Navigating Substance Use in High-Performing Environments

By Molly Bierman, CADC

When Success Stories Become Cautionary Tales

KEY TAKEAWAYS:

• High-functioning individuals often develop addiction as a solution to performance demands—it works initially, making it particularly dangerous

• Success doesn't protect against addiction; in some ways, it increases vulnerability through perfectionism, high pain tolerance, and stigma around asking for help

• Physical dependence can develop quickly with prescription medications (benzodiazepines in weeks, stimulants with regular use)

• "Hitting bottom" is a terrible strategy for high-stakes professionals—the bottom might be permanent career consequences or death

• Treatment for high-functioning addiction must maintain dignity, address underlying drivers, and fit life circumstances rather than requiring complete disruption

I've been working in addiction treatment for fifteen years. I've treated over two thousand individuals. Some of the most severe addiction cases I've seen have been among the most successful people you'd ever meet.

That surprises people. We have this image of addiction as something that happens when lives are falling apart. But with high-functioning individuals, addiction looks completely different.

It looks like success, right up until it doesn't.

The high-functioning addiction nobody sees

Here's what most people don't understand: the addiction often develops as a solution to a problem, and it works for a while. That's what makes it so dangerous.

The college student takes Adderall to maintain their 4.0 while playing varsity sports and leading campus organizations. It works. They get more done, sleep less, and stay focused. The young professional drinks wine every night to decompress from a high-stress job. It works. They feel less anxious, sleep better, and can actually relax. The executive takes prescription pain medication after surgery, and finds it helps with stress too. It works. They're more productive, more social, and less irritable.

These aren't cases of someone seeking drugs for recreation. These are people trying to optimize performance or manage legitimate symptoms. The problem is that the brain doesn't distinguish between "good reasons" and "bad reasons" for substance use. Addiction develops the same way regardless of intention.

Understanding the neuroscience

When you use substances repeatedly, your brain chemistry changes. Your dopamine system, that's responsible for pleasure, motivation, and reward, gets recalibrated. Two things happen: normal activities stop providing satisfaction, and you need the substance just to feel normal. This is dependence.

For high-functioning individuals, this creates an insidious cycle. As brain chemistry changes, they need the substance more just to maintain baseline functioning. They're not using to get high—they're using to not feel terrible.

And because they're still performing well externally, nobody notices. Including, often, the person themselves.

The red flags everyone misses

High-functioning addiction is designed to be invisible.

But there are signs:

Increased tolerance. If someone needs more of a substance to get the same effect, dependence is developing.

Inability to cut back despite wanting to. They say they'll take a break or only use on weekends. Then they don't. Not because they lack discipline, but because they're physiologically dependent.

Using to avoid withdrawal. Using a substance to prevent feeling bad rather than to feel good is physical dependence.

Continued use despite negative consequences. Strained relationships, health issues, slipping work performance, but they keep using anyway.

Preoccupation and planning. Making sure they always have enough. Planning their schedule around when they can use. Feeling anxious that they might run out.

The prescription drug problem

ADHD medications, anxiety medications, sleep medications, pain medications—these are legitimate treatments. They help millions of people. I'm not anti-medication. I'm anti-misuse.

We live in a culture that normalizes using substances to enhance performance and manage stress. For high-performing individuals, there's tremendous pressure to optimize everything, including neurochemistry.

This creates an environment where prescription drug misuse starts almost accidentally. Someone borrows a friend's Adderall during finals. It works. They do it again. Before they realize what's happening, they're dependent.

Benzodiazepines are incredibly effective for acute anxiety and incredibly addictive. Physical dependence can develop in weeks. Withdrawal can be life-threatening, which means once you're dependent, stopping becomes medically complex.

With pain medications, addiction often begins with legitimate medical treatment. The medication helps physical pain, then someone finds it also helps with emotional pain—stress, anxiety, depression. The line between treating physical pain and self-medicating gets blurry.

Why "hitting bottom" is a terrible strategy

There's this idea that people need to hit bottom before they're ready to change.

I'm going to say something controversial: that's garbage when applied to high-functioning individuals in high-stakes situations.

The "bottom" for a physician might be losing their medical license after a decade of training and hundreds of thousands in student loans.

The "bottom" for an attorney might be disbarment.

The "bottom" for a young person might be a fatal overdose.

Those aren't acceptable bottoms.

We don't get to say "they needed to learn the hard way" when the hard way means permanent consequences or death.

Early intervention works better than crisis intervention. The research is clear. People who get help earlier have better outcomes, period.

The unexpected truth about substance use in high-performing environments

High-performing environments don't just fail to prevent addiction, they often actively contribute to it.

These environments reward working unsustainable hours, pushing through discomfort, competing constantly, optimizing every aspect of performance, and never showing weakness.

Those same qualities that make someone successful can make them vulnerable to addiction. When you're taught that the answer to every problem is to work harder and push through, substances that let you work harder feel like solutions, not problems.

I worked with a young man from a family of physicians. He'd grown up watching his parents handle 80-hour work weeks by sheer willpower. When he started residency and felt overwhelmed, his thought wasn't "this is unsustainable."

It was "I need to figure out how to handle this the way my parents did."

His parents had done it with coffee and determination. He did it with Adderall and Xanax. By the time we met, he was physically dependent on both and convinced he was weak for needing help.

He wasn't weak. He was trying to meet inhuman expectations using the only tools available.

The right kind of treatment

What works for someone whose life has unraveled often doesn't work for someone still functioning at a high level.

High-functioning individuals need treatment that addresses underlying issues driving substance use, maintains dignity and autonomy, considers their life circumstances, provides medical expertise for complex cases, and plans for the long game.

Recovery isn't a 30-day event. It's a long-term process.

What families need to know

Your concern is probably warranted. If your gut is telling you something's wrong, trust it.

You're not helping by covering for them. Making excuses, cleaning up messes, protecting them from consequences, you're enabling the progression of the disease.

Treatment works, but only if it's the right treatment. Find providers who specialize in this population and understand the specific challenges.

You need support, too. Living with or loving someone with addiction is traumatic. Get your own therapy, join a support group.

This isn't about moral failure. Addiction is a brain disease. It has nothing to do with character or willpower.

Final thoughts

Success doesn't protect you from addiction. In some ways, it makes you more vulnerable. The same qualities that drive achievement can work against you when it comes to recognizing and addressing substance use problems. Substance Use in high-performing environments is much more common than the pubilc realizes.

If you're reading this and recognizing yourself or someone you love, don't wait.

Don't wait for things to get worse. Don't wait for a crisis.

Get an assessment from someone who specializes in addiction. Be honest about what's really happening. Consider treatment options that fit the actual situation.

Recovery is possible. But it requires acknowledging the problem and taking action.

The success stories I'm proudest of aren't the ones where someone hit bottom and clawed their way back up. They're the ones where someone recognized a problem early, got appropriate help, and never had to lose everything.

If you're concerned about substance use in your family, reach out for a confidential consultation. We can help you understand what you're seeing, what it means, and what options you have.

Molly Bierman, CADC, is a partner at YES Family Consulting and brings 15 years of transformative experience in addiction treatment and behavioral health. She previously served as Executive Director of Innovo Detox and Corporate Director of Admissions at Maryland Addiction Recovery Center. Her methodology integrates medical, clinical, and holistic perspectives with a strong emphasis on family involvement and long-term success.