It has been suggested that about half of alcoholics can be described as high-functioning alcoholics.…
High-Functioning Addicts: Who They Are and Who Is at Risk
By Matthew Goldenberg, D.O., Board Certified Psychiatry and Addiction Psychiatry
Associate Medical Director, Promises Professionals Treatment Program
It is estimated that 10% to 14% of the U.S. population is addicted to drugs or alcohol. Many of those affected, including nearly 20% of all alcoholics, do not fit the stereotypical image of an addict — they are able to maintain their job, they may have spouses and children, and often enjoy busy social lives. These “high-functioning” addicts (HFAs) abuse alcohol or other drugs while maintaining a façade of normalcy.
Identifying a High-Functioning Addict
With HFAs, the consequences of their drinking or using are not always obvious to the casual observer — at least for a while. The high-functioning addict may face hangovers and other physical problems related to their substance abuse, but are able to hide the effects, or may attribute them to other causes (e.g., sickness, stress, lack of sleep) to prevent others from taking notice.
In many cases the addiction is taking a serious toll, but the individual and/or those around them may be in denial. In other cases, the individual is so high-functioning that they have a reserve that someone else might not. We often see doctors, lawyers and executives who are no longer able to perform at their usual extremely high level of function. For them, they may objectively experience a marked decrease in their customary level of performance, yet to the external observer, or to those who do not know them well, they may just be functioning on average with the general population and the decrements may not be noticed. Nonetheless, for those in safety sensitive roles, like physicians and pilots, even a small decrease from previous function levels may be unacceptable.
While the negative impact of drugs and/or alcohol may be subtle in HFAs, there are a few signs that may identify an addiction problem, including:
- A high volume of consumption. When HFAs drink socially or go for a drink with colleagues, one drink may actually be several drinks — every time.
- Using drinking as a reward. If others notice the HFA consuming a high volume of drinks and comment on it, the HFA may deny a problem and defend their drinking (or using) by saying they worked hard so they “earned” it, or they are just enjoying their day off.
- Using drinking to cope: HFAs often live highly chaotic and stressful lives. In many cases, the drug and alcohol use can both exacerbate the level of stress and also be used as a way to cope with it. Going out for drinks may feel like a good way to escape the looming deadlines of the office. However, avoidance of the stress and obligations leads to further pressures and further drug and alcohol use to cope and escape.
- Socializing always involves drinking or drugs. The HFA is more likely to socialize only with others who drink or use drugs, attending social events that typically focus on drinking (i.e., at bars, clubs or cocktail parties).
- Cancellations of non-drinking social engagements. As alcohol or drug use increases, the HFA may cancel appointments or other engagements in an effort to hide hangovers, withdrawal symptoms or other telltale signs of addiction.
- Many rough mornings. The HFA may begin to show up for work most mornings with a headache, or might be grumpy, ill or worse-for-wear on Monday mornings, likely after a drinking binge or “party” weekend — using excuses to hide the cause.
- A loss of interest in sports or hobbies. An HFA who formerly played sports every weekend or engaged in hobbies may stop participating in these activities in favor of drinking or using drugs.
While some addicts rapidly spiral out of control, experiencing dramatic turmoil and upheaval in their lives, HFAs tend to keep their problems well-hidden, sometimes for years. Unfortunately, while they are managing to “keep it together,” HFAs are less likely to seek treatment for their addictions and related problems. Asking for help might not even be part of their lexicon, because they may be accustomed to success and controlling all areas of their life. Accepting that they need help with addiction may be a foreign concept for HFAs. In many cases, the highest functioning professionals do not seek help until they reach a crisis point, such as facing job loss or deteriorating health.
In Which Professions Do We Find HFAs?
According to the Substance Abuse and Mental Health Services Association (SAMHSA), restaurant and food preparation/service is the profession that carries the highest risk for addiction. The construction and media/entertainment industries are #2 and #3 on the list. Other professions, such as law enforcement, have relatively high rates of addiction because of the work culture, as well as the stress and cumulative trauma involved.
However, the people I treat most often in the Professionals Treatment Program at Promises are health care professionals. Although physicians and other health care practitioners are #16 on SAMHSA’s list of the top 21 professions most at risk for addiction, it is worth noting that when health care professionals develop addiction, they are very likely to be “high-functioners.”
