3. Limitations of the quantitative studies

After assessing 50 inpatients of an alcohol and drug treatment center, it concluded that the loss can influence the pattern of alcohol consumption in different ways as the intake can be started, remain unaltered, increase, or even decrease. She also described that the onset of alcoholism after loss could perhaps reflect a precipitating factor that unmasks the predisposition in a stable phase of the individual concerned. Moreover, 83.2% of SUD patients (alcohol, cocaine, and heroin dependence) stated that after suffering a loss of a significant person, they increased drug consumption [27]. On the other hand, Furr et al. [28] differentiated between different types of losses: losses prior to addiction, losses while abusing substances, and losses associated with entering treatment. They interviewed 68 addicted patients using a self-report instrument. They concluded that the loss was an issue that may appear during any phase of addiction counseling but authors are prudent and avoid

Moreover, some results also emphasized the fact that substance use was a strategy used as a coping mechanism in certain traumatic vital circumstances. According to Bowser et al. [29], drug abusers may be people with a variety of background traumas and these accumulated traumas, and respondents and their families' inability to deal with or process emotions, were what motivates their self-medication and extremes in life-threatening and risk-taking behavior. In this regard, they reported that 26.4% of 592 participants experienced one or more sudden deaths of adult family members before the age 15. The same research showed that those drug dependent people with incomplete mourning had the highest level of heroin use and injection of cocaine. According to the study, almost half of the respondents (48%) used heroin as an adaptive attempt to regulate and control high anxiety at the same time as a way of managing stressful life events. Related to stressful life events, the authors claimed a significant relationship between those who under-mourned and being sexually abused as children. Moreover, the earlier the death that respondents experienced, the higher was the

e. The type of substances consumed has also been studied. Different studies have focused primarily on alcoholism and have found a link between bereavement and alcohol problems. Among bereaved men, the risk of alcohol-related problems tends to be higher than nonalcohol [30], although other types of drugs have undergone a study. Among the heroin-dependent patients sample, loss events and potentially traumatic events were present and tend to increase in passing from the before- to the after-dependence age of onset period. During the prior-dependent age of onset period, "the death of a close friend or relative," "divorce," and "being neglected or abandoned" were rated by the patients as the most important events. Exposure to stressful life events is associated with an increase

f. Suicide. At this point, we can include aspects related to the way the person died, such as the study by Wilcox et al. [32], which showed that parentally bereaved youths were found to show higher rates of alcohol and substance abuse symptoms than their nonbereaved counterparts. The results described the association between parental death and addiction. Offspring of suicide decedents had an especially high risk of hospitalization for suicide attempt. Child survivors of parental suicide were at particularly high risk of hospitalization for drug

establishing causal relationship.

40 Drug Addiction

likelihood that they would become involved in the sex trade.

in the risk of becoming drug addicted [31].

When arriving to this point, it is clear that the subject we are dealing with has great theoretical and methodological complexity. For example, the different terminology used relative to bereavement, such as grief or abnormal grief responses, as Blankfield [20] pointed out.

Despite the fact that we can find some recent research, some of the articles are from the late 70s and 90s. For this reason, dated studies also affect the concept and model of bereavement. In the few studies where the conceptual framework is defined, this is based on the popular model of Kubler-Ross stages [41]. Today, different limitations of models based on stages are well known.

secondary phenomenon as a symptom and not as a mental disorder itself. In this sense, there is

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125 43

Following Furr et al. [28] and Beechem [43], it is also important to distinguish between different kinds of losses: prior to SUD diagnosis, while abusing substance and those losses associated with entering addiction treatment centers. Moreover, some studies focus on bereavement before SUD diagnosis. It will be important to consider also bereavement during

However, despite the shown limitations of these studies, we cannot underestimate them because each of them includes a contribution to the complex, complicated, and difficult field

