How Bad Theology Makes the Opioid Crisis Worse
(John Moore/Getty) Oxycodone pain pills
The first time I was ever given morphine I was 25 years old. It was 2010, and I was hospitalized with acute pancreatitis. Doctors sent me home with pills of the potent opioid hydromorphone. My pain was extreme, and my doctors were concerned. The potentially life-threatening condition is rare in young people. Mine was caused by an abnormally formed bile duct with a small gallstone lodged in it—a condition made worse by a botched procedure that led to an extended stay in the ICU.
All the while, the pain, and pain medicine, increased. Occasional injections of morphine became a button I could push every 15 minutes for another release of the liquid opioid hydromorphone. As the weeks went by, doctors added a patch on my arm with a second opioid; I didn’t understand its significance at the time, as I had never heard the word “fentanyl” before.
The doctors had put my odds of survival at 50-50, and I was lucky how that coin landed. While I recovered after months in the hospital, I didn’t know that I was developing a new potentially fatal complication: an opioid addiction.
It was far from inevitable but not unusual. In 2010, the term “opioid crisis” was not common parlance, but deaths had already skyrocketed. More than 14,000 people in the United States would die that year from prescription opioid overdoses alone. Crackdowns on prescribing opioids then shifted many users to seek out illicit opioid drugs, including heroin and fentanyl, driving the death toll higher.
In 2014, when I first became aware of the scope of the problem, opioid overdoses (prescription and illicit) claimed the lives of 78 people in the United States per day. When I first told my story publicly in 2016, that number was 115. In 2017, when I started writing my book Addiction Nation, the death toll from opioids was 130 per day.
Again, I was lucky. Addiction exists along a spectrum, not a duality, and mine was caught early. My doctor was empathetic and compassionate in a way that made it easier to accept the help that I needed. I was not forced into quitting “cold turkey.” Instead, I was given time, ongoing pain treatment, and the resources I needed to step down gradually.
Even with all the support I had, the process was not easy. My Christian faith was a crucial part of that journey. I prayed and meditated. I looked to the wisdom of my tradition for hope and inspiration. A friend was making plans to start a church and picked me up every week for our meetings in his house.
Faith and spirituality have been important parts of the recovery stories of countless people. At the same time, there are beliefs that arise from my own American Protestant tradition that distort cultural and public policy views toward both addiction and drugs. The “demonization” of substances and the emphasis on complete abstinence from drugs or alcohol in recovery can hinder the most effective treatment methods, particularly for opioids. This ideology undergirds a “war on drugs” that has not only failed, but has also made our overdose crisis worse. As long as bad theology helps drive our drug policy, we will be held back from some of the most effective and life-saving ways of addressing addiction.
The American Protestant view of drugs is best traced through the most popular and widespread spread drug in human history—alcohol. Christopher Cook, psychiatrist and professor of religion and theology at the University of Durham, tackles this project in his 2006 book Alcohol, Addiction and Christian Ethics. He argues that throughout Christian history and theology, Christians have expressed caution and condemnation against drunkenness but not necessarily against the consumption of alcohol itself.
In the Hebrew Bible, wine is often referred to as a “blessing,” but warnings against drunkenness and excess are also ubiquitous. In the New Testament, the first miracle of Jesus is to make more wine for wedding guests, but elsewhere drunkenness is condemned. For the theologian Augustine, wine was a good thing but as Cook writes, “drunkenness is a result of a disordered will.” Cook argues that Thomas Aquinas in his seminal work Summa Theologica cautioned against both total abstinence and regular drunkenness as extremes to be avoided.
The nineteenth century marked a substantial shift around alcohol in the United States. Many ministers of the Second Great Awakening preached abstinence from the evils of alcohol, and the temperance movement was born in response to serious concerns about the effects of alcohol on society. “Drunkenness was essentially conceived as being a disease of the will, caused by alcohol itself,” Cook writes. Alcohol was thought to be inherently addictive and the direct cause of poverty, crime, and moral deterioration. Alcohol, Cook argues, became a kind of evil incarnate that could have no good or redeeming use.
By the 1910s, the preacher and Prohibition leader Billy Sunday told crowds, “Whiskey and beer are all right in their place, but their place is in hell.” Prohibition temporarily outlawed the production, sale, and trade of alcohol, from 1919 to 1933, but its larger project failed. The prohibition of alcohol had terrible unintended consequences, including exacerbating organized crime. Prohibition simply didn’t work, but even after alcohol became legal again, the belief that alcohol was the “Devil’s drink,” or that some substances were inherently evil, did not entirely fade away.
When Bill Wilson and Robert Smith founded Alcoholics Anonymous (AA) in 1935, shortly after Prohibition’s end, Protestant spirituality was embedded in the program. Adherents were taught to rely on God or a “higher power” to overcome their addiction. The founders met through a Protestant mission organization called the Oxford Group. One of its core tenets was a commitment to “absolute purity.” Seeking to transform their lives, participants learned through AA and its offshoots to commit to total abstinence from alcohol and drugs.
