what is addiction?

'Can you control your drinking?' a colleague innocently asked a circle of doctors, at the bar at 5pm, followed by: 'and why do you think you need to control it?'

The issue of control is at the heart of addiction. I will look at psychoactive substances in this article, but the same principles apply to any activity that controls us, such as gambling, social media, pornography, eating habits or shopping.

The psychiatric manual DSM5 defines substance misuse according to four features that signal addiction: impaired control, the impact on relationships, predictable harms, and pharmacological indicators (tolerance and withdrawal). (1) Useful questions include:

• Do you want to cut back or stop?
• Do you spend a great deal of your time obtaining, taking, or recovering from your use?
• Do you experience strong desires or cravings to use?
• Do you continue to use even though you suspect, or even know, that it creates or worsens interpersonal or social problems? Or problems with your mind and body?
• Do you find that you need to use more than in the past in order to achieve the same desired effect?

why do people take drugs?

These questions may ring alarm bells for some of us. So what reasons do we give for our addictive behaviours? Most people use caffeine or nicotine as a stimulant and alcohol as a social lubricant. Some use riskier drugs out of boredom. Hallucinogens are often used for a mind-expanding, even transcendent experience. Others are simply pleasure-seeking, although invariably there are diminishing returns to quick 'fixes'. People who are dependent use chemicals to treat withdrawal symptoms, and many users are trying to regulate mood or fill an emotional, even spiritual void.

'I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom.' Edgar Allan Poe

For most of us, heavy drugs like crack, smack or spice are not very tempting. But in the wrong context, they might be. For instance, half of the American soldiers fighting in the Vietnam War tried heroin, and two-thirds cannabis, with half becoming addicted. Yet 99% escaped addiction on returning home. (2) How can we explain this?

Broadly speaking, there have been three schools of thought about what causes addiction. Historically, society tended to blame the addict as weak-willed or self-indulgent. As doctors came to understand the pharmacology of addictive drugs, experts stressed their ability to 'hijack' the brain's reward circuits. For instance, patients taking L-Dopa for Parkinson's are at greater risk of addictions. (3) More recently, an influential experiment suggested that the social environment is a major factor. In the 1950s, rats were given the choice of drinking sugar water or opiate water. Often the rats preferred the chemical hook to food, and died due to self-neglect. This fitted with the doctrine that drugs are inherently evil, a view which drove the global 'War on Drugs'. But in the 1980s researchers used a different setup called 'Ratpark', in which rats were given larger and more stimulating cages to explore. The rats had other rats to socialise and mate with. This time the rats rejected the morphine, even if they had previously been addicted. (4) The conclusion: it's not the chemical hook that causes addiction, so much as 'the cage you are in'. If someone feels trapped in life's 'proverbial cage', they will be much more vulnerable than if their world feels like an adventure playground with deep social connections to others. For instance, the harrowing experience of warfare in the Vietnamese jungle provoked far more addiction than life back home with the family. Whilst humans are not caged rats, researchers saw parallels with life in poor housing, especially for those with difficult family relationships and limited employment prospects. (5 )It's a powerful, new narrative that challenges the demonisation of those living with addiction.

theories of drug addiction:

• Degeneracy: addiction is personal weakness
• Pharmacology: some chemicals are dangerously addictive
• Vulnerability: adverse life experiences predispose to addiction

assessing drug harms

All societies have used psychoactive drugs of some sort. But perceptions about the latest drug are constantly changing as harms emerge. For example, Pope Leo XIII endorsed cocaine wine before it became the milder Coca-Cola. (6) Queen Victoria's physician recommended cannabis, and probably prescribed it to her. (7) Sigmund Freud had a blind spot for his tobacco addiction that ultimately killed him. Troops in WWI were sent amphetamines and Harrods gift packs containing heroin. (8)

Social prejudices also shape how we view drugs. When at Eton, it is alleged that a future Prime Minister was found with cannabis, and was merely given a hundred lines of Latin as punishment. (9) But a black person caught in possession of drugs is six times more likely to be arrested, and eleven times more likely to be imprisoned. (10) Cocaine use for bankers is tolerated as a way to boost assertiveness and unwind, whereas the cheaper crack cocaine is associated with social deprivation and vice.

As well as class and race, we need to be aware of how the media and corporate interests can bias us. A friend of mine was found dead in the bath by his children. It was a devastating shock. Which drug comes to mind? Cocaine? Ecstasy? Heroin? In fact, it was alcohol, the drug that causes more harm than any other.

