Many people see addiction . . . as a character flaw or a bad choice. They don’t recognize that addiction is in fact a chronic disease of the brain.” That statement by Vivek Murthy, surgeon general of the United States, reflects the current medical and scientific consensus about addiction. Murthy and others believe the language of moral choices only increases shame and decreases funding for more scientifically rigorous treatments. To make progress in saving lives, they argue, we need to change the way we think about addiction.
In fact, we need to recognize at least four dimensions in addiction: moral, social, biological, and spiritual. Addicts are moral agents, in community, with biology working against their spiritual goals. Biological science gives us insight into the particular ways an addict’s body makes a normal life that much harder to live. Public health can describe how a community and its institutions make recovery more accessible to people trapped in addiction. A moral framework helps us understand how addiction harms ourselves and the people we love, while also providing the basic routines of living free. Most importantly, spirituality helps us to understand God’s love for everyone (no matter how lost they are) and gives us the power to live healthy, whole lives.
Biology and the Brain
Our brains were created with neurotransmitters to help us enjoy the physical pleasures of life, adapt to stressful situations, and direct us to do what is necessary to maintain our bodies’ physical and mental health. Addictive substances (and, to a lesser degree, other addictions like pornography or gambling) pervert all of these basic brain functions, breaking the biological systems we depend on to think and choose as we ought.
It is important to differentiate between dependence and addiction. Dependence refers to the basic physiological need that some drugs create in our bodies when used over time, leading to measurable physical symptoms when the drugs are withdrawn. Dependence is almost negligible for certain drugs, but it can make complete withdrawal fatal for others. Such physical dependence on heroin and prescription painkillers creates severe withdrawal symptoms when a user tries to stop. (Some people with severe chronic pain—from cancer, for example—can be physiologically dependent on opioids but not addicted.) Some medications available for treating addiction work primarily by preventing these withdrawal symptoms.
The biochemical effects of addiction, as Timothy King’s cover story for CT illustrates, tend to be more complex. The most obvious effect of many addictive substances is pleasure, but even that isn’t so simple: Drugs can overstimulate and alter the pathways that normally connect pleasure with healthy activities. Over time, the brain’s reward system becomes tied more exclusively to the drug of choice, decreasing an addict’s ability to experience natural pleasures while heightening the effect of the drug.
At the same time, the pleasure centers of the brain adapt so that using a drug is itself rarely euphoric anymore. Instead, the altered neurochemical reward pathways that once led to pleasure are instead fruitlessly stimulated over and over until other areas of the brain—such as systems linked to critical thinking and decision-making—are hijacked into supporting this never-ending cycle. Many drug addicts will describe the routine of using a needle as nearly as important as actually getting high, just as porn addicts will spend hours looking at pornography without masturbating. Both are fruitlessly reenacting the reward pathways that normally teach our brains to seek out good things, corrupting them so we merely anticipate and want instead of actually enjoy.
At the same time, drugs especially subject to abuse also tend to tamp down stress factors in the brain. When the drugs are no longer present, these neurochemicals are often released in greater volumes, heightening anxiety and creating another set of incentives to keep using. This makes the initial withdrawal that much harder, and makes addicts more likely to relapse in stressful situations.
Just like drinking nothing but soda will rot one’s teeth until one cannot even bite an apple, so using drugs will alter the physical and neurochemical structures of our brains until many of our personal resources for doing the right thing are impaired. Many of these biochemical alterations have been found to persist for months after an addict stops using. Addiction is not simply about “getting high.”
One of the most important (and controversial) treatments for opioid addiction is medication-assisted treatment—using methadone or buprenorphine (Suboxone) to prevent physical withdrawal symptoms while addicts learn how to manage their lives without abusing drugs. At first, it may seem counterintuitive to use one powerful drug to treat addiction to another. Many people stigmatize the use of methadone or Suboxone as “just another kind of addiction.” However, in cases of addiction (versus dependence), these medications can be very useful.
