Abstract
Objective:
With the opioid epidemic reaching declared a public health emergency in recent years, a synthesis of recent knowledge outlining the impact of opioid use disorders on youth and families is needed. To this aim, this exploratory literature review examined how the role of family is discussed in research on youth opioid misuse, with the goal of acting as a springboard for further research and treatment development that could mitigate the negative impacts opioids are having on families and youth.
Method:
Peer-reviewed journal articles between 2008 and 2018 were accessed through PsycINFO in March 2018. A total of 279 unduplicated articles were identified through the search. Upon abstract and full-text review, a total of 21 articles met criteria for inclusion in the systematic review.
Findings:
Overall, the role of the family in adolescent opioid misuse was not commonly discussed in the literature, with 21 of 279 (7.5%) of articles meeting inclusion criteria for the current study. In the included articles, the following major themes were identified: (1) family factors affecting adolescent opioid misuse behavior and (2) family’s role in treatment of adolescent opioid misuse.
Conclusions:
The review evidences there is a relative paucity of literature on relational variables and youth opioid misuse. More practice-based scholarship, as well as more rigorous clinical research, is needed to inform future steps for clinical processes, policy, and research.
The Centers for Disease Control and Prevention (CDC, 2018) estimates that more than 42,000 Americans died from an opioid overdose in 2016; preliminary 2017 CDC reports have estimated a record-breaking 72,000 drug overdose deaths, a 10% increase from 2016 (Ahmad, Rossen, Spencer, Warner, & Sutton, 2018). According to the CDC’s National Center for Health Statistics, life expectancy in the United States has dropped to 78.6 years, with the opioid epidemic identified as a principle causal factor (Kochanek, Murphy, Xu, & Arias, 2017). The breadth of the opioid epidemic spans from coast to coast and the incidence of fatal overdoses is rising across all demographics (gender, race/ethnicity, socioeconomic status [SES], age, etc.; Hedegaard, Warner, & Miniño, 2017).
Further, adolescents and young adults are a high-risk population for substance misuse including opioid misuse. In 2016, 3.6% of adolescents between 12 and 17 years of age and 7.3% of youth between the ages of 18 and 25 years reported misusing opioids in the past year (Substance Abuse and Mental Health Services Administration, 2017). In 2015, an estimated 4,000 deaths of individuals 15–24 were attributed to drug overdoses and roughly half of these were opioid related (National Institute on Drug Abuse, 2018). The CDC estimates that for every young adult overdose death, there are 119 emergency room visits and 22 treatment admissions (National Institute on Drug Abuse, 2016). As these statistics indicate, young people are significantly impacted by the opioid epidemic.
With the opioid epidemic now declared a nationwide public health emergency (Department of Health and Human Services, 2017), numerous efforts have been undertaken to reign in its negative impact. State prescription drug monitoring programs have been enhanced and opioid overdose prevention efforts, including increased circulation and training on naloxone (opioid reversal agent), have been strengthened (Department of Health and Human Services, 2017). Prescribers are facing increased pressure from legislative bodies, insurance entities, and medical associations to judiciously prescribe pain medications (H.R. 6, 2018). Patients are being greater informed of the addiction potential of opioid medication and educated on risk mitigation strategies for safe use (Genord, Frost, & Eid, 2017). Advocacy groups are working to reduce the stigma associated with opioid addiction; viewing addiction as warranting medical intervention (Shatterproof, 2018). Considerable efforts are underway to increase funding for, availability of, and quality of addiction treatment facilities (H.R. 6, 2018).
Of the recent literature that is available on treatment for youth opioid misuse, the focus is largely on individualistic interventions such as medication-assisted treatment (Chang, Klimas, Wood, & Fairbairn, 2018) and psychosocial interventions (Minozzi, Amato, Bellisario, & Davoli, 2014). Systemic-relational dynamics of opioid use in this population are discussed to a lesser extent, despite there being robust literature showing the efficacy of family-based treatments in substance use among youth (National Institute on Drug Abuse, 2014). For instance, several comprehensive literature reviews, meta-analyses of controlled outcomes studies, and quality of evidence studies support family-based treatment strategies for youth suffering from addiction and mental health conditions (Donohue, Allen, & Lapota, 2009; Hogue & Liddle, 2009; Liddle, Dakof, Henderson, & Rowe, 2011; Robbins et al., 2011). Further, federal agencies (Center for Substance Abuse Treatment, 1999), national associations (American Academy of Child and Adolescent Psychiatry, 1997), and influential policy-making groups (e.g., Drug Strategies, 2003, 2005) have established guidelines underscoring the importance of involving caregivers and other family members in the treatment of adolescent drug use.
