A Theology of Addiction and the Opioid Epidemic

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In 2017, the United States Department of Health and Human Services (HHS) declared opioid overdose a national emergency.[1] The situation leading to this official declaration, and the developments since, have been bleak. Statistics from The Centers for Disease Control and Prevention (CDC) indicate that opioid overdoses have increased 70% in the Midwest alone from July 2016 through September 2017.[2] In 2018, 2 million Americans regularly abused prescription opioids, and 128 people died from overdoses each day. Another CDC report in 2016 described a 200% jump in opioid painkiller and heroin overdose deaths since 2000.[3] Although these statistics do not begin to capture the magnitude of opioid abuse in the U.S., the implications are clear: opioid abuse is a public health crisis.

Addiction to opioids and other substances have been viewed under a litany of models. However, two of the most prominent have been the disease and moral, or choice, models. Although the disease model of addiction has largely replaced the moral model of addiction in the literature, reducing addiction to merely a medical phenomenon neglects significant principles of sin and guilt found in addiction.[4] While no model can perfectly describe addiction, an understanding of addictive behavior as an idolatrous orientation away from God must be held in tension with the biological realities of addiction. Models emphasizing the moral aspects of addiction while ignoring addiction’s physiological effects risk an overly simplistic view of addicts’ ability to extricate themselves from their addiction.[5] On the other hand, recognizing the biological issues without acknowledging the moral issues risks minimizing the theological impetus to avoid addictive behaviors.[6]

In this paper, I will argue that a theology of addiction, especially addiction involving substance abuse, understands that the agency of the user is compromised while recognizing that the user retains moral culpability. A theology of addiction should recognize the multidimensional aspect of addiction as it pertains to the biopsychosocial nature of the addiction, rather than merely the spiritual. This tension is necessary to understand the overarching nature of addiction as sin while recognizing the challenging biological changes associated with substance abuse. This article will first examine opioids and the ongoing opioid crisis, also called the opioid epidemic, in the United States. Next, this article will analyze various models of addiction and the significance of models in one’s response to addiction. Finally, this article will construct a theology of addiction through an examination of the Christian doctrine of sin. This theology of addiction can be utilized in reflections on how churches might engage those with addictions amidst the opioid epidemic. While the theological perspectives in this paper are presented primarily from the Reformed tradition, this paper draws broadly from historic and contemporary Christian sources in an attempt to craft a broadly-applicable biblical response to the problems present in addiction.

I. The Ongoing Crisis

A. Opioids

Opioids are a class of drugs whose compounds bind to opioid receptors in the body.[7] Opioids include natural drugs extracted from opium poppy seeds, such as morphine, and synthetic drugs, such as fentanyl.[8] Opioids also include drugs such as heroin, oxycodone (OxyContin), Tramadol, codeine, and others.[9] These drugs are used in cough suppressants and antidiarrheals as well as in regimens to treat chronic and acute pain and pain related to cancer or surgical operations. When opioids bind to receptors in the body, they act as a central nervous system depressant, causing analgesia, sedation, constipation, and respiratory depression. Accompanying these effects is a sense of euphoria, as opioids cause an increased release of dopamine within reward pathways.[10] Opioid users can develop dependence as they continue to take opioids to replicate the euphoric effect. Tolerance can develop within days with dependence following soon after, as the user transitions from taking opioids to achieve a high to taking opioids to avoid unpleasant withdrawal symptoms.[11] Opioid dependence and withdrawal symptoms have also been described in fetuses when a pregnant mother uses opioids.[12] It is important to note that opioid dependence, like many substance addictions, involves physiological changes in the user’s brain as nerve connections adapt to the stimulation from the opioid, resetting the body’s “normal” functioning to account for opioid use.[13]

Regarding the treatment of opioid users, naloxone is used to treat life-threatening nervous system and respiratory depression in opioid overdoses.[14] For treatment of opioid use disorder, drugs such as methadone, buprenorphine, and naltrexone are used to avoid serious withdrawal symptoms while weaning a person off more potent opioids.[15] Even with these drugs to aid in recovery from opioid addiction, researchers still find high rates of relapse in those recovering from opioid addiction.[16].

