Helping a loved one get into treatment is a “full time job”: Experiences of family and friends

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For individuals with substance use disorders, relationships with family and friends can influence the likelihood that someone initiates and sustains recovery. This study explored how these family members and friends respond to their loved one’s substance use, encourage them to seek treatment, and navigate the larger treatment system.

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recovery science
with the free, monthly
Recovery Bulletin

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WHAT PROBLEM DOES THIS STUDY ADDRESS?

There are many barriers to engaging in treatment for opioid and other substance use disorders. As a result, only 20% of individuals with opioid use disorder in the United States receive any treatment. Challenges include personal motivation and willingness to attend as well as the ability to access treatment. Access can be difficult due to financial barriers (e.g., being underinsured or uninsured) or system capacity challenges (e.g., long waitlist). Family and close friends of individuals with opioid use disorder can play a major role in supporting recovery as they may support their loved one with tangible resources or relational support in navigating the system. They may also be a driving force for why a person initiates or sustains treatment (i.e., an individual’s drug use interferes with the quality of important relationships enhancing their motivation for recovery). As a result of their close relationship with a person experiencing an opioid use disorder, family members and friends also may experience a variety of challenges related to providing this support, including relational conflict or stress and stigma navigating the treatment system. They may seek out support from others in their community in similar situations or join a formal family support group (such as Al-Anon/Nar-Anon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends).

This study examines the experience of family and close friends navigating a recovery-support role by exploring data and themes around experiences, concerns, and perceptions related to drug treatment for a loved one with opioid use disorder.


HOW WAS THIS STUDY CONDUCTED?

This was a mixed methods study that first conducted qualitative interviews with 22 participants followed by a quantitative survey with 260 participants. This study was part of a larger study, where the overarching purpose was to examine barriers and facilitators to the utilization of the Massachusetts Naloxone Standing Order by people who use illicit opioids and potential opioid overdose “bystanders.” In this study, “bystander” was defined as individuals who have a close relationship (family or friend) with someone at risk of opioid overdose but do not use illicit opioids themselves.

They recruited adult Massachusetts residents who did not use illicit opioids in the past 30 days, and who had a close relationship with someone who currently uses illicit opioids. For recruitment, they partnered with a support network for parents and family members of persons with a substance use disorder from the North and South Shore areas of Massachusetts.

Interview phase. Participants in the interview phase completed a brief survey and the interview, which lasted 1-1.5 hours. They asked interview participants a variety of questions on, for example, overdose risk perceptions and experiences, naloxone knowledge and attitudes, and experiences with health services. They did not explicitly ask participants about how they were able to help their loved one engage with treatment: the findings related to navigating drug treatment (qualitative themes) emerged as the researchers examined the interview data.

Survey phase. Participants in the survey phase completed a survey that lasted about 30 minutes. The survey was multiple choice and included questions on access to naloxone and its use, attitudes and beliefs toward substance use, social supports, and experiences responding to overdose and navigating the substance use disorder treatment system.

Of the sample of 22 interview participants, most were female (63%) and White (95%).  The median age of the sample was 54 years, with many participants being 46-61 years old. They had one or more children (63%), close friend(s) (14%), sibling(s) (14%), or a spouse/partner (9%) who used illicit opioids. The median number of people at risk of an overdose whom the qualitative participants knew was 13 with many participants knowing between 6 to 30 people at risk.

Of the sample of 260 survey participants, most were female (66%) and White (92%). The median age of the sample was 53 years with many participants being ages 37-61. They had one or more children (34%), close friend(s) (45%), other family member(s) (17%), sibling(s) (13%), a spouse/partner (6%), and/or a parent(s) (3%) who used illicit opioids. The median number of people whom the survey participants knew used illicit opioids was 10, with many participants knowing 4 to 30 people at risk.


WHAT DID THIS STUDY FIND?

Friends and family learned about recovery through experiences supporting a person with an opioid use disorder, which family support groups helped them navigate.

Friends and family described not fully understanding the chronic nature of addiction and how it could be a condition that required multiple attempts and might involve several treatment episodes and even a return to using after treatment.

Nearly all survey participants reported having attended a family support group related to substance use disorder (94%). Although many survey participants also indicated feeling knowledgeable about addiction as a disease and equipped to support a loved one, the interview participants suggested these were knowledge and skills built over time and not something they had at the beginning of the process. Engaging in a support group seemed to help participants better understand the process of supporting a loved one in a recovery journey and to feel more connected and less shame about this experience.

