The Many Victims of Substance Abuse

| September 5, 2007 | 0 Comments

by Tara Mauro, DO

Series Editor: Paulette Gillig, MD

Drs. Mauro and Gillig are from the Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Abstract

Substance abuse is a complicated disorder and has far reaching consequences. The victims of substance abuse extend beyond the unfortunate ones suffering from this disorder and often include family and friends. Treatment options for substance abuse are many; however, positive outcomes are not always guaranteed. Many factors play into the potential for successful treatment. Some of these include the adherence and motivation of the substance abusing patients as well as patients’ surrounding environments and support systems. In this article, we present a clinical case of opioid dependence and discuss various treatment options and modalities. We will discuss different variables that may maximize positive treatment outcomes. Also a review of the current literature regarding substance abuse treatment, psychotherapy with the drug abuser, and grief therapy should the substance abusing patient die for the surviving family members will be presented.

Key Words: substance abuse, psychotherapy, grief, detoxification, motivational interviewing, family intervention

Clinical case

Tom called his father to tell him that he was going to a friend’s graduation. He then proceeded to call his drug supplier seven times.

At age 17, Tom had his whole life ahead of him. He enjoyed hanging out with his friends, of which he had many. He had a knack for fixing anything that was electronic. He was handsome (but didn’t like his freckles). Tom loved his family and his black German Shepherd dog—a love his family returned unconditionally. But, he had a terrible secret life he kept hidden from his family.

Typical signs of opiate abuse

The behaviors that are seen in the presence of drug addiction, especially opiate addiction, are due to a loss of control over the use of a drug. This results in excessive and continuous use of the drug despite the negative consequences. The drug becomes the center of the user’s life, despite adverse consequences. The pattern of addictive use begins with preoccupation with acquiring the drug, followed by compulsive use, and finally a pattern of relapse. The commonly accepted criteria of addiction are as follows: Using larger doses for longer periods of time; persistent desire or unsuccessful attempts to cut down or control the substance use; preoccupation with attaining the drug; abandoning or decreasing important social, occupational, or recreational activities; and using the drug despite knowledge of adverse physical or psychological problems caused by or exacerbated by it.[1]

Patients with drug addiction also allocate their income to buying drugs at the expense of required items. Their relationships suffer because the addicted persons are preoccupied with getting and maintaining their addiction at the expense of their family and friends. The addicted person becomes emotionally unavailable and not invested in previous relationships. The person may also lie or engage in illegal activities to obtain drugs.[1]

Family members may notice sudden personality changes that include abrupt changes in work or school attendance; outbreaks of temper; changes in overall attitude; and a loss of interest in what was once favorite hobbies and activities in favor of more drinking or partying activities. The patient may begin to talk a great deal about alcohol or drugs, and may come to believe that he or she needs to drink alcohol or use drugs in order to have fun. The addicted person often pressures others to drink or use drugs.[1]

In general, addicted persons show difficulties in concentration and paying attention. They may reveal sudden jitters, nervousness, or aggression and become increasingly secretive. Slurred speech is common, as is memory impairment and loss of coordination. There may be a deterioration of physical appearance and grooming, wearing of sunglasses at inappropriate times, and continual wearing of long-sleeved shirts to hide track marks due to intravenous needle use. The person begins to associate with known substance abusers, will begin unusual borrowing of money from friends, coworkers or parents, and stealing small items from employer, home, or school.[1]

Eventually, the addicted person is not able to keep promises to stop or cut down use. He or she gets high or intoxicated on a regular basis. The person lies about use, especially about how much or how often he or she is using drugs or alcohol. The person becomes defensive or angry when confronted about use. Risk-taking increases, such as driving while high on drugs or when drunk or taking sexual risks. The person may have periods of time that he or she cannot remember.[6]

Clinical case, continued

As a child, Tom enjoyed the usual childhood activities, such as swimming, Boy Scouts, and skateboarding. In his early teens, Tom lost interest in school and dropped out, but with his family’s urging earned his GED and talked about getting his education back on track, going to college, and earning a writing degree. He concealed from his parents the fact that the money he received from his family was used to support an increasingly severe drug habit, starting with marijuana and later experimentation with hallucinogenic mushrooms, “speed,” and “acid.” He then moved on to using heroin. This became his drug of choice, and Tom was able to keep his heroin addiction hidden from his parents for some time, despite living in their home.

