According to the 2023 United States National Survey on Drug Use and Health (NSDUH):
- 48.5 million (16.7%) of Americans aged 12 and older battled a substance use disorder in the past year.
- 10.2% of Americans 12 and older had an alcohol use disorder in the past year.
- About 27.2 million Americans 12 or older (9.7%) reported battling a drug use disorder in the past year.
- That same year, 7.5 million (2.7%) of Americans 12 and older struggled with alcohol and drug use disorders simultaneously.
- 20.4 million American adults (7.9%) suffered both a mental health disorder and a substance use disorder, or co-occurring disorders in the past year.
And while drug and alcohol use has declined post-pandemic, those with substance abuse disorders often do not seek out treatment. The U.S. also remains the leader in overdose deaths.
Drug and alcohol abuse can pose special challenges in the workplace, despite companies having strict policies on hiring, and firing, those who drink to excess and take drugs. According to the U.S. Commission on Civil Rights, under the Americans With Disabilities Act, or ADA:
- “An employer may not discriminate against a person who has a history of drug addiction but who is not currently using drugs and who has been rehabilitated.
- “An employer may prohibit the illegal use of drugs and the use of alcohol at the workplace.
- “It is not a violation of the ADA for an employer to give tests for the illegal use of drugs.”
To delve into this complex subject, we turned to Nicolette Natale, DO, chief medical officer for Recovered.org, an organization that provides information and resources for mental health and addiction treatment.
Natale, who is board-certified in emergency medicine and licensed in psychiatry, supports patients with mental health conditions, including addiction; C-PTSD (complex post-traumatic stress disorder, which goes beyond PTSD); veterans’ mental health; and co-occurring disorders.
She received a doctorate in osteopathic medicine (D.O.) from Nova Southeastern University and holds a Bachelor of Arts from the University of Miami, where she double-majored in psychology and English literature.
Dr. Natale, thanks for your time. Addiction is rarely out of the news these days and has often served as the dramatic basis for fictional stories in which the addict/alcoholic continues to lead a “normal” work life. Describe for us the differences among the terms “user,” “addict/alcoholic” and “functional addict/alcoholic.”
“As attention and education on addiction continue to increase, many of these terms are used interchangeably and aren’t really reflective of the actual mental health disorder that individuals are facing. Substance abuse is a mental health disorder and not a choice. Typically, the term ‘user’ refers to someone who uses a substance recreationally but isn’t physically or psychologically dependent on it. An ‘alcohol user’ may be used to refer to someone who drinks alcohol on occasion or socially, usually less than seven drinks a week (for women) to less than 14 drinks a week (for men). This doesn’t mean consuming this much alcohol in one sitting, but rather alcohol consumption spread throughout a seven-day period.
“An ‘addict’ or ‘alcoholic’ is usually used to refer to those who have a physiological or psychological dependence on a substance, and it is often outwardly apparent to others that their addiction is impacting their lives. Addicts/alcoholics often deal with relationship, work, education, financial or legal troubles due to their substance use, and although their addiction is causing problems, they continue to seek out the drug. ‘Functional alcoholics or addicts’ (although not an actual medical diagnosis) is usually used to refer to individuals with substance abuse problems but who may still be able to hold jobs, conceal their addiction from others, maintain relationships and manage finances. These individuals don’t usually fit the stereotype of an ‘addict” yet are still struggling equally as much with their addiction.”
Is there such a thing, then, as a drug/alcohol user who will never cross over into addiction? What makes an addict?
“Yes. Drug users may never cross into addiction. Addiction differs in that it is a chronic condition of compulsively seeking the drug. Although the use of the drug leads to negative consequences in the person’s life, addicts continue to seek out the drug. Many addicts will also experience withdrawal symptoms after stopping the drug, which can be dangerous or even deadly in certain situations.”
From what you’ve seen, how common are drug and alcohol addictions or use in the workplace?
“Based on research, it’s estimated that almost 9% of employed individuals suffer from a substance abuse disorder. These rates may be increasing as remote positions become more popular, potentially making it easier to conceal an addiction from an employer.”
The work-addiction relationship would seem to be a complex one. On the one hand, the stress of work might lead to or exacerbate addiction. On the other hand, work, like addiction, is sometimes an escape.
