Death by drug overdose: impact on families ([dagger]).
Drugs (Patient outcomes)
Drugs (Social aspects)
da Silva, Eroy Aparecida
Noto, Ana Regina
Formigoni, Maria Lucia O.S.
|Publication:||Name: Journal of Psychoactive Drugs Publisher: Haight-Ashbury Publications Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2007 Haight-Ashbury Publications ISSN: 0279-1072|
|Issue:||Date: Sept, 2007 Source Volume: 39 Source Issue: 3|
|Topic:||Event Code: 290 Public affairs|
|Geographic:||Geographic Scope: Brazil Geographic Code: 3BRAZ Brazil|
Abstract--Death by overdose is loaded with social/moral stigmas, in
addition to strong feelings of anger, helplessness, guilt and shame in
the families. The objective of this study was to analyze the impact of
these feelings on families facing death by overdose. Qualitative
methodology was used to study six families with a history of death by
overdose of one of their members. The interview was open, and guided by
the question "What did you feel with the death of your family
member by overdose and what was the impact of this death on your family
as a whole?" The families were grouped into two categories:
families who knew about the drug use of their family member, and
families who were not aware of it. The reports show that secrecy
regarding drug use followed by death by overdose arouses feelings of
anger, guilt, helplessness, and deprives the family members of
information that could allow them to take action. As regards families
that were aware of the drug use, there seems to be a "veiled
preparation" for a possible death by overdose, bringing about
ambivalent situations of grief and relief. The report stresses how
disturbing it is to lose a family member by overdose, and points to the
need for psychological support for those families.
Keywords--death, drug dependence, family, overdose, qualitative family research
Even though death is a natural process and the only certainty left in a changing world, it usually exerts a great impact on the lives of families. This impact can be even more devastating in the case of death by overdose. It is an abrupt loss by non-natural causes that is loaded with social/moral stigmas, secrecy, shame and denial, in addition to producing strong feelings of anger, helplessness and guilt. The families who lose a member by drug overdose go through a long period of mourning. Moreover, after the death of the user, other deaths (mainly the parents') frequently occur in the family, disrupting the balance in the family vital cycle (Stanton & Todd 1988).
Death has been a universal fear since ancient times. The way the man deals with it, however, has changed over time, possibly as an attempt to reduce the anguish in the face of the finitude of being (Kubler-Ross 1998).
In ancient times, people had to face death earlier. Ancient rituals related to death aimed at controlling the wrath of the gods. American Indians believed that people were dominated by evil spirits when they died, so they fired arrows to scare them away (Kubler-Ross 1998). In ancient Egypt, the pyramids preserved the mummies of the pharaohs and their belongings, since the people believed that the goods placed there could be enjoyed after death (Aries 1990). Later on, and throughout many centuries, terminal patients remained at home, surrounded by their relatives, making final requests and recommendations. These people were aware of their end beforehand. A sudden death was considered a curse that prevented one from fully living to the end of his life. After the death occurred, the family members covered mirrors, lit candles, sprinkled their houses with holy water and stopped their clocks. The bells tolled and the friends of the deceased performed wake rituals that, depending on their social position, could last many days. After the burial, the family started the mourning ritual, which included restrictions regarding their social life, black clothes to express their grief and their longing, and a period of reintegration of the family members to their routine without the presence of the deceased relative (Maranhao 1992).
In Western societies, men's attitude in the face of death has gone through profound changes in the last 50 years. Death became a veiled issue: death and the dead were concealed from children, and the topic was banned from social conversations.
A society focused on progress and productivity began to deny death. Man was deprived of his ancient right to know that his end was near. Mainly in larger cities, the place of death was also displaced, since it began to occur more and more in hospitals. On one hand modern medical care can provide the sophistication of highly technological equipment and more sophisticated therapies than the homes of the old times, but it also deprives families of their individual ritual regarding their loss (Aries 2003, 1990; Kubler-Ross 1998; Maranhao 1992). Both the family members and the person in the critical state are lonely and very afraid, wondering what the "final moment" will be like. The wake does not take place at home anymore. The body is buried in a quick ceremony. By denying the experience of death and dying, society objectifies the individual (Maranhao 1992).
