Grieving a Drug-Related Death in the Context of One's Own Drug Use: An Exploratory Study

Drug-related deaths (DRDs) are a major societal challenge. People who use drugs are at particular risk of witnessing DRDs, and of losing people close to them to a DRD, and experiencing an overdose or other health issues themselves. People who experience sudden, unexpected, and stigmatized deaths, such as DRDs, are found to struggle more afterward than when the death is more natural and expected. Additionally, people who use drugs are more likely to experience a complicated grieving process following the loss of someone. Despite this, knowledge about the connections between a person's own drug use and reaction following bereavement from a DRD is scarce. This article makes a start at filling this knowledge gap. Based on interviews with people who used drugs and were bereaved following DRDs, the article explores how the bereaved spoke about the relationship between their drug use and losing a close friend or intimate partner to a DRD. We present four types of stories about the relationship between grief following DRDs and drug use. Informed by the Dual Process Model of Coping with Bereavement, we discuss the stories and highlight how drug use is used to handle emotional overload, how drug use leads to uncommon expressions of grief, and how the relationship between grief and drug use may lead to an avoidance of the reality of loss. We point out that drug use and grief are strongly intertwined and how stigma associated with DRDs and drug use creates obstacles to openness and relating to social networks in support processes.


Introduction
This article investigates how people who use drugs and are bereaved following a drug-related death (DRD) speak about the relationship between their drug use and their grief.DRDs are drug-induced deaths, deaths directly attributable to the use of illicit psychoactive drugs, and deaths caused by illness, accidents, suicide, and violence related to the intake of drugs.As described in the European Drug Report (EMCDDA, 2023), DRDs are a significant societal challenge in many countries and have a major impact on the lives of the bereaved (Kalsås et al., 2023;Titlestad et al., 2019Titlestad et al., , 2022)).
Bereavement is the situation of having recently lost a significant person through death and grief is the emotional reaction to bereavement (Stroebe et al., 2007).Bereavement is a normal and natural life experience that most people manage over time.Still, it is also a period of intense suffering with an increased risk of developing mental and physical health problems.Bereavement is therefore a subject for both preventive care and clinical practice (Stroebe et al., 2007).Those who experience sudden, unexpected, and stigmatized deaths, such as DRDs, are found to struggle more afterward than when the death is more natural and expected (Boelen & Smid, 2017;Christiansen et al., 2020;Titlestad et al., 2022).
People whose lives are dominated by drug use often have close relationships with others who use drugs and are at particular risk of witnessing a DRD and of losing people close to them through a DRD (Kenny et al., 2022;Schlosser & Hoffer, 2022;Wojtkowiak et al., 2019).Drug use and the so-called "complicated grief" are also found to be interconnected (Parisi et al., 2019).Despite this, the experiences of persons using drugs losing people close to them to a DRD have been given little attention in research, and there is a need to gain an increased understanding of the relationship between being bereaved following a DRD and drug use (Macmadu et al., 2022;Masferrer et al., 2016;Valentine et al., 2016).Given this literature gap, we sought through our research project to gain insight into the relationship between experiencing DRD and personal drug use.Based on individual interviews where participants talk about their experiences of grief and use of drugs, we explore the following research question: How do participants describe the relationship between the experience of losing a close friend or intimate partner to a DRD and their own use of drugs?

Background
The latest European Drug Report (EMCDDA, 2023) estimated that over 6,600 deaths involving one or more illicit drugs were reported in 2021 in the European Union, including Norway and Turkey.These deaths were premature, and predominantly affected people in their thirties and forties.Four out of five drug-induced deaths were men.Opioids, often heroin, were involved in 74% of the drug-induced deaths reported.Most deaths involve polydrug drug use.Norwegian statistics show that people facing drug-related challenges are at risk of early death, 10 to 20 times higher than the general population (Gjersing & Bretteville-Jensen, 2014).More than 106,000 Americans died from a drug-involved overdose in 2021, including illicit drugs and prescription opioids (National Institute on Drug Abuse, 2023).In addition, there are deaths that have occurred due to illness, accidents, and violence related to drug use and unregistered drug-induced deaths.So, even though the numbers are disproportionately high, they are underestimated (EMCDDA, 2023;Robertson et al., 2019).
The high number of DRDs creates a very high number of those who are closely bereaved.A conservative estimate is that a death strongly impacts 10-15 people close to the deceased (Dyregrov et al., 2020).This implies that globally, over two million people are bereaved by a DRD every year.A systematic review revealed little research on the consequences of a DRD for bereaved family members (Titlestad et al., 2019).Based on eight studies, the review revealed that the bereaved experienced an emotional overload, stigmatization, and a lack of support and understanding from both their informal and formal networks.Moreover, the review indicated that those bereaved from DRDs felt a heavier emotional impact, more stigma and less help and understanding than others bereaved due to both natural and unnatural causes (Titlestad et al., 2019).
Stigma, the process of interrelated components such as labeling, assigned to out-groups, stereotypes, discrimination, and social distancing of persons with substance use problems, are internationally documented (Corrigan et al., 2017;Yang et al., 2017).Stigma is displayed at both structural and individual levels and can be of different types, such as public stigma (from the general population), self-stigma (applying stereotypes to themselves), and label avoidance (e.g., not seeking help to avoid stigma) (Corrigan et al., 2017).Stigma may also be experienced as an associative stigma by individuals who are connected to persons with stigmatized status (Sheehan & Corrigan, 2020).A DRD is documented as a stigmatized death where the bereaved people are tarnished by associative stigma, with a substantial risk of barriers to seeking healthcare, internalized self-stigma, and loss of social support (Dyregrov & Selseng, 2021;Kheibari et al., 2021).
Further, grief following DRD is found to be disenfranchised, meaning that the feelings and needs of the bereaved are discredited or overlooked and may thus lose opportunities for social support (Barney & Yoshimura, 2020;Lambert et al., 2022;Valentine et al., 2016).Several researchers refer to DRDs as a special death (Dyregrov et al., 2020;Guy & Holloway, 2007;Titlestad, 2021), which recognizes characteristics that make a DRD especially difficult to grieve.The defining characteristics for the bereaved of DRDs are that there is often a high level of trauma and emotional strain, that the death may lead to associative stigma, and that the grief is disenfranchised (Dyregrov et al., 2020;Guy & Holloway, 2007).Research on sudden and unnatural deaths has highlighted that such a death can have severe, serious, and long-lasting consequences for the closely bereaved, including complicated grief reactions such as prolonged grief disorder, mental health problems, physical illness, and social isolation (Djelantik et al., 2020;Kristensen et al., 2012;Stroebe et al., 2017).Key factors in coping with grief are meaningmaking (Neimeyer, 2000;Valentine, 2019), the interaction between the construction of hope, selfcompassion, and posttraumatic growth (Morris et al., 2021;Sperandio et al., 2021), and relational support (Dyregrov & Dyregrov, 2008;Kalsås et al., 2023).

