At least 2,357 people died from opioid-related overdoses in 2022 in Massachusetts, according to state health department figures. That makes 2022 the seventh year in a row with a death toll greater than 2,000.
Each of those deaths leaves a ripple of grief that can devastate parents, partners, spouses, children, co-workers, friends, and acquaintances. Often overlooked in this web of suffering are the care providers who help or treat people with substance use disorder (SUD) and people who use drugs. From street outreach and harm reduction workers to hotline operators, recovery coaches, social workers, and nurses, these providers face a special set of challenges in processing their grief, including pervasive stigma around drug use and the cumulative stress of repeated loss.
The nature of direct service work often means building trusting relationships with clients and patients, which can make a loss hit harder, says Gabriel Quaglia, who coordinates the Direct Service Provider Program at Support After Death by Overdose (SADOD), a Massachusetts organization that runs peer grief support groups for providers.
“In human services, there’s much more of a tendency to talk about relationship-building. And that works well — that’s what gives people the trust in a provider to help them with their health or other issues they might have,” Quaglia says. “But it can be a double-edged sword, because you are getting more personal, you end up knowing a lot about them and caring about them. You can’t just ‘set boundaries’ and all of a sudden you’re good.”
Facing stigma when grieving overdose deaths
A major challenge around overdose deaths is the pervasive stigma around addiction that can exacerbate grief’s isolation.
“If somebody got hit by a car, it would be, ‘Oh, that’s horrible,’ but when somebody dies from a drug overdose, it’s not always seen that way. Their deaths aren’t given the same respect,” says Quaglia, who also has worked in harm reduction, a set of strategies to reduce negative consequences of drug use, such as promoting safer use and providing access to clean syringes. “I’ll have some random person or even an acquaintance or friend of mine talking about how we should just let them die, they deserve it, we shouldn’t be giving them Narcan. They’ll say it right to your face.”
“In a stigmatized loss, society fails the griever…With some other deaths, there’s a circle of support that gathers around. For those with disenfranchised losses — like an overdose death — that circle of support may move further away.”
Maureen Patterson-Fede, MSW, LICSW, is program manager at Boston Medical Center’s Good Grief Program, which offers support to pediatric patients and their caregivers after a significant loss, including death of a parent from opioid overdose. She cites the concept of disenfranchised grief, coined by gerontology professor Ken Doka to describe grief not openly acknowledged or publicly mourned.
“In a stigmatized loss, society fails the griever,” Patterson-Fede says. “With some other deaths, there’s a circle of support that gathers around. For those with disenfranchised losses — like an overdose death — that circle of support may move further away.”
Premature deaths, cumulative loss
Stephen Murray, MPH, NRP has seen overdose from multiple angles. He is an overdose survivor himself, and worked nearly 10 years as a paramedic as the overdose crisis grew and fentanyl played an increasingly deadly role. He estimates he has responded to more than 100 overdoses and pronounced more than 30 people dead.
Compounding the pain of losing patients he had come to know, he says, was seeing how overdoses took lives prematurely.
“Most of those people dying were my age,” says Murray, who is now 35. He recalls his first fatal overdose response as particularly devastating. “I pronounced someone [dead] in their house. They were basically lying in a bed of children’s shoes. I never saw the kids, but seeing the shoes was traumatic, knowing there were children sleeping upstairs that were going to have lost their parent.”
Today, Murray works at BMC managing the hospital’s harm reduction program and providing training in BMC’s Grayken Center for Addiction Training and Technical Assistance program. He also directs the Massachusetts Overdose Prevention Helpline, a statewide overdose detection and response hotline housed at BMC and funded by the Massachusetts Department of Public Health and the nonprofit foundation RIZE Massachusetts.
While this work helps Murray be part of the solution, it also multiplies experiences of loss.
“On the hotline, I’ve had two cases this year where I was the operator when someone overdosed,” he says, “And as the director, overseeing 15 other operators, I review calls for quality improvement, so even when I’m not the one talking, I’m still hearing the stories.”
Murray adds, “I would consider myself to have chronic grief that has acute exacerbation every time somebody dies.”
Another stress factor for providers is seeing the problem seem to only get worse.
“In so few other health conditions do we see backward progress,” says Murray. “With cancer, we’re constantly seeing advances in treatment and survival. Even with AIDS, after the first wave of horrible deaths we made progress; people can now live a full life again. But with the overdose crisis, over the last 10 or 15 years our numbers have gotten worse. 2,357 people died from overdose in Massachusetts last year. We are the ones that put faces to those numbers.”
How to help: Acknowledgment and support
Those on the front lines clearly could use support in processing grief, whether that’s through peer support, employer programs, or simple understanding by others of the stress of loss.
SADOD, which launched in 2019, currently offers two grief support groups for direct service providers weekly and provides training to organizations.
“If you look at any issue out there, whether it’s Alcoholics Anonymous or the grief group Compassionate Friends, that peer support is always really crucial,” says Quaglia.
An even more elemental starting point, Quaglia says, is acknowledging that grief is there. “Part of what can cause some of the stress is denial, that sense of ‘No, you’re a provider, so you should just ‘suck it up, buttercup,’ because that’s just going to happen,'” he says. “But that doesn’t mean that we don’t need to somehow process this. Recognizing loss is an important piece.”
Employers can play a crucial role in support as well, from offering Employee Assistance Programs (EAPs) and grief support workshops to acknowledging and accommodating the needs of emotionally impacted providers who might be struggling and need some time off. Murray notes a rise of available services within BMC. Beyond healthcare coverage and an EAP, the hospital provides internal trainings and engages groups like SADOD and RIZE to provide training and resources.
“If you look at any issue out there, whether it’s Alcoholics Anonymous or the grief group Compassionate Friends, that peer support is always really crucial.”
At the Good Grief Program, each of Patterson-Fede’s three clinician team members are working with families whose loss includes an overdose death. Holding weekly one-on-one and full-team meetings, she says, allows clinicians to discuss not only client stories but what they are experiencing as providers.
Another strategy Patterson-Fede recommends is encouraging staff to pursue activities away from the front line, even on the job. For example, some clinicians deliver trainings in schools and other settings.
“It provides some distance from the stories,” Patterson-Fede says. “So that’s a strategy to feel more whole by engaging your mind a little differently. We try to find a balance between clinical work and other ways to contribute.”
She also keeps her eye on ways clinicians can connect with resources and peer providers both within BMC and outside, like the recent national training by the National Alliance for Children’s Grief that focused on overdose loss. SADOD hosted a Finding Hope in Grief conference last fall that offered a chance for providers to learn and connect in person — still a rarity since the pandemic — and RIZE also hosts training events.
“Grief is isolating,” Patterson-Fede says, “so finding antidotes to that is really important.”
And finally, simply allowing people to slow down can help.
“Often in our work we are facing a sad story, but there are other sad stories waiting. You feel pressure to pick up and move to the next person in need,” says Patterson-Fede. “We need to focus on where we can provide opportunities for folks to slow down. It’s in that slowing-down that they can take a breath and think about, ‘What is the impact on me? What is the cumulative impact of holding these losses?’
