Grief and Addiction

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According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 20.4 million Americans (aged 12 and older) battled a past year substance use disorder in 20191 while the CDC reported 70,630 drug overdose deaths in the U.S. in 2019.² The psychological and physiological reactions that follow the loss of a loved one are collectively known as grief.³ Estimates suggest each death leaves an average of five people bereaved.⁴

The bereavement process among patients diagnosed with substance use disorder has been an observed reality in clinical practice. Substance use and bereavement are related and common themes: untreated grief might impact high-risk behavior, substance use and recovery treatment outcomes.⁵ Loss of family members, overdose, suicide, and family relationships are unfortunate yet common events in families affected by substance use disorders. Research indicates that alcohol use, mental health concerns and parenting can be affected by the loss of a spouse.^{6, 7} It is important to understand the implications that death and grief can have on the substance use disorder (SUD) population to deliver more adequate treatment.

Usually, we think of grief in individual terms, but events such as the opioid epidemic have had a compounding ripple effect throughout communities, affecting quality of life, economic opportunity, and prosperity. Collective grief can happen when a community, society, village, or nation all experience extreme change or loss. Collective grief can manifest in the wake of major events such as war, natural disasters, or others that result in mass casualties or widespread tragedy. Like individual grief, there is a feeling of lack of control that comes with collective grief.

Impact of Substance Use on Mortality

The full impact of the drug epidemic on U.S. mortality may extend beyond deaths resulting directly from an overdose. Drug use may increase the risk of dying from other disease and injury processes in ways that are not recognized in assignments of underlying or even contributing cause of death. Adverse trends since 2010 in midlife mortality are largely attributable to drug-associated mortality. Recent declines in U.S. life expectancy have been blamed to a great extent on the drug epidemic.⁸ Every day, Americans are dying from fatal drug overdoses, and whether we struggle personally with addiction or not, the likelihood of knowing someone who dies from a fatal drug overdose is high.

A meta-analysis indicated that standardized mortality rates among opioid-dependent individuals are almost 15 times those of the general population; in addition to drug overdose, the most common causes of death among this group were AIDS, trauma, suicide, and liver-related causes (including viral hepatitis), and to a lesser extent, cardiovascular disease, cancer, other digestive diseases, and respiratory disease.8 In a study of patients followed for 19 years after entering specialized treatment for substance use disorders, patients with alcohol use disorder alone died more often from somatic disease than patients with poly-substance use disorders, and all subgroups of patients had an increased risk of death compared with the general population.⁹ All mental disorders are associated with an increased risk of premature mortality compared with the general population, and substance use disorder has the highest mortality rates.^{10, 11}

Grief and Substance Use

Grief and addiction are concepts that are closely intertwined. Complicated grief (CG) has been defined as a deviation from the normal (in cultural and societal terms) grief experience in either time, course, intensity, or both, entailing a chronic and more intense emotional experience, which either lacks the usual symptoms or in which the onset of symptoms is delayed.¹² The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) adopts the notion of CG as persistent complex bereavement disorder (PCBD).³

Estimating the incidence of CG symptoms is not easy since the study has been carried out on different samples and with different definition criteria.¹² However, a study with patients at a treatment center in Spain aimed to determine if the presence of symptoms of CG was more frequent among drug-dependent patients than a control group (non-addicted participants) found that the presence of symptoms of CG among SUD patients was 34.2%, in comparison to 5% in the control group.¹³

Previous research has identified a link between the loss of a significant person, grief complications and substance abuse.^{14, 15} In addition, people with SUD often report personal losses in their life histories that make recovery difficult,16 and are more likely to report complications in bereavement after the loss of a significant individual.¹³

Bereaved children appear to be at elevated risk for later substance misuse, particularly children who experience the loss of both parents or losses between the ages of six and 18 years.^{17, 18} Moreover, the likelihood of developing an SUD is nearly doubled among young adults who experience multiple deaths in a short period.¹⁹

