Sam Quinones’s 2015 book Dreamland revealed the story of whole communities in Appalachia completely taken over by addiction, and traced the trail of the heroin that was replacing opioid pain pills for those who could no longer find or afford them. In 2017, the reality of the opioid epidemic and its consequences has become well known. Stories of opioid addiction appear regularly in the national news, and the massive increase in overdose-related deaths is now widely recognized as a public health and policy crisis.
But in all the news coverage of the epidemic and its devastating effects on individuals, families, and communities, there has been little mention of the church’s response to opioid addiction. I set out to write this article in hopes of finding out what the church was doing about the opioid epidemic, and perhaps more importantly, what the church should be doing.
What I found, in talking with a variety of Christians who are involved in dealing with this crisis, is that it’s actually very difficult to say what anyone should be doing without first addressing the question of what addiction really is. Is it a sin? A brain disease? I have come to believe the church must first contribute to solving the problems of the opioid epidemic by offering a clear and coherent view of the reality of addiction.
Historically, addiction has been viewed as a personal failing resulting from a failure of willpower. In other words, in order to really become addicted to something, addicts had to be unwilling to extricate themselves from their own drug use. As Kent Dunnington puts it in his 2011 book Addiction and Virtue,
The failure of willpower on the part of the addicted person is construed as a standard case of willful misconduct akin to other actions that involved the capitulation of the will in the face of temptation. What is at work in addiction, this view suggests, is not that a disease vitiates human willpower, but rather that, due to some kind of moral weakness, the addicted person repeatedly makes a deliberate decision to use. If the addicted person does not recover, it is only because he does not really want to. (p. 33)
In this view, the self-destruction that results from addiction to drugs and alcohol is entirely the responsibility of the addicted person who has chosen his own fate.
Bruce Stanley, a former addict and the program director of a Christian recovery program in Tennessee, says that in his experience churches “see addiction as a moral issue.” Not only the acts of addicted persons feeding their addiction, such as lying and stealing, but addiction itself, is seen as a sin. As a result, Stanley finds that many churches are willing to host support groups for addicts in their facilities, but they are reluctant to get involved any further. “I’ve heard of pastors telling people that they need to get clean before they can come back [to church],” Stanley says. “The church isn’t against recovery, but they don’t want to deal with it.”
But in many communities, this is becoming a harder stance to adopt as opioid addiction becomes increasingly common. Elliott Lewis of Huntington, West Virginia, one of the states hardest hit by the epidemic, says of his community, “Everyone has if not a direct, then a secondary connection to a friend, a family member, who uses. It permeates into the churches—it’s not a couple of people in the congregation, it’s a fact of life.” Lewis’s own mother has struggled with opioid addiction, as have other family members. He says he’s fortunate to live in a community where people’s response to addiction is usually to reach out to those who are struggling, rather than to turn away.
In Dreamland, Sam Quinones writes at length about the role of middle class teenagers and young people in spreading the opioid epidemic. “Children of the most privileged group in the wealthiest country in the history of the world, were getting hooked and dying in almost epidemic numbers from substances meant to, of all things, numb pain” (p. 8), he writes. For a long time, many parents who lost their children to opioid addiction and overdoses tried to hide it—but eventually, families started to see that they were not alone. As each successive case came forward, it became more difficult to dismiss these families’ losses as simply the result of poor parenting or weak-willed children.
The pervasiveness of opioid addiction isn’t limited to the states like West Virginia and Ohio that are at the center of the crisis, either. “The stereotype of the drug addict under the bridge is long over. Judges, doctors, pastors—addiction doesn’t discriminate,” says Adam Comer. “We see everybody from six-figure earners to the guy with the meth addict mom,” is how Derek Faulkner puts it. Both Comer and Faulkner are directors of Christian addiction recovery centers in Middle Tennessee, and both are former opioid addicts themselves. Addiction has become a problem that belongs not to the homeless and the despised, but to us all.
