OBJECTIVE: To study the association between benzodiazepine prescribing patterns including dose, type and dosing schedule and the risk of drug overdose death among US veterans receiving opioid analgesics. DESIGN: Case-cohort study SETTING: Veterans Health Administration (VHA), 2004 through 2009. PARTICIPANTS: US veterans, primarily male, who received opioid analgesics between 2004 and 2009. All veterans who died of a drug overdose (n = 2,400) while receiving opioid analgesics and a random sample of veterans (n = 420,386) who received VHA medical services and opioid analgesics were included in the study. Main outcome measure: Drug overdose death, defined as any intentional, unintentional or indeterminate poisoning death caused by any medication or drug, determined by cause of death information from the National Death Index. RESULTS: Twenty seven percent of veterans who received opioid analgesics also received benzodiazepines during the study period. Approximately half of the drug overdose deaths (n=1,185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of drug overdose death increased based on benzodiazepine prescription history: formerly prescribed vs. not prescribed (adjusted hazard ratio [HR]=2.33, 95% confidence interval [CI]: 2.05-2.64); currently prescribed vs. not prescribed (HR=3.86, CI:3.49-4.26). Risk of drug overdose death increased as daily benzodiazepine dose increased. When compared to clonazepam, temazepam was associated with a decreased drug overdose death risk (HR=0.63, CI: 0.48-0.82). Benzodiazepine dosing schedule was not associated with drug overdose death risk. CONCLUSIONS: Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of drug overdose death in a dose-response fashion.

This study explores the experiences of people who have lost loved ones due to socially stigmatized deaths. Drawing from eight individual interviews, the author argues that the stigma associated with death due to drug overdose, suicide, substance abuse, or murder can cause traumatic or prolonged grief and can complicate the way the bereaved talk about grief as a part of their healing process. With the mortality rate in the U.S. rising, there is an epidemic of disenfranchised grief affecting millions of bereaved individuals. Using Coordinated Management of Meaning and Communication Privacy Management theories, the author uncovers strategies the traumatically bereaved employ to manage interactions and relationships with others. A qualitative analysis of participant interviews revealed that social stigma, whether experienced or anticipated, affects the way the bereaved communicate and can cause self-silencing. Findings indicate a need for safe, supportive, and non-judgmental spaces for the traumatically bereaved to share their stories.