Journal of Psychoactive Drugs

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Death by Drug Overdose: Impact on Families

Eroy Aparecida da Silva , Ana Regina Noto & Maria Lucia O. S. Formigoni

To cite this article: Eroy Aparecida da Silva , Ana Regina Noto & Maria Lucia O. S. Formigoni
(2007) Death by Drug Overdose: Impact on Families, Journal of Psychoactive Drugs, 39:3,
301-306, DOI: 10.1080/02791072.2007.10400618

To link to this article: http://dx.doi.org/10.1080/02791072.2007.10400618

Published online: 08 Sep 2011.

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DEATH BY DRUG OVERDOSE:
IMPACT ON FAMILIES t
Eroy Aparecida da Silva, B.Sc. *
Ana Regina Noto, Ph.D.**
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Maria Lucia 0. S. Formigoni, Ph.D.***
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, qualita­
tive 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 Jives of families. This impact can be even more
devastating in the case of death by overdose. It is an abrupt
Joss by non-natural causes that is loaded with social/moral
tResearch for this article was supported by Associ�ao Fundo de
Incentivo a Psicofarmacologia-AAP. The authors would like to thank
the families who volunteered to participate in this study.
*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 .
Journal of Psychoactive Drug_s
Short Communication
stigmas, secrecy, shame and denial, in addition to produc­
ing strong feel ings of anger, helplessness and guilt. The
families who Jose 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 1 988).
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 1 998).
In ancient times, people had to face death earlier. An­
cient 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 1 998). 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 1 990).
Later on, and throughout many centuries, terminal patients
remained at home, surrounded by their relatives, making fi­
nal 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
fami ly started the mourning ritual, which included restric­
tions regarding their social l ife, 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 1 992).
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
* **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: eroy @psicbio.epm.br
301 Volume 39 (3), September 2007
 Da Silva, Noto & Formigoni
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 famil ies of their individual ritual
regarding their loss (Aries 2003, 1 990; Kubler-Ross 1 998;
Maranhao 1992). Both the family members and the person
in the critical state are lonely and very afraid, wonderi ng
what the "final moment" will be l i ke. 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 1 992).
THE FAMILY VITAL CYCLE AND DEATH
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Cul tural and social changes that took place in the way
people deal with death had direct repercussions on the
psychological and emotional l i ves of fami l ies. 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 1 995 ; Carter & McGoldrick 1 995).
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 i nfarction
(Brown 1 995). Sudden deaths hit the families abruptly, caus­
ing 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 1 984)
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 sud­
den. 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 1 984).
In general , the death of older people is better accepted,
being considered a natural process, than the death of chil­
dren, 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 i m pact when the parents have
Journal of Psychoactive Drugs
Death by Drug Overdose
a dysfunctional relationship with this child. If the sudden
death of the chi ld takes place in adolescence, the level of
fami l y 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 1 995).
DEATH BY OVERDOSE
Studies on the deaths of drug dependent persons show
that this population expects to l i ve 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
1 988).
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 fam i l y members regarding death by drug over­
dose should be deeply reflected upon.
Even though these deaths are mostly associated with
ill icit 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.
I n a study with 400 i njection 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 i nterviewees 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 Brazil ian Center of I nformation on
Drugs analyzed 1 20, 1 1 0 forensic reports by the Forensic
Medical I nstitutes 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
1 987 and 1 99 1 . The prevalence of positive reports for drugs
increased from 22% in 1 987 to 77% in 1 99 1 (Carlini, Nappo
& Galdur6z, 1 993).
Epidemiological data on the number of deaths by drug
overdose are sti l l scanty in Brazil. Those deaths do hap­
pen, but their numbers are certainly lower than those for
accidents, fol lowed by deaths that i nvolve alcohol directly
or i ndirectly.
Overdose is a result of "super-dosage" in the use of
one or more substances that trigger physiological altera­
tions which can seriously compromise the user's health and
require i mmediate medical attention to avoid death. These
302 Volume 39 (3), September 2007
 Da Silva, Noto & Fonnigoni
events have various causes: they can be accidental, premedi­
tated, 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 mi ght 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 1 8 to 27, that
is, a younger portion of the population (Stanton & Todd
1 988; Stanton 1 977; Vail lant 1 973).
The drugs that pose a higher risk of overdose are co­
caine/crack and heroin, used alone or i n association with
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other drugs. In a situation of overdose, mainly if the use
happens in groups, people often become terrified and trau­
matized. 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 ai med at descri bing, through a
qualitative methodology, the feelings of and the impact on
families of the death by overdose of one of its members.
METHODS
Family in this work was defined as people connected by
living together i n a relationship of belongi ng and perform­
ing basic tasks of care, education and upbringing (fathers,
mothers, spouses, children and others). The authors used the
qualitative content analysis methodology to i nterview family