He finally had such a high tolerance for the drug, however, that he could not keep up with his habit financially. Tom would wake up at 4 or 5:00AM in order to steal from others out in the community so that he could support his habit. Eventually, his parents recognized his drug addiction and, upon his mother’s insistence, he was admitted into a drug rehabilitation program. He went unwillingly, but stayed in the rehabilitation unit for a year. He then went to an outside residential program for another six months.

Unfortunately, upon discontinuation of the program, Tom relapsed and started getting “sick” and not showing up for work, which at the time was not characteristic of him.

One day, Tom called his father from a bus station. When his father arrived there, he was shocked by Tom’s appearance. Tom was black and blue and very confused. His father took him to an urgent care center, where he was diagnosed with rhabdomyolysis, which was caused by a loss of consciousness after Tom injected a mixture of heroin and another toxin and then lay on his arm for at least 24 hours. This subsequently led to a long period of hospitalization for renal failure.

Approaches to the treatment of Substance Abuse

Detoxification options: Inpatient, partial hospitalization, outpatient. Detoxification refers to the process whereby an individual who is physically dependent on a drug is taken off that drug either abruptly or gradually.[6] Because few narcotic-addicted patients stop their drug habit after detoxification alone, detoxification is usually viewed as pretreatment or, in other words, the first stage of treatment. Successful outcome criteria for a detoxification program may include minimal discomfort, safety, a high number of patients completing the treatment, and, finally, a high number of patients going on to long-term treatment.[6]

Addicted patients are often unrealistic about being able to remain drug free and believe that detoxification is all that is necessary to get rid of their habit. When they return for a second or third time for detoxification, they are often more realistic and are usually more willing to consider long-term treatment. An example would be a 12-step group such as Narcotics Anonymous (NA) or Alcoholics Anonymous (AA). Studies show that a patient’s chances of remaining drug free are much greater if he or she completes a treatment program and then continue in a 12-step program on a regular basis for an extended period of time. In these programs, patients can gain a greater understanding of their addiction, learn new coping skills, and receive assistance in making the personal and behavioral changes needed for recovery. These objectives are accomplished through didactic, group, family, and individual therapies, as well as treatment of any comorbid medical or psychiatric conditions.[6]

Detoxification can take place in an inpatient, partial hospitalization, or outpatient setting. Outpatient detoxification is the least expensive of the three and enables the patient to remain at work and to carry on his or her life. It forces patients to cope with the home and/or work settings where they will be after they have become drug free. The disadvantages include (1) being surrounded by temptations at a time when the patient is least able to handle them, (2) greater difficulty assessing and dealing with other medical conditions, and (3) the possible need for detoxification to proceed more slowly.[6]

Inpatient detoxification has the advantages of (1) taking place in a protective setting where access to drugs or even to craving-inducing stimuli are absent, (2) allowing the patient to be observed more closely for possible medical problems or complications of withdrawal, and (3) more rapid withdrawal from substances. The disadvantage is primarily the cost, but also the disruption of the patient’s life and the need to be away from work and home. Day programs are considerably less expensive than inpatient programs but unfortunately, they are relatively uncommon, and the clinician is usually forced to choose between inpatient and outpatient, with the decision is often based on factors like insurance coverage and availability of programs in the community.[6]

Detoxification from heroin and other opiates. With heroin, or other short-acting opiates, withdrawal begins with anxiety and craving about 8 to 10 hours after the last dose. This progresses to dysphoria, yawning, lacrimation, rhinorrhea, perspiration, restlessness, and broken sleep. Later, there are waves of goose flesh, hot and cold flashes, aching bones and muscles, nausea, vomiting, diarrhea, abdominal cramps, weight loss, dilated fixed pupils, and low-grade fever. The heroin withdrawal syndrome reaches its peak 48 to 72 hours after the last dose, and the acute symptoms usually substantially subside after five days.6 Subtle disturbances of mood and sleep can persist for weeks or months. The severity of the withdrawal symptoms depend on what drug is used, the short-acting opiate heroin has a more intense, but shorter withdrawal period. The longer-acting drugs, such as methadone, have less intense but longer lasting withdrawal symptoms. The larger the amount of drug used, the more severe the withdrawal. Clinically significant withdrawal requires daily use for at least three weeks.

