The dynamic interaction between family and substance dependence: an international perspective
Family factors relating to substance dependence through the life cycle
Substance dependence and family breakdown
Health and psychosocial factors associated with substance abuse in the family
Substance dependence and the role of families across cultures and geographic regions
South and South-East Asia
Author: L-N. HSU
Pages: 3 to 18
Creation Date: 1994/01/01
The purpose of this article is to highlight the complex interrelationship between the family and psychoactive substance dependence and the important role of the family in the prevention, treatment, rehabilitation and social reintegration of substance- dependent persons. In addition, illustrations of the influence of the family on substance dependence and the effect of substance-dependent members on the family are analysed on the basis of data from countries in Africa, the Americas, Asia and Europe.
The family has a special role in relation to the initiation of the use of psychoactive substances (also referred to as substances or drugs) as well as in the prevention of substance abuse or in helping persons recovering from substance dependence to avoid relapsing into the use of inappropriate substances. Conversely, substance dependence of one or more family members can influence the survival of a family.
Some families in certain parts of the world are dependent on drug production, trafficking and dealing for their economic survival. The relationship between psychoactive substances and families is a cultural, social and economic development issue. To understand the dynamic interrelationship between families and substance dependence, it is necessary, beyond focusing on individuals who are physically dependent on substances, to deal with the complete chain of drug production, trafficking, dealing and abuse.
Substances or drugs in this article include illicit and licit drugs, alcohol or other substances such as glue or organic solvents.
A healthy family nurtures the coping skills, respects and supports the development of individual members, and creates an environment w ere an individual acquires the ability to deal with diverse situations through the different stages of life.
In many cultures, the traditional family structure provides the moral and behavioural standards for an individual. With rapid socioeconomic changes, the technological revolution, urbanization and international mobility of population, the traditional checks and balances on an individual's behaviour have given way to external influences. In some families, technological innovations such as television or video games provide a substitute for parental time with children.
The increasing generation gap in communication and other difficulties in personal relationships among family members often precipitate substance dependence within a family.
The family is the first environment where an individual is influenced by drug use. Parental smoking, drinking or use of other drugs can affect the formation and development of their children [ 1] . In addition, most habits and behaviours, including patterns of drug use, are formed through the influence of families.
Adolescence is a malleable stage of life where peer pressures may override the better judgement or family upbringing. Open communication within the family between parents and children is important in prevention and early detection of problematic use of illicit drugs. Further- more, families can provide support and positive life skills to help adolescents deal with external pressures and build self-confidence and self-respect.
Some adults, when encountering difficulties in interpersonal relationships, especially within the family, a life crisis, difficulties on the job or the pressure of economic instability, may resort to substance use and be- come dependent on drugs.
Ageing is often accompanied by physical infirmity and the increased likelihood of receiving prescription drugs from physicians. The loss of family members, friends and regular gainful employment may aggravate a drug-related problem among the elderly.
Reversals in family substance use patterns do exist, however. Where children experience particularly traumatizing events, such as scenes of domestic violence or repeated intoxication of parents, an aversion to sub- stance use may occur [ 2] .
Families can be damaged from the immediate effects of drug use by family members, such as violence associated with intoxication, or longer- term effects, such as economic problems, discord and breakdown in communication resulting from dependence and impaired health.
Infants born to substance-abusing parents may prove to be difficult to care for as a result of their health problems. Child neglect is particularly common among families with a drug abuse problem. The parent- child interaction is, as a consequence of substance, abuse by parents, a particularly vulnerable one.
Children who can no longer take physical and psychological abuse from parents who are problem users of psychoactive substances escape to the streets only to face another violent world [ 3] . Some children under extremely difficult circumstances resort to drugs while living on the streets.
Many children who remain in families with drug use problems have to take on adult roles of caring and protecting younger siblings or other vulnerable family members [ 3] . As family resources are diverted to drug use, the need for children to undertake food production and income- generating activities keeps many of them away from school.
Estimates made in cities of Yemen and Somalia show that consumers may spend up to one quarter of their daily earnings on the purchase of khat [ 4] . In some households the amount of money spent on khat may equal or exceed that spent on food [ 5] .