Drug Use and Grief
A meta-analysis and systematic reviews have shown emotional regulation and drug use to be significantly related (Weiss et al., 2022) and that complicated grief and drug use are mutually connected (Parisi et al., 2019).There is no overall definition of "complicated grief," but the term is used to describe a grieving process that deviates from the natural healing process (Rando, 2013).Most often the term "complicated grief" refers to the new grief diagnosis in the eleventh revision of the International Classification of Diseases (ICD); prolonged grief disorder, which is characterized by persistent and strong symptoms (still after six months) such as intense yearning for the deceased, difficulties accepting the loss, and significant impairment of daily functioning.In 2022, a related but distinct disorder with the same name was included in the text revision of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5-TR, American Psychiatric Association, 2022).
However, several other forms of grief exist, such as delayed grief, absent grief, distorted grief, traumatic grief, and excessive grief (Dodd et al., 2020).Parisi et al.'s (2019) systematic review (which included 12 articles published between 1997 and 2017) examining the connection between drug use and complicated grief, identified increased drug consumption following the death of a significant person.Moreover, the review showed that people using drugs were at increased risk of subsequently developing complicated grief.Within a clinical sample of adult patients in drug treatment who had lost a significant person (N = 196), 34% of participants had Complicated Grief symptoms (scored above 25 on the Inventory of Complicated Grief [ICG]).In contrast, only 5% of the control group (100 bereaved people who did not present any drug problems) had Complicated Grief symptoms (Masferrer et al., 2017).The participants using drugs and having complicated grief symptoms also presented symptoms of anxiety disorder (54%), symptoms of major depressive disorder (18%), and symptoms of PTSD (9%) (Masferrer et al., 2016).Parisi et al. (2019) conclude that it is likely that persons seeking treatment for drug problems may have grief-related treatment needs and vice versa.The researchers point to a need for further research to better understand the relationship between grief and drug use.
People who use drugs risk having overdoses themselves, witnessing overdoses, and losing significant persons to overdoses.Cumulative overdose events are found to be associated with a severe response to grief and loss (Kenny et al., 2022).Macmadu et al. (2022) point out that people who use drugs experience profound and recurring trauma, bereavement, and other emotional effects following the overdoses of people they know.Schlosser and Hoffer (2022) highlighted how complex social relations shaped the grief of people who use opioids and how their mourning was interrupted by involvement with social services and criminal legal systems.Selseng et al. (2023) found that the bereaved of DRDs who use drugs had little social support and professional help related to their grief.Wojtkowiak et al. (2019) studied the grieving processes of 10 men using drugs who had experienced losing people close to them due to a DRD.They identified that the use of drugs led to the inhibition of feelings, delayed grief, and a fragmented grief process where the reactions to the death could be stronger in periods where they used fewer drugs, even if this was months or years after the death (2019).Wojtkowiak et al. (2019) also point to social exclusion, disenfranchised grief, and the experiences of multiple losses as important factors.Furr et al. (2015) point out that addressing potential losses might be essential to helping people move away from a life dominated by drug use.However, the process of facing and tolerating difficult emotions such as those associated with grieving may be demanding (Furr et al., 2015).Furr et al. (2015) suggested that continued research is needed to gain more knowledge about the experiences of people who use drugs in relation to loss and in order to gain insight into the impact of these losses on recovery processes.Parisi et al.'s review (2019) identified two studies supporting the use of grieffocused interventions to address complicated grief and drug use (Sandler et al., 2016;Zuckoff et al., 2006), but no available studies were found that evaluated outcomes for people with complicated grief who were in drug treatment.
Overall, previous research has documented a clear and mutual connection between drug use and grief, but we lack insight into how this relationship should be understood.Such knowledge is critical for understanding their complex life situation and being able to interact with this group of mourners appropriately.In this exploratory study, we seek to gain insight into the experiences of being both bereaved following a DRD and a user of drugs.