Cultural understandings of drugs often incorporated Christian language. Many substances became “demonized” over the years. Crack cocaine is another major example, argue sociologists Craig Reinarman and Harry Levine, editors of Crack in America: Demon Drugs and Social Justice. “This demonization invests the substances themselves with more power than they actually have,” they write. “Drugs, unlike viruses, are not active agents; they are inert substances. They do not jump out of their containers and into people’s bodies.” Still, talk about addiction often resembles the religious language of demon possession more than a scientific or medical understanding of addiction and how it functions.
Today, in seeing the widespread death and devastation from drug overdoses, it is tempting to label certain substances like fentanyl as inherently “evil.” Even as cultural attitudes and public policy have shifted around marijuana, the idea that some substances automatically degrade character, or only people of bad character use drugs, is evidenced by the former Attorney General Jeff Sessions’s statement that “good people don’t smoke marijuana.”
But as Augustine or Aquinas might have argued, these substances are not inherently evil, and they are not direct causes for moral degradation. The concern is in a person’s relationship to the substance and the real and potential consequence for their life and the lives of others.
Opioids may have helped save my life. The heavy doses of pain medicine certainly eased my extreme pain. It was only later that what had been an important medicine became a threat to my health and well-being. What had changed was not the nature of the substance but the manner of my relationship toward it.
This belief in the “demonic” nature of certain substances has real world consequences. First, it underlies the myth that prohibition is the only solution. If we believe that certain substances are inherently evil, then prohibition is a logical solution. We need a “war on drugs” because they are the enemy. But, if we recognize that the primary moral concern should be the potential harm to oneself or others that excessive or habitual use might bring, then the primary moral issue at stake is not getting rid of all drugs but reducing the potential harm they might cause. We need to ground our discussion not in stark statements of inherent good or evil but in understanding that our relationship to a substance like an opioid can exist along a spectrum, from harmful to beneficial.
Harm reduction is an alternative to the “war on drugs” and refers to a public health approach to addiction that encourages “any positive change.” Using IV drugs with a clean needle is less harmful than sharing needles. Reducing the risk of accidental overdose by using in a supervised injection site is less harmful than use on the street.
Maia Szalavitz, journalist and author of The Unbroken Brain, has described the opposition to harm reduction measures by politicians and even some social workers while she was actively using IV drugs. In her book, she writes, “We were thought to be hopeless unless we kicked drugs, unable to learn and change if we weren’t in recovery.” It was assumed there was no opportunity to learn or change unless complete abstinence had been achieved.
My story of recovery did not begin with abstinence. I had months of therapy and alternative pain treatment before I slowly stepped down from opioids over time. My story of slow change is much more common than most think. Szalavitz writes, “While recovery stories are often told as though they result from sudden insight that prompts life-altering action, in reality, studies find that psychological breakthroughs are not the typical path to change and rarely lead directly or in any linear way to alterations in behavior.”
It is also a myth that the ongoing use of any substance is inherently negative. While abstinence-based approaches like AA or spin-offs like Narcotics Anonymous have been helpful for many, that experience is far from universal. Medically assisted treatment (MAT), which involves using drugs such as methadone or buprenorphine to both manage cravings and, in the case of buprenorphine, block the effects of other opioids, has shown been shown to reduce overdose deaths by nearly 50 percent. A study in Massachusetts found a 59 percent reduction in overdoses for those on methadone and a 38 percent reduction with the use of buprenorphine. However, their use is not allowed in many treatment facilities, prisons and abstinence-based recovery programs.
Why? MAT is effective in part because the medicine includes opioid agonists—meaning they interact with opioid receptors and are able to reduce withdrawal symptoms. They are, in effect, milder forms of the drugs themselves. In a view in which the drug, and not our relationship to it, is the matter of moral concern, this is anathema.
This belief, buttressed by Christian theological developments about substances, holds back progress on addressing addiction and overdoses. An addiction does not involve being taken over by an evil or demonic substance; it stems from a disordered relationship with one. Prohibition and punishment have failed. Approaching addiction as only an individual moral flaw—instead of a public health crisis—has only made things worse. And the eschewal of effective approaches like MAT means more needless deaths.
These beliefs have real consequences. If my doctor had used blame and shame to confront me and then immediately cut me off from pain medicine, I likely would have found myself in the position many others have: seeking them illicitly. Yes, addiction can be harmful but so can the way we have chosen to treat those with addictions as a society.
A Protestant ethos still shapes many cultural perceptions around addiction and recovery. AA and abstinence-based approaches have helped many and will continue to do so, but they don’t work for everyone. When taken as dogma and not as one strategy among many, they can create harm. A better theology could help shift our approach to addiction and drug policies, creating a powerful force for change.
Timothy McMahan King is a writer in New Hampshire and the author of Addiction Nation: What the Opioid Crisis Reveals about Us. Follow him @tmking.