THE FAMILY VITAL CYCLE AND DEATH
Cultural and social changes that took place in the way people deal with death had direct repercussions on the psychological and emotional lives of families. The fact that "death specialists" (professionals working at hospices, funerary services) have become valued contributes to the fact that family members stay away from the person who dies, which reduces their capacity to deal with the stress and the rupture brought about by death. Many feelings, such as loss, anger, guilt, loneliness and abandonment, are involved when a family member dies, disrupting the family's functioning balance (Brown 1995; Carter & McGoldrick 1995).
The circumstances and the nature of death, the different moments of the vital cycle in which it occurs, as well as the position and the role of the person who dies in the family, significantly affect the family's adjustment and might lead to destabilization over time.
As regards the nature of the deaths, they can be expected and involve care over a long period of time, as in the case of chronic diseases, or sudden and more traumatic, as in deaths by accident, suicide, drug overdose and sudden infarction (Brown 1995). Sudden deaths hit the families abruptly, causing great shock. There is no time for anticipatory mourning or farewell. A study in the Monthly Vital Statistics Report in the USA (National Center for Health Statistics 1984) reported that the initial sadness due to sudden death is more intense than that due to a prolonged and natural death. It is more difficult to deal with the loss when the death is sudden. Sudden death, however, does not entail long periods of stress as is the case of deaths after long-lasting diseases. It is not uncommon that long-lasting diseases bring the terminal patient the wish to die, as well as the family's wish that the patient would die (Shanfield, Benjamin & Swain 1984).
In general, the death of older people is better accepted, being considered a natural process, than the death of children, adolescents and young adults. Many dreams and life expectations are placed on children and youths. Therefore, the loss of a child is an existential blow of the hardest type; there can be nothing more painful to the parents. The death of a child has an even greater impact when the parents have a dysfunctional relationship with this child. If the sudden death of the child takes place in adolescence, the level of family disruption increases. A chronic disease in youth leads the parents to build a narrow border where everything becomes an imminent threat. Deaths take on different levels of importance to the family core. The higher the meaning of the person to the family, the greater the impact of his/her death will have on the future generations (Brown 1995).
DEATH BY OVERDOSE
Studies on the deaths of drug dependent persons show that this population expects to live shorter lives than the general population, presents higher incidence and risk of sudden and accidental death, and experiences less fear of death than other psychiatric patients (Stanton & Todd 1988).
Drug dependence is a systemic process that affects and is affected by the interaction between the dependent person, the drug and the other people involved. In this sense, the concepts of family members regarding death by drug overdose should be deeply reflected upon.
Even though these deaths are mostly associated with illicit drugs (e.g., cocaine/crack or heroin, the latter little used in Brazil), they may also occur as a result of licit drugs such as amphetamines, barbiturates, benzodiazepines and, more frequently, due to accidents resulting from excessive use of alcohol.
In a study with 400 injection drug users in Brazil, Mesquita and colleagues (2002, 2000) reported a significant number of overdose episodes among this population. Out of the users interviewed, 20% had had at least one episode of cocaine overdose, in addition to a considerable number of users who knew of fatal cases. The users were often together with other users (friends, family members or sexual partners) who often provided help. The interviewees also stated that they would not look for help at health services for fear of being mistreated or reported to the police.
Researchers at the Brazilian Center of Information on Drugs analyzed 120,110 forensic reports by the Forensic Medical Institutes from the cities of Sao Paulo and Santos, and identified traces of cocaine, alone or combined with other drugs, in the blood and viscera of corpses between 1987 and 1991. The prevalence of positive reports for drugs increased from 22% in 1987 to 77% in 1991 (Carlini, Nappo & Galduroz, 1993).
Epidemiological data on the number of deaths by drug overdose are still scanty in Brazil. Those deaths do happen, but their numbers are certainly lower than those for accidents, followed by deaths that involve alcohol directly or indirectly.
Overdose is a result of "super-dosage" in the use of one or more substances that trigger physiological alterations which can seriously compromise the user's health and require immediate medical attention to avoid death. These events have various causes: they can be accidental, premeditated, or suicide attempts. The compulsive use of drugs over many hours often leads the individual to totally lose his/her awareness as to how much of it has been ingested, which in turn leads to an unintentional "super-dosage." Moreover, high purity drugs such as cocaine may have a higher lethal potential. The deep depression brought about by the use of some drugs might have some rather unpleasant symptoms that lead to an "unbearable craving" only relieved by high consumption, or "one more shot or fix" that could be lethal.