The incorporation of family in youth opioid misuse inquiry warrants special attention in light of the opioid epidemic riveting the United States, and the noted efficacy of family involvement in treatment and recovery among substance-using adolescents, more broadly speaking (Hogue & Liddle, 2009). While there is also a robust literature from the 1970s to 1980s examining the inclusion of families in the treatment of opioid use disorders, a result of the escalation of heroin use in the United States at that time (e.g., Landau-Stanton, 1990; Stanton & Todd, 1982; Stanton et al., 1978), a synthesis of more recent literature related to adolescent opioid use and family involvement the current opioid epidemic is missing from the literature.
This systematic literature review aims to explore how the role of family is discussed within the context of youth opioid misuse literature in order to inform current practices and future clinical and research platforms related to this timely and significant public health issue. In conducting this review, clarity on family involvement in treatment and family factors that affect opioid misuse is sought.
Method
Search Strategy
The current literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to model the literature review process (Liberati et al., 2009) and Figure 1 summarizes the search results. An electronic literature search was conducted using PsycINFO in March 2018 for studies that were relevant to the current research question and that were published between 2008 and 2018. Search terms included were as follows: adolescen* OR teen* OR youth* OR minor* AND opioid* OR opiate* OR heroin* AND famil* OR relative* OR caregiver*. The search yielded a total of 282 articles. After removal of duplicates, a total of 279 articles remained.
Literature search methodology.
Study Selection
An abstract review was conducted by the three authors to identify articles that conformed to the following inclusion criteria: U.S. populations only, nonmedical use of opioids, youth as the identified respondent (active user), age range of 12–25 years old, discussion of at least one family component, and emphasis on opioid use. This resulted in a total of 56 articles qualifying for full-text review. After reading the full texts and assessing for conformity to our inclusion criteria, a total of 21 articles on opioid misuse in youth discussing family were identified as meeting the inclusion criteria for the review. Summaries of each of these 21 articles are included in Table 1.
Summary of Articles Used in Systematic Review.
Note. N/A = not applicable.
Credibility and Data Organization
Credibility in coding and analysis was considered by having each coauthor code the first three articles independently and then compare codes. The codes that emerged from this process were used to guide the review of the remaining articles. Codes were created on the basis of general themes and content with respect to family and each of the 21 articles was screened, paragraph by paragraph, for pertinence. The following codes were used “confidentiality,” “negative family effects,” “positive family effects,” “family conflict/turmoil,” “specific family role,” “family’s perspective,” “youth’s perspective,” “treatment involvement,” “treatment outcomes,” and “treatment implications.” Articles were then read once more for other family-related themes and subthemes and codes were then reorganized to better reflect content and synthesis. The following revised codes emerged as the final codes from the review: “confidentiality,” “family as source of opioids,” “family conflict,” “family as substance misusers,” “family SES,” “family residential stability,” “parental education level,” “family structure,” “parental involvement,” “family attitudes toward substance misuse,” “youth’s perspective,” “family’s perspective,” and “family treatment involvement.” These codes were synthesized into relevant themes in the Results section.
Results
The themes that emerged from the literature review are visualized in Figure 2. Two overarching themes were discovered: (1) family factors affecting adolescent opioid misuse behavior and (2) the role of family in treatment of adolescent opioid use disorders. Of note, family was not the chief focus of the majority of the articles with only a paragraph or two allocated to the subject. The following paragraphs summarize the family-related themes and associated content identified and outlined in the literature.
Family-related themes identified in literature review.
Theme # 1: Family Factors Affecting Adolescent Opioid Misuse
Within this main theme, three major subthemes emerged including (a) youth’s perspective on the role of the family in their opioid use, (b) family factors, and (c) specific parental factors. Each subtheme is detailed below.