Theoretical Framework
We seek to understand their stories in the light of grief research in order to contribute to a new theoretical framework for exploring drug-related problems (Seear & Valentine, 2022).Several theories and concepts relating to bereavement have been developed that could be fruitful in understanding the participants' stories, such as grieving as a meaning-making process (Neimeyer, 2000), regulatory flexibility (Bonanno & Burton, 2013), and theories of attachment and loss (Bowlby, 1980;Shear et al., 2007).We have chosen to comment on and discuss the analytical results in light of the Dual Process Model of Coping with Bereavement (DPM) (Stroebe & Schut, 1999, 2010; for a systematic evaluation, see Fiore, 2019).This model has been increasingly applied to coping with bereavement in general, but it has not, as far as we are aware, been used to elucidate grief among the bereaved using drugs.The selection of the DPM model follows its implementation by Titlestad et al. (2020) in their study of drug-death-bereaved parents.Through their research, these investigators found that while a number of different models have been developed to understand ways of coming to terms with bereavement, the DPM proved useful in helping to understand the experiences participants had with DRD bereavement.
In short, the DPM model explicitly states the need for flexibility in the coping process: to cope effectively, a bereaved person must oscillate between loss-oriented and restoration-oriented coping.Loss orientation (LO) refers to dealing with the loss itself, with all the stressful aspects that the death of the close person involves.LO includes symptoms of grief, sadness, longing, and all related thoughts and actions surrounding the loss directly.Restoration-orientation (RO) denotes coping with the so-called secondary stressors that result from the death of a close person, such as changes in status and identity and having to perform new tasks that the deceased person used to do.These additional difficulties may potentially lead to exhaustion and anxiety.Stroebe and Schut have subsequently expanded on the DPM and put forward the idea of overload, describing "the bereaved person's perception of having more than s/he feels able to deal with-too much or too many activities, events, experiences and other stimuli" (Stroebe & Schut, 2016, p. 100) and the impact of family dynamics on personal grieving and vice versa (Stroebe & Schut, 2015).The DPM can be used to explore both quantitative and qualitative data.In this article, it is used to discuss and reflect on the typology of stories developed based on qualitative interviews.

Methods
The study is part of a major Norwegian research project called "The Drug-Related-Death Bereavement and Recovery Project" (The END-project).The overall goal of the main project is to contribute to a greater understanding of the consequences of a DRD for the bereaved and to enhance quality and competence in health and welfare services.

Recruitment
Six of the participants were recruited from the questionnaire sample.These six participants had agreed to be interviewed, reported that they had lost a friend or intimate partner, and reported that they used or had been using drugs.As we wanted a larger sample with this very background, we recruited seven more persons for the project.These persons were recruited through the snowball method by professionals working in substance-use services and peer-support organizations.

Participants
The sample included 13 bereaved people, seven women and six men, with experiences of drug use from across the country.The age of the bereaved varied between 21 and 54 years, and the age of the deceased varied between 16 and 39 years.Two informants reported drug use at the time of the interview, two were in treatment, eight reported that they had stopped using drugs, and one reported using them occasionally.The length of time the participants had used drugs varied from 5 to 40 years.Eight reported ongoing drug use at the time of the death, two were in treatment or detoxification, and three were not using drugs at that time.The time since the death ranged from 1 year to 40 years.Two of the interviewees were present when the person died.Nine persons were friends with the deceased, three of whom had previously been intimate partners.Three had lost an intimate partner, and one had lost an ex-partner.Except for the person who had lost her ex-partner, all described having a very close and important relationship with the deceased.Nine had lived with the deceased either privately, in a treatment institution, or in a youth home.Three of the bereaved had children with the deceased.

Interviews
The face-to-face interviews were carried out during the period from July 2019 to October 2020.The first and third authors conducted the interviews, except for one, which was conducted by another researcher working on the END project.Each interview lasted approximately one and a half hours and was recorded and transcribed verbatim by an experienced secretary.The interviews were designed to be dynamic, teller-focused meaning-making occasions (Hydén, 2014), where the participants were invited to tell stories about their experiences of being both mourners who lost a close friend or intimate partner to a DRD and their experiences of using drugs.Some main questions were: Can you tell me about your relationship with the deceased before the death?How did you experienced losing him/her?Can you tell me about your own drug use after the death?Can you tell me about your experiences with help and support after the death?Can you tell me about how your experiences have promoted or hindered your coping with grief?

Analysis
Narrative analysis is a diverse analytic tradition building on the premise that people understand their situations through stories (Riessman, 2008).This analysis is inspired by Frank's dialogical narrative analysis ( 2012).The dialogical narrative analysis points out that any individual voice is a dialogue between voices and how the stories told are composed of fragments of previous stories.The stories of loss, grief, and drug use told in the interviews are meaning-making tools to understand and portray how drug use and drug-related loss are related.Further, the stories are addressed and contextualized, meaning that the stories told are addressed to the interviewer and co-constructed by the interviewer's response and the stories are constructed from the generalized others of a speech community (Frank, 2010).
Our analysis can be divided into two sequences.Based on our interest in examining the stories of how grief and drug use are related, in our initial examination, we identified narrative sequences that contained the interrelated topics of losing a close person to a drug-related death and drug use.In our second examination, we explored the stories more in detail by asking the analytical question: "How is drug use given meaning in relation to grief?" Inspired by Frank's dialogical narrative analysis (2012), we were concerned with how the stories told were linked to other stories shared in society and the contexts in which they were told.Additionally, we explored how the stories reshape the past, project the future, and how the stories create identity.We studied the similarities and differences between the stories across the interviews.Based on this work, we developed a typology of stories based on the core of those told to us.After this, we read and discussed the stories through the lens of the DPM model.We consider the dialogic analysis and the DPM model to be compatible approaches, where both are based on an understanding that people's experiences are embedded in a social context.While the first rounds were conducted as an inductive analysis grounded in the data, the reflections through the lens of the DPM model were influenced by the researchers' theoretical assumptions, disciplinary knowledge, personal experience, and socio-cultural anchoring.These reflections are explored in further detail in the "Discussion" section.
The main analysis was conducted by the first author and then discussed and developed in dialogue with the co-authors.Additionally, our analysis was validated by discussions with four experts-by-experience working on the END project.The experts-by-experience confirmed and recognized the findings and gave input on topics for discussion.

