In a recent blog article on the dangers of having chronic drinkers going ‘cold turkey’ from alcohol, I pointed out that alcohol remains the most harmful drug in this country, more harmful than opioids. In a separate article, I also noted that the opioid overdose epidemic is a public health emergency that has resulted in far more deaths in Canada than the COVID-19 pandemic (Canada’s other public health emergency). But while more needs to be done to address the opioid overdose epidemic, I argue that a similar response is necessary to address the ongoing harm of alcohol on Canadian households.
Chronic drinkers experience much of the harms associated with alcohol. Addiction researchers have known for some time that there is a particular ‘subtype’ of chronic drinker or drug user – the ‘high-functioning’ alcoholic or addict* (‘HFA’; Moss et al., 2007). An HFA does not fit the stereotype of the ‘skid row’ addict: unemployed, homeless, and impoverished. HFAs are deemed ‘high functioning’ because they are able to maintain successful careers and a social circle of family, friends, and associates despite consuming large amounts of alcohol or drugs. In this blog article, I examine the social phenomenon of HFAs and why their addictions go largely unnoticed, even by their loved ones.
*Note: At SCHC, we no longer use the terms “alcoholic” and “addict” due to the stigmatizing and discriminatory nature of the terms. These terms are being referenced in this article as the cited research used them.
What is a ‘High Functioning’ Addict or Alcoholic?
Before I examine the research on high-functioning addicts/alcoholics (HFAs), let’s have a brief review of what I mean by the term. HFAs are often difficult for most people to identify as having an addiction because they appear to have their lives under control. The influential addiction researcher E. M. Jellinek explained In his 1960 book, The Disease Concept of Alcoholism, that ‘delta’ alcoholics’ (his term for HFAs) have, unlike most problem drinkers, no loss of control over their drinking. They drink enough to get in the ‘zone’ and drink just enough to stay there. In addition to controlling how much alcohol or other drugs they consume, HFAs may also be able to control when they consume them.
A high-profile example of an HFA is actor Jamie Lee Curtis, who was able to control her addiction to Vicodin (a prescription opioid) and alcohol for over 20 years: “I was the wildly controlled drug addict and alcoholic. I never did it when I worked. I never took drugs before 5 p.m. I never, ever took painkillers at 10 in the morning … I also drank too much in a very controlled way.”
But not all HFAs hide their addictions. In fact, many are quite public with their addictive behaviours. This is particularly true of HFAs whose drug of choice is alcohol. The high prevalence of alcohol in Canadian society – 76.9 percent of Canadians ages 15 and older reported consuming alcohol at least once in 2015 (Health Canada, 2016) – means that family, friends, and work associates do not always recognize the harms alcohol inflict on HFAs.
I recently conducted a study of former clients of Sunshine Coast Health Centre. One of the study’s participants, ‘Ed’, described himself as a “functional” husband and father and successful businessman. For many years, Ed was able to control his drinking to weekends: “Twice a week, I’d probably be finishing off three-quarters of a 40 [ounce bottle] of rum.” On vacations with the family, Ed would start drinking at 10:00 each morning and stay drunk until late in the evening. When asked how he balanced his many obligations with his heavy drinking, he explained that he “was able to kind of manage around it.”
Ed could have probably continued his drinking lifestyle for many more years had it not been for a pivotal event in his life. During a trip out of town for his son’s hockey, Ed got “black-out drunk” while dining at a restaurant with all the players and their families. He ended up in jail after getting into an altercation with a police officer. The humiliation of that evening motivated him to get help. A friend told him about us and three days later he was in treatment. Ed has been in recovery ever since.
The High-Functioning Addict and The 3 Cs of Addiction
A good way to understand Ed’s ability to drink excessively for years without raising alarm bells is to review an addiction test called the 3 Cs of Addiction. The 3 Cs test is a simple, yet effective test to figure out whether you or someone you care about has an addiction. The 3 Cs stands for compulsion, control, and consequences. They represent 3 symptoms of addiction that are typically present when a bad habit – substance-related or otherwise (e.g. gambling) – crosses the line into addiction.
