Pain Avoidance – Dr David Outridge

The role of pain in the development of addiction

16 MINUTE READ

from Luke’s Journal 2018 | Pain & Faith | Vol.23 No.1

This essay looks at the role of pain in the development of addiction, and how we as the church can potentially minister to sufferers of addiction. 

From the book of Genesis, we see that an increase in the experience of pain is linked to The Fall. Man was excluded from the Garden of Eden where he could potentially eat from the Tree of Life and live forever. Scripture indicates that these impositions were necessary to limit the effect of man’s disobedience and for God’s order to be preserved (Gen 3.22), but by deduction (God’s love for man), for the good of man as well. C.S. Lewis points out that in the absence of pain, we would never seek God; he speaks about pain as God’s ‘megaphone to rouse a deaf world’.1 Similarly, physical pain imposes a limitation on damage occurring to the body by compelling the individual to act.

“C.S. Lewis points out that in the absence of pain, we would never seek God.”

The suffering consequent upon the Fall is described as affecting the sexes differently – man in his role as provider is burdened by frustration and hard work; woman by the pains of childbearing.

Similarly, pain (or more correctly suffering), manifests in the various dimensions of our being, e.g. childbirth (physical pain), loss (emotional pain), hopelessness (mental), frustration (the will), shame (moral), loneliness (social) or meaninglessness (spiritual). Pain always reflects something wrong in the structure of either us or the surrounding environment (physical, psychological, social or spiritual), and, as such, it is a necessity if we are to avoid destruction. 

The mysterious unity between body and spirit

Within our medical role, we gain a unique insight into the mysterious unity between body and spirit. For example, antidepressants are a class of drugs that can ‘lift the spirit’ or allow some patients to feel hope again where counselling and social support has failed. There are some substances which are able to mimic aspects of human experience to the extent that they can be very attractive. However, inevitably there are downsides. For example:

  • Methamphetamine can overcome fatigue and increase attention, or in higher doses produce such an intense reward that whatever actions went into achieving that state, will be repeated to the exclusion of important responsibilities; 
  • Hallucinogenic drugs can produce a sense of spiritual enlightenment. Unfortunately these effects are not based on reality and can lead to permanent perceptual distortions; 
  • Opioids produce a relief from various types of pain, emotional and physical, but can also cause a deadly dependence; 
  • MDMA (‘Ecstasy’) is being studied for its potential benefits in PTSD through its action of releasing oxytocin and promoting social bonding,2 but this effect is non-discriminatory, and presents other risks as part of the dance-party scene. 

The unique qualities of many drugs can be used powerfully to do good (or feel good), but they remain a relatively blunt instrument, and one that can also do much harm if used unwisely. Therefore, drug use is traditionally regulated by society through laws, social rituals and boundaries. 

In relation to pain experienced by human beings, there is indeed much that we can do as health professionals to both cure disease and alleviate suffering. However, when faced with pain in the absence of a cure, our instinct to help can lead us to do harm. Indeed, the attempts by our profession to alleviate pain contribute to over 550 deaths per year in Australia,3 and a staggering 17,500 deaths per year in the USA from prescription opioid use.4 The interconnectedness of all things means that nothing can be changed without an unintended consequence. We, as doctors with experience, become more and more aware of the limitations of our profession, that pain in some form is often unavoidable, and that man’s attempts to completely avoid it lead to other problems (often more serious).

“…pain in some form is often unavoidable, and that man’s attempts to completely avoid it lead to other problems (often more serious).”

The question of why we must suffer is ultimately a mystery, (however as far as reason can go, Lewis’ book The Problem of Pain is recommended).1 Knowing God’s full character as revealed in Christ, we can safely say that pain must have been unavoidable in God’s deeply laid plans for creation, which included His foreknowledge of The Fall.

