Identifying and Treating High Functioning Substance Use Disorder

Rachel Rohaidy, MD, discusses the diagnostic and therapeutic challenges of helping patients with high-functioning substance use disorder (SUD). Rohaidy emphasized that these patients often maintain careers, family roles, and social responsibilities, making early detection difficult.¹ A comprehensive clinical assessment is essential, including detailed inquiry into sleep, irritability, stress management, and subtle functional impairments. Laboratory test evaluation and prescription monitoring may also reveal concerning patterns in these patients.

Because high-functioning individuals frequently exhibit strong denial and heightened concern about stigma or career impact, Rohaidy stressed the importance of nonjudgmental engagement, confidentiality, and rapport between clinician and patient. Motivational interviewing is particularly effective, allowing clinicians to explore discrepancies between patients’ values and substance use without confrontation. Treatment planning should be flexible and discreet, aligning with patients’ professional and personal demands while maintaining clinical effectiveness.

Integrated, multidisciplinary care is important, she said; coordinating psychiatry, psychotherapy, and primary care can optimize outcomes. Family involvement, when appropriate and permitted, can reinforce treatment adherence and support recovery. Rohaidy noted that co-occurring conditions such as anxiety disorders, depression, attention-deficit/hyperactivity disorder, and perfectionistic or high-achieving personality traits are often prevalent.² In many cases, substance use begins as self-medication for these underlying psychopathologies. Addressing these comorbidities through targeted pharmacologic and psychotherapeutic interventions can reduce reliance on substances for these high-functioning patients.

Ultimately, Rohaidy underscores that clinicians must “meet patients where they are,” balancing empathy, discretion, and medical discovery to preserve function while guiding patients toward sustained recovery.

Dr Rohaidy is a double board-certified psychiatrist in adult and addiction psychiatry at Miami Neuroscience Institute.

References

1. Behind the facade of high-functioning drug addiction. Integrative Life Center. June 24, 2024. Accessed November 6, 2025. https://integrativelifecenter.com/substance-abuse/behind-the-facade-of-high-functioning-drug-addiction/

2. Common Comorbidities with Substance Use Disorders Research Report. National Institutes on Drug Abuse (US); 2020.