Families of people who use drugs: health and social responses
Introduction
This miniguide is one of a larger set, which together comprise Health and social responses to drug problems: a European guide. It provides an overview of the most important aspects to consider when planning or delivering health and social responses for families of people who use drugs and reviews the availability and effectiveness of the responses. It also considers implications for policy and practice.
Last update: 6 July 2023.
Contents:
Overview
Key issues
The children and other family members of a person who uses drugs problematically may experience a range of health, social and economic harms. This miniguide focuses on both the families of adults who have drug-related problems and the families of children and young people in need of support as a result of drug-related behaviours. Family members can make an important contribution by supporting the relative who uses drugs and encouraging them to engage with treatment. However, family members may experience a range of problems related to their relative’s drug use, including worry and psychological distress, strains on family relations and financial burdens.
Children whose parents or primary carers use drugs problematically can be particularly vulnerable, but many children who live with a parent who uses drugs do not experience any harm. Building and supporting children’s resilience is therefore important, alongside identifying and addressing their specific problems.
Family members can also make a positive contribution by supporting the relative who uses drugs and encouraging them to engage with treatment.
Evidence and responses
- Dedicated family support services providing help and support to family members in their own right.
- Providing support for family members who take on parental responsibilities for the children of a drug-using relative.
- The provision of appropriate health care by medical practitioners in primary care, including evidence-based interventions, such as the 5-Step Method.
- Provision of training to teachers and other school staff on trauma-informed approaches to dealing with vulnerable children, ensuring a supportive school environment.
- Undertaking a proper assessment of family relationships at the point of entering drug treatment and providing support to family members in order to enhance their contribution to successful outcomes.
- Specialist interventions, such as intensive family-based therapy, behavioural couples-therapy, multidimensional family therapy and social network approaches.
- Developing responses to prevent harms, promote resilience and provide support to children affected by parental drug use at different stages of their development.
- Bereavement support.
European picture
Most information on the availability of drug-related interventions for families in Europe is specific to policies and interventions targeting or including the children of people who use drugs. The importance of supporting children affected by parental substance use is recognised in EU policy documents and in the drug strategies of most EU countries.
Different approaches are taken to ensuring that appropriate interventions are available to support and meet the needs of children across the different age ranges and in a variety of circumstances. Existing resources include the European Platform for Investing in Children (EPIC) and the EMCDDA Xchange prevention registry.
There is little information on the availability of programmes to support adult family members of people with drug problems in Europe. Peer-led national family support and advocacy organisations are available in some European countries, where bereavement support is often an important component of their work. These organisations may also be involved in campaigning for or promoting naloxone distribution programmes.
Key issues related to families of people who use drugs
The children and other family members of a person who uses drugs problematically may experience a range of health, social and economic harms. The focus of this miniguide includes both the families of adults with drug-use problems and the families of children and young people in need of support as a result of drug-related behaviours. Family members can make an important contribution by supporting the relative who uses drugs and encouraging them to engage with treatment. However, family members may themselves experience a range of problems, including:
- worry and psychological distress leading to physical and mental ill-health;
- strain on family relationships, with a potential loss of social life and an increased sense of isolation because of the stigma associated with having a relative who is using drugs;
- the financial burden of giving direct and indirect financial support to the relative using drugs, which may include providing care to their children;
- the potential impact on employment arising from stress or additional caring responsibilities;
- harm from intimate partner violence or the physical abuse of children;
- exposure to threats and violence associated with drug debts and the involvement of the drug-using relative in the illicit drug market.
The specific impact that a person’s drug use may have on members of their family will vary between individuals and depends on their own circumstances and their relationship to the person using drugs. In addition, although many people who use drugs manage their parental responsibilities well, some require support, and for some childcare responsibilities can be very challenging and this can have an impact on the family. For example, parents of people who use drugs problematically may be required to bring up their grandchildren on a temporary or permanent basis. Siblings may be affected by drug users’ chaotic behaviour. They may also feel neglected by their parents, whose attention is focused on their drug-using sister or brother. Life partners may have to take sole responsibility for all aspects of family life and, in addition to worrying about their drug-using partner, may feel guilt and anxiety about the impact on their children.
Sometimes, families may feel it necessary to disengage with the person using drugs, which can pose further problems and have a significant psychological impact. Whether or not families remain engaged, the damage to relationships can be profound.
Children whose parents or primary carers use drugs problematically can be particularly vulnerable, especially if they have a chaotic and unpredictable lifestyle. The experience of children of people who use drugs has been referred to as a ‘hidden harm’ – a term that refers to two key features of the experience: the children may suffer harm in a number of ways as a result of compromised parenting; and they are often not known to or supported by the relevant services.