Friends and family reported many barriers to treatment initiation for their friend or loved one.

First, ensuring their loved one sought and engaged in treatment was an initial barrier. They described using different approaches to increase their loved one’s likelihood of entering treatment and sustaining recovery behaviors. Their approach to this was often linked to their views on the importance of abstinence. The use of a “tough love” approach to encourage treatment entry was described by participants as making practical supports, such as housing and financial assistance, contingent on one entering treatment or substance abstinence, or the use of legal, civil, or informal influence. The use of an “in their corner” approach to encourage treatment entry involved greater provision of practical support, less use of coercion, and emphasizing connection. Participants also experienced feeling pressure, at times, from the support group to take a tough love approach with their loved one, which did not always feel right to them.

Second, participants reported that facilitating treatment entry for their friend or loved one was time-consuming and costly because of the structure of the treatment system. Most survey participants reported that they had sought information about drug treatment for someone close to them (93%) or that they had helped someone secure a treatment slot (88%). Less than half (44%) of survey participants agreed or strongly agreed that treatment programs were readily accessible to those needing them and qualitative participants reported experiencing not enough treatment slots and having financial troubles due to funding the treatment of someone close to them.

There are also a variety of different treatment approaches to consider, and participants in the interviews felt that the person needed to be approached on an individual basis to figure out the best treatment approach for their needs. That is, some programs operate with very strict rules – that lead to consequences if not followed – and little room for deviation which may get in the way of individual progress.

In addition, having a single treatment episode with no follow-up care for recovery was viewed as irresponsible. Participants also differed in their views around the use of medication for opioid use disorder. While 38% had more favorable views of programs that offered medications like buprenorphine and methadone, 24% of survey participants felt it was just substituting one drug for another and the qualitative participants had mixed reactions to it, with some feeling it could be “abused.”


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In this study of friends and family of someone in recovery, participants often report experiencing a small “window of opportunity” to ensure their friend or loved one engages in treatment. There are barriers at the individual level, in the motivation of the person to seek treatment as well as at the system level, in the ability to access treatment at a time when one is ready. Friends and family found difficulty in both navigating the system and figuring out how to support someone close as the process of recovery went on, sometimes over many years and many attempts to recover.

This study highlights the many challenges friends and family face when supporting someone to engage in treatment and the need for education and support that is targeted to this group specifically. Although treatments that involve family members may indirectly improve outcomes for participants, research can also help develop and test strategies that focus on family and friends, themselves for improving their own experience in this process. These services can help the individual engage in self-care to reduce the negative consequences of family addiction as well as to more effectively support their loved one, such as through the use of remaining emotionally supportive setting appropriate boundaries. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries and support their loved one. The key pillars of CRAFT are cultivating a non-confrontational, positive relationship while actively supporting treatment entry whenever the loved one expresses interest, and these are built on principles of contingency management and allowing loved ones to experience the natural consequences of their substance use.

Studies show that engaging families in CRAFT can improve treatment engagement. Although this study describes “tough love” as counterproductive and potentially harmful, some examples of this approach provided in the article (e.g., limiting practical supports like housing and financial assistance, making supports contingent on treatment entry), overlap with some CRAFT principles. For example, CRAFT helps family members use their attention contingently to encourage abstinence, while also teaching them how to avoid reinforcing substance use and other behaviors inconsistent with change (e.g., treatment refusal). CRAFT has strong empirical support and was developed primarily for spouses and other partners, but has been extended to other friends and family, to help them develop the skills to support their loved ones who are struggling with substance use and to help facilitate treatment initiation for their loved one.

Friends and family also had mixed views on the use of medication for opioid use disorder, an evidence-based treatment approach. This suggests a need for education targeted to clinicians working with families on how to support them to understand the utility of medication and how treatment approaches using medication can help support their loved one.


  1. This study makes use of mixed methods, through both qualitative interviews and surveys, yet the interview and survey participants were not the same individuals, so the different types of results need to be considered with that in mind. This is also cross-sectional data, captured at one point in time and future work examining the experience of friends and families would benefit from capturing data at several points in time to identify key areas of perspective changes and barriers throughout the process of supporting a friend or loved one’s recovery journey.
  2. The study did not set out to examine the experience of navigating treatment and so the results may be different than if participants were specifically asked more direct questions about this. The findings were also reported regardless of relationship status. The experiences of close friends and family are likely very different and worth examining further with perhaps more specific questions relevant to the challenges faced for these different types of relationships and whether the addicted loved-one is living with them or living somewhere else.

