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3,000 years of Jewish wisdom, 3,000 people seeking healing, and one nice Jewish doctor with messy, curly hair trying to use one to make sense of the other. Take two stone tablets and call me in the morning?

The Torah of Treating People with Substance Use Disorders

Originally delivered as the D’var Torah at Congregation Beth Israel, Vancouver, BC, Canada, Shabbat Yitro, 5784 (February 3, 2024).  Event co-sponsored by JACS Vancouver (Jewish Addiction Community Services). Edited for clarity.

When I was a senior in high school, a band called The Black Crowes released their hit song, “She Talks to Angels.”  The song opens, “She never mentions the word ‘addiction’ in certain company.”

Even so, she must mention the word more often than the Torah does, which is never.  The “Torah” of working with people grappling with substance use must be extrapolated from other topics we encounter in the text, like laws relating to electricity or space travel.  Unlike those twentieth-century inventions, however, addiction has been around since the dawn of time – we just didn’t mention the word.

I don’t specialize in addiction medicine.  I’m a primary care doctor, but in the US (and Canada, I’m sorry to break it to you), substance use disorders are nearly as common as low back pain, headaches, and depression – and often coexist with these three common reasons that people come to see me.  It’s critically important to me, as a believing, practicing Jew who chose medicine because several well-meaning relatives talked me out of rabbinical school, to figure out how to help them in a Jewish way.

One common theme in these visits is that most substance abuse begins not as youthful adventuring, nor as doctors overprescribing pain medication.  While these behaviors provide the person with the tools that facilitate the addiction, the catalyst is a behavior we call self-medication – consciously or sub-consciously treating a pain that I am not very good at healing.

Some self-medication is a person’s attempt to keep pace with impossible demands – to work longer hours, exercise super-human powers of concentration, and produce more revenue for a system that is already swimming in it.  Those demands don’t always come from raw capitalism, though.

Take Moshe in our parsha today.  In Shmot 18:13, “Moses sat as magistrate among the people, while the people stood about Moses from morning until evening.”  When Yitro sees what his son-in-law is doing, he says, “What is this thing that you are doing to the people? Why do you act alone, while all the people stand about you from morning until evening?”  Moshe tries to explain that the people demand this of him, that he has no choice, but Yitro isn’t buying.  “The thing you are doing is not right; you will surely wear yourself out, and these people as well.”

Our teacher Moshe is a workaholic, to borrow a more modern phrase.  Once reluctant to take on his mission to lead the people, he has now so internalized the idea that only he can do the job that he never rests, and never delegates.  And indeed, work can be a dangerous addiction.  The Exodus story has already taught us that the Egyptians oppressed the Israelites with avodah b’farekh, back-breaking labor.  More recently, a study just this past year from the UK found that vigorous exercise in the context of a person’s job, at levels we think of as “healthy” when we do that exercise in our leisure time, makes us less healthy.

That type of overdrive is not only unhealthy on its own, but it also leads to desperate efforts to sustain the pace.  In the movie version of Bret Easton Ellis’ novel, Bright Lights, Big City, the lead character, played by Michael J. Fox, describes his use of “Bolivian marching powder,” cocaine, to keep him from falling behind in his high-powered finance job.  Students with and without ADHD seek out prescriptions for psychostimulant medications, often to the point of developing dangerously aggressive behavior, so they can complete the work necessary to remain competitive – including for the purposes of getting into medical school.

Even when the addictions aren’t illegal, or misuse of legal medications, they push us to places where we feel we are about to fall apart.  A current advertisement on US television for Amazon features the classic Chicago tune, “25 or 6 to 4,” as the backdrop for a sleep-deprived new dad who will do anything he can to stay awake, including ordering what appears to be thousands of dollars in coffee-making paraphernalia from the retail giant.  Raise your hand if you can’t identify with this ad – it will take less time to count you than the other folks.

Other people are self-medicating to feel less, not to do more.  My first two talks this weekend dealt with the effects of trauma and the need to continue working through it.  Certainly, resilience is one of the approaches to trauma, loss, and grief.  Chronic, functional illness is another response, one which our bodies choose for use.  For many, however, the response is to seek numbness.  When handed a joint by a friend at a party, or a script for Percocet by an orthopedic surgeon treating their dance injury, they now have the means to achieve that end.

The Torah tells us about this route also, in Bereshit 9:21: “He (Noah) drank of the wine and became drunk, and he uncovered himself within his tent.”  You won’t see anything about self-medication in the traditional commentary, but let’s think about what Noah was up to before he got drunk.

After the Flood, the story goes that Noah planted a vineyard, picked grapes and made wine.  The kinder commentators explain that Noah was inventing viticulture, the first person to grow wine grapes, and didn’t realize that what he was making would make him drunk (kind of like the drug companies in the ‘90s didn’t realize OxyContin was addictive, right?).  Most, however, seem to think he let himself get carried away.  But why?