The harms children may experience can vary at different ages and depending on the substances that their parents use and if, or the extent to which, their drug use impacts on their parenting abilities. They can be categorised in four main domains: health and well-being; education and cognitive ability; relationships and personal identity; and emotional and behavioural development. Table 1 highlights some of the harms or difficulties that may be experienced at different stages of childhood.
Table 1: Summary of domains of potential impact on children across their developmental stages, that have been found to be associated with parental substance use
|
Age in years |
Health and well-being |
Education and cognitive ability |
Relationships and personal identity |
Emotional and behavioural development |
|---|---|---|---|---|
|
0 to 4 |
Neonatal abstinence syndrome Poor hygiene and diet Missed immunisations and health and dental checks Safety risks due to inadequate supervision Physical violence |
Lack of stimulation due to parental preoccupation with drugs and own problems Irregular or non-attendance at pre-school |
Separation from one or both biological parents Problems with attachment to parents or carer May be expected to take on excessive responsibility |
Emotional insecurity due to unstable parental behaviour and absence Hyperactivity, inattention, impulsivity, aggression, depression and anxiety – all more common Continued fear of separation Inappropriate learned responses due to witnessing violence, theft and adult sexual behaviour |
|
5 to 14 |
School medicals missed Dental checks missed Poor support in puberty Early smoking, drinking and drug use more likely |
Poor school attendance, preparation and concentration due to unstable home situation, especially if looking after siblings Increased risk of school exclusion |
Restricted friendships May take on excessive responsibility for parents or siblings Poor self-image and low self-esteem |
More antisocial acts by boys; depression, anxiety and withdrawal among girls Emotional disturbance and conduct disorders; for example, bullying and sexual abuse are more common |
|
15+ |
Increased risk of problem substance use, pregnancy and sexually transmitted diseases |
Lack of educational attainment may affect long-term quality of life |
Lack of appropriate role models may impact on relationships and personal identity |
Greater risk of self-blame or guilt, increased risk of suicide Higher risk of offending and criminality |
Risks may be increased when:
- the child is exposed to multiple problems;
- the child lives with two parents who use drugs problematically;
- the problems are of a greater severity;
- there is significant disruption to the family.
However, there is evidence that children can grow up in many varied and difficult circumstances without developing significant problems and enjoy good outcomes. Building and supporting children’s resilience is important in this context, alongside identifying and addressing their problems.
In addition to providing support with day-to-day living, families can be a major source of motivation and financial help to enable a relative to change their drug-using behaviours, and, when necessary, to start and remain in drug treatment. Research shows that there may be benefits to involving families in treatment.
Evidence and responses to drug-related problems within families
Responses to drug-related problems, particularly those centring on treatment, typically focus attention on the individual with a substance use problem. Where adult family members are involved in some way, this tends to be in relation to the ethos that the family can have an important role in supporting engagement with drug treatment and reducing use. Multidimensional family therapy, for example, is a comprehensive family-based treatment for adolescents with drug use and behavioural problems. It has been found to be more effective in supporting retention in treatment and in reducing use than individual psychotherapy.
At the point of entering drug treatment, undertaking an assessment of family relationships can be key, including recognition of the contribution made by family members in supporting the person with a drug problem. This could typically include the provision of information and education about drug misuse, the identification of sources of stress, suggestions on handling relapses and the promotion of coping skills. Treatment services need to respect patient confidentiality, but protocols can be developed that allow family support where appropriate.
More recently, there has been growing awareness that adult family members of people who use drugs may benefit from services and interventions in their own right. For instance, peer support groups and specialist support services can be valuable in reducing social isolation. Other services include the provision of bereavement support and assistance for kinship carers, for example grandparents looking after the children of their drug-using child.
Medical practitioners working in primary care can also play an important role in recognising and addressing the health needs of individuals affected by a relative’s drug use. A range of programmes focus on addressing the support needs of adult family members and helping to develop coping strategies. An example here is the 5-Step Method, for which an evidence base is emerging. The 5-Step Method is a brief psychosocial intervention that focuses specifically on the family members of people who use drugs and supports them in their own right as people facing a challenging problem.
Some people will need more intensive and specialised support, provided through interventions such as intensive family-based therapy, behavioural couples therapy, multidimensional family therapy, community reinforcement and family training and social network approaches.
