Anxiety and Substance Use Disorder

A drink to quiet a racing mind. A pill to get through a meeting. For a lot of people, that is where substance use and anxiety first meet - not as a reckless choice, but as a way to feel okay for a few hours. The trouble is that the relief is borrowed. Anxiety and substance use disorders tend to circle each other, and over time each one can make the other harder to treat. The encouraging part: when both are addressed together, people do get better. This guide explains how the two conditions overlap, why “self-medicating” tends to backfire, and what evidence-based treatment actually looks like.

What we mean by anxiety disorders

Everyone feels anxious sometimes. An anxiety disorder is different - the worry doesn’t switch off, it shows up across many situations, and it can get worse over time. According to the National Institute of Mental Health, about a third of U.S. adolescents and adults experience an anxiety disorder at some point in their lives. The main types include generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias.

Symptoms reach past nervous thoughts. People describe a pounding heart, trouble breathing, restlessness, muscle tension, and sleep that won’t come. The fear can be intense enough that someone avoids social situations, skips work, or stops leaving the house. When it interferes with daily life that way, it is a medical condition - not a character flaw, and not something a person should be expected to simply push through.

Why the two so often travel together

When a substance use disorder and a mental health condition occur in the same person, clinicians call it a co-occurring disorder (the older term was “dual diagnosis”). It is common. SAMHSA’s 2024 National Survey on Drug Use and Health estimated that about 21.2 million U.S. adults had both a mental illness and a substance use disorder in the same year.

A reasonable question is which one comes first. The honest answer is that it varies, and one does not necessarily cause the other. NIDA describes three ways the two get tangled:

• Shared risk factors. Genetics, trauma, chronic stress, and a person’s environment can each raise the odds of both conditions. The same roots feed two different problems.
• Anxiety leading to substance use. People who feel anxious or overwhelmed “may use drugs to try to feel better, especially if they lack access to mental health care,” as NIDA puts it. This is the self-medication route.
• Substance use worsening anxiety. Drugs and alcohol change some of the same brain systems involved in mood and anxiety. Heavy use, and the withdrawal that follows, can spark anxiety or deepen anxiety that was already there.

In real life these overlap. Someone with untreated social anxiety drinks to get through gatherings; the drinking grows; hangovers and withdrawal crank the anxiety higher; the next drink starts to look like the only relief. That loop is the heart of the problem.

The self-medication trap

Alcohol and benzodiazepines like Xanax genuinely do quiet anxiety in the short term - that is exactly why they get used this way. According to the National Institute on Alcohol Abuse and Alcoholism, roughly one in five people with social anxiety disorder also has problems with alcohol, and self-medication is a big part of why.

The relief is the trap. The brain adapts. Tolerance builds, so it takes more of the substance to get the same calm, and the calm gets shorter. Then there is rebound anxiety: as alcohol or a sedative wears off, the nervous system swings the other way, and the anxiety that comes back is often sharper than where it started. So a person uses again, partly to treat the very symptom the last use created. What began as coping slowly becomes its own disorder, sitting on top of the anxiety it was supposed to fix.

This matters for medication, too. Benzodiazepines are effective anti-anxiety drugs, but NIMH notes that people can build tolerance and become dependent, which is why guidelines favor short-term use. For someone who also has a substance use disorder, that risk is sharper - a reason clinicians often steer toward non-addictive options first.

If you or someone you love is struggling, call or text 988 (US) anytime to reach the Suicide & Crisis Lifeline, or contact SAMHSA’s National Helpline at 1-800-662-HELP (4357) for free, confidential treatment referrals.

Signs the two may be feeding each other

Because the loop builds quietly, it can be hard to see from the inside. A few patterns are worth paying attention to - in yourself or in someone you care about:

• Needing a drink or a pill to face ordinary things: a phone call, a party, the start of the day.
• The anxiety getting worse over time, not better, even as use goes up.
• Sharp anxiety, shakiness, or panic in the hours after the last drink or dose - a hint of rebound and withdrawal.
• Using more than intended, or to manage feelings rather than for any other reason.
• Pulling away from people and activities that used to help with stress.

