Signs of a substance use problem

A substance use problem is not a weakness or a lack of willpower. Drugs and alcohol can change the parts of the brain that handle reward, stress and self-control. That is why stopping can feel impossible, even for a person who badly wants to stop.¹ Substance use disorder is a medical condition, and people recover from it.

This page lists the common signs, from mild to severe. It also gives a few questions you can ask yourself or a loved one, shows how the signs can look different in an older adult, and explains when a situation is an emergency. For the big picture, start with the overview of substance use and addiction.

How common is this?

Substance use disorder is very common. In 2024, about 48 million people in the U.S. aged 12 or older (about 17 percent, or roughly 1 in 6) had one in the past year. About 28 million had an alcohol use disorder, and about 28 million had a drug use disorder. Some people have both.⁸

Most people who need care do not get it. Only about 1 in 5 people who needed treatment received it in the past year.⁸ If you are worried, you are far from alone.

What is a substance use disorder?

"Substance use" covers alcohol, nicotine, cannabis (marijuana), opioids, sedatives, stimulants and other drugs. It also includes prescription medicines taken in ways the doctor did not intend.¹

Using a substance is not the same as having a disorder. A substance use disorder means use has become hard to control and keeps causing problems in a person's life. Doctors rate it as mild, moderate or severe, depending on how many signs a person has.²

Misuse can be harmful even without a disorder. Taking an opioid to get high, or mixing substances, can lead to injury or overdose even if a person uses only now and then.¹

The main signs

Doctors look at 11 signs for alcohol use disorder. They ask about the past year. The same pattern is used for other substances.² The signs group into four ideas.

1. Losing control

• Using more, or for longer, than you meant to.
• Wanting to cut down or stop, or trying and not managing it.
• Spending a lot of time using, being sick from it, or recovering from it.

2. Craving and a narrowed life

• Strong urges to use that push other thoughts aside. This is called craving.
• Giving up or cutting back on activities you used to enjoy.
• Other pleasures feeling less enjoyable than they used to.^1,2

3. Problems that continue

• Use that gets in the way of home, family, work or school.
• Continuing even when it causes trouble with people you love.
• Continuing even when it worsens depression, anxiety, other health problems or memory blackouts.
• Using in risky situations, such as before driving.²

4. Changes in the body

• Tolerance: needing more of the substance for the same effect, or getting less effect from the usual amount.
• Withdrawal: feeling sick or unwell when the substance wears off. For alcohol this can include poor sleep, shaking, restlessness, nausea, sweating, a racing heart and low mood. In serious cases it can include seizures or hallucinations (seeing or hearing things that are not there).²

How doctors rate severity

For alcohol, the count of signs sets the level.²

The count is a guide, not a label. More signs mean the need for change is more urgent. Mild does not mean "nothing." Early help works best.² Many people notice problems long before they reach the severe level.

Questions you can ask yourself

These questions are not a test, and they cannot diagnose anything. They follow the 11 signs above.² Think about the past year.

• Have I used more, or for longer, than I planned?
• Have I wanted to cut down or stop, and found I couldn't?
• Do strong urges or cravings fill my thoughts?
• Has it caused trouble at home, with family or friends, or at work?
• Have I given up things I used to enjoy?
• Have I needed more to get the same effect?
• Do I feel sick, shaky or very uneasy when it wears off?
• Have I kept using even though it hurt my health, mood or memory?

If you answered yes to even one or two, that is a good reason to talk with a doctor or nurse. If you answered yes to several, ask for help soon. Your doctor can use brief, standard screening questions. A national task force of experts recommends that adults be asked about unhealthy alcohol use and drug use in primary care, so these questions are part of routine care.^9,10

For alcohol, one common screening question asks how often in the past year you had 5 or more drinks in a day. For women and for adults over 65, the number is 4 or more.⁹ A standard drink is about 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor.¹¹ Your pours at home may be larger than you think.

You can also try the mood and wellbeing check-in on this site. If alcohol or drugs are tied up with low mood, anxiety or trauma, see the pages on depression and anxiety. These problems often show up together.

Signs in an older parent or loved one

Substance use problems in older adults are often missed. The signs can look like normal aging, or like other health problems.³ Possible signs include:³

• Memory loss or confusion
• Depression or anxiety
• Poor appetite
• Unexplained bruises
• Falls
• Sleep problems
• Neglecting cleanliness or appearance

Many things on this list have other causes, so do not jump to conclusions. But if you see several together, or a sudden change, ask a doctor to look at alcohol, sleep aids and pain medicines as one possible cause.

Older bodies handle alcohol differently. Older adults can have problems at lower amounts than younger people. They also tend to be more sensitive to alcohol's sleepy, unsteady effects, which raises the risk of falls and car crashes.³ Mixing alcohol with sleep, anxiety, allergy or pain medicines can be deadly.³ Life changes such as retirement, the loss of a spouse or new health problems can lead to more drinking.³

Medicines matter too. Benzodiazepines (a group of sedatives often used for anxiety or sleep) can cause physical dependence and withdrawal, even when taken as prescribed.⁵ An older person may not think of a pill from their doctor as "a drug problem." Be gentle about it. Read more on alcohol, medicines and older adults and see the guide for older adults.

Signs in someone you love

If you are a family member, you might notice:

• Changes in mood, sleep, appetite or energy
• Pulling away from family and friends
• Missing work, appointments or bills
• Money problems or things missing
• Secrecy, or defensive answers when asked
• Smell of alcohol, empty bottles, or unusual pills

None of these proves a problem on its own. The most useful step is to speak with kindness, in private, at a calm time. Say what you have seen and that you care. Do not call the person names or demand an answer. Find more help in helping a family member and the page for caregivers.

When it is an emergency

Withdrawal can be dangerous

Stopping alcohol or sedatives suddenly after heavy, regular use can be life-threatening. For alcohol, mild symptoms can start about 6 to 8 hours after the last drink. Seizures are most likely in the first 12 to 48 hours. A severe form called delirium tremens, with deep confusion, fever and hallucinations, usually starts 2 to 3 days after the last drink. It is uncommon, but it needs hospital care.⁴ Benzodiazepine withdrawal can also be serious, and doctors lower these medicines slowly.⁵

If a person drinks heavily every day or uses sedatives regularly, do not quit alone and "cold." Talk to a doctor first. There are medicines that make withdrawal safer.² See alcohol use disorder and cannabis, sedatives and stimulants.

Thoughts of suicide

Alcohol and drug problems can come with deep despair. If you or someone you know is thinking about suicide, call or text 988 (the Suicide and Crisis Lifeline) at any time. If life is in danger right now, call 911. A safety plan can help you prepare ahead.

When to get help

Do not wait for things to get worse. Get help if:

• You answered yes to several of the questions above
• You have tried to cut down and could not
• Use is hurting your health, safety, money or relationships
• A loved one has told you they are worried

Start with your doctor, nurse or pharmacist. You can also call the SAMHSA National Helpline at 1-800-662-HELP (4357). It is free, private and open 24 hours a day, every day of the year, in English and Spanish. It provides referrals to treatment and information for people and families.⁷ See treatment and recovery for what care involves. Relapse can be part of recovery. It does not mean failure, and help is still available. More options are on our help page.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.