Adolescents from substance -abusing families tend to have problems related to anti-social personalities, such as aggressive behaviour, difficulties of adjustment and achievement in school, and involvement in delinquent behaviour, including early substance use.
Some children from dysfunctional families with substance-dependent members seek early marriages hoping for anew home to substitute for the broken ones they came from. Unfortunately, unplanned pregnancy and child-bearing combined with inadequate education and marketable skills as a result of dropping out of school often destabilize these young families, and some couples end in divorce or separation [ 3] .
Substance use affects the equilibrium in the household relationship. The disequilibrium includes the inability of substance users to function in their expected roles within a household, to participate in family activities, to perform at work and to keep up with personal hygiene and appearance. The substance dependent spouses may also contribute to aggressive interactions within the family. A list of the health and psychological factors associated with substance abuse in the family is summarized below.
Difficulty in pregnancy and foetal development
Vertical transmission of human immunodeficiency virus (HIV) and other infectious diseases
Premature birth and low birth weight
Coping, adaptive problems
Sexual relationship risks
Mental retardation and physical malformations
Substance abuse risks
|Addiction- withdrawal syndrome|
Health, nutritional neglect
Occupational, employment and financial difficulties
Illness, accident risks
Cost of substance consumption and medical care
Parent- child bonding
Chaotic home, family breakdown
Parent- child separation
Substance abuse risks
Data from the United States of America reveal that nearly 18 per cent of the workforce use marijuana [ 6] . In Panama, 21 per cent of employees in various sectors have tested positive for cocaine use [ 7] .
Substance abuse has been correlated with reduced economic productivity due to absenteeism, impaired performance, physical illness or accidents and injuries. Those workers with substance dependency problems are at agreater risk of losing employment which might be the only source of family income.
Once unemployed, the difficulty of securing new employment for a substance-dependent person is immense, especially when employers screen candidates for problems related to substance abuse. The substance abusers, along with their families, thus may enter into adownward spiral of loss of financial resources, inability to secure gainful employment, social marginalization and selling off family properties. The result is often a vicious circle which deepens the possibility of acute or chronic substance abuse within the family.
Adolescents and adults today are increasingly exposed to life styles, occupations and activities related to substance abuse. This exposure is enhanced with the increasing availability of substances and the relaxing of traditional forms of community and family bonds. Some of the inter- relationships between family dynamics and substance dependence are manifested across cultural, religious and geographic boundaries.
A project funded by the United Nations International Drug Control Programme and conducted by the author assessed substance dependence in countries from 1991 to 1993, and revealed the dynamic interrelation- ship between the family and substance dependence. To illustrate the interrelationship, the data gathered by country and region are analysed below.
A study in Egypt has found that family disharmony is significant in the families of drug-dependent persons. Deviation of one of the parents from a healthy pattern of social development negatively affects the other partner's health and development, as perceived by children, and 58 per cent of the substance- dependent persons need family support [ 8] .
In Egypt, a study of imprisoned substance-dependent persons showed that relationships with parents, the home atmosphere and the history of drug addiction among family members were the main factors leading to drug dependence [ 9] .
Other surveys in Egypt identified the role of parents and friends in starting drug abuse among students. In a study of 503 students who used psychotropic substances, it was found that in 9 per cent of cases their mothers initially provided the abused drug. These mothers did not realize the possible danger in their behaviour. Another study of 292 students found that among the urban users, 31 per cent obtained the drug from colleagues, 14 per cent from their fathers, 13 per cent from their friends and 11 per cent from their mothers. Among rural users, 24 per cent obtained their drug initially from colleagues, 16 per cent from friends, 13 per cent from their fathers and 6 per cent from their mothers [ 10] .
Excessive use of khat in Kenya was found to be associated with marked socioeconomic problems, such as family instability, economic hardship, prolonged absence of fathers from their families, malnutrition and poor educational performance leading to delinquency in some children. One study in Nairobi's Mathare Valley showed that separation and divorce was found to be common among alcohol abusers who also smoked cannabis and engaged in the sex trade [ 11] .