The youth’s perspective
A total of four studies discussed the perspectives from youth regarding the role of family in youth opioid dependence, but specifically among youth in recovery (Guarino et al., 2009; Majeed, 2017; Moore, Guarino, & Marsch, 2014; Vo, Burgower, Rozenburg, & Fishman, 2018). Some youth perceived their family’s involvement in their recovery process as positive, some believed it to be unnecessary and intrusive, while other youth perceived that their recovery was ultimately their own responsibility.
Positive youth perspectives
A few of the articles specifically reported positive youth perspectives about family involvement among youth who are in recovery. Vo, Burgower, Rozenburg, and Fishman (2018) reported that most youth found communication and involvement of parents as pivotal to increasing their motivation and stability. Both Guarino et al. (2009) and Moore, Guarino, and Marsch. (2014) indicated that youth participants generally found familial support to be beneficial in their recovery journeys, although the perceived impact was marginal.
Negative youth perspectives
One of the nine participants in Vo et al.’s (2018) case series believed family involvement to be an intrusion of privacy and subsequently invoked her right to confidentiality. In Majeed’s (2017) case report, the participant decided against informing her parents of her occasional recreational opioid misuse given that it was infrequent and she wished not to burden her dying mother.
Youth as own driving force for change
Some of the articles spoke to the youth’s perspective that they themselves were ultimately responsible for their behavioral change, despite their family’s involvement (Guarino et al., 2009; Moore et al., 2014). For instance, Guarino et al. (2009) found that no amount of external pressure and persuasion from family compelled them to stop using and seek treatment. Adolescents stated that family encouragement in treatment was beneficial but that ultimately the decision to “become clean” and seek treatment was independent (Moore et al., 2014).
Youth coping by isolating from family
Moore et al. (2014) reported that youth described their relationships with family members as disintegrating as their opioid addictions escalated. Lies and theft that the disease of addiction subjected youth’s families to led to a rift between misusing youths and their families. Further, many youth isolated themselves in an effort to limit the amount of hurt and disappointment their family members experienced due to their opioid use (Moore et al., 2014).
Family factors
There are several subthemes within the theme of family factors, including (1) family as a source of opioids, (2) family history of use and normalization, (3) family conflict, (4) family structure, (5) residential stability, and (6) family SES.
Family as a source of opioids
Family was identified as a source of prescription opioids for adolescents, both knowingly and unknowingly, in a total of six articles (Lankenau et al., 2012; Majeed, 2017; Monnat & Rigg, 2016; Russell, Trudeau, & Leland, 2015; Schepis & Krishnan-Sarin, 2009; Yule, Wilens, & Rauch, 2017). For instance, friends and family were identified to be the most common sources of opioid access for adolescents among a sample of 21 students enrolled in substance use recovery high schools (Russell et al., 2015). Among a sample of 50, 22% disclosed that their first instance of opioid misuse was by mode of stealing a family member’s prescription and nine participants reported misusing family members’ prescription opioids secondary to initiation via alternative sources (Lankenau et al., 2012). Additionally, data from the 2005 and 2006 National Survey Drug Use and Health (NSDUH) indicated that youth ages 12–17 identified friends or relatives as the most common sources of opioids (33.4–49.7%; Schepis & Krishnan-Sarin, 2009). Data from the 2011 and 2012 NSDUH also revealed that friends and family (67%) were the most common sources of prescription opioids among adolescents (Monnat & Rigg, 2016). Another article spoke to the availability of opioid medication among families with a member engaging in pain management (e.g., hospice care; Majeed, 2017). The implications from these articles are all similar, with an emphasis on the importance of parents and legal guardians exerting greater control over prescription medications within the household (Lankenau et al., 2012; Monnat & Rigg, 2016; Schepis & Krishnan-Sarin, 2009).
The literature has also indicated the role of helping professionals as it relates to family being a major source of access to opioids. For instance, Yule, Wilens, and Rauch (2017) reported health-care providers should routinely discuss safe storage (e.g., lockboxes at home) and disposal of prescription opioids with patients and family members (e.g., drug take-back days and medication drop boxes).
