ADDICTION: A VIEW FROM THE FRONT LINE

John Latham looks at substance abuse.

'Freedom is a word I seldom use without meaning' sang Bob Dylan. But freedom is a word and a concept that is frequently used in Scripture to describe the effect that God has on individual believers:

The Spirit of the Sovereign Lord is on me, because the Lord has anointed me to preach good news to the poor. He has sent me to bind up the brokenhearted, to proclaim freedom for the captives and release from darkness for the prisoners.(1)

This was the passage that Jesus read from the scroll that was handed to him when he stood up to read in the synagogue in Nazareth.(2)

Addiction is the very antithesis of freedom and in my experience substance misusers (even those without any real concept of sin) always understand the idea that addiction is slavery, whilst release from addiction is freedom. In counselling people whose lives are controlled by substances or habits, these biblical principles are instantly understood.

The problem of substance misuse

My work over nearly 20 years as an inner city Dublin general practitioner (GP) has been hugely affected by the widespread misuse of alcohol and other drugs. I feel confident in estimating that at least 30% of my clinical and organisational energy in caring for this community has been expended in dealing with the consequences of such substance misuse.

Our surgery is on a street corner, very close to a cheap off-licence. Nearly every day the drinkers gather outside, swigging from cans and bottles, singing and frequently vomiting, urinating and defecating over the side of our building. They are usually gentle men and women, bewildered and lost in a world in which they have searched for meaning and been disappointed.

So pervasive and corrosive is the effect of alcohol, cocaine, heroin, ecstasy, cannabis and of course tobacco, on this already deprived area that I am sometimes tempted to cry out with anger, frustration and sorrow at the terrible waste of human potential, health, happiness and life. Even as I write I mourn the tragic death of a dear patient who had accomplished much in giving up heroin and rebuilding his life, only to succumb to the despair of his long battle with AIDS. He threw himself under a train early one morning.

Yet, as a Christian and as a doctor I have great cause for hope and a clear purpose in continuing my spiritual and clinical battle against the odds. I will illustrate some aspects of this fight by describing the struggles of patients I have known (details have been altered).

Sean's story

Sean was a tall, good looking young man. He was the eldest of three boys in an inner city family. At the age of 14 he was offered heroin; this was about 1982 when Dublin was being flooded with heroin by one infamous drug dealing family. Unfortunately Sean loved heroin and he soon became 'strung out' (needing regular fixes every day). When I got to know him in the late eighties he was the father of a beautiful little daughter and was becoming very sick with HIV related illness. He still looked striking, was well dressed and rode a motorcycle around town doing deals here and there in the inner city flat complexes. He became terminally ill in 1989 despite the best medical efforts of the time. In his final weeks Sean was severely cachectic, bed-ridden and helpless. He was the first person for whom I prescribed methadone.

His two younger brothers took a nursing role and fed him, cleaned him and tenderly helped the nurses and family; they were grief stricken when he died. Neither of them had tried drugs before Sean's death, but they both started injecting heroin subsequently and have been close to the grave themselves on several occasions. They are now stable on a methadone programme and are working, looking after their families and keeping on the right side of the law. These two boys have found a measure of freedom by following an evidence based treatment programme,(3) but have yet to experience the true liberation of knowing Christ.

Even in the midst of these terribly sad situations, God is clearly at work. At least one member of the infamous drug dealing family mentioned above (many of whom have died or remain in prison) has become a Christian and is a pastor in England. He spreads the gospel with great vigour to the amazement of his family and neighbourhood - what a victory for real freedom!

Jimmy's story

One biblical principle that is a great inspiration and which is borne out in the lives of addicted people who have found freedom in Christ is that of being 'dead to sin and alive to God',(4) yet often we see the reverse. Paul states in Romans 6:12,13, 'do not let sin reign in your mortal body so that you obey its evil desires. Do not offer the parts of your body to sin, as instruments of wickedness, but rather offer yourselves to God'. When I see ravaged young bodies with thrombosed veins, enlarged livers and other bodily manifestations of sin, these verses become vividly alive.

