, such as a psychologist, psychiatrist, or clinical social worker.

• To learn more about alcohol treatment options and search for quality care near you, visit the NIAAA Alcohol Treatment Navigator.
• Find treatment for substance use disorders at FindTreatment.gov or call 1-800-662-HELP (4357), or TTY: 1-800-487-4889.
• The Partnership To End Addiction helps families and caregivers find treatment options for teens.

Community Support

Mutual-support groups can be particularly helpful for family members. A growing number of groups have online communities, and it is important to try different ones to find a good fit.

• Narcotics Anonymous supports individuals who want to stop using drugs, lose the desire to use, and find a new way to live.
• Alcoholics Anonymous supports individuals who want to stop drinking. 
• Alateen supports teens whose lives have been affected by someone’s drinking.
• Al-Anon helps family and friends of people who are worried about someone’s drinking.
• SMART Recovery supports individuals who desire to gain independence from any type of addictive behavior.
• Women in Sobriety offers tools designed specifically for women who want to get sober and stay sober.
• Life Ring provides abstinence-based, secular, and self-directed recovery ​pathways through meetings and support communities.

Other resources include:

• Use helplines to talk with people who are trained to help. These services are free and confidential.
  • Call the Childhelp National Child Abuse Hotline at 1-800-4-A-CHILD (1-800-422-4453) if you are concerned about child abuse.
  • Call or text 988 Suicide & Crisis Lifeline if you or someone you know is struggling with or having thoughts of suicide, or chat at 988lifeline.org.
  • Call the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline 1-800-985-5990 or text “talk with us” 24/7 on 66746.Smokefree.gov helps you build a plan to quit smoking, get support, and keep going.
• Rethinking Drinking helps you get to know your personal drinking pattern can help you understand if alcohol will affect your health.
• National Association for Children of Addiction helps children who are hurt by a parent’s alcohol use.
• National Recovery Month is a national observance held every September to educate Americans that substance use disorder treatment and mental health services can enable those with mental and substance use disorders to live healthy and rewarding lives.
• Linking Older Adults With Medicine, Alcohol, and Mental Health Resources
• SAMHSA has resources available online for families coping with mental and substance use disorders.

Note: This resource list is for informational purposes only. It is not comprehensive, and an organization’s inclusion does not constitute an endorsement by NIH. 

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery.

NIH supports and conducts research to develop and implement safe and effective treatments for substance use disorders, including research on new medicines, brain stimulation, psychosocial treatments, integrated health services, and other innovative approaches.

The NIH Helping to End Addiction Long-term®(HEAL) Initiative coordinates research across NIH to develop scientific solutions to the U.S. opioid crisis while advancing non-opioid treatments for chronic pain. Since its launch in 2018, HEAL has significantly expanded NIH's research on preventing substance use and overdose, and expanding treatment and recovery options for substance use disorders.

Prevention

NIH supports a broad portfolio of research to improve prevention of early-life drug use and addiction, including research to understand patterns of youth substance use. Research shows that adverse early childhood experiences are associated with early substance misuse, which may alter the brain in ways that increase the risk of addiction. NIH supports two long-term studies of brain development, the HEALthy Brain and Child Development (HBCD) Study and the Adolescent Brain Cognitive Development (ABCD) Study, that are collectively following more than 12,000 youth from birth to early adulthood to understand risk and protective factors for substance use, addiction, and other health outcomes. Other NIH research focuses on developing, testing, and implementing evidence-based substance use prevention and screening programs across settings such as primary care, emergency departments, schools, and justice systems.

Overdose rescue and response

NIH helped develop the first nasal spray containing the overdose reversal medicine naloxone. Current research focuses on developing new, more potent overdose medicines, as well as wearable devices designed to detect overdose and alert first responders. In addition, the Research on Interventions for Stability & Engagement (RISE) Network supports studies to improve the reach of overdose prevention approaches such as naloxone distribution.

Treatment

Innovative potential treatments under study include:

• Non-invasive neuromodulation approaches like transcranial magnetic stimulation (TMS) to help reset the brain circuitry underlying brain disorders.
• GLP-1 agonists: Studies suggest that people who take semaglutide people who take semaglutide and other GLP-1 medicines for diabetes and weight-loss have a lower risk of alcohol and other drug use disorders. Clinical trials are testing whether GLP-1 agonists can be used to treat substance use disorders.
• Psychedelic drugs: NIH supports research on therapies using psychedelic drugs like psilocybin and dissociative drugs like ketamine. There is some evidence that these drugs may support addiction recovery when used in clinical settings in combination with psychotherapy.

Recovery

Through the HEAL-funded Consortium on Addiction Recovery Science (CoARS), researchers are partnering with communities to evaluate a wide range of recovery supports, including recovery housing, youth programs, and recovery community centers, which seek to integrate peer-led services with clinician-led medical treatment for substance use disorders. CoARS also develops and disseminates evidence-based recovery practices and resources to improve the quality, availability, and effectiveness of recovery support services.

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.