Substance use disorders are associated with substantial morbidity and mortality, including deaths due to drug overdose (1, 2). In 2016, 63,632 individuals in the United States died of drug overdose, which brought the total number of drug overdose deaths between 1999 and 2016 to 632,331 (3). Since the majority of drug overdoses involve opioids, a key component of the public health response to the opioid epidemic has been to increase access to evidence-based treatments for opioid use disorder (4).
One barrier to accessing treatment for individuals with opioid use disorder has been a shortage of both substance use treatment programs and providers who have undergone the additional training required to receive the Drug Enforcement Agency waiver that is needed to prescribe buprenorphine/naloxone, one of the medications approved by the U.S. Food and Drug Administration for the treatment of opioid use disorders (5). Furthermore, many of the providers who complete the waiver training never prescribe buprenorphine/naloxone (6) or only prescribe it for a small number of patients (6–8). Identified barriers to prescribing buprenorphine/naloxone include limited clinical time, insufficient office support, low reimbursement, and concern about medication diversion (6, 9, 10).
One possible barrier that may be contributing to low provider engagement in the treatment of opioid use disorder with buprenorphine/naloxone is the possibility of adverse patient outcomes, such as death due to drug overdose. Although treatment with buprenorphine/naloxone has been shown to decrease the risk for overdose (11, 12), individuals with an opioid use disorder are still at elevated risk for overdose relative to the general population. As we work to engage more providers in treating individuals with opioid use disorder, it is important that providers be prepared to cope with patient deaths due to drug overdose.
To our knowledge, the provider’s experience after drug overdose death has not been studied, and no practice guidelines exist to guide providers after an overdose death. The family’s experience after an overdose death has been characterized in a small but growing literature (13–15). For example, the response of parents whose child died from a drug overdose has been found to be similar to that of parents whose child died from suicide (13). Both groups of parents have higher rates of characteristics associated with more complicated bereavement, such as symptoms of complicated grief, depression, and posttraumatic stress, when compared with parents whose child died of natural causes (13).
Indeed, similarities exist between deaths from drug overdose and those from suicide, including the sudden and unexpected nature of the deaths as well as the social and moral stigma associated with self-inflicted deaths. Additionally, there has been increasing concern that many drug overdoses may have been suicides (16, 17). Opioid use is associated with serious thoughts of suicide and suicide attempts (18), and the number of intentional overdoses involving opioids doubled between 1999 and 2014 (19). It is unclear, however, to what degree intentional self-harm contributes to drug overdose deaths, because drug overdoses are classified as accidental or unintentional if there is no clear evidence of self-harm intent on the day of death (16, 20). Since there are similarities between deaths from drug overdose and from suicide, and some drug overdose deaths are suicides, we will reference the existing suicide literature to describe possible provider experiences and management strategies after a patient drug overdose death.
Provider Experience
Common emotions experienced by providers after a patient suicide include shock, disbelief, guilt, shame, fear of blame, and self-doubt (21–24). One survey of psychiatrists found that 50% of respondents who had a patient in their practice die of suicide had stress levels in the weeks following the suicide that were comparable to those of people seeking treatment following a parent’s death (25). In that study and others, younger providers with less experience had higher levels of stress after a patient suicide when compared with older providers with more clinical experience (25, 26). Other factors associated with increased levels of provider stress after a patient suicide include having felt close to the patient, direct exposure to the suicide through seeing the deceased patient’s body, and inadequate support after the suicide (26). Support after suicide is a variable that has been found in several studies and commentaries to influence providers’ reactions. Clinicians in solo practices who were more isolated from colleague support were more likely to have increased symptoms of grief (23, 27). Another theme in the literature regarding provider experiences after patient suicide is the ways in which the provider’s clinical practice is affected (22–24, 28–31). A study based on structured interviews of 20 therapists who had a patient suicide in their practice (29) found that 85% were much more direct in their assessment of suicidality after they had a suicide in their practice. Countertransference reactions described in the literature that can arise when continuing to work with suicidal patients include being overly protective and conservative in assessing risk, avoiding discussing suicidality, or avoiding patients at risk for suicide (22–24, 30).
In considering provider reactions after suicide and the similarities between suicide and drug overdose deaths, it follows that providers like Drs. Smith and Jones in the vignette are likely to experience similar emotional reactions. Now that medications are available to treat opioid use disorder and can be provided in less restrictive settings, such as office-based practices, in which providers may be in a small or solo practice, some providers may be relatively isolated after a patient drug overdose death. Providers who are working in a small or solo practice with individuals with opioid use disorder may benefit from being more deliberate in creating a peer supervision/support network for emotional support and supervision to increase awareness of countertransference reactions should a drug overdose death occur in their practice.