Some studies show that deaths by overdose are more prevalent among men with ages ranging from 18 to 27, that is, a younger portion of the population (Stanton & Todd 1988; Stanton 1977; Vaillant 1973).
The drugs that pose a higher risk of overdose are cocaine/ crack and heroin, used alone or in association with other drugs. In a situation of overdose, mainly if the use happens in groups, people often become terrified and traumatized. They try to revive the user unsuccessfully, delaying the search for help.
Studies on the impact of death by overdose on the families of users are scarce in Brazil. In general, the use of drugs in the family core brings much pain and discomfort. Those feelings are even more aggravated when the family faces death by overdose. Even if the family is aware of the drug use, sudden death is a traumatic event that haunts the survivors for a long time, hindering the mourning process.
The present study aimed at describing, through a qualitative methodology, the feelings of and the impact on families of the death by overdose of one of its members.
Family in this work was defined as people connected by living together in a relationship of belonging and performing basic tasks of care, education and upbringing (fathers, mothers, spouses, children and others). The authors used the qualitative content analysis methodology to interview family members who lost a relative due to drug overdose (Bardin 1979). The content analysis of the interviews started with a floating reading of the material, in order for the authors to get acquainted with the contents. After this procedure, we selected the following analysis categories: knowing or not knowing that the family member used drugs (secrecy x non-secrecy); feelings about that death (pain, anger, guilt, helplessness) and the impact of that death by drug overdose on the family (devastating, massive).
Since this population is hard to identify, we started the search through indications of key informants (therapists and self-help groups) in the city of Sao Paulo. The sample was intentional and, starting from the indications of the key informants, we located other participants through a snowball sampling technique (WHO 1994; Diaz, Baruti & Doncel 1992 ; Biernacki & Waldorf 1981). We identified six families with a history of death by overdose, and invited one member of each family to participate in the interview. After the objective of the study had been explained, the participants were provided with a written consent form in which they were assured of the confidentiality of the data. The Committee of Ethics in Research of the Federal University of Sao Paulo approved the study protocol. A family psychotherapist, the main author of this study, carried out the interviews in a quiet, neutral place, where only the therapist and the interviewee were present. Each interview lasted about an hour. The interviews were taped and based on the open-ended question "How did you feel in relation to the death by overdose of your family member, and what impact did it have on your family as a whole?" The choice of an open-ended interview was made because it allows the interviewer to investigate new issues that might come up as the interview develops (Minayo 2000; Rizzini, Castro & Sartor 1999). Since the answer was comprehensive, the authors felt no need to ask any further questions.
After the analysis of the interviews, the families were grouped into two categories: those who were aware of the drug use before their relative died of overdose, and those who were not. Six extracts of statements from family members are reported below. The three first interviewees were not aware of their family member's drug use, and last three were aware of it.
Family Members Who Were Not Aware of The Drug Use
1. Female, 47 years old, whose daughter died of a cocaine overdose in 1997:
2. Male, 64 years old, whose son died of cocaine overdose in 1985:
3. Female, 39 years old, whose brother died by a drug cocktail in 1994:
Family Members Who Were Aware of the Drug Use
1. Female, 60 years old, whose son died of crack overdose in 1995:
2. Male, 55 years old, whose son died of a cocaine overdose in 1995:
3. Female, 42 years old, whose brother died of a cocaine overdose in 1990:
In general, all the statements show how disturbing it is to lose a family member by drug overdose. The family vital cycle is deeply scarred by those losses, which makes the mourning process even more difficult, with repercussions in the future generations. In the statements of the families where the use is intense and open, it is possible to observe a "veiled preparation" for a possible death by overdose. This brings about ambivalent situations: pain on one hand and relief on the other hand. "What I'm going to say is strange, but when my son died I had ambivalent sensations: on one hand, immeasurable pain, the pain of irreparable loss; on the other hand, relief. Relief from his suffering as well as ours." "The year that preceded his death was terrible, we expected the worst everyday." "I knew that overdose would be a risk at some point." The awareness of the use in those families led them to look for help, actions that were fruitless in most cases, as can be observed in phrases such as "we failed in our attempts to help him." These families usually have a paradoxical functioning: now they focus too much on the drug problem (or rebel against it), now they give everything up and "adapt to the problem." The search for many concomitant treatments, the disappearance of the user for many days, the frantic search in morgues, hospitals, friends' houses, the disappearance of objects from the house become part of the family routine. After some time, the exhausted family gives everything up and expects the worst. "The family becomes exhausted and, strange though it may seem, begins to prepare for the worst." According to some authors, this is a way for the family to keep their balance and conceal other problems and dissatisfactions in the family core (Stanton 1977, Stanton & Todd 1988).