People whose loved ones are addicted to opioids not only find that they cannot dismiss addicts as weak and especially sinful people, but also that addicted persons’ experience and behavior do not look like a simple choice to willfully do wrong. In Addiction and Virtue, Dunnington writes, “As addicted persons interpret and describe their addictive thought and behavior, they testify that the pull of addiction is qualitatively distinct from any other kind of strong temptation” (p. 35). In other words, once addicted to a certain drug, an addict cannot resist the urge to use in the same way a non-addicted person might turn down a piece of chocolate cake that they would like to eat.
Some level of personal difference or even choice may be involved in addiction—after all, not everyone who has taken an opioid pain pill has become addicted. But addiction is also described as a condition that renders the addict incapable of choosing. Quinones writes, “In heroin addicts, I have seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior” (p. 37). Having once chosen to pursue the opioid’s promise of freedom from pain and worry, the addict is rendered incapable of reversing their choice, no matter how much harm it does to themselves and those around them.
This paradox around the problem of whether or not people become addicted to drugs because of weak willpower, as well as whether or not they can simply choose to defeat their own addictions, is reflected again in the recovery concept introduced by Alcoholics Anonymous. AA’s first principle is that in order to leave addiction behind, an addict must first admit to himself that he is incapable of choosing to do so. Dunnington explains it like this: “Addicted persons claim to be powerless over their addictive behavior, yet this admission itself is the inroad to regaining power over that same behavior” (p. 32). In other words, addiction isn’t defeated by the addicted person choosing to overcome it, but rather by that person admitting that he or she cannot do so.
Ultimately, the paradox of addiction cannot be resolved by reducing it to a mere choice or moral failure. This model only works by denying addicts’ experiences of wanting to stop using and being incapable of doing so, as well as the successes of programs that have encouraged addicted persons to embrace their inability to defeat addiction through choice. In short, calling addiction a failure of willpower is not a sufficient explanation of the complexities that have led to the opioid epidemic.
The choice or willpower model of addiction has another problem, as well: it assumes that human minds have full and complete control of our bodies and actions through the use of will. But according to long-held Christian doctrine reaching back to the Church Fathers, we do not in truth inhabit our bodies like a driver at the wheel. Dunnington puts it this way: “the body has a bearing on the way that humans think, feel and behave” (p. 28). James K.A. Smith makes a similar argument in his book You Are What You Love, saying, “we view our bodies as (at best!) extraneous, temporary vehicles for trucking around our souls or ‘minds,’ which are where all the real action takes place” (p. 3).
But our brains are not in as full control of our bodies as we have come to believe. As Smith points out, human beings frequently experience “a gap between what you know and what you do” (p. 5). Christians, in particular, should recognize this: Smith uses the example of feeling empowered to do right by what we learn in a sermon on Sunday morning, then falling back into our old sinful patterns by Tuesday. If knowing what we ought to do were enough to make us do it, none of us would still be holding on to our old bad habits.
In order to find a better understanding, we need to stop clinging to this wrong idea that we can think our way into right behavior, or that the people around us ought to be able to think their way out of addiction. “Instead,” says Smith, “we need to embrace a more holistic, biblical model of human persons that situates our thinking and knowing in relation to other, more fundamental aspects of the human person” (p. 6). But first we must acknowledge that in blaming addiction solely on the mind or soul, in calling it a choice or a moral weakness and therefore turning away from addicts, the church has done a great disservice to people suffering from addiction.
In response to a growing acknowledgement of the wrongheadedness of this stance, many Christians are stepping forward to contribute to providing treatment and support for those suffering from addiction. Some, like Adam Comer, Bruce Stanley, and Derek Faulkner, are recovering addicts themselves. All three of these men work in Christian addiction recovery and have dedicated their professional lives to helping others escape addiction. Additionally, many other Christians who have not turned away from opioid addicts but who are committed to addressing this epidemic shared their ideas with me for how churches and Christian individuals can help.
One important role for churches is knowing about the addiction recovery resources in our communities and being able to direct people to them. As Gregg Fairbrothers, the president of Groups: Recover Together (and a member of Fare Forward’s Board of Directors), pointed out, we ought to know more than just what programs exist: the church should be able to point people to the best, most effective programs available and to know how payment is handled, what wait times are like, and what kind of support is needed for people waiting for treatment.