Familial substance use: History, using with family, attitudes of family, and consequent normalization
A total of four articles discussed the overarching theme of familial substance use among youth experiencing issues with opioids (Lankenau et al., 2012; Russell et al., 2015; Silva, Schrager, Kecojevic, & Lanekenau, 2013; Walker et al., 2014). For instance, in Lankenau et al.’s (2012) sample, 80% of study participants grew up in a household where a family member misused substances, with one third of the participants reporting parents or relatives who misused their own prescription opioids. Among a sample of 21 high school students in a recovery high school, all but three participants had drug-using family members (>90%); many also had a family history of opioid use (42%; Russell et al., 2015). Further, Walker et al. (2014) conducted a study on a sample of 72 Mexican and Mexican American adolescents with opioid dependence enrolled in treatment programs. Many of the participants reported that their parents’ generation had drinking problems and that relatives from their own generation had significant drug problems.
Another finding from the literature was the high prevalence of youths using drugs with family members; almost half (46%) of participants reported such (Walker et al., 2014). Further, in Walker et al.’s (2014) study, they found youth who used drugs with family members were more likely to initiate heroin use at a younger age, including by injection compared to youth that did not (21% vs. 5%). The study draws attention to the normalization of drug use in households which facilitate aberrant drug use patterns in adolescents.
Silva, Schrager, Kecojevic, and Lanekenau (2013), in their study assessing prevalence of nonfatal overdoses of prescription opioids and/or tranquilizers, also highlighted the high prevalence of family drug problems in this sample, with over a third (34.7%) of participants witnessing a family member overdose. After separating the subjects who never experienced an overdose, it was discovered that youth with a lifetime incidence of a nonfatal overdose reported witnessing family members overdose in greater frequency (50% vs. 32.3%; Silva et al., 2013).
Two articles specifically discussed family approval or disapproval of substance misuse and the impact of such on adolescent opioid use tendencies. In Monnat and Rigg’s (2016) study on regional differences in adolescent opioid misuse patterns across the United States, parental disapproval of substance use was hypothesized to decrease the risk of prescription opioid misuse among adolescents and the unadjusted models supported this claim. In Walker et al.’s (2014) study on heroin use among adolescents of Mexican heritage, the normalization of substance misuse in households is deemed to adversely impact youth’s attitudes and behaviors on the subject, with nearly 40% of adolescents agreeing that clear rules against alcohol and drug use in the family were not established.
Family conflict
Three of the articles touched on family conflict and turmoil in the backdrop of adolescent opioid misuse (Majeed, 2017; Meyers, 2014; Moore et al., 2014). These articles supported prior research indicating that family conflict can be both an antecedent to youth opioid use (Majeed, 2017) and a consequence from the youth’s opioid misuse (Meyers, 2014; Moore et al., 2014).
Family structure
Family structure was described in a total of 10 studies (Donaldson, Nakawaki, & Crano, 2015; Lankenau et al., 2012; Monnat & Rigg, 2016; Nakawaki & Crano, 2012; Pugatch, Knight, McGuiness, Sherritt, & Levy, 2014; Silva et al., 2013; Spoth et al., 2013; Sussman et al., 2012; Walker et al., 2014; Wong et al., 2013). Overall, although evidence suggests that family structure impacts youth opioid use, the findings were not robust and associations found were correlational.
For instance, Donaldson, Nakawaki, and Crano (2015) examined the associations between adolescents’ family structures, social ties, drug-related attitudes, and their opioid and stimulant misuse behavior and found that youth living in single-parent households are more resource deprived, more vulnerable to peer influence, experienced less parental supervision, and had weaker emotional connections with parents than their peer counterparts living in dual-parent households. Similar findings were indicated in a study examining Mexican and Mexican American adolescents in treatment for heroin use, with being raised by someone other than their biological parents identified as a risk factor for opioid misuse (Walker et al., 2014).
Findings from other studies examining family structure were less clear but still indicated an impact of family structure on youth opioid use. For instance, Nakawaki and Crano (2012) used sociodemographic variables and user status of common illicit substances (e.g., cigarettes) to predict persistence of opioid and stimulant misuse in teenagers. With respect to opioid use, parental status associations were mixed. They found that teenagers from mother-only households had higher odds of recent onset of opioid use and those from absent-parent households were at higher risk of nonpersistent opioid use, in comparison to dual-parent household counterparts.
Still, other articles did not find a significant relationship between family structure and youth opioid use (e.g., Monnat & Rigg, 2016), and other studies only mentioned family structure as a demographic variable, without including it in the analysis related to the youth’s substance use (Lankenau et al., 2012; Pugatch et al., 2014; Silva et al., 2013; Spoth et al., 2013; Sussman et al., 2012; Wong et al., 2013). For instance, in Monnat and Rigg (2016), results from the unadjusted models suggested that the presence of both parents and more people in one’s household are protective and reduce odds of prescription opioid misuse. However, this protective effect of parental status did not carry over in the adjusted models.
