Substance Use Disorders and the Family

Donna L. Londino M. D.

Medical College of Georgia

Alcohol Medical Scholars Program

I. Introduction

A. The goal of this lecture is to present an overview of the family influences

on substance use disorders. A brief introduction to include the relevance of this topic is presented followed by a discussion of genetic variables of substance use. Family roles in psychological development are reviewed as relevant to an individual’s perspectives on use. Family responses to alcohol and substance use are addressed as well as a discussion of the family as a social unit and how this can be affected by substance use. Lastly, family aspects of treatment are reviewed.

B. (Slide 2): This issue is important because –

l. Substance use and associated disorders are common.

a. Alcohol is one of the most commonly misused substances. The

majority of Americans drink including 50% of teenagers who reportedly engage in some form of alcohol use (4)

(l) Approximately 18 million adult Americans will experience

problems associated with alcohol use (1)

(2) 30%, as many as 80% of college students identify themselves

as frequent heavy episode drinkers (2,3)

(3) There is a lifetime risk of alcohol abuse or dependence of at

least 20% in men and 10% in women.

b. The majority of people in Western societies are current or past

users of at least one psychoactive drug.

(1) This includes a subset of people who will later meet criteria

for substance abuse or dependence.

(2) The most prevalent drugs of abuse are tobacco, marijuana,

and caffeine.

(3) Specific drug use (marijuana, cocaine) in teenagers has

doubled over the past decade.

(Slide 3): Percentage of U.S. Population who have ever used drugs

of abuse.

2. (Slide 4): The use, development of problems, and abuse/dependence

in any family member impacts on all other family members. The individual exists in the context of a bigger family system.

C. Therefore, the clinician must understand the way that alcohol and

illicit drugs impact on relatives. To address these issues, this lecture will

cover biologic (familial) determinants of substance use, family influences on development and attitudes towards substance use, the effect of substance use on family functioning as a system and in a social role, and a brief discussion of the role of the family in treatment.

II. (Slide 5): Factors that contribute to the impact of substance problems, abuse and dependence in the family.

A. (Slide 6): Alcohol and drug use have genetic influences

1. “Novelty seeking” temperament – the “choice to drink”, genetic

influences on personality traits of impulsivity, antisocial behavior (5,6)

2. Genetic predictors of response, metabolism, and risk of later

substance dependence (8, 9, 10, 11)

3. Familial factors in medical consequences to alcohol use (15)

4. Independent psychiatric disorders – Antisocial personality disorder, bipolar, panic disorder, schizophrenia. These disorders are known to have genetic predispositions and may increase the risk of alcohol and substance use.

B. The family plays an important role in the development of an individual’s attitude towards substance use.

1. (Slide 7): “Family perspectives and beliefs” –

Alcohol can play a major role in family rituals, celebrations and social events. Families develop patterns of use which become integrated into family functioning and greatly influence an individual's opinion of substance use. These patterns can be modeled and are often passed on to future generations.

2. (Slide 8): Cultural use of drugs is common in other countries

3. (Slide 8): Religiosity and personal conservatism appear to have a protective value (16, 17)

C. Substance use disorders can have a tremendous impact on how well the

family functions

1. (Slide 9): “The Alcoholic Family”

Alcohol and drugs may cause havoc in families. Inappropriate use may lead the alcohol or drug user to behave in ways that are perceived as being very negative by other family members.

2. (Slide 10): Among the most serious problems within families related

to substance use and abuse is that of violence (18, 19). Prevalence

rates are presented to support this statement.

a. It has been estimated that more than 80% of cases of spouse-to-

spouse violence are alcohol related (20)

b. Physical abuse of children involves 20-30% of parents who are

heavy drinkers (20)

c. A Boston study in 1991 (21) noted that of 206 abused children,

43% of the parents abused alcohol or drugs.

d. Often the child-abusing parent is under the influence of alcohol

at the time the incident occurs. Famulero et al (22) noted that 52% of abusing parents were currently under the influence of alcohol as compared to 12% of matched controls who were not under the influence.

3. (Slide 11): It is not only in terms of single problems such as violence

and conflict that one needs to assess the impact of alcohol and drugs

on a family. Once people start to drink or take drugs

inappropriately or unsafely, alcohol and substance use can interfere

with the structure and functioning of the family as a system of

relationships.

a. Marital conflict (23) – separation, divorce, spousal abuse

b. Poor parental attachments (24)

c. Family of origin

d. Cross-generational effects (26)

D. Work in the area of families and alcohol use has given evidence of

observable family patterns of functioning

1. The “Family Dance”

a. (Slide 12): Rituals – A fairly substantial part of family life

consists of rituals which are generally symbolic in nature. They

tend to be practiced by the whole family who are aware of these

traditions and tend to take pride in their repetition. They are self

sustaining and self corrective, often cementing family

relationships. They usually involve a phase of preparation as the

rituals are anticipated and prepared for. One of the prime

consequences of alcohol or drug miuse is that it can have a highly

disruptive effect on such family rituals (18, 24). Example given.

b. (Slide 13): Family responses to substance use –

Peter Steinglass and colleagues have noted sequences of behavior

that begin to emerge as a response of members in alcoholic families (27). These are generally highly typical and predictable in response to stress. They are noted to be individuated to each family but can be observed by unbiased clinical observers as a “family pattern of response”. (Slide 14)

(1) Changes in roles as other family members take on more

responsibility to compensate for the impairment of the

substance user – often involves role reversals in child care, financial management, overall “care” of the family.