Jesus himself was not exempt from experiencing pain. Indeed, his incarnation and suffering is profoundly integral to our salvation. We yearn to know the reasons for suffering, but God usually does not reveal it, e.g. in the story of Job, he never knew of the heavenly challenge by Satan of God to test Job’s fidelity. We could ask too, if knowing would make pain any easier to bear, and could we understand such an immense and complex truth? Ultimately, despite all rational understandings, (or rationalisations), suffering can only be acceptable by knowing that God suffers with us, and that eternal joy will be the final outcome. In His providential love, He has also provided science and medicine to relieve suffering, and even today new understandings of neuroplasticity give us reason to believe that chronic pain can be managed. Yet there is suffering – a mystery which we must learn to address, not with ‘why’ questions, but ‘how’ (how can I respond)?

Even with a relationship with God through Christ, sinful man inevitably responds to suffering in ungodly ways, which will be dysfunctional and lead to more pain in the long-run. A cycle develops of seeking another form of relief or distraction, followed by disappointment leading to a deepening despair. Thus, the soul tortured by pain and disappointment comes to one of two positions – either crying out to God and turning to Him, or expressing anger toward God. This latter interaction with God is not necessarily evil as we see in Job, as it is an interaction which opens the way for a response. Even rebellion towards God is evidently something with which He can work, as shown by Jesus’ preference for hot or cold, rather than lukewarm faith (Rev 3.16).

“Even with a relationship with God through Christ, sinful man inevitably responds to suffering in ungodly ways, which will be dysfunctional and lead to more pain in the long-run. ”

Substance abuse and addiction are consequences of one of the ways man seeks relief from the suffering of life after The Fall. There are other more ‘socially acceptable’ ways to do this, such as workaholic behaviour, taking up ‘causes’, seeking entertainment/social activity, personal achievement, accumulation of money, etc.. There are some less socially acceptable ones such as anger and violence to others, dysfunctional coping mechanisms such as projection or self-directed anger, stealing, ungodly pleasure-seeking, etc.. Irrespective of society’s values, substance misuse is no greater a sin in God’s eyes than any other ungodly method of coping. Nevertheless, it is often a very self-destructive one, and the humbling effect of addiction does place the sufferer in the same category as ‘sinners and tax-collectors’, people with whom Jesus spent a lot of time.

As Christian doctors, we should be no more surprised at substance use than any other sin we see in mankind. However, dealing with it can be very confronting and perplexing. So-called ‘normal’ people will tend to boost their sense of moral self-esteem by comparing their own behaviours to others further to the left on the bell-curve of a given moral criterion. We as Christians cannot do that if we are honest with ourselves. This is not to say that dealing with people with addiction is straightforward. On the contrary, it takes a very different perspective on progress and an approach which reflects the multi-dimensional nature of the problem. To the ‘bio-psycho-social’ model we add ‘spiritual’, since ultimately the presence of suffering and man’s dysfunctional approach to it can only be fully understood from that perspective.

How should we approach addiction?

Various dimensions to the problem have come to prominence over the years, but the idea of moral failure is a widespread belief that contributes to severe stigma around addiction and reduces in society’s eyes ‘worthiness’ of help. Yet modern mainstream understandings of addiction acknowledge that moral failure is only a relatively small contributor to the development of addiction. Peer pressure is a factor, but less important than concerned parents often imagine. Public policy on legal availability and taxation of addictive substances is a powerful determinant of addiction prevalence.

Individual vulnerability probably plays one of the greatest roles in determining addiction, including genetics/epigenetics, and personality development. Trauma, neglect and parental influences have a big effect on vulnerability. Those little kids that we see in our practices, being raised under circumstances of psychosocial inadequacy, become the substance use patients of tomorrow. 

The implications of this causality are that there is much more to do for substance-addicted patients than simply detoxing followed by a three-month course of recovery meetings. Of course, this works in some cases, but these are generally people with ‘intact’ personality foundations who have slipped into addiction. In most established cases there is long term restoration and developmental work to be done, and this can take five, ten or twenty years, along with life-long attention to relapse prevention. 

