James H. Berry
Americans are dying from addiction at an alarming rate. Almost 64,000 people died in 2016 from drug overdose. This is more than the number of Americans who died during the Vietnam conflict, more than those who died at the apex of the HIV-AIDS epidemic, more than those who died from drug overdose in 2015, which was more than 2014, and so on—a horrible pattern that has essentially remained constant for the past decade. Since 2008, more Americans die each year from overdoses than from car accidents and firearms. From 2000 to 2015 more than a half million Americans died from overdoses. Approximately 88,000 Americans die from alcohol related complications every year and around 430,000 die from tobacco-related causes. We are facing an addiction crisis the likes of which has never been seen in this country.
Astonishingly, the life expectancy for Americans has declined since the turn of the century. While one would assume the richest nation in the world, blessed with the planet’s best technology and resources, would have the longest lifespan, this is not the case. Why not? Are common chronic diseases such as heart disease or diabetes suddenly killing more people? Is there an epidemic of a deadly infectious disease such as meningitis or an exotic virus such as Ebola? No. There are three main factors driving this accelerated death rate: accidental overdose, suicide, and liver failure. All three are closely tied to addiction-related behaviors and all are entirely preventable.
For every death, typically a spouse, parent, child, or friend endured countless hours of soul-wrenching agony attempting to rescue the loved one. Rarely does addiction go unnoticed by those who are closest. Rather, they are acutely aware (indeed, are the collateral damage) of the destructive behaviors of a life ensnared by addiction. In the wake of the devastation, they are often left to pick up the pieces and futilely make sense of the social- and self-destruction caused by the relentless pursuit of a substance. Thousands of dollars are spent on residential treatment programs and hospital detoxifications promising a cure. Thousands of dollars are spent on bail, fines, and court costs. Thousands of tears are spilled in prayer for change. Thousands of hours are spent in sleepless worry that the next phone call will be from the hospital or police department.
As a physician who specializes in treating addiction, I recognize a tremendous need for church communities to understand what addiction is and how to care for those suffering from this disease. When I meet fellow believers and they learn that I am an addiction psychiatrist, I usually get one of two disparate responses: skepticism that addiction and mental illness are diseases requiring treatment rather than sin to be confessed, or relief that a Christian is in this profession and pleas for greater instruction on how the church can minister to those who are suffering. Almost daily I find I must persuade others that addiction is primarily a brain disease with significant behavioral consequences that can be effectively treated. Here I introduce the medical model of addiction with the hope that church officers may benefit from this understanding and be better equipped to serve their parishioners who suffer from this disease.
Addiction is a chronic brain disease that has biological, psychological, and social etiologies and manifestations. The bio-psycho-social model of illness has been established and taught in medical schools for several decades and delineates three interrelated domains forming the basis of disease. The biologic domain consists of a bodily organ or system that is impaired due to any number of factors such as an infectious process, genetic malformations, physical trauma, etc., or due to an unknown cause. The dysfunction of the organ or system results in a predictable constellation of symptoms that are directly correlated with the damaged organ. The psychological domain comprises thoughts and emotions. Thought patterns may lead to decisions that elevate the risk of contracting a disease and then of perpetuating the illness. Furthermore, an emotional state may directly influence the disease state: Research has demonstrated that during periods of heightened anxiety or depression the body makes stress hormones that may wreak havoc on various organs and cause disruptions in normal functioning. The social domain involves the impact interpersonal relationships have on illness. Humans aren’t created as isolated islands but are social creatures. Social relationships have a considerable influence on the genesis of disease and its progression. Additionally, each social demographic carries attending health risks or protective factors. For instance, individuals in Native American communities are at increased risk of heart disease. Certainly, there are genetic and interpersonal factors contributing to this risk, but larger cultural influences affect health disparities.
As an example, let’s look at how the disease of diabetes fits within the bio-psycho-social model. In diabetes, the main organ of impairment is the pancreas. The pancreas secretes a hormone, insulin, which is essential for transporting blood glucose to the cells of various organs. These organs need glucose in order to survive. Without glucose, organs become energy deprived and break down. In the form of diabetes known as Type 2, in addition to an impaired pancreas, the body’s organs do not respond properly to the insulin available. This dysfunction leads to an overabundance of sugar in the blood and causes symptoms such as frequent urination, excessive thirst, and excessive eating. If left untreated, acute life-threatening consequences such as coma and death may occur. How does someone get Type 2 diabetes? While genetic predisposition plays a strong role, so do personal choices and community. Being overweight and living a sedentary lifestyle are the main factors precipitating this disease. Obesity, for instance, tends to run in families due both to genetics and to family-specific dietary and activity habits. In times of stress or depression, many turn to food with high fat and sugar content to self-sooth, which is typically learned behavior from an early age. All these biological, psychological, and social factors contribute to and compound the disease of diabetes.
