11 Sep Opioid-use disorder: Treat the family, not just the patient
published in AMA
Opioid use disorder affects us all. The impact on families is becoming better understood, as is the need to involve patients’ loved ones in a treatment plan.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has described families as interconnected systems where a change in one part will spur changes in the other parts. A person’s family is often vital to recovery. That is where family opioid treatment can help.
What families need to know
Families need to recognize that opioid-use disorder is a biological brain disease in which part of the cause and risk is driven by genetic factors and another part by environmental factors, said Andrew J. Saxon, MD, a professor of psychiatry and behavioral sciences at the University of Washington (UW) School of Medicine in Seattle.
Dr. Saxon directs the addiction psychiatry residency program at UW and sits on the editorial boards of the journals Drug and Alcohol Dependence and General Hospital Psychiatry. His research focuses on pharmacotherapies and psychotherapies for alcohol, cocaine, nicotine and opioid-use disorder.
This biological disease of substance-use disorder can manifest in maladaptive behavior that can be seen as deliberatively harmful toward the family. The family needs to know that the behavior is being driven by the disease and not the person, Dr. Saxon said.
“It’s important to take action,” he added. And while opioid-use disorder is a chronic disease, “the real person can shine through again” with the proper treatment. That means medication treatment using buprenorphine, methadone or naltrexone, as well as behavioral support as an adjunct treatment.
The AMA Opioid Task Force supports comprehensive treatment for opioid-use disorder and urges removing all barriers to treatment for substance-use disorder.
Find out more at the task force’s End the Epidemic website.
Getting rid of the guilt
For Sarah E. Wakeman, MD, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, educating family about the effectiveness of medication treatment—lower risk of death or relapse—is a critical element to helping patients living with opioid-use disorder.
She finds that many families retain the notion that rehabilitation involves inpatient treatment and an abstinence approach.
“That’s what we see in the movies,” Dr. Wakeman said. “That’s what we read about, and that’s what family members think this treatment ought to look like. Many family members don’t know that outpatient treatment, for many people, can be as effective as inpatient treatment.”
Well-meaning family members can make recovery more difficult unless they are involved from the start, she said.
“The patient may be getting pressure from family members to taper off their meds,” Dr. Wakeman said. “They’ll say, ‘You’re fine now. You don’t need this.’”
“Tough love” is another message that physicians can help counter to increase the chances of treatment success, she added.
“Families are often confused about what is the right thing to do,” Dr. Wakeman said. “They may feel guilty if they are being kind to the person,” worried about supposedly enabling the patient’s substance-use disorder. “Removing some of that guilt is the most important thing. The main job is to love the family member the way they always did. They are not the treater or the clinician. The best way they can help is to understand what effective treatment looks like.”
For patients 12–24 years old with substance-use disorders and co-occurring mental-health disorders, SAMHSA’s Adolescent Community Reinforcement Approach is administered by a behavioral health clinician through sessions for adolescents alone, for parents or caregivers alone, and for adolescents and parents or caregivers together.
A 10-minute talk can save a life
Another important role for the family involves having access to naloxone and knowing how to administer it, which Dr. Saxon said can be done in a 10-minute discussion.
“There’s some thought that people may be willing to take more risks if they have access to naloxone, but I don’t think that’s really true and, on balance, it’s best to have it available,” Dr. Saxon said. “Naloxone is not a panacea, but it’s good for the family to have it—whether their loved one is on treatment or not.”