Donaldson et al. (2015) hypothesized that adolescents coming from a neither or single-parent household had lower perceptions of parental monitoring and warmth and would consequently identify with social attitudes and groups more lenient to substance use. Results from the sample of 17,399 respondents found that adolescents from dual-parent households reported greater levels of parental monitoring (Donaldson et al., 2015). Family structure, however, did not consistently correlate with levels of parental warmth.
Family residential stability
Four studies discussed familial residential stability in the context of adolescents with opioid use disorders (Lankenau et al., 2012; Silva et al., 2013; Vo et al., 2018; Wong et al., 2013). Overall, the literature regarding this theme asserts that residential stability has a protective effect against opioid initiation and is beneficial in treatment recovery for youth. Vo et al. (2018) found that residential stability was integral to the intervention of delivering doses of extended-release naltrexone at home, with homelessness positing a barrier to successful treatment and wellness.
Homelessness was identified as a risk factor for youth opioid use in the literature. Lankenau et al. (2012) reported that prescription opioid use was found to be a key feature of the trajectory to injection drug use, with 60% of their sample of injection drug users reporting current homelessness and 98% reporting ever experiencing homelessness. Wong et al. (2013) also found that both family homelessness and current homelessness were linked to participants with more severe problems in drug use. Using the same data as Wong et al. (2013), Silva et al. (2013) found that homelessness was also related to more lifetime nonfatal overdoses.
Family SES
Eight articles discussed the role of family SES on adolescent opioid use patterns (Donaldson et al., 2015; Edlund et al. 2015; Monnat & Rigg, 2016; Murphy, Friesner, & Rosenman, 2015; Nakawaki & Crano, 2012; Silva et al., 2013; Sussman et al., 2012; Wong et al., 2013). Four of the articles extrapolated data from the NSDUH. Overall, findings regarding this theme indicated that family SES is also linked to youth opioid use.
Studies examining family income as an SES variable indicated a trend toward the association between lower family income and increased risk of opioid misuse among youth. For instance, Nakawaki and Crano (2012) included family income as a variable in assessing persistent and nonpersistent opioid users and found adolescents hailing from households making <$20,000 and <$49,999 annually to more likely be nonpersistent or persistent opioid users than those raised in wealthier homes. Similar findings were reported by Edlund et al. (2015), with youth reporting opioid misuse more likely to be in the <$49,999 annual family income bracket as compared to their counterparts, and by Donaldson et al. (2015), who reported a link between family income, family structure, and nonmedical prescription opioid use. Other studies examining SES through a more comprehensive measure also found that SES is related to youth opioid use. For instance, Monnat and Rigg (2016) examined SES through annual family income, family receipt of public assistance (e.g., Supplemental Nutrition Assistance Program and cash assistance), and adolescent health insurance. In the unadjusted model, lower SES was found to be a predictor of adolescent prescription opioid misuse.
Silva et al. (2013) found that family SES influenced adolescent overdose risk. Participants reporting a history of overdose were more likely to grow up in poor/working class environments (56.2% vs. 41.1%). Using the same data, Wong et al. (2013) employed the technique of latent profile analysis to empirically derive coping and emotion regulation typologies to then predict different patterns of substance use. Four latent classes were identified as suppressors, others-reliant copers, self-reliant copers, and active copers. The study’s authors further examined the association between family socioeconomic class and coping/emotional regulation classes. SES, however, was not found to be a predictor of membership into a certain coping/emotion regulation class.
Murphy, Friesner, and Rosenman (2015) used parental education as a proxy for SES and assessed its impact on adolescent opioid misuse behavior. The authors further explored the association between SES and misclassification (survey bias and response inaccuracy). Individuals who did not respond to parental education questions were found to be less likely to misuse their own prescriptions and more likely to misuse diverted prescriptions. Individuals with at least one parent with a college degree had a decreased likelihood of misreporting use of prescription drugs.
And lastly, Sussman et al. (2012) used SES as a measure to calculate “drug use risk score” of students in high schools to identify samples that would most benefit from their drug abuse education curriculum. Once again, parental education level was used as a proxy for SES.
