The Overdose Conundrum

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TALES FROM THE CLINIC

In this installment of Tales From the Clinic: The Art of Psychiatry, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly affect psychiatrists, the impact of patients’ overdose deaths on physicians is not well studied. Despite physicians’ best efforts in treatment, patients on medications for opioid use disorder may die of accidental opioid overdoses from having misestimated their current opioid tolerance or overdosing on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

Case Study 

“Ms Verona” was a 45-year-old woman with an opioid addiction and anxiety who was enrolled in an addictions treatment program. She had 7 children and was motivated to stop her opioid use because it was taking a toll on her health and her family. Ms Verona’s children sensed their mother’s lack of engagement with them; she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. Because she met criteria for severe opioid use disorder, she was a good candidate for buprenorphine therapy. She preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg daily to adequately address her opioid cravings.

As treatment progressed, Ms Verona chronically arrived more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of child care arrangements. Her psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of buprenorphine refills; however, these accommodations placed Dr Smith and the treatment team under time constraints in the busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments or would lead to the appointment with Ms Verona feeling rushed. After a few late visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

Dr Smith also questioned whether attention-deficit/hyperactivity disorder (ADHD) was affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She described a childhood history with symptoms of difficulty concentrating. They explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having received Adderall “but not recently, Doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to reduce treatment-interfering behaviors and promote punctuality. Ms Verona was started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, her tardiness continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona saw a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist, Dr Smith, met with one of his active patients, Mr Kim, and the following dialog ensued:

Dr Smith: “How are you doing today?”

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yes, it was sad….She [Ms Verona] said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or overdose has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be affected in such a situation. Younger clinicians and trainees are often affected more adversely because they may feel more vulnerable in terms of their experience and knowledge base.¹ According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.² The number of physicians who have patients who died from an overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.^3,4 The sheer magnitude of these numbers suggests that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes and the fear of lawsuits that may occur in these situations, the overall emotional toll on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the now-deceased patient. We often hear team members say, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

Physicians processing the suicide of a patient should be mindful to not isolate. Efforts should be conducted to reach out to colleagues, as it is likely they have dealt with similar experiences in the past and can normalize and validate the experience. Discussing experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or a group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings may help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated because of their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

When treating substance use disorders (SUDs), it may be helpful to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, patients do not find it easy to talk about them. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or they may be due to stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use, as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being, as opposed to punishment. Motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient’s internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.⁵

How Do You Find a Balance of Boundaries?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.⁶ In addition, it is important to acknowledge the role of untreated ADHD (as in Ms Verona’s case) in reducing recovery success.⁷ At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach because other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, without putting 1 patient at risk at expense of another.

In this case, did the boundary setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem solve, and lead to the approach that the physician drives the treatment, instead of the dyad having a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affect outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient suicide can affect physicians, there is a lack of data, particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support.

In addition, it is important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental but ultimately occur due to overestimated tolerance, unknown ingestion, or increased amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention.⁸ Although the percentage of intentional overdoses is the minority, another thing to consider is if the clinician will feel more intense guilt if the overdose is intentional. A physician may feel guilt for not effectively being able to manage a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regard to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,⁹ mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem. The estimated prevalence of suicidal ideation today is higher in comparison with the prevalence prepandemic.¹⁰

If a clinician’s natural tendency is to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at some point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.¹¹ Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that they also would contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians and to develop more efficient strategies and support for dealing with the aftermath.

Dr Li is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. Dr Khan is currently a resident in psychiatry at Baylor College of Medicine. Dr Moukaddam is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the Psychiatric Times™ Advisory Board.

References

1. Ruskin R, Sakinofsky I, Bagby RM, et al. Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry. 2004;28(2):104-110.

2. Plakun EM, Tillman JG. The impact of patient suicide on clinicians. Psychiatric Times. May 13, 2016. https://www.psychiatrictimes.com/view/impact-patient-suicide-clinicians

3. Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths - United States, 2000–2014. Centers for Disease Control and Prevention. Accessed September 12, 2022. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

4. Mattson CL, Tanz LJ, Quinn K, et al. Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths - United States, 2013-2019. MMWR Morb Mortal Wkly Rep. 2021;70(6):202-207.

5. Melemis SM. Relapse prevention and the five rules of recovery. Yale J Biol Med. 2015;88(3):325-332.

6. Williams N, Bossert N, Chen Y, et al. Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection. J Subst Abuse Treat. 2019;102:33-39.

7. Gupta S, Bhatia G, Sarkar S, et al. Adult attention-deficit hyperactivity disorders and its correlates in patients with opioid dependence: an exploratory study. Indian J Psychiatry. 2020;62(5):501-508.

8. Austin AE, Proescholdbell SK, Creppage KE, Asbun A. Characteristics of self-inflicted drug overdose deaths in North Carolina. Drug Alcohol Depend. 2017;181:44-49.

9. Doctor JN, Nguyen A, Lev R, et al. Opioid prescribing decreases after learning of a patient’s fatal overdose. Science. 2018;361(6402):588-590.

10. Farooq S, Tunmore J, Ali W, Ayub M. Suicide, self-harm and suicidal ideation during COVID-19: a systematic review. Psychiatry Res. 2021;306:114228.

11. Menon NK, Shanafelt TD, Sinsky CA, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780.