B. The Opioid Epidemic in America

Opioids have an extensive history with human society, but the precursor to the U.S. crisis is found in the early 1900s.[17] At that time, opioid use, even medically, was socially and legally suppressed.[18] Society viewed opioid addiction as a moral issue, rather than a medical one, and the medical use of opioids for pain treatment remained largely restricted, even as the moral view of addiction morphed into a disease model throughout the Vietnam War era.[19] The restrictive use of opioids for pain changed in the 1970s as pain management became an established field.[20] The emphasis of practitioners on reversing undertreatment of chronic pain, accompanied by the American Pain Society’s campaign advocating that “Pain is the Fifth Vital Sign,” led to more widespread prescriptions of opioids for chronic pain.[21] Simultaneously, opioid manufacturers propagated misleading and unfounded claims on the safety and non-addictiveness of opioids for chronic pain.[22]

These calls for progress in pain management were readily taken up by government bodies and medical societies. Starting in the late 1990s and continuing to today, the effects have been dramatic. The early 2000s saw a massive increase in the use and abuse of prescription opioids.[23] Although the rate of opioid prescriptions began to taper off around 2010 in response to the public health crisis, people dependent on opioids had already begun to shift to heroin, which was cheaper and more readily accessible than prescription opioids.

[24] Today, illicit drugs, such as heroin and fentanyl, remain the primary drivers of the opioid crisis.[25]

II. Models of Addiction

Having discussed the current opioid crisis, this article will now address prominent models for understanding addiction. A medical definition of addiction describes it as a “chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequence, and long-lasting changes in the brain.”[26] Addiction, however, is also used to describe behaviors other than substance abuse, so a more general definition could describe addiction as “behavior over which an individual has impaired control with harmful consequences.”[27] Both these definitions frame addiction as an inherently negative enterprise, and the second one highlights a deficiency in addicts’ ability to control their behavior. As shall be seen, this concept of free choice in relation to culpability impacts the model and response one has towards addiction.

The first model of interest is the moral model, often framed in contemporary settings as the choice or volitional model.[28] This model emphasizes the moral weakness and personal responsibility of the addict engaging in an evil practice.[29] This model would challenge the notion in the second definition that addicts have an impaired ability to control their behavior, instead arguing that addiction entangles the addict only by virtue of the addict’s choice to remain addicted.

The moral model has fallen out of favor, largely because of neurobiological evidence suggesting that addiction alters the decision-making capacity of the addict.[30] The now prominent disease model frames addiction as a neurological pathology. Addicts are not responsible for their addiction, though they maintain culpability for crimes resulting from the addiction, and the solution for the addiction is to receive treatment through medications and psychotherapy.[31]

While the disease model dominates the contemporary conversation on addiction, both models are recognized as being oversimplistic, and various nuances are applied to try to remedy their shortcomings. Some authors adopt the choice model of addiction without including an aspect of moral culpability,[32] while other models emphasize learning and behavioral processes of addictions, rejecting both the moral and disease models as primary frameworks.[33] A plethora of models have reached publication.[34] However, it seems that the specific model of addiction etiology matters only to the extent that people use it to understand the addict’s responsibility.[35] In other words, the exact etiology is not the crux of addiction model debates, as most can appreciate a multifactorial cause of the addiction experience. Rather, the primary concern is in connecting etiology and the responsibility of an addict to end the addiction.

III. A Theology of Addiction

A. The Doctrine of Sin

When examining the nature of sin and addiction, we must begin before the Fall and entrance of sin into humanity. God created humanity no less than “very good” (Gen. 1:31, ESV), the purpose of our creation being “to glorify God, and fully to enjoy him forever.”[36] Thus, humanity was created in a covenant relationship with God. However, humanity lives not only in relationship with God but also with fellow human beings. This is summed up in Jesus’ description of God’s law as the command to love God and love one’s neighbor (Matt. 22:36–40). The fulfillment of humanity’s created purpose in accordance with God’s law is then the glorification and enjoyment of God alone through one’s relationship with Him and through relationship with other human beings.

While humanity was created perfect in pursuit of this good, the liberty endowed by God to Adam enabled him to violate God’s law, introducing original sin—corruption, guilt, and punishment—into humanity.[37] Wayne Grudem further defines sin as “any failure to conform to the moral law of God in act, attitude, or nature.”[38] Sin, thus conceived, is the shattering of the covenant between God and humanity, both the cause and the practice of humanity’s inability to fulfill its purpose in loving relationship with God and each other.[39] Humans, thoroughly affected by “culpable evil,”[40] are lawbreakers.

