Alcohol use in the United States has reached historic lows. That’s good news for the public’s health. A 2024 study from the CDC concluded that alcohol was the direct or indirect cause of more than 175,000 deaths annually in the United States, so any positive movement is cause for celebration.

But amid that overall decline, there are still pockets of the population that suffer from disproportionately high rates of alcohol misuse. In general, people with lower incomes tend to suffer the worst outcomes if they develop a problem with alcohol, but alcoholism is also found among professions that our society thinks of as “high status,” including lawyers, journalists, and — especially — doctors and nurses.

One 2023 global metaanalysis found that one out of every five health care professionals drink enough for it to be hazardous to their health and frequently engage in binge drinking. The rates of problematic drinking in this group, perhaps unsurprisingly, rose during the pandemic. Another international paper found that rates of alcohol abuse among providers rose in recent years — the opposite direction of the celebrated drop-off among the general public.

When it comes to American physicians, a 2015 study found that 13 percent of male physicians and 21 percent of female physicians would meet the criteria for alcohol misuse. Alcohol misuse by health care providers is associated with a poorer work performance and worse patient outcomes, raising the stakes not only for the person with an alcohol dependency but the people they’re caring for.

And for health care workers, the pandemic could still be having a lingering effect on the high rates of alcohol use. The deep trauma of those years persists, medical work remains very stressful, and using some kind of substance to cope with those difficult feelings can be tempting.

We have come a long way in recognizing alcohol and substance abuse as not a moral failing but as a combination of physiological, dependent, and life circumstances. But these “high status” workers can present unique challenges as we strive to make further progress. Persistent beliefs about who is (and isn’t) affected by addiction means their risky drinking may not be obvious. They may not be as receptive to interventions. If they seek treatment and then attempt to return to their work, they may be stigmatized by their coworkers or, in the case of doctors, lose their patients’ trust.

This subject has been on my mind for the past few months because of a major storyline on this season of The Pitt, the hit HBO show about a city emergency department, which airs its finale on Thursday. It focuses on one doctor trying to get back to work after going away for substance treatment — and it neatly captures both how far we have come and how far we have to go.

At the end of The Pitt’s first season, we learn that Dr. Frank Langdon has been sneaking medications from the hospital supply and using them himself. It’s a shocking moment: Up until this point, he’s been the most reliable right hand for the protagonist, Dr. Michael “Robby” Robinavitch. Dr. Langdon has been a valuable mentor to some of the medical residents who make up much of the rest of the show’s cast — and clashed with at least one, Trinity Santos, whose abrasive personality had turned some audience members against her. Nobody questions Dr. Langdon, because he seems to be on top of his game.

And the show’s lessons about substance use start there: Somebody can be highly effective at work while still struggling with addiction. That makes even identifying the problem particularly challenging within the medical field. They may also believe that they can continue to meet the high standards of their job despite misusing alcohol or other drugs.

“It is very difficult to treat a physician. Physicians just, in general, have a lot of ego,” Dr. Jason Kirby, chief medical officer at Recovery Centers of America, told me. “A lot of the treatment of anybody with substance use disorders, you have to break down that cognitive distortion. You break down that ego. And it can be very difficult for physicians to get to that point.”

As Kirby told me, most doctors who go into rehab are directed there because of an issue raised by a colleague, or superior, or patient. They don’t tend to seek out treatment themselves until the issue is forced upon them.

At the start of Season 2, Langdon is back in the Pitt’s ER after spending time in treatment. He appears to be humbled, and he makes a point to offer his apologies to some of his coworkers for his behavior.

And here again, the show strikes a notably realistic tone. Some of his colleagues are understanding and ready to work with him again; in one detail that I appreciated, Dr. Cassie McKay, who had already been through alcohol treatment prior to the show’s beginning, offers Langdon her support. But some of his fellow doctors — including his old mentor, Dr. Robby, and his new nemesis, Santos — have been dubious. They don’t know if they can trust him, they think his repentance is dishonest or superficial, and they worry about him relapsing or otherwise not being up to the task of treating patients.

I haven’t seen the finale yet — I’m a health care reporter, not a TV critic who gets those early screeners — but one of the major storylines to be resolved tonight is whether Langdon can fully come back and reclaim his place in the hospital or whether he ultimately decides he can’t. If he slips up, or if his colleagues decide they can’t forgive him for his betrayal of trust, it will hurt — but it will have a ring of truth. But I’ll admit it’s my hope that he can find peace and reconciliation with Robby and Santos. That’s the recovery story we are always rooting for — and the one we should be striving to tell in our own reality.

We’re getting closer to a world where the Dr. Langdons get the help they need and are welcomed back to work with open arms. But we’re not there yet.

The good news is that treatment has advanced and become standardized. We have interventions that have been proven to work for a range of substances. For physicians, in particular, most states have a dedicated recovery program; Kirby told me that those programs enjoy something like a 95 percent success rate, because they are more intensive and last longer than what is typical for people outside the field.

And cultural attitudes have evolved, which is great. People are more accepting of substance misuse as a medical problem to be treated. But stigma remains, particularly for high-performing professionals like physicians. Doctors often enter treatment with greater dependency, because they have hidden their issues and put off seeking help, often out of fear of reprisal from their colleagues. When they do come back to work, they are back in the environment that led to their risky behavior in the first place — as Dr. Langdon has done in his return to The Pitt’s ER.

“It could be very difficult for physicians to return to work,” Kirby told me. “They’re going back into the environment that could have made them sick in the first place, or at least aided in that process.”

And that is perhaps the biggest remaining challenge: fixing the conditions that lead people to misuse alcohol or other substances in the first place.

The pandemic accentuated the highly stressful nature of medical work and left many doctors and nurses with painful memories, but there are new traumas every day, especially when working in a hospital where life and death are regularly on the line. At the same time, we don’t have enough doctors. We don’t have enough nurses. Many providers find themselves overworked without the necessary institutional support for their mental health.

“Knowing the trauma that physicians and and nurses and everybody who works in the field face every day, there needs to be healthy outlets for that,” Kirby told me. “When folks don’t have the healthy outlets, unfortunately, they’re going to turn to unhealthy outlets.”

The Pitt deserves credit for centering this issue, which has been taboo for too long. But it only matters so much as we take its lessons and apply them to the real world. Alcohol misuse can be tricky to identify. As experts have put it to me, alcohol use disorder is not based on the specific amount of drinking you do; it’s whether you have tried to stop drinking in the past year but failed, have alcohol cravings, or believe drinking interferes with your life.

Those are subtle signs — the kind that only a loved one or close colleague might be able to notice.

If you notice those warning signs in someone you know or yourself, please ask for help. That’s where the recovery story, for doctors or anyone else, begins.