The church can also support addicts who are not currently in recovery. “I would love for the church to really try to have relationships with these people,” Stacee Lewis told me. Stacee is a medical resident in Huntington, West Virginia, where she lives with her husband Elliot. Both of the Lewises stress that in their community, where people overdose in public regularly, the opioid epidemic is impossible to ignore. They are proud of their community and of the churches in it for not avoiding it, either. “You have to invest in openness before people will magically reveal their problems. The biggest thing is to show in your everyday lives that you care,” Elliot says. This openness to sharing about addiction, as well as about other problems, can come both from individual congregation members and from the pulpit as a church’s official stance.
The church can also provide care for the people more tangentially affected by opioid addiction. “What does it practically look like to offer a sense of normalcy for people’s lives without it being a bandaid?” Elliot asks. “How can the church really be a sanctuary?” He and Stacee particularly point to the children of addicts as secondary victims that churches can reach out to support and love.
People who are suffering from or in recovery from addiction also need physical help. Fairbrothers points out, “The Church can be a powerful asset for clinics that are open for people to get support, be in a community, deal with family problems, get jobs, make meals for each other—the kind of things that churches at one point were good at.”
Christians can also volunteer their time to help at addiction centers. Zachary Nayak, a specialist in internal medicine and pediatrics in West Baltimore, spends two days a week at an addiction clinic. As a physician, he says, he approaches his addicted patients “trying to see them as God would see them and hopefully addressing every part of them.” So should any Christian offering assistance to an addicted person strive to approach them. Daniel Hindman, another Christian physician in Baltimore who recently finished his residency at Johns Hopkins, suggests giving a recovery center your phone number as someone who those in recovery can talk to when their cravings are strong. “A lot of times cravings come when addicts are by themselves,” he says. “It helps to have someone around, a safe place you can go where someone cares about you.”
All of these things are good things to do, and Christians and the church ought to be doing them. But they are also all things that anyone can do, and that many secular and non-religious groups do, and do very well. And one of the things that secular society views as outside of the province of the church altogether is the medical treatment of addiction.
There is a second model of addiction that removes it from the realm of willpower altogether. Looking to the physical aspects of addiction, secular science has placed it in the category of a disease. According to the National Institute on Drug Abuse, “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works.” Dr. Matthew Loftus, writing for Christianity Today, explains further:
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 brain functions, breaking the biological systems we depend on to think and choose as we ought. (“Is Addiction a Disease? Yes, and Much More,” 11/23/16)
This alteration in brain function is, according to NIDA, what makes addiction a disease. Comparing addiction to heart disease, their website states, “Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, and are preventable and treatable, but if left untreated, can last a lifetime.” As Loftus explains, opioid drugs can not only affect the brain in the short term while they are being taken, but they can also alter the brain’s neurological pathways, sometimes permanently, when they are taken over long periods of time. He says, “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.” In other words, other things become less pleasurable in comparison to the drug the addicted person craves.
In the case of opioids, continuing to take the drug also dulls the brain’s pleasurable response to it. That’s why people who suffer from chronic pain are gradually prescribed larger doses of opioid painkillers in order to achieve the same levels of relief. It’s also why drug addicts seek out larger or more frequent doses of their drug of choice in order to achieve a high. This insidious effect of opioids, known as tolerance, is also a neurological adaptation and is thus seen as further evidence that addiction to opioids is a brain disease. Tolerance is the symptom of addiction that leads so many of those addicted to opioids to overdose, sometimes over and over again, and frequently fatally.
The third physical symptom of addiction is withdrawal, which, according to Dunnington, results from “the cessation or curbing of the use of the drug, involving the body’s agitation at the disruption of the modified equilibriums it has established through the process of use” (p. 18). The symptoms of opioid withdrawal are profoundly painful. In Dreamland, Sam Quinones writes, “Humans with the temerity to withdraw from the morphine molecule were tormented first with excruciating pain that lasted for days. If an addict was always constipated and nodding off, his withdrawals brought ferocious diarrhea and a week of sleeplessness” (p. 38). Or as one former addict told me, “Opiate withdrawal can’t kill you, but you’ll wish you were dead.”