Psychologically, the patient’s personality and state of mind can also influence the withdrawal severity, as can general physical health and ability to handle stress. Fatigue, dysphoria, irritability, and insomnia may all lead to a state that increases the likelihood of relapse.[1]

Treatment of withdrawal includes clonidine, a non-opiate alpha-2-agonist that decreases sympathetic outflow in the body. Clonidine can reduce opiate withdrawal in an outpatient setting by 50 to 75 percent, if given in adequate dosages. Generally, oral clonidine at a dose of 0.1mg as needed are given daily, and a 0.2mg clonidine patch is used weekly for 1 to 2 weeks.[1] Doses should be held if the patient is too sedated, if he or she experiences orthostatic hypotension, or if the blood pressure drops below 90 systolic or 60 diastolic. Clonidine is better than methadone for detoxification because post-withdrawal rebound that can cause relapse is less likely to occur, no special license is needed, and visits to the physician can be less frequent.[1] It is not effective, however, for muscle aching, nervousness, or irritability.

Benzodiazepines, such as diazepam, work at the GABA-A receptor and are used to relieve agitation, insomnia, muscle aches, and cravings. Doses are typically 5mg of diazepam four times per day as needed for 48 to 72 hours, although this can be given for longer periods of time, depending on the severity of the withdrawal.[1] Oxazepam may be used both for the muscle aches and as well as the insomnia. Because of the abuse potential it is best to limit use to 1 to 2 weeks. This includes flurazepam as well. Diphenhydramine and tricyclic antidepressants, such as amitriptyline and doxepin, can be used for insomnia as well, and for a longer period of time.

Other medications used for helping with opiate withdrawal are hydroxyzine 50mg or trimethobenzamide 250mg orally or 200mg rectally for nausea and vomiting. Loperamide 4mg is used for abdominal cramping while acetaminophen or ibuprofen is used for headaches and other pains.

Naltrexone is a mu antagonist and has been used in conjunction with the above medications for an accelerated detoxification. The advantage to this is shorter withdrawal time with the lower costs. Typically, a 12.5mg dose is used the first day, with an increase to 25mg on the second day and 50mg on Day 3.[1] Some motivated patients may also want to be maintained on naltrexone at a dose of 50mg daily to help maintain abstinence from opiates. The side effects of naltrexone include abdominal pain, headache, insomnia, anxiety, nausea, and vomiting. A more serious problem is potential hepatotoxicity, especially if the dose is increased above 50mg. Liver enzymes should be monitored monthly for at least six months and every 2 to 3 months thereafter if the enzymes are normal. Naltrexone is contraindicated in patients with severe liver disease, such as hepatitis, and in those taking opiate agonists.

For a rapid withdrawal from heroin or methadone, a combination of clonidine and naltrexone can be used. The patient is premedicated with clonidine and oxazepam; an hour later, naltrexone is initiated. Clonidine at 0.1 to 0.2mg up to 1.2mg and oxazepam 15 to 30mg are given every 4 to 6 hours as needed.[1]

Opiate medications, such as the long-acting methadone, can be used for detoxification from other opiate medications. They are effective in reducing symptoms of opiate withdrawal, especially for intravenous opiate users, and can be used instead of the above-mentioned medications. Generally 10 to 20mg of methadone are given on the first day. If the person experiences withdrawal, the dose can be increased by 10mg increments to 20mg to 40mg per day for duration of withdrawal. After that, the methadone is tapered in 5mg to 10mg decrements to zero levels.[5] There can be problems withdrawing from the methadone, such as a decrease in the addict’s subsequent motivation to become drug free.

Another challenge is that methadone can only be dispensed in the US by clinics that are licensed by the Food and Drug Administration and Drug Enforcement Agency; therefore, this limits its use by physicians. Also, methadone may cause adverse events including joint pain, muscle pain, elevated transaminase levels, vertigo, diarrhea, rigors, jaundice, abdominal pain, swollen lower legs, appetite loss, insomnia, joint pain, vomiting, respiratory difficulties, headache, potential for overdose, and death (Table 1 and Table 2).

