Anxiety and Substance Use: Why Treating Both Together Works Better

Maybe a drink helps you get through social events, or a little cannabis is the only thing that quiets your mind at night. Over time, you may notice your anxiety getting worse, not better. A dual diagnosis of anxiety and substance use is common, and it's very treatable when both conditions are addressed together.

Key takeaways

• Anxiety and substance use often feed each other through self-medication, rebound anxiety and withdrawal.
• Treating both conditions at the same time tends to work better than treating one and waiting on the other.
• Many effective anxiety medications carry little or no risk of misuse.
• FDA-approved medications for alcohol and opioid use disorder can be part of outpatient care.
• Stopping alcohol or benzodiazepines suddenly after heavy or long-term use can be dangerous and may need medical supervision.

If you need help now: If you've taken too much of a substance or someone may be overdosing, call 911. If you're having thoughts of suicide, call or text 988, or text HOME to 741741. For free, confidential treatment referrals at any hour, call the SAMHSA National Helpline at 1-800-662-4357. More options are on our crisis resources page.

What a dual diagnosis of anxiety and substance use means

A dual diagnosis, also called co-occurring disorders, means a person has both a mental health condition and a substance use disorder at the same time. Anxiety disorders are among the conditions that most often occur alongside substance use. The NIMH page on substance use and mental health explains why these conditions so often overlap.

Anxiety can include generalized anxiety, panic disorder, social anxiety and other related conditions. The substance might be alcohol, cannabis, sedatives, opioids or stimulants. The specifics shape treatment, but the core pattern is often similar.

How anxiety and substance use feed each other

Self-medication

Many people start using a substance to cope with anxiety. Alcohol and cannabis can bring quick, short-term relief from worry, tension or social discomfort. Because the relief works fast, it's easy to reach for again and again.

Rebound anxiety

The calm doesn't last. As alcohol or a sedative wears off, the brain swings back the other way, and anxiety can return stronger than before. Many people know this as the anxious, jittery feeling the morning after drinking. That rebound makes the next drink or dose feel more necessary.

Withdrawal anxiety

With regular use, the body adapts. When the substance is stopped or reduced, withdrawal can cause anxiety, restlessness, irritability and poor sleep. These symptoms can look exactly like an anxiety disorder, which can make it hard to tell what came first.

Substance-induced anxiety

Some substances cause anxiety directly. High-THC cannabis can trigger panic in some people. Stimulants, including cocaine and misused prescription stimulants, can cause intense anxiety. Even heavy caffeine use can add to the problem.

Over time, these patterns form a loop: anxiety leads to use, use leads to more anxiety, and the cycle tightens.

Why both need treatment together

It's tempting to tackle one problem first. But if anxiety is left untreated, the urge to self-medicate stays strong and relapse is more likely. If substance use continues, it keeps fueling anxiety and can make anxiety medications work less well.

Integrated care treats both conditions at the same time, with one plan and a care team that sees the whole picture. This approach also helps sort out which symptoms are an anxiety disorder and which are caused by the substance or its withdrawal. Some anxiety improves a great deal after a period without substances, and some needs its own treatment.

What outpatient addiction psychiatry looks like

Outpatient addiction psychiatry lets you get care while you keep living your life, working and staying at home.

A thorough evaluation

Your first visit will cover your anxiety symptoms, your substance use history, past attempts to cut back, withdrawal symptoms, physical health, sleep, other mental health conditions and family history. Lab work may be part of the picture. Honesty helps here, and your provider is there to help, not to judge.

Anxiety medications that avoid misuse risk

Several effective anxiety medications have little or no potential for misuse:

• SSRIs and SNRIs, such as sertraline, escitalopram, venlafaxine or duloxetine, are common first-line options for many anxiety disorders. Antidepressants carry an FDA boxed warning about suicidal thoughts and behavior in children, teens and young adults.
• Buspirone is used for generalized anxiety and isn't habit-forming.
• Hydroxyzine, an antihistamine, is sometimes used for short-term anxiety relief.
• Propranolol may help with the physical symptoms of performance anxiety. Learn more in our post on propranolol for anxiety.

Anxiety care also often includes skills-based treatment with a trained mental health professional, which your psychiatric provider can help you coordinate.

Medications for alcohol and opioid use disorder

FDA-approved medications can reduce cravings, lower the risk of relapse and, for opioid use disorder, lower the risk of overdose.

• For alcohol use disorder: naltrexone, acamprosate and disulfiram are approved options.
• For opioid use disorder: buprenorphine, methadone and extended-release naltrexone are approved options. Methadone for opioid use disorder is provided through certified opioid treatment programs, so your provider would refer you if it's the best fit.

There are currently no FDA-approved medications specifically for cannabis use disorder, but treatment can still address cravings, sleep and anxiety. Talk with your prescriber before starting, stopping or changing any medication.

Caution with benzodiazepines

Benzodiazepines, such as alprazolam, lorazepam and clonazepam, work quickly for anxiety, but they carry an FDA boxed warning about misuse, addiction, physical dependence and withdrawal. Combining them with alcohol or opioids can slow breathing to a dangerous degree, and they carry a separate boxed warning about use with opioids.

For people with a history of substance use, prescribers are usually very cautious with benzodiazepines and often prefer other options. If you already take one, don't stop suddenly. Work with your prescriber on a safe plan.

When withdrawal needs medical supervision

Withdrawal from some substances can be dangerous on its own.

• Alcohol withdrawal after heavy, regular drinking can cause seizures and a severe state of confusion called delirium tremens, which can be life-threatening.
• Benzodiazepine withdrawal after regular use can also cause seizures and other serious symptoms.
• Opioid withdrawal is very uncomfortable and is less often dangerous in itself, but it raises the risk of overdose if use restarts, because tolerance drops quickly.

If you drink heavily every day or take benzodiazepines regularly, don't quit on your own. Talk with a medical provider first. Some people can withdraw safely as outpatients with close monitoring, while others need a medically supervised withdrawal program. Your provider can help you decide which is right and coordinate a referral if needed.

If anyone in your life uses opioids, keeping naloxone on hand can save a life. Naloxone nasal spray is available over the counter.

Frequently asked questions

Which came first, the anxiety or the substance use?

It can be hard to tell, and it often doesn't need to be settled right away. A careful history and a period of reduced use or abstinence can help clarify things. Either way, treating both together is the goal.

Can I take anxiety medication while I'm still drinking or using?

Sometimes, but it's important to be honest with your prescriber about what and how much you use. Some combinations are risky, especially with sedatives. Your provider will choose options that are safe for your situation.

Do I have to stop completely before I can get help?

No. Many people start treatment while still using and work toward their goals over time. Your provider will help you set a plan, including whether withdrawal needs medical supervision.

Is my treatment confidential?

Your health information is protected by privacy rules, and some substance use treatment records have extra protections. Ask your provider how your information is handled and who it can be shared with.

Get help for both, in one place

You don't have to choose between treating your anxiety and treating your substance use. At Musec Medical, our psychiatrist and psychiatric physician assistants provide outpatient addiction psychiatry and anxiety care, in person in Chicago and by telehealth anywhere in Illinois. Request an appointment to take the first step.