Medication-assisted treatment, when used in conjunction with a rigorous treatment program, has been shown by many studies to help people stop abusing drugs and live healthy, functional lives. That does not mean it makes recovery easy. When I was practicing medicine in Baltimore, my patients often described craving heroin even when they were on a strong dose of Suboxone. I had to explain again and again that the drug would not necessarily prevent cravings. They had to do the work of recovery to retrain their brains and bodies to manage without abusing drugs. Still, these drugs are a powerful adjunct in some people’s recovery. They are not the right choice for everyone, but to extend my earlier dental metaphor, they are like a set of false teeth that makes good nutrition more accessible.
Public Health and Community
Johann Hari, author of Chasing the Scream, has said that “the opposite of addiction isn’t sobriety—it’s connection.” This is true, as long as we’re talking about a healthy community, not codependent connections with family and friends (some of whom may also be addicted). Connection and community are very important in overcoming addiction, but not always in the way that we might think.
An addict’s internal personal judgment and decision-making are corrupted, making other people necessary to reality-test the patterns of thought that would otherwise reinforce addiction. The church has an important opportunity here, not just in helping connect addicts in need with loving friendships but also in re-centering us in our basic human purpose of worship. Whether one walks in on Sunday morning five years sober or still a little intoxicated from Saturday night, our brains and bodies were created to worship God. It is by living in the typical patterns of life and worship that our bodies can be healed.
Recovering addicts always require this basic level of community support, but many also need a more intensive regimen. Many small groups and churches have implemented an explicitly Christian 12-step program like Celebrate Recovery (though there is no robust evidence that 12-step programs, as popular as they are, are superior to other treatment programs like cognitive-behavioral therapy).
What is important is ensuring that some sort of treatment is widely available. Waiting lists for treatment programs are often months long, meaning that someone who decides they want to get better has to wait to get the help they need—often still using and occasionally dying of an overdose before they get into treatment. We cannot expect our national addiction problem to get better until treatment is better funded and more accessible, including making sure medication-assisted treatment is available to anyone who wants it.
Morality and Spirituality
Addiction and recovery also have moral and spiritual components, and it is useful to distinguish them. As Eve Tushnet says, “Selfishness and idolatry are moral categories, in which . . . the proper hierarchy of our loves is disrupted. That’s different from addiction as a misdirected expression of a spiritual longing, an attempt to feed a spiritual hunger.” All people—addicts in particular—are called to start with the gospel that satisfies our hunger, trusting in God’s love for us and repenting of our sin. Many people recover without trusting in Christ, yes, but those who are grasped by the gospel have a significant head start in sorting out the “hierarchy of our loves” as they untangle the particular ways in which sin has created strongholds in their lives.
One of those strongholds, undoubtedly, is the perverted biochemistry of addiction. Our reward pathways and pleasure centers didn’t simply evolve to help us eat and reproduce; they were created to glorify God and enjoy him forever. Addiction cripples our brain’s ability to mediate the moral and spiritual ends we were intended for, which means that in recovery, we don’t just obey and worship but work to regain the capacity to obey and worship.
Understanding addiction as a disease does not mean that prayer and moral discipline are any less potent or important in recovery. But it does underscore the ways that medication and therapy can be helpful, and helps us to appreciate just how difficult and costly recovery can be. The process of an addict recognizing their need for help, finding a treatment program, and walking through the recovery process (including relapses, which are very common) will usually take more time, energy, and money than one person with a broken brain can bear. Not everyone will need all of these different elements, but our current crisis demands that kind of holistic response.
King’s CT essay reflects this complex interaction of body, mind, and soul. His doctors had to show him that the opioids were doing him more harm than good and acknowledge the role they had played in his addiction. They had to use their professional skills to develop a medical plan for dealing with his pain and his addiction that complemented the support from friends and family. But he also chose to get better, committed to the plan, and was willing to do the work necessary to confront the way that painkillers had changed his mind and body for the worse.
To help addicts heal, we have to bring all the forces available to us to bear—sometimes even to the extent of using medications like methadone and Suboxone. Loving people who have become trapped in biochemical bondage is not easy or cheap, but love never is. And when we use every possible resource God has given us to combat addiction, we also demonstrate the goodness and power of God, who seeks to transform us in every way—even the neurons in our brains.
Matthew Loftus, MD (MatthewandMaggie.org) teaches health workers and practices family medicine in South Sudan with his family.
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