Buprenorphine. Buprenorphine, a semisynthetic, long-acting opioid, offers a decreased overdose risk compared to methadone because of its partial agonist properties at mu-opioid sites. Buprenorphine is approved for office-based use in the US. A shift to buprenorphine-based approaches has a potential to reduce methadone overdose-related deaths, improve access to treatment, reduce stigma, and facilitate treatment coordination with other medical conditions. More research is still needed to evaluate office-based buprenorphine treatment. A newer single-dose depot buprenorphine formulation shows promise as an effective detoxification medication with gradual onset, sustained release, and minimal withdrawal symptoms. In fact, it has recently been proposed that buprenorphine should replace methadone as a treatment for heroin dependence.[4]

Little is known about buprenorphine’s impact on everyday practice. Concerns include expense, limited knowledge about its use, patient limits, and social and clinical attitudes regarding opioid treatment or heroin dependence. The side-effect profile is similar to other opioid agonists; common side effects are nausea, headache, withdrawal syndrome, non-specific pain, and constipation. These side effects are milder than with other opioid agonists and are easily manageable, often resolving within three weeks.[4] Randomized clinical trials suggest that buprenorphine is superior to clonidine with regard to withdrawal symptom relief. Buprenorphine was associated with a significantly increased length of stay and treatment completion. Additionally, clinical staff reported better subject engagement in treatment and psychosocial group sessions. Recent studies have involved rapid detoxification using buprenorphine and naltrexone. Because the withdrawal from buprenorphine is milder than that from heroin or methadone, a rapid detoxification method involving the first transition to buprenorphine and then some variant of the clonidine/naltrexone approach would appear to be the least painful and have the highest rates of success.[4]

Engagement in Ongoing Treatment

A major challenge is helping substance abusers to accept and continue treatment. Seventy-five percent of substance abusers credit family as a major reason for their entering a treatment program.[5] Family can often be a key in helping the patient stop the denial and avoidance and begin dealing with the problem. Family members can do something to instigate change. In fact, studies in these areas tend to support the premise that family members and extended social support networks can have a positive influence on treatment engagement, regardless of initial resistance and ambivalence.[5]

Particularly relevant to the engagement question is the long-standing belief, held by many in the field (with, incidentally, little empirical support), that substance abusers must “hit rock bottom” before they can be helped.[5] The logic is that the substance abusers themselves must call for the appointment, thereby demonstrating significant self-motivation. Such an approach has led many agencies to be reactive, waiting for the substance abuser to approach them for care.[5] This view can, however, be counterproductive, because it discourages active attempts to get help for potential patients at an earlier point in the addiction process.

Clinical Case, Continued

After recovering from renal failure, Tom moved out on his own again. It wasn’t long before Tom relapsed into his old drug habits. One night, Tom was with a friend in a motel in Texas “shooting up” heroin and cocaine. They both had consumed alcohol as well. Tom went to the bathroom and fell on the floor. The other boy who was with him put him in the shower to try to revive him. Tom vomited all over himself. The other boy called 911, and the paramedics came and took Tom to the hospital. He died later that night.

The friend was arrested because of the bag of drugs found in his backpack and, therefore, was unable to notify Tom’s family of his death. Tragically, Tom’s body was left at the hospital morgue for a week until Tom’s father was finally notified about his death.

The Concepts of Family Meeting, Family Consultation, and Intervention

In recent years, there has been a shift from the old Johnson Intervention model toward Johnson-based models that are less confrontational and blaming and more positive in their approaches. These methods now avoid the word intervention when describing the process to the substance abuser, opting instead for terms like family meeting or family consultation.[5]

The ARISE model (A Relational Sequence for Engagement) is a three-stage, graduated continuum of intervention. Stage I begins the moment a family member takes action and phones or physically contacts a clinician or treatment program to get help for a substance abuser; this is the “First Call.”[5] The goal of the conversation is to encourage the caller to invite as many significant others from his or her support system as needed to help motivate the substance abuser to enter treatment or self help. The substance abuser is invited to this first meeting. Stage II is after 1 to 5 sessions begin, and if the substance abuser is still not engaged in treatment/self help, the network moves into Stage III. Stage III occurs only if the network members agree to enact specific consequences for the substance abuser if he or she chooses not to enter treatment or self help. Stage III is called Carefrontation and Systemic Family Intervention.5 It is designed to maximize the probability of substance abuser engagement at the earliest possible stage, thus minimizing the amount of time and energy required of staff and network. ARISE normally achieves its goal within 1 to 3 weeks.