In describing human longing despite sin, Cornelius Plantinga synthesizes the writings of two major figures in church history.[41] First, he describes St. Augustine’s concept of the summum bonum, the “supreme good” without which humanity cannot be fulfilled. Augustine describes this supreme good of human fulfillment as fellowship God, writing in his Confessions, “O Lord . . . Thou madest us for Thyself, and our heart is restless until it repose in Thee.”[42] Writing further in The City of God, Augustine identifies the end of good, or “that for the sake of which other things are to be desired,” as eternal life, which is gained through “liv[ing] rightly . . . by faith.”[43] Thus, Augustine’s conception of an impetus for goodness is found in the innate longing of all people for eternal life and fellowship with God.

Second, Plantinga supports Augustine’s assertions of human longing for God with John Calvin’s concept of the sensus divinitatis, an “awareness of divinity,” that precludes ignorance of God’s law and instead feeds our longing for its fulfillment.[44] Calvin argues that these yearnings are inescapable, reflecting our created nature even when humans sin by substituting lesser goods in place of God. Writing in his Institutes, Calvin states that idolatry itself is evidence for the sensus divinitatis:

We know how man does not willingly humble himself so as to place other creatures over himself. Since, then, he prefers to worship wood and stone rather than to be thought of as having no God, clearly this is a most vivid impression of a divine being. So impossible is it to blot this from man’s mind that natural disposition would be more easily altered.[45]

Calvin demonstrates a critical connection between humanity’s longing for God and idolatry and sin. Humanity possesses a recognition of the divine, but when God is rejected as the sole object of worship, the sense of the divine does not disappear. It is instead misplaced towards other objects or practices.

Scriptural evidence for a misplaced sensus divinitatis is found in Paul’s epistle to the Romans, where Paul writes in chapter 1:18–32 that God’s “invisible attributes, namely, his eternal power and divine nature, have been clearly perceived, ever since the creation of the world, in the things that have been made,” but that sinful humans “did not honor him as God or give thanks to him, but . . . . exchanged the glory of the immortal God for images resembling mortal man and birds and animals and creeping things” (Rom. 1:18-32). Alec Lucas comments on this passage, noting that it “establishes human culpability for suppressing the knowledge of God, a knowledge manifestly discernible in the works of creation.”[46] This culpability matters in describing a theological framework of sin because a misoriented sensus divinitatis is implicated as the driving force behind idolatry when it is pursued apart from God.

B. Sin, Addiction, and Sanctification

Within this framework of sin, addiction, in its entanglement of the addict toward worldly goods and away from God, should be understood as a practice of sin, an undeniably immoral enterprise. Christopher Cook redirects the conversation of sin and addiction away from choice, the emphasis of most debates regarding addiction, and to its orientation away from God.[47] Against the claims of the moral model of addiction, Cook argues that the moral model fails to account for psychological, social, and biological factors that affect addiction, but he emphasizes that theological engagement does not necessitate a return to the moral model.[48] Rather, theological engagement in addiction provides the groundwork for a sympathetic and explanatory stance towards those struggling with addictions. Drawing from Augustine’s Confessions and Paul’s description of sin and desire in Romans 7:14–25, Cook applies the universal human experience of fleshly struggles against sin to the challenge that the addict faces in seeking freedom.[49] To be sure, not all those who struggle with sin (all people) are addicted, but Cook argues that “the subjective experience of division of will and self is universal and is experienced in different ways by different people.”[50] Although recognized as a struggle against sinful practice, addiction is not simply a question of free choice, as it also incorporates the universal struggle of all human beings against the corruption wrought by original sin. For Cook, the pursuit of God’s grace as a goal transcending the addiction represents Augustine’s description of humanity’s pursuit of the supreme good that is found only in God.[51]

Kent Dunnington offers a Thomistic view of addiction as a habit to describe the behavior of addicts in continuing a practice known to be harmful to oneself.[52] Just as Aquinas, following Aristotle, promoted virtuous habits, or reasoned dispositions, as critical to developing ethical behavior, addiction as a reasoned habit, and not merely a passion, holds explanatory power for the long-term sway that addiction holds on a person, especially when describing relapsing addicts.[53] Like Cook, Dunnington both recognizes a role for theological analysis in addiction and applies the doctrine of sin to this engagement. As was argued previously, sin extends beyond bad choices to encompass states and situations that humans find themselves in.[54] Deeper than individual sinful actions, humanity, through original corruption, finds itself battling a predisposition to rebellion against God.[55]

