One Sunday afternoon, days before Christmas, two police officers knocked on Janice Persson's door in Ludlow, Massachusetts. Her son Brian, 30, was dead.
For years, Persson had offered support and calm reassurance to people when they felt scared or overwhelmed. She has worked as a nurse caring for organ transplant patients, staying by their side throughout their procedure and recovery.
But the news that her own son had died of an overdose put her "in total shock." In the months that followed that December 2022 day, her marriage crumbled, as her husband blamed her for their son's death, Persson, 59, said. She had never felt so alone.
"We're not supposed to blame ourselves, but it's hard," she said through tears.
Every year, more than 100,000 people fatally overdose in the United States. While evidence suggests deaths from overdose have been declining overall, each death plunges loved ones left behind into a deep well of loss and grief.
"For every person who actually dies, there are lots of people involved in that person's life," said Dr. Anita Everett, who directs the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration.
As many as 125 million Americans know someone who fatally overdosed, according to one estimate. Another federal study suggests that between 2011 and 2021, more than 321,000 children lost a parent to overdose. But instead of receiving a kind word or a casserole, these families and friends often are confronted by stigma, shame and blame from strangers and neighbors alike. They may be told that their loved one's death was self-inflicted or through some fault of their own.
READ MORE: Overdose fatalities fell last year, but the full picture is more complicated
Alison Athey led a study by the RAND Corporation published earlier this year in the American Journal of Public Health that estimated 2 in 5 U.S. adults know someone who has died from overdose.
The trauma and death toll tied to overdoses demands urgency "to think more creatively and more expansively," Athey said. "There's this huge gap that needs to be addressed from all sides."
Nationwide, established support group networks exist for people with a parent, child or sibling who is struggling with substance use as they seek out treatment with the goal of entering recovery. But the same is not true for those who have witnessed that struggle end tragically, according to Everett.
Scarce resources for the bereaved
In the months that followed Brian's death, Persson ached for her son and wished so many things had gone differently.
Once a happy boy and man, Brian thrived on adventure and in the outdoors — he "always liked to stay busy" and did well academically, Persson said.
But late in high school, she said, Brian experimented with drugs, sneaking into prescription pain medications at his family's home before purchasing it elsewhere.
"I never saw the addiction, even as a nurse – no clue," Persson said.
He eventually was placed in a rehabilitation program, where he recovered and relapsed. The cycle continued for years. Along the way, Persson said he was introduced to heroin, and he stole items from their home to sell in order to buy more heroin. By 2017, Persson said Brian "had to leave the house" after his father found drugs at home. Ultimately, he was arrested, convicted and sent to jail.
READ MORE: New study sheds light on ripple effects of overdose deaths
Upon his release less than a year later, Persson said Brian came home, found a job and began to build relationships with people, eventually dating the woman who became his fiancee. He experienced relapse (a normal part of recovery), but Persson said he immediately recommitted himself. During those four years before Brian's death, Persson said, "We just were able to really see him."
Then one Labor Day weekend, he got into a motorcycle accident, suffering injuries that required surgery. He missed time at work, stopped going to counseling and grew quiet about his relationship. Brian had relapsed again, and eventually fatally overdosed.
Consumed by guilt and grief, Persson tried to piece together how she had lost her son. Where had everything gone wrong? She thought of all the things she would have told him to try and save his life.
"Why couldn't he have had one extra phone call?" she said.
She scoured the Internet for help to manage her sorrow. She found a support group in her hometown, but it was oriented toward families with loved ones in recovery, "or basically still alive," she said. "It was too hard for me to go to those. It was a lot of PTSD."
In Massachusetts, people who have endured what is sometimes called opioid bereavement or overdose bereavement have sought out each other, building camaraderie through grief as they figure out how to go on. They have started working with state agencies to build a more systematic approach in hopes of helping more people.
This work is important "because nobody does it," said David Swindell, a grief counselor in Milford, Massachusetts, whose son, Chris, died of a fentanyl overdose in 2018.
Since 2000, more than 25,000 people have fatally overdosed in Massachusetts, according to the state Department of Public Health in December. Fentanyl has fueled many of those deaths, and state officials have ramped up an overdose prevention helpline, increased access to housing along with greater distribution of naloxone and fentanyl test strips. The state also has invested in prevention strategies, intervention, treatment and recovery services.
Beyond the Bay State, experts say resources for the bereaved are scarce. People from Michigan, Florida and California have joined Swindell's virtual group therapy sessions because they don't know whom else they can turn to closer to home. Researchers are looking to expand these supports in a way that's sustainable and accessible, especially as overdose deaths continue to rise in more than a dozen states.