In Kenya, children in especially difficult circumstances, that is, street children, provided an example of what happens to children when parents, especially mothers, abuse either alcohol or drugs. Excessive use of alcohol and drugs were found in the communities where the street children come from. It is undeniable that substance use has a direct influence in driving children onto the streets. These children, especially girls, were found to be sexually molested by their mothers' clients. Many street girls were found to have sexually transmitted diseases. Some of them, only 10 or 11 years of age, already had babies [12, 13].
Among the Kenyan mothers of street children, a picture emerged showing some commonalities of experience among these women. Most of the women reported abandonment by their fathers, so that they had to be raised by their single mothers. In most cases they dropped out of school after having become pregnant, and most reported having their first babies rather early (between 13 and 15 years of age). The families were large, which is consistent with family size in Kenya, but they were overwhelmingly large for a deserted mother. Some mothers continued having babies with different boyfriends after the initial abandonment.
Many Kenyan women moved to towns to try to make a living. Some of them leave their children with relatives in the villages, and engage in selling home brews and in the sex trade. They may send money home to support their children, but the amount of money sent depends on the level of their alcohol or drug abuse.
Most of the women are likely to have children who have been sexually assaulted. If they live with their children, the children are often left at the mercy of neighbours or relatives. Those who marry do so at very early age and tend to have partners who also abuse substances [ 14]
Studies carried out in Nigeria showed that the factors contributing to substance abuse by women relate to the unequal social status of men and women as reflected in the social, political, economic and cultural aspects of women's lives in Nigeria [ 15] . In the formal sector of the Nigerian economy, women do not have equal job opportunities, and there is discrimination at the workplace which often results in slow career progress. In the informal economic sector, women face exploitation by husbands and male colleagues.
The institution of marriage is another source of stress for many Nigerian women. Stress is related, for instance, to wife-battering, the outside wife syndrome (a modified form of polygamy), widowhood, barrenness, lack of reproductive freedom (in most cases men dictate the number and even the preferred sex of the children they want from their wives, which may often result in repeated pregnancies) and arranged marriage. A cultural practice such as female circumcision, which has been related to psychosocial problems [ 16] , is still experienced by some females in Nigeria [ 17] .
In Zimbabwe, women of child-bearing age traditionally are not allowed to drink in public. However, married women are gradually allowed to drink with their husbands in social settings and at home. As the traditional extended family support system disappears, more families become urbanized and nuclear, with no one to turn to in time of difficulty. There is an increasing number of youth, both females and males, using alcohol, cannabis and volatile solvent inhalations [ 18] .
A study of user prevalence in Bolivia noted different types of cocaine paste users. Cocaine paste is the product of the first stage of the chemical process in the production of cocaine. The paste results from the addition of sulphuric acid, kerosene and gasoline to the macerated coca leaves. This paste contains from 40 to 90 per cent of cocaine sulphate, other coca-derived alkaloids and a variety of residual chemicals. The paste may be smoked alone or with tobacco.
There are three types of cocaine paste users in Bolivia: street children; adolescents from families of the middle and upper socioeconomic classes; and casual workers in the coca production zone.
Adolescents and young middle -class adult users between the ages of 17 and 35 tend to start abusing cocaine for recreation, often mixing alcohol with cocaine hydrochloride. Some of them feel the need for something stronger, and go on to cocaine-based paste.
There are many pregnancies and abortions among the females in this group. Secondary effects of substance abuse among this group are malnutrition, growth retardation, vitamin deficiency, tooth decay, bronchitis, various infections and sequelae to wrongly treated trauma.
The evolution of problems and deterioration of physical health and social functioning among this group are usually slower than among street children, and are often delayed until these young people break their family ties [ 19] .
The drugs most commonly abused by youth in Brazil are solvents, cannabis and anticholinergics ("Artane" or "Bentil" and trihexafenidil) [ 20] . While solvent-sniffing in a low-income student population is mostly a solitary habit, for street children it is typically a group phenomenon [ 21] . The reasons for the abuse also differ. Students typically give evasive answers, such as curiosity and "don't know', while street children admit using drugs to get a high or a "dreamlike state". Deficiencies in family relationships and school attendance are related to increased drug use in these young populations [ 22] .
