The impact of family engagement in opioid assisted treatment: Results from a randomised controlled trial

Background

There is an increasing body of evidence to support the premise that engaging family and significant others in substance use disorder (SUD) treatment enhances initial patient engagement and retention in treatment (Copello & Orford, 2002; Liddle & Dakof, 1995). Family related interventions and wider social care were proposed to reduce harm inflicted on the family, enhance family functioning and optimise outcomes of SUD treatment (Copello & Orford, 2002). In contrast, the lack of family support and engagement in treatment hampers recovery and social integration of patients completing inpatient SUD treatment in the United Arab Emirates (UAE) (Alsuwaidi, 2019). Providing family education on addiction and recovery contributed to the reduction of family related disorders and patient isolation in the UAE (Alsuwaidi, 2019). Several family interventions have been studied in the treatment of SUD, for example Behavioural Couple Therapy, Unilateral Family Therapy, Network Therapy (Copello et al., 2005). Despite this, SUD treatment programmes continue to focus on the individual substance user and fail to capitalise on the value of engaging families in treatment (Copello et al., 2005).

Barriers to deliver family interventions in SUD treatment include patients’ resistance to involve families, and family’s reluctance to be involved in treatment, as the latter think it is the individual member’s problem (Orford et al., 2009). Other barriers pertain to the consideration of family related interventions as an ‘adjunct’ rather than central to treatment by many treatment programmes. Thus, these programmes are not appropriately designed to involve families in treatment and may not be adequately staffed with clinicians trained to deliver such interventions. Finally, the logistical challenges in arranging family meetings, and social stigma, were described as key barriers to delivering family interventions although this may vary from one country to another (Orford et al., 2009).

Established in 2002, the National Rehabilitation Center (NRC) is the national SUD response centre in the UAE. The rate of family engagement in SUD treatment was examined in a study of 632 patients admitted to the NRC during the year 2013. Family attendance measured by a record of attendance of one to three sessions at the outpatient clinic, was reported at 30% (Elkashef et al., 2017). Families attending more than three sessions constituted 8%, while 62% of the families did not attend any sessions. A higher percentage of family attendance was reported for patients older than 50 years, compared to those younger than 20 years (35% vs 16%, respectively). The authors attributed the low level of family engagement in treatment to possible social stigma, and recommended delivering family interventions at home (Elkashef et al., 2017).

In this paper, we used data from the Suboxone Treatment and Recovery Trial (STAR-T) to examine the impact of family engagement in treatment on opioid use and rate of retention in treatment (Elarabi et al., 2019). We further suggest opportunities for developing and delivering family related interventions.

Methods

Results

In the experimental group, 27 participants (49.1% of the valid data) had a family member visit on one or more occasion to support their treatment. In the control group, 26 participants (45.6% of the valid data) had one or more family visits. No significant difference was observed between both groups (p = .80).

The association of opioid use with family engagement in treatment was not significant (Spearman’s rho 0.03, p = .78). In contrast, retention in treatment was significantly associated with family engagement in treatment (Spearman’s rho 0.25, p < .01). A logistic regression analysis, after adjusting for group allocation, age, family history, city of residence and scores of the ASI family disorder subdomain, showed that patients with family involvement were 2.95 times more likely to be retained in treatment, that is, complete the 16-week period compared to those with no family engagement (adjusted OR 2.95, 95% CI 1.31–6.65). Table 1 summarises the details of the logistic model.

OPEN IN VIEWER

Table 1.

Multiple logistic regression of family involvement on retention in treatment.

Factors	Adjusted odds ratio	Lower 95% CI	Upper 95% CI
Study allocation (reference = control)	1.10	0.48	2.40
City of residence (reference = Abu Dhabi)	1.22	0.55	2.70
Family involvement	2.95	1.31	6.65
Addiction Severity Index family disorders score	1.70	0.42	6.85
Age (years)	1.02	0.98	1.10

Note. CI = confidence interval.

Discussion

In this paper, we examined the association of family engagement in treatment and rate of retention in treatment for adults with OUD receiving Opioid Assisted Treatment (OAT) for 16 weeks at an outpatient clinic. Results show that patients with families who attended at least one outpatient family-session, were almost three times more likely to be retained in the full 16-week treatment period, compared to those without family attendance. There was no statistically significant association between family attendance and reduced opioid use. The clinical implication of increasing retention in treatment is demonstrated by a higher abstinence rate, reduction in morbidity, mortality and violations of the criminal justice system (French et al., 2008).

