We have a serious public health problem called “opiate addiction.” It affects all age groups, and in the last 2 decides it has spread across the country. It used to occur only among the poor and minorities. Now it impacts everyone, even family members of those running for presidential office.
We have a serious public health problem called “opiate addiction.” It affects all age groups, and in the last 2 decades it has spread across the country. It used to occur only among the poor and minorities. Now it impacts everyone, even family members of those running for presidential office.
The medical community has contributed to the problem by using opiates for treatment of pain. Opiate addictions have a high death rate, particularly among those who use street drugs. Our government tries to manage this by limiting pain prescriptions. Police and firemen do their best by using Narcan or similar drugs as an antidote against overdose.
Those who are severely addicted require expert management, but I believe we may be able to identify those not severely ill by diagnosing those who are predisposed. This essay is about the benefits of and the time needed to take an adequate personal and family history before patients develop opiate addictions.
What would it take to discover risk factors that predispose patients to opiate addiction? My premise is the need to spend more time taking comprehensive family histories. Perhaps the “real patient” might be what a few thinkers refer to as “the 3-generation family system.”
Thomas H. Lee, MD, MSc, of Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, in his 2014 article “Time after time-health policy implications of a three-generation case study,” wrote about 3 generations of a single family cared for by the same primary physician. The physician recognized that similar issues kept arising with discouraging predictability.
According to Lee: “This three-generation case study shows the intertwined effects of poverty, depression, alcoholism, drug addiction, unemployment, domestic violence, and occasionally incarceration on individual family members and the family as a whole. Each family member was born into a chaotic social context, social [and perhaps] genetic factors combined to lead to a downward personal spiral.”
Unlike the victims with backgrounds cited by Lee, many victims now come from middle- and upper-class families, and have been given legitimate painkiller prescriptions. But even in upscale families, addictions and other dysfunctions often pass from 1 generation to the next. Lee concludes that if pediatricians intervene in the first or second generation, we can favorably affect health, discovering meaningful signs of addiction in earlier generations that might have been overlooked. He felt it’s our best hope for ensuring that 1 or 2 generations from now, the story line of patients’ families might be a different one.
In short, if you take a multigenerational perspective, you can demonstrate risk factors for family dysfunction. May I suggest that we place ourselves at significant disadvantage if we see our real patient as only the child or the adolescent? I believe it is more useful to consider that the real patient could be the multigenerational family system.
NEXT: The power of listening
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.
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.