BOTTOM LINE

In this study of individuals of family members and friends who had a close relationship with someone who uses opioids, participants reported often experiencing a small “window of opportunity” and many barriers to help engage someone close to them in treatment. Participants described difficulty in navigating the system and figuring out how to support their loved one as the process of recovery progressed. Formal support groups populated by other affected family members and friends with “lived experience” of dealing with these challenges, were an important source of information and support that helped them to navigate this experience.


  • For individuals and families seeking recovery: It is important to know that you are not alone when navigating the difficult experience of having a loved one with addiction and to seek out support for this experience. One treatment, Community Reinforcement and Family Training (CRAFT), implements many of the strategies family members described as helpful when supporting their loved one. A virtual CRAFT may also be freely available to you, depending on state funding. There are also a variety of formal groups, such as Alanon/Narcanon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends, that can support a family member or friend during this experience. Most if not all of these can be accessed online as well as in person. Support groups may have different perspectives about the recovery process, so it is worth it to explore several to find a support group that best suits the needs of your situation.
  • For treatment professionals and treatment systems: Family members and friends are important influences on a person’s engagement in treatment and also need their own support to address the challenging emotional reactions related to their loved one’s experience with addiction. Until an individual is ready to enter treatment, approaches to help those around them engage in self-care to reduce the negative consequences of addiction as well as to more effectively engage with their loved one may be necessary. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries, support their loved one, and actively facilitate treatment entry.
  • For scientists: This study highlights the many challenging experiences of families and friends as they navigate their loved one’s treatment and recovery experiences. Yet, because this is cross-sectional data, future work examining the experience of friends and families would benefit from capturing data at several points over time to identify key areas of perspective changes, resources, and barriers throughout the process of supporting a loved one’s recovery journey. As well, there is a need to more clearly differentiate the experience and needs of family and close friends when supporting someone to seek out treatment and whether the addicted loved one is living with the friend or family member or living elsewhere. Further longitudinal research is also needed on freely accessible mutual help organizations for family members and friends and identify the best ways to support them in this process, to mitigate negative experiences or consequences as a result of supporting someone’s recovery journey.
  • For policy makers: Friends and families often are severely impacted by a loved one’s experience with addiction. They are also often the most important influence on a person’s engagement in treatment as they are often involved in facilitating treatment initiation. Policy and decision-makers could work with treatment programs and systems to identify and address barriers to implementation and dissemination of interventions and supports which involve friends and families of those with substance use disorders. These efforts could include increasing funding for training in family and friend involvement and infrastructure development, and research funding support for implementation and dissemination research.

CITATIONS

Slocum, S., Paquette, C. E., & Pollini, R. A. (2023). Drug treatment perspectives and experiences among family and friends of people who use illicit opioids: A mixed methods study.Journal of Substance Use and Addiction Treatment, 209023. doi: 10.1016/j.josat.2023.209023.


Stay on the Frontiers of
recovery science
with the free, monthly
Recovery Bulletin

l

WHAT PROBLEM DOES THIS STUDY ADDRESS?

There are many barriers to engaging in treatment for opioid and other substance use disorders. As a result, only 20% of individuals with opioid use disorder in the United States receive any treatment. Challenges include personal motivation and willingness to attend as well as the ability to access treatment. Access can be difficult due to financial barriers (e.g., being underinsured or uninsured) or system capacity challenges (e.g., long waitlist). Family and close friends of individuals with opioid use disorder can play a major role in supporting recovery as they may support their loved one with tangible resources or relational support in navigating the system. They may also be a driving force for why a person initiates or sustains treatment (i.e., an individual’s drug use interferes with the quality of important relationships enhancing their motivation for recovery). As a result of their close relationship with a person experiencing an opioid use disorder, family members and friends also may experience a variety of challenges related to providing this support, including relational conflict or stress and stigma navigating the treatment system. They may seek out support from others in their community in similar situations or join a formal family support group (such as Al-Anon/Nar-Anon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends).

This study examines the experience of family and close friends navigating a recovery-support role by exploring data and themes around experiences, concerns, and perceptions related to drug treatment for a loved one with opioid use disorder.


HOW WAS THIS STUDY CONDUCTED?

