The opioid crisis and fentanyl, the opioid most responsible for drug overdoses, has once again brought addiction into focus. In British Columbia, where the crisis is at its worst in Canada, the overdose death rate from illicit drugs has been rising since 2008. By 2015, overdose deaths had reached 526, a number never seen before in the province, of which 152 were fentanyl-related (29%). In response, on April 14, 2016, BC’s Chief Medical Officer declared a provincial health emergency. Since then, our interventions have focused on reversing overdoses, treating users with opioid substitution medications, educating drug users on the dangers of fentanyl, and funding new treatment beds.

Two-and-a-half years into the health emergency, we appear to have accomplished little. In 2016, there were 667 fentanyl-related deaths, 67% of all illicit-drug deaths. Then, in 2017, there were 1,210 fentanyl-related deaths, 84% of all illicit-drug deaths. Most recently, in the first six months of 2018, there were 601 fentanyl-related deaths, 81% of all illicit-drug deaths (BC Coroners Service, 2018).

Faced with such dismal numbers, not only in B.C. but throughout Canada and the United States, a handful of psychologists have admitted we’ve overlooked fundamental dynamics that underlie the crisis. In a study of 600,000 drug overdose deaths, for example, Hawre et al. (2018) have shown that the current opioid-overdose crisis is not a standalone, discrete event. It is the most recent manifestation of an exponential rise in (American) drug overdoses since 1979, which have included, at various times and places, cocaine, methamphetamine, and other drugs. Rather than focus on opioids, the authors called for elucidating the “‘deep’ drivers of the overdose epidemic” (p. 1188), such as “despair, loss of purpose, and dissolution of communities” (p. 1188).

Despite being labeled by the media and professionals as the opioid crisis, these “‘deep’ drivers” have little to do with a type of drug, its prevalence, or its potency. The crisis is not about a class of drugs known as opioids; it’s about addiction, itself, and specifically the psychosocial drivers that make intoxication appealing, even when users know that the drug leads to severe and chronic suffering (American Psychiatric Association, 2013).

What Hawre and colleagues hint at is that addiction is a response to a meaningless life. Interpreting chronic drug use (including opioids) as a problem of meaning has been a minor topic in addiction psychology. Frankl (1984) is generally credited with stating this idea formally in Man’s Search for Meaning, where he argued that addiction is “not understandable unless we recognize the existential vacuum underlying [it]” (p. 124). In the decades since Frankl’s proposal, research has consistently associated low levels of meaning and purpose with addiction and high levels of meaning and purpose with recovery (Csabonyi & Phillips, 2017; Robinson, Cranford, Webb, & Brower, 2007). Studies have also shown that high levels of meaning and purpose are a protective factor against chronic drug use (Giordano et al., 2015).

In 2006, INPM sponsored a conference on Addiction, Meaning, and Spirituality, based on the proposal that that chronic intoxication was a response to a dull and impotent life. One of the keynote speakers, Stanton Peele, had been unimpressed with the mainstream view of addiction as neurobiological pathology or a consequence of conditioning—“the compulsion to bypass human experience” (Peele, 1998, p. ix). He pointed out that the drug user’s weak self-efficacy, lack of direction in life, superficial relationships, and disregard for others and community was not conducive to living a fulfilling life.

Thompson’s (2016) inductive study at a residential facility for addicted men found that addiction was associated with weak self-definition, poor relatedness, and extrinsic motivations. Roos, Kirouac, Pearson, Fink, and Witkiewitz (2015) found associations between temptations to drink, purpose in life, and drinking outcomes. Although there is no agreed upon theory or model describing the link between meaning and addiction, the body of meaning research in addiction psychology indicates that chronic intoxication is appealing to those who experience life as without significance.

Seeing addiction through the lens of meaning offers insights into the epidemic. For example, if chronic drug use is a response to a lack of personal meaning, then addiction must be in the person, not in the drug. Contrary to popular thought, there is nothing in a drug, itself, that dooms anyone who uses it. The vulnerability for addiction lies in an individual person’s experience of daily life as without meaning and purpose. In fact, the frequent media reports of people overdosing multiple times on opioids or using safe injection sites is not evidence that opioids have hijacked their brains but rather that they can find no reason to quit the drug.