Trainee Experience
As noted earlier, younger providers with less clinical experience are likely to be more affected by patient suicide. A survey of residents (28) found that exposure to a completed suicide during their training had an impact on their emotional health and on their view of the profession, and it increased their awareness of the medicolegal aspects of psychiatry. One finding from that study that is concerning is that trainees were reluctant to use formal support, such as employee assistance programs, because of concerns about confidentiality and insurance. Another survey of trainees (32) found that 27% felt unable to ask for help after a patient suicide despite the fact that all had a supervisor to contact in an emergency and that the majority felt that someone was available to help. Although most training programs (70%) have a clear requirement that a supervisor be notified after a patient suicide, program directors may be involved less often; surveys of chief residents and program directors found that only 32% to 66.5% of programs recommend or require that the training director be notified in a timely manner (33, 34).
Few training programs have written protocols to guide trainees and educators on steps to take to support trainees after a patient suicide. In a national survey of chief residents (34), training programs that had written protocols to follow after a patient suicide were found to be more likely than programs without written protocols to have implemented procedures to support trainees, such as timely notification of the program director, process sessions, therapy or counseling, and emergency leave. An example of a training program protocol, created by the National Capital Consortium psychiatry residency in response to an increased rate of military suicides, has been described in detail (35). Written protocols on procedures to follow after adverse events such as a patient suicide or drug overdose death may help programs better support trainees. Additionally, because residents may struggle to reach out for support after a suicide or drug overdose death, it is important that training directors be notified of such adverse events, as Dr. Jones notified Dr. Smith’s training director in the vignette. This allows the training director to reach out to the trainee and to monitor the impact of the death on the trainee over time, since supervisors like Dr. Jones may not work with individual trainees longitudinally.
In studies in which residents and training programs were surveyed about training on suicide, most (91% to 94%) reported that formal teaching on suicide risk factors was provided (33, 36). However, training in postvention—interventions to support the bereaved after suicide—was less common and existed in only 25% to 47% of programs (33, 36). Several postvention curricula have been described in the literature (37–39). These programs have been well received by residents and were found to be associated with improved knowledge on how to cope with a patient suicide (37, 38) as well as increased self-competence in how to manage the emotional, clinical, and medicolegal issues that arise after patient suicide (37). As the field of psychiatry works to increase trainee interest and training experiences in addiction psychiatry, the literature suggests that it is important for training programs to develop or strengthen postvention curricula to support trainees after suicide and drug overdose deaths.
Interacting With Families
Concern from family members or close friends is often the catalyst that leads individuals with substance use disorders to engage in treatment, and social support is a key component to helping patients sustain change. At the point of initial treatment engagement, providers should encourage the patient to involve a support person in their care. At a minimum, this would include a release of information, allowing information to be shared between the provider and the support person should concerns arise. Opening lines of communication between the provider and the support person can be important if the patient is struggling in treatment.
After an adverse outcome such as death from drug overdose, providers may assume that families will blame them, and they may feel reluctant to reach out to or meet with the patient’s family. One study in which therapists of patients who died by suicide were surveyed (24) found that most therapists expected anger and criticism from families. However, as in the case of Drs. Smith and Jones in the vignette, when these therapists met with families, most of the relatives were not critical of the therapist and expressed gratitude for the help provided. If a provider is contacted by a family after a patient drug overdose death, it is important to respond. In a review of litigation after suicide, Gutheil (40) noted that families were sometimes motivated to file a malpractice suit to access information to help them understand their loss when providers were not responsive to family members’ attempts to contact them.
If a family member was part of the patient’s treatment, it is important for providers to offer the option to meet with family members, since families may feel isolated by stigma as they grieve. If a patient’s family was not part of their treatment but it was clear that the family knew that the patient was in treatment, reaching out with a telephone call or a condolence card are ways to recognize the patient’s death and communicate a willingness to support family members in the initial grieving process. Condolence cards have been identified as one way to help families and physicians cope with a patient’s death (41). When interacting with family members, providers need to be aware that the confidentiality provisions of the Health Insurance Portability and Accountability Act continue after the death of the patient. If it is unclear whether a patient’s family knew that the patient was engaged in substance use treatment, it is important to honor the patient’s confidentiality and not contact the family until this can be elucidated.