A recent narrative review (McGovern et al., 2021) investigating the adverse health and social outcomes resulting from the substance use of a close relative, found behavioural interventions likely to be effective in improving the social well-being of family members (reducing intimate partner violence, bolstering family stability and increasing relationship satisfaction) when delivered conjointly with the person using drugs. It also found that family members may benefit from an individual therapeutic intervention component. More research is needed to develop multi-component psychosocial interventions that fully address the complex and intricate harms which can be experienced by families affected by substance use. Overall, evidence suggests that psychosocial interventions can have positive effects on both the person with the substance use disorder and the affected others.
Responses addressing the needs of children affected by parental drug use tend to promote resilience and provide support at different stages of their development. Many of these programmes target young people with vulnerabilities more generally and are not specific to children affected by parental drug use.
Family programmes generally focus on improving parenting skills and parent-child interactions, and can have positive impacts on both parents and children, improving parent-child relationships and developmental outcomes. Such initiatives may be implemented across a wide range of developmental stages, although the content and focus will vary. Some programmes, such as Incredible Years, the Parent Management Training Oregon programme and the Triple P programme, have been adapted for use across different age groups.
School programmes, such as school-based support groups, and other projects like Teen Club, a community-based nursing intervention designed to reduce high-risk behaviours in girls with substance-using parents, focus primarily on supporting young people to improve their coping and resilience skills (see Schools and drugs: health and social responses and Communities and drugs: health and social responses).
Reviews of the evidence for the effectiveness of responses suggest that key features of effective programmes include:
- involving children as well as parents, providing opportunities for positive parent–child interactions;
- the inclusion of family skills training components;
- ensuring engagement through building trust, offering supportive peer-to-peer relationships and building addiction knowledge; and
- allowing sufficient time – preferably more than 10 weeks.
Outcomes close to the intervention, such as programme-related knowledge, coping skills, and family relations, were also found to yield better results than longer-term goals achieved over an extended period of time, such as developing self-worth and preventing substance use initiation. However, the evidence on longer-term outcomes is limited.
There is some evidence to suggest that psychological and social interventions for dependent and non-dependent substance-using parents can also have benefits for their children, even though the primary focus is on addressing the parent’s drug use. However, in cases of extreme child maltreatment or neglect, prevention programmes on their own are unlikely to be sufficient, and child protection system responses may be necessary in order to safeguard individual children.
Overview of the evidence on … interventions for drug-related problems within families
| Statement | Evidence | |
|---|---|---|
| Effect | Quality | |
| Psychosocial interventions can have positive effects (wellbeing and substance use outcomes) on both the person with substance use disorder and the affected other(s). | Beneficial | Moderate |
Evidence effect key:
Beneficial: Evidence of benefit in the intended direction. Unclear: It is not clear whether the intervention produces the intended benefit. Potential harm: Evidence of potential harm, or evidence that the intervention has the opposite effect to that intended (e.g. increasing rather than decreasing drug use).
Evidence quality key:
High: We can have a high level of confidence in the evidence available. Moderate: We have reasonable confidence in the evidence available. Low: We have limited confidence in the evidence available. Very low: The evidence available is currently insufficient and therefore considerable uncertainty exists as to whether the intervention will produce the intended outcome.
European picture: availability of drug-related interventions for families
Most information on the availability of interventions in Europe for families of people who use drugs relates to policies and interventions targeting or including the children of people who use drugs. Less data are available on interventions aimed at adult family members.
In 2013 the European Union adopted the Recommendation for Investing in Children, which recognised the importance of promoting children’s well-being, protecting the rights of the child, combating social exclusion and discrimination, and promoting social justice and protection for all children. The Recommendation advocates investing in children to break the cycle of disadvantage and has led to the establishment of the European Platform for Investing in Children (EPIC), which provides information on evidence-based policies and programmes that provide support to children and families facing a range of challenges and vulnerabilities. It includes a platform for sharing the best of policymaking for children and families and aims to foster cooperation and mutual learning in the field. The EMCDDA Xchange database also provides examples of positively evaluated prevention programmes that have been implemented within Europe.
The importance of supporting children affected by parental substance use is also recognised in the drug strategies of most EU countries; however, different approaches are taken at the national level. In Ireland, a series of government policies, with planned and monitored actions, have been developed across a number of ministries to address the challenges faced by children of parents who use drugs. Within these actions, evidence-based parenting programmes may be introduced. In the Netherlands, a series of evidence-based parenting programmes have been introduced, targeted at specific vulnerable communities and groups.