L. Madison Perry expands upon Dunnington’s argument of addiction-as-habit through an analysis of Calvin’s writings on the person.[56] Perry makes a direct link between humanity’s sensus divinitatis and the misguided worship that defines addiction, arguing that the original corruption affecting all humans does not eliminate this sensus divinitatis. Rather, the sensus divinitatis becomes misoriented in the rebellion of humanity from the worship of God.[57] By characterizing addiction as an extreme habit, Dunnington and Perry establish a tension between the addict’s physically affected agency and cognitive culpability. This recognized tension drives a theological perspective to recognize the complicated nature of addiction as it affects the reasoning and biology of the addict, while still acknowledging the state of addiction as a struggle against sin. This multidimensional perspective understands God’s grace through salvation, humanity’s redemption to its summum bonum, as the only real solution to addiction. However, in contrast to a moral model’s emphasis on choice as the exit from addiction, the multidimensional understanding of addiction presents biology, psychology, and sociology as being of issue, though not fundamentally so. Daniel Mallinson argues that a church’s response to addiction must recognize social and biological dimensions but stresses that a spiritual foundation, salvation and subsequent sanctification, is the only fulfilling answer to addiction.[58] While spiritual regeneration remains the crux of addiction, models espoused by Mallinson, Cook, Dunnington, and Perry recognize the critical importance of care for the biological and communal aspects of the person, especially as the person will never be fully rid of sin and sinful tendencies in this life.[59]

Some commentators disagree with the characterization of addiction as sin. Janet Warren admits that addiction “can be considered a sin,” but does not allow them to be equated, pointing out superficial differences (e.g., that all people have sin, but not all people have an addiction).[60] Interestingly, Warren states that both sin and addiction are rooted in an “avoidance/alleviation of angst through any manner other than trust in the triune God.”[61] While addiction so described ought to be considered a sin with regards to a misplaced sensus divinitatis and summum bonum, it is unclear how Warren differentiates addiction from sin. Similarly, Hans Madueme argues that addiction may involve no sin, such as in the case of a baby affected by prenatal drug addiction.[62] While such a baby is not responsible for the onset of a cocaine addiction, the situation of a continued cocaine dependence would be sin in its wrongful orientation from God. The baby, through no choice of itself, is indeed caught up in sin and requiring of salvation to escape this entrapment.[63] Like all people, this child is called to struggle against a sinful tendency that it did not choose to begin. Moral responsibility in addiction relies on the divorcing of sin from choice, and this distinction is seen both in the universal presence of corruption in humanity’s daily struggle against sinful desire and in specific instances of an addict’s struggle with an addiction. Recalling Grudem’s definition of sin, sin includes corruption in our attitude and nature.[64] Sin and addiction reach deeper than a series of bad choices. As Theodore Turnau describes, sin is radical idolatry and rebellion and can be healed only through the transforming grace of God.[65]

C. The Church and the Opioid Epidemic

The reformed doctrine of total depravity views sin as permeating every aspect of humanity and creation.[66] Yet there is an aspect about creation that remains good because God created it, and what he makes is good.[67] This tension of a created good yet totally depraved humanity is particularly helpful in the analysis of the opioid epidemic. A natural flower, the opium poppy, was investigated for a good and proper intention, to relieve physical pain. Yet a combination of social factors (organized campaigns and reckless pharmaceutical advertising) and biological factors (the effects of powerful opioids like heroin on the body) led to one of the greatest public health crises in United States’ history. These factors certainly do not define the whole of addiction, as many people recover from addictions without medical treatment, and addiction is seen as theologically rooted in a misplaced pursuit of the supreme good.[68] However, these considerations reorient our analysis to understand that addiction is more complex than an addict’s ability to “just say no.” Thus, while theology is the fundamental issue, other factors cannot be ignored in the understanding of addiction, especially when it occurs on the scale of the opioid epidemic.

A theologically minded approach to understanding addictions leaves Christians with a great burden. Addiction as misoriented idolatry in tension with affected agency behooves Christians to seek the healing of those afflicted. Christian engagement with cultural phenomena will differ based on the community within which the engagement occurs.[69] Talking of God in churches looks different than talking of God in the legislature. But, for the Christian, all engagement must proceed from God and His word (whether explicitly or implicitly), for he is the supreme good of humankind. Thus, Christian engagement, both influencing and creating aspects of culture, proceeds from faithfulness towards God’s command to love him and one’s neighbor.