The pain of losing his son drives Swindell to work with families who have lost loved ones to the disease of addiction, he said. He and others also established Chris' Corner Recovery Resource Center to throw a lifeline to people struggling with substance use.
"I've got to do something with this pain. This pain is so much," Swindell said. "I've got to do something to help others. I don't want anybody to go through this."
"The light at the end of somebody's tunnel might just be me."
'A feeling of peace'
After months of struggle, a family friend and social worker suggested Persson contact Learn to Cope, a support group based in Easthampton, Massachusetts, for people experiencing opioid bereavement. When she did, Persson was matched with a peer support ally named Kathryn, who had also lost a son through similarly tragic circumstances a decade earlier.
Persson could contact Kathryn at any time, and they often texted back and forth. They talked about their sons, what they once did together, how they were feeling and what they were doing to stay active. They found comfort in sharing memories.
Beyond talking to her ally, Persson also joined the group's virtual meetings with other people coping with the loss of a loved one due to overdose. Those interactions offered Persson "a feeling of peace," she said, even as she managed "these waves [of grief] that come over you."
"It was just so different to actually talk to someone who's been through exactly what you were going through," Persson said. Within that community, she did not encounter the stigma and shame that at times confronted her when she described her son's struggle with addiction, recovery and relapse. "The more people talk about it, the more knowledgeable other people will be," she said.
READ MORE: 6 tips on showing up for someone in mourning
Glen Lord, CEO for Peer Support Community Partners, his wife, Tanya Lord, and their colleague, Franklin Cook, have worked to create resources for people adrift in loss and grief after an overdose fatality, when the conversation is "shrouded in all this shame," Tanya Lord said.
One of these projects includes SADOD, or Supporting After a Death by Overdose, which was founded in 2019 and is funded by the Massachusetts Bureau of Substance Addiction Services.
Stigma often silences families from being transparent about their loved one's cause of death and asking for help when they're in need of it themselves, Glen Lord said.
Talking about those who have died
Often, people don't know what to say after someone dies, and that is especially true if the death was linked to overdose, Swindell said. This awkward tension can lead people to say nothing. That may feel safe, but it can compound the sense of isolation for the person who is grieving. Alternatively, people may say something hurtful, whether they mean to or not.
In one such instance, Swindell said he had gone to the cemetery to replace the candle at his son's grave. While he sat there, an older man walked by and noticed the dates on the marker.
"'How did he die?'" Swindell remembers the man asking.
"'He died from substance use and addiction,'" Swindell replied.
"'Oh, don't worry,'" the stranger told Swindell. "'God will forgive him.'"
Speechless, Swindell stared at the man until the stranger walked away.
People who want to support individuals in grief can do so in a few ways, according to Swindell.
READ MORE: What two decades of data on overdose suicides shows about mental health care disparities
Ask how they are doing and then "really listen and don't judge," he said. Do not give the "promise of false hope," such as saying things like "it'll get better" or "don't worry, you'll feel better," because those assurances can come off as dismissive. Grief and healing are not linear, he added. A person may be years out from losing a loved one, but find themselves overcome with grief due to an anniversary, a sudden memory or a situation that brings back a flood of emotions.
If you happen to think spontaneously of someone's deceased loved one, Swindell recommends telling that individual.
"They love hearing about their child or spouse or sibling being remembered – just being there for them," he said. If a person who wants to offer support can remember the loved one's birthday or the day they died, Swindell said, "even a simple text to say, 'Hey, I'm thinking of you' – something as simple as that is huge. It's that connectedness that's important."
Keeping memories alive
An August baby, Brian loved to celebrate his birthday at the beach, Persson said. Their whole family used to gather and make good memories together in the gritty sand and brisk water every year. But last August, she did not know how to spend Brian's birthday without him.
She called Kathryn. Her ally encouraged Persson to "do something special" to remember Brian. Persson thought of a group activity she had done with Learn to Cope months earlier where everyone quietly painted rocks and shared space with each other. It had brought calm to her: "To me, there was just this peace – something in the air."
Persson asked the family to gather once more in Brian's memory. The day before his birthday, they painted stones they had collected from the beach and remembered how much they loved him. On Aug. 1, his birthday, they scattered the rocks in a spot on the beach where Brian always walked to. If, in the future, people picked up the rocks left for Brian, it would be as if her son was traveling and seeing the world once more, Persson said.
As her family walked away, Persson's 8-year-old niece – one of the youngest members of her family – lingered to talk. She looked up at Persson and said, "'We should do this again next year.'"