Addiction

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Addiction: How can pastors and laypeople help?

Chris Sumey, MD (St. Paul, Lakewood, CO)

West Central Delegate Conference

Valentine, NE

May 24, 2011

            How often do we hear statements like, “I’m addicted to football,” or “You must be a choco-holic!”?  We all have that something that we just can’t seem to get enough of.  For me it’s probably music.  I own so many music CDs I have some that I have seldom heard.  But when does a habit become a true addiction?  What happens when someone we care about finds himself caught up in drugs or alcohol?   How should we respond when a church member’s habitual behaviors become a detriment to her family and her own life?  In full disclosure, I am not an expert in behavioral sciences or mental health, but I do have a well-rounded medical background and experience assisting patients with these issues. Whether I am counseling a military veteran with emphysema on the importance of smoking cessation or treating an alcoholic patient with liver disease who will die without a transplant, I see all too often what harms true addiction can bring and I work with them to help them quit. 

We can all probably think of people close to us who have struggled with some form of addiction.  To better understand how we can help others overcome a problem such as this, we will first spend some time defining the problem and identifying the basic mechanisms that drive addiction.  Next we will talk about what God’s Word has to say about the matter, and how we should react to someone who is addicted.  Finally we will discuss how we can best serve others in this regard and some strategies we can employ.

            It is important to begin with some definitions.  Addiction is a lay term that means: “the state of being enslaved to a practice or habit.”[1]  This word is quite loaded and doesn’t tell us much about the problem, so the medical literature does not use this term much.  Instead we will focus on two other terms: dependence and abuse.

            Dependence is defined as the presence of three or more of the following in the DSM-IV (the medical manual that defines all mental health disorders) [2]:

 

  1. Tolerance: Developing a tolerance to the substance/behavior such that you need more and more for the same effect
  2. Withdrawal: Absence of the substance/behavior leads to physical or psychological withdrawal
  3. Overuse: Using larger amounts than what was intended
  4. Desire to cut back
  5. Time: A great deal of time is used in pursuit of the substance/behavior
  6. Activities are given up due to the habit
  7. Persistent use despite knowing the negative effects

 

These are the things to look for when trying to understand the scope of the problem.  For example, physicians are taught to screen patients for alcohol dependency using the CAGE questions[3]: Have you thought about Cutting back?  Are you Annoyed by others who criticize your drinking?  Have you felt Guilty about drinking?  Have you needed an Eye-opener in the morning (to prevent withdrawal, etc.)?  These questions and other tools draw directly from the definition of dependency.

            Abuse is essentially dependence that also has clear interference in the individual’s personal life.  Warning signs of abuse include:

 

  1. Failure to fulfill obligations at work/home/church/school, etc.
  2. Getting into hazardous situations (physical danger)
  3. Legal problems
  4. Interpersonal problems such as recurrent arguments, separation/divorce, etc.

 

Someone who is abusing a substance or behavior is causing clear harm to himself or herself yet the habit continues.  We distinguish abuse from dependency because those with abuse arguably have a greater need for help.

            What can be misused or abused?  I have alluded to two broad categories: substances and behaviors.  The DSM-IV (and my training) predominantly addresses substances of abuse.  These include: alcohol, marijuana, cocaine, amphetamines, heroin, etc.  Due to their different properties and potencies, the withdrawal pattern and the “strength” of the addiction can vary quite a bit.  For example, nicotine is a substance that often leads to dependence but seldom leads to abuse, whereas marijuana is not associated with any particular withdrawal symptoms.

            Sometimes a behavior can be just as addictive as a drug.  Some examples include gambling, pornography, and binge eating[4].  Some psychologists may argue that many other vices can be labeled as “addictions” as well.  Regardless, as Christians we know that we are all slaves to sin in general.

 

            John 8:34 (NKJV)  – “Jesus answered them, ‘Most assuredly, I say to you, whoever commits sin is a slave of sin.’ ”

 

            However, I believe that truly being dependent upon or abusing a behavior is more complicated than simply being a sinner.  There may well be a “gray zone” here which I have no intention to delineate.  I propose that such questions are best addressed on an individual basis with God’s Word open as a guide.  Ultimately, we are all sinners and all need to hear God’s Word in both Law and Gospel to guide us on our Christian walk.