In addiction the brain is the main organ of impairment. Brain circuitry responsible for memory, reward, and motivation is dysfunctional due to both genetic and behavioral factors. Normally, the brain releases a neurotransmitter called dopamine during pleasurable activities. Food, exercise, sex, finding shelter, getting praise from others are all examples of rewarding activities that release dopamine. When dopamine is released, an exquisite series of electrochemical communications takes place within the brain’s neural network that reinforce whatever activity has caused the release of dopamine. This is a built-in feedback mechanism designed to encourage the person to continue to engage in the activity. The activity is rewarding, we remember how good it feels, and we are motivated to re-experience the feeling. When this activity is repeated frequently over time, neural networks grow, change, and form to encourage this activity. This is advantageous when the activity is finding a warm fire in the middle of a snowstorm but becomes pathologic and detrimental when the activity is repeated use of cocaine. Finding warmth in a storm releases a small amount of dopamine. Smoking cocaine releases a massive amount of dopamine. Because cocaine use causes the release of so much more dopamine than naturally rewarding activities, frequent use will cause the brain to rewire to favor cocaine consumption over other natural pleasures. This is aptly illustrated in studies done with rats. Rats who have been frequently exposed to cocaine will choose to press a lever delivering a bolus of cocaine rather than a lever delivering a food pellet. These unfortunate animals will continue to choose the cocaine lever to the point of starving to death. A dysfunctional reward center has contributed to the rat’s destruction.
One of the main biologic features that distinguishes a human brain from a rat’s brain is the large concentration of neurons in the human forebrain. A basic taxonomy demarcating a brain’s functional structure consists of three interconnected components: the hindbrain, the midbrain, and the forebrain. Moving from hind to fore (or inside-out) increases the degree of functional complexity and sophistication of the animal’s neurocognitive capabilities. The hindbrain controls very basic life supporting features such as breathing and reflexes. The midbrain houses the pleasure center, emotion center, and memory center. The forebrain, among other higher order duties, houses the prefrontal cortex. This is the primary area responsible for making rational decisions known as executive functioning. Executive functioning involves balancing the pros and cons of particular actions, anticipating consequences, perceiving reality, and making reasoned decisions. Executive functioning allows us to control our tongue or put the brakes on an impulsive urge. Rats are woefully lacking in prefrontal cortical tissue and therefore do not have the degree of impulse control that humans do. Rats are mostly drive and impulse. Humans are typically better equipped to make good decisions—unless, of course, one has had one too many glasses of wine at a wedding reception. The high amount of alcohol impairs executive functioning, distorts reality, and makes one believe he is a much better dancer than he really is. Over time, frequent drinking episodes in large enough amounts may cause changes in the brain such that the midbrain circuits are no longer influenced as strongly by the prefrontal cortex, and the role of the prefrontal cortex becomes diminished. The midbrain has been unmoored. In addition to this loss of a rational rudder steering the brain’s drive mechanism, there is a loss of pleasure in normal activities. When copious amounts of dopamine are released repeatedly over time, a negative feedback loop occurs such that the dopamine receptors become less numerous and less active. This results in a persistent state of dysphoria. A dark cloud seems to hang over much of life. The only thing that relieves the doldrums is the pursuit of the substance. Many of my patients report that they don’t use drugs to get high anymore, but simply to feel “normal.” This is largely due to a brain with low levels of available dopamine and other neurotransmitters affecting a sense of well-being.
Of course, we are much more than a collection of neural tissue. We are bigger than our brains (metaphysically speaking). We are spiritual creatures with minds that are capable of transcending anatomy. We know this is true as Scripture teaches we will continue to be sentient in the time between the loss of our earthly body and the gain of our heavenly body. Nonetheless, while on this earth, we are bound by physical limitations. Matter matters. We see this dramatically illustrated when a person has a major stroke that affects the portions of the brain responsible for speaking or walking. In addiction the brain impairment causes distorted thinking, severe cravings, emotional dysregulation, and compulsive substance use despite horrible consequences.
This biological foundation must not be pressed to the point of becoming overly reductionistic or fatalistic. Brain impairment does not necessitate addictive behavior at all times and at all costs. If a loaded gun is placed to the head of Tom, who has a serious heroin addiction, and he is threatened with execution for using, Tom will likely not use. The immediate saliency of a potential bullet to the brain will most likely be enough to dissuade Tom. Tom’s prefrontal cortex, although diminished, is not dead. However, if Tom is then released from the immediate threat and told he would be shot if caught using in the future, he will likely still use. Tom’s ability to feel the full weight of a future consequence is weak and the drive to find relief with heroin in the moment is much stronger. Tom will likely rationalize his use as necessary to survive another day and minimize the likelihood of being caught using. He may even tell himself that living with such pain and misery is so unbearable that finding relief now may be worth a bullet tomorrow. Addiction also does not absolve one of the responsibility for bad behavior. If Tom robs a gas station to pay for heroin, Tom should be held responsible for his crime. Furthermore, we are all required as image bearers of God to behave according to his will. Those who are hindered from doing so are obligated to seek help to manage their disease. Nonetheless, there are incredibly powerful biophysiological forces at work that keep people doing unhealthy, dangerous, and even sinful things.