None of these is a diagnosis on its own. Together they are a reason to talk with a clinician who can look at both the anxiety and the substance use, rather than treating either in isolation.

Why both conditions need treatment at the same time

There is an old assumption that you have to “get clean first” and deal with the anxiety later. The evidence points the other way. NIDA is direct about it: integrated treatment - addressing the substance use and the mental health condition together - leads to better outcomes than treating one and ignoring the other.

The logic is plain once you see the loop. Treat only the addiction, and the untreated anxiety is still there, still pushing toward the next drink, so relapse is more likely. Treat only the anxiety while heavy use continues, and the substance keeps undermining the very treatment meant to help. SAMHSA notes that people with co-occurring disorders are also more likely to be hospitalized than people with either condition alone - part of why coordinated care matters.

Yet most people don’t get that coordinated care. Among the 21.2 million U.S. adults with a co-occurring disorder in 2024, SAMHSA’s NSDUH found that only about 14.5% received treatment for both their substance use and their mental health, and roughly 41% received no treatment of either kind. The gap between what works and what people actually receive is wide - which is one reason knowing to ask for integrated care is worth so much.

What integrated treatment looks like

There is no single protocol, but effective care for anxiety and a substance use disorder usually weaves a few threads together.

Therapy that treats both. Cognitive behavioral therapy (CBT) is the workhorse - for generalized anxiety disorder, NIMH calls it the “gold standard” choice for psychotherapy. It helps a person catch the anxious thought patterns that drive both the worry and the urge to use, and build other ways to cope. Other approaches, such as acceptance and commitment therapy, can help as well.

Medication, chosen with both conditions in mind. For anxiety, clinicians often start with antidepressants - SSRIs and SNRIs - which are not addictive but take several weeks to reach full effect. Buspirone is another non-sedative anti-anxiety option. When there is also an alcohol or opioid use disorder, FDA-approved medications for that condition may be part of the plan too. The point is a single, coordinated medication strategy rather than two clinicians working blind to each other.

The same team, talking to each other. What makes treatment “integrated” is coordination. Whether care is co-located in one clinic or shared across providers, the people treating the anxiety and the people treating the substance use are working from the same plan - not handing the person back and forth.

FAQ

Should I quit drinking or using before I get my anxiety treated? No - you don’t have to wait. The evidence supports treating both at once. Tell a provider about the anxiety and the substance use so the care can be coordinated. If you’ve been drinking heavily every day, talk to a doctor before stopping, since alcohol and benzodiazepine withdrawal can be dangerous and may need medical supervision.

Can substance use cause an anxiety disorder, or only make an existing one worse? Both happen. Some people have anxiety first and use substances to cope; for others, heavy use and the withdrawal that follows trigger anxiety that wasn’t there before. Often it runs both ways. NIDA emphasizes that the two conditions interact, and that one does not have to be the single cause for both to need treatment.

Are anti-anxiety medications safe if I have a substance use disorder? It depends on the medication, and it’s a conversation to have honestly with your prescriber. Benzodiazepines carry a real risk of tolerance and dependence, so clinicians are often cautious with them for someone who has a substance use disorder and may favor non-addictive options like SSRIs or buspirone. Be open about your history so the choice fits your situation.

Is recovery realistic when I’m dealing with both? Yes. Co-occurring disorders are more complex to treat, but they are treatable, and integrated care improves the odds for both conditions. Many people manage their anxiety and their recovery at the same time and build a stable life.

Sources

• National Institute of Mental Health (NIMH) - Anxiety Disorders, Generalized Anxiety Disorder, and Psychotherapies
• National Institute on Drug Abuse (NIDA) - Co-Occurring Disorders and Health Conditions
• National Institute on Alcohol Abuse and Alcoholism (NIAAA) - Mental Health Issues: Alcohol Use Disorder and Common Co-occurring Conditions
• Substance Abuse and Mental Health Services Administration (SAMHSA) - Co-Occurring Disorders and the 2024 National Survey on Drug Use and Health (NSDUH)