Parent factors
Thirteen articles discussed the role of parents in youth opioid misuse. Parental education was mentioned as part of demographic data and then level of parental involvement was also described.
Parental education level
Parental education level was briefly discussed in four articles included in this review (McCabe, Kloska, Veliz, Jager, & Schulenberg, 2016; Murphy et al., 2015; Pugatch et al., 2014; Sussman et al., 2012). It was used merely as a descriptive variable in assessing baseline characteristics (McCabe et al., 2016; Pugatch et al., 2014) and as a marker of familial SES (Murphy et al., 2015; Sussman et al., 2012). As a proxy measure for family SES, overall findings indicated that higher parental education appeared to be a protective factor against nonmedical prescription opioid use among youth.
Parental involvement
Eleven articles discussed the theme of parental involvement to varying extents (Donaldson et al., 2015; Edlund et al., 2015; Guarino et al., 2009; Monnat & Rigg, 2016; Moore et al., 2014; Murphy et al., 2015; Pugatch et al., 2014; Spoth et al., 2013; Vo et al., 2018; Walker et al., 2014; Yule at al., 2017). Some studies inherently involved parents by mode of study design while others quantified and qualified the level of active parenting and implications on substance misuse.
Numerous articles reported the protective effects of parental monitoring and warmth against youth opioid use. Donaldson et al. (2015) reported higher levels of lifetime nonmedical prescription opioid misuse found in adolescents who had low parental monitoring and warmth. Positive parental influence and involvement, such as someone being home when youth got back from school (59%) and whether parents could tell if adolescents were high (56%) also helped reduce the risk of youth opioid use (Walker et al., 2014). Further, parental involvement and support was denoted as a factor promoting entry into and continuation of treatment among recovering youth (Moore et al., 2014). Parental involvement has also been reported to act as a protective buffer between youth opioid use and other risk factors such as major depressive disorder (Edlund et al., 2015).
Of note, several articles discussing parental involvement were intervention research studies. For instance, parental involvement in adolescent opioid misuse recovery was viewed favorably in Pugatch, Knight, McGuiness, Sherritt, and Levy’s (2014) study examining a 13-week psychoeducational group therapy program. In Guarino et al.’s (2009) study examining an innovative methadone maintenance treatment program the parents support group was considered beneficial in aiding the recovery process, parents developed new strategies of relating to recovering adolescents and reconsidered initially negative attitudes about methadone treatment. Brief universal interventions, which included educational training of parents along with adolescents, were found to reduce the potential of prescription drug misuse in adolescents and young adults (Spoth et al., 2013).
Other articles reported suggestions for parents in helping their children maintain abstinence (e.g., Vo et al., 2018; Yule at al., 2017). In Murphy, Friesner, and Rosenman’s (2015) misclassification report, analytic models identified that youth whose parents praised them when appropriate were less likely to misreport the source of a diverted prescription.
While the majority of the findings indicated a significant relationship between parental involvement and youth opioid use, Monnat and Rigg (2016) found that parental factors were not statistically significantly related to differences in prescription opioid misuse among adolescents in rural versus urban settings.
Theme # 2: The Family’s Role in Treatment
The two subthemes identified under this main theme include (a) ethical considerations and confidentiality and (b) family involvement in treatment. In terms of treatment involvement, families were often included directly in interventions. The use of a child psychiatrist in engaging family in treatment is also discussed in one article (Yule et al., 2017).
Ethical considerations and confidentiality
A total of three articles explicitly discussed the ethical considerations regarding treatment of opioid misuse in youth. This research illustrates the legal complexities of parental and familial involvement in the treatment of opioid misuse in youth. Parental and familial involvement in treatment of opioid use in adolescents is encouraged; however, the right to confidentiality should not be overridden unless there is an immediate threat.
Yule et al. (2017) provided implication statements regarding the inclusion of parents/caregivers in youth treatment, highlighting that many state statutes allow minors to receive treatment for substance abuse without parental consent. This law offers youth the option of independently seeking treatment without the fear of potentially negative repercussions of informing caregivers. However, self-referrals made by youth constitute a very small percentage of treatments (16.5%). Although engaging family in care is ideal, adolescents may initially be reluctant (Yule et al., 2017).