But Paul goes further:

Don't you know that when you offer yourselves to someone to obey him as slaves, you are slaves to the one whom you obey - whether you are slaves to sin, which leads to death, or to obedience, which leads to righteousness?(5)

Jimmy was one such young man who was a slave to sin and who continually offered the parts of his body as instruments of wickedness. He, however, found freedom in Christ in a most unlikely way. As a severely addicted heroin misuser he required several hundred pounds in cash each day to feed his habit. One evening he broke into the house of an elderly woman and prepared to remove her television and video. However, since the house was empty, he decided to sit down and have some heroin before legging it with the loot. The dose of 'gear' was too strong and he became comatose. Jimmy was woken some time later by the house owner who shook his shoulder vigorously, proclaiming, 'Wake up, Jesus loves you!'

Jimmy was so impressed that he went to church with the woman the next day. He subsequently did an induction course with Teen Challenge (a Christian organisation dedicated to working alongside people with addictions) in Dublin and then spent nearly two years at a Teen Challenge residential centre in Wales.

He is now married with a child and is a Christian worker. The local police who once treated him as a troublesome villain now consider him a changed person and a useful community liaison man.

Christopher's story

Another biblical principal is that 'No one can serve two masters. Either he will hate the one and love the other, or he will be devoted to the one and despise the other. You cannot serve both God and Money.'(6) This is so well illustrated in the divided loyalties of the addicted person who may not primarily serve money (though he may steal it), but who certainly serves his habit.

Doctors and medical students are not immune from this. They commonly fall into the trap of serving more than one master and sometimes substance dependence becomes the most powerful one.

Christopher was just such a doctor. He was a vocationally trained, single handed GP with ongoing academic commitments and a very strong social conscience. He was a committed Catholic and a devoted husband and father. But he began injecting pethidine and morphine and writing more and more prescriptions for these until the police and the Medical Council investigated his suspicious prescribing. He was prohibited from prescribing controlled drugs and his name was published in national newspapers. Christopher commenced a drug treatment programme and continued to run his practice. He has now been drug free for several years and has had his full prescribing privileges restored.

Defining addiction

Addiction is the process by which drug taking behaviour in certain individuals evolves into compulsive patterns of drug seeking, often at the expense of most other activities. It also involves the inability to cease drug taking.(7)

I can think of several commodities or activities to which people may be addicted: drugs, alcohol, sex, food (including chocolate), stealing (kleptomania) and even religious practice. Some of these, or others, may have affected your life. For the purposes of this article, only addiction to chemical substances will be discussed. A medical definition of addiction to chemicals is found in the International Classification of Diseases (ICD-10).(8) Dependence is defined as three or more of the following:

• A strong desire or sense of compulsion to take the substance.
  
• Difficulties in controlling substance taking behaviour.
  
• Physiological withdrawal - causing either the characteristic withdrawal symptoms or use of the same (or closely related) substance to avoid withdrawal symptoms.
  
• Evidence of tolerance and increased doses needed to achieve the same effects.
  
• Progressive neglect of other activities and interests because of time spent in using the substance, recovering from its effects or obtaining the substance.
  
• Persistence with the substance despite clear evidence of ongoing harmful consequences.

I think that the verses from Romans(9) quoted above fit in very well with the picture painted by this classification. An addicted person persists in the habit beyond the point where the body and soul become progressively damaged, so that it is a definite form of slavery.

Some biblical guidance on the use of alcohol

Alcohol was the most common psychoactive substance known in Bible times, so it is not surprising that there are several passages that mention it.

Proverbs 23:29-35 gives a graphic and very clinical description of the appalling psychological, social and physical effects of alcohol misuse, which is accurate enough to be worthy of a modern clinical manual. Medical students particularly should take this to heart in the midst of the obvious peer pressure to drink too much alcohol.

Genesis 9:20-27 records how even the great Noah came to serious grief through the unwise use of too much wine.