Ethical Consideration
The END project was conducted according to the Helsinki Declaration and approved in February 2018 by the Norwegian Regional Committees for Medical and Health Research Ethics (reference number 2017/2486/REK vest).Before each interview, participants were provided with written and oral information about the study and then gave their written consent to participate.The interview data were treated confidentially, and all personal data were stored securely on the research server at the university.
We were aware that the research topic was sensitive and involved vulnerable persons, and we ensured that the participants were taken care of in line with appropriate recommendations (Dyregrov, 2004).

Findings
We identified four types of stories about the relationship between grief following a DRD and drug use.We have labeled them (1) stories about managing grief through the use of drugs, (2) stories of silence, (3) stories of guilt and responsibility, and (4) stories of death as a transformative life event.Some of the bereaved narrated just one of these stories, while others told stories that encompassed several of the story types.Many of the interviewed persons told a variant of stories about managing grief through the use of drugs, stories of silence, and stories of responsibility, while a few told us stories of death as a transformative life event.We illustrate each type of story with excerpts from the interviews.The interviewees have been given pseudonyms and identifying details have been removed.
"The heroin was the only thing that made me able to bear my grief" -Stories about managing grief through the use of drugs Many interviewees talked about how their drug use was a way of dealing with their grief.Some people used drugs when the death occurred and said that they continued with it to deal with the loss, and many told us about how the death led to an intensification of their drug use.For example, Tom, 28 years old and currently using drugs, told us about his reactions after his best friend died of an overdose: "My drug use just took off after the death.I lost 20 kg in six months.I didn't eat.I didn't exercise.I just did cocaine and drank alcohol."Several of the bereaved who were not using drugs when the death occurred, described the grief as leading them to new periods of drug use.They explained that they left treatment institutions, detoxification, or started using drugs again after a long time without taking them.Drug use was described as a way to cope with the grief in various ways.Many explained how the use of drugs helped them by "taking the edge off" their difficult emotions, thus making the grief more manageable.Eva's story illustrates this well.Eva, 29 years old, told us of intense and painful grief after finding her boyfriend dead and of intrusive and traumatic memories of her trying to save him.At the time of his death, she had not used drugs for two months, but she quickly returned to extensive drug use.Eva described how the use of heroin was the only thing that helped her deal with the pain of having lost him: Nothing in the world can take away the pain of him dying in my arms, but it gave me a good kind of peace.It shuts off my emotions, all pain, and all sorrow, for a short period.Then it's possible to breathe and just be able to remember the good times, the good memories, the wonderful love.Because as soon as the heroin wore off, it was just grief and pain.Then the memories just went, and all that was left was the fact that he died, nothing else.The heroin was the only thing that made me able to bear my grief.I think if I had not had the heroin there and then, I would have killed myself.
In addition to the drug use being described as alleviating the pain, some said that the drugs made them see things more clearly, one explained how drug use contributed to a false, wishful belief that the loved one was not dead, while some stories explained how the drug use helped them to get closer to the deceased.When the use of drugs was something that they had in common with the deceased, the use of drugs brought out more memories, and the deceased's presence was experienced more strongly.Eva's story illustrates this: When I cook up heroin and smell it, it reminds me of the early days of love.It reminds me of everything, inserting the syringe and feeling the hit of the heroin and the heat in my body reminds me of him and the security he gave me.And that's often the main reason I take heroin, it justifies it somehow.It's okay to do heroin because then I feel closer to him.
Eva's account illustrates how her drug use was used to get closer to her dead partner.In the lens of the DPM model, this can be seen as a story of a loss-oriented coping strategy where she used drugs to cope with the stressors related to her yearning for her partner and the life they had together.Drug use has the same function in her story as other actions described in mourning literature, such as looking at pictures to seek closeness and a continued relationship with the deceased (Stroebe & Schut, 1999, 2010).
Eva's story is also a story of emotional overload.At the time of the death, she had not used drugs for two months, but the overwhelming feelings of grief were experienced as impossible to cope with without using drugs.Feeling that she had no other alternatives, she said that "if I had not had the heroin there and then, I would have killed myself." Stories of dealing with grief through drugs are told both by people who have lost their loved ones a short time ago and by people who lost someone several years ago.Eva had lost her boyfriend four years previously and said that the need to alleviate the grief and pain of drug use was still present.She wanted to have a life without drugs and had sought professional help for her drug use several times since her boyfriend's death.At the time of the interview, she was undergoing in-patient treatment for her drug-related problems.Eva told us that she had many relapses in the first months of her treatment because she could not cope with her feelings.She had now had a stable period without the use of drugs.Eva describes a dilemma in which, on the one hand, she thought she had to deal with the loss of her boyfriend in order to live without drugs, while at the same time, she feared that a confrontation with the loss would make her emotions too difficult to handle without using drugs.This understanding prevents her from talking about the loss with her therapists: I have a great psychologist here, but, again, when they want to go into the loss, I always say, "not now, not now, later, later," which she accepts.(…) I have agreed that it's probably a good idea to start to do some work with the grief, soon.But I'm not sure if I can do it because for four years, I have just pushed it down and pushed it down and pushed it down, and if I let it come up again, I don't know if I can stay drug-free.
Within the DPM framework, Eva presented a story of avoidance of grief and of delayed grief.A dynamic process of a realization of the loss and working through the grief with the help of others (Stroebe & Schut, 1999, 2010) seems to be hindered by the fear that the pain would make her use drugs again.In Eva's story, the high level of grief is experienced as too difficult to regulate and contain without the use of drugs.
Tom, 28 years old, with current drug use, presented a narrative of how drug use was the only way he knew of coping with the grief: I've never mourned anyone.For me, it has always been drugs.It's like drugs take the edge off.If it takes half a year, three years, it does not matter to me.That's what I did.My story is a bit set up like that.These are the cards I have, in a way.I have not had a support system, so I've used drugs, and it works in part.It does.But I never get.… I never get over it.No, I do not.
The interviewer asked if he could imagine getting help to deal with the grief in other ways, and he answered: I don't really want to because I'm terrified of how I would react if I had to work on these things without the drugs.I'm frightened because I'm not like everyone else.All my emotions, besides joy, come out in anger, and I am terrified of my anger and what it does to other people.Yes, there's a lot that holds me back, but, basically, I'm scared of what will happen.
Tom describes, as Eva did, how drug use is perceived as having an essential role in coping with bereavement.Drug use is seen as a predetermined way of coping, "the cards I have."Drug use is also perceived as a responsible and considerate action since he fears how he will react if he is confronted with the grief without using drugs.
According to the DPM model, in both Tom and Eva's stories, drug use is presented as a substantial strategy to deal with loss-orientation stressors.Drug use is portrayed as having different functions to cope with the stress of the loss.For some, their drug use helped them alleviate the pain, for some to bring out memories of the deceased, for some, it helped them confront the loss, and for some, it helped them take necessary "time off" from the grief, including thinking that the death was not real.However, a similarity across the stories is that the emotions of grief are not persistently reduced or processed through attempted suppression.The experience that the grief is not processed creates a potential difficulty in life situations without using drugs, as they state lacking confidence that they can cope with the loss without using drugs.In line with the DPM model, they avoided loss-related stimuli, driven by the fear that confronting these reminders would be unmanageable.Such anxious avoidance is found to be associated with complicated grief symptoms (Boelen, 2021).