It is estimated that roughly 10% to 15% of health care professionals misuse drugs or alcohol at some point during their careers. Alcohol is the most common substance of abuse, followed by prescription medications. Statistics show that those at highest risk for substance abuse are emergency room physicians, emergency nurses and staff, anesthesiologists and psychiatrists.
Access to drugs of abuse in their practice of medicine is a large risk factor for many physicians and other health care providers, including dentists and veterinarians.
Another high-risk group is pharmacists. A 1987 study of pharmacists and pharmacy students showed that 46% of pharmacists and 62% of pharmacy students had misused a controlled substance without a prescription. The National Institute on Drug Abuse further found that 11% to 15% of pharmacists experience alcohol or drug dependency problems at some time in their careers. Some studies of drug addiction among professionals cite “unrestricted” access to addictive pharmaceuticals, or “convenience,” as a major factor impacting which professionals get addicted.
Other professionals I see in our program include lawyers and financial industry managers who come in due to stress, burnout or poor work-life balance. Their problems are very similar to those experienced by physicians and other health care professionals. Eventually, job performance and family commitments suffer and they are no longer able to hide their drug or alcohol problem.
Treating High-Functioning Addicts
Addiction treatment is most effective when it includes the following:
- 30 to 90 days of treatment with other high-functioning peers. For example, we recommend physicians receive treatment with other health care providers. This helps them to focus on occupational issues that are specific to those who work in patient care roles. This is also so that they can connect through fellowship with like-minded colleagues in recovery. The length of treatment should be dependent on the person’s individual history and needs.
- Discussion and problem-solving around professional issues (e.g., how to return to work, how to disclose to HR/colleagues)
- Ongoing monitoring to prevent relapse (e.g., drug testing and monitoring groups)
- Self-help programs such as Alcoholics Anonymous or equivalent programs
- Accepting, viewing and treating addiction like a disease
As with other addiction treatment programs, a program geared for professionals or other high-functioning addicts should avoid shaming and further stigmatizing people because of their addiction. One of the major fears professionals often have about seeking treatment is the loss of their career. The treatment program should be a safe space where those in recovery can learn to be honest with themselves and others. Addiction is often an isolating disease, and treatment should not further isolate the addicted professional.
Because they seek to hide their addiction for as long as possible before bottoming out, many high-functioning addicts are grappling with relatively advanced behavioral, emotional and physical issues by the time they come to treatment. In short, their disease is often more advanced than it is for others who may seek treatment earlier. For these reasons, treatment for HFAs should encompass all of the biological, psychological and social risk factors and triggers for relapse. A program that addresses the family as a unit is also important. Addiction is a family disease and HFAs need their families’ support and assistance so that old patterns do not persist after primary treatment is completed.
The good news is that by following these recommendations, HFAs can achieve better outcomes than the general population. The drive of HFAs and their desire to return to work can help motivate them to achieve successful recovery. The recommended accountability tools, such as monitoring and recovery groups, provide additional support and catch relapses early when they do occur.
5 Tips for Recognizing the High-Functioning Alcoholic or Addict. David Sack, MD. Psych Central, 2012.
The Problem of Surgeons and Drinking. Physician Health Program. Addiction Treatment for Doctors, 2015.
Drug addiction among nurses: Confronting a quiet epidemic. Many RNs fall prey to this hidden, potentially deadly disease. Mary Ann B. Copp. Modern Medicine Network, 2009.
Pharmacists get addicted, too. Jared Combs, PharmD. Drug Topics, Voice of the Pharmacist. Modern Medicine Network, 2009.
Use and abuse of controlled substances by pharmacists and pharmacy students. WE McAuliffe et al, 1987.
Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction. LJ Merlo et al, 2012.
Trinkoff AM, Zhou Q, Storr CL, and Soeken KL. Workplace access, negative proscriptions, job strain, and substance use in registered nurses. Nurs Res. 2000 Mar-Apr; 49(2):83–90. [PubMed]
Hughes PH, Storr CL, Brandenburg N, Baldwin DC, Anthony JC, Sheehan DV. Physician substance use by medical specialty. Journal of addictive diseases. 1999; 18(2):23–37. [PubMed]
Bennet J, O’Donovan D. Substance misuse by doctors, nurses and other healthcare workers. Current Opin Psychiat. 2001; 14(3):195–199.
The relationship to alcoholism of occupation, class and employment. Ojesjo L. Journal of Occupational Medicine. 1980; 22(10):657-66.