Noah was a righteous man in his generation.  Later, when Abraham sees that God is going to destroy Sodom and Gomorrah, he argues with God to save the righteous people – because Abraham is righteous, and he wants God to do justice to the other people who deserve it.  Well, Noah was saved due to his righteousness – if he’s that righteous, wouldn’t he be a little disturbed, just a little, at the sight of his friends, hometown, country, world laid waste by the God who said, “I’m going to save you?”  Wouldn’t he be even more disturbed by the fact that, at least as far as we know, he did nothing to save them?Maybe he couldn’t take it – and knew full well that wine might gladden the heart, but it also erases the memory.

Ultimately, both paths of self-medication, and the despair that drives them, lead to a clouding of judgment.  In Noah’s case, the Gur Aryeh comments on the fact that the word for “uncovered,” “vayitgal,” is from the same root as the word galut, exile: “when a person goes after getting drunk and one’s rational faculties get lost – then one is in exile” – presumably, exile from oneself.  Moshe, on the other hand, was presumably not intoxicated with any substance, yet Chizkuni teaches that:

Yitro felt that both Moses and the litigants would become confused (the words navol tibol, “you will surely wear yourself out,” are connected to the story of Bavel, where language becomes confused). One would shout that he wanted to be heard next and another litigant would also shout. As a result, Moses himself would become confused since he would be unable to hear each person correctly. And they would also be unable to hear what you say.

In other words, in Moshe’s addictive need to judge everything himself, he was rendering himself incapable of rendering sound judgment – and the litigants incapable of hearing it even if he could.

The word for “uncovered” in the Noah story is also connected to the word gil, a word that can mean age, joy, or even someone’s Zodiac sign.  A ben gilo is a person with whom you have something in common, someone whose presence can be healing for you because they are like you in some important way (Talmud Bavli Nedarim 39b).  And in the sense of “uncovered,” it can also mean vulnerable, transparent, or revealed.  Alcohol and other intoxicants may take us away from ourselves – but sometimes in that inebriated state we end up revealing things that are uncomfortable, raw truth.

So the first “commandment,” if you want to call it that, of working with people who have substance use disorders is finding that gil that we share, in the sense of commonality. 

Who raised their hands when I asked about not identifying with the Amazon ad?  OK, all of you are excused.

As for the rest of you, just acknowledging that you know how that guy feels about coffee, that you identify with the thought that you must have another cup of coffee or you will not be able to function, is a powerful tool.  The substance may be different, but the feeling of dependency on something that you no longer control is a shared gil, in the sense of a vulnerability.  We are not, after all, so different.

Our health center employs multiple peer support specialists, a category of trained mental health workers who have experienced the same trauma or life stress as the people they work with.  Two men who are themselves in recovery bring tremendous strength to the people they meet with – even across cultures where admitting to drinking alcohol at all is taboo.  Many programs training certified drug and alcohol counselors go even further, requiring all their students to be on their own recovery journey (including a few of my patients, I am proud to say).

The second “commandment” is to tell ourselves the stories we just read.  Traditional understandings of Torah may disagree on the details but are uniform in understanding that we are learning about flawed humans.  If we recognize that among those flaws were behaviors we recognize as addictive or self-medicating, how can we then have contempt for anyone we care for who is not somehow more perfect than Moshe Rabbenu or Noah?

This empathetic view of the person suffering from a substance use disorder is in keeping with the principle of rahamim, mercy.  Rabbi David Hartman taught, “Medicine brings rahamim into social political reality.  In coming inside the walls of a hospital, one intuitively needs to feel confirmed as a human being.  One does not want at that moment to be reminded that one is poor or rich, black, or white, Catholic or Protestant, Jew or Arab.”  To which we could add, sober or “an addict.” 

But Hartman taught in the very same article, “on account of din (justice, the principle that counter-balances rahamim in the world) the doctor invites the patient to become responsible . . . the patient is enabled to discover resources within the self to find ways of navigating through the hazards of life.”  Vayikra 19:17 teaches, “You shall not hate your kinsfolk in your heart. Reprove your kin but incur no guilt on their account.”  We are required, not just permitted, to chastise someone for their behavior – but not to do so in a way that is cruel, causes them public embarrassment, or arises from a place of malice.  The third “commandment” of treating people with substance use disorders is that we need to love, care for, and value them – even as we set and enforce limits and expectations. 

Our program to treat opioid use disorder with buprenorphine or naltrexone, both highly effective opioid-like medicines shown to help people break free of their addictive behaviors, requires engagement with a mental health professional, regular attendance at appointments, and short-duration prescriptions that can only be lengthened after establishing a record of reliability and urine-tested abstinence from non-prescribed opioids.  On the other hand, in a departure from older programs using the same tools, we do not punitively dismiss people for having “dirty urine” or use shaming language to convey our disappointment.  A misstep results in deepening the relationship between the patient and the provider because it returns them to more frequent visits and a deeper dive into what is troubling the patient.

This approach suggests a fourth “commandment” of doing this work, one which comes from the same chapter in Vayikra as the third one: “you shall not . . . place a stumbling block before the blind.”  We’ve already seen how living with an addictive disorder can cloud judgment, and that clouding can render a person oblivious to threats to their sobriety even when they’re doing well.  I spend a lot of time cajoling people into continuing therapy, attending AA meetings, or accepting the medications I mentioned above, because I have seen them “stumble” when they try to “do it on their own.”  Even my judgment gets clouded into believing that they don’t need these things sometimes, to forgetting that these diseases are every bit as lifelong as diabetes or Parkinson’s, and I am nearly always reminded the hard way that they are not cured.