"So in order to avoid having to open up about myself, I've had to avoid talking about him"-Stories of silence
Another story that was often related in the material was a variation on how the understanding that drug use is illegal and illegitimate prevented them from telling others about their drug-related loss.At the core of these stories is that others would not understand and acknowledge their drug use.Speaking about the loss would involve a risk of they themselves being associated with drug use, something which several said they would try to avoid.Sara's story illustrates this.At the time of the interview, she was 42 years old, had not been using drugs for several years but had a history of many years of illegal drug use: I have told very few people that I had a boyfriend who died of an overdose.That's maybe a bit because I know it leads to a lot of questions about my part in it.And I worked so hard to distance myself from the whole drug scene and my own drug history.So, in order to avoid having to open up about myself, I've had to avoid talking about him.
Another example is from the interview with Isak (54 years old).He had struggled with drug use for several years, but he had managed to be drug-free recently, and now he worked at a drug treatment institution.One weekend, he was off work and met up with an old friend from when he used drugs.His old friend was still using drugs.They went home to his friend's house.Isak explained that he had bought alcohol for himself, while his friend had illegal drugs.When Isak woke up the following day, he found his friend dead from an overdose.This experience, Isak said, was not something he could not talk about with anyone.It would create distrust due to his own drug use and could lead to negative consequences for his job, among other things.
Dina (43 years old) said that she had previously had many years of problematic drug use but had not been using drugs for several years.She had a child with her ex-boyfriend, who continued to use drugs.Six years before the interview, he died suddenly and unexpectedly due to his drug use.She explained how she had avoided talking with their child about the loss of her ex-boyfriend and the child's father.She said she felt ashamed of her history of drug use and did not want her child to know.She explained that she feared the topic might raise questions about her relationship with him and her own drug use.This shame prevented her from talking about the loss with her child: Dina: She had a lot of questions, and she was so upset that she was not allowed to talk about him.There was no talking about him, so she was just left wondering.I don't talk about him at all, in fact.
Interviewer: What makes it difficult, do you think, and something that you haven't talked about?Dina: Well.The thing is.… It's the way he died.That he was a drug user, and it reminds me of my past.We used drugs together, so it's a difficult topic to get into with a child.I struggle.How can one explain everything so that she can understand it?
In DPM-revised (2015), where Stroebe and Schut expanded their consideration of family level coping processes, they point out that family dynamics influence personal grief.In line with this, Dina's story demonstrates how her former drug use interfered with family level coping.Her difficulties explaining her own drug use to her daughter made her avoid talking with her daughter about the DRD of her ex-boyfriend and her daughter's father, creating barriers to supporting each other in their grief.
Both Sara, Isak and Dina's stories are based around them avoiding talking to others about the drug-related loss to avoid having to talk about their own drug use.This way of thinking is based on the awareness that drug use is illegitimate and illegal and that it could have negative consequences if they talk about their own drug use.They chose not to tell people about their loss to sustain an acceptable self.
Sara, Dina and Isak's variants of a story of silence underline the point in the DPM model that the process of coping with grief does not take place in isolation but is played out in a context of culture, legal regulations, social networks, and daily activities (Stroebe & Schut, 1999).The avoidance of sharing their grief experiences with others can be understood within the context of public stigma, selfstigma and following label avoidance to which individuals with a history of substance use are exposed (Corrigan et al., 2017;Yang et al., 2017).The stories demonstrate how stigma produces silence around the loss and thus reduces access to social support for the bereaved person in the process of coping with the loss.

