Why 'high-functioning' is one of the most misused terms in substance use - and how it quietly shapes workplace and disability claim decisions.
The Word We've Stopped Hearing Carefully
"High-functioning." It comes up in almost every conversation about substance use in a workplace or claims context.
"They're a high-functioning drinker." "He's high-functioning - he's never missed a day." "She's high-functioning at work, so we didn't think it was a problem."
Used carefully, it's shorthand for a real clinical reality. Used carelessly - which is most of the time - it's one of the most consequential misconceptions in the way workplaces and claims teams interpret substance use disorder.
What The Word Gets Right
There is something genuinely true underneath the label. Substance use disorder does not present uniformly, and impairment is not always visible. A meaningful number of people living with a SUD hold steady jobs, meet family responsibilities, and perform at expected levels for extended periods.
That's an important corrective to the older, narrower picture of what "someone with a substance use problem" looks like - a picture that has never been clinically accurate and has done real harm in delaying help, deepening stigma, and shaping policies around a stereotype rather than a reality.
Recognizing that SUD spans a wide range of presentations is important. In that narrow sense, the word gets something right.
What It Gets Wrong
Where "high-functioning" breaks down is in the assumption most people layer on top of it - that visible function equals absence of clinical impact.
That assumption is wrong in several specific ways:
- Function is a snapshot, not a trajectory. A person who is meeting work demands today may be doing so at increasing cost - physiological, cognitive, relational, financial. The clinical picture is usually progressing, even if the observable one isn't.
- "Functioning" is usually being measured against a narrow slice of life. Someone can perform at work and be significantly impaired in domains that aren't visible to a manager - sleep, relationships, physical health, mental health, decision-making, safety at home.
- The label delays intervention. People described as "high-functioning" often don't meet the informal threshold for concern that gets someone offered help - until the visible function fails, at which point the clinical picture is much further along than it needed to be.
- It creates a hierarchy of use. "High-functioning" implicitly divides SUD into acceptable and unacceptable presentations. That hierarchy shapes who gets stigmatized, who gets supported, and who gets left to manage alone until things break.
- It flatters, and flattery isn't clinical. Being described as "high-functioning" can feel like a compliment. That framing makes it harder for the person to name the difficulty they are actually navigating - including to themselves.
Why It Matters in Claims Contexts
The consequences of the label show up specifically in disability and workplace claims:
- At intake, a "high-functioning" framing can lead assessors to minimize the substance use in favour of the presenting complaint. The SUD becomes a footnote instead of a factor.
- In apportionment analysis, function that has been sustained for years can be misread as evidence that SUD wasn't affecting capacity - when in reality it may have been draining reserve capacity that failed at the point of injury or stress.
- In return-to-work planning, the assumption that someone is "high-functioning" can produce ambitious plans that don't account for the actual cost of that maintained function.
- In legal contexts, the label can be used strategically by either side - to argue either that impairment wasn't present or that the current claim isn't credible - neither of which reflects the clinical complexity.
What Better Looks Like
The alternative isn't to abandon the observation. Variation in SUD presentation is real. The alternative is to replace the label with the actual clinical work.
- Describe function, don't summarize it. Instead of "high-functioning," describe what the person is currently sustaining, in which domains, and at what apparent cost.
- Look across domains, not just the workplace. Sleep, physical health, mental health, relationships, safety, and financial function are all part of the picture.
- Assess trajectory. Where has function been over the last one, three, five years? Is it stable, declining, precarious?
- Look at the interaction with everything else. SUD rarely operates alone. Comorbid mental health conditions, chronic pain, sleep disturbance, and prescribed medications all shape the presentation.
- Use language that opens the conversation rather than closes it. "Managing significant demands while dealing with substance use" is a different sentence than "high-functioning" - and it invites a more useful clinical response.
Words shape decisions. In substance use, few words shape decisions as often, or as quietly, as "high-functioning."
For the case managers, employers, and legal teams working these files, being more careful with the word is one of the smaller changes with one of the largest downstream effects. Better assessment starts with better questions - and the first question is often "what does 'functioning' actually mean in this file?"
At SOMA, our substance use assessment services - led by Alexandra Perry, our National Director of Substance Use Policy and Programs - are structured to answer that question with clinical depth rather than shorthand. If your team is managing files where the SUD picture has been under-assessed or over-simplified, reach out at referrals@somamedical.com