In summary, scientists define addiction as a disease because it alters the normal functioning of an organ, in this case the brain. It is considered a chronic disease because sufferers from addiction frequently experience relapses. People make poor choices under the influence of addiction because, according to NIDA, “Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.” There is therefore no moral responsibility at stake—a person suffers from addiction just as she might suffer from cancer. We do not blame people for having diseases.
But despite the real physical symptoms of addiction, the disease model too falls short of a full explanation of the paradox of addiction. As Dunnington puts it, “I do not deny that science has much of interest and importance to say on the subject of addiction. However, science has not and cannot say everything of interest and importance about addiction” (pp. 16-17).
If the experience of addicts denies that addiction belongs solely to the realm of willpower, it also resists the idea that willpower is not involved at all. Frequently, addicts themselves point to spiritual and emotional problems that contributed to their addiction. “Opioids have a numbing effect—on real, physical pain, but soon on everything, including emotions,” says Adam Comer, one of the recovery program directors I mentioned before. He adds that once someone is addicted, this symptom of opioid abuse can make recovery seem even more impossible. “There’s no hope,” he says. Elliott Lewis of Huntington, in sharing the story of his mother, who drifted from depression to addiction in the years following his father’s death, says, “You lose a job, you lose a loved one. These are painkillers—they ease physical pain, but they also ease the emotional, mental, and spiritual pain. They’re an escape.” Frequently, addicts have comorbidities including depression, anxiety, and bipolar disorder.
Sam Quinones also points to the changing culture of the United States, and particularly the growth of individualism, as one of the keystones of the opioid epidemic. He writes,
Heroin is, I believe, the final expression of values we have fostered for thirty-five years. It turns every addict into narcissistic, self-absorbed, solitary hyper-consumers. A life that finds opiates turns away from family and community and devotes itself entirely to self-gratification by buying and consuming one product—the drug that makes being alone not just all right, but preferable. (p. 353)
Heart disease, asthma, and cancer cannot be described this way. Patterns of incidents of addiction, then, resist the idea that addiction is simply a disease that has nothing to do with the addicted person’s mental or spiritual state. The process of addiction recovery resists the disease model, as well. Opioid addiction recovery, and indeed most addiction recovery, frequently involves many trips to rehab or recovery programs, followed by repeated relapses. The disease model deals with frequent relapses by calling addiction a chronic disease. But unlike other chronic diseases like asthma or diabetes, addiction relapses cannot be resolved through medical intervention alone.
Instead, the pattern of repeated relapses and rehab visits continues, over and over, until the addicted person reaches “rock bottom” and makes a change that sticks. Even opioid addicts who have access to medical care, such as a suboxone or methadone treatment that ought to keep them from craving their drug of choice, relapse frequently. It is also widely acknowledged that in order to avoid or even put off relapse, the addict or recovering addict needs to join a community where they can continually be held accountable and be open about their struggles with addiction. As Elliott Lewis puts it, “If you start in isolation for recovery, you are shooting yourself in both feet. Recovery is relational.”
In Addiction and Virtue, Dunnington looks for comparative diseases, as well. He writes, “If addiction were a disease, it would be a disease that presents the deterioration of the human power of choice as its primary symptom. There are diseases that attack cognitive and conative powers—Alzheimer’s comes to mind. But with Alzheimer’s, the only hope of recovery is pharmacological, which is not true of addiction” (p. 27). Neither is Alzheimer’s ever the result of a difficult life experience or a troubled spiritual state. With each comparison to a disease as we commonly think of them, addiction looks less and less like a disease. Dunnington continues, “Indeed, if the defining symptom of a condition is a bad habit that requires amendment, one wonders why the condition should be called a disease instead of a bad habit” (p. 27).