"You inevitably have a level of responsibility"-Stories of guilt and responsibility
Several interviewees told stories about feelings of responsibility and guilt related to the topics of losing someone close to them to a drug-related death and their own drug use.These were stories of "I should have or shouldn't have.…" One of those who told such a story was Thomas.He was 24 years old, with current drug use and talked about the loss of his best friend to an overdose.Thomas and his best friend used to take drugs together, and Thomas explained that he felt guilty because he was the first of them to start injecting drugs and his friend followed right after: Thomas: I was the first of us who started with needles, right?So, in that way, I have.… You inevitably have a level of responsibility.[…] I feel guilty that I started with that first, and then he followed me, right.[…] In the aftermath of the death, in their grief, his parents, his siblings and others close, they blamed me because I was the first to start injecting, of him and me.And he followed right after.One day, I just sat up there in his shed, and then I just picked up the syringe and then, not only do I pick it up, but I get him to help me stick it in me.… And that's a bloody heavy load to bear.Some guilt stories relate to an experience where they feel they did not do enough to try to help the deceased.Several describe having a bad conscience for having withdrawn from a situation to avoid starting using drugs again themselves.Other stories of responsibility are about them being involved in obtaining the drugs that led to the death.Some stories are about how agreements with the deceased on secrecy or how drug use should be handled created feelings of responsibility and guilt when the death occurred.
Tom, 28 years old and currently using drugs, related one such account.He and his best friend used to take drugs together.For his best friend, it was important that drug use experiences were not ruined by having to go to the hospital and use an antidote.Tom had an agreement with his friend not to call an ambulance if he became very intoxicated, but rather to put him in a lateral position and keep an eye on him.He explained that he had done this many times.On the occasion where his best friend overdosed, he had received a phone call from another person who was there and who was worried, and Tom recommended, as before, that he should put him in a stable position on his side.I felt, in many ways, guilty because I asked him to put him on his side, a stable side position and not call an ambulance […] I should never have kept that promise (voice cracks) … but I understand why he asked me to.He would have been so pissed off if he had woken up in hospital after an overdose.He would have gone crazy.But, anyway, that doesn't help me.Hindsight's a wonderful thing.It's like I sit and get annoyed every time that I didn't do things differently.But it's done, and no matter what people say and do, I can't get away from it.
Common to these stories about guilt and responsibility is that their own drug use is connected to the feeling of guilt.Through the lens of the DPM model, their stories describe a difficult aspect of loss-orientation stressors: Feeling guilty and counterfactual thinking are described in research as associated with grief, especially after sudden and unnatural deaths (Kennedy et al., 2019;Li et al., 2014).However, as described earlier, the stigma and illegality associated with a DRD, and the experience of a lack of cultural acceptance and understanding of actions that are part of a life dominated by drug use, seem to prevent them from sharing their experiences of guilt and responsibility.The lack of openness may hinder them from getting help from others to cope with their experience of guilt and responsibility.
"It was a wake-up call"-Stories of the death as a transformative life event Some interviewees told variants of a story of how the experiences of losing a close person to DRD had given them new insights and reflections about their own drug use, which led to substantial changes in their drug use.Some told us of how experiencing someone you love dying had given them a recognition of how final and painful death is, which gave rise to new reflections about the risk and pain of their own drug use.Louise, 24 years old, with former drug use, illustrates this point.She talked about intense grief, which she initially tried to suppress with drug use, but she also spoke of thought-provoking reflections she had about DRDs: I have previously used drugs very, very uncritically, and have been close to death many, many times.… So, in a way, it's like I understood something which I kind of knew-I understood that death is final.Because I got like a "Ah! Right!Yes! It's so final."Even though I knew, I have known so many who have died, and I know what it is like.But it was like-when you have been so close.For the first time, I think I was a bit afraid of death.
Furthermore, Louise shared another essential insight she had gained through experiencing how painful death also was for her loved ones who were close to the deceased.Louise explained how the death of her boyfriend had given her the insight that death, first and foremost, is an experience for those who are left behind.This recognition gave her a new perspective about how it must have been for her next of kin, and new ideas about what she had to do in the future about her own drug use: I felt a lot of guilt towards my own parents because they were grieving so, so badly.It felt like they were grieving for both him and for me.Because they had come so close to it, mum had planned my funeral: She planned my funeral when I was at my worst.She made playlists of music, and like everything, was prepared.I hope it's not like that anymore.I think it really hit them that it could have been me.And then I saw how hard it was for them, that he was gone, and then I saw how it was for his parents, and then I thought, I started thinking about what I have exposed my family to for so long.And to see how painful it is for the parents to attend their son's funeral, only to know that my mother has planned mine.That is really powerful.I still feel very guilty about that.I still get pretty emotional now when I think about it… Louise described that although she had not been using drugs for a while, in the first days after her boyfriend's death, she managed the shock and grief with heavy drug use.People around her were worried, and she was offered the option of getting in-patient treatment for her drug use.She said that her reflections on her parents' grief made her accept the offer: It was mainly that I saw that there are no winners here.My parents went through hell in their grieving process, in addition to the fact that they worried about me … yes, yes, that there will soon be another funeral.That was my main motivation to enter rehab treatment […] So that was the main thing, that I just, okay, I'm doing this for you guys, and I wasn't sure, back then that I would be sober for the rest of my life, that I would never use again.I just thought now you guys can have a break; and not have to think about all this right now.Even though that meant that I had to think a lot more about it all then […] then I started to think that maybe I should think that my death is not really about me.So, if I continue to do drugs, and I die, it's actually not about me, because it is those left behind who have to live with my death.So, perhaps it's okay to live life a bit for someone else too.I thought about it a lot, that is at least a start, even if I'm not motivated to continue.And I know deep down that if I had kept using then I knew I would be dead pretty soon because I was using so uncritically.But, yes, it turns out that living for someone else isn't such a bad idea.After a short time, I came to think that it works pretty well.
Sara, 42 years old with a former drug use, lost her boyfriend after an overdose, and she says that his death might have saved her in a way.She explained that they took drugs together and that it wouldn't go well if they had continued in the same way.She describes that something positive came out of the death in that the death taught her and gave her the strength to decide on a change: It was like a wake-up call, in a way.I managed to get a bit of bird's eye view of myself and see what I was actually doing.So, the death itself perhaps gave me a kind of strength, which I very much needed […] And I got the thought in my head: okay then I'll do it for both of us.I thought the least that I can do to honour him is to get clean.
Both Louise and Sara's accounts are variants of a story that is told by a few of the bereaved of how their partner's death put their own drug use in a new perspective.The stories express how their experiences of their own grief produce new notions of their drug use.Their new ways of seeing their own drug use convinced them to take new actions, and the death became a transformative event.
Through the lens of the DPM, their stories underscore the importance of the meaning that is assigned to the loss, as highlighted in the model.Stroebe and Schut (2001) point out that how a person feels and reacts to becoming bereaved depends on the meaning of the loss.They point out that positive appraisal thinking associated with loss impacts the grief recovery process and will support the adjustment process (2001).