Another consideration is honoring the youths’ confidentiality. Majeed (2017) describes a case report of a 15-year-old girl undergoing intensive outpatient treatment for attention deficit hyperactivity disorder and major depressive disorder who is discovered to be stealing opioid medications from her mother for recreational purposes. This highlights the confluence of legal, ethical, and professional issues that govern the substance abuse care of a minor. Another example can be found in Vo et al. (2018) who outlined findings of a pilot program that required a heavy reliance on parental involvement. In this study, it was noted that parental inclusion was seen as intrusive and patronizing by some participants. In one case, a 19-year-old female with a history of opioid abuse dropped out of the program after relapsing. In the context of conflict over parental communication and involvement in treatment, she perceived her family’s engagement in her treatment course as excessive.
Family involvement in treatment
A total of five articles discussed the role of family specifically in the treatment of adolescents with opioid use disorders (Guarino et al., 2009; Pugatch et al., 2014; Spoth et al., 2013; Vo et al., 2018; Yule et al., 2017). Overall, two subthemes emerged from the literature related to family involvement in treatment including the benefits of comprehensive treatment that involves family and the role of health professionals in engaging family in treatment.
Benefits of comprehensive treatment that includes family
Multiple articles highlighted the importance of including family in the treatment process. Guarino et al. (2009) discussed findings from focus groups held for adolescents with opioid dependence, their parents, and clinical staff at the Young Adult Methadone Program. The purpose of the focus groups was to better understand components of effective treatment for opioid-dependent youth from multiple perspectives, and it was concluded that effective treatment for young opioid addicts incorporates family members, particularly parents. Pugatch et al. (2014) implemented a psychoeducational curriculum focused on addiction awareness and recovery for both youth and parents separately. Lessons included discussion, reflection, and reinforcement exercises in a group setting. The parental curriculum addressed addiction as a family disease and helped parents identify family-strengthening tactics to empower youth. Adolescents and parents were encouraged to discuss what they learned after group sessions.
Other articles reported similar findings and implications, including that family-based therapies are among best practice treatments for adolescent opioid use (Moore et al., 2014; Pugatch et al., 2014), and that parental/familial inclusion was key, fortifying the social support system for youth in recovery and educating parents/caregivers on how to be a support for their family member and better understand addiction (Pugatch et al., 2014; Vo et al., 2018).
Additionally, Spoth et al. (2013) reported on the longitudinal effects of “brief preventive intervention” programs focused on family strengthening on adolescent prescription drug use and opioid use in three randomized controlled trials. Findings indicated that interventions focused on strengthening families and fostering healthy relationships and attitudes, not specific to prescription drug misuse, can in fact help reduce adolescent prescription opioid misuse behavior.
And lastly, the inclusion of family was essential to the home-based delivery of extended-release naltrexone in Vo et al.’s (2018) study. In the case of youth absenteeism and difficulty contacting, family members were instrumental to enforcing reengagement strategies. Families also participated in home-based joint family sessions to support open communication about addiction and recovery.
The role of helpers in engaging family in treatment
Yule et al. (2017) provided conceptual insight on the utility of a child psychiatrist in the treatment of opioid dependence in adolescents. Child psychiatrists can help with prevention, early intervention, treatment, support, and family guidance in the care of youth with opioid addiction. Child psychiatrists should be familiar with the recommended evidence-based treatments for opioid use disorder in youth and refer them to appropriate levels of care. Among the preferred evidence-based therapies for substance use disorders in youths are family-based treatments. Child psychiatrists can work with families of opioid-dependent youth to effectively build motivation to engage in care through “contingency management.” The article references the Community Reinforcement and Family Training program as an example that teaches parents behavioral and motivational strategies to help youth cope with addiction.
Discussion
This systematic literature review significantly contributes to the current knowledge based on youth opioid use by examining the current literature in order to better understand how family is discussed within the context of youth opioid misuse. In reviewing 21 of 279 articles that met established inclusion criteria, two major themes were identified, including the impact that family factors have on youth opioid use and the role of family in youth’s treatment for opioid misuse. Several implications can be drawn from this review.
