Who, Why and What?
The problem of ‘drug abuse’ has been a matter of concern for health care professionals, prophets, politicians and society at large for many, many years; certainly since well before the birth of Christ. An archetypal image of the problem is evoked in the Book of Proverbs:-
‘Who has woe? Who has sorrows? Who has strife? Who has complaining? Who has wounds without cause? Who has redness of eyes? Those who linger late over wine, those who keep trying mixed wines. At last it bites like a serpent, and stings like an adder. Your eyes will see strange things and your mind will utter perverse things.’ (Proverbs 23. 29, 30 & 32 NRSV).
A new situation
Until the era of rapid international travel and sophisticated chemical techniques, however, the range of psychoactive (mind affecting) substances available in any one location tended to be limited, and those that were available had been encultured (a useful recent addition to the English language). By this I mean that each local culture had evolved strategies for regulating the use of any locally available psychoactive substance, such as by associating it with specific social or religious events, and for castigating or disciplining those who did not conform. It seems that advances in chemistry and in transport over about the last fifty years have facilitated the development of a highly lucrative trade in substances that can cause temporary alterations in our perceptions of and feelings about ‘life, the universe and everything’. This applies both to the modern pharmaceutical industry and other commerce involving legal and illegal drugs.
Different terms explained
The word ‘drug’ tends have different connotations in different circumstances, so I will explain my usage of a cluster of related terms before taking the discussion any further. Amongst health care professionals and biomedical scientists a drug is a chemical that can influence the functioning of one or more biological systems, and pharmacology is the study of drugs defined in this way. Solvents have generally been thought of as being distinct in some way from drugs and the term ‘substance abuse’ was introduced to include the misuse of solvents as well as drugs. Medicines are drugs formulated pharmaceutically for clinical use. Alcohol (known chemically as ethyl alcohol or ethanol), caffeine and nicotine are recognised by pharmacologists as potent psychoactive agents (the term ‘agent’ being used to avoid connotations associated with ‘drug’ but having no other distinctive meaning) that are available legally for recreational use in many parts of the world.
From what I have just written, it can be discerned that the way in which ‘drugs’ are used can be sorted into three fairly distinct categories: clinical use (also known as therapeutic), recreational use, and misuse, which can be addictive. The distinctions between these groupings are not, however, always as clear as they might seem at first. Patients sometimes misuse medicines that have been prescribed for legitimate, clinical reasons; and what is regarded as recreational use, of alcohol for example, by one sector of society is regarded as misuse by others.
Shrouded in mystery and prejudice
In writing this article for Chrism, I am taking it as axiomatic that members of the Christian community, who are interested in healing, are concerned to explore what might be done to help those who misuse drugs and consequently cause harm to themselves or others. For many in Church circles ‘drug abuse’ is a topic that is shrouded in both mystery and prejudice. Both of these shrouds need to be discarded so that the Church can take its place amongst the many caring organisations that are striving to help those individuals and communities that are suffering from drug-related problems. As a pharmacologist I take the view that the drugs themselves are only a very small part of a highly complex psychosocial enigma, and the better our understanding of the drugs that are misused, the better placed we are to locate them meaningfully within a wider picture. One aspect of that wider picture is to recognise that the designation of particular groups of drugs, or herbal products containing psychoactive agents, as ‘legal’, ‘illegal’ or ‘controlled’ (legal in certain defined circumstances for particular therapeutic or research purposes) is, in part, a happenstance of history and varies globally between different countries. A fascinating book called Murder, Magic and Medicine (Mann 1992) provides a highly readable account of the history and actions of many substances of interest in this context.
Having set the scene for the wider picture, I will now explore some key issues under four main headings:
- Who misuses drugs?
- Why do people take drugs for non-medical purposes?
- What do they take?
- What do these drugs do?
Finally, there will be a short reflection relating theology to possibilities for Christian action in relation to non-medical use of psychoactive substances.
WHO MISUSES DRUGS?
During the course of varied discussions with many people who are concerned with drug misuse, professionally or as volunteers, it has been possible to identify some typical characters whose lives involve usage of drugs in ways that some people would regard as misuse.
Norman is 45 and a middle manager. He is quite stressed by his job, and relaxes at weekends by drinking rather a lot of beer and spirits.
His teenage children suffer because he takes little interest in their activities is quite often unfit to give them lifts he has promised earlier. His wife is very unhappy with the situation but does not know what to do about it.
Charlotte is 35 and a senior executive. She is very health conscious and exercises regularly, but enjoys white wine and cocaine at weekends.