When Dunnington uses the word “habit,” he isn’t referring to a bad habit like chewing your nails or looking at your iPhone as soon as you wake up. We tend to think of habits as small good or bad behaviors that are difficult to change, but generally not significant to our moral character. But “habit” is also a theoretical category of human behavior with a philosophical tradition going back to Aristotle, Augustine, and Aquinas, and that’s how Dunnington is using it here.
In rejecting the model of addiction as a failure of willpower I argued, following James K.A. Smith, that the whole person is not the body, and it is not the mind or soul. Rather, humans are made up of all of these, and none of them are separable from one another. This ancient Christian understanding of the self is central to the idea of habit. In You Are What You Love, Smith argues that our internal orientation, the telos or goal toward which we live our life and make our decisions, is not located in the rational mind, but in the affective center of the human person that Scripture calls “the heart.” The things that we love are the things that we are oriented toward, because no matter what we may think or decide to do, we ultimately make decisions based on what we love. “Love as we’re talking about it here—love as our most fundamental orientation to the world—is less a conscious choice and more like a baseline inclination, a default orientation that generates the choices we make” (p. 16). This orientation directs our actions, which then form our practices, which in turn form our habits, and our habits become, in a sense, who we are.
Smith isn’t writing about addiction, but his description of habit comes from the same philosophical underpinnings as Dunnington’s. He writes, “The consistent failure of the addicted person even in the absence of vehement or resilient desires can be explained by the role that habit plays in the formation and execution of moral agency” (p. 80). Addicts frequently describe their addiction as taking over their willpower, compelling them to act against their own interests. In other words, “The behavior of the addicted person becomes baffling, frighteningly so, precisely because it seems disconnected from the control that agents exert through deliberation” (p. 160). That is to say, addicts act against their own interests and even against their own conscious desires. Dunnington continues, “That is why persons with addictions often speak of ‘watching themselves’ pour another drink or take another hit” (p. 160).
The paradox of addiction is that people cannot choose to leave drugs behind until they fully admit to themselves that they are powerless to do so. Addiction can be physically treated to an extent, but even in modern recovery programs, says Dunnington, “the diseased victim, although perhaps not culpable for his actions, is nevertheless responsible to rectify them” (p. 39) Both choice and physical disease are inextricably bound up in the problem of addiction, but neither can provide a fully coherent explanation of this affliction. The concept of habit as a force that determines human orientation and character is a third way between disease and choice that can offer an explanation of what addiction really is.
“In the most perplexing cases of addictive behavior,” writes Dunnington, “we are confronted, not with reason struggling against appetite or emotion, but rather with free-floating reason struggling against reason as rooted in the habits of the imagination and the cognitive estimation” (p. 81). Addiction, understood as a habit, is difficult to fight because it becomes a central goal or aim of the addict’s life, coming to form a part of who they are. As Smith puts it, habits “become so woven into who you are that they are as natural for you as breathing and blinking. You don’t have to think about or choose to do these things: they come naturally” (p. 17). For an addicted person, using their drug of choice comes naturally to them both because it has altered their brain’s neural pathways, and it because it has altered their moral character. Both of these contribute to addiction’s categorization as a habit, and the dual physical and spiritual nature of addiction serves to demonstrate how closely related and mutually influencing are our bodies and minds.
Dunnington writes, “Because so much of the public discourse on addiction is conducted in scientifically reductive terms, many Christians who rightly sense the spiritual significance of addiction are unable to articulate this significance in theologically substantive ways” (p.11). I believe that the church’s primary responsibility in response to this epidemic is to learn ourselves and teach each other how to speak thoughtfully and correctly about addiction. And I believe that in order to do so, the church must first speak out on how to properly locate people in their whole selves.
We have allowed ourselves to follow the prevailing culture, led by Descartes’ cry of “I think, therefore I am,” in separating ourselves from our selves, of thinking of our selves as a “mind that has a body” or “body that has a mind.” When Christians understand both ourselves and others as both spiritual and embodied creatures, we will be in a better position to help with the long, difficult task of helping people who are in the process of extricating themselves from addiction.