When communicating with families, providers should focus on addressing the family members’ feelings about the patient’s death to help support the family’s grieving process (42). If a full release of information is on file for a family member, as there was for Mr. A’s parents in the vignette, or the family member is the legal executor for the patient, a provider can answer specific questions about a patient’s course in treatment. In states with apology statutes, providers can express sadness and sympathy without fear of malpractice, since expressions of sympathy are not admissible as evidence of an admission of liability in a civil lawsuit (43). When communicating with a contentious family, it is important to avoid self-incriminating or self-exonerating statements, since this can cause additional stress to the family (42).
Providers can also consider attending a patient’s funeral after a drug overdose death, as Drs. Smith and Jones did. Surveys of providers who experienced a suicide in their practice found that funeral attendance was relatively uncommon, with rates ranging from 2% to 14% of providers (21, 28, 31, 44). The literature does suggest, however, that funeral attendance after a patient suicide can help families and providers mourn and work through their grief after suicide (24, 31, 45, 46). As noted by two primary care providers (47), funeral attendance is a gesture of respect to the deceased that is appreciated by families. Furthermore, they describe experiences where their funeral attendance allowed family members to follow up with the providers to discuss their experience surrounding the death, which may help family members process their grief. In a commentary describing the psychiatrist’s role after patient suicide, Kaye (46) described feeling welcomed by a patient’s family at the funeral and finding it helpful to learn more about the patient through other people’s memories.
Support For Providers
As noted earlier, it is important for providers to receive support from colleagues after a drug overdose death. After a patient suicide, providers have found it helpful to discuss the case with colleagues and to hear other providers’ experiences with patient deaths from suicide (48). This can also be helpful after an overdose death, as in the example of Dr. Jones listening to Dr. Smith discuss Mr. A’s case and sharing his experiences after patient overdose death. Although it may be tempting to provide reassurance to a provider after a patient’s drug overdose death, premature reassurance that a provider did nothing wrong after a patient’s suicide has not been shown to be helpful (23, 24). In addition to colleagues, a provider’s family and friends have been identified as a source of support after a patient suicide (28, 31). While patient confidentiality regulations limit what information can be shared, providers can still disclose that an unexpected death occurred and can discuss their emotions about the death with family and friends.
If a provider is working within a treatment system, it is important to file an incident report after a patient drug overdose death, as Dr. Jones did in the vignette. A quality assurance and improvement meeting after the incident report can be helpful to facilitate learning, improve patient care, and bring closure to the provider who treated the deceased patient (46). Quality assurance and improvement meetings are confidential, and the content that is discussed in the meeting is privileged information that cannot be subpoenaed in a malpractice lawsuit. Care needs to be taken to be sensitive to the timing and tone of the quality assurance and improvement meeting to avoid shaming the provider or worsening provider doubt (49).
Providers working in a small or solo private practice should consider contacting their malpractice insurance carrier regardless of whether there was a contentious interaction with the deceased patient’s family.
Recommendations For The Future
Providers who work with patients with opioid use disorders need to be prepared for a drug overdose death in their practice. Providers should consider their practice setting, develop a protocol of steps to take after a patient drug overdose death, and identify and strengthen their support system. It is important that providers seek support for themselves after a patient drug overdose death to minimize the psychological trauma associated with the death. They also need to be prepared to support colleagues who worked with the deceased patient, as well as the deceased patient’s family.
The larger health care system also has a role to play in supporting providers by creating a culture that supports routine reviews of adverse outcomes to identify opportunities for change and improvement. For providers in private practice, this may involve incorporating quality improvement and assurance discussions into peer supervision, or perhaps establishing opportunities for consultation with local psychiatric societies. There could even be a role for incentives from malpractice insurers or health insurers to provide discounts or greater reimbursement, respectively, for providers who incorporate into their practice quality assurance and improvement projects or reviews after adverse events.
There is a need for increased research on the impact of drug overdose deaths on providers and families. Formal training in postvention needs to be strengthened in residency training programs as well as in continuing medical education, particularly when education on evidence-based practices for the treatment of opioid use disorder is being provided. Finally, we would all benefit from discussing adverse events more regularly, so that no one is worrying alone about a past event or the possibility of a future adverse event. Provider distress after an adverse patient event is particularly relevant in the current era of increasing rates of provider burnout, since distress after an adverse patient event can be a contributing factor (50). We need to do better with supporting one another and to work together collectively as a field to identify ways to improve our practices and system of care as we care for patients at risk for adverse events such as unexpected death.
References
1.
