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In this article, adapted from a seminar at this year's National CMF Students' Conference, Mick and Sally Leach discuss how we can recognise, treat and manage addiction and addictive tendencies not only in our patients, but also in our colleagues and ourselves.
Perhaps the simplest definition to use relates primarily to chemicals and comes from the International Classification of Diseases (ICD10), which defines harmful use as a pattern of psychoactive substance use that is causing damage to physical or mental health. It then defines dependence as three or more of the following:
A few of these points need emphasising; users will look for almost anything, prescribed or otherwise, that they think may help them to avoid withdrawal. The need for ever-increasing doses because of tolerance can lead to some people spending hundreds of pounds a day (if they are using drugs such as heroin or cocaine). Thus the drug, or more especially the procurement of the drug, becomes the over-ruling focus of a user's life. 'Where am I going to get...?' and 'How am I going to pay for...?' are the first thoughts on waking up in the morning.
The list of 'possibles' is very long; we can become addicted to almost anything. Things to do with our bodies or bodily desires (such as food, weight loss, exercise or sex) can become addictive, as can things to do with material gain or possessions (such as money and shopping). People can become addicted to stimulation or risk (such as gambling, pornography, TV, computer games), or can develop addictions for less tangible things (such as an inappropriate attachment to a particular person, a necessity for approval, or the need to feel guilty). In all of this there may be a need for control, organisation, or perhaps for ritual, for example, addiction to 'doing' religion (including an interest in the occult) or even to a particular style of worship. All of these behaviours can be seen as trying to meet valid human needs but in far less than ideal ways.
Drug use has been seen as an aid to spiritual experience, a route to God, for many religions over many centuries (eg the use of ganja in Rastafarianism). It has also been used in private experiences of transcendence (eg Coleridge's 'divine repose' achieved from opiate use). Perhaps the best-known example in modern era is the use of LSD to cause hallucinations: 'I never had any bad LSD. I saw God regularly, every Saturday afternoon for two years.' But such experiences are user or chemical dependent and are confusing to interpret at the time; often, the user can only make sense of his experiences once he is sober/clean. Using some of these chemicals may make people feel more relaxed, or help them stop worrying about things that otherwise get in the way of worshipping God, but are the experiences really anything to do with transcendent absolute meaning?
Users may report that they feel more fully alive and that drug use helps them to mature mentally, giving them personal fulfilment and meaning. Paul McCartney said that LSD made him 'a better, more honest, more tolerant member of society'. Heroin users report a feeling of having 'come home' and of finding what they had been looking for.
Alcohol, stimulant and opiate users report a heightened sense of community, and ecstasy users often feel an intense sense of communal bonding. But is there any real change in people and their attitudes to each other? The sense of sharing and camaraderie may be more to do with the perceptual distortion induced by the drug than any long-lasting attitudinal change. Many users genuinely care and look out for each other, but the whole situation often seems very fragile and precarious. A sense of community can switch rapidly to aggression and violence. Also because of tolerance, ever-increasing amounts of substance must be used to replicate the initial experience, and dependence with all its attendant problems can develop.
All three of these desires - for transcendence, personal fulfilment and community are part of the human condition: 'Thou hast made us for thyself and our hearts are restless until they find their rest in thee' (St Augustine). Christians believe that Jesus is the authentic way to God and that, through his Holy Spirit, he meets us where we are: 'You will seek me and find me when you seek me with all your heart' (Je 29:13); the spiritual search is one of the heart, not the senses. The longing for community is a God-given desire that brings pain as well as joy, and will be fulfilled by the one who gave us the desire, ultimately in heaven (Henri Nouwen).
The models range from the extremes of 'moral weakness' (in Christian terminology, 'sin') to a purely biological or medical model.