Apart from the illegality of her cocaine and the need to obtain her supplies from criminals she currently acknowledges no problem with her habit.
Bill and Mary are in their mid-20s and unemployed. They are addicted to heroin. They live in a council house and have two young children who are reasonably well cared for, with help from their grandparents.
One priest with many such families in his parish commented that if their heroin habits could be funded from sources other than criminal activity many would live relatively normal lives. It was the criminal activity required to pay for their supplies that caused most social disruption in the area.
Darren is 15 and seeking novel experiences on a minimal budget. He tries alcohol, cannabis, cigarettes or solvents whenever he can.
Of all the people sketched here, Darren is at greatest risk of sudden death, because of his solvent usage. If only his adventure-seeking tendencies could be diverted into healthy and beneficial interests and activities he would not need to experiment so dangerously.
Jennifer is 19 and in her second year at University. Intermittently, she uses alcohol, cannabis, ecstasy, and lots of caffeine from coffee and cola drinks.
She is an example of those people who are classed as recreational users, but the range of drugs that she uses goes beyond that which is currently legal. The quantity and quality of active ingredients in her ecstasy tablets and cannabis are uncontrolled and could vary greatly from batch to batch, posing serious risks to health.
Fred is 68, a heavy smoker with chronic respiratory tract disease and severe difficulty in breathing.
Of all the characters depicted here, Fred is suffering most intensely, because of his addiction to nicotine, and putting immense strain on his family and local health and social services provision.
WHY DO PEOPLE TAKE DRUGS FOR NON-MEDICAL PURPOSES?
All of the above individuals are fictitious caricatures, drawn to illustrate my points that it is not only currently illegal drugs that are harmful and that many different types of people consume psychoactive drugs for non-medical purposes. Why do they do it?
This is one of the questions asked in a survey of alcohol drinking, illicit drug use and stress in junior doctors published in The Lancet (Birch et al 1998). They found that of the 93% who drank alcohol, more than 60% of both sexes exceeded recommended safe limits, and did so for ‘pleasure’. More than 35% of men and 19% of women reported current use of cannabis. 13% of the men and 10% of the women also reported current usage of one or more of the following: hallucinogenic mushrooms, lysergic acid diethylamide (LSD), ecstasy, amyl nitrite, cocaine and amphetamines. ‘Pleasure’ was also the main reason for taking illicit drugs (76% in both sexes). The use of alcohol or illicit drugs was unrelated to high scores for anxiety or mental ill health.
Experimentation, relaxation and peer-pressure are other reasons given commonly for the non-medical use of psychoactive agents. The pursuit of mystical or spiritual experiences has been highly influential in the use of hallucinogenic agents in various cultures, and David Hay (1987, p.97) reported research conducted by Professor Huston Smith demonstrating that reports of spontaneous and LSD-induced religious experiences were indistinguishable.
A further factor that merits more consideration than is generally evident is escapism. By stimulating the ‘pleasure centres’ of the brain, many misused drugs provide temporary relief from the difficulties and discomforts of daily lives that are themselves lacking pleasurable aspects. As I have highlighted previously, it seems that many of those who become addicted to chronic drug misuse (as opposed to experimental or recreational use) have lifestyle difficulties (including poverty and unemployment) that predispose them to seek this form of escapism (Leathard 1998). It is important to distinguish clearly between this addictive use of drugs to escape from psychosocial pain and the medical use of opioids to relieve acute physical pain. There is no evidence that the medical use of morphine and related medicines for pain relief results in addiction, and it is of interest that none of the junior doctors reported that they had used opioid drugs such as morphine or heroin in their pursuit of pleasure.
WHAT DRUGS DO PEOPLE TAKE FOR NON-MEDICINAL PURPOSES?
The main examples are listed below (Buxton 1998), and their various actions and effects will be outlined in the final section. At this point, however, I want to highlight the fact that while the quality of legally-produced products such as alcoholic and caffeine-containing drinks and medicines marketed for clinical use are subject to strict quality controls, substances bought from criminal sources are not. The purchaser does not, in fact, know what they are buying; and this was amply illustrated by a small-scale piece of research into ecstasy tablets reported in the Guardian (1996). This showed that of fourteen ‘ecstasy’ tablets bought in clubs in various towns and cities around Britain only five contained any MDMA (methylenedioxymethamphetamine, the supposed active ingredient), and none contained a psychoactive dose. Several contained small quantities of related weaker chemicals but, most alarmingly, two contained ketamine, ephedrine and procaine. Ketamine is a powerful, veterinary anaesthetic rarely used in human anaesthesia because it causes hallucinatory ‘emergence phenomena’ as people recover consciousness. Ephedrine has very mild stimulant effects, but is most commonly encountered as a nasal decongestant in cough and cold remedies, while procaine is a local anaesthetic that lacks the psychostimulant actions of its chemical relative cocaine. People who buy ‘ecstasy’, therefore, are spending their money on either very expensive placebos (biologically inactive products that ‘please’ the recipient) or highly dangerous drugs, or a mixture of both.