Psychotherapy with the Substance Abuser

Once the substance abuser is engaged in treatment, one can perform psychotherapy. It complements pharmacotherapy by enhancing the motivation to stop drug use by taking prescribed medications and providing guidance for use of these medications after the patient achieves an initial period of abstinence, providing relationship elements to prevent premature termination, and helping the patient to develop skills to adjust to a life without drug use. Individual therapy allows a higher percentage of therapy time from an individual’s perspective. The therapist must have good didactic knowledge of substances and treatments and need to recognize affective states, including drug-induced ones. An early task for psychotherapists is to gauge the patient’s level of motivation to stop drug use by exploring his or her treatment goals and teach coping skills. In assessing an individual’s readiness for change, the therapist may ask the patient if he or she perceives the substance use as a problem.[6]

Stages of change

The stages of change are as follows: 1) Precontemplation—the individual denies there is a problem; 2) Contemplation—the individual is ambivalent but has considered that change is possibly needed; 3) Termination of use—the individual has made a decision to change but has not acted on it; 4) Action—the individual is abstinent and is in treatment; 5) Maintenance—the individual is in recovery; and 6) Relapse—the individual returns to drug use. It is important to encourage patients back into recovery in this stage or they may give up and return to drug use. This is commonly called the abstinence violation effect.[6]

Motivational Interviewing

Motivational interviewing strategies for the ambivalent patient may be helpful. Develop “discrepancy.” In this technique, future goals and cost-benefit ratios are explored. Present arguments and reasons for change. Express empathy. Use “reflective listening.” Avoid argumentation because arguing is counterproductive. If you find that you are arguing, stop and listen instead. Do not necessarily react to or comment on resistance.

Clinical case example of motivation interviewing—self efficacy:

Patient: I don’t think I have a problem.

Psychiatrist: Maybe changing isn’t right for you now. [or] So this isn’t a problem for you…I’m wondering how other people around you are viewing this.

In psychotherapy with a substance abusing person, it is important to support self-efficacy. The individual must believe he or she is the most important factor to change behavior and that the individual is held responsible for carrying out change.[6

Defenses against change. The three most common defense mechanisms that patients use to resist change are 1) Denial—the addict believes he is truthful but is not; 2) Rationalization—the addict provides good reasons instead of the true reasons for his use; and 3) Projection—the addict places blame for use on someone else.[6]

The psychiatrist’s job is to engage the patient in the process of recovery and to incorporate individual and group counseling approaches to expose the individual to recovery concepts and techniques. This also is an opportunity to diagnose and treat medical and psychiatric problems associated with the disease of addiction.[6]

One single treatment cycle is not going to dramatically engage the patient in the recovery process. However, if an individual has not made obvious attempts to engage in recovery-oriented activities, the behavioral expectations are raised on each subsequent admission to treatment as a requirement to receive medications. To do otherwise risks placing the psychiatrist in the position of enabling, in which the detoxification process rescues the user from the consequences of addiction.[6] Therefore, if after three treatment cycles, the patient is coming for medication only and not going to group sessions, not attending Narcotics Anonymous (or similar) meetings, and essentially not participating in the recovery process, an extended treatment hold is placed on the person, during which the person will be required to make a choice to either continue using (with all of the problems that it entails) or go back into treatment.[6]