Discussion
Bereavement has been neglected in drug research, and drug use as a coping strategy has been neglected in the field of bereavement research.In this article, a novel, qualitative exploration of the accounts of bereaved persons who use drugs telling researchers about the relationship between drug use and grief, enables us to connect the two research fields.Using dialogical narrative analysis of their accounts of their experiences of being both bereaved following a DRD and using drugs, we identified four types of stories: (1) stories about managing grief through the use of drugs, (2) stories of silence, (3) stories of guilt and responsibility, and (4) stories of the death as a transformative life event.Based on our readings of the stories through the lens of the DPM model, we want to discuss three themes that we find important to highlight; (a) drug use to handle overload, (b) uncommon ways to cope with common grief reactions, and (c) locked in avoidance.

Drug use to Handle Overload
In a paper from 2016, Stroebe and Schut incorporated the phenomenon of overload within the original framework of DPM.They define overload as "the bereaved person's perception of having more than s/ he feels able to deal with-too much or too many activities, events, experiences and other stimuli" (2016, p. 100).Stroebe and Schut point out that if a person experiences stressor overload, taking action to gain control over the overload would seem necessary.
The concept of overload appears to represent the experiences several of the bereaved persons spoke about in the time directly after the loss of their loved person.Whether or not they were in treatment, whether or not they were using drugs at the time, several spoke of more intense drug use or going back to a new period of drug use after a period without using drugs.Drug use seems to be a reaction to a situation they perceive that they cannot cope with.The burdens are so overwhelming, and there is so much to deal with, that the coping strategies they are using at the time are not viewed as sufficient.That the death of a loved one leads to, sustains, or increases, drug use is in line with other research (Caparrós & Masferrer, 2021;Lee et al., 2020;Macmadu et al., 2022;Parisi et al., 2019;Schlosser & Hoffer, 2022).
Our study contributes insight into how losing close people to a DRD for people using drugs can be experienced and what role drugs have in dealing with grief.Since intensified drug use and relapse into drug use carries a great health and overdose risk, this is vital knowledge.Our study underscores the need to develop further knowledge about how to help them deal with the acute experience of overload without intensive drug use.

