For decades, I practiced medicine as a dermatologist and dermatopathologist, serving patients and teaching medical students at UC Irvine. I believed I could recognize addiction when I saw it. I was always alert for signs, such as the patient whose story didn’t quite match the evidence, or whose habits hinted at something deeper.

When alcohol came up in conversation, I learned early to quietly double whatever amount the patient reported; experience had taught me that honesty about drinking is rare. Yet even as I prided myself on awareness and compassion, I missed the most important diagnosis of all: my own.

By all appearances, I was fine. I never missed work, my lab results looked good, and my patients liked me. I was what the world now calls a “high-functioning alcoholic.” But here’s the uncomfortable truth: There’s really no such thing. Functioning only looks “high” until the façade cracks.

That’s the blind spot medicine still has; the illusion that addiction has a certain “look.” We think we’ll recognize it when we see it: the disheveled patient, the erratic employee, the slurred words, or trembling hands. But addiction, especially alcohol dependence, is far more insidious and often lives behind polished veneers, including in the medical community itself.

The patients who “look fine”

Doctors are trained to rely on observable evidence. We measure, we test, we quantify. But addiction isn’t always quantifiable until it’s late-stage, and it doesn’t respect professional credentials or good intentions. Many of our patients and colleagues live for years in what I call the zone of denial: drinking just enough to numb but not enough to crash. And as long as they “look fine,” we tend to let it go.

I certainly did. I believed that as long as I could perform at a high level, my drinking couldn’t be a problem. After all, I had a medical license, a family, a home, and a full practice. That illusion, that “functioning” protects us, is what keeps so many people, including doctors, from seeking help until the damage is undeniable.

Why doctors miss it

There are four main reasons the medical profession continues to miss high-functioning addiction, in patients and in ourselves.

• We underestimate alcohol: Even in 2025, alcohol remains the most normalized and socially accepted drug on the planet. Medical training emphasizes the dangers of opioids, stimulants, and benzodiazepines, but alcohol often gets only a cursory mention. We warn patients about liver disease or drunk driving, yet rarely confront the broader neurochemical and behavioral dependence it creates. The science is clear: alcohol is a neurotoxin that affects nearly every organ system. But our cultural relationship with it clouds our clinical objectivity.
• We rely too heavily on lab results: Abnormal liver enzymes, macrocytosis, or elevated GGT levels might confirm suspicion, but by the time those markers appear, the disease has already advanced. Early-stage alcohol dependence often hides in plain sight. The absence of lab abnormalities isn’t proof of wellness; it’s proof of how well the disease hides.
• We’re uncomfortable talking about it: Addiction forces conversations that feel personal, even threatening. Many physicians, especially those who drink socially, fear hypocrisy, “Who am I to judge?,” so we avoid probing deeper. That avoidance protects our comfort, not our patients’ health. A brief, compassionate inquiry about drinking patterns can save lives, but only if we’re willing to ask the uncomfortable questions.
• We see addiction as “other”: Medicine has long treated addiction as something separate from the rest of health, a behavioral issue, not a medical one. Despite years of neuroscience proving that addiction alters brain function, stigma still divides “us” from “them.” But the truth is that addiction doesn’t discriminate. It infiltrates every demographic, profession, and level of education, including the medical field.

What I wish I had known

I wish I’d known that denial doesn’t look like denial when you’re inside it. It feels rational. It feels like control. I told myself I was managing stress, that I deserved to unwind, that my drinking didn’t affect anyone else. And because I was still performing, still the reliable doctor, husband, and father, I used my success as evidence that I couldn’t possibly have a problem.

That’s the paradox of high-functioning alcoholism: success becomes its camouflage. And unless physicians learn to recognize that pattern in themselves and their patients, we’ll keep missing it.

How medicine can evolve

The solution isn’t another lecture on substance abuse. It’s a cultural shift within medicine itself, one that integrates addiction screening, education, and compassion into every level of care.

• Start early: Medical education should include more than a passing mention of alcohol’s neurobiological impact. Students should learn to recognize subtle dependence and be encouraged to examine their own biases around alcohol.
• Ask without accusation: Patients (and colleagues) are far more likely to open up when we approach with empathy instead of interrogation. Replace “How much do you drink?” with “How is alcohol part of your daily life?”
• Normalize help-seeking: Physicians fear professional repercussions if they admit to a problem. Medical boards and institutions must prioritize treatment over punishment. Addiction is a disease, and doctors deserve the same care we give others.
• Model honesty: When appropriate, clinicians who have found recovery can play a powerful role in destigmatizing addiction. Sharing that perspective, even subtly, tells patients: you are not alone, and this disease doesn’t define you.

Recovery and what comes after

It took me years to confront my own dependence. Recovery was neither quick nor easy, but it clarified something I now believe with certainty: Medicine can’t treat what it refuses to see. Every physician carries influence, the power to identify suffering early, to name what others can’t, and to guide them toward help. But to use that power well, we have to look beyond the obvious signs and question our assumptions.

Addiction doesn’t always look like chaos. Sometimes it looks like competence. Sometimes it looks like us.

When physicians start seeing that, when we stop separating addiction from medicine and start addressing it as an integral part of human health, we’ll finally begin to heal not just our patients, but our profession.

Jeff Herten is a dermatologist and dermatopathologist.