This was a mixed methods study that first conducted qualitative interviews with 22 participants followed by a quantitative survey with 260 participants. This study was part of a larger study, where the overarching purpose was to examine barriers and facilitators to the utilization of the Massachusetts Naloxone Standing Order by people who use illicit opioids and potential opioid overdose “bystanders.” In this study, “bystander” was defined as individuals who have a close relationship (family or friend) with someone at risk of opioid overdose but do not use illicit opioids themselves.

They recruited adult Massachusetts residents who did not use illicit opioids in the past 30 days, and who had a close relationship with someone who currently uses illicit opioids. For recruitment, they partnered with a support network for parents and family members of persons with a substance use disorder from the North and South Shore areas of Massachusetts.

Interview phase. Participants in the interview phase completed a brief survey and the interview, which lasted 1-1.5 hours. They asked interview participants a variety of questions on, for example, overdose risk perceptions and experiences, naloxone knowledge and attitudes, and experiences with health services. They did not explicitly ask participants about how they were able to help their loved one engage with treatment: the findings related to navigating drug treatment (qualitative themes) emerged as the researchers examined the interview data.

Survey phase. Participants in the survey phase completed a survey that lasted about 30 minutes. The survey was multiple choice and included questions on access to naloxone and its use, attitudes and beliefs toward substance use, social supports, and experiences responding to overdose and navigating the substance use disorder treatment system.

Of the sample of 22 interview participants, most were female (63%) and White (95%).  The median age of the sample was 54 years, with many participants being 46-61 years old. They had one or more children (63%), close friend(s) (14%), sibling(s) (14%), or a spouse/partner (9%) who used illicit opioids. The median number of people at risk of an overdose whom the qualitative participants knew was 13 with many participants knowing between 6 to 30 people at risk.

Of the sample of 260 survey participants, most were female (66%) and White (92%). The median age of the sample was 53 years with many participants being ages 37-61. They had one or more children (34%), close friend(s) (45%), other family member(s) (17%), sibling(s) (13%), a spouse/partner (6%), and/or a parent(s) (3%) who used illicit opioids. The median number of people whom the survey participants knew used illicit opioids was 10, with many participants knowing 4 to 30 people at risk.


WHAT DID THIS STUDY FIND?

Friends and family learned about recovery through experiences supporting a person with an opioid use disorder, which family support groups helped them navigate.

Friends and family described not fully understanding the chronic nature of addiction and how it could be a condition that required multiple attempts and might involve several treatment episodes and even a return to using after treatment.

Nearly all survey participants reported having attended a family support group related to substance use disorder (94%). Although many survey participants also indicated feeling knowledgeable about addiction as a disease and equipped to support a loved one, the interview participants suggested these were knowledge and skills built over time and not something they had at the beginning of the process. Engaging in a support group seemed to help participants better understand the process of supporting a loved one in a recovery journey and to feel more connected and less shame about this experience.

Friends and family reported many barriers to treatment initiation for their friend or loved one.

First, ensuring their loved one sought and engaged in treatment was an initial barrier. They described using different approaches to increase their loved one’s likelihood of entering treatment and sustaining recovery behaviors. Their approach to this was often linked to their views on the importance of abstinence. The use of a “tough love” approach to encourage treatment entry was described by participants as making practical supports, such as housing and financial assistance, contingent on one entering treatment or substance abstinence, or the use of legal, civil, or informal influence. The use of an “in their corner” approach to encourage treatment entry involved greater provision of practical support, less use of coercion, and emphasizing connection. Participants also experienced feeling pressure, at times, from the support group to take a tough love approach with their loved one, which did not always feel right to them.

Second, participants reported that facilitating treatment entry for their friend or loved one was time-consuming and costly because of the structure of the treatment system. Most survey participants reported that they had sought information about drug treatment for someone close to them (93%) or that they had helped someone secure a treatment slot (88%). Less than half (44%) of survey participants agreed or strongly agreed that treatment programs were readily accessible to those needing them and qualitative participants reported experiencing not enough treatment slots and having financial troubles due to funding the treatment of someone close to them.

There are also a variety of different treatment approaches to consider, and participants in the interviews felt that the person needed to be approached on an individual basis to figure out the best treatment approach for their needs. That is, some programs operate with very strict rules – that lead to consequences if not followed – and little room for deviation which may get in the way of individual progress.