In understanding Christian faithfulness as a love for God and neighbor, churches must not only call addicts to repentance but must themselves identify and mend failures to show Christian love towards those with addictions. From the multifaceted model described above, Christians may exercise loving kindness towards persons with addictions in many domains. (This should occur with humility, for the sin of idolatry is universal and affects even Christians.) Christianity, with its inherent pursuit of the transcendent and its comprehensive understanding of human sinfulness and sanctification, is uniquely equipped to address the spiritual aspects of addiction. Although Cook’s Augustinian philosophical foundation differs from the Thomistic perspective of Dunnington, both identify the fundamental cause and solution of addiction in the pursuit of a transcendent ideal.[70] Particularly in the culture of modernity and postmodernity that denies the presence of transcendent purpose, addiction appears to “[offer] the most powerful available response to this peculiarly modern lack.”[71] In contrast to the lure of addiction as an answer to a culture devoid of transcendent purpose, Christian theology identifies humanity’s pursuit of the transcendent God as the only fulfilling response to the longing that addiction attempts to satisfy. Understanding that sanctification is a lifelong process and that even Christians continue to sin in this life, churches should aid, rather than alienate, Christians who relapse into addictions. Likewise, the broader social domain of addiction should spur churches to provide community for struggling addicts, not just in Narcotics Anonymous meetings, but within the body of the church.[72] Importantly, this theological perspective does not preclude recovery from addiction where the addict remains a non-Christian. Churches may see many addicts recover who are not Christians. Although God’s common grace has allowed them to escape this slavery, Christians recognize that those people are still in bondage to sin without Christ, and their lack of addiction remains an unsolved spiritual problem as long as their sumum bonum is directed away from God.

Practically, churches can seek training to use life-saving naloxone for opioid overdoses. HHS has developed a practical toolkit that outlines these and other action steps that churches can take to address opioid abuse in their communities.[73] In counseling, church leaders should also consider how to guide members who are considering using opioids for pain relief. Although engaging a community trapped in addiction is no easy task, the message of Christianity and the work of churches has and can continue to have a life-saving impact on the lives of addicts.[74]

Conclusion: Not Against Flesh and Blood

Addiction is a complicated phenomenon but fundamentally describes a habit of pursuing a created thing rather than God, the Creator. However, Christians must recognize the tension between the sinful aspect of addiction and the physiological realities of substance dependence. Churches occupy a unique position to serve those with addictions by addressing the fundamental need for God that addictions seek to fill while also aiding in the social restoration of persons with addictions. As addiction occurs on a spectrum—different addictions have varying levels of severity, and the basic root of addictions is the sin of idolatry that all people face—Christians must act in humility, knowing that medical and social support is necessary for addiction treatment, but that only the grace of God can solve the fundamental problems in addictive behaviors.


[1] Mohammadreza Azadfard, Martin R. Huecker, and James M. Leaming, “Opioid Addiction,” in StatPearls (Treasure Island, FL: StatPearls, 2020), https://www.ncbi.nlm.nih.gov/books/NBK448203/.

[2] Marcia Meldrum, “Opioids’ Long Shadow,” AMA Journal of Ethics 22, no. 8 (2020): 729, https://doi.org/10.1001/amajethics.2020.729.

[3] Rosa A. Rudd et al., “Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014,” Morbidity and Mortality Weekly Report 64, no. 50 (2016): 1378.

[4] Christopher Cook, Alcohol, Addiction and Christian Ethics (New York: Cambridge University Press, 2006), 129.

[5] L Madison Perry, “The Word for an Addict in Geneva (Calvin on Addiction),” Christian Bioethics 20, no. 1 (2014): 85, https://doi.org/10.1093/cb/cbu010.

[6] Daniel J. Mallinson, “Tackling Addiction: A Case for Drug Policy Reform Based on Science and Christian Ethics,” Perspectives on Science & Christian Faith 70, no. 4 (2018): 268.

[7] Neelam Grewal and Martin R. Huecker, “Opioid,” in StatPearls (Treasure Island, FL: StatPearls, 2020), https://www.ncbi.nlm.nih.gov/books/NBK551720/.