Clinical Case, continued

Six hundred people attended Tom’s funeral. A friend spoke the following words at the funeral in remembrance of Tom:
“There is something that has always gone through my mind that I wish Tom would do things a little differently. If he could have stopped and took a second thought about what he was doing. Or if he could just understand this concept and grasp this one idea, then maybe it wouldn’t come to this. I’ve come to realize that the reason I love Tom is because of the fact that he did things his unique way. He lived his life to the fullest, every moment. He had the ability to make each moment, and all the people who shared that moment with him, feel like it was the only thing that mattered in the world. Everything else was insignificant, nothing else existed. No worry, no fear, no hatred, no dislike or selfishness. Every moment shared with Tom was filled with laughter, love, and complete selflessness. Everyone wanted to know Tom. I can remember walking down the halls at school, on the rare occasion that I went, and I would hear all the gossip from the weekend and sometimes it would be about Tom and the situations he had created. I would see two people that I have never seen before in my life talking about Tom as if they were his best friends. They brag about “being there” when Tom did this or that. Of how they saw him do this or even had a conversation with him about something. I knew they were lying because either I was there at that moment or the rumor was just a fallacy. I find it interesting that somebody who probably had never met Tom would lie to his friend about being in Tom’s presence. Or lie about spending time with Tom because it made him feel “cooler.” I think that goes to show everyone that Tom was the type of person everyone wanted to be around— everyone wanted to be a part of his life and share his stories and share his laughter.”

When Sudden, Unexpected Death Occurs: Helping the Family Members Left Behind

When a family member dies as a result of any sudden traumatic death, the immediate shock and chaos that follow can lead to complicated grief and bereavement. Most parents and friends who suffer a sudden, unexpected loss of a child feel guilt for not adequately protecting their children or for not realizing that the child was having serious difficulties. In some cases, parents feel that their children rejected and abandoned them. They also feel a social stigma. In other cases, parents may feel rage and seek revenge against a person(s) they think helped to “murder” their child. Although all grieving persons wrestle with issues of reason, causes, and meaning of death, adapting to the sudden death of a child is especially difficult, especially if the child’s actions partly caused his or her death. In cases of substance abuse, parents may feel anger at the deceased child for prioritizing drugs over the relationship with his or her parents. The parents may feel angry at their child and then feel guilty about that anger. Parents may feel terribly guilty simply for living when their child has died.[7]

With a sudden death, the need by those family members left behind to blame someone for what happened is extremely strong, especially when dealing with substance abuse. The grieving individual, although experiencing grief autonomously, does in fact project his or her symptoms onto the other members of the family. There is emptiness, a sense of “if only I did something.” The bereft family members become more protective of each other, while at the same time questioning each other’s actions as they struggle to accept rational explanations to “Why?” With the death of a child, many of these questions go unanswered and the once solid family system becomes fragmented. Many parents blame the other spouse and stop communicating with each other after the death; thus, there is a high divorce rate for bereaved parents.[7]

Grief Therapy after a Death by Substance Abuse

Grief therapy is used with people who have serious problems with grief, such as what might follow the drug overdose of a child. The goal of grief therapy is to identify and solve problems the mourner may have in separating from the person who died. Grief therapy may be available as individual or group therapy.[8]

In grief therapy, the bereft talks about the deceased and tries to recognize whether he or she is experiencing abnormal amount of emotion about the death. Grief therapy may allow the bereft to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.[8]

Remind survivors that others cannot define the loss for them. Only they can determine what the loss means to them. Even when friends, family, or colleagues have experienced a similar loss, this does not mean that the loss and the impact of the loss are the same. In this light, most survivors find themselves repeating the story of their loss over and over again. During this repetition, the exploration and identification of what the loss really means to the survivor can begin.[8]

The goal of the therapist is to use expertise in guiding patients along a continuum of adaptive coping and functional grief. Begin by asking the patient to identify some important goals for emotional and functional stabilization. Identification and commitment to small short-term goals can provide a sense of accomplishment, a sense of control, and a sense of “getting better.”[8] It is critical to validate that any grief work toward accomplishment of these goals will most likely be painful and that this pain may manifest itself in many different ways.[8] Many families fear the reality that the only way to get to the other side of grief is to “go all the way in and all the way through.”[8] During this early phase of the grief process, it is important for the patient to mourn the loss by allowing a full range of emotions while avoiding the minimization of what the loss means in an attempt to please others. Although tears are not necessary for functional grieving, crying should be validated as a typical and acceptable form of expression.[8]

Survivors can experience problematic beliefs of uncertainty, inadequacy, perceiving the world as dangerous, and feeling an overt lack of control. Survivors should be reminded to accept, rather than avoid, the support from those who care. Teaching survivors to be proactive can maximize the acceptance of the help of the family and friends who may want to help but who may be unsure of what to do. The pain and emotion that accompanies loss and grief can be lessened when emotional support is readily available and utilized.