For example, a letter in the BMJ from a prison doctor questioned the idea of drug misuse as a disease, in the sense of a disease being an 'unfortunate assault on one's health'. 'Drug misuse stems from an individual's autonomy to choose whether or not to misuse drugs', he wrote. 'Using a medical model upholds the myth that addicts are the passive agent in a disease process over which they have no control'. (2)
On the other hand, writing in the Lancet, O'Brien makes an interesting case for drug dependence as a chronic relapsing disorder, and compares it to other chronic diseases such as asthma, diabetes and hypertension. (3) With all four conditions, persistent maintenance treatment is needed - whether pharmacological, psychosocial or both. He argues that once recreational drug use moves into dependence there is a large involuntary aspect to the condition. With all four conditions there is a confluence of genetic, biological, behavioural and environmental factors in their aetiology. Particularly with diabetes, hypertension and drug dependence changes in environmental and behavioural aspects are vital in management, and the rates of compliance with these changes are similar with each condition. Furthermore, in all three conditions, poor treatment compliance is associated with co-morbid psychiatric morbidity, lack of family support and low socio-economic groups.
Much research has been done into the biological, medical, familial and behavioural causes or predispositions to addictions. Studies into alcohol dependence show the importance of non-genetic familial factors, as well as some evidence of a genetic component, through twin and adoption studies. Psychiatrists recognise certain personality types are more likely to develop substance misuse problems, such as risk taking, novelty seeking traits and antisocial personality disorders. Mental illnesses also predispose to addictions: depression, anxiety (especially social phobia) and occasionally organic brain disease or schizophrenia. Tolerance and withdrawal probably develop as a result of neuro-adaptive processes that are part of a homeostatic response to acute administration. Shared transmitters explain cross-tolerance (eg benzodiazepines, alcohol and GABA).
Dependence is probably a complex interaction between pharmacological properties of the drug, biological characteristics and personality of the user and the social environment. As Christian doctors, we need to know what God's view of the matter is, and find where in this melange of opinion our own thoughts and beliefs lie most comfortably. There may be no 'right' answer as yet, but we need to have an opinion.
The answer to this must, in principle, be yes. All doctors aspire to be responsible, safe prescribers of chemicals (some of which may additionally have illegal uses, eg diamorphine, benzodiazepines). Jesus drank alcohol responsibly and made use of it in other ways.
Nothing that God has created is inherently evil (Gn 1:31), so none of the naturally occurring chemicals, at least, are bad in themselves. But we are called to worship God alone (Ex 20:2,3) and called to be a holy people, set apart for his service. We are to emulate Jesus as far as is possible for us to do (1Pet 1:16). Indeed our very bodies are intended to be a holy temple and offered as a living sacrifice to God (1Cor 6:19; Rom 12:1).
In the light of this, when deciding whether to take a drug, it would be wise to consider if the chemical is addictive; are we likely to lose control, or find that the drug has come to dominate our life? Most prescribed chemicals are at least potentially psychologically addictive. Also, is the drug harmful to our bodies, and in what dosage?
Our problems or emotions can be viewed as part of our spiritual development that prompt a dialogue with God, such as those seen in the lives of Elijah and Job. Both these men suffered terribly and became seriously depressed, yet they did not abandon their dialogue with God. They shouted at him, and raged against him, but they did not deny their emotions or seek to blot them out. Taking their problems to God brought them out of the depression to a more mature, deeper faith in him. A wise psychiatrist has said: 'if you're drinking to relieve an emotion, watch out! If you've got a problem that causes unpleasant emotions, such as anxiety, sort out the problem and then go and have a drink. But if you have a drink to get rid of the emotion, be very, very careful.' (4) We must consider why we are turning to chemicals in our low moments... and always turn to God.
We are commanded to submit to the authorities and obey the laws they put in place (Rom 13:1), so we should not be using illegal drugs or helping others obtain them. God has given us relationships with families and friends, where each carries duties and responsibilities. (5) Out of love for God and his people we should carry these out faithfully. God's plan for us includes the work he has given us to do (Gn 2:15), so we should not abuse our positions and should always work as if working for the Lord, and do it all in his name (Col 3: 17,23,24). It is intended that we are good examples to others and don't lead them astray.
Some good questions to ask ourselves when thinking of using a drug are:
In order to reflect God, love must be at the heart of our calling; a self-giving love that makes us vulnerable. People with drug use classically have low self-esteem, feel hopeless and are in great need of love and acceptance. We must remember what God has taught us in the Bible about our fellow men.