The statements of the family members who were unaware of another member's use show that the secrecy of the use followed by death by overdose brings about feelings of anger, guilt, helplessness, indignation, and shame. "Death by drug overdose is brutal, sudden, my family lost it, we felt angry, ashamed, guilty, cheated. Nobody at home knew that he used drugs; we only knew it after he died. Our anger increased." "Losing a son for drug use is incomprehensible, I never suspected he used cocaine, he didn't smoke neither drank, so you can imagine, when I knew it, I lost it." "After his death my family mourned for many years." The family has its self-esteem, values and rules shaken by the death. The families who are kept unaware of the use are deprived of information that could allow some kind of action, which generates a strong feeling of guilt. According to Brown (1995), in that context, the family functioning goes through a long period of destabilization, and the elaboration of the mourning process is slow.
The drama faced by the people in those statements draws attention to the importance of support work. It can be based on a community network of support to those families in a moment of deep crisis. What can one do about the feeling of pain and loss when death comes so brutally? The sharing, the subtlety, the room for pain, the rescue of farewell rituals help the families carry on in spite of the suffering. The experience of sharing and the solidarity in those situations also work as an aggregating element in the process of mourning.
This pilot study emphasized mainly the deaths by drug overdose, deaths which are usually sudden and traumatic. This issue has not been systematically investigated in Brazil, either from the epidemiological or the clinical
perspective. It is important to stress, however, that diseases such as hepatic cirrhoses, infarctions, and cerebral vascular accidents, all associated with the chronic use of alcohol, as well as infection by the HIV virus, as in the case of injected drugs, also cause strong impact on families. Those are slower deaths, and seem to be more prevalent than the deaths by drug overdose in Brazil.
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([dagger])Research for this article was supported by Associacao Fundo de Incentivo a Psicofarmacologia--AFIP. The authors would like to thank the families who volunteered to participate in this study.
Eroy Aparecida da Silva, B.Sc. * Ana Regina Noto, Ph.D. ** Maria Lucia O. S. Formigoni, Ph.D. ***
* Family Therapist, Researcher in the area of alcohol and other drugs at the UDED (Drug Dependence Unit) of Department of Psychobiology--UNIFESP (Federal University of Sao Paulo), Brazil.
** Doctor in Sciences, Researcher at CEBRID (Brazilian Center of Information on Psychotropic Drugs); Professor at the Department of Psychobiology of UNIFESP, Brazil.
*** Full Professor, Coordinator of the UDED--Department of Psychobiology--UNIFESP, Brazil.
Please address correspondence and reprint requests to Eroy Aparecida da Silva, Rua Botucatu, 862, Vila Clementino, Unidade de Dependencia de Drogas, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil CEP: 04023-062; email: email@example.com
The death of my daughter by drug use was the worst thing that happened in my whole life. She was well and happy as she left to travel with friends and never came back home, she died of cocaine overdose, caught the whole family by surprise. We never suspected anything in relation to her drug use. So much so that when it happened, we didn't believe it. Reality only dawned on us when we saw her motionless body. Many feelings are involved: pain, much pain, anger at the secret, guilt for not knowing your own daughter. Your mind reels; I got into a deep depression, I wanted to die too. After six years I still suffer a lot, I hate drugs, I don't read anything about it, it's a disgrace, it makes you so angry, my life will never be the same, the pain doesn't go away ... The impact on the family was devastating, she was my only daughter. I have two sons and after that I began to search through their things at home looking for drugs; even though I've never found anything, I always think I'm being cheated. My marriage got really bad, my husband also got into depression, we can see no more fun in this life.
Losing a son I think is the most difficult test in this life. It's a pain I can't describe. No matter how much I try to talk about how I felt, it's still far from what really happened to me, it's an endless pain. Losing a son for drug use is incomprehensible, I never suspected he used cocaine, he didn't smoke neither drank, so you can imagine, when I knew it, I lost it. I felt anger, pain, cheated, helpless, completely helpless. After his death my family mourned for many years. Five years after the death of this son, I also lost my wife. I think she died of sadness, she could never get over the brutal death of our son. I stayed with my other daughter, who got married four years ago, and now I have a granddaughter who has helped me a lot. This child brought joy back into my life, sometimes she is in my arms and I remember good moments of the past when I lulled my children. Longing, much longing.