In grief therapy after a death by substance abuse, it is important to understand the complicating factors inherent to such a sudden, traumatic death in order to promote successful navigation through the grief process. In order to accomplish this, one must educate the survivor about the normal reactions to grief as well as those factors that may result in complicated bereavement.[8]

The Usual Stages of Grief

The well-known stages of grief have been identified by Kubler-Ross (denial, anger, bargaining, depression, and acceptance).[8] According to Rando,9 the six R’s of mourning are as follows: 1) recognizing the loss, 2) reacting to the separation, 3) recollecting and re-experiencing the deceased and the relationship, 4) relinquishing the old attachments of the deceased, 5) readjustment to move into the new world without forgetting the old, and 6) reinvestment into the current world and life. According to Rando, grief and mourning are complicated when the grieving process has had some compromise, distortion, or failure in one or more of the R’s, such as can happen when dealing with a substance abuse-related death.

A helpful first step for the grieving person is for the psychiatrist to encourage the survivor to talk about the loss. By doing so the psychiatrist promotes validation that the loss has occurred and can facilitate reinvesting in life.[8] Emphasize that telling the story, not only to the psychiatrist but also to other family and friends, can facilitate this process. Remind survivors that as they find themselves confronted with the realities of the loss, it is possible for grief to affect them mentally, emotionally, physically, and spiritually.[8] It also forces survivors to look at their own mortality. It is normal for grief responses to vary among family members, even as they grieve together as a unit. Grief responses are not wrong or bad, instead, culturally sensitive assessment can prevent unnecessary concern or conflict among family members already burdened with different emotions.8 For example, all people do not need to cry to be considered effectively grieving, yet many people believe that not crying is not good. Just because some people simply do not allow themselves to cry in the presence of others does not mean they are grieving improperly.

Different Responses to Loss: Internalization and Externalization

There are two presentations that are typically observed in emotional and behavioral responses: Internalization and externalization. An internalized response by the survivor may be exhibited in depression, avoidance, or withdrawal. On the other hand, an externalized response may consist of anger, outbursts, or labile mood. As a clinician, it is important to remember not to personalize these responses and that gender and age may affect the manner in which one expresses grief.[8]

For example, men may verbalize concerns less often than women, and children sometimes manifest grief through regressive behaviors, guilt, fear, or problems at school.

One myth often encountered by surviving family members is that there is an established timetable of when grieving should be over, causing many family members to wonder, “Why am I not over this yet?,”[8] and this may be further complicated when dealing with a death related to substance abuse. Grief-related symptoms are typical for at least the first year, especially as the date for the one-year anniversary of the death nears. Contrary to the common belief that at one year, survivors should be feeling better, it is actually more likely that most people feel worse as the one-year anniversary approaches because they are reminded of the event that caused the loss of their loved one. Grief symptoms may continue into the second year and still be considered normal. However, at any point in the grief continuum, where grief-related symptoms are extreme to the point of disruption of activities of daily living, medical or mental health intervention may be required. Finally, the use of drugs, alcohol, and violence are not a normal part of the grieving process, and anyone displaying such behavior should be referred immediately for additional assessment and possible intervention.[8]

Distinguishing Grief from Depression

The predominant emotions in grief are sadness and a yearning for the return of what has been lost accompanied by a sense of emptiness. Additional features of grief are similar to those of depression, including guilt, anger, anxiety, social withdrawal, loneliness, forgetfulness, weight change, and nightmares.[8] It is critical, however, for the clinician to distinguish between grief and depression. One distinguishing feature is that self-esteem in the grieving person is usually uncompromised, whereas a depressed person often has decreased self-esteem. Other possible aspects of grief, especially when it occurs after the loss of a loved one, are dreams of the deceased person and visualizations or other illusions of them.[8] Generally, depression is not considered unless grief is present for more than two months after the loss. While the reactive depression of bereavement may not require pharmacology, a relapse of a mood disorder, such as major depression, may necessitate it. Dysfunctional grief accompanied by severe depression and suicidal intent generally calls for psychiatric referral, hospitalization, or both. Assessing the duration and the severity of symptoms can help differentiate these otherwise similar conditions. Distinguishing normal grief from abnormal grief or a mood disorder is an essential skill for family physicians, and open, supportive communication is the most critical management tool in which to do that.[8]