WHAT DO THESE DRUGS DO?
Neuroscience research has now produced convincing evidence that drugs ‘that elicit drug-seeking activity in the user’ act by ‘hijacking’ systems within mammalian brains that have evolved to ensure the survival of the individual (through eating and drinking) and the species (through sex and infant nurturing activities) (Abbott 1992, Koob 1992). These systems provide the sensation of pleasure associated with those activities that are essential for our survival, and with the use of addictive (or potentially addictive) drugs these feelings are reproduced. The reasons why some individuals prefer one drug and others a different drug remain a mystery (Blakemore 1990, p 90). It seems that lack of other pleasures in life tends to predispose towards addictive drug taking, but the actualising of this tendency depends upon many additional factors such as drug availability.
The evidence that pleasure is the psychological effect common to misused substances is entirely consistent with the main reason given above for taking such substances. It is in the variety of other effects they produce that the differences between the drugs in their actions, effects and dangers lie. For those that are legal in social or clinical use, their individual profiles of actions and effects are well established. There is, however, no equivalently sound information about illegal drugs because of the virtual impossibility of conducting controlled trials. Reports of their effects tend to come from addicts who attend clinics or other centres for treatment, and it is never possible to be sure of exactly what they have taken, separately or in combination (including alcohol, nicotine and caffeine) or how much of the various items they have consumed in relevant time periods. It is with this proviso that a brief overview of attractive properties and risks is given in the following table, distilled from a wide range of pharmacology textbooks and other sources.
CHRISTIAN HEALING MINISTRY AND PSYCHOACTIVE DRUGS
Although the ability of some psychoactive drugs to evoke mystical experiences has been reported widely, such effects have largely been ignored in objective pharmacological research. An interesting question for the Church, that has been posed not infrequently when I have presented talks on substance misuse, is whether deficit of mystical, spiritual experience might be a factor in the increasing experimentation with psychoactive substances by young people of recent generations. I am unaware of any research that answers this question. If, however, we accept the case made above that drug-seeking behaviour is pleasure (or relief-from-pain) - seeking behaviour, we need to consider carefully whether our current pattern of Christian ministry is conveying adequately the joy that Jesus intended (John 15. 11). Paul warmly commended joy among the fruits of the Spirit, that contrast to ‘desires of the flesh’ (Galatians 5. 16-22). Does some fear of inappropriate spiritual hedonism inhibit us from seeking to evoke (or admitting that we sense) pleasure, joy or euphoria during private prayer or communal worship? How best might we convey Jesus’ healing gift of joy to those who take mind-altering chemicals as a substitute? Pastoral and other approaches such as those taken by Kenneth Leech (see this issue of Chrism) certainly make important contributions to the healing of those who are already suffering. The challenge of providing Christian pathways to pleasure as a diversion from the drug route is one that merits dedicated prayer and meditation as a prelude to inspired action.
- Abbott A (1992) Neurobiological Perspectives on Drugs of Abuse. Trends in Pharmacological Sciences, 13 (5), 169.
- Blakemore C (1990) The Mind Machine. BBC Classics.
- Birch D, Ashton H, Kamali F (1998) The Lancet, 352, 785 - 786.
- Buxton P (1998) Drug Use in the United Kingdom. In: The Chemical Generation: Understanding Young People and Drug Use, edited by Paul Buxton. Published by Southwark Diocesan Board for Church and Society in partnership with The National Council for Social Concern, pp 31 - 39.
- Hay D (1987) Exploring Inner Space. Mowbray and Co.
- Koob GF (1992) Drugs of Abuse: Anatomy, Pharmacology and Function of Reward Pathways. Trends in Pharmacological Sciences, 13 (5), 177 - 184.
- Leathard HL (1998) A Christian Perspective on Substance Abuse. In: The Chemical Generation: Understanding Young People and Drug Use, edited by Paul Buxton. Published by Southwark Diocesan Board for Church and Society in partnership with The National Council for Social Concern, pp 87 - 91.
- Mann, J (1992) Murder, Magic and Medicine. Oxford University Press.
- The Guardian (1996) Sorted or Distorted. Friday Review, 26th January, pp 2 - 3.
© Guild of St Raphael