I am a practicing addiction psychiatrist in New York City and research scientist funded by the NIH. With these twin lenses of clinical and research perspectives on addiction, I have learned a lot about how different addictions can appear across populations and settings. At its core, however, addiction (“substance use disorder” according to the DSM-5) is the escalating and compulsive use of a given drug despite worsening problems in life. Clearly, each class of substances has its own characteristics and impacts someone’s life and health in different ways. In combination with each individual’s own genetic makeup, personality, and lived experience this leads to addiction manifesting in myriad ways across the country. For a quarter century now the US has been in the throes of a massive opioid crisis and it is just getting worse by the month, exacerbated by COVID isolation and economic disruptions. Additionally, we are seeing spikes in psychostimulant use (cocaine, methamphetamine) and heavy cannabis use given all of the many cannabinoid products on the market now. Read on to find out major signs of addiction—and to ensure your health and the health of others, don’t miss these Sure Signs You’ve Already Had COVID.

Often the first sign is other people noticing. It could be friends or family noticing you are prone to over drinking, or seeming to be intoxicated — they pick up on some sort of change in your personality or behavior. This doesn’t necessarily happen as some addictions remain hidden. Often the people closest to you start to notice something is off, even if they cannot name it.

Drug or alcohol use isn’t fun anymore, but you keep doing it anyway. People often start using drugs or alcohol in a social context, with peers, for fun, out of curiosity. Initially, if people keep using it is because they like something about the feelings they get, about the experience. Over time with more frequent and heavy use there tends to be a shift, however. And the substance use isn’t as fun, as rewarding as it may have been in the past and yet it has become so habitual it is hard to cut down. Many daily users of any substance (cannabis, alcohol, nicotine) report they have tried to cut down or intend to cut down in the coming year. It speaks to both psychological and physical dependence, which of course are closely intertwined.

More and more problems. Health problems, financial problems, difficulty keeping up with activities with friends, at work, with hobbies. Many people experience a narrowing in life where they give up more and more activities in order to focus on obtaining, using, and recovering from using substances. These sacrifices are often subtle and people may not notice until all of a sudden they are a bit stranded in a relationship with a substance and isolated from most other people and things they use to value.

You can’t sleep through the night. Most drugs and alcohol often help people initially fall asleep, at least for a while. However as someone’s tolerance grows and he or she uses more and more of their preferred substance to achieve the same effects, there is a greater risk that sleep architecture becomes disturbed. Some people even go into early withdrawal while they are sleeping. For instance, one of the strongest indicators of the severity of nicotine dependence is how early in the day (i.e. before getting out of bed) someone might start smoking or vaping. When you have to wake up in the middle of the night to keep drinking, or using a substance, it is a sign that the substance use disorder is getting more severe.

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Using other drugs to compensate is often a sign that use of the primary drug has spiraled out of control. There are some classic examples — for instance, cocaine users who become dependent on Xanax, heavy drinkers who use stimulants like caffeine or amphetamines to keep drinking, heroin users (who increasingly are using fentanyl, whether intentionally or not) who add in methamphetamine to offset rapid sedation. These combinations tend to prolong heavy use of the original substance and lead to higher physical tolerance with more damaging health effects over the long term.

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Look for an addiction specialist—a provider or program that is credentialed specifically for helping patients struggling with substance use. Unfortunately, there are a lot of mediocre programs that are highly ideological but not necessarily effective in helping people reduce or quit substance use.

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There is an outdated but widespread belief that if someone needs treatment for addiction they “have to go to rehab.” Usually, this conjures a residential rehab or inpatient detox program. The reality is that addiction is a chronic progressive relapsing disorder. The best treatment is often long-term community based care. Fortunately, this means most people do not need to go away for weeks or months to a residential setting to start getting better. They can receive treatment while continuing to work or go to school, keep up relationships and activities. With telehealth now widely available this is even more true. Patients can have regular sessions from the comfort of their own home or even during a lunch break at work. Telehealth has revolutionized access to high quality care. But not all providers and tele-platforms are the same. The best care is face-to-face clinical sessions with credentialed advance practitioner providers such as nurses and physicians. While medication access and messaging systems can help support recovery, most patients do best when they get personal attention and care with the same provider or team of providers over many months or years. And to protect your life and the lives of others, don’t visit any of these 35 Places You’re Most Likely to Catch COVID.