The Primary Care Office Visit for the Grieving Person: Some Suggestions

For a person who is having trouble coping with grief from any loss, including the death of a loved one from a drug overdose, a physician may want to schedule relatively frequent office visits with progressive lengthening between visits as the person feels more stable. The physician may also encourage relaxation, help in identifying new and rewarding activities, and reinforce the patient’s efforts in developing social connections (e.g., attending a grief support group meeting). Counseling should focus on positive images of the deceased. Such a psychotherapeutic relationship can be comforting to grieving persons by enhancing their self-esteem and personal interactions.[8]

Grief is a Process and Not an Endpoint

This sometimes mystifying goal of an endpoint to grieving contributes toward significant confusion for many survivors. The goal of grief is neither to forget about nor to get over the loss, a commonly stated goal of survivors.[8] Rather, the goal of grief is to remember the decedent, understand the changes created by the loss, and determine how to reinvest in life. There are many ways to identify progress in functional grieving. Survivors may display an increased ability to talk about the loss without feeling overwhelmed or bursting into tears. Energy level improves and participation in various activities (including work, school, or social activities) increases. Sleep and diet, commonly affected by grief among survivors, begin to normalize. Survivors begin to describe a sense of reorganization in their lives, and decision-making is easier. Psychosocial reintegration may be described as feeling more at ease with being around people.[8]

As the inner pain begins to decrease, survivors typically begin to feel increasing comfort about talking about the loss. There may be a return of their senses of humor. Survivors may report that decision-making now occurs without feeling the need to second-guess themselves. Inner healing occurs over time. Survivors may recognize that they have completed the process when they find themselves reinvesting in life. Survivors should not be alarmed or surprised to find themselves saddened during the holidays and special occasions or as they near the anniversary date of the loss. These are typical times for thoughts to be focused on the loss. As the healing progresses, the sadness will decrease but will never completely go away.[9]

In summary, physicians and other therapists should be mindful that the goal of good grieving is not to forget the loss, but to put the loss into perspective in one’s own particular life history while reinvesting or seeking out what is enjoyable in life. One must remember the decedent, understand the changes created by the loss, and determine how to reinvest in life. Grief is a process, not an endpoint.[9]

References

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2. Kleber HD. Outpatient detoxification from opiates. Prim Psychiatry 1996;9:42–52.
3. Heilig M, Gronbladh L, Kakko J, et al. A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: A randomized controlled trial. Am J
4. Boverman J, Kovas A, McCarty D, et al. Buprenorphine for acute heroin detoxification: Diffusion of research into practice. J Subst Abuse Treat 2007;32(2):199–206. Epub 2006 Nov 21.
5. Baciewicz G, Brinkman-Sull D, Browning A, Garrett J, et al. Outcomes with the ARISE approach to rngaging reluctant drug and alcohol-dependent individuals in treatment. Am J Drug Alcohol Abuse 2004;30(4):711–48.
6. Aszolos R, McDuff D, Montoya I, et al. Engaging hospitalized heroin-dependent patients into substance abuse treatment. J Subst Abuse Treat 1999;17(1–2):149–58.
7. Handsley S. But what about us?” The residual effects of sudden death on self-identity and family relationships. Mortality 2001;6(1):9–29.
8. Krigger K, McNeely D, Lippmann S. Dying, death, and grief: New research—questions to and for professionalism. Kinderkrankenschwester [German] 2002;21(5):18390.
9. Clements P, DeRanieri J, Vigil G, Benasutti K. Life after death: Grief therapy after the sudden traumatic death of a family member. Perspec Psychiatr Care 2004;40(4):149–53.

Category: Past Articles, Psychiatry, Psychotherapy Rounds, Substance Use Disorders

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