In addition, having a single treatment episode with no follow-up care for recovery was viewed as irresponsible. Participants also differed in their views around the use of medication for opioid use disorder. While 38% had more favorable views of programs that offered medications like buprenorphine and methadone, 24% of survey participants felt it was just substituting one drug for another and the qualitative participants had mixed reactions to it, with some feeling it could be “abused.”


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In this study of friends and family of someone in recovery, participants often report experiencing a small “window of opportunity” to ensure their friend or loved one engages in treatment. There are barriers at the individual level, in the motivation of the person to seek treatment as well as at the system level, in the ability to access treatment at a time when one is ready. Friends and family found difficulty in both navigating the system and figuring out how to support someone close as the process of recovery went on, sometimes over many years and many attempts to recover.

This study highlights the many challenges friends and family face when supporting someone to engage in treatment and the need for education and support that is targeted to this group specifically. Although treatments that involve family members may indirectly improve outcomes for participants, research can also help develop and test strategies that focus on family and friends, themselves for improving their own experience in this process. These services can help the individual engage in self-care to reduce the negative consequences of family addiction as well as to more effectively support their loved one, such as through the use of remaining emotionally supportive setting appropriate boundaries. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries and support their loved one. The key pillars of CRAFT are cultivating a non-confrontational, positive relationship while actively supporting treatment entry whenever the loved one expresses interest, and these are built on principles of contingency management and allowing loved ones to experience the natural consequences of their substance use.

Studies show that engaging families in CRAFT can improve treatment engagement. Although this study describes “tough love” as counterproductive and potentially harmful, some examples of this approach provided in the article (e.g., limiting practical supports like housing and financial assistance, making supports contingent on treatment entry), overlap with some CRAFT principles. For example, CRAFT helps family members use their attention contingently to encourage abstinence, while also teaching them how to avoid reinforcing substance use and other behaviors inconsistent with change (e.g., treatment refusal). CRAFT has strong empirical support and was developed primarily for spouses and other partners, but has been extended to other friends and family, to help them develop the skills to support their loved ones who are struggling with substance use and to help facilitate treatment initiation for their loved one.

Friends and family also had mixed views on the use of medication for opioid use disorder, an evidence-based treatment approach. This suggests a need for education targeted to clinicians working with families on how to support them to understand the utility of medication and how treatment approaches using medication can help support their loved one.


  1. This study makes use of mixed methods, through both qualitative interviews and surveys, yet the interview and survey participants were not the same individuals, so the different types of results need to be considered with that in mind. This is also cross-sectional data, captured at one point in time and future work examining the experience of friends and families would benefit from capturing data at several points in time to identify key areas of perspective changes and barriers throughout the process of supporting a friend or loved one’s recovery journey.
  2. The study did not set out to examine the experience of navigating treatment and so the results may be different than if participants were specifically asked more direct questions about this. The findings were also reported regardless of relationship status. The experiences of close friends and family are likely very different and worth examining further with perhaps more specific questions relevant to the challenges faced for these different types of relationships and whether the addicted loved-one is living with them or living somewhere else.

BOTTOM LINE

In this study of individuals of family members and friends who had a close relationship with someone who uses opioids, participants reported often experiencing a small “window of opportunity” and many barriers to help engage someone close to them in treatment. Participants described difficulty in navigating the system and figuring out how to support their loved one as the process of recovery progressed. Formal support groups populated by other affected family members and friends with “lived experience” of dealing with these challenges, were an important source of information and support that helped them to navigate this experience.


