Dying Without a Dream


Drug use is not only a consequence of addiction. It can also be a response to a deeper, existential problem.



His explanation was clear enough. I was just unable to process what he said. The young man was there for a follow-up outpatient visit, his third since he had been discharged from a 30-day residential substance abuse program. His original ticket to the program had been a short detoxification stay in hospital after an opiate overdose. The overdose had been a close call. The fast action of the paramedic administering naloxone was the only thing that kept him alive.

He was the youngest son of faculty members at a private high school and appeared to have been raised well, in a liberal sort of non-pressured way. Not particularly motivated by his own hopes, he had a bachelor’s degree in fine arts and steady job as a waiter at an east-Asian restaurant. The restaurant’s owner, a motherly figure, gathered the staff together after the restaurant closed for the night and insist that they sit together at the biggest table and consume remarkable portions of the best food as she urged: “Have some more! Have some more!”

Author photo

This event was perhaps the only socially engaged moment of his week. He lived with a person who he referred to as his girlfriend, but neither of them seemed committed to the relationship. I had noted, but not made much of, the seeming emptiness of his life in prior visits. Even with that caveat, during the prior follow-up visits, I had been able to check all the boxes that represented the agency’s aspirations for his success. He had reported neither cravings nor any sense of missing opiate drugs.

He now described to me his most recent overdose and the experience of coming to consciousness in the ambulance as he was being transported to the hospital emergency department. This time the hospital did not even bother to admit him or notify us that he had overdosed again. Both he and his girlfriend were (to use his term) messing with fentanyl. He was amused at the amazement in my voice when I asked why. “There was nothing good at the movies,” he replied. Yes, they knew that fentanyl was deadly. Still, that risk was part of the fun for them. Not quite as definitive as Russian Roulette, but certainly life-endangering. So, for a second time, his life had been saved by naloxone, which ambulances had only started carrying 10 years ago.

That moment of dumbfounded amazement was my introduction to the opioid crisis, which seems to have only gained momentum since that time. Opioid overdose deaths rose steadily from that date to 2018 when we saw a “significant decrease … to 46,802 deaths.”1 Most prognosticators are suggesting that the death rate will rise again as the result of COVID-19, with its emotional stress and enforced lack of productive activity. The medical establishment’s journals and editorials have bemoaned the overly casual prescribing of pain medications as the initiating cause of this great disaster. A regiment of state attorneys general have joined in suits against big pharmaceutical companies for promoting use of high-potency opioids and have impressed juries with their arguments. The accepted story line is that individuals with addiction are being victimized by the availability of opioids in the country.

In my opinion, the media, as well as much of the institutional health effort, has described the opioid epidemic as if it is outside of the larger picture of what some are calling deaths of despair. In the year 2018, deaths from heroine (15,000), methamphetamine (13,000), cocaine (15,000), alcohol (88,000),2 and suicide (47,000)3 are rising right along deaths due to opioids.

Perhaps it is only a partial truth, but is it possible that individuals who die of these causes do not feel that their own lives are worth protecting? The authorities that society has charged with understanding this rolling disaster are self-motivated and curious individuals who have achieved much in their lives. Is it possible, then, that the existential experience that one’s own life is not worth protecting is so distant from researchers’ experiences that they simply do not or cannot have the imagination to explore this possibility.

The September edition of Psychiatric News reports: “Emergency department patients who survive an opioid overdose are 100 times more likely to die of an unintentional overdose and 18 times more like to die of suicide within a year than patients who visit the emergency department for other reasons.”4 In addition, “of the 21,080 who were revived from an opiate overdose by ER visit, 368 died within a year of an unintentional overdose,” and another 29 died of what was judged to be an intentional opioid overdose. Other research quotes similar sequences for those revived from sedatives and hypnotics. The conclusion offered is: “patients who survive an opioid overdose, whether unintentional or intentional, should be carefully evaluated for substance use disorders and suicide risk …[and ]… receive appropriate referrals for follow-up substance use and mental health care.”4

The previously mentioned study (and many like it) do not explore the possibility that there might be something other than the standard explanation of substance use disorder. Is it not possible to ask whether these individuals are trapped in a world that provides no sense of meaning or engagement for them? Without a sense of meaning or engagement, they might have no reason to protect their own lives and, like the young man who initiated me to this world of despair, would be as happy messing with fentanyl as they would be to go to a good movie in the evening. Spending more money on drug rehabilitation will not move the needle on the death rate for such individuals.

