If part of you keeps wondering whether you’re overreacting, here are the numbers that pushed many families past that question. In 2022, about 48.7 million people in the U.S. aged 12 and older had a past-year substance use disorder. Of those, 29.5 million had an alcohol use disorder, 27.2 million had a drug use disorder, and 8.0 million carried both at the same time ².

Sit with the overlap for a second. Eight million people aren’t choosing between alcohol and another drug — they’re using both, often to soften the edges of each. That polysubstance pattern is part of why “is it the drinking or the pills?” rarely has a clean answer at the kitchen table.

What this means for you: what you’re seeing isn’t rare, and it isn’t a character flaw in your family. Substance use disorder is a chronic, treatable medical condition with criteria a clinician can apply ^{1, 11}. The work ahead is to figure out which category you’re actually dealing with, because the answer changes everything about what help should look like.

Alcohol is the one most families miss the longest, because so much of it looks like life. Wine at book club. Beer after the mower. A nightcap that became two, then four, then a bottle you don’t talk about. With 29.5 million Americans meeting criteria for alcohol use disorder in a single year ², the odds that the heavy drinker you love is “just a drinker” are smaller than you’ve been telling yourself.

The household signals tend to be quiet ones. Recycling bins that fill faster than they used to. A spouse who showers before bed, every night, no exceptions. Mornings that start with shaky hands or a fast heart, smoothed out by 10 a.m. Defensiveness when you bring up cutting back. Promises that hold for three days.

Opioid use disorder often introduces itself through the body before it shows up in conversation. Prescription painkillers, heroin, and fentanyl all act on the same brain receptors, which is why a back surgery in 2019 can become a fentanyl problem in 2025 ^{1, 15}.

What you might notice at home: your son nodding off at the dinner table mid-sentence, then snapping awake and insisting he’s fine. Pinpoint pupils in bright rooms. Constant itching, especially on the face and arms. Long sleeves in July. A stomach that’s always off — constipation, nausea, cycles of both. Money that goes missing in small, deniable amounts. A prescription bottle that empties faster than the date on the label says it should.

Withdrawal from opioids is rarely life-threatening on its own, but it is brutal — body aches, sweats, vomiting, and the kind of psychological pain that sends people back to the drug within hours ¹⁵. This is why “just stop” almost never works with opioids, and why medication-assisted treatment with buprenorphine or methadone is considered a first-line option in evidence-based care ¹⁷. If you smell something acrid and chemical on foil or a spoon, call a treatment line that day. Fentanyl has changed what a single mistake costs.

Stimulants run in the opposite direction from opioids, and the signs follow suit. Where opioids slow a person down, stimulants speed them up — cocaine, crack, methamphetamine, and prescription medications like Adderall or Vyvanse when they’re taken outside of how a doctor wrote them ^{1, 15}.

The pattern families describe sounds something like this: stretches of frantic productivity followed by days of sleeping through everything. Weight loss that can’t be explained by a new gym routine. Jaw clenching, tooth grinding, skin picking. A daughter whose pupils stay wide even in lamplight. Talking that loops back on itself, fast, with a brittle edge. Bank accounts that swing hard each month. For someone with a stimulant use disorder, the crash after a binge can look like severe depression — sleeping for two days, not eating, saying things that frighten you.

There is no FDA-approved medication for stimulant use disorder the way there is for opioids or alcohol, so treatment leans heavily on behavioral therapies, contingency management, and structure ¹⁷. The crash phase is also when suicide risk climbs, which is why families often need to involve a clinician sooner with stimulants than they think they should.

The substances in this section share a single, frustrating quality: they all look less serious than they are.

Sedatives — benzodiazepines like Xanax, Klonopin, Ativan, and Valium, plus sleep medications like Ambien — start as a prescription for anxiety or insomnia and end as a daily dependency the prescriber may not know about. Withdrawal from long-term benzodiazepine use is in the same medically dangerous category as alcohol withdrawal; seizures and severe agitation are real risks, and tapering should be supervised ¹⁵. If your spouse is taking more than the bottle says, or filling at multiple pharmacies, treat it the way you’d treat opioids — quietly, urgently, and with professional help.

Cannabis is the one parents argue about most. Daily high-potency use, especially in adolescents and young adults, meets diagnostic criteria for cannabis use disorder and is associated with anxiety, depression, and, in vulnerable users, psychotic symptoms ^{1, 15}. “It’s just weed” stops being true when grades collapse, friendships narrow to other users, and a 21-year-old can’t wake up without a dab pen.

Nicotine, including vaping, is on the CDC’s list of substances that cause use disorders for a reason ¹. It’s not the one that breaks up a marriage, but it’s the one that shortens it. Hallucinogens and inhalants round out the list — less common, but inhalant use in particular (aerosols, solvents) can cause sudden cardiac death even on a first try ¹.

The throughline: don’t let a substance’s cultural reputation set your alarm level. Let the pattern of use — the lying, the loss of control, the consequences your loved one keeps absorbing — do that instead ¹¹.

Here’s the part that surprises most parents: you don’t need a drug to get addicted. The brain’s reward system — the same circuitry that lights up when someone takes an opioid or pours a drink — also responds to a winning bet, a level cleared at 2 a.m., or a notification that pings just often enough to keep a thumb scrolling ¹⁴.

What researchers call behavioral or non-substance addictions share the core features of substance addictions: compulsive engagement, diminished control, and continued behavior despite consequences your loved one can clearly see ^{8, 13}. The cycle of craving, indulgence, and regret looks the same from across the dinner table. That’s why it feels familiar to you even when there’s no bottle or baggie involved.

Among the seven behavioral addictions most studied worldwide — gambling, gaming, internet and communication technology use, sex, food, sports, and shopping — only two have crossed into formal diagnostic territory ⁹. Gambling disorder and internet gaming disorder are the ones clinicians can diagnose using the same kind of criteria they use for substances ^{7, 8}.

Gambling at home rarely starts with a casino. It starts with a sports app, a fantasy league, or a few late-night spins. The signals families describe: a checking account that swings hard on Sundays, a partner who lies about a paycheck, secret credit cards, mood that rises and falls with a score you didn’t know was being tracked. Gambling disorder is the behavioral addiction with the longest research history, and brain imaging shows it activates reward pathways in patterns close to what stimulants do ⁸.

Gaming earned its diagnostic status — internet gaming disorder — because the evidence got hard to ignore ⁷. The pattern parents notice: a son who skips meals to keep playing, falling grades, irritability when the console is off, sleep cycles flipped backward, friendships that exist only inside a headset. Not every heavy gamer has gaming disorder. But when the game is winning against school, work, hygiene, and the people in the room, you’re not watching a hobby anymore.

This is where you’ll want a careful answer, because the internet will sell you a louder one.

Food addiction, sex addiction, shopping addiction, problematic social media use, and broader internet addiction all show up in serious research ^{9, 18}. People meet self-report criteria. Brain scans light up in suggestive ways. Families describe lives that have narrowed around a single behavior. And yet none of these have reached formal diagnostic status the way gambling and gaming have ⁷. The science isn’t denying these struggles — it’s still arguing about where the line falls between a compulsion, an impulse-control problem, and a true addiction ⁸.

For you, the practical answer is simpler than the academic one. If your spouse can’t stop online shopping despite mounting debt, if your daughter’s phone use is wrecking her sleep and her friendships, if your partner’s pornography use is hiding inside every spare hour — those are real problems that deserve real help, whether or not the DSM has caught up. A good clinician will treat the pattern, not wait for the label. Bring what you’re seeing. The name can come later.