Meaning and purpose in the context of opioid overdose deaths

Austin Brown recently tweeted a link to an editorial from Drug and Alcohol Dependence which is, unfortunately, behind a paywall.

The editorial was written by Eric Strain, the outgoing Editor in Chief, reflecting on the research he’s observed in his 15 years as an editor. Coincidentally, it articulates the core message of my blogging over the last 15 years. [all emphasis mine]

He affirms the importance of overdose prevention, arguing it “is a medical, social, and moral tragedy, and there is a personal agony that a drug-related death evokes in family, friends and providers. In response to this sustained and unacceptably high number of overdose deaths, there has been a focus on a number of social and medical strategies to intervene and prevent these deaths. This is a highly worthy goal, and we should not in any way decrease our focus on that goal.“

While asserting the important of overdose prevention, he observes that the field “in both its research as well as treatment efforts is not giving due consideration to flourishing.”

He speaks to the shift in goals that is probably not visible to people outside of the field, “However, efforts to address this have resulted in a focus on decreasing overdose deaths as an endpoint… Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point. We fool ourselves and do a disservice to patients if we allow this to be the measure that allows us to declare success.”

He notes the suffering that is too often invisible in academic discussions and can be obscured in statistical improvements in metrics like overdose rates: “Decreasing the percentage of deaths is a numerical goal that can be quantified and for which achievement can be celebrated when it is attained. A 100% decrease would be ideal, but goals of 30 or 40% decreases seem to be often proposed. And it is worrisome and problematic to think that decreasing the percentage of opioid overdose deaths will solve the problem of opioid use. For patients and their families, it will not.“

He comments on the ways we fail patients with low ambitions and the politics that limit the service array: “Our failure to forcefully advocate that patients need to flourish is tacitly acknowledged through interventions such as low threshold opioid programs, provision of naloxone with no follow up services, and buprenorphine providers who only offer a prescription for the medication. We have alarmingly high dropout rates from treatment with an OUD medication, fail to engage most high-risk patients in treatment, and fail to have broad use and agreement for treatments such as contingency management (CM) despite robust evidence that it doesn’t simply work, but that can be highly effective. Federal impediments further obstruct the use of CM despite its effectiveness.“

He also points to the irony that researchers and providers so often relentlessly pursue meaning and purpose in their own lives while neglecting meaning and purpose for these patients. He notes here that facilitating flourishing is hard work and not easily quantifiable.

Before closing the editorial, he offers readers the following questions to consider:

• “What do patients want, and what would it mean to them to flourish?”
• “Can contingency management be used to help patients flourish?”
• “How do the circumstances of different medications and their delivery enhance or impede a person from moving forward in their life?”
• “What factors (interpersonal, religious, vocational, educational) are most salient to patients with a SUD?”
• “Is flourishing best addressed individually, as a part of a family or community, or in group settings?”
• “How do we understand the biological and sociological mechanisms underlying flourishing, and why do some people flourish, and others do not?”
• “What is the relative role of religious engagement in helping a person with a SUD find meaning and purpose in their life?”
• “Is there a stage in the cycle of substance use when flourishing can take root (the AA concept of bottoming out)?”
• “Are there racial, gender, and other differences in particular themes of meaning and purpose?”

I’d never heard of Eric Strain, but I’ll follow him now. I’m grateful for his message. I couldn’t have said it better.