[8] Grewal and Huecker, “Opiod.”

[9] Cynthia Kuhn, Scott Swartzwelder, and Wilkie Wilson, Buzzed (New York: W. W. Norton, 2019), 237.

[10] Grewal and Huecker, “Opioid.”

[11] Azadfard, Huecker, and Leaming, “Opioid Addiction.”

[12] Grewal and Huecker, “Opioid.”

[13] Dimy Fluyau and Thomas E. Charlton, “Addiction,” in StatPearls (Treasure Island, FL: StatPearls, 2020), https://www.ncbi.nlm.nih.gov/books/NBK549783/; Judith A Toronchuk, “Addiction: Diseased Brain, Divided Will, or Restless Heart?” Perspectives on Science and Christian Faith 70, no. 4 (2018): 224–25; Kuhn, Swartzwelder, and Wilson, Buzzed, 252.

[14] Azadfard, Huecker, and Leaming, “Opioid Addiction.”

[15] Nora D. Volkow and Francis S. Collins, “The Role of Science in Addressing the Opioid Crisis,” New England Journal of Medicine 377, no. 4 (2017): 391–93, https://doi.org/10.1056/NEJMsr1706626.

[16] Grewal and Huecker, “Opioid.”

[17] Sam Quinones, Dreamland (New York: Bloomsbury Press, 2015), 52.

[18] Meldrum, “Opioids’ Long Shadow,” 730–31.

[19] Meldrum, “Opioids’ Long Shadow,”731.

[20] Meldrum, “Opioids’ Long Shadow,”731.

[21] Andrew Kolodny et al., “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,” Annual Review of Public Health 36, no. 1 (2015): 562–63, https://doi.org/10.1146/annurev-publhealth-031914-122957.

[22] Kolodny et al., “The Prescription Opioid and Heroin Crisis,” 562; Quinones, Dreamland, 124–27, 132–39.

[23] Kolodny et al., “The Prescription Opioid and Heroin Crisis,” 562–63.

[24] Bertha K. Madras, “The Surge of Opioid Use, Addiction, and Overdoses: Responsibility and Response of the US Health Care System,” JAMA Psychiatry 74, no. 5 (2017): 441, https://doi.org/10.1001/jamapsychiatry.2017.0163.

[25] Volkow and Collins, “The Role of Science in Addressing the Opioid Crisis,” 391.

[26] Fluyau and Charlton, “Addiction.”

[27] Cook, Alcohol, Addiction and Christian Ethics, 17.

[28] Jostein Rise and Torleif Halkjelsvik, “Conceptualizations of Addiction and Moral Responsibility,” Frontiers in Psychology 10 (2019): 2, https://doi.org/10.3389/fpsyg.2019.01483.

[29] Cook, Alcohol, Addiction and Christian Ethics, 17.

[30] Toronchuk, “Addiction,” 218–19; Lily E. Frank and Saskia K. Nagel, “Addiction and Moralization: The Role of the Underlying Model of Addiction,” Neuroethics 10, no. 1 (2017): 129–30, https://doi.org/10.1007/s12152-017-9307-x.

[31] Cook, Alcohol, Addiction and Christian Ethics, 17.

[32] Rise and Halkjelsvik, “Conceptualizations of Addiction and Moral Responsibility,” 2.

[33] See, for example, Marc Lewis, “Addiction and the Brain: Development, Not Disease,” Neuroethics 10, no. 1 (2017): 7–18, https://doi.org/10.1007/s12152-016-9293-4.

[34] See Dan J Lettieri, Mollie Sayers, and Helen Wallenstein Pearson, eds., Theories on Drug Abuse: Selected Contemporary Perspectives (Rockville, MA: National Institute on Drug Abuse, 1980).

[35] Anna E. Goldberg, “The (in)Significance of the Addiction Debate,” Neuroethics 13, no. 3 (2020): 311–24, https://doi.org/10.1007/s12152-019-09424-5.

[36] Westminster Divines, “The Westminster Larger Catechism (1648): Question 1,” Ligonier Ministries, accessed June 14, 2020, https://www.ligonier.org/learn/articles/westminster-larger-catechism/.

[37] John Calvin, Institutes of the Christian Religion, ed. John T McNeill (Louisville, KY: Westminster John Knox Press, 2011), 2.1.8.