Uncommon Ways to Cope With Common Grief Reactions
Reading the stories from the bereaved in the light of the scientific literature in general, and DPM in particular, makes it clear that the bereaved experience several grief reactions that have been identified as common grief reactions.They experience, as do others, different stressors associated with bereavement (Stroebe & Schut, 1999, 2010).They experience, for example, a need to calm the pain, they struggle with feelings of responsibility and guilt and express the need to come closer to the deceased.Previous research has also pointed out that it is common to increase drug use after the death of a significant other to reduce their pain (Parisi et al., 2019).Nevertheless, the extent and way of using drugs as a coping strategy differs from the majority of people and seems to not generally be considered as a culturally accepted way of coping with grief reactions.For example, looking at old photos or keeping the deceased's clothes are culturally accepted ways of trying to get closer to the deceased.Recalling old memories by using a syringe is not.Reducing pain with the use of sleeping pills is accepted, but injecting heroin is not.
Stigmatization associated with drug use and DRD is known to occur (Dyregrov & Selseng, 2021;Revier, 2020;Robertson et al., 2021;Russell et al., 2020).Following a DRD, bereaved persons who are using drugs seem to experience a double stigma where both the way the deceased died and their own way of handling the grief are stigmatized.The participants' storytelling demonstrates that they draw on cultural resources that inform them that their drug use is culturally unacceptable and shameful.This understanding creates a silence around their own grief experiences, leaving no room for processing the grief with the help of social networks, which is pivotal to coping with grief (Dyregrov & Dyregrov, 2008;Kalsås et al., 2023;Nurullah, 2012).Our findings are in line with Masferrer et al.'s (2017) comparison of grievers with substance use problems with grievers not using substances.They found that 25.5% of the bereaved using substances reported low perceived support, and only 2% of the nonusing participants reported low support.
In their review of the literature, Parisi et al. (2019) found that people using drugs are exposed to a range of risk factors that may lead to developing complicated grief symptoms, with nonnatural loss such as overdose being one of the potential risk factors.Social support is found to be a protective factor against complicated grief (Parisi et al., 2019).Our analysis contributes to increased insight into how stigma is experienced, how it leads to withdrawal and silence, and helps shed light on how harmful the stigma associated with illegitimate drug use can be.Seeing bereaved persons who use drugs as grievers with recognizable reactions and needs, is central for society and social networks to be more able to understand and support them in their grief processes.

Locked in Avoidance
In addition to silence and avoidance of talking about grief due to stigma, the stories also provide an insight into the discomfort and uncertainty about how grief can be overcome without drug use.This insecurity leads to an avoidance of working through grief.Our bereaved interviewees present drug use as a coping strategy that gives them short-term relief, but is not presented as an effective long-term strategy.Instead, several describe inhibited grief and a situation where they are locked in their continued grief since the avoidance strategy does not work for them in the longer term.When they are in a situation where they want to live their life without using drugs, this creates a demanding situation for dealing with their grief.To avoid using drugs, the strategy they know for coping with grief, they avoid confronting grief feelings and avoid talking about their grief experiences.
As for the societal stigma, the avoidance coping strategy hinders them from getting support from their social networks and professional help-an essential resource for processing unnatural deaths.At the same time, they reflect on the fact that the avoidance strategy does not help them process the grief and that they should be able to process the grief to be able to move from a drug-using to a nonusing lifestyle, but they do not know how to manage this coping process without using drugs.
The challenges described in processing grief without drug use are consistent with previous research exploring grief and loss in drug treatment (Bethune Scroggs et al., 2022;Furr et al., 2015;Zuckoff et al., 2006).Boelen and Smid (2017) point out that prolonged grief disorder might be maintained by anxious avoidance behavior.The dynamic of avoidance points to a need for better recognition in the research field and an important area to gain more knowledge about in drug treatment and grief treatment.Caparrós and Masferrer (2021) emphasized that treatment approaches for people with substance use problems and complicated grief should focus on decreasing frequently occurring mechanisms such as self-criticism and social withdrawal and increasing strategies to manage stressful situations and optimize social support.It is important to note that in their literature review, Parisi et al. (2019) found no studies that evaluated the outcomes of interventions for people in drug treatment with complicated grief.
An adaptation process focusing on both drug use and grieving difficulties may be facilitated if the support system can help people struggling with grief and drug use.Helping people develop long-term effective strategies to deal with their grief can also make it easier for them to cope with life without using drugs.Experiencing loss can also, as our study has shown, be a transformative life event that becomes a motivation for a change in a person's drug use.This is in line with the body of literature on meaning-making and positive growth during bereavement (Calhoun & Tedeschi, 2014;Neimeyer, 2000;Tedeschi & Calhoun, 2004).Enabling and supporting such positive processes, support and help is of utmost importance.

Strengths, Limitations, and Implications for Practice
The article is the result of a fruitful collaboration between two researchers who specialize in drug research and two who specialize in grief research.In addition, we have validated the findings with people with experience of being bereaved following a DRD and having had drug use experiences.Connecting different backgrounds of expertise has made it possible for us to unite two research fields in a way that hopefully provides valuable insights for both knowledge fields.
At the same time, people who are bereaved following a DRD and who use drugs are a heterogeneous group; our participants do not represent the diversity within this group.Furthermore, our analysis is not based on systematically examining the DPM.The application of the DPM is post hoc, and the study did not set out to investigate DPM constructs.Other models of grief may also offer different insights.However, the analysis has provided insights into how drug use and grief are strongly intertwined and shows the need for more focus on this relationship.Given its essential role both in the knowledge of grief and in the knowledge of drug use support and treatment, the relationship between grief and drug use deserves more scientific attention and rigorous exploration.
To provide better support to people both bereaved and experiencing drug use problems, this paper suggests some lines of further investigation.First, there is a need to investigate how grief support for bereaved people using drugs can be optimized.For example, there is a need for knowledge of how to help this group of bereaved develop coping strategies that enable a longterm grief recovery process.One implication of the present study is the need for health and welfare services to see the bereaved both as grieving persons and as people for whom drug use is an important coping strategy.This means that the field of drug use treatment and services needs training on grief reactions and grief support, while the grief field needs to be aware that those bereaved through a DRD are different people, and for some, drug use is an integral part of the grief management process.For both fields, it is central that health and welfare workers explore the stories of the bereaved about their needs, the meaning of their grief, and the function of their drug use in order to provide adequate help.Furthermore, helpers must be sensitive to the stigma and shame related to drug use and seek to facilitate grieving that is possible and helpful for those bereaved following a DRD.