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In the case of opioid addiction, the trauma history is such a profound influence that if I meet someone without a history of childhood sexual abuse (which occurs in 90% of cases) then I am looking for a major psychiatric illness (or assume that it is too painful to disclose at present). Opioids work very well for people with co-occurring Cluster-B personality traits simply because they address the pain of trauma. I have seen people who try to do a detox from their opioids (because that is what is expected of them by family), quite rapidly start to re-live past traumas to the extent that they must restart their opioids.

The reason why opioid maintenance treatment is so effective, and abstinence-based treatments are so ineffective and dangerous (from lethal overdose), is because it treats the pain and stabilises the patient whilst they work through the developmental deficits and traumas. This trauma aspect of opioid addiction is not widely appreciated. Consequently, almost without fail, the first question people ask me after I tell them that I prescribe methadone, is ‘how long before you get them off it?’ Childhood trauma is a profound problem taking an average of twenty years for a person to achieve a fair level of stability. Abstinence-based approaches are associated with a fifty percent mortality rate over the same period without Opioid Substitution Treatment, a high price to pay for an ideal. 

How can the church help?

Getting back to the spiritual dimension of substance use, what is the unique contribution that the church can make in this area? Should we be trying to cast out the demons of addiction – is it simply a matter of deeper and more heartfelt repentance? Or can we make people better by taking them away to a Christian environment and make them attend chapel? Is AA/NA the only type of self-help we should endorse (or better still, transform it into a fully Christian format)?

There are robust observations in research over the years, showing that religiousness is inversely associated with alcohol and drug problems, and that people entering treatment for addiction have a low level of religiousness and spiritual practice. Attendance at AA and learning meditation has been associated with lower rates of relapse, yet the causality of these relationships is far from being clarified scientifically.5 Nevertheless, psychosocial treatments and medical treatments do work, even in the absence of an ‘epiphany’. Much of the work of recovery is personal growth, and in view of the contribution of personal developmental difficulties, it is not surprising that generic assistance is comparable to, if not as good as, Christian assistance. In the same way that good parenting is good parenting, good therapy is good therapy, and some services offered by well-meaning Christians can even be bad therapy. 

“…religiousness is inversely associated with alcohol and drug problems, and that people entering treatment for addiction have a low level of religiousness and spiritual practice.”

But here’s where the church can help: generic recovery services simply are not available in sufficient quantity and quality to help the vast numbers of people who need help. Long-term healing of the personality developmental deficits and disorders that so often accompany substance addiction is not well addressed by mainstream services and results in the repeated cycling through services over a long period of time.

Personal development in fundamental areas such as trust, identity, shame, belonging, value, etc. is spiritual development, because it is building a healthy sense of fatherhood and sonship so essential to relating to God. These aspects of child-psychology (and adult personality disorder) are core business for us as churches, because we are Christ’s body and true family. Families are places of both love and structure, places where people are nourished and grow under the Father’s (and fathers’) protective hand. They are also places for restoration – as sinners saved by grace, we are all ‘in recovery’.

So, in practical terms, how can the church interact with these very broken and needy members of society, helping to bear their burdens, being the missing role-models of brothers, fathers, sisters, mothers, yet not endangering the structures and people in those communities?

There is no place for spiritual pride amongst Christians, and we all want to be as vulnerable and honest with each other as possible. Yet clearly there is a potential for compromise if, say, a police officer and a known recurrent offender attend the same church or the same ‘connect group’. In theory it could work, but personal sharing about struggles might be inhibited. There must be structures and boundaries in place, for the same reasons that a business deal between friends must be backed up with legal contracts. Human sin and iniquity, and the work of Satan, can wreak havoc. We only need to think of the terrible stories coming out of the Royal Commission into Institutional Responses to Child Sexual Abuse to realise the awful consequences of thinking ‘it couldn’t happen in the church.’