And of course, in order to begin this re-integration, we must not only think and talk about it. As Smith recommends, we ought to include our bodies in the practice of worship. The physical aspects of the liturgy, the standing and kneeling, the taking of the bread and wine of the Eucharist, teach us that our bodies are essential to the formation of our faith. As Smith writes, “Christian worship that will be counterformative needs to be embodied, tangible, and visceral” (p. 85). We need to deliberately seek out liturgies and Christian practices that address our habits, the ways that we instinctively respond to the world. “If worship is formative, not merely expressive, then we need to be conscious and intentional about the form of worship that is forming us” (p. 80), says Smith.
Moreover, the church can also speak out on the things that affect their congregants’ bodies as well as their minds. The proper and appropriate use of medication, for instance, ought not to be a subject left only to our physicians, as talented and well-meaning as they may be. When we leave our bodies out not just of worship but of Christians discourse, we remove a crucial part of our selves from communion with the Body of Christ. The church and the gospel ought to be a part of not just how we think, but of our bodily lives. The correct teaching of the human self and the embodiment of church practices and teaching is crucial to the thriving of all Christians. But further, the practice of worship can provide a direct insight into the causes of the opioid epidemic. According to Dunnington, “addiction can be interpreted as one available modern response to the lack of any common consensus about the telos of human action” (p. 104). There has never been less consensus about what our telos ought to be, what our lives should be directed toward, and how we ought to live them, than in modern society.
The massive uncertainty that this creates, Dunnington argues, may play a role in why so many people have succumbed to addiction in the last twenty years. He quotes one addicted person who says, “I realized suddenly that I had two diseases—the disease of addiction and the disease of Too Many Options… What if I made the wrong choice? … I had always been afraid to make the wrong choice” (p. 109). In the face of his inability to choose, this person chose addiction. It gave him a singularity of purpose that was otherwise unavailable. Obviously not everyone who lacks purpose in life turns to addiction, but Dunnington says, “Addictions provide compelling motivation towards specific ends in a way that is otherwise inaccessible to the modern person who can find no final criterion to justify activity in a definite direction” (p. 116). Addiction, then, provides a purpose and a way of life towards which an addicted person can orient his or her loves. AA has long taught that “the habit of addiction can only be supplanted through the development of another habit that is as pervasive and compelling as the habit of addiction” (p. 165). Following the twelve steps of AA becomes that alternate habit, and the recovering addict must continue to follow them even after a long period of sobriety.
Christian worship, as Smith argues, is designed to orient human persons toward Christ, to “embed us in—and embed in us—a different orienting Story, the story of God in Christ reconciling the world to himself” (p. 106). This Story provides a telos or purpose toward which our loves and habits can be directed. Dunnington writes, “Right worship strives to relate all human desire and activity to God; it is an exercise in reorientation toward one all-sufficient end” (p. 170). This claim not just on an hour of one’s time each week, but on the whole of one’s life toward that one goal, makes worship a proper response to addiction. It provides an answer, too, to the directionless life that leads the addict to seek the totalizing purpose of addiction. Rightly understood, Christian worship is a force powerful enough to provide an alternate path, a new habit, in answer to addiction. “Because it is so powerfully destructive and death-dealing, addiction provides the church with its most profound invitation to witness to the gospel it proclaims, to make manifest in its own life the resurrection that is its own origin and end” (p. 194), says Dunnington.
The correct response of the church to the opioid epidemic is not to turn away from addicts, and it is not simply to hand them over to physicians to be cured (or not) of a chronic disease. Rather, the right and responsibility of the church is to both present a compelling explanation of what addiction is in the context of the reality of the human self, and to offer in turn a sufficient alternative to the telos of addiction.
For their help with this article, I would like to thank Gregg Fairbrothers, Matthew Loftus, Elliott and Stacee Lewis, Daniel Hindman, Zachary Nayak, Adam Comer, Bruce Stanley, and Derek Faulkner. I could write ten articles with the material you gave me for this piece. Thank you for sharing your time, experience, and vision for healing with me.
[This article appears in Fare Forward Issue 8 (Dec. 2017), order here.]