However there are differing opinions on the use of alcohol in general. Searching Scripture reveals some guidance on what is permissible.

1 Timothy 5:23 suggests the medicinal use of wine long before the studies suggesting that one or two glasses of red wine per day are good for the cardiovascular system!

John 2:1-11 describes Jesus' first miracle, changing water into wine at a wedding. This is a remarkable example of the Lord not only condoning recreational use of alcohol but also actively encouraging it in certain circumstances.

Luke 22:14-20 records the Passover meal that Jesus shared with his disciples, now known as the 'last supper'. During the meal, Jesus drank wine and broke bread with his followers and instituted the central ritual shared by virtually all Christians down through the ages in remembrance of his sacrifice. Thus most Christians use wine (usually alcoholic) as an important and regular part of fellowship with other believers.

We are not told in Scripture about the use or misuse of opiates or cocaine as they were not available (as far as we know) in biblical times. However, the wise and correct use of alcohol is often extolled, thus belying the view that the chemical ethyl alcohol is evil in itself and must always be avoided.

The overarching principle for anyone born again and living a life of freedom in Christ seems to be one that Paul gave. To those who claimed 'everything is permissible', his response was, 'but not everything is beneficial'.(10) I know that this passage is mainly concerned with religious eating codes but I believe that it may also be construed to include the use of psychoactive chemicals. Certainly no Christian should be using any substance in a way that leads them to dependence, is detrimental to their health, or ultimately challenges God for supremacy in their life.

Physical and clinical matters

No doctor or nurse should deny the need to care for the physical needs of addicted people, be they traumatic injuries, damage due to viral infections (including HIV) or organ damage such as cirrhosis. However, negative attitudes pervade the thoughts of many healthcare professionals and this is exposed in a good review article.(11) I was once at a medical dinner where a GP announced that he would never treat drug addicts as they had brought their illness upon themselves. The same gentleman smoked two cigarettes with his after dinner coffee!

Inner city doctors and especially GPs and emergency department staff know how many consultations are as a result of addiction or substance abuse. The cost of providing emergency and long term care for substance misusers can be huge. Regardless of this, duty of care seems to be incontrovertible and all doctors of whatever speciality have to deal with a certain caseload as a direct result of addiction or substance abuse. Perhaps this is the easy part, rolling up our sleeves and getting on with the medicine or surgery.

Psychological and spiritual considerations

A great deal of psychiatric and psychological illness has links (either as cause or effect) with substance misuse. Acute psychosis caused by Ecstasy or depression caused by alcohol abuse are examples.

Patients with psychological illness often self medicate with alcohol. Those in my practice being treated for opiate abuse frequently suffer psychological problems and close liaison with psychiatrists specialising in substance abuse is essential.

In addition to these factors, I firmly believe that there is a deep spiritual dimension to every single case of addiction. We should therefore be praying for (and sometimes with) our addicted patients, that the power of the addiction would be broken, either by natural medical means, supernatural means or a mixture of the two. There is often excellent opportunity for discussion of faith issues with addicted patients, especially in general practice where a long term trust relationship can be built up.

Social consequences

The social consequences of substance abuse are wide ranging and appalling.(12) A large percentage of homeless people and hostel residents abuse alcohol, drugs or both. The scourge of substance misuse has devastated families, communities and neighbourhoods. Countless children have been orphaned or placed in care; many grandparents have to bring up the next generation because their sons or daughters are addicted. Violence, street crime and homicide are consequences of addiction.