  • For individuals and families seeking recovery: It is important to know that you are not alone when navigating the difficult experience of having a loved one with addiction and to seek out support for this experience. One treatment, Community Reinforcement and Family Training (CRAFT), implements many of the strategies family members described as helpful when supporting their loved one. A virtual CRAFT may also be freely available to you, depending on state funding. There are also a variety of formal groups, such as Alanon/Narcanon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends, that can support a family member or friend during this experience. Most if not all of these can be accessed online as well as in person. Support groups may have different perspectives about the recovery process, so it is worth it to explore several to find a support group that best suits the needs of your situation.
  • For treatment professionals and treatment systems: Family members and friends are important influences on a person’s engagement in treatment and also need their own support to address the challenging emotional reactions related to their loved one’s experience with addiction. Until an individual is ready to enter treatment, approaches to help those around them engage in self-care to reduce the negative consequences of addiction as well as to more effectively engage with their loved one may be necessary. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries, support their loved one, and actively facilitate treatment entry.
  • For scientists: This study highlights the many challenging experiences of families and friends as they navigate their loved one’s treatment and recovery experiences. Yet, because this is cross-sectional data, future work examining the experience of friends and families would benefit from capturing data at several points over time to identify key areas of perspective changes, resources, and barriers throughout the process of supporting a loved one’s recovery journey. As well, there is a need to more clearly differentiate the experience and needs of family and close friends when supporting someone to seek out treatment and whether the addicted loved one is living with the friend or family member or living elsewhere. Further longitudinal research is also needed on freely accessible mutual help organizations for family members and friends and identify the best ways to support them in this process, to mitigate negative experiences or consequences as a result of supporting someone’s recovery journey.
  • For policy makers: Friends and families often are severely impacted by a loved one’s experience with addiction. They are also often the most important influence on a person’s engagement in treatment as they are often involved in facilitating treatment initiation. Policy and decision-makers could work with treatment programs and systems to identify and address barriers to implementation and dissemination of interventions and supports which involve friends and families of those with substance use disorders. These efforts could include increasing funding for training in family and friend involvement and infrastructure development, and research funding support for implementation and dissemination research.

CITATIONS

Slocum, S., Paquette, C. E., & Pollini, R. A. (2023). Drug treatment perspectives and experiences among family and friends of people who use illicit opioids: A mixed methods study.Journal of Substance Use and Addiction Treatment, 209023. doi: 10.1016/j.josat.2023.209023.


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l

WHAT PROBLEM DOES THIS STUDY ADDRESS?

There are many barriers to engaging in treatment for opioid and other substance use disorders. As a result, only 20% of individuals with opioid use disorder in the United States receive any treatment. Challenges include personal motivation and willingness to attend as well as the ability to access treatment. Access can be difficult due to financial barriers (e.g., being underinsured or uninsured) or system capacity challenges (e.g., long waitlist). Family and close friends of individuals with opioid use disorder can play a major role in supporting recovery as they may support their loved one with tangible resources or relational support in navigating the system. They may also be a driving force for why a person initiates or sustains treatment (i.e., an individual’s drug use interferes with the quality of important relationships enhancing their motivation for recovery). As a result of their close relationship with a person experiencing an opioid use disorder, family members and friends also may experience a variety of challenges related to providing this support, including relational conflict or stress and stigma navigating the treatment system. They may seek out support from others in their community in similar situations or join a formal family support group (such as Al-Anon/Nar-Anon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends).

This study examines the experience of family and close friends navigating a recovery-support role by exploring data and themes around experiences, concerns, and perceptions related to drug treatment for a loved one with opioid use disorder.


HOW WAS THIS STUDY CONDUCTED?

This was a mixed methods study that first conducted qualitative interviews with 22 participants followed by a quantitative survey with 260 participants. This study was part of a larger study, where the overarching purpose was to examine barriers and facilitators to the utilization of the Massachusetts Naloxone Standing Order by people who use illicit opioids and potential opioid overdose “bystanders.” In this study, “bystander” was defined as individuals who have a close relationship (family or friend) with someone at risk of opioid overdose but do not use illicit opioids themselves.

They recruited adult Massachusetts residents who did not use illicit opioids in the past 30 days, and who had a close relationship with someone who currently uses illicit opioids. For recruitment, they partnered with a support network for parents and family members of persons with a substance use disorder from the North and South Shore areas of Massachusetts.

Interview phase. Participants in the interview phase completed a brief survey and the interview, which lasted 1-1.5 hours. They asked interview participants a variety of questions on, for example, overdose risk perceptions and experiences, naloxone knowledge and attitudes, and experiences with health services. They did not explicitly ask participants about how they were able to help their loved one engage with treatment: the findings related to navigating drug treatment (qualitative themes) emerged as the researchers examined the interview data.

Survey phase. Participants in the survey phase completed a survey that lasted about 30 minutes. The survey was multiple choice and included questions on access to naloxone and its use, attitudes and beliefs toward substance use, social supports, and experiences responding to overdose and navigating the substance use disorder treatment system.

Of the sample of 22 interview participants, most were female (63%) and White (95%).  The median age of the sample was 54 years, with many participants being 46-61 years old. They had one or more children (63%), close friend(s) (14%), sibling(s) (14%), or a spouse/partner (9%) who used illicit opioids. The median number of people at risk of an overdose whom the qualitative participants knew was 13 with many participants knowing between 6 to 30 people at risk.

