Not Alone, Not Weak
If your hands are unsteady reading this, if the second drink of the night has been about quieting your chest more than enjoying the wine, if the prescribed Xanax stopped being enough months ago, you are not alone and you are not weak.
Anxiety disorders are the most prevalent class of mental health conditions in the United States, affecting approximately 40 million adults annually. They are also among the most common co-occurring conditions in addiction treatment settings.
The link between anxiety and substance use is neurobiological: the brain systems involved in the stress response and threat detection are deeply implicated in both anxiety disorders and substance use disorders, and many of the substances most commonly used to self-medicate anxiety, including alcohol, benzodiazepines, and cannabis, are also among those most likely to worsen anxiety with chronic use.
Roanoke Refuge treats co-occurring anxiety and substance use disorder as a substance-use-primary outpatient program where co-occurring mental health is addressed inside the same treatment plan. Our treatment approach grounds the clinical framework, and our dual diagnosis program details the broader structure of co-occurring care. The level-of-care recommendation for each client is made during the admissions assessment using an ASAM level-of-care assessment.
The Anxiety-Substance Use Cycle
The cycle is predictable, and we see it walk through the door from Roanoke City, Salem, and the surrounding counties every week:
Anxiety feels unmanageable
You reach for the thing that quiets it.
The substance works, fast
The brain registers the equation that substance equals safety, and the next time anxiety arrives the reach is automatic.
Tolerance develops
Anxiety returns more intensely as rebound anxiety.
Dependence develops
The absence of the substance itself begins to produce anxiety and withdrawal.
You end up using to manage what you believe is your underlying anxiety, without recognizing that the substance has become a significant cause of it. Most clients we treat have spent years inside that loop without naming it as a loop. Breaking the cycle requires treating both conditions simultaneously, within the same clinical framework.
Anxiety Disorders We Address
Anxiety isn’t one diagnosis; it’s a class of related conditions, each with its own clinical signature and self-medication pattern. The five we address most often — GAD, panic disorder, social anxiety, PTSD, and specific phobias — each respond to substance-use-primary outpatient care, with post-traumatic stress disorder covered in detail on a dedicated page.
Generalized Anxiety Disorder (GAD)
Chronic, pervasive worry across multiple life domains with significant physical symptoms including muscle tension, restlessness, and sleep disturbance.
Panic Disorder
Recurrent, unexpected panic attacks and significant concern about future attacks, often leading to avoidance behaviors that further restrict daily life.
Social Anxiety Disorder
Intense fear of social or performance situations. Frequently self-medicated with alcohol, which provides short-term relief while reinforcing the avoidance pattern over time.
Post-Traumatic Stress Disorder
Addressed in detail on the dedicated trauma and PTSD page, with substantial overlap with the broader anxiety treatment framework. Learn more
Specific Phobias and Agoraphobia
Less commonly the primary clinical issue but often present in clients with broader anxiety patterns.
How We Treat Co-Occurring Anxiety at Roanoke Refuge
Most clients ask us what is going to replace the bottle or the pill once it is no longer doing the job of quieting the anxiety. That is a fair question, and the answer is the part of the work we take most seriously.
Cognitive Behavioral Therapy is the most empirically validated treatment for anxiety disorders, with strong evidence across all major anxiety diagnoses. Our CBT-based approach for co-occurring anxiety and substance use disorder addresses both simultaneously, targeting avoidance, safety behaviors, catastrophic thinking, and the substance use that has functionally served as an anxiety-management strategy. The non-pharmacological anxiety management skills built into the curriculum include:
Diaphragmatic breathing and progressive muscle relaxation
Practical physiological tools for the acute moments of anxiety that previously drove substance use.
Mindfulness-based stress reduction
Skills for managing the relationship to anxious thoughts rather than fighting them directly.
Cognitive restructuring
Identifying and modifying the anxiety-maintaining thought patterns that drive the cycle.
Exposure principles
Gradually confronting feared situations rather than avoiding them, calibrated to the client’s clinical readiness.
Sleep hygiene
Specific tools for the anxiety-related insomnia that often persists into early recovery.
Exercise as a neurobiological anxiety intervention
Built into the recovery routine as a meaningful, evidence-based contributor to anxiety reduction.
The exposure-based work is the part clients dread most before they start it, and the part that produces the most relief once they are inside it. We want to be honest about that up front.
Avoidance is the most common anxiety-management strategy across clinical populations, and it is also one of the most reliable mechanisms by which anxiety disorders maintain themselves over time. The clinical work involves gradual, carefully calibrated exposure to feared situations rather than continued avoidance, and the results in the research are consistent: exposure-based CBT produces durable reduction in anxiety symptoms across most anxiety disorders.
The pacing of the work is set by your clinical readiness, not by an external timeline. Nobody pushes you off a cliff.
A Note on Benzodiazepines
This is the part that worries clients most when they call admissions. Many people entering treatment for substance use disorder arrive on prescribed benzodiazepines for anxiety, and the fear of losing access to that medication on day one is real. Here is what you need to know: the clinical management of benzodiazepine use in the context of anxiety disorder treatment is complex.
Conditions like this rarely show up alone. Many clients live with more than one mental health condition stacked on top of substance use. The deeper picture of how integrated treatment works across multiple diagnoses is on the co-occurring disorders page.
Psychiatric Coordination
For clients whose anxiety persists beyond the early stabilization phase and requires non-benzodiazepine pharmacological treatment, we coordinate with psychiatric prescribers in the Roanoke region. SSRIs, SNRIs, buspirone, and other non-addictive options are within the prescribing provider’s scope, and our clinical team communicates regularly to keep the pharmacological and behavioral components aligned.
Local, regional, and accessible.
Roanoke Refuge serves clients from across the Roanoke Valley — Roanoke City, Salem, Vinton, and the surrounding counties of Roanoke County, Botetourt County, and Bedford County. Our facility at 1630 Braeburn Drive in Salem sits just off I-81 exit 137, a short drive from downtown Roanoke via I-581 South and accessible from most of the Valley within 20 to 30 minutes. Whether you live near the Mill Mountain Star or out toward the Blue Ridge Parkway, the outpatient model is the same.
If a co-occurring condition alongside a substance use disorder is the picture for you or someone you love, the first step is a conversation, not a commitment. A short call with the Roanoke Refuge admissions team covers fit, level of care, and insurance — before any clinical work begins. Free, confidential insurance verification runs during the same call. Call (540) 900-0353 when you are ready.