Data collected from health services at So Paulo between 1984 and 1989 indicated an increase in HIV seroprevalence among injecting drug users (IDUs) from 74 to 85.5 per cent, while among sexual partners of IDUs it increased from 33 to 82.4 per cent. Among HIV-positive heterosexual women, 57.8 per cent were sexual partners of IDUs [ 23] .
Studies carried out in El Salvador showed that the psychological effects of war led many to practice self -medication with amphetamines and tranquillizers. Widespread poverty and the relatively high cost of medical services also aggravated problems caused by self - medication. The effects of war, high levels of unemployment and underemployment and the large number of single women as heads of households are factors that create unstable families. Children must often move out or look for work, cutting short their education and being forced to face the constant dangers of the streets. They are extremely vulnerable to substance abuse, primarily in the form of inhalants, alcohol or cigarettes. [ 24] , [ 25]
The Mexico National Household Survey on Addictions in 1989 reported that 17 per cent of urban females between the ages of 12 and 65 who have been pregnant at least once drank alcohol during their last pregnancy. In 8 per cent of the total sample, pregnancy did not modify their drinking habits. Alcohol abuse was also observed during the period of breast-feeding. Of the females who reported having breast-fed their last child, 11 per cent consumed alcohol during the lactation period.
Miscarriage and congenital malformations are related to high levels of alcohol consumption during pregnancy [ 26] .
Children born to substance-abusing parents in the United States of America have higher rates of morbidity, mortality, accidents and injuries when compared to children whose parents do not abuse substances [ 27] .
In India, heroin or opium abusers have higher daily drug expenditures than alcohol abusers. The female drug user is usually associated with a drug-using spouse, sibling or sexual partner, or with a spouse dealing in drugs, and often has an affluent family background or a certain financial independence, if employed.
A survey carried out in India showed that the most common factors associated with maintenance and support of the drug habit were monthly earnings, borrowing money from family and friends, or pocket money provided by parents.
In the case of married users, misappropriation or manipulation of household expenses was reported. As the severity of drug abuse increased, respondents resorted to desperate measures to support their habit, such as selling family jewellery and ornaments, stealing or begging for money, and some of the drug abusers were forced into sexual subjugation for drugs or involvement in drug dealing.
Coping strategies used by family members included expulsion of drug abusers from the household, locking them up, discontinuing their pocket money, hiding the drugs or putting continued family pressure on the abuser to seek treatment.
Those drug abusers who discontinued drug use cited major changes in their lives as the decisive factor in their discontinuation. Those factors included marriage, the birth of a child, a prison conviction or discontinuation of drug use by the spouse [ 28] .
In the Philippines, 70 per cent of the patients of both sexes in drug rehabilitation centres are single. The modal age among males is 23, among females, 18. This indicates that drug abuse is a problem among adolescent females, who are often found to use alcohol and other drugs simultaneously [ 29] .
A study of imprisoned female drug offenders in Sri Lanka revealed that 16 were convicted of using dangerous drugs. Twelve of the 16 imprisoned users had a history of family breakup due to divorce, death or remarriage [ 30] .
A study carried out in 1990 by the Sri Lanka National Dangerous Drug Control Board (NDDCB) showed that 17 per cent of female heroin users, compared with only 1 per cent of male users, were introduced to drugs by family members [ 31] . An NDDCB study of 1993 found 13 per cent of women started drug use with their spouses [ 32] . Three per cent of women in a poor urban neighbourhood of Colombo smoke cannabis. These women are the wives of men who themselves are cannabis smokers [ 33] .
Koknar is the head and upper part of the stalk of the ripe and dried poppy, pounded in a mortar. The chemical components are alkaloids of the opium group (morphine, codeine and traces of apaverine, narcotine, heroin, dionine). The latter four alkaloids can be produced by boiling the poppy straw in vinegar and anhydride. In addition to the active narcotic components, the compound contains hydrocarbon, protein, resin, oil and pigments.
Traditionally, koknar was served during national or religious holidays or at funerals. Large quantities of koknar would be bought, prepared and served to all present. Everyone would take a few sips. There also exists a custom of giving everyone some dry koknar to take home, which reflects the wealth of the family that held the party. The "Bunghi" (koknar-dependent persons who were known to everyone in the village) would sit apart, and during the party they would take as much as they considered necessary.
