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NETWORK A national newsletter on substance misuse management in primary care

Chris Ford is Dr Fixit to a GP who is supporting the mother of someone who is using crack. Ed.

Dr Fixit on addiction: a family disease

Dear Dr Fixit,

I wonder if I could ask for your help with a patient of mine? Susan McDonald is 46 years old and has recently become a frequent attendee at the surgery, usually with low grade stress and chronic chest problems. She smokes between 20 and 30 cigarettes per day and says she is unable to stop because she feels it helps her with her stress, which is mainly to do with her son, Michael, aged 22 years who lives at home. Until recently he was paying his way but lost his job about 3 months ago due to absenteeism. Since then he sits at home and spends most of his time smoking crack. He keeps saying he will get another job and hasn’t started to claim benefits. Susan works in a supermarket and doesn’t earn well but she tells me that if she doesn’t pay for his drugs, Michael goes out to steal to pay for his habit and she is terrified he will end up in prison.

Susan tells me that she has encouraged Michael to get help; twice she has even taken him to a local drug service but he hasn’t engaged. I know the boy’s father was alcohol dependent and had left the family when the boys were young. Susan blames herself and feels Michael’s problems are a result of his childhood. She is torn as to what to do, especially in terms of money, but she knows that ‘enabling’ him to use crack is also not the answer. Susan keeps coming back and I feel at a loss as to how to help her and whether I can get Michael into treatment – can you help?

Firstly I must congratulate you on your care of Susan so far. You obviously have a good relationship with her and she is getting invaluable support from you. As I am sure you are aware, addiction of all sorts is a family disease. When one or more members of a family are using substances or being troubled by another addiction, the whole family is affected. GPs are uniquely placed to manage individual addictions of family members, but as is common, Michael doesn’t want our help at the moment and we can do no more than continue to offer to support him. But we can support the family, as you are doing in Susan’s case. As Adfam’s Manifesto for Families states, families need support in their own right1


care we are ideally placed to support the whole family as it is common that most family members are registered with the same practice

“ In primary ”

The Drug Policy Commission suggest that at least 1.5 million adults are affected by someone else’s drug use2

while Velleman and Templeton3 report there could be up

to 8 million affected by someone else’s drug or alcohol use. Addiction in the family can have serious negative consequences on the family including social, financial, mental and physical health problems. The family becomes dysfunctional and can stop being a working unit and move towards chaos or crisis.

Degrees of co-dependency, which are unhealthy patterns of relating between the problem substance user and their family member/s, and a lack of intimacy in relationships can develop. Co -dependents may develop compulsions of their own. Family members such as Susan develop compulsive behaviour,

1 Adfam’s manifesto for families 5 key challenges for supporting families affected by drugs and alcohol use Adfam 2010

2 UK Drug Policy Commission (2009) Adult family mem- bers and carers of dependent drug users: prevalence, social cost, resource savings and treatment responses drug_users_research_report_final.pdf

3 Velleman R & Templeton L (2007) Substance misuse by children and young people: the role of the family and implications for intervention and prevention. Current Paediatrics 17 (1); 25-30


perhaps smoking in her case, in order to cope and survive in a family experiencing such pain. Families can also set up a pattern of denial, refusing to accept that an alcohol or drug problem is developing and / or to acknowledge the extent of that problem. In trying to help, family members, just as Susan is doing, try to ‘support’ but actually ‘enable’ substance use, making it easier for the substance user to continue with their disease.

Many of us may choose to think we are helping by providing money to a loved one for drugs but by doing this we are enabling and the user can then avoid the consequences of their actions. Michael can continue his drug use, secure in the knowledge that Susan will always be there to rescue him from his mistakes. Enabling is not helping: it is doing something for someone that they could, and should be doing themselves. I think the key in this situation is to support Susan to care for herself. Support her to decline further hand-outs to Michael and to consider that he leaves the home until he is in control of his drug use. Susan will need your on- going encouragement to do this and may need additional help.

Treatment for people who have drug problems has improved in recent years and services have begun to recognise the importance of family, particularly in policy4 but often people who use are still seen as a ‘drug user’ in isolation and there is still a lack of interventions and support for families. We are very fortunate to have an excellent family therapy service nearby but this is not available in all areas. There are also groups such as the 12-step Families Anonymous and other family self-help groups, which Susan could use. Find out what is available to your area. We know where family support is used, families experience significant improvements in their wellbeing and of the person who is using.

Some family members don’t want to use these services, often because they don’t recognise their own needs and because of their own feelings of shame and social stigma but encourage Susan to do so and explain that most of the people using the groups will have similar feelings. If she still declines, continue to see her and allow her to work through these feelings. In primary care we are ideally placed to support the whole family as it is common

4 HM Government (2008) Drugs: protecting families and communities The 2008 Drug Strategy

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