            As additional background to understanding addiction, especially substance abuse, I want to discuss neurotransmitters very briefly.  The brain consists of roughly 100 billion neurons, or nerve cells that are all intricately interconnected.  They can send signals to one other extremely quickly using more than a half-dozen signaling molecules called neurotransmitters.  Many drugs of abuse act directly on this communication system.  For example, dopamine is the neurotransmitter thought to be responsible for the basic reward pathway in the brain, telling you, “that was good, you should do that again.”  Drugs such as cocaine and amphetamines directly affect this pathway, essentially “hard-wiring” someone to use these substances again and again.  Alcohol may lower inhibitions in part because it acts on the GABA receptor of the brain, decreasing the activity of the signals that tell us, “don’t do that, something bad might happen,” so we say or do whatever pops into our heads.[5]  This is not to say that drug users has no control over or responsibility for their actions, but clearly it can be much more difficult to make the right decision.  So we see how manipulation of the neurotransmitters in our brains can work against us to promote addiction. 

On a higher level, it is crucial to acknowledge the situations that can promote addiction.  When dealing with someone who is abusing/dependent upon a substance or behavior, we are likely to encounter many of the following issues:

            Denial is often a central problem.  The individual may say things like, “This is not really a problem” or “I can quit any time I want to.”  Those close to the individual may fall into the same trap.  This issue will need to be addressed before any progress can be made.

            Enabling occurs when loved ones do something that promotes the habit in question.  Often they are unaware that their actions are actually reinforcing the individual’s addiction.  Examples of enabling include taking on the responsibilities that an alcoholic person has forsaken, bringing large quantities of junk food to an overeater too obese to leave the house, or leading someone to think that his methamphetamine habit is nothing serious.  Sometimes, as difficult or loveless as it may seem, allowing someone to endure the full burden of his or her mistakes helps to hasten their decision to change. 

            Mental health disorders are beyond the scope of this essay but are possibly the most important complicating factor.  People struggling with depression often will “self-medicate” with alcohol.  Bipolar disorder is characterized by manic episodes, periods of unusually heightened mood which often feature substance abuse and any number of behavioral indiscretions.  Delusions, or fixed false beliefs, are central to schizophrenia and can be incredibly tormenting.  Patients often turn to cigarettes, marijuana, alcohol, and other drugs to help them cope.  The first step to helping these people is to address the underlying psychiatric disorder, which very often requires the care of a mental health professional.

            Other circumstances may also be driving someone’s dependency or abuse.  Bereavement, a stressful work environment, or other social pressures can lead some to substances or behaviors as an attempt to escape.  There can even be genetic factors involved.  Alcoholism, for example, has been shown to run in families regardless of their environment. 

            Throughout the medical and behavioral science literature, the abuse of substances or behaviors is considered to be an illness.  It is certainly not an illness that is easily cured like an ear infection with a short course of medication.  Rather, it is beneficial to compare it to a familiar chronic disease such as diabetes.  With rare exceptions, the focus on treatment of diabetes is not eradication of diabetes but instead learning how to live with it and minimize its harms.  Often significant lifestyle changes are required.  If diabetes progresses unchecked, major harm can occur, which is often identified only when it is too late.  With this construct in mind, we will consider how we can help our fellow Christian cope with addiction.

            First we need to prayerfully and humbly turn to God’s Word for guidance on this matter.  The temptation is strong to consider ourselves somehow above this problem of addiction.  One may think, “This would never happen to me”, “I would never allow things to get this bad”, or even “That person must not have very strong faith if they are in this situation.”  If we are to openly discuss another Christian’s addiction with them, we need to make it clear we are doing so with the utmost humility.

 

            Romans 3:23 – “For all have sinned and fall short of the glory of God.”

 

            Matthew 7:4-5 – “Or how can you say to your brother, ‘Let me remove the speck from your eye’; and look, a plank is in your own eye?  Hypocrite!  First remove the plank from your own eye, and then you will see clearly to remove the speck from your brother’s eye.”

 

            Similarly, if someone is returning to the church after a notable absence for help with a vice such as substance abuse, we should not react with disdain or an “I told you so” attitude.  Rather we should heed the parables of Jesus in Luke 15.  I envision that the prodigal son did not deliberately squander his wealth but rather was ensnared by evils such as alcohol abuse, gambling, and the like.  It is not until he has hit rock bottom that he humbly returns to his father for help.  Likewise, our first reaction when confronting addiction should be to rejoice that the Lord has guided a lost sheep back to the fold.

            Sin is clearly at the root of addiction, particularly egocentrism – focusing on one’s own desires.  Recalling the aforementioned passage from the gospel of John, we bear in mind that the Christian with substance dependence is simply another slave of sin as we all are; however, the pattern of abuse often makes this enslavement more evident to the observer.