However, some of the stumbling blocks to sustained recovery have come from the punitive practices I talked about above.  When we turn away a patient who is late for their monthly naltrexone injection, refuse to refill a buprenorphine prescription for “dirty urine,” or shame a person with our language so that they disengage from the program, the most likely outcome is that they will resume using their drug of choice.  The most dreaded outcome is that they will use that drug for the final time, out of options and out of hope, and die of an overdose, a drug-induced fatal accident, or by suicide.

Rabbi Yehudah HaLevi wrote, “And in my going out to meet you, I found you coming toward me.”  With all the shame attached to these illnesses, many people who suffer with them do not “go out to meet us.”  We need to “come toward them,” using validated screening questionnaires and neutral language to let people know that it is OK to share that information with us and be trained and prepared to offer treatment when they do share.  The US only recently dropped the requirement for prescribers to hold a special “X-waiver” to prescribe buprenorphine, even if they were licensed to prescribe powerful opioid painkillers through the DEA.  That requirement severely limited the human resources available to treat these disorders.  Even with that looser requirement, there is no universal training in prescribing addiction treatment medications; providers need to seek it out or be in training programs that have made it a priority.

 Only by creating policies and procedures that “come towards” the person with the addiction, instead of walling off the treatment behind high barriers made of stumbling block after stumbling block, can we hope to help a substantial number of people with these illnesses.  Beyond that, our “fifth commandment” of treating substance use disorders is to treat them, to make this kind of care, this kind of medicine, something that all of us do, whether we are professionals prescribing the medicine or friends staging an intervention, or holding someone steady while they go through withdrawal.

These are, after all, fatal illnesses, as we discussed a moment ago.  Sometimes the death is accidental, by suicide or by some violent entanglement, and sometimes a suicide.  Very often these deaths happen within days, even hours, of a person visiting a medical provider, one who could not see or did not address the disease.  One of my biggest gaffes as a doctor, fifteen years ago and thankfully not a fatal one, was draining an abscess on the top of a patient’s foot, just between the tendons leading to their first and second toes.  Three weeks later the same patient came back walking 100% better and said, “OK, now can we talk about my heroin addiction?”  I hadn’t a clue that the abscess was a tell-tale sign of injection drug use when all the other veins except those huge ones in the foot were scarred beyond use.

Even our workaholic leader Moshe suffered from a passive death wish at times.  As he is leaving Midian to return to Egypt and face Pharaoh in Shmot chapter 4, the text tells us that he met God at an inn along the way vayivakesh lehargehu, “And he tried to kill him.”  Why on Earth would God try to kill Moshe just as he is headed to do a task that God sent him to do?  My friend Dr. Brian Primack, himself something of an expert on addiction and despair (he studies the negative health effects of social media)[1], taught me that the Biblical criticism scholar Richard Elliot Friedman thinks this means that Moshe asked God to kill him rather than make him go through with what was ahead of him.  Later texts bear this out when in Bamidbar, Moshe tells an angry God that if God plans to destroy Israel, God had better finish off Moshe as well.

The verse in Vayikra adjacent to our verse about rebuke is one many of you know: “Do not stand idle on the blood of your neighbor.”  There isn’t anyone else coming to help; substance use treatment and mental health support are sorely lacking in your country, my country, and everywhere else in the West.  We don’t have the luxury of saying we don’t know what to do – we have to learn, learn fast, and do it, because there are lives at stake.

Which I guess implies one final “commandment.”  After upbraiding Moshe for his workaholic behavior, Yitro demands he share the burden of his work with other, subordinate judges.  Apparently, these other leaders are finally able to lighten his load, hopefully enough to allow him some time with his family, who according to Mekhilta D’Rabbi Yishmael had not seen him the entire time he was back in Mitzrayim lobbying Par’oh to let the people go.  Yitro practically has to reintroduce him to his own wife and children, who barely recognize him.

I’ve written many times about finding the strength as professionals – and as a community – to sit with people in trauma and in sorrow and be with them in that space.  Having recognized that so much of addiction is self-medication when life demands the seemingly impossible, let us resolve to help our loved ones and our neighbors handle those demands with something other than “Bolivian marching powder” or “milk of amnesia.”  The Bhutanese-Nepali culture is fond of telling Westerners, “A friend is a psychologist.”  So let us follow the advice of Pirke Avot: wherever we see someone in distress, k’neh l’kha haver – acquire yourself a friend.  Don’t let them go through it alone.

If this essay moves you, let it move you to befriend someone grappling with an addiction, or to contribute to a local organization providing support for addiction treatment and recovery.  For those in Canada, JACS can be found on the web at: https://www.jacsvancouver.com/support-jacs/.


[1] Brian’s book, You Are What You Click, is available at https://www.chroniclebooks.com/products/you-are-what-you-click.

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