Bahorik AL, Satre DD, Kline-Simon AH, et al: Alcohol, cannabis, and opioid use disorders, and disease burden in an integrated health care system. J Addict Med 2017; 11:3–9
Lindblad R, Hu L, Oden N, et al: Mortality rates among substance use disorder participants in clinical trials: pooled analysis of twenty-two clinical trials within the National Drug Abuse Treatment Clinical Trials Network. J Subst Abuse Treat 2016; 70:73–80
Rosenblatt RA, Andrilla CH, Catlin M, et al: Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med 2015; 13:23–26
Walley AY, Alperen JK, Cheng DM, et al: Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med 2008; 23:1393–1398
Andraka-Christou B, Capone MJ: A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in US office-based practices. Int J Drug Policy 2018; 54:9–17
Sordo L, Barrio G, Bravo MJ, et al: Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017; 357:j1550
Larochelle MR, Bernson D, Land T, et al: Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med 2018; 169:137–145
Feigelman W, Jordan JR, Gorman BS: Parental grief after a child’s drug death compared to other death causes: investigating a greatly neglected bereavement population. Omega (Westport) 2011; 63:291–316
Rockett IRH, Caine ED, Stack S, et al: Method overtness, forensic autopsy, and the evidentiary suicide note: a multilevel National Violent Death Reporting System analysis. PLoS One 2018; 13:e0197805
Piscopo K, Lipari RN, Cooney J, et al: Suicidal Thoughts and Behavior Among Adults: Results From the 2015 National Survey on Drug Use and Health. Rockville, Md, Substance Abuse and Mental Health Services Administration, September 2016
Rockett IR, Lilly CL, Jia H, et al: Self-injury mortality in the United States in the early 21st century: a comparison with proximally ranked diseases. JAMA Psychiatry 2016; 73:1072–1081
Wurst FM, Kunz I, Skipper G, et al: How therapists react to patient’s suicide: findings and consequences for health care professionals’ wellbeing. Gen Hosp Psychiatry 2013; 35:565–570
Castelli Dransart DA, Heeb JL, Gulfi A, et al: Stress reactions after a patient suicide and their relations to the profile of mental health professionals. BMC Psychiatry 2015; 15:265
Erlich MD, Rolin SA, Dixon LB, et al: Why we need to enhance suicide postvention: evaluating a survey of psychiatrists’ behaviors after the suicide of a patient. J Nerv Ment Dis 2017; 205:507–511
Ellis TE, Dickey TO, 3rd, Jones EC: Patient suicide in psychiatry residency programs: a national survey of training and postvention practices. Acad Psychiatry 1998; 22:181-189
Tsai A, Moran S, Shoemaker R, et al: Patient suicides in psychiatric residencies and post-vention responses: a national survey of psychiatry chief residents and program directors. Acad Psychiatry 2012; 36:34–38
Cazares PT, Santiago P, Moulton D, et al: Suicide response guidelines for residency trainees: a novel postvention response for the care and teaching of psychiatry residents who encounter suicide in their patients. Acad Psychiatry 2015; 39:393–397
Lerner U, Brooks K, McNiel DE, et al: Coping with a patient’s suicide: a curriculum for psychiatry residency training programs. Acad Psychiatry 2012; 36:29–33
Pheister M, Kangas G, Thompson C, et al: Suicide prevention and postvention resources: what psychiatry residencies can learn from the Veterans Administration experience. Acad Psychiatry 2014; 38:600–604
Wurst FM, Kunz I, Skipper G, et al: The therapist’s reaction to a patient’s suicide: results of a survey and implications for health care professionals’ well-being. Crisis 2011; 32:99–105
Goldstein S, Schwebach AJ: The comorbidity of pervasive developmental disorder and attention deficit hyperactivity disorder: results of a retrospective chart review. J Autism Dev Disord 2004; 34:329–339
The Pediatric Psychopharmacology Program, Division of Child Psychiatry, Massachusetts General Hospital, and the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston (Yule); New York State Psychiatric Institute, Division of Substance Abuse, and the Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (Levin).
The Pediatric Psychopharmacology Program, Division of Child Psychiatry, Massachusetts General Hospital, and the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston (Yule); New York State Psychiatric Institute, Division of Substance Abuse, and the Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (Levin).
National Institute on Drug Abuse10.13039/100000026: 5K12DA000357-17, K24DA029647-08
Supported by the American Academy of Child and Adolescent Psychiatry Physician Scientist Program in Substance Abuse (grant 5K12DA000357-17 to Dr. Yule) and NIDA (grant K24 DA029647-08 to Dr. Levin).Dr. Yule has received grant support from the Massachusetts General Hospital Louis V. Gerstner III Research Scholar Award, and she has served as a consultant for Phoenix House and the Gavin House (clinical service). Dr. Levin has served as a consultant for Major and Minor League Baseball.
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