(2) The preponderance of the “family energy” begins to

surround the substance use and its sequelae. Of particular difficulty is that problem drinking or drug taking becomes unpredictable and interferes with the family’s ability to plan or stick to routines. “Although the problem drinker/drugtaker may be giving up his or her previous roles within the family, he or she nonetheless appears to dominate it” (18).

(3) Family defenses of ambivalence and denial (27)

(4) Social withdrawal/decreased outside activities

(5) “Fear of shame”

2. (Slide 15) Effects on Children

a. Increased risk of conduct problems including aggressiveness,

delinquency, limited frustration tolerance, hyperactivity

b. Academic problems – learning difficulties, impaired

concentration, behavioral disruption, truancy

c. Emotional problems – psychosomatic concerns, poor self

esteem, withdrawal, depression, mood lability, irritability

d. Possible causal effects on earlier onset of drinking

(1) Biologic factors

(2) Modeling of parental drinking patterns (28, 29, 30)

“Persons who started drinking earlier in life may have learned to drink in less controlled situations with peers whose drinking norms are to drink to intoxication rather than with family and parents who might drink more moderately.”

(3) Adaptation to family dysfunction (31, 32, 33)

“Persons who develop alcoholism later in life may have had more adverse experiences in childhood such as psychological, physical and sexual abuse, domestic violence, and substance abuse by parents. Drinking earlier and more heavily may be an attempt to cope with these experiences.”

III: (Slide 16): The lecture to date has reviewed both biologic and developmental

variables as they contribute to alcohol and substance use. The effect of alcohol

and substance misuse on the family in a social role is significant also. “Many

expensive and disturbing social problems can be traced directly to drug

dependence.” Estimates of drug dependence costs on the United States

approximate $67 billion annually in crime, lost work productivity, foster care,

medical care, and other social problems. (12)

A. (Slide 17): Direct social effects on the family

1. Legal implications of crime, unpaid financial responsibilities, DUI’s,

incarcerations.

2. Financial – loss of job, expense of substance, neglect of financial

obligations

3. Health costs and medical consequences – HIV, fetal alcohol syndrome,

premature deaths, increased risk on injuries and risk taking activities

4. Foster care placement resulting from neglect and abuse

5. Social interactions usually decrease secondary to isolation, “shame”.

The family often develops a “reputation”.

IV: Treatment Implications

A. (Slide 18): Family Considerations in the Treatment of Alcohol and

Substance Abuse. The best treatment programs are comprehensive and

multidimensional

B. (Slide 19): The reasons for family involvement in treatment

1. Treatment can be effective (34, 35, 36, 37, 38). Drug treatment reduces

drug use by 40% to 60%, significantly decreases criminal activity

during and after treatment, reduces the risk of HIV infection (39),

decreases accidental injuries, contributes to overall improved

individual functioning.

2. Treatment does not have to be voluntary to be effective. Strong

motivation, including family influences can help facilitate both entry and engagement in the treatment process and treatment outcomes (38).

3. Lack of family support has been implemented in poor compliance with

treatment recommendations (40).

B. (Slide 20): The role of families in treatment

1. Screening – Individual and Family

More than two thirds of people with addiction see a primary care or urgent care physician every 6 months (38). Many others are seen by other medical specialists. If you add family member’s presentation to medical services, the number increases. These physicians are in a prime position to help patients who may have or live with substance abuse problems. These physicians can help by recognizing and diagnosing the problem, helping to direct patients and families to treatment, and helping to monitor progress (38, 41, 42).

2. Support groups include groups for family members – AA, NA, Al-

Anon, Al-Ateen, Families Anonymous, Adult Children of Alcoholics

C. (Slide 21): Specific family therapies can be useful to teach more adaptive

coping styles, to identify structural family issues which may be

contributing to dysfunction, and to educate the family on substance use

disorders (27, 43).

1. Stress management

2. Assertiveness training

3. Psychoeducation

4. Addressing family communication and response patterns

5. Problem solving tasks

V. (Slide 22) Conclusions

1. Family consideration in substance use disorders include biologic, developmental, and social contributants.

2. It is difficult to establish cause and effect – easier to note correlations.

3. The family should be an integral part of a multidisciplinary treatment approach.