There is a relationship between grief and substance use in a bidirectional way: people with complicated grief have a higher risk of substance misuse, and people with SUD have a higher incidence of loss-related experiences such as death of a loved one and loss of significant relationships.⁷ Substance abusers and dependent populations experience a wide range of drug-related problems, some of which can be regarded as antecedent to such abuse or dependence, others as consequences, and still others as both antecedent and consequent.¹³ These circumstances interact with physical health problems, medical complications and high psychiatric comorbidity among the addicted.¹³ However, the dynamics and directionality of the relationship between CG and substance misuse are unclear and remain relatively unexplored. This lack of research attention is likely due in large part to the use of an SUD diagnosis as an exclusion criterion within the majority of studies examining the efficacy of CG treatments.¹⁵

Understanding the relationship between CG and SUD could have significant implications for current SUD treatment practices. Although previous research has supported the potential benefit of grief treatment for persons with substance misuse,¹⁴ more research is needed to identify interventions that simultaneously and effectively address both conditions.

Grief and Gender

Grief is considered a risk factor for substance use disorder in women.⁵ In particular, death of a significant other or unresolved grief has been found to be a common experience in women with this disease.²⁰ Women in residential treatment for substance use engaged in a grief process group for two hours on a weekly basis. Specific outcomes to this program included greater understanding of grief as well as increased awareness of the relationship between their personal substance use and their grief.⁵ Although research is still pending to understand the close relationship between the aggravation of substance use and death, evidence suggests that women can benefit from interventions to process grief.

A study that analyzed the relationship between bereavement and alcohol consumption accounting for time and gender differences on a national (Hungarian) representative sample found that men bereaved for one year scored higher on two dimensions of AUDIT (dependence symptoms and harmful alcohol use), while men bereaved for two years scored higher on all three dimensions of AUDIT compared to the non-bereaved.²¹ These facts draw attention to the importance of prevention, early recognition, and effective therapy of hazardous drinking in bereaved men.

Research suggests variation in how grief develops across time, and gender may account for some of this variation,²² but very little research has been conducted analyzing the relationship between bereavement, substance use, and gender differences^.21

Grief Issues in Substance Use Disorder

Grief and loss associated with substance use disorder have been connected to early-life losses, losses that occurred while abusing substances, and losses encountered upon entering recovery.²³ To enhance treatment efficacy, it is important to address multiple aspects of grief.²⁰

A descriptive study examined the self-reported losses experienced throughout life in individuals currently receiving treatment for substance use disorders. Results are summarized in Table 1 and include a list of losses that a participant may have experienced prior to abusing substances, while using substances, and upon entering treatment.¹⁶

Loss is a prevalent issue among clients in treatment for substance use disorders. Given that individual response to loss can vary, it is important that clients are provided the opportunity to grieve losses they identify as important to their emotional well-being.¹⁶

Interventions

Positive statistical evidence has been observed in the effects of grief-centered therapeutic work amongst individuals living with both substance use disorders and complicated grief. Group processing and complicated grief and substance use treatment (CGSUT) showed promising results when applied to the treatments of individuals within the demographic. Individuals that underwent treatment using these means reported less depression, a decrease in cravings, and improved optimism versus individuals who did not undergo grief-specific treatment.^14,15

In a study performed by Denny and Lee, individuals were placed in grief-specific therapeutic groups after being administered The Beck Depression Inventory. The experimental subjects were to attend five sessions for three hours each with the experimenter and cofacilitator. Each session utilized predetermined tasks and activities that were decided upon by the facilitators. The first session involved the clients writing a good-bye letter to their deceased loved one, education about the grief process and its connection to behavior, and an exercise where the participants attempted to locate their present stage on those of each other. For the second session, the participants reviewed the grief process and continued sharing about their letters. For the third session, the group continued discussion of feelings, and facilitators guided their movement through the stages of numbness/shock, denial, anger, depression, guilt, and acceptance/reconstruction. The fourth session focused on the participant's early losses. The final session was used to bring closure to the group and for data collection where a second Beck Depression Inventory and a posttest questionnaire were administered. Upon analysis of the results, the participants showed noticeable improvements in acceptance of their losses over a control group that had not received the grief-specific work.¹⁴

