The control that conceals dependency: understanding drug use in high-functioning lives
International Overdose Awareness Day (31st August) asks us to confront the realities of drug-related harm. One of those realities is that serious substance misuse does not always announce itself through obvious deterioration.
A person may still chair the meeting, make the school run, train five times a week, travel internationally, make complex financial decisions, maintain a marriage, and appear socially composed.
That continued functioning can become evidence in their own internal argument:
- I haven’t missed work.
- My family is provided for.
- I never use before a certain time.
- I only use in certain circumstances.
- Nobody knows.
- I can stop when I need to.
While “high-functioning addiction” isn’t a clinical diagnosis, research supports the broader phenomenon. In one study of people meeting criteria for substance use disorder, the ability to continue working and fulfil responsibilities contributed to some participants not recognising their substance use as problematic. Some actively modified when and how they used drugs or alcohol to protect their ability to function.
High functioning: part of the problem?
Clinically, we must be careful about using external functioning as a proxy for internal wellbeing. Work, family, physical fitness, success: the ability to preserve the most impressive parts of life can delay recognition that something isn’t right.
“Employment, relationships, financial stability, fitness, or professional achievements tell us important things about somebody’s life. They can’t tell us whether their relationship with a substance is safe.”
Recent reporting has examined cocaine use among professionals to extend working hours and sustain alertness, confidence, or performance. Within law and finance, there is growing discussion around a culture of “toxic stoicism”, where admitting to difficulties with stress, drugs, alcohol, or other compulsive behaviours feels incompatible with professional identity.
These environments don’t provide an explanation for dependency. But they do remind us that substance use exists within a context. The ability to tolerate pressure can become so closely associated with competence that even acknowledging dependency feels like evidence of personal or professional failure.
What began socially, recreationally, or as a means of managing pressure can acquire a different psychological function. The substance itself may vary – cocaine, ketamine, prescription opioids, for instance – but clinically, the changing function and pattern of use are as important as the drug involved.
The architecture around an individual
“We must ask whether, in a particular situation, the systems surrounding someone are protecting them, or simply preserving the appearance of continuity.”
Greater resources can create an unusual capacity for someone’s life to absorb disruption. Responsibilities can be delegated, diaries rearranged, and professional support brought in to soften consequences that might otherwise become visible.
Privacy adds another layer. People who notice changes may belong to a very small circle: a husband or wife, family member, confidante, advisor, assistant, colleague, or member of household staff. Their relationship with the individual may be complicated by loyalty, confidentiality, professional boundaries, or uncertainty about whether what they are seeing truly warrants concern.
The architecture around an individual can become so effective at preserving function that deterioration becomes harder to see.
Private rules of control
Moreover, substance use may be governed by strict personal rules: never during the workweek. Never before a meeting. Never around the children. Only socially. Only after 8pm. Only a certain amount.
These boundaries may genuinely constrain certain behaviours and it would be simplistic to dismiss them as denial. But clinically, I think it’s fascinating to study what can happen to those rules over time. When they move, it tells us something. Does the permitted amount increase? Does Friday become Thursday? Does an exception become the rule? Is the substance necessary to decompress, sleep, socialise, perform, or feel normal?
“Control over the surrounding life should not be mistaken for control over the substance.”
The body doesn’t recognise professional status
There is an important physical reality beneath this. Someone’s ability to organise their life around drug use is not the same as their ability to control its physiological consequences.
Tolerance can change. Patterns can escalate. Different substances may be combined. Opioids carry particular overdose risks, while fentanyl and other potent synthetic substances can introduce dangers that are difficult for an individual to judge from one episode of use to another. The relationship between dose, individual physiology, other medications, alcohol, and composition can introduce risks that cannot be controlled through willpower.
“A person’s body is, ultimately, indifferent to their professional stature.”
Waiting for someone’s life to visibly unravel can be a dangerous threshold for concern.
How much evidence do we need?
With high-functioning substance misuse, there may always be evidence that “things are under control”: the promotion arrives, the transaction completes, the children are cared for, the relationship continues. Everything seems stable.
But absence of catastrophe is not evidence of clinical safety.
International Overdose Awareness Day represents an opportunity to remember: we do not need to wait for somebody to lose their career, relationships, health, or reputation before taking their drug use seriously.
Good clinical care looks beyond whether a person is still functioning by considering things like:
- The frequency and pattern of use
- Psychological and physiological dependency
- Tolerance
- Risk
- Coexisting mental health difficulties
- The function the substance has acquired
- What happens when it is removed
How much evidence should we require before accepting that someone who appears in control may no longer be? Recognising that as a possibility is not a judgement on someone’s strength, success, or self-control. It creates an opportunity to intervene while there is still so much worth protecting.
Selected clinical references:
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7032932/
- https://www.lemonde.fr/en/campus/article/2026/07/11/you-re-expected-to-perform-but-no-one-wants-to-know-how-you-do-it-cocaine-the-toxic-fuel-of-young-professionals_6755382_11.html
- https://www.fnlondon.com/articles/how-law-firms-are-stepping-up-to-tackle-addiction-stigma-f714ae3d
- https://pmc.ncbi.nlm.nih.gov/articles/PMC3883816/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC4441015/
- https://jamanetwork.com/journals/jama/fullarticle/2679931
- https://gaspsdata.dbhdd.ga.gov/data/trends-and-characteristics-drug-overdose-deaths-involving-illicitly-manufactured-fentanyls
- https://www.cdc.gov/stop-overdose/caring/polysubstance-use.html
- https://journals.sagepub.com/doi/abs/10.1177/07067437241231128