This review presents different research studies which show the relationship between stressful life events and addiction over a wide range of years of publication. The majority of the revised quantitative studies support the hypothesis that there is evidence of a relationship between bereavement and addiction. According to Rugani etal. [31], the addiction might be affected by traumatic life events but it also has an impact on their development. Highlighting the possible relationship between the loss and the SUD could help to build a theoretical background. At a therapeutic level, it would be useful to take into account the bereavement of a significant person to improve the dishabituation treatment. However, a few of the studies [21, 34, 36–37] showed no relation between these two constructs. More research is needed to support and describe the bereavement phenomenon related to the addiction framework to support the inclusion of grief psychotherapy for those patients at risk of developing CG symptoms in

Considering the studies shown, we can conclude that loss could have a role in the process of addiction. Because loss can have different influences on the pattern of drug consumption (precipitating the initiation of consumption, intake remaining unaltered, increasing or decreasing), it is important to be cautious. Loss could be a factor but more research is needed to clarify

It would be significant to be able to understand the specific interplay of bereavement in the patient's personal situation and hopefully be able to develop even more effective and person-

The authors appreciate the great contributions of Elisenda Escalé. They also thank Dr. Gabriel Beceiro for his support and his comments. The authors would like to express gratitude to Dr.

a danger of diminishing, minimizing, or downplaying all that addiction entails.

the SUD process.

4. Conclusion

addiction treatments.

what kind of factor it is [26].

Acknowledgements

Stroebe for her suggestions.

alized treatment for each specific personal situation [44].

of addiction treatment.

At the methodological level, in many of the presented studies, there is a comprehensive and detailed description of both the sample and the procedure or statistical analysis. In this sense, it is worth noting that there are few studies that consider the relationship between these two constructs: SUD and bereavement. On the other hand, it should also be pointed out that in some cases they are evident and that some studies present some problems of scientific rigor and validity. Due to the characteristics of SUD patients, it is difficult to collect data, so some studies presented small size of the samples. As Hilgard and Newman [22] pointed out, some studies were characterized by poorly defined and incomplete samples.

In relation to the assessment of different variables, the psychometric tests assess the psychopathology, personality, alcohol and drug use or dependence, self-esteem, social support, coping strategies, trauma-life history, and paternal bonding, but in general there is a lack of information about the measurement of bereavement. Few studies have measured the symptoms of complicated grief, except Masferrer's research [42], in which 34.2% of SUD patients reported symptomatology of CG.

Another technique used which can cause a bias is retrospective call, as Hilgard and Newman [22] described. This outlines the different hazards involved in using old hospital records to derive statistical information and also the retrospective call depends on participants' memories, which could be different from reality.

Another important aspect to note is that, as Gregory [40] summarized, it is very common for the control groups to have been casual (medical students, hospital orderlies, not equated for age, sociodemographic factors that could be important). In most of the cases, the main characteristics of the sample are defined by two categories: (a) patients, which means that the person is attending a treatment and (b) participants, people who are not attending any treatment. This categorization may not identify addiction cases. They are not receiving treatment and may be included in a control group if this variable is not controlled in some way.

Locations of the vast majority of the studies cited were in the U.S.A. Six research studies were from Europe. Only one study was from Japan and two from Australia. This point is closely related to cultural variables that can be involved, both in relation to consumption and loss. More transcultural research on this topic is needed.

In many of the studies presented, a deterministic vision could be obtained, in the sense that a linear and direct relationship between loss and addiction were described. Therefore, it is essential to be cautious with the interpretation of the outcomes. It should be remembered that an SUD diagnosis is much more complex, complicated, multifactorial, and even dynamic than simple cause–effect relationships. In this regard, the studies do not consider other etiologic factors involved in addiction, so it is relevant to take into account the limitations from a reductionist point of view. From a psychodynamic approach, addiction is understood as a secondary phenomenon as a symptom and not as a mental disorder itself. In this sense, there is a danger of diminishing, minimizing, or downplaying all that addiction entails.

Following Furr et al. [28] and Beechem [43], it is also important to distinguish between different kinds of losses: prior to SUD diagnosis, while abusing substance and those losses associated with entering addiction treatment centers. Moreover, some studies focus on bereavement before SUD diagnosis. It will be important to consider also bereavement during the SUD process.

However, despite the shown limitations of these studies, we cannot underestimate them because each of them includes a contribution to the complex, complicated, and difficult field of addiction treatment.
