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Fresh proposals to respond to rising opioid use/addiction/deaths arrive daily, but are striking in their collective silence on the needs of affected others parents, siblings, intimate partners, children, extended family members, and social network members. Neglect of affected families has deep historical roots within the history of addiction treatment and recovery. Historically, family members were more likely to be viewed by addiction professionals as causative agents of addiction or hostile interlopers in the treatment process than people in need of recovery support services in their own right. Overcoming such attitudes has taken on added urgency due to the rising prevalence, morbidity, and mortality of opioid addiction in the United States and its rippling effects upon families and communities. In this brief communication, we offer some reflections on this issue and how we might use the current social crisis to forge a new chapter in the nation's response to addiction-affected families and children.
Scientific research on the effects of opioid addiction on children and families is robust and its findings are unequivocal. Opioid addiction of a family member exerts profound consequences on the physical, emotional, and financial health of other family members and the family as a whole. Opioid addiction dramatically alters family roles, rules, rituals, and the family's internal and external relationships. Its effects are observed across all family subsystems: adult intimacy relationships, parent-child-relationship, sibling relationships, and the relationship between the nuclear family and kinship networks.
The emotional life of opioid-affected families is rife with denial, shock, anger, verbal confrontations, confusion, guilt, humiliation, shame, fear, fleeting glimmers of hope, frustration, anticipatory grief, and feelings of extreme isolation and helplessness. Such feelings are exacerbated in the presence of an addicted family member's threatening behavior, physical violence, lying, manipulation, failed promises, pleas for money, and damage or theft of property. Affected family members often report role disruption across generations (e.g., grandparents or aunts and uncles raising children of an addicted parent), a restricted social life, financial distress, a reduced standard of living (from the direct effects of opioid addiction, legal expenses, and repeated episodes of addiction treatment), and a progressive, stress-related increase in their own alcohol and other drug use. The presence, severity, and duration of these effects are mediated by multiple factors, such as the type, severity, complexity, and duration of the opioid addiction and the internal and differences in the external resources available to be mobilized to respond to the addiction crisis.
Many reports note the significant increase in the use of opioids and opioid-related deaths, with much of the focus on prescription practices, the specific opioids used, and the epidemiology of overdose in various communities. Yet, each OD death affects many people left behind. The loss of a loved one through death, incarceration or incapacitation causes immeasurable suffering for the family and other concerned people. One of the authors recently attended a Vigil of Hope in which family members honored the memory of a loved one lost to addiction. Over 130 attended this event. Photos of lost family members lined a table, most of them of young adults. The majority of participants lit a candle and made a statement about losing a loved one (a few lit candles to express gratitude that their loved one is in recovery). One little boy said I light this candle in memory of my dad who died when I was 3 years old. A man lit a candle in memory of two brothers and a cousin who died from drug overdoses. Several couples and families lit candles as a group in memory of their lost loved one. Tears flowed throughout this Vigil as members shared their sadness and grief. We must all remember that there is a person's story behind every case of addiction. There are also multiple family stories behind each case of addiction. Addiction truly is a family disease affecting us all. Death by overdose and incarceration from criminal behaviors caused by addiction affects us all. And our pain as family members may persist for years after losing our loved one.
Research and our combined clinical experience on the effects of opioid addiction on children (beyond the effects of prenatal opioid exposure) and the effects of parental opioid addiction on the parent-child relationship are equally unequivocal. Children of opioid-addicted parents are at increased risk of developing attachment, mood (including suicide risk), anxiety, conduct, and substance use disorders and experiencing problems in school adjustment and performance. These effects tend to be gender-mediated with female children experiencing greater mood and anxiety disorders and male children experiencing more disruptive and substance use disorders. These risks are exacerbated when the parental intimate relationship is marked by conflict, violence, and cyclical patterns of engagement, abandonment, and reengagement. Studies of the effects of parental opioid addiction on parental effectiveness and the parent-child relationship note cyclical patterns of disengagement, neglect, abandonment, and guilt-induced over-protection, over-control, and over-discipline?combinations that often leave children confused and rebellious.