Table 1. Percentage of Participants Who Experienced Situations at Each Time Frame

In a pilot study, participants were offered 24 individual sessions of manual-guided treatment for CGSUT, delivered over approximately six months.¹⁵ Three of the participants' sessions utilized Motivational Interviewing to incorporate techniques that included a decisional balance discussion, a values card sort exercise, and a written change plan and five sessions of skills building for emotional coping and communication, which included diaphragmatic breathing, safe-place mental imagery, feeling recording exercises, and skills for listening to and understanding others and for effectively expressing feelings, perceptions, and wishes to others.¹⁵ Other sessions utilized an emotionally evocative revisiting exercise but only with patients who showed no increase in substance use or cravings, and no suicidal ideation after telling the therapist the story of their loved one's death.¹⁵ A comparison was made between individuals who had completed the six months of treatment with those who had not; findings indicated decreased scores on the Beck Depression Inventory as well as a decrease of cravings for those who had completed the treatment. While the study was hindered by a fifty percent dropout rate and a small sample size, it was concluded that this approach could warrant further testing due to its potential to improve client's symptoms.¹⁵

Sandler et al. conducted a six-year follow-up of a randomized controlled trial (RCT) of the Family Bereavement Program (FBP), a 12-session program for caregivers and children following the death of a parent.⁶ The authors explored which aspects of parental adjustment were impacted by the FBP, which factors moderated this impact, and how the FBP affected changes in parental adjustment over the course of six years. Participants in the original RCT included families bereaved by parental death with one or more children between the ages of eight and 16 years. Families were randomly assigned to the FBP or to the control condition, which consisted of a self-study group. This six-year follow-up study examined only parent outcomes.⁶

At six-years post-study and as compared with parents assigned to the self-study control condition, parents assigned to the FBP group were less likely to meet symptom criteria for CG. Between group comparisons also indicated that parents in the FBP group were less likely to demonstrate alcohol misuse. The results of the six-year follow-up supported the effectiveness of the FBP intervention regarding CG and alcohol misuse.⁶

Bereavement Following Drug and/or Alcohol-Related Death

A study by Feigelman et al. investigated how bereaved parents adapt after and are impacted by the overdose death of a child.²⁴ The evidence suggests that parents who lose a child to a drug-related or overdose death encounter much the same stigmatization and exclusionary treatment that suicide survivors confront. The evidence also suggests that these bereaved experience much the same grief problems and mental health difficulties as those bereaved by suicide.²⁴ Valentine et al. described substance misuse deaths as "stigmatized" deaths.²⁵ For the bereaved, they were said to be associated with "disenfranchised grief," which follows a loss that is not, or cannot be, openly acknowledged, depriving the bereaved of the opportunity to share their experiences with others and therefore the opportunity to receive social support.²⁵ A systematic review suggested that family members who were aware of the drug use experienced years of uncertainty, despair, stigma, hopelessness and powerlessness before the loss.²⁶ The results indicate that those bereaved as a result of a drug-related death (DRD) perceived a heavier emotional burden and lacked even more support from their social environment than those bereaved by other types of unnatural and natural deaths.²⁶

Conclusion

The interplay between complicated grief and substance use disorder is a multifaceted issue that can have major impacts on an individual's recovery. Individuals with substance use disorders statistically face high instances of grief, which has been shown to increase use and risk-seeking behavior.^{7, 20} Loss is a prevalent issue among clients in treatment for substance use disorders. Given that individual response to loss can vary, it is important that clients are provided the opportunity to grieve losses they identify as important to their emotional well-being.¹⁶ Ultimately, research that demonstrates the impact of grief counseling on relapse prevention will provide an impetus for infusing grief counseling into models of recovery.¹⁶ Studies have shown that grief-specific interventions such as group processing and CGSUT have had positive impacts on symptoms experienced by individuals with a substance use disorder.^{14, 15}