One of my mentors stressed that obtaining a family history is critical in treating people with addiction. In addition to possible genetic components, trauma is often a huge part of substance use and addiction, and much trauma begins in the family.
Another mentor, Howard Shaffer, MD, pointed out that there are common causes for seemingly different disorders. He wrote there is a common etiology of behavioral and substance-related addictions. In a 3-generation family, diagnoses such as depression, alcoholism, domestic violence, and abuse are often repeated from 1 generation to the next unless there is appropriate intervention.
If we want to understand why someone is predisposed to opiate addiction, it is helpful to know whom he or she takes after. We need to be professionally curious in our search for “family secrets,” including family members who struggle with alcoholism. If we discover that an addict had a parent or grandparent who had been abused or was an alcoholic, then it makes sense where the addict came from. Even if young people haven’t demonstrated a tendency toward opiate addiction, we should consider checking for problems of addiction in parents, grandparents, aunts, or uncles. There could be real benefit. It might help diminish the likelihood, one day, of adolescents or adults developing serious opiate addiction.
Listening and outcomes
What are the implications of this approach for our patients and their families? Hopefully we can discover younger family members who might be predisposed to family addiction and prevent opiate addiction at a later age. Another might be that, if we took time in prenatal visits, we might discover a history of family dysfunction that might impact children in the absence of constructive intervention.
What would it take to incorporate the 3-generation family system mindset into our pediatric practices? It would require asking ourselves, when meeting with parents to take the time for an adequate history, “Who is the real patient?” It also would require the willingness of parents to trust us.
Pediatricians have a choice. We can spend 15 minutes in a well-child visit with a patient who 1 day might develop opiate addiction, or we can invite young patients or their parents to return for an hour-long visit to see if we can discover family dysfunction that hadn’t previously been acknowledged. Again, who is the “real patient”? If we invite parents for an hour-long history as needed, we might make available appropriate counseling or alcoholism services. In fact, we have successfully pilot-tested such hour-long visits and their outcomes in my practice and our teaching program.
Insurers often reimburse pediatricians for providing time for such counseling. Michael Yogman, MD, FAAP, chair, Children’s Mental Health Task Force, Massachusetts Chapter, American Academy of Pediatrics, suggested that the best ICD code is F43.20 or F43.29 for adjustment disorder, or F94.8 for childhood disorders of social functioning. I hope the availability of such codes will encourage pediatricians to conduct the sessions I am proposing.
Wouldn’t it be something if we could use the scourge of opiate addiction to help us master a new skill if we invest the time? What is the most important idea in this essay focused on diagnosing opiate addiction at the earliest time? It is that there are 2 kinds of pediatricians. The one I identify with asks these questions in the family interview. The second kind is not yet ready to do so.
Dr King is a board-certified pediatrician, founder and director of the Children’s Emotional Health Link, and honorary member of the medical staff at Newton-Wellesley Hospital, Newton Lower Falls, Massachusetts.