Of the sample of 260 survey participants, most were female (66%) and White (92%). The median age of the sample was 53 years with many participants being ages 37-61. They had one or more children (34%), close friend(s) (45%), other family member(s) (17%), sibling(s) (13%), a spouse/partner (6%), and/or a parent(s) (3%) who used illicit opioids. The median number of people whom the survey participants knew used illicit opioids was 10, with many participants knowing 4 to 30 people at risk.


WHAT DID THIS STUDY FIND?

Friends and family learned about recovery through experiences supporting a person with an opioid use disorder, which family support groups helped them navigate.

Friends and family described not fully understanding the chronic nature of addiction and how it could be a condition that required multiple attempts and might involve several treatment episodes and even a return to using after treatment.

Nearly all survey participants reported having attended a family support group related to substance use disorder (94%). Although many survey participants also indicated feeling knowledgeable about addiction as a disease and equipped to support a loved one, the interview participants suggested these were knowledge and skills built over time and not something they had at the beginning of the process. Engaging in a support group seemed to help participants better understand the process of supporting a loved one in a recovery journey and to feel more connected and less shame about this experience.

Friends and family reported many barriers to treatment initiation for their friend or loved one.

First, ensuring their loved one sought and engaged in treatment was an initial barrier. They described using different approaches to increase their loved one’s likelihood of entering treatment and sustaining recovery behaviors. Their approach to this was often linked to their views on the importance of abstinence. The use of a “tough love” approach to encourage treatment entry was described by participants as making practical supports, such as housing and financial assistance, contingent on one entering treatment or substance abstinence, or the use of legal, civil, or informal influence. The use of an “in their corner” approach to encourage treatment entry involved greater provision of practical support, less use of coercion, and emphasizing connection. Participants also experienced feeling pressure, at times, from the support group to take a tough love approach with their loved one, which did not always feel right to them.

Second, participants reported that facilitating treatment entry for their friend or loved one was time-consuming and costly because of the structure of the treatment system. Most survey participants reported that they had sought information about drug treatment for someone close to them (93%) or that they had helped someone secure a treatment slot (88%). Less than half (44%) of survey participants agreed or strongly agreed that treatment programs were readily accessible to those needing them and qualitative participants reported experiencing not enough treatment slots and having financial troubles due to funding the treatment of someone close to them.

There are also a variety of different treatment approaches to consider, and participants in the interviews felt that the person needed to be approached on an individual basis to figure out the best treatment approach for their needs. That is, some programs operate with very strict rules – that lead to consequences if not followed – and little room for deviation which may get in the way of individual progress.

In addition, having a single treatment episode with no follow-up care for recovery was viewed as irresponsible. Participants also differed in their views around the use of medication for opioid use disorder. While 38% had more favorable views of programs that offered medications like buprenorphine and methadone, 24% of survey participants felt it was just substituting one drug for another and the qualitative participants had mixed reactions to it, with some feeling it could be “abused.”


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In this study of friends and family of someone in recovery, participants often report experiencing a small “window of opportunity” to ensure their friend or loved one engages in treatment. There are barriers at the individual level, in the motivation of the person to seek treatment as well as at the system level, in the ability to access treatment at a time when one is ready. Friends and family found difficulty in both navigating the system and figuring out how to support someone close as the process of recovery went on, sometimes over many years and many attempts to recover.

This study highlights the many challenges friends and family face when supporting someone to engage in treatment and the need for education and support that is targeted to this group specifically. Although treatments that involve family members may indirectly improve outcomes for participants, research can also help develop and test strategies that focus on family and friends, themselves for improving their own experience in this process. These services can help the individual engage in self-care to reduce the negative consequences of family addiction as well as to more effectively support their loved one, such as through the use of remaining emotionally supportive setting appropriate boundaries. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries and support their loved one. The key pillars of CRAFT are cultivating a non-confrontational, positive relationship while actively supporting treatment entry whenever the loved one expresses interest, and these are built on principles of contingency management and allowing loved ones to experience the natural consequences of their substance use.