 

            Romans 7:19 – “For the good that I will to do, I do not do; but the evil I will not to do, that I practice.  Now if I do what I will not to do, it is no longer I who do it, but sin that dwells in me.”

 

            Often while preparing this essay I was reminded of the above verse, which of course applies to all Christians but should be of particular import to those battling addictions.  It is quite a comfort to know that one is not alone in this battle, but that even the apostle Paul felt this way.

 

            1 Corinthians 6: 19-20 – “Or do you not know that your body is the temple of the Holy Spirit who is in you, whom you have from God, and you are not your own?  For you were bought at a price; therefore glorify God in your body and in your spirit, which are God’s.”

 

            Virtually all the vices discussed above have detrimental effects on the individual’s body.  Alcohol damages the brain and the liver, cigarette smoke irreversibly scars the lungs and increases the risk of cancer, cocaine can lead to heart attacks, and those who abuse any substance often neglect their bodies’ basic needs. 

 

            2 Timothy 2: 24-26 – “And a servant of the Lord must not quarrel but be gentle to all, able to teach, patient, in humility correcting those who are in opposition, if God perhaps will grant them repentance, so that they may know the truth, and that they may come to their senses and escape the snare of the devil, having been taken captive by him to do his will.

 

            While I am no Greek scholar, I have read that the verb here “to come to their senses” is the Greek word ananepho[6] – to become sober again.  This verse not only guides us in how we should approach someone struggling with addiction, but also makes important points for the individual – we need God to grant repentance, and to become sober in mind (or in body) is to escape Satan’s traps for us.

            Ultimately, this is an opportunity for us to remind the individual that “without (Christ) we can do nothing.” (John 15:5).  As powerless as one can feel to overcome an addiction, it is vitally important to emphasize everything that God has done for us.  Our redemption has already been accomplished by Jesus’ suffering and death.  The Holy Spirit continues to work saving faith in our hearts.  God will guide us through our daily Christian walk.  When Christians are actively toiling against the Old Adam to overcome these temptations, they will be encouraged when they remember this verse:

 

            1 Corinthians 10:13 – “No temptation has overtaken you except such as is common to man; but God is faithful, who will not allow you to be tempted beyond what you are able, but with the temptation will also make the way of escape, that you may be able to bear it.”

 

            Here we are reminded that we are never alone in fighting a particular temptation; many others have struggled with the same problems before.  Also, we should not despair and give in to the habit because the addiction is just too powerful, genetic, or “hard-wired”, but rather we should approach each new temptation looking for the way of escape through prayer, studying God’s Word, and reaching out to our fellow Christians.

            An effective professional counselor undertakes years of dedicated study and many months of practical experience before learning the skills necessary for the job.  While it is certainly an unrealistic goal to provide such training today, we will review some fundamentals of confronting and working through addiction.  The first task is to assess someone’s readiness to make a change.  This is often very easy to do – simply ask someone how they feel about the habit in question.  These stages are summarized as follows[7]:

 

  • Precontemplation: enjoys the habit and does not want to change
  • Contemplation: identifies need for change but not ready to act
  • Preparation: is ready to act but is unsure how
  • Action: “quitting” is a new and active process with dynamic challenges that one might need help with
  • Maintenance: considers himself/herself reformed but the temptation always remains

 

I use these stages all the time to address my patients’ tobacco use.  The stages dictate the most appropriate intervention for the person at that point in time.  For example, it is unrealistic to expect someone to take action against an addiction until they are at the preparation stage.  Below is a set of suggested approaches to someone struggling with addiction based on which stage they are in:

 

  • Precontemplation: sow seeds of discontent, point out benefits of quitting/harms of continuing the substance/behavior
  • Contemplation: resolve the ambivalence over the habit by exploring why feelings are mixed and emphasizing the benefits of cessation
  • Preparation: help identify specific strategies to quit and implement them (or identify someone else who can help)
  • Action: explore what barriers/relapse triggers exist and address them
  • Maintenance: both you and the individual need to keep in mind that one is never “cured” of addiction, continue vigilance and discuss ongoing struggles openly

 

You can also clarify the scope of the problem.  Is this simply a matter of dependence on a substance, or are problems with everyday function arising?  To what extent does this impact their health, interpersonal relationships, finances, or legal situation?  This can give you a sense of how urgent or aggressive an intervention should be. 

