Addicted to Christ. Helena Hansen
us exclusively on pursuit of the drug, and making future oriented, cost-benefit analysis impossible.” It was an updated rendition of “Diseases of the Will” that historian Marianna Valverde (1998) had traced to Victorian doctors trying to account for addiction as a condition that took away self-control. Self-control, Valverde pointed out, was the distinguishing trait of humanity (as opposed to animal life) according to Enlightenment philosophy.
Biomedicine blames not only the substances, as Victorian temperance campaigns had, but also blames the individual’s genetic predisposition to addiction, and blames irreversible damage to the brain from long-term drug use. For instance, biomedicine’s “opiate receptor depletion hypothesis” proposes that chronic opiate use leads neurons to stop producing opiate receptors, to dampen the effect of high levels of opiates on neurons. This change explains why tolerance develops—that is, as the brain stops producing opiate receptors, higher doses of opiates are needed to achieve the same experiences of pain relief and pleasure. According to this theory, taking high doses of opiates daily over a period of years makes this down-regulation of opiate receptors irreversible: the brain permanently requires higher doses of opiates to control pain and feel pleasure. The brain stops responding to its own physiological opiates, such as endorphins, and without doses of external opiates such people live in a state of pain and anhedonia, unable to experience everyday pleasures. This is the principal neurophysiological argument for opioid medication maintenance with methadone or buprenorphine as a clinical treatment for opiate addiction.
My supervisor’s biological hijacking lecture came on the heels of President George H. W. Bush’s “Decade of the Brain” (1990–2000), a decade during which Congress allocated billions of dollars to the National Institute of Drug Abuse (NIDA) for neuroscientific studies of addiction as a “chronic, relapsing brain disease.” Addiction researchers and clinicians believed that conceptualizing addiction as a disease would reduce the stigma of addiction by mainstreaming addiction treatment into general medicine. The end of the decade was marked by a lead article in the Journal of the American Medical Association—authored by four prominent addictions researchers and entitled, “Drug Dependence: A Chronic Medical Illness” (McLellan et al. 2000). It argued that the heritability, etiology, and treatment adherence of addicted patients were similar to those of patients with diabetes, hypertension, and asthma, and that addiction should be treated in the same way (with medications) and in the same settings (in general clinics) as chronic physical illnesses. Addictions researchers hoped it would leave sufferers less stigmatized and with the more realistic goal of stabilization (instead of cure), than would a moral-deficiency concept of addiction.
In Puerto Rico—a U.S. territory that receives federal public-health funding—this biomedical view of addiction was making inroads. Two major universities near the capital city of San Juan had substantial NIDA funding for addiction research. State-funded biomedical detoxification and rehabilitation programs were firmly established and were being privatized in Puerto Rico’s move toward managed care. Most of the converts I met in Puerto Rican street ministries had tried biomedical addiction treatment, and many of the patients that I interviewed in biomedical programs had been in street ministries; biomedical and Pentecostal approaches thus were intertwined in their biographies.
Yet, biomedicine and Pentecostalism are rooted in different views of the self. In biomedicine, the addicted self is damaged, cannot regulate itself, and therefore cannot protect itself from further harm. Its closed loop of physiology and behavior is captured in biomedicine’s foundational “self-medication hypothesis,” the hypothesis that addiction is a faulty attempt to treat oneself with substances that relieve symptoms, but that simultaneously weaken one’s capacity for self-care (Khantzian 1985). The idea of self-medication infuses biomedicine’s primary addiction-treatment strategies to this day—from maintenance medications such as methadone that relieve the discomfort of withdrawal and mimic the action of illegal opiates, to cognitive behavioral therapy and dialectical behavioral therapy, designed to give patients non-pharmacological strategies to regulate their own distressing emotions. A more recent addition to this framework is the “Stages of Change” theory (Prochaska and DeClemente 2005) that identifies deficits in patients’ recognition of, and motivation to change, self-harming behavior such as addictive behavior. This theory has been combined with communicative strategies called “Motivational Enhancement” and “Motivational Interviewing” (Miller and Rollnick 1992). Physicians and therapists use these strategies to change harmful behavior by providing verbal reinforcements that are tailored to the patient’s stage of change, and are adjusted as the patient’s motivation and insight progress. In this way, willpower is directly bolstered by the clinician. To interrupt the addictive loop of physiology and behavior, therefore, biomedicine provides either pharmaceutical or psychotherapeutic prosthesis that enables addicted people to care for themselves. Prosthesis is the technology of hope offered by biomedicine: the hope of targeting neuroreceptors and psychological deficits that drive addictive responses by using precise molecular and psychotherapeutic techniques—techniques that, by the scientific master-narrative of progress, continuously improve with new breakthroughs over time, restoring self-dominion. According to biomedicine, however, the addicted self always will require psychosomatic technologies to adapt to the world. This cultural model calls on our investment in the pastoral care of individuals as a requirement for their everyday survival.
For their part, street ministries turn the biomedical view on its head. In the ministries’ frame, rather than helping addicted people to adapt to their environment, they call on people to remake their environment with spiritual techniques. Rather than accepting their powerlessness against their biology as “drug dependent,” ministries attempt to tap the power of a spiritual movement. Rather than asserting that addiction is a disease of the individual, ministries see it as a sign of societal disease. The goal is not to adapt to the world, but to create a new one. By this logic, prosthesis (such as medications or psychotherapy) only delay the liberation awaiting addicted people when they reject the world. The self is not permanently damaged; rather, the self is an embryonic seed, stunted by addiction, whose capacities must be cultivated with spiritual practice. This is in contrast to an inward-looking biomedical concern with inherited or historically shaped individual flaws; Pentecostal discourses of addiction are future oriented, calling on communities of worship and spirits as agents of change. The street ministry pastors that I knew had their own critique of biomedical addiction clinics, saying “You can’t cure drug addiction with drugs.”
As a prescriber of methadone and other medications used to treat addiction, I agreed with them. Drugs do not cure addiction. Yet, clinicians do not claim to cure, they only claim to manage a chronic disease (of addiction) with their medications. The most committed and skilled addiction doctors do help people to transform their lives, in part with medications that make withdrawal and cravings tolerable, medications that enable addicted people to face the complexities of family and work with less distraction.
Apart from a small, committed group of addiction specialists, however, most doctors are not eager to treat addicted patients. The chronic disease concept of addiction has only penetrated biomedicine so far. In both Puerto Rican and U.S. mainland medical schools, students and clinical residents run from patients who have “drug dependence” on their charts, delaying their admission exams for the next shift, or scanning their medical histories for reasons to refer them to a specialist. Addicted patients are non-compliant, have hidden motives, and are comorbid: sick with many diseases at once, including infections, liver disease, vascular disease, psychosis, and depression. They are the nemesis of overworked clinicians. Also, like many North and Latin Americans, clinicians often doubt that addicts deserve care.
In my own medical training, I was drawn to addicted patients. I pored over their social histories, convinced that they held the key to patients’ compulsions. I did find a pattern: almost all of these patients grew up neglected; were sexually, physically, or emotionally traumatized; or lived in violent neighborhoods, with unstable housing, pervasive unemployment, truncated schooling, and other deprivations. Population studies show that drug-use rates increase when industries leave local towns, or when people are forcibly relocated to reservations (Shkilnyk 1985) or to new housing projects under Urban Renewal (Fullilove 2004) or planned shrinkage (Wallace 1999) when extended family systems are broken apart by welfare eligibility policies (Pessaro 1993) or forced migration (Borges et al. 2007, Alaniz 2002), or when organized