1. All people are made in the image of God and are of infinite and unique worth (Gn 1:27). Patients may unexpectedly and unwittingly reveal aspects of God to us, and in serving them we are serving Christ (Mt 25:40). Batchelor (4) has suggested that the experience of powerlessness and struggle may make people more fully human and alive, and Paul tells us that suffering breeds perseverance, character and hope (Rom 5:3-4). There is a great deal of kindness, generosity and humour to be found among addicts, especially the homeless.
2. There are no first and second class citizens in God's kingdom - we are all equally in need of grace (Rom 3:23). When God invites people to his wedding banquet, he himself provides the necessary wedding clothes, so that all men, initially dressed in unworthy rags, are equal before him (Mt 22:1-14).
Jesus did not condemn or judge people who failed to live up to God's standards, and neither should we. Nor should we be like the Pharisees who believed that all suffering was a punishment for sins committed and thus deserved.
3. God calls out for justice and advocacy for the powerless and disadvantaged (Mi 6:8; Am 5:24).
4. The Christian standards of truth and hope should inform our practice. The way we relate to our patients should bring them hope and encourage motivation. Our relationships must be honest and tough where needed (Mt 10:16).
All of us have some degree of difficulty in coping with non-chemical addictions; we are all sinners. Everything that God created good has been spoiled by our sin - not just our use of chemicals but also our very selves, our relationships, our work, even our worship of him (Gn 3:17; Rom 8:22). Thankfully, because of God's great grace, we can be put right with him through Jesus (Rom 5:1).
The first and most fundamental step in dealing with all addiction is to acknowledge that there is a problem. If you don't acknowledge it then you can't even begin to be helped. Useful questions to ask yourself about your addictions are:
Addiction can be a physical or mental problem. We may need skilled specialist medical or psychological help to overcome addiction. However, not everyone will need this level of input; some people have simply determined that they will give up an addictive habit and then done so. Many others manage to give up old ways through self-help groups or supportive voluntary agencies, by simply taking one day at a time (which is one of the steps to recovery in the programmes of the Alcoholics and Narcotics Anonymous groups).
However, addiction is not solely physical and mental; it is also a spiritual problem. All three aspects are closely inter-related, and because both the root and effects of the problem include a spiritual dimension, no solution is complete without taking this into account. Being addicted to something is akin to worship of it; we should rely on God alone. Addiction is a form of idolatry that squeezes God out of his rightful place at the centre of our lives, and we may be ignoring his voice to feed our cravings. Indeed, addiction may be a form of denial of our need for God, or an attempt to deal with the deep hole in our lives that only God can fill.
We must hand all our hurts and worries to God (1 Pet 5:7; Mt 6:34), turn back to him, confess and repent of wrongdoing, and know our free and full forgiveness (1 Jn 1:9). This leads to renewed hope for life ahead.
If we have been blocking out something from the past, or the future, discovering this and praying about it is a step to dealing with the root problem.
We are designed to have rich relationships with other people, so we must make sure that we have them! We must be honest, not just with ourselves, but with others too, and learn to be accountable to them. Then we will have the support of others, including our Christian leaders that God has placed over us for our good (Acts 2:42; Eph 2:19; Jas 5:16). And never, ever, forget that we have powerful help on our side as Christians: the Holy Spirit and prayer (Gal 5:22; Eph 3:20, 5:18,19; 2 Tim 1:7).
Be prepared, gently, to challenge others. They are unlikely to react well to this, but in our relationship with them we have a duty towards them. If they are not Christians they may not be willing to accept that there is a spiritual dimension to the problem. However, if they recognise that that there is a problem, we must at least help them to begin dealing with it at another level. If they refuse to accept the problem (and we are all good at denial as a defence mechanism), keep praying for them and try to maintain the relationship (keep loving), all the while gently looking for another opportunity to challenge.
What if we think we see a problem in fellow students or qualified colleagues? In addition to our duties as friends and Christians, we have a responsibility to make sure that our patients come to no harm. (6)
Each medical school, hospital, area of general practice or other employer will have a carefully designed procedure for raising concerns confidentially. The aim is to offer advice and help, rather than immediately initiating a disciplinary procedure (although that is a final option).
Finally, we must remember that recovery from addiction is usually a process, not an immediate life-changing event, so we may need to go back over these steps several times. God is a God of miracles and no-one is beyond his help.