The observed enhanced retention in treatment was associated with a record of ‘attendance’ rather than a specific family intervention. In other words, by just demonstrating engagement in treatment via attending a family session, families were able to contribute to an enhanced patient retention in treatment. In the UAE, family psychoeducation on the nature of the disease and providing better understanding of the recovery process is reported to decrease family problems and augment recovery from SUD (Alsuwaidi, 2019). As family related matters are highly valued and respected in the UAE (Alsayegh, 2013), family engagement emerges as an opportunity to enhance treatment retention rate (Elkashef et al., 2017).

Additionally, family therapy has been reported to increase the rate of treatment retention and reduce substance use (Copello & Orford, 2002). Family therapy or family-related interventions can be delivered during any of the phases of treatment and include interventions addressing family stress and strengthening coping capacity, and interventions targeting patients for engagement in treatment (Copello & Orford, 2002). A 5-step model composed of non-judgemental listening, exploring coping tools, establishing social support and encouraging seeking help was developed to address the associated family stress and strain (Copello et al., 2010). Enhancing the effectiveness of this model through flexible and personalised intervention is suggested for achieving optimal treatment outcomes (Copello et al., 2010). There is also evidence for multidimensional family therapy (MDFT), a relatively brief personalised comprehensive multiphase environmental and manual guided intervention, to reduce substance use related disorders in early adolescents (11–15 years) (Liddle et al., 2004).

In order to enhance treatment accessibility and optimise retention in treatment, services should plan towards alleviating of treatment seeking. For example, social stigma and the cultural and religious framework that reject substance users should be addressed for better treatment accessibility and retention (Alam-mehrjerdi et al., 2016; Elarabi et al., 2013). Social stigma associated with SUD also resulted in delayed treatment seeking (Buchman & Reiner, 2009; Livingston et al., 2012). Treatment is, hence sought at a later stage in illness that may be associated with higher complexity and severity. At this stage, family exhaustion, strain and stress, caused by the illness and the absence of adequate coping skills and social support are observed. In other words, families become ‘too tired’ to be engaged in treatment. This scene may further be complicated by multiple failed treatment attempts.

A possible way to deal with the challenge of engaging families in treatment has emerged during the Covid-19 pandemic. Several health care providers and business sectors resorted to digitised virtual communications. Emanated out of necessity, many have overcome the barriers of anxiety, confidence, reliability and prejudices to engage in the use of such means of communication. Previously, telemedicine and internet based interventions were examined in mental health disorders and found to be effective (Barak et al., 2008; Hilty et al., 2013). Nevertheless, the uptake of interventions has been low, particularly among older generations. The increasing acceptance and utilisation of virtual communications serves as an opportunity to develop family interventions in a culture where stigma has shown to be a barrier for family engagement in treatment.

We propose developing a multidimensional family intervention programme, based on evidence based approaches and leveraging on advances in digitised virtual communication based technologies like video streaming, holograms and possibly machine learning and artificial intelligence. These tools will undoubtedly assist developing treatment programmes that could deliver family based interventions, with the necessary flexibility, and privacy, that could circumvent the identified barriers, primarily social stigma, and logistical challenges. The latter should also not be under estimated in a country where treatment centres could be located a fair distance from where families live and key family members may not be living in one location.

The first component of the family intervention programme is, suggested to be a generic family education developed and delivered using digital tools and platforms. This component aims at enhancing the understanding the nature of SUD and the recovery process while highlighting the challenges observed by the patients during recovery. It will further describe the vital role of the family in treatment and will include a measure to identify family needs challenges to engage families in treatment. This component will reinforce that families pivotal in treatment while recognising that families have needs that should be adequately met to optimise treatment outcomes. We suggest that this component be supplemented with accounts from real patients and families on their experience with family based interventions.

The second component will focus on addressing the family stress and strain guided by the five-step approach developed by Copello et al. (2010) and is suggested to be delivered by a trained professional using accessible virtual communication platforms. A viable alternative is the MDFT given its successful evidence in adolescents. This intervention may be of particular relevance in the UAE since family involvement in treatment lowest in families of patients under 20 years compared to families over 50 years (Elkashef et al., 2017).

Conclusion

Our results show that family attendance was independently associated with higher retention in treatment of adults with opioid use disorders receiving outpatient OAT. The existing evidence that retention in treatment is strongly associated with holistic treatment outcomes, makes a strong case for increasing efforts to enhance family engagement. The current advances of technology and changes in attitudes towards digitised virtual communication methods, provide an opportunity to develop accessible family intervention programmes. It is strongly recommended that such programmes are developed and evaluated, particularly in countries where family engagement in the treatment of substance users have been shown to be low.