Clashes of culture or personal habits can also arise, not only the difficulty posed, for example, by the very bad body odour of the homeless man you’ve invited home for lunch, but the recipient of the generous welcome may feel very uncomfortable too. When people who have been raised in various kinds of poverty (social, financial, moral) are immersed in a community full of genuinely ‘nice’ people with nice things, nice manners, educated and thoughtful, not necessarily even snobbish, the potential is created for a sense of inadequacy or jealousy, such that it overwhelms the newcomer. This is not to say that we should only aspire to the lowest common denominator, but it means we must be realistic, (and not proud). In this regard, there is often cultural clustering of people within churches and into churches. This is just as normal as ethnic clustering in certain churches.

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We need to affirm each other’s calling and strengths and mutually support each other. A wealthy middle-class church community is generally a time-poor community. Though they may not have time to give to ministering to certain groups, they may be able to support a ministry financially. Another example is a mature responsible church person in a busy and demanding job. They might not have time to give to a cause, but may be able to mentor a less mature Christian who has more time for service. Such networking between and within churches could be enhanced by more conscious sharing of needs, perhaps even social media. 

In the case of people who have experienced a distortion or poverty of parental care, or been victims of abuse, such people may have been through a series of churches, leaving a trail of burnt bridges behind them. These are the group for which we need a dedicated sub-group of informed and mature helpers within churches. It should not fall to just one or two people to try to manage such sufferers, but a network, even a roster of people. Crises are make-or-break moments and should be prepared for in advance with professional input and contingency plans. Events such as self-harm, court matters, outbursts, fights, mental health deterioration, substance relapse or bingeing, should not cause the church shock and withdrawal, but be handled calmly – bedding down another experience of a parent-like response in the sufferer, which cumulatively leads to growth and a more accurate picture of fatherhood and sense of identity as His child.

Behaviour management plans may need to be developed to encourage desirable, and discourage dysfunctional, patterns of coping in the person with the disorder. There is no shortage of professionally-trained people in churches who have skills to impart, but there is a gap in the recognition of this somewhat specialised caring ministry within churches. With a little planning, the necessary expertise could be disseminated. We have a majority of fairly ‘normal’ people in our churches, even ‘boringly normal’ people who are, in fact, an enormous resource for helping people. 

“The abundance of stability and good values that we take for granted in middle class churches, is a valuable resource that is rare in the circles that many addicted people come from.”

Regarding the teachings of Jesus about radical generosity and hospitality, we haven’t had a lot of help integrating these teachings with the practical aspects of present day culture, e.g. should we welcome a homeless stranger into our house out of obedience to Christ’s teaching? We are called to be gentle, but wise also. Ministers of the Word need to drill down to the practical applications of some of these tricky areas so that members are not left vulnerable to exploitation.

The abundance of stability and good values that we take for granted in middle class churches, is a valuable resource that is rare in the circles that many addicted people come from. I would love to see us tap into that resource but, more importantly, bring the added spiritual depth to healing from these issues that is lacking in purely medical and psychosocial approaches.


Dr David Outridge 
David is a GP in Newcastle with a special interest in addiction medicine. He and his wife Loraine work alongside an Anglican NGO supporting people with substance use problems and those exiting custody.


References:

  1. Lewis CS. The problem of pain. London: Collins; 2012.
  2. Yazar-Klosinski BB, Mithoefer MC. Potential Psychiatric Uses for MDMA. Clin Pharmacol Ther. 2017;101(2):194-6.
  3. ABS. 3303.0 – Causes of Death, Australia, 2016. In: Australian-Bureau-of-Statistics, editor. Canberra: Australian Government; 2017.
  4. NIDA. Overdose Death Rates. In: National-Institute-of-Drug-Abuse, editor. September 2017 ed: National-Institutes-of-Health; 2017.
  5. Miller WR, Bogenschutz MP. Spirituality and addiction. South Med J. 2007;100(4):433-6.

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