Interpreting addiction as a problem of meaning can also guide interventions. Pursuing meaningful activity, such as volunteering, has been shown effective for recovery (Johansen, Brendryen, Darnell, & Wennesland, 2013), and addressing the existential vacuum is likely, as Frankl (1980) said, a “prerequisite” (p. x) to overcoming chronic drug use. Mikal-Flynn (2015) concluded that interventions aimed at helping people overcome drugs must

promote an individual’s biological, psychological, and spiritual abilities to transform and experience higher levels of functioning—actually brought about by traumas and personal life crises such as addictions and dependencies. These conditions become vehicles, providing opportunities to creatively restructure the self and find significant existential meaning. (p. 144)

Similarly, Diaz and colleagues (2014), confirming the association between addiction and a lack of meaning, promoted creativity, service, and solitude (prayer) as important factors to develop meaning and purpose in life for those recovering from drug addictions.

Compare these meaning-centered approaches to our current interventions. The medical professions and U.S. National Institutes of Health blamed the crisis on physicians (and pharmaceutical companies), who were prescribing too many opioid medications for patients in pain, essentially turning them into addicts. According to this thinking, addiction is in the drug and not in the person. Patients who take enough opioid medication enough times become addicted. When the physician refuses to refill the prescription, the patient is abandoned, left to search out the street dealer. Medical regulatory bodies intervened by making it more difficult for physicians to prescribe opioid medications.

But reducing the crisis to opioid medications does not stand up to scrutiny. Research has consistently shown that only 1-2% of those prescribed opioids actually develop an addiction, although some current research puts the rate at 3-7%. Beyond this addiction rate, research in British Columbia has indicated that overdoses are not limited to opioids, such as fentanyl (76%) and heroin (23%), but also include cocaine (48%) and amphetamines (31%) (BC Coroners Service, 2018).

We’ve given priority to biomedical models: ensuring a supply of naloxone to reverse opioid overdoses, opening safe-injection sites, and expanding the North American Opiate Medication Initiative, which provides medical-grade heroin to users. Indeed, medication is now emphasized more than counseling and psychotherapy to curb the crisis. Medically assisted therapy (MAT) for opioid addiction, such as prescribing opioid replacement drugs (typically, methadone or Suboxone), has historically been combined with psychosocial therapy. Today, however, many consider that MAT, alone, is effective (Brady, McCauley, & Back, 2015; Sheridan, 2017). The problem, and the solution, is a chemical one.

We’ve also intervened by educating drug users on the dangers of opioids, under the assumption that if they knew how risky fentanyl was, they wouldn’t use it. As part of this effort, the B.C. government even provides portable mass spectrometers to festivals and clinics where patrons can test their drugs to detect the presence of fentanyl. Yet, like our other mainstream interventions, education has done little. Clancy (2016) reported one opioid user who overdosed on fentanyl-laced drugs seven times in one day. It’s obvious that a lack of education was not his problem.

The reality is that opioid users usually search out fentanyl. A client I worked with told me, “If I don’t get fentanyl mixed in with my drugs, I consider I’ve been ripped off.” And it hasn’t escaped notice that as the media published more and more stories of fentanyl overdoses, fentanyl dealers did more and more business. It was the best advertising they could have hoped for. Interpreted from within a meaning framework, the reason why some drug users are attracted to fentanyl is precisely because it is so risky. Those suffering from addictions live with a drug-fueled intensity as a substitute for living meaningfully, and it is at the line between life and death that they find life is most intense. For those who can find no meaning in their lives, “Death is,” as the poet Henry Scott Holland said, “nothing at all.” In Vancouver, a new ritual has emerged known as yo-yoing, in which one person injects an opioid drug while another person is ready to inject naloxone in case of overdose.

More treatment beds have been promoted as a solution to the public health crisis (Vancouver Police Department, 2017). The assumption is that once a person is revived from an overdose, or just wants help, then treatment is immediately available. The reality, however, is that most opioid users do not ask for help, even after the near-death experience of overdosing (Kolodyny et al., 2015). Calls for more treatment beds also assume that addiction treatment is quite effective. The reality, however, is that our mainstream treatments have not produced any inspired success rates. Treatment typically helps only 1 in 4 clients keep away from the drug for a year; the rest will reduce drug use by 40 to 60% for a year. Successful treatment is not so much quitting the drug as it is reducing use at a statistically significant level.

At the last meaning conference in Vancouver, Bruce Alexander (2018), one of Canada’s foremost addiction psychologists, complained that our interventions into the opioid crisis are the same as those we used when he first started studying addiction psychology 50 years ago. It’s a discouraging observation, but it makes clear that the addiction field desperately needs new energy. Our failure to curb the crisis is an invitation to recognize that the deep driver of the crisis is not opioid use but a life that lacks personal meaning. If we don’t accept this invitation, it’s guaranteed that we’ll be talking about another crisis when the next popular drug hits the streets.

References

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