It is also very important to identify underlying mental illness.  The easiest way to find out someone is depressed is to ask them, “Have you lost pleasure doing things you would typically enjoy?” or even, “Do you think you might be depressed?”  Health care providers screen for depression by asking about the following:

1) change in sleep,

2) losing interest in hobbies,

3) feelings of guilt or worthlessness,

4) decreased energy,

5) impaired concentration,

6) change in appetite,

7) feeling weighed down physically, or

8) thoughts of suicide or self-harm. 

 

People with bipolar disorder (manic depression) may have the above symptoms but also have periods of very high energy and mood with little sleep, heightened self-importance, and risky or irresponsible behavior (giving all one’s money away, getting involved in physical altercations, etc.)  Psychotic disorders have some sort of identifiable delusion: a fixed false belief that you cannot overturn with logic or evidence (“The government is controlling my mind through my dental fillings”).  This is a very rudimentary framework but it provides clues for you to identify.  If any of these are present, the individual needs a psychiatric assessment.  Without treating the mental illness, addressing the addiction will be unsuccessful.

I wanted to share some strategies and tips I use when confronting someone with an addiction and when helping him or her kick the habit.  This list is by no means exhaustive and I also welcome your thoughts and anecdotes.  First, enlist the help of friends and family, whether you are working to help someone in the precontemplative stage recognize the harms of the addiction, or you are formulating a quitting strategy.  Every person that you bring “into the loop” adds accountability and can provide strength during the action stage when the individual falters.

The question of how best to quit varies depending upon the substance or behavior and from person to person.  That being said, with a few specific exceptions, quitting “cold turkey” is usually the way to go.  As an aside, the term “cold turkey” refers to what it feels like to go through withdrawal of heroin or other opioid pain medications.  The gooseflesh, shaking chills, and tremors can be absolutely miserable, but the withdrawal from these drugs is seldom a true health risk.  Too often I see patients who want to taper tobacco or alcohol very gradually, but because they don’t have a clear stopping point in mind they inevitably lose sight of their goal.

The substances that may be unsafe to quit instantly are alcohol and sedative medications called benzodiazepines or barbiturates.  Those with heavier use are more at risk of withdrawal, which can include tremor, agitation, hallucinations, seizures, and death.  If someone is ready to quit drinking alcohol but has a substantial daily intake (or if they have had withdrawal symptoms before), they should seek the aid of a physician, or at least taper down over days to weeks.

One aspect that is often neglected when attempting cessation is the person’s environment.  A smoker whose spouse continues to smoke in the home will have a very difficult time quitting.  An alcoholic man whose only social meeting place is a bar will soon either be isolated from his friends or back in the bar drinking again.  The substance or behavior needs to be as inaccessible as possible, and this usually requires a complete change including moving away from the alcoholic roommate or finding all new friends.

 

1 Corinthians 15:33 – “Do not be deceived: ‘Evil company corrupts good habits.’ ”

 

Proverbs 6:27 – “Can a man take fire to his bosom, and his clothes not be burned?” (speaking specifically of adultery)

 

For most people who decide to break with their addiction, there is a “wake-up call”, a moment that brings everything into perspective.  With my patients who are still precontemplative, sometimes it’s the diagnosis of cancer or possibility of cancer.  For others it’s the development of an irreversible organ dysfunction such as heart or liver failure.  Maybe it’s the ending of a marriage or other meaningful relationship.  You can reframe these tragedies as a clear message that now is the time to quit. 

While a Christian may turn first to a pastor or elder of the church when struggling with addiction, this may be more than one person can manage, regardless of their training.  There are many resources available that can help.

Rehabilitation centers often seem like an ideal solution to the problem.  Bringing someone to a controlled environment with intense counseling is intended to give them every opportunity to succeed.  This may be especially desirable when there may be physiologic withdrawal from a substance that staff can help the individual manage.  There are several problems with rehabilitation, however.  The treatment can be quite expensive and some health insurance providers do not pay for it.  Also, success within the controlled environment may not prepare them for the sudden shift back to reality and all the temptations that come with it.

Physicians, whether they are psychiatrists or primary care providers, also have much to offer.  We’ve already talked about the importance of identifying and treating other mental illness.  Primary doctors may not have lots of time for one-on-one counseling, but they are well trained to characterize the situation and involve the right people who can help.  They also may consider substitution therapy (replacing the abused substance with a safer medication), which often requires a prescription, and is a useful tool when combating such strong habits.  Nicotine replacement is often available over the counter, but instructions from a physician can help ensure it is used correctly to increase the chance of success.  Disulfiram (Antabuse) is a medication that inhibits the body’s ability to metabolize alcohol, leaving the drinker feeling ill instead of intoxicated.  Methadone and other similar medications work the same way that heroin or opioid painkillers work but does not cause the same highs or lows and can lessen the high if the opioid is used again.