While koknar is normally taken as a drink, it may also be chewed or used in the form of a thin gruel after boiling. Persons who are dependent on other types of drugs sometimes use boiled koknar intravenously when other drugs are not available.
In most cases, koknar is used as a universal home remedy for a variety of conditions such as loss of appetite, pain in the joints and prolonged coughs. Koknar provides temporary relief and enhances the capacity to work, and these beneficial results lead to repeated use of the substance. Probably 10 to 20 per cent of koknar use is due to curiosity, because koknar users praise it and describe its miraculous effects in alleviating various diseases and conditions. This perpetuates the tradition of using koknar, resulting in the development of dependence on koknar and other substances [ 34] .
Opium smoking has been a traditional habit among the population of Turkmenistan. "Passive opium smoking" sometimes led to withdrawal symptoms in the wife and children of an opium smoker in his absence, symptoms which ceased on his return to the house and renewed opium smoking [ 35] .
A survey conducted among substance abusers in the Czech Republic and Slovakia identified factors and events contributing to their substance - related problems and factors helpful in overcoming their substance-related problems.
Most commonly, the events and factors that contributed to substance-related problems were linked with close relationships and the f amity. The most often cited problems were difficulties in interpersonal relationship with' lovers, followed by nonspecific family problems relating to divorce, parents, children, death and the extended family.
Secondary factors identified as contributors to substance abuse are related to friends, occupation and other socioeconomic issues. The most frequently cited factors that were helpful in overcoming substance-related problems were the family and close relationships [ 36] .
Opiate dependence is the most prevalent type of dependence in Poland among both women and men. Injecting drug use is common in both sexes. However, prevalence of sedative abuse tends to be high among females. The sedatives are readily prescribed by physicians.
Since 1988, HIV seropositivity has been noted among IDUs. Irrespective of the actual proportion of IDUs among HIV seropositives, the public perception links HIV to drug abuse, and many are driven away from the family and society. At the time of the study carried out in 1991, drug rehabilitation centres were the only places where HIV carriers could find shelter [ 37] .
Casabona and others have reported that in Spain, 87 per cent of HIV - positive children were born to HIV infected mothers who used injecting drugs. Approximately 48 per cent of infants born to heroin-using parents, were living with substitute parents and by preschool age, 91 per cent of these infants were living with someone other than their own parents [ 38] .
Family relationships can influence personal choice in substance abuse. The family is the first environment where an individual learns various habits. Supportive families with open communications between parents and children may provide models for positive life skills which prevent substance abuse.
However, substance use is engrained in certain cultures and societies on the basis of ancient ceremonial rituals or as a social lubricant within the constraints of cultural norms. The contemporary breakdown of traditional systems, the rapid change in social and economic conditions, the increased availability of drugs and the mobility of the population have made the abuse of psychoactive substances more prevalent.
Families with a substance abuser suffer from a breakdown in communications, the deterioration of economic and household food security and the threat of domestic violence and accidents.
Despite the diversity of geographic locations and cultural differences, problems related to substance abuse are similar for families throughout the world.
As the many causes and consequences of dependence on psychoactive substances are related to family dynamics, prevention and treatment efforts should target family relationships in their biological, psychological, social, cultural and economic dimensions.
To reduce substance demand, it is vital for policy makers, communities, providers of health and social services and employers in private enterprise to form an alliance with families and to deal with the whole spectrum of drug production, trafficking, dealing and abuse by supporting families, by reducing gender disparities in society, and by mobilizing communities for prevention, treatment, rehabilitation, relapse prevention and social reintegration.
Resources and social support networks are necessary for families effectively to adapt to and cope with traumatic experiences of hardships, so as to prevent a family member falling victim to substance dependence.
Drug abuse and its associated ills are social and economic development issues, and must be tackled from the social and economic development perspective. Drug abuse and its related harmful consequences to families and communities occur among the populations of both drug-producing and non-producer countries. For effective drug demand reduction, an integrated intervention strategy dealing with both the supply and the demand side is necessary.
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