Up to 35% of all A&E attendances are alcohol related. (11) Liver disease has surpassed lung cancer as the leading cause of years of working life lost, and is set to overtake ischaemic heart disease within three years. (12) Alcohol is implicated in 40% of violent crime and 50% of child protection cases. (13) The total cost of alcohol harm is up to £52 billion annually. (14) The drinks industry would have you believe otherwise, with their 'drink aware' message. But 60% of their profits come from problem drinkers. (15) No wonder they were linked to a campaign to highlight the risks of ecstasy, when this cheaper drug threatened their profits. (16)

What about other drugs? The Advisory Committee on the Misuse of Drugs scored drugs for the harm they cause (see graph). (17) It's important to recognise not just the impact on physical and mental health, but the collateral damage to family life, the economy and crime, both at home and abroad. For instance, even when cocaine is taken 'recreationally', its trade causes an epidemic of knife crime and gang warfare. (18)

Finally, medics need to recognise our complicity with the growing problem of dependence forming medications (benzodiazepines, pregabalin, opioids and hypnotics) affecting 9% of the population. (19) It's a shocking fact that prescription drugs are involved in the majority of overdoses. (20) Are we the pushers now?

a biblical overview

Look in a Bible concordance and you won't find crack or spice. But the Bible does mention at least five psychoactive substances, including gall (which may have been hemlock or an opiate), (21) mandrake, wormwood and myrrh. But alcohol tops the list with 250 references, and is a helpful worked example.

In everyday life, wine was seen as a gift that refreshes and 'gladdens the heart', (22) and eases distress. (23) There was probably some value to lightly fermented drinks where clean water was hard to come by. Wine was also seen as a sign of God's blessing (24) but the 'grapes of wrath' were a metaphor of God's judgment.

There are numerous warnings about excess drinking (25) and the dangers of addiction. (26) Specifically, hazardous drinking impairs judgment and causes disinhibition. (27) Drinking can lead us to forget God's good laws, (28) and entangle us in actions we may regret. (29) Scripture was millennia ahead of modern medicine in recognising the link between alcohol and violence, (30) and morning drinking as a significant red flag. (31) Scripture outlines some woes for 'drinking heroes and champions', (32) including a vivid description of a hangover. (33) And there are disastrous stories of misuse in the lives of Noah, Lot, King Xerxes, Herod, and an appalling ruse by David to spike a friend's drink. (34)

One of the commonest reasons for taking drugs or an addictive activity is that it regulates mood, or numbs some inner pain.

Jesus' example here is extraordinary. He knew how to celebrate, and was accused of enjoying a party too much. (35) But on the cross, Jesus needed to remain alert to finish the task of liberating us from sin and death. So he refused the emotional and spiritual anaesthetic that was offered him in 'gall wine'. (36) We too, need to remember that we are in a spiritual battle, and must remain alert. (37)

Later in the Bible, the disciples were so boisterous at Pentecost that they were mistaken for drunks. (38) But there were no chemicals involved. (Perhaps the disciples had experienced a shot of divine love, (39) which Bob Dylan rated as better than any drug.)

Instead of getting drunk on wine that distorts and deadens the senses, we are encouraged to be filled with the Holy Spirit, (40) who wakes us up to reality and heightens our senses.

'I'll handle it, quit it. Just one more time, then that's it.' Kelly Clarkson, Addicted

value your freedom, don't surrender it

'"I have the right to do anything," you say — but not everything is beneficial. "I have the right to do anything" — but not everything is constructive. No one should seek their own good, but the good of others.' (41)

What does this mean personally? First, we can be thankful for the huge freedom the Christian has been given; we are no longer under the Old Covenant. God is for us, and not out to scold us. Even though our freedom in the New Covenant is substantial, Paul reminds us not everything is a beneficial use of our time and energy. How are we going to cherish and best use our freedom? Instead of retreating into escapism, the gospel invites us to join God in building a better world. The gospel turns us inside out, and helps us seek the good of others.

Second, God liberated us from slavery to sin and death, (42) so let's not surrender that hard won freedom! He has gifted us self-control as a work of the Spirit, to keep us from being enslaved or mastered again. (43) When temptation does come, we have God's word that now we really are free to say no:

'God is faithful; he will not let you be tempted beyond what you can bear. But when you are tempted, he will also provide a way out so that you can endure it' (1 Corinthians 10:13)

Often, I am in a substance misuse clinic, imploring and coaxing a revolving door client not to let a chemical rule and ruin any more of their life. The poor dentition, the emaciation and the track marks, all tell a tale of captivity and waste. I wonder if the Lord ever views my stubbornness over my cravings and idols in the same way. How much better that 'my heart and my flesh cry out for the living God'? (44) Dare we confess our weaknesses, where we are prone to become enslaved? The Alcoholics Anonymous method encourages a 'searching and fearless moral inventory of ourselves'. (45) It might be diagnostic and therapeutic to fast from things that we suspect are in danger of mastering us. (46)

what can we do?

Why not visit an AA meeting or rehab centre? It's a profound experience to hear testimonies of healing, and the humility of those who recognise their powerlessness. (47) Many will not have an explicit faith, but some will thank a 'greater power'. (48) Once in clinic I nipped out of the consulting room, but my patient stopped me: 'I wouldn't leave your flashy stethoscope here, Doc. It's too much temptation.' Are we as honest in our struggles? It can be very rewarding working in substance misuse, with modern day 'untouchables'. Do you hear a call to reach out?

Alex Bunn is CMF Associate Head of Student Ministries and a GP in London

questions for reflection

• Which chemicals do I use? Do I use them to escape?
• Am I addicted to something I should fast from?
• How can my church engage with addictions?

recommended resources

• Nutt D. Drugs without the Hot Air. Cambridge: UIT, 2012
• Batchelor O. Use and Misuse: a Christian perspective on drugs. London: IVP, 1999
• Films: Narcos, Traffic.