Losing someone in the family is very sad, even more so when he is your most loved brother, who secretly uses drugs. Death by drug overdose is brutal, sudden, my family lost it, we felt angry, ashamed, guilty, cheated. Nobody at home knew that he used drugs; we only knew it after he died. Our anger increased. When somebody dared touch on the subject, I destroyed them, accused them, threatened even to report them to the police. Our family became isolated from everything and everyone, we lost our trust in people. After all, his friends frequented my house, and never said anything about it. I, my mother, my father and one more brother remained isolated, keeping ourselves to ourselves. The impact of this death on the family? Massive, his absence is the worst thing, he was our big brother, the favorite child, our role model, then the fact that he died of drug overdose destroyed a bunch of our family values. My parents blamed themselves a lot, their marriage was pretty shaken. The secret he kept from us is incomprehensible until today. But worse than anything else is that, as time goes by, the longing increases. We went into therapy, it helped a lot, but we still suffer a lot from this death that arrived in our home so stupidly, horribly, my family didn't deserve to go through this.
What I'm going to say is strange, but when my son died I had ambivalent sensations: on one hand, immeasurable pain, the pain of irreparable loss; on the other hand, relief. Relief from his suffering as well as ours. The year that preceded his death was terrible, we expected the worst everyday. He had been in rehab many times, he would run away, disappear, he wouldn't work, and he constantly stated that he wouldn't quit crack. The feeling is of helplessness, anger, shame, fear, guilt. We failed in our attempts to help him. Until today we attend the meetings with the family members of the Narcotics Anonymous and try to share our experience with families that are going through similar situations, and we have the sensation that our pain has an echo: other people feel the same, so solidarity helps us deal with the loss. The impact on the family after the death is terrible, while the person is alive you fight, you go for it, you look for help, you have hope. When he's gone, only anger, helplessness, failure, basically darkness remain. My family is still painstakingly recovering from this death. His definitive departure called our attention to things that went unnoticed before.
I knew that overdose would be a risk at some point. My son got involved with drugs when he was 13, died at 23, in the prime of life, but he chose it, it was 10 years of suffering. He started by drinking and smoking cigarettes, and as time went by we totally lost control of his life. He got involved with heavier drugs, with the traffic, was arrested, he would steal and finally he went to live on the streets. Many feelings result from this situation: anger, helplessness, guilt. Where did I go wrong? I spent all that time blaming myself, arguing with my wife, whose opinions on the issue always differed from mine, I thought she protected him in the wrong things, many of which she hid from me. I felt I was being betrayed twice, by my son and my wife. When he died I felt a lot, we had a strong bond, I wanted a different life for him. But I must confess I also felt relieved, I couldn't stand suffering to see him any longer ... The strongest impact on the family was that even though we missed him a lot, we became more united. The arguments and the anxiety subsided. We were calmer in spite of the sadness. It is hard to say so, but that's what happened. I have a small family here in Sao Paulo, me, my wife and my daughter. But even today I keep asking myself: What have I done to deserve all this, I've always worked, I'm not very educated, but I've always given my children everything I had, I don't know, it is things that are beyond our comprehension.
The feeling is of pain, but also anger, much anger. To notice that your brother is completely involved with drugs, alcohol, cocaine and crack and doesn't accept help is terrible. The family becomes exhausted and, strange though it may seem, begins to prepare for the worst. It was like that in my family. There were four siblings, two men and two women, my father and my mother. Only he, the baby brother, the most protected and loved one chose to use drugs. My parents suffered a lot when he left for good, because actually he had been gradually leaving us for a long time. For us (siblings) it was hard, too, but we got married, remember him with longing every now and then, but we got back on our feet. It was much worse for my parents; they felt guilty, when he died the pain increased. The situation is better now, I think they are more relieved, but they won't confess to it. Living with a drug dependent is very hard, I did to him everything I could and also what I couldn't. Then I eventually I realized that one share was his to do, but he was not willing to. He had made a pact of complete faithfulness to the drug, a pact of love and hate, life and death, where death beat him and all of us. What a shame, what anger, what longing!
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