Family-based selective interventions are reported as being available in almost all countries (see Figure)
Figure. Availability of family-based interventions for children affected by parental substance use, 2019
The source data for this graphic is available in the source table on this page.
| Country | Provision level |
|---|---|
| Austria | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Belgium | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Bulgaria | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Croatia | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Cyprus | Rare provision: exists in just a few relevant locations |
| Czechia | Rare provision: exists in just a few relevant locations |
| Denmark | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Estonia | No information available |
| Finland | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| France | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Germany | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Greece | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Ireland | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Italy | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Latvia | Rare provision: exists in just a few relevant locations |
| Lithuania | Rare provision: exists in just a few relevant locations |
| Luxembourg | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Malta | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Netherlands | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Norway | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Poland | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Portugal | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
| Romania | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Slovakia | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Slovenia | Full provision: exists in nearly all relevant locations |
| Spain | Limited provision: exists in more than a few relevant locations (but not in a majority of them) |
| Sweden | Extensive provision: exists in a majority of relevant locations (but not in nearly all of them) |
While there is little information on the overall availability of programmes to support adult family members of people with drug problems in Europe, a number of schemes have been documented. In Ireland, for example, the former National Family Support Network, a peer-led organisation, provided backing for peer-support networks across the country and advocated for policy and practice improvements. In addition, the problem of drug debt and intimidation is recognised in the Irish National Drug Strategy and a Drug-Related Intimidation Programme established by the police in collaboration with the former National Family Support Network. Similar peer-led national family support and advocacy organisations are found in other European countries. Bereavement support is often an important component of the work of these organisations, and they may also be involved in campaigning for or promoting naloxone distribution programmes.
Implications for policy and practice
Basics
- Family members of people who use drugs may experience a wide range of harms and can require support services to help them address these. Appropriate responses can include primary health care provision to alleviate the anxiety and stress they experience, peer support, bereavement care and support for kin carers.
- Children affected by parental substance use are at increased risk of a range of harms, and programmes are needed to provide them with support and build resilience at different developmental stages. These include family-based parenting programmes and initiatives that directly support the children themselves.
- The needs of family members and their potential contribution to the effectiveness of drug treatment should be recognised in drug policy and practice guidelines.
Opportunities
- The involvement of adult family members of people with drug problems in policy and practice development, as well as in the provision of peer support, has the potential to improve the provision of service generally, as well as specifically for family members.
Gaps
- Information on the scale, extent and nature of the interventions available for family members is limited, and research and monitoring in this area needs to be improved.
Further resources
EMCDDA
- Xchange prevention registry.
- Best practice portal: evidence database.
- Responses to the needs of children of people who use drugs, 2022.
- Multidimensional family therapy for adolescent drug users: a systematic review, 2014.
- Pregnancy, childcare and the family: key issues for Europe’s response to drugs, Selected issue, 2012.
Other sources
- European Platform for Investing in Children (EPIC).
- McGovern, R., Smart, D., Alderson, H., Araújo-Soares, V., Brown, J., Buykx, P., Evans, V., Fleming, K., Hickman, M., Macleod, J., Meier, P. and Kaner, E. (2021), ‘Psychosocial interventions to improve psychological, social and physical wellbeing in family members affected by an adult relative's substance use: a systematic search and review of the evidence’, International Journal of Environmental Research and Public Health 18(4), p. 1793. doi:10.3390/ijerph18041793.
References
- Advisory Council on the Misuse of Drugs (ACMD) (2003), Hidden harm: responding to the needs of children of problem drug users, ACMD.
- Cleaver, H. Unell, I. and Aldgate J. (2011), Children’s needs – parenting capacity. Child abuse: parental mental illness, learning disability, substance misuse, and domestic violence, 2nd edition, The Stationery Office, London.
- McGovern, R., Gilvarry, E., Addison, M., Alderson, M., Carr, L., Geijer-Simpson, E., Hrisos, N., Lingam, R., Minos, D., Smart, D. and Kaner, E. (2018), Addressing the impact of non-dependent parental substance misuse upon children. A rapid review of the evidence of prevalence, impact and effective interventions, Public Health England, London
- Peleg-Oren, N. and Teichman, M. (2006), ‘Young children of parents with substance use disorders (SUD): a review of the literature and implications for social work practice’, Journal of Social Work Practice in the Addictions 6(1–2), pp. 49–61.
About this miniguide
This miniguide provides an overview of what to consider when planning or delivering health and social responses for families of people who use drugs, and reviews the available interventions and their effectiveness. It also considers implications for policy and practice. This miniguide is one of a larger set, which together comprise Health and social responses to drug problems: a European guide.
Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2022), Families of people who use drugs: health and social responses, https://www.emcdda.europa.eu/publications/mini-guides/families-health-a….
Identifiers
HTML: TD-04-22-269-EN-Q
ISBN: 978-92-9497-840-0
DOI: 10.2810/86561