[38] Wayne Grudem, Systematic Theology (Grand Rapids, MI: Zondervan, 1994), 490.

[39] Daniel J. Treier, Introducing Evangelical Theology (Grand Rapids, MI: Baker Academic, 2019), 185.

[40] Cornelius Plantinga Jr., Engaging God’s World (Grand Rapids, MI: Eerdmans, 2002), 51.

[41] Plantinga, Engaging God’s World, 6–7.

[42] Augustine, “Confessions,” in Augustine, trans. Edward Bouverie Pusey, Great Books of the Western World 18 (Chicago, IL: Encyclopedia Britannica, 1952), I.I.1.

[43] Augustine, “The City of God,” in Augustine, trans. Marcus Dods, Great Books of the Western World 18 (Chicago: Encyclopedia Britannica, 1952), XIX.1, XIX.4.

[44] Calvin, Institutes of the Christian Religion, 1.3.1, 1.3.3.

[45] Calvin, Institutes of the Christian Religion, 1.3.1.

[46] Alec J. Lucas, “Reorientating the Structural Paradigm and Social Significance of Romans 1:18–32,” Journal of Biblical Literature 131, no. 1 (2012): 131.

[47] Cook, Alcohol, Addiction and Christian Ethics, 146–47.

[48] Cook, Alcohol, Addiction and Christian Ethics, 163–64.

[49] Cook, Alcohol, Addiction and Christian Ethics, 136–62.

[50] Cook, Alcohol, Addiction and Christian Ethics, 165.

[51] Cook, Alcohol, Addiction and Christian Ethics, 168–69.

[52] Kent Dunnington, Addiction and Virtue (Downers Grove, IL: InterVarsity Press, 2011), chap. 3.

[53] Dunnington, Addiction and Virtue, 81.

[54] Dunnington, Addiction and Virtue, 129.

[55] Dunnington, Addiction and Virtue, 130–31.

[56] Perry, “The Word for an Addict in Geneva,” 90.

[57] Perry, “The Word for an Addict in Geneva,” 87.

[58] Mallinson, “Tackling Addiction,” 271.

[59] Mallinson, “Tackling Addiction,” 271.

[60] E. Janet Warren, “‘I Do Not Do What I Want’: Commonalities in Addiction and Sin,” Perspectives on Science & Christian Faith 70, no. 4 (2018): 258–59.

[61] Warren, “‘I Do Not Do What I Want,’” 259.

[62] Hans Madueme, “Addiction and Sin: Recovery and Redemption,” AMA Journal of Ethics 10, no. 1 (2008): 56, https://doi.org/10.1001/virtualmentor.2008.10.1.oped1-0801.

[63] See Treier, Introducing Evangelical Theology, 157 for a description of responsibility for sin in involuntary acts.

[64] Grudem, Systematic Theology, 490.

[65] Theodore A. Turnau, “Reflecting Theologically on Popular Culture as Meaningful: The Role of Sin, Grace, and General Revelation,” Calvin Theological Journal 37, no. 2 (2002): 275–76.

[66] Ruth Groenhout, “Not Without Hope: A Reformed Analysis of Sickness and Sin,” Christian Bioethics: Non-Ecumenical Studies in Medical Morality 12, no. 2 (2006): 134, https://doi.org/10.1093/13803600600805278; John Frame, Systematic Theology (Phillipsburg: P&R, 2013), 860–62.

[67] Groenhout, “Not Without Hope,” 134.

[68] Dunnington, Addiction and Virtue, 24–27.

[69] Allen Verhey, Reading the Bible in the Strange World of Medicine (Grand Rapids, MI: Eerdmans, 2003), 23–31.

[70] Dunnington, Addiction and Virtue, chap. 5; Cook, Alcohol, Addiction and Christian Ethics, 168–69.

[71] Dunnington, Addiction and Virtue, 101.

[72] Mallinson, “Tackling Addiction,” 270–71.

[73] U.S. Department of Health and Human Services, “Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities,” HHS.gov, August 31, 2017, https://www.hhs.gov/about/agencies/iea/partnerships/opioid-toolkit/index.html.

[74] Brian J. Grim and Melissa E. Grim, “Belief, Behavior, and Belonging: How Faith Is Indispensable in Preventing and Recovering from Substance Abuse,” Journal of Religion and Health 58, no. 5 (2019): 1713–50, https://doi.org/10.1007/s10943-019-00876-w.