Studies show that engaging families in CRAFT can improve treatment engagement. Although this study describes “tough love” as counterproductive and potentially harmful, some examples of this approach provided in the article (e.g., limiting practical supports like housing and financial assistance, making supports contingent on treatment entry), overlap with some CRAFT principles. For example, CRAFT helps family members use their attention contingently to encourage abstinence, while also teaching them how to avoid reinforcing substance use and other behaviors inconsistent with change (e.g., treatment refusal). CRAFT has strong empirical support and was developed primarily for spouses and other partners, but has been extended to other friends and family, to help them develop the skills to support their loved ones who are struggling with substance use and to help facilitate treatment initiation for their loved one.

Friends and family also had mixed views on the use of medication for opioid use disorder, an evidence-based treatment approach. This suggests a need for education targeted to clinicians working with families on how to support them to understand the utility of medication and how treatment approaches using medication can help support their loved one.


  1. This study makes use of mixed methods, through both qualitative interviews and surveys, yet the interview and survey participants were not the same individuals, so the different types of results need to be considered with that in mind. This is also cross-sectional data, captured at one point in time and future work examining the experience of friends and families would benefit from capturing data at several points in time to identify key areas of perspective changes and barriers throughout the process of supporting a friend or loved one’s recovery journey.
  2. The study did not set out to examine the experience of navigating treatment and so the results may be different than if participants were specifically asked more direct questions about this. The findings were also reported regardless of relationship status. The experiences of close friends and family are likely very different and worth examining further with perhaps more specific questions relevant to the challenges faced for these different types of relationships and whether the addicted loved-one is living with them or living somewhere else.

BOTTOM LINE

In this study of individuals of family members and friends who had a close relationship with someone who uses opioids, participants reported often experiencing a small “window of opportunity” and many barriers to help engage someone close to them in treatment. Participants described difficulty in navigating the system and figuring out how to support their loved one as the process of recovery progressed. Formal support groups populated by other affected family members and friends with “lived experience” of dealing with these challenges, were an important source of information and support that helped them to navigate this experience.


  • For individuals and families seeking recovery: It is important to know that you are not alone when navigating the difficult experience of having a loved one with addiction and to seek out support for this experience. One treatment, Community Reinforcement and Family Training (CRAFT), implements many of the strategies family members described as helpful when supporting their loved one. A virtual CRAFT may also be freely available to you, depending on state funding. There are also a variety of formal groups, such as Alanon/Narcanon, Learn to Cope, Families Anonymous, NAMI Family Support Group, Parents of Addicted Loved Ones, and SMART Recovery Family & Friends, that can support a family member or friend during this experience. Most if not all of these can be accessed online as well as in person. Support groups may have different perspectives about the recovery process, so it is worth it to explore several to find a support group that best suits the needs of your situation.
  • For treatment professionals and treatment systems: Family members and friends are important influences on a person’s engagement in treatment and also need their own support to address the challenging emotional reactions related to their loved one’s experience with addiction. Until an individual is ready to enter treatment, approaches to help those around them engage in self-care to reduce the negative consequences of addiction as well as to more effectively engage with their loved one may be necessary. Community Reinforcement and Family Training (CRAFT) is one such way to support families in the process of balancing how to set boundaries, support their loved one, and actively facilitate treatment entry.
  • For scientists: This study highlights the many challenging experiences of families and friends as they navigate their loved one’s treatment and recovery experiences. Yet, because this is cross-sectional data, future work examining the experience of friends and families would benefit from capturing data at several points over time to identify key areas of perspective changes, resources, and barriers throughout the process of supporting a loved one’s recovery journey. As well, there is a need to more clearly differentiate the experience and needs of family and close friends when supporting someone to seek out treatment and whether the addicted loved one is living with the friend or family member or living elsewhere. Further longitudinal research is also needed on freely accessible mutual help organizations for family members and friends and identify the best ways to support them in this process, to mitigate negative experiences or consequences as a result of supporting someone’s recovery journey.
  • For policy makers: Friends and families often are severely impacted by a loved one’s experience with addiction. They are also often the most important influence on a person’s engagement in treatment as they are often involved in facilitating treatment initiation. Policy and decision-makers could work with treatment programs and systems to identify and address barriers to implementation and dissemination of interventions and supports which involve friends and families of those with substance use disorders. These efforts could include increasing funding for training in family and friend involvement and infrastructure development, and research funding support for implementation and dissemination research.

CITATIONS

Slocum, S., Paquette, C. E., & Pollini, R. A. (2023). Drug treatment perspectives and experiences among family and friends of people who use illicit opioids: A mixed methods study.Journal of Substance Use and Addiction Treatment, 209023. doi: 10.1016/j.josat.2023.209023.


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