First, it is noted that family was not commonly discussed in the literature on adolescent opioid misuse, with only a handful of articles pertaining to the research question (21 of 279 total articles from the original search). When mentioned at all, most papers allocated a brief subsection to the topic, with the focus of their piece addressing a separate issue on opioid misuse. With literature to support the benefit of family involvement in the treatment of youth substance abuse, it is interesting to find that such related to opioid misuse specifically has not been extensively explored. Given the uniquely easy accessibility of prescription opioids, unlike other illicit substances such as cocaine and heroin, often times from one’s own household, there is a consequent need to understand the role of family for opioid use. This is evidenced in the current findings and from prior research (Guarino et al., 2009; Majeed, 2017; Moore et al., 2014).
Family was identified as among the most common sources for prescription opioids. This can be explained by the easy availability of prescription drugs within one’s household. This finding calls for greater monitoring and safekeeping of controlled substances by parents. This further calls for medical professionals to educate parents and children on proper use, addiction potential, proper storage, and proper disposal of opioid medications. The literature in this review highlights the importance of these considerations (Donaldson et al., 2015; Majeed, 2017).
Next, both risk and protective factors of family for adolescent opioid misuse were discussed. Risk factors included family stressors such as positive family substance use history, ambivalent or supportive attitudes toward substance use, internal conflict, fragmented family structure, homelessness, lower SES, lower parental education level, and lack of parental involvement in care. Protective factors included the opposite: lack of family substance misuse history, attitudes disapproving of substance use, healthy family relationships, dual-parent households, residential stability, higher household incomes, higher parental education status, and engaged parenting. While the literature highlighted potential familial risk and protective factors related to adolescent opioid misuse, more research is needed to fully understand these connections.
A few studies discussed the perspectives of youth in recovery and their thoughts on family involvement in their treatment. Generally speaking, familial support was well received and viewed positively; however, many youths added that the decision to seek treatment was ultimately an independent endeavor. This suggests that the incorporation of family in adolescent opioid misuse treatment is helpful. Family serves as a support system to hold youth accountable. Under professional guidance, family members can better understand how they can modify their own behaviors to facilitate adolescent opioid addiction recovery. The direct involvement of families in adolescent opioid treatment was mentioned in a number of studies. Family was incorporated into the treatment intervention in the form of self-help groups, support groups, educational programs, and the execution of home-based medication-assisted treatment. These group interventions, however, were individual focused. Relational family treatment specific to opioid misuse was not discussed at all and few articles mentioned family therapy, with no further elaboration. This raises concerns about the availability of family therapy as an option for adolescent opioid misuse. More work is needed to understand how specific systemic interventions, such as multisystemic therapy (Henggeler et al., 1986; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009) and multidimensional family therapy (Liddle, 1991, 2013), might work to mitigate youth opioid use. Research on other systemic models such as structural family therapy theory (Colapinto, 2015; Minuchin, 1974) and contextual family therapy theory (Boszormenyi-Nagy & Krasner, 1986; Flores-Ortiz & Bernal, 2014) should also be further explored.
While the findings from this systematic literature review contributes to the current knowledge base by synthesizing what we know about the role of family in youth opioid use, several limitations need to be delimited. Few articles (n = 21) met our search criteria and discussed the role of family in adolescent opioid misuse disorders. Future research expanding the search criteria to other databases is definitely warranted. Further, this review focused specifically on opioid use disorders (OUD) in adolescents, and it is possible that broader substance use literature would also contribute to understanding adolescent OUD since many adolescents who engage in opioid use are polysubstance users (e.g., Russell, Trudeau, & Leland, 2015).
Despite these limitations, this review affirms the strong influence of family environment on youth opioid misuse behavior and supports the notion that altering family-related risk factors could decrease adolescent opioid misuse. The findings also indicate that direct family involvement in adolescent opioid misuse treatment can be advantageous to recovery and improve outcomes. However, studies of relational treatment design (actual family therapy interventions) need to be conducted to corroborate this claim. Additionally, this literature review highlights several needs for future research. Studies of more robust design and quantitative strength should be conducted. The articles in this review are mostly case reports, statistical analyses, and interpretations of cross-sectional data. A single article described the results of randomized controlled trials on brief family interventions. Given that family is a common source for prescription opioids, that family factors can place youth at risk or guard youth against opioid misuse behavior, that youth generally perceive familial involvement in their recovery efforts to be beneficial, and that family-based therapies are best practice treatments for adolescent opioid misuse, family therapy needs to be further researched. Additionally, literature on gender differences and ethnic/racial differences was scant. Future research should address identified gaps.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