Controversies

I quote three well-known statements and add some thoughts of my own.

i) 'Addicts have only themselves to blame and the medical model is just a cop-out'

Addicts may indeed have themselves to blame, but if Jesus had taken this attitude to mankind's sin he would never have thought it worth dying for us. If we were to take this attitude and withhold clinically proven treatments from those who have harmed themselves we would be guilty of negligence.

ii) 'Abstinence is the only acceptable solution to dependence. Prescribing substitutes such as methadone is unethical and is simply legalised drug pushing'

Obviously abstinence is the most desired outcome, but if (as in the majority of cases) this seems impossible, I believe we are duty bound to offer a safer, controlled form of 'harm reduction'. I can state from my own experience with a methadone treatment programme, that it relieves suffering, reduces crime, allows proper family life and childcare and gives the person the opportunity to receive care for other allied problems such as Hepatitis C and HIV infection.(13) Some experts even suggest the use of prescribed heroin and there is evidence from Switzerland that this is a useful medical intervention.(14)

Having said this, it should be the goal of any such treatment programme to wean an addict gradually off their dependence in manageable steps.

iii) 'There is almost no support or help for substance dependent medical students'

Recently I came across the case of a medical student who died of a heroin overdose; neither the medical school authorities nor his friends seem to have noticed any problems before the tragic event. I do know from discussion with students that heavy drinking and recreational drug taking are extremely common amongst their peers. Most universities and medical schools are very aware of this problem and do offer expert medical and psychiatric help. Medical students are representative of society and young men and women are very likely to use drugs recreationally (to begin with) and a certain percentage will become ensnared by dependence. Obviously greater vigilance by university medical services, medical school staff and fellow students in a spirit of openness and honesty will perhaps prevent some addictive behaviour from becoming uncontrolled.

Conclusion

Clinical evidence now abounds that there are medical models available with which to treat many addictions, including those to alcohol and opiates. As doctors we have an obligation to help needy patients to receive this treatment though this may be harm reduction rather than cure.

Yet as Christian health workers we know that there is more than enough evidence to show that only salvation by faith in the Lord Jesus, repentance of past sins and asking him into our lives will allow certain cure and healing for those afflicted by addiction. Galatians 5:19-23 lists the acts of the sinful nature (sexual immorality… drunkenness, orgies and the like) and then contrasts these with the fruit of the Spirit (love, joy, peace, patience, kindness, goodness, faithfulness, gentleness and self-control). The former list is a fairly complete symptom schedule for addiction and the second list is a description of those who have overcome the mental, bodily and spiritual control of addiction.

I conclude by humbly reiterating that in the midst of chaos there is hope and though many physicians have been discouraged and even frightened by the prospect of dealing with addiction and its consequences (I have been one), there is spiritual healing and wisdom available from our Father along with clinical expertise and knowledge within the profession. Caring for those caught in addictions is an excellent way of healing God's hurting creation using the gifts he has given us.

Further Reading

I include just a few out of many possible useful sources:

• Batchelor O. Use and Misuse - a Christian Perspective on Drugs. London: IVP, 1999 (see review on p38)
  
• Dixon P. The Truth About Drugs. London: Hodder and Stoughton, 1998
  
• Dixon P. The Truth About Drugs. Nucleus 1999; July:26-32
  
• Pullinger J, Quicke A. Chasing the Dragon. London: Hodder and Stoughton, 1980
  
• The Teen Challenge website - teenchallenge.com

References

• Is 61:1,2
  
• Lk 4:16-21
  
• Ward J et al. The role of methadone treatment in opioid dependence. Lancet 1999;353:221-226; Farrell M. Methadone maintenance treatment in opiate dependence - a review. BMJ 1994:309:997-1001
  
• Rom 6:11
  
• Rom 6:16
  
• Mt 6:24
  
• Robinson T, Berridge K. The psychology and neurobiology of addiction: an incentive-sensitisation view. Addiction 2000;95:S91-S117
  
• The International Statistical Classification of Diseases and Related Health Problems (tenth revision, three vols). Geneva: WHO, 1992-4
  
• Rom 6:12-16
  
• 1 Cor 10:23
  
• Mistral W, Velleman R. Are practice nurses an underused resource for managing patients having problems with illicit drugs? Journal of Substance Use 1999;4:82-87
  
• Is 28:7,8
  
• Farrell M. Op cit
  
• Perneger T et al. Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatment. BMJ 1998;317:13-18