members who lost a relative due to drug overdose (Bardin
1 979). The content analysis of the interviews started with
a floating reading of the material, i n 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 i mpact of that death by drug overdose
on the family (devastating, massive).
Si nce this population is hard to identify, we started the
search through i ndications 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 i nformants, we located other participants through a
snowball sampling technique (WHO 1 994; Diaz, Baruti &
Doncel 1 992 ; Biernacki & Waldorf 1 98 1 ). We identified
six famil ies with a history of death by overdose, and invited
Journal of P:.ychoactive Drugs
Death by Drug Overdose
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 i n Research of the Federal Uni­
versity 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 i nvestigate new issues that might come up
as the i nterview develops (Minayo 2000; Rizzini, Castro
& Sartor 1 999). Since the answer was comprehensive, the
authors felt no need to ask any further questions.
RESULTS
After the analysis of the i nterviews, the families were
grouped i nto 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 mem­
bers are reported below. The three first i nterviewees were
not aware of their family member's drug use, and last three
were aware of it.
Family Members Who Were Not Aware ofThe Drug Use
l . Female, 47 years old, whose daughter died of a co­
caine overdose i n 1 997:
The death of m y daughter b y drug use w as 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 feel­
ings 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.
2. Male, 64 years old, whose son died of cocaine over­
dose i n 1 985:
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
303 Volume 39 (3), September 2007
 Da Silva, Nolo & Formigoni
how I felt. it's still far from what really happened to me. it's
an endless pain. Losing a son for drug use i s incomprehen­
sible, I never suspected he used cocaine, he dido 't smoke nei­
ther 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.
3. Female, 39 years old, whose brother died by a drug
cocktail in 1 994:
Losing someone in the family is very sad, even more so when
he is your most loved brother, who secretly uses drugs. Death
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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 in­
creased. When somebody dared touch on the subject, I de­
stroyed them, accused them, threatened even to report them
to the police. Our family became i solated 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 mar­
riage was pretty shaken. The secret he kept from us is incom­
prehensible 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.
Family Members Who Were Aware of the Drug Use
I. Female, 60 years old, whose son died of crack over­
dose in 1 995:
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 i rreparable 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 Anony­
mous and try to share our experience with families that are go­
ing 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 un­
noticed before.
Journal ofPsychoactive Drugs
Death by Drug Overdose
2. Male, 55 years old, w hose son died of a cocaine
overdose in 1 995:
I knew that overdose would be a risk at some point. My son
got involved with drugs when he was 1 3 . died at 23, in the
prime of life, but he chose it, it was I 0 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 i ssue always differed from mine, !
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.
3. Female, 42 years old, whose brother died of a cocaine
overdose in 1 990:
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 hi m 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!
DISCUSSION
In general , all the statements show how disturbing it i s
t o lose a fami l y member b y 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 i ntense and open, it is possible to observe a
"veiled preparation" for a possi ble death by overdose. This
304 Volume 39 (3), September 2007
 Da Silva, Nolo & Fonnigoni
brings about ambivalent si tuations: 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 pai n, the pain of irreparable loss; on
the other hand, relief. Relief from his sufferi ng as well
as ours." "The year that preceded his death was terri ble,
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 i n phrases such
as "we fai led in our attempts to help him." These families
usually have a paradoxical functioning: now they focus too
much on the drug problem (or rebel agai nst 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, hospi­
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tals, friends' houses, the disappearance of objects from the
house become part of the family routi ne. After some time,
the exhausted family gives everything up and expects the
worst. "The family becomes exhausted and, strange though
it may seem, begi ns 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 1 977, Stanton & Todd 1 988).
The statements of the family members who were un­
aware of another member's use show that the secrecy of the
use fol lowed by death by overdose brings about feelings of
anger, guil t, helplessness, i ndignation, 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 i ncomprehensible,
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Journal of Psychoactive Drugs
Death by Drug Overdose
I never suspected he used cocaine, he didn't smoke neither
drank, so you can i magine, 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 feel ing of guilt. According to Brown
( 1 995), 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 comm unity 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 pai n, the rescue of
farewell rituals help the families carry on in spite of the
suffering. The experience of sharing and the solidarity i n
those situations also work a s a n 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 cl inical perspective. It
is i mportant to stress, however, that diseases such as hepatic
cirrhoses, infarctions, and cerebral vascular accidents, all
associated with the chronic use of alcohol, as wel l as i nfec­
tion by the HIV virus, as i n the case of i njected drugs, also
cause strong impact on families. Those are slower deaths,
and seem to be more prevalent than the deaths by drug
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