A very effective and somewhat more affordable strategy is counseling.  This may take several sessions to make progress and therefore may not be suited to someone in need of a more urgent intervention.  This approach can be successful because the individual has someone actively listening and formulating a tailored action plan and identifying what specific pitfalls that individual should expect.

If someone approaches you for help with an addiction, they may be more comfortable working through their issues with you rather than with a psychologist or psychiatrist whom they do not know.  If you find yourself providing more structured counseling and are uncomfortable with this, there are plenty of books available to help.  One such book, Doing What Works in Brief Therapy[8] can be skimmed in 1-2 hours.  It contains dialogue of many example encounters and pointers for how to direct the discussion.

Another aid to substance abuse is Alcoholics Anonymous and its derivatives (Narcotics Anonymous, Cocaine Anonymous, etc.).  Anyone not familiar with the program could request to attend a meeting as an observer to have a better understanding of what it entails.  It has many desirable elements.  Groups are quite prevalent and can be found in many communities across America.  There is essentially no cost to the participant (although they may take a collection).  They have high success rates (although they do not make this publicly available).  New participants are often paired with a reformed alcoholic for additional support and accountability.  They refer to alcoholism as a “spiritual disease” and recognize a Higher Power in their materials and sessions.  This can possibly pose fellowship issues; prayer is often part of the meeting.  Because the organization is decentralized, the experience at one AA meeting may be very different from that of another location.  Ultimately this is a decision the individual may wish to prayerfully consider with the pastor.

Regardless of the tools used to combat addiction, recovery is a very difficult journey and relapse back to the substance or behavior is common.  It is easy for the individual or for those helping him or her to get discouraged when relapses occur, but this should be expected.  I have patients who have to quit smoking half a dozen times or more before they have quit for good.  Rather than thinking that it’s back to square one, we should emphasize the successes and try to find out why relapse occurred so he or she can avoid the same snare next time.

Of course the most important tool of all is God’s Word.  I have already outlined some verses that I find to be especially applicable.  Those who are abusing or dependent upon substances or addictive behaviors need to be reminded first of their sin through the Law. 

 

 

 

1 Corinthians 6:9-10 – “Do you not know that the unrighteous will not inherit the kingdom of God?  Do not be deceived.  Neither fornicators, nor idolaters, nor adulterers, nor homosexuals, nor sodomites, nor thieves, nor covetous, nor drunkards, nor revilers, nor extortioners will inherit the kingdom of God.”

 

Lest we lead someone into despair, we also must provide the blessed Gospel message.  As Paul continues in this letter to the Corinthians:

 

1 Corinthians 6:11 – “And such were some of you.  But you were washed, but you were sanctified, but you were justified in the name of the Lord Jesus and by the Spirit of our God.”

 

How to balance the Law and the Gospel is best based on the individual. Are we dealing with a contrite, active member of the church with a heavy burden of guilt, or with someone who is not well acquainted with his Savior and sees no real harm in his substance abuse?  Ultimately, we know that no man can say it better than the Holy Spirit Himself.  Therefore we should sit down with the individual and pore over the Scriptures for guidance.

 

            James 1:12-15 – “Blessed is the man who endures temptation; for when he has been proved, he will receive the crown of life which the Lord has promised to those who love Him.”

[1] Random House Dictionary, 2011

[2] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

 

[3] JA Ewing (1984) ‘Detecting Alcoholism: The CAGE Questionaire’, Journal of the American Medical Association 252: 1905-1907.

[4] Sadock, B.J., et al. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (Synopsis of Psychiatry), 10th ed. Philadelphia, PA; Lippincott Williams & Wilkins, 2007.

[5] Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. (2008). Harrison’s principles of internal medicine (17th ed.). New York: McGraw-Hill Medical Publishing Division

[6] ἀνανήφω ananepho {an-an-ay’-fo} Meaning: to return to soberness Origin:  from ana and nepho

Usage:  KJV – recover (one’s) self, 1 verse total

 

[7] http://nicotinefreedom.com/articles/readiness-to-change

[8] Ellen Quick. Doing What Works in Brief Therapy: A Strategic Solution Focused Approach. Elsevier 1996

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