In this conversation I find the pastoral care literature much more relevant than the psychiatric literature. That literature carries the concept of an orienting system. Orienting systems, or how we think about ourselves, are a specific theme of these Mind-Body Alliance columns. Orienting systems are defined as: “Embedded beliefs and values, perhaps outside of one’s awareness but enacted in one’s practices, especially under stress.”5 The idea of orienting systems is more specifically defined by the psychologist Kenneth Pargament, PhD. I first learned of his work when he presented the Oskar Pfister Award Lecture at the 2009 American Psychiatric Association Annual Meeting.6 His work recognizes that the orienting systems of each individual can be very different. Some are deliberate beliefs that have been taught in formal religious education, but most of them have been informally taught in the school of experience or absorbed by imitation of parents. No matter how a person has assembled their orienting system, Pargament says it must meet 4 criteria7:

1. Must be complex enough to bear the weight of suffering.

2. Must integrate one’s values and beliefs with one’s actual practice.

3. Must be a flexible enough spiritual basis to cope with stress.

4. Must incorporate beliefs of the goodness of life or goodness of God that foster self-compassion and compassion for others.

The idea that healing from addiction involves spiritual practice is not a new idea. Alcoholics Anonymous (AA)’s The Big Book of makes repeated references to spirituality. In an appendix written shortly after the first edition emerged in 1939, spirituality was explained in this way8:

Quite often friends of the newcomer are aware of the difference long before he is himself. He finally realizes that he has undergone a profound alteration in his reaction to life; that such a change could hardly have been brought about by himself alone. What often takes pace in a few months could seldom have been accomplished by years of self-discipline. With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves.

The AA movement continues to be the most effective and most accessible program for alcoholism. Modifications of this format are now widely used for other addictions as well. With the concept of orienting system as our lens, my reading of The Big Book concludes that the conscious intent of the program was to support individuals in replacing an experience of vacuity with a strong sense of self. I hasten to say not an inflated sense of self, but a self that acknowledges and claims its own scars and wounds. To reflect back to Pargament, a self that is complex enough to bear the weight of suffering, and still claim that life itself is good. Traditional religions, whatever their shortcomings, did convey this sort of orienting system to their adherents. The liberal tradition, wishing to free itself from the baggage of a supernatural lawgiver, appears to me to have not figured out how to sustain the function of incorporating individuals into a functional orienting system.

With some 64,000 individuals dying annually from self-administered recreational drugs in the United States, perhaps the solution lies outside the narrow understanding of medical addiction management, with its focus on dopamine reward systems. Is it possible with our national concern for separation of church and state to work through government funded programs to work on the issue of vacuous lives? Or are we locked into rules that will require us to continue to spend money on things we consider totally secular to deal with a problem that is at base a question of meaning?

This set of columns is titled “Body Mind Alliance: How We Think About Ourselves.” Up to this point I have been referring to how our patients think about themselves. We can, of course, flip the lens and inquire as to how we think about ourselves. What is the orienting system upon which we ourselves rely? Is it not true that we are almost always blind to our own orienting systems and too easily assume that our patients think about themselves in more or less the same way that we think about ourselves? And how is it that we can manage to catch sight of our own orienting system since it is so fully integral to ourselves? Would I have ended up with an understanding of my own orienting system if I had followed the advice of my residency faculty and gone into analysis as my co-residents did? Do we not often lose track of the fact that how we think about ourselves is intensely individual? The parallel to that statement is that how our patients think about themselves is intensely individual and beyond our control or prescription pens. To the degree that we assume the normative nature of our own orienting systems when we talk about deaths of despair, we will altogether miss the main conversation.

Dr Gilbert is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

The opinions expressed in this article are those of the author and do not necessarily reflect the opinions of Psychiatric TimesTM.

What do you think? Do you have an orienting system? Is the field’s approach to treating addiction missing the boat? Share comments with your colleagues by emailing PTEditor@mmhgroup.com. Comments may be shared online pending review and editing for style.


1. National Institute on Drug Abuse. Overdose Death Rates. March 10, 2020. Accessed November 24, 2020. https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. National Institute of on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. Updated October 2020. Accessed November 5, 2020. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

3. National Institute of Mental Health. Suicide. Accessed November 5, 2020. https://www.nimh.nih.gov/health/statistics/suicide.shtml

4. D’Arrigo T. Risk of suicide, unintentional death soar after nonfatal overdose. Psychiatric News. 2020;55(17):24.

5. Doehring C. Practice of Pastoral Care. Westminster John Knox Press; 2006.

6. American Journal of Psychiatry. 2009;167(2)226:232. Accessed December 15, 2020. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.167.2.226

7. Pargament K. Spirituality: a pathway to posttraumatic growth or decline? In: eds Calhoun L, Tedeschi R. Handbook of Post Traumatic Growth: Research and Practice. Routledge; 2006:121-138.

8. Wilson W. Alcoholics Anonymous: The Big Book. Ixia Press; 2019.

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