Much like other chronic diseases, addiction has varying degrees of severity and periods of relapse and remission. Some people have a mild form of the disease and can successfully abstain from the offending substance with little to no treatment. They make up their mind to quit smoking one day and never pick up a pack of cigarettes again. Likewise, some diabetics can simply change their eating habits and maintain healthy levels of blood glucose. The temptation for many observers is to extrapolate a uniform solution as though these examples are normative. “My brother quit drinking by sheer willpower and so should you!” We can celebrate and rejoice that many are able to quit using without much help. This does not negate the fact that many others are not so fortunate and may have a more severe form of the disease requiring intensive assistance. Also, I’ve had many patients who have been able to go years, even decades, without using and decide one day it is safe to pick up a drink. Before long, they were back in the dangerous position of active, unhealthy, compulsive drinking. A common refrain heard in Alcoholics Anonymous meetings is “One’s too many and a thousand’s not enough.” For most, abstaining for life is recommended.
I encourage church officers to begin viewing addiction through the lens of chronic disease. Yes, as creatures bearing God’s image, we are morally culpable whenever we make decisions that transgress God’s law. We are morally culpable whenever we want anything more than to glorify God and to enjoy him forever. All of us fail mightily to live according to those values we most highly regard. We inhabit a broken world and this brokenness includes our brains and our bodies. In a fundamental sense, all disease is a result of sin since the Fall poisoned everything. Yet, we must be sensitive to the reality that people who struggle with addiction, by nature and experience, are handicapped by incredibly powerful biologic drives. They do not do that which they truly want to do, and they do that which they truly do not want to do. For the Christian, these forces continue to persist despite conversion. The apostle Paul’s thorn was not plucked from his flesh when he bowed the knee to Christ. He continued to suffer but did so in the hope of glory.
Church officers can minister to those entrusted to their care by addressing the biologic, psychologic, and social domains of addiction. Biologically, there are several FDA-approved medications available to help specifically with alcohol, tobacco, and opioid addiction. These medications have demonstrated efficacy to decrease substance use and increase levels of functioning. The use of these medications should not be considered a moral failure any more than the diabetic’s use of insulin should be seen as a moral failure. We should praise God that he has given us the science to curb the devastating effects of many diseases and allow people to live healthy lives. Officers should help parishioners obtain access to qualified physicians who can thoroughly screen for substance use disorders and treat medically if necessary. Additionally, many evidence-based psychological therapies help people recognize the cognitive and behavioral patterns contributing to ongoing substance use and develop positive strategies for dealing with these. Well-trained physicians, psychologists, and social workers may be a tremendous resource for helping your parishioner. Finally, the church has a significant social role to play in keeping the parishioner well. Spending time with fellow believers, especially in worship, is critical to shape us according to God’s design of wholeness. God, in his kindness, has given us the church to nurture those who are weak and uplift the downtrodden. We should constantly encourage the diligent use of the means of grace, knowing these are God’s graces intended to sustain his people in a world of disease, dying, and death. We should always hold forth Christ as both the example to follow in maintaining faithfulness through suffering and the fountain of forgiveness and strength when we fail. We should constantly proclaim the Word, declaring who we truly are in Christ and the goal of our ultimate destination. We hold forth, at all times, that we will be seated in glory, sweetly enjoying God and one another in the perfect union of resurrected body and imperishable spirit—a body impenetrable by any thorn.
 Princeton Economics professors Anne Case and Angus Deaton aptly refer to these deaths as “deaths of despair”: Anne Case and Angus Deaton, “Mortality and Morbidity in the 21st Century,” Brookings Papers on Economic Activity, Spring 2017, Brookings Institution, https://www.brookings.edu/wp-content/uploads/2017/08/casetextsp17bpea.pdf.
 For a comprehensive and helpful definition of addiction, see the American Society of Addiction Medicine’s Public Policy Statement: https://www.asam.org/resources/definition-of-addiction.
 Not to sell rats too short, they do have executive functioning that is adaptive for survival and allows them to remember and solve puzzles for rewards. They simply do not have it to the same extent as humans (well, most of us anyway).
 In fact the bio-psycho-social framework was a reaction against the overly reductionist “biomedical” model.
 A good medical review article that outlines addiction as chronic disease and compares rates of remission with other diseases such as diabetes and hypertension is: McLellan AT, Lewis DC, O'Brien CP, Kleber HD, “Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation,” Journal of the American Medical Association (2000) 284 (13): 1689–95. doi:10.1001/jama.284.13.1689.
James H. Berry is a ruling elder in the Orthodox Presbyterian Church. He practices as an addiction psychiatrist and is an associate professor of the Department of Behavioral Medicine and Psychiatry with West Virginia University. Ordained Servant Online, June–July 2018.