While the above addiction-related effects on families and children have been extensively documented in the scientific and professional literature, that same body of literature offers surprisingly little data about the prevalence of recovery from opioid addiction and how affected families recover as individuals and as a family unit. The neglect of families effected by opioid addiction ignores the damage such addiction inflicts on the family, but it also fails to convey the very real possibility of long-term recovery, and offers no normative map to guide families into and through the recovery process. Below are examples of what family-oriented care would look like within policy, prevention, treatment, recovery support, and research contexts.
*Family members affected by opioid addiction are included within policy and service planning discussions to provide family perspectives on service needs.
*Such representation includes a diversity of family experience, e.g., partner, parent, and child perspectives; families who have experienced opioid-related deaths, families experiencing active addiction, and families in recovery from opioid addiction.
*Targeted prevention and/or counseling services are offered to all children/siblings affected by opioid addiction.
*Where possible, assertive linkage to professional and peer-based family support services accompanies all opioid addiction encounters, e.g., emergency services, point of arrest and adjudication, treatment admission, and mutual help contact.
*Families affected by opioid addiction are provided an independent advocate to help them navigate legal and service systems and to reduce the risk of financial exploitation by helping organizations.
*The basic unit of service within addiction treatment programs and recovery community organizations is reconceptualized from the addicted individual to the family unit.
*Family education and support programs are integrated within all organizations offering opioid addiction treatment and recovery support services. Family education includes (at a minimum) information on the neurobiology of opioid addiction, the very real prospects of long-term recovery from opioid addiction, treatment and recovery support options, the diversity of pathways of recovery from opioid addiction, the effects of opioid addiction on the family and family members (including children), and the commonly experienced stages of family recovery.
*Affected family members (adults and children), including those who have experienced addiction-related losses within their families, are provided safe venues to share their stories and experience mutual support with others similarly affected.
*Family-oriented care within treatment programs spans the functions of assessment, treatment and recovery planning, service delivery, and post-treatment monitoring (recovery checkups), support, and, if and when needed, early re-intervention. Periodic recovery check-ups are continued for a minimum of five years following initial recovery stabilization.
*Every family involved in addiction treatment and/or peer-based recovery support services is exposed to individuals and families in long-term recovery from opioid addiction.
*Affected families are given opportunities to use their experiences as vehicles for community education and policy advocacy.
Of the above actions, none is more important than bringing affected family members into policy development and service planning venues and listening--really listening--to their stories and letting the experiences and needs reflected in those stories shape a family-focused policy agenda. Put simply, national and local responses to opioid addiction are most effective when they begin with the lost art of listening?listening to the raw urgency of unmet needs.
Selected References
Daley, D.C., & Ward, J. (2015). The impact of substance use disorders on parents, Part I. Counselor, 16(2), 28-31.
Daley, D.C., & Ward, J. (2015). The impact of substance use disorders on parents, Part II. Counselor, 16(3), 25-28.
Kirby, K.C., Dugosh, K.L., Benishek, L.A., & Harrington, V.M. (2005). The Significant Other Checklist: Measuring the problems experienced by family members of drug users. Addictive Behaviors, 30(1), 29-47.
Lander. L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: From theory to practice. Social Work and Public Health, 28(0), 194-205.
Nunes, E.V., Weissman, M.M., Goldstein, R., McAvay, G., Beckford, C., Seracini, A., Verdeli, H., & Wickramaratne, P. (2000). Psychiatric disorders and impairment in the children of opiate addicts: Prevalences and distribution by ethnicity. The American Journal on Addictions, 9, 232-241.
Velleman, R., Bennett, G., Miller, T., Orford, J., Rigby, & Tod, A. (1993). The families of problem drug users:A study of 50 close relatives. Addiction, 88, 1281-1289.
White, W., & Savage, B. (2005). All in the family: Alcohol and other drug problems, recovery, advocacy. Alcoholism Treatment Quarterly, 23(4), 3-37.