“High-stress jobs can lead to substance use as a way to ‘escape’ the pressures of the job, deal with anxiety or depression or, for some, make it easier to perform their job. (Think of a salesman who feels more confident after a drink or two pitching a new product.) On the other hand, work, like substances, can also become an addiction. Both work and substance use trigger reward centers in the brain that release certain chemicals that make us feel good. As we feel a sense of joy or accomplishment from completing a work project, we can similarly become addicted to the ‘high’ of this feeling.”
What about recovering addicts? Even if you are clean and sober for years, can past addiction impair judgment through altered brain chemistry?
“When individuals are in recovery, they are working on changing automatic behaviors and responses that have become essentially ‘wired’ into their brain via neuroplasticity (the brain’s ability to change). As recovering addicts stop using and alter their behavior, their brains also begin to rewire themselves, extinguishing the pathways associated with addiction. As time goes on, these changes become more permanent, but the pathways of addiction will always be present, so it is something individuals in recovery need to always be aware of and how it may impact their decisions.”
What roles do the current mental health challenges, especially among the young, play in addiction? Is it a chicken-and-egg case in which it’s hard to determine whether mental health issues cause addiction or addiction causes mental health issues?
“It can absolutely be thought of as a chicken-and-egg situation. Individuals with mental health conditions like PTSD (post-traumatic stress disorder), anxiety or depression are at higher risk of using substances, and it is often a way people cope with their illness, essentially self-medicating. This is particularly true among adolescents, who may not have other more effective and appropriate tools to cope. On the other hand, substance abuse disorders can worsen or even trigger certain mental health conditions. The two often feed into each other, producing a cycle that can be challenging to break free from without professional help.”
The United States declared war on drugs in 1971, spending more than $1 trillion over the years, and while there have been some gains, it seems to remain a dance with the devil. Can you share any statistics and insights into recidivism and addiction?
“Substance abuse is a chronic, relapsing mental health disorder. Relapse rates are estimated between 40% and 60% for most individuals. Although most people don’t think of addiction the same way as other chronic illnesses – like type 2 diabetes, for example – once in remission, the relapse rate for this condition is quite similar (somewhere around 30% to 40%) to addiction. This doesn’t mean these conditions aren’t treatable, but when it comes to substance abuse, recovery requires ongoing support and may require multiple attempts or treatments, just like other chronic diseases.”
Given the enormous challenges of addiction, what are the best treatments? Did we miss an opportunity by focusing on incarceration?
“Addiction is a complex condition and often requires a combination of evidence-based approaches to help individuals achieve sobriety and maintain it. Typically, medication-assisted treatment, psychotherapy (such as cognitive behavioral therapy), and peer support all play a role. Incarcerating individuals with substance abuse disorders has definitely led to missed opportunities. Putting someone behind bars doesn’t address the underlying reasons they are using. When we start treating addiction as the health issue that it is, rather than just a crime, individuals will have a better chance at a lasting recovery.”
Would new strategies toward pain management help, given that pain medications are often paths to addiction?
“The opioid crisis has led to a surge in addiction over the last 20 years. Recently, Journavx (suzetrigine), a new non-opioid pain medication, has become FDA (U.S. Food and Drug Adminstration)-approved, which will hopefully provide an alternative to prescribing opioids and reduce rates of addiction.”
What roles should local, state and federal health agencies play?
“Local, state and federal health agencies have a responsibility to provide affordable addiction treatment for everyone, funding preventative education for our youth and supporting harm reduction programs like naloxone distribution and syringe exchanges. These small changes can make big differences when it comes to addiction. Also, public policy will hopefully start seeing addiction for what it is, a mental health condition, rather than a choice, which may help treatment become more accessible and acceptable.”
What’s the best way for us to avoid the trap of addiction?
“Focusing on prevention is key to avoiding addiction. This can be done by providing individuals with mental health support (both professionally and peer-to-peer), teaching individuals healthy coping strategies and educating youth about the dangers of substance abuse early. Teaching parents signs of addiction to recognize in their children/teens is also an excellent way to potentially prevent an addiction.”