The first C stands for compulsion. Compulsion is obsessive behaviour that individuals demonstrate when it comes to their bad habit. Examples of compulsion include excessively planning for, talking about, or engaging in a bad habit. A person who repeatedly turns down family outings unless they involve alcohol might be a person whose bad habit has become a compulsion. Many HFAs can hide their compulsivity as Jamie Lee Curtis did.
HFAs can also hide their compulsions in ‘plain sight’ because they have lots of access to their bad habits. For many, alcohol is an ever-present part of their jobs (e.g. business executives, salespeople, restaurant and bar staff, and musicians). Ed was a business executive who drank but never allowed it to interfere with work. And his family and friends always served alcohol at social gatherings.
The second C stands for control. Control refers to a person’s ability to control the amount, time of day, or behaviours associated with their bad habit. Ed exhibited control over when he drank alcohol. Until the hockey tournament, he also exhibited control over his behaviour while drinking.
The third C stands for consequences. A consequence is defined as the outcome of an action and is the most important of the 3 Cs in terms of distinguishing bad habits from addictions. In order for a bad habit to qualify, the consequence has to be negative and the bad habit must continue in spite of continued negative consequences. Examples of consequences associated with a bad habit include repeatedly getting into trouble with law enforcement, falling into debt or getting fired, experiencing relationship problems, and experiencing addiction-related physical harm to the body. Ed had experienced physical consequences like excessive weight gain due to his drinking but had largely avoided other negative consequences until his arrest.
Other HFAs Have Not Been as Fortunate as Ed
Ed was lucky and took action at a relatively early stage in his addiction to alcohol. Other high functioning addicts we’ve treated were not as fortunate. They continued to drink or use drugs excessively long past the point of where their bodies could bounce back from the physical punishment. A typical scenario is a family member calling us to help with a loved one who is starting to wet himself or show sudden and dramatic cognitive decline. Many of the diseases linked to chronic drinking such as alcoholic dementia and Wernicke-Korsakoff syndrome cause steady, irreversible brain damage.
Blood work and other diagnostic tests we do for our clients may also reveal other illnesses associated with long-term, chronic substance use. According to a 2017 report by the Canadian Institute for Health Information, approximately 56,600 Canadians were hospitalized for the treatment of conditions entirely caused by alcohol in 2015, such as pancreatitis and hepatitis. According to Shield et al. (2014), alcohol is a contributing factor in the development of numerous chronic diseases, including diabetes, colon cancer, cardiovascular diseases, and cirrhosis of the liver. These are common diseases with our clients.
Early Intervention is Key to Helping HFAs
As Ed’s story illustrates, early intervention is key to mitigating the impact of chronic substance use on the high-functioning addict/alcoholic. Ed knew something was not right with his constant drinking and less-than-satisfactory relationship with his family. Getting arrested was the proverbial straw that broke the camel’s back and motivated him to get help for his addiction. Interestingly, Ed’s family did not support his decision to go to treatment. They thought he was blowing his arrest out of proportion. Fortunately, Ed persisted in his decision to get help, in spite of his family’s reservations.
If you are a family member or friend of someone who you suspect is a high-functioning addict/alcoholic, it is important to talk about it. Ask your loved one to get help. Do not let the stereotype of the ‘skid row’ alcoholic stop you from having a heart-to-heart conversation with the high-functioning alcoholic or addict in your life.
High Functioning Alcoholics (Source: WebMD)
CNN Article on High-Functioning Heroin Addicts (yes, there is such a thing)
Actor Brad Pitt: High-Functioning Alcoholic (Source: Psychology Today)
High Functioning as an Alcoholism Subtype (Source: US-Based National Institutes of Health)
Health Canada. (2016). Canadian tobacco, alcohol and drugs survey: Summary of results for 2015. Ottawa, ON: Health Canada.
Jellinek, E. M. (1960). The disease concept of alcoholism. New Haven, CT: Hillhouse Press.
Moss, H. B., Chen, C. M., & Yi, H. (2007). Subtypes of alcohol dependence in a nationally representative sample. Drug and Alcohol Dependence, 91(2), 149–158. doi:10.1016/j.drugalcdep.2007.05.016
Shield, K.D., Parry, C., & Rehm, J. (2014). Chronic diseases and conditions related to alcohol use. Alcohol Research: Current Reviews, 35(2), 155–171.