Alex Woodruff is a Policy Analyst at Boston University School of Public Health. He tweets at @aewoodru.
A “traumatic event” is when someone is exposed to a life-threatening event and/or actual or threatened serious injury. An overdose fits squarely under this definition. People who experience an overdose have gone through a life-threatening event and often subsequently experience the effects of trauma including intense fear, distress, and helplessness.
It can be tempting, even for medical professionals, to imagine that non-fatal overdose is a common, and even anticipated, experience for people who use illicit drugs. The rate of non-fatal overdose is many times higher than fatal overdose, with roughly 45 percent of people who use drugs experiencing a non-fatal overdose once in their lifetime. But for the patient, these events are often profound. Patient testimonials reveal the distress and horror that comes from being revived from an overdose.
Unfortunately, there is very little academic literature that explores the psychological effects of an overdose on the patient. A literature search around overdose and psychology tends to turn up papers on the links between post-traumatic stress disorder (PSTD) and overdose, stress and addiction, and even the emotional toll of witnessing an overdose, but never the short-term psychological impacts on the patient. This lack of research points to a gap in our knowledge about how overdose, substance use, and acute stress interact, and how these impacts affect treatment seeking behavior and long-term recovery.
Approximately 5-20 percent of people exposed to a traumatic event develop an acute stress disorder (ASD), a precursor for PTSD. If left untreated, ASD can develop into severe anxiety, depression, and chronic stress conditions — factors that are all linked to increased substance use. PTSD symptoms are more prevalent for people with multiple overdoses, but whether or not overdoses contribute/exacerbate to these symptoms is unclear.
Stress and substance use disorders are understood to have a bidirectional relationship. That is, stress increases the likelihood and severity of substance use, and increased substance use comes with increased exposure to stressors. Some research indicates that substances, opioids especially, interrupt the biochemical stress cycle. The stress related symptoms opioids initially address become exacerbated by using them. Over time, the brain’s ability to manage those stressors becomes compromised by a reliance on opioids. If overdose is indeed able to begin or strengthen this vicious cycle, it would be critical to recognize it as a traumatic event to effectively treat its emotional impact and to prevent the development of a more severe substance use disorder.
The lack of information on this topic limits providers’ ability to screen for trauma-related symptoms in a post-overdose patient. Negative mood, gaps in memory, isolation, and irritability are all symptoms of both ASD and withdrawal, making careful evaluation necessary to understand a patient’s risk for the development of trauma related symptoms. An emergency medicine clinician focused on the medical complications of overdose could misattribute a trauma response to withdrawal. PTSD and substance use disorders also mimic each other’s symptoms, especially those related to strained relationships with friends and family, sleep and mood disturbances, risky behavior, and decreased interest in activities.
Current research suggests using non-fatal overdose as a touch point to initiate medication-based addiction treatment. Conducting necessary research to understand overdose and acute stress could also have implications for furthering trauma informed care, and possibly increasing treatment retention. For a patient who survives an overdose and is revived in the emergency department, the hospital is the location of the trauma. Asking a traumatized patient to return to the hospital for care is a strategy poised to fail. Using low-barrier addiction treatment, mobile non-fatal overdose care teams, or telemedicine might be better options for patients post-overdose.
We know that how people are treated after experiencing a traumatic experience is critical to whether or not they develop a trauma-related disorder. Overdose is no different. Restructuring post-overdose care to be more effective will require further research into the relationship between overdose and trauma.