How Do You Know When Someone Needs Detox?

The question is not whether someone uses too much. Plenty of people use too much and do not need detox.

The question is whether their body has adapted to the substance.

Detox is for physical dependence: the state in which stopping makes the body sick. Addiction and dependence often travel together, but they are not the same thing, and the signs below are sorted by which one they point to.

Physical signs

Morning shakes, sweating, nausea, or a racing heart within hours of the last drink or dose are the clearest physical signals of dependence. Needing alcohol or a substance to feel “normal,” not to feel high, is another one. If you are unsure what dependence itself means, our What Is Medical Detox? Everything You Need to Know explainer covers it in plain language.

Two of the eleven criteria clinicians use to diagnose a substance use disorder are physical, and they are the two that matter most for detox:

• Tolerance. Needing much more than before to get the same effect.
• Withdrawal. Symptoms when the effect wears off, or using to relieve or avoid them.

A first drink in the morning to steady the hands is withdrawal relief. So is a pill taken to stop feeling sick rather than to feel good. Either one means the body now expects the substance.

The other nine criteria describe the pattern, not the body. NIAAA’s plain-language version of the checklist, written for alcohol but built on the same eleven criteria used for other drugs, asks, for the past year, whether you have:

• Ended up using more, or longer, than you meant to
• Wanted to cut down or stop, or tried, and could not
• Spent a lot of time using, getting it, or getting over it
• Felt a strong craving or urge to use
• Had use get in the way of home, family, work or school
• Kept using even though it caused trouble with family or friends
• Given up or cut back on activities that mattered, in order to use
• Ended up in risky situations, such as driving, more than once
• Kept using despite feeling depressed or anxious, or after a memory blackout

Two or more in a year meets the threshold for a substance use disorder: mild at two to three, moderate at four to five, severe at six or more. That tells you whether there is a disorder. It does not tell you whether detox is needed. The physical signs do.

One caution: DSM-5 does not count tolerance and withdrawal toward an opioid use disorder diagnosis when the opioid is taken solely under appropriate medical supervision, and the 2025 benzodiazepine tapering guideline says physical dependence on a prescribed benzodiazepine is distinct from a substance use disorder. Dependence on a prescribed medication does not by itself mean addiction. It still means the medication should never be stopped abruptly without the prescriber.

What withdrawal looks like, by substance

• Alcohol. Tremor, anxiety, sweating, insomnia and nausea, typically starting 6 to 24 hours after the last drink. Seizures, when they happen, cluster early. Delirium tremens comes later. The alcohol withdrawal timeline covers it hour by hour.
• Opioids. MedlinePlus lists early symptoms as agitation, anxiety, muscle aches, tearing, runny nose, sweating, yawning and insomnia, and later ones as cramping, diarrhea, dilated pupils, goosebumps, nausea and vomiting. It says symptoms usually start within 12 hours of the last heroin use and within 30 hours of the last methadone exposure.
• Benzodiazepines. Anxiety, insomnia and tremor that can progress to seizures. Never stop a benzodiazepine abruptly: the FDA warns that doing so can cause life-threatening withdrawal reactions.
• Stimulants. Exhaustion, long sleep, hunger and a hard drop in mood. ASAM’s stimulant guideline warns that suicidal thinking can rise in early withdrawal.

Behavioral signs

Missed work or school, secret use, hiding bottles or bags, sudden financial strain, and social withdrawal often move faster than families expect. When someone reorganizes their day around using, down to the timing, the place and who they see, that is a signal. The same pattern shows up with cannabis; see Greening Out: When Too Much Marijuana Becomes More Than a Bad High.

Behavioral signs point to addiction. They do not, on their own, tell you whether detox is needed. Someone can be deep in a cocaine pattern with no dangerous withdrawal, and someone can be physically dependent on a prescribed medication with no behavioral problem at all. Clinicians weigh both.

Red flags that call for same-day care

Seizure history, prior withdrawal complications, use of high-dose alcohol or benzodiazepines, fentanyl exposure, pregnancy, or serious co-occurring medical conditions all move detox from “a good idea” to “today, in a licensed unit.”

Call 911 for active seizures, chest pain, or altered consciousness. Do not wait. The emergency room is a legitimate way into detox, not a detour from it.

Pregnancy changes the plan, not the urgency. For alcohol, ASAM says inpatient treatment should be considered for every pregnant patient who needs withdrawal management, with an obstetrician consulted. For opioids, ASAM’s practice guideline recommends methadone or buprenorphine rather than withdrawal management for pregnant patients who are physically dependent on opioids. Say you are pregnant in the first sentence of the first call, and see the opioid detox guide for the medication options.

Signs it may not need a bed

Some people need detox but not an inpatient one. ASAM’s alcohol withdrawal guideline says outpatient withdrawal management can typically be done safely for people with limited or mitigated risk factors: mild or moderate symptoms, no past seizures or delirium tremens, stable health, and a reliable person at home. For opioids, starting buprenorphine with a prescriber may be the whole first step. Our outpatient detox guide covers who fits, and can you detox from alcohol at home covers the at-home question.

What happens after you decide

Once the decision is made, most people want to know what the stay will actually be like. Our What Happens During Medical Detox? A Step-by-Step Guide walks through admission, stabilization, and discharge planning step by step. The guide to getting into detox in NJ covers the phone call itself.

How to have the conversation

Lead with concern, not ultimatums. Say what you have noticed, ask how they are feeling, and offer a concrete next step: a call, an assessment, a ride. Pick a time when they are not high and you are not angry. The first conversation may not end in a yes. Its job is to make a second one possible.

Some New Jersey programs can admit the same day, though it is not guaranteed. If they have NJ FamilyCare or no insurance, the IME Addictions Access Center at 1-844-276-2777 can screen them and refer them to treatment.

If the answer is no, read what if someone refuses detox. If opioids are in the picture, keep naloxone in the house either way; our naloxone guide for families explains how to get it. The family guide covers the rest.