Most popular posts of 2015 – #9 – Opiate-addicted Parents in Methadone Treatment: Long-term Recovery, Health and Family Relationships

I recently came across this 10 year follow-up of parents in methadone treatment and their children from 2011.

Here’s a review of their outcomes.

First, here’s their definition of recovery:

Recovery status was based on recent drug use, history of drug problems, and history of incarceration. Long-term recovery was defined as no recent drug use (self-report or urinalysis [UA]) and no drug problems or incarcerations for at least 10 years (LHC data). Moderate recovery was defined as no recent drug use and no history of drug problems or incarcerations in the past 5 years.

Here are the outcomes for their definition of recovery:

Of the 144 parents in the original study, 34 (24%) had died. Nineteen (13.2%) appeared to meet our criteria for recovery for at least 10 years. Another 14 (9.7%) met these criteria for 5 to 10 years. Ten (7%) could not be characterized on recovery because they could not be located or contacted. The remaining 46% of the original sample did not meet our criteria for recovery because they experienced continuous or intermittent drug use or incarceration.

If that definition of recovery is a little too muddy for you, here’s some of the data on drug use.

Of the parents who reported no drug problems in the past 10 years (n = 37), over a third (n = 16) self-reported using illegal drugs in the previous 30 days and did not consider this a problem. Forty-nine percent of parents interviewed reported some illegal drug use in the past 30 days

Did they stay in treatment over the 10 years?

Forty-one percent of the parents reported participating in some form of drug treatment every year, and 32% were in methadone treatment every year. Methadone treatment was intermittent for 43% of the sample.

What about criminal justice involvement?

Arrests and convictions were common (90% had some WA state criminal record in the past 10 years), and periods of incarceration over the last 10 years were reported by 54% of parents interviewed, compared to a lifetime prevalence rate of arrests in the United States of 3%.

Mortality?

Mortality among the addicted parents was high. Thirty-two (25%) of the 130 families experienced the death of the addicted parent, and in 2 cases both parents had died before the long-term follow-up interview (34 deaths total). For comparison, mortality in the general population of Washington State was 7.5% ²⁵in 2005 and 14.8% among heroin users in the Seattle metropolitan area.

Mental health?

Mental health was also compromised. Forty-eight percent met DSM III criteria for a major depressive disorder in the last 10 years. . . .  Twenty-one percent felt their mental health was not good every day (mean days = 12.47, SD = 11.53). This is a high compared to the general population in Washington (mean days of mentally unhealthy days = 3.3).

Employment?

Unemployment was common. At the time of the interview, 52% reported no employment in the past year (55% of women and 40% of men, NS), compared to the unemployment rate for Washington State, which was 5.5% in 2005.²⁹ Forty-one respondents (35 women, 6 men, NS) reported no time in the past 10 years in which they were employed more than 30 hrs/week for at least 9 months.

Stable housing?

Thirty-six percent reported at least one year in which they did not have a regular place to live. There were no differences by gender. Four parents reported being homeless during the entire 10-year period and were homeless at the time of the long-term follow-up interview. Parents in long-term recovery were less likely to report homelessness (5.3%) compared to those in shorter term recovery (35.7%) or those still using (44.8%, X² = 10.0, p = .007).

The experience of the kids?

Overall, however, this study fills an important gap in the literature by providing a window into the lives of parents struggling with drug addiction. Our study shows similar negative long-term outcomes for opiate-addicted parents in methadone treatment as other studies have found for more general populations of drug addicts and methadone clients.

. . .

Very few of the children were doing well at the long-term follow-up. As previously reported,⁹ only 24% of the children met criteria for functional resilience by being constructively engaged in school or work, not having abused drugs, and avoiding criminal charges in the last 5 years.

Keep in mind that this is the treatment frequently referred to as the “most effective” treatment. You should ask, “Compared to what? And, as for what outcome measure?”

Further,  recent media coverage of the issue paints anyone who raises these kinds of questions as out-dated, moralistic, simple-minded and one-wayers. Some coverage comes close to implying that anyone who questions ORT is enabling overdose deaths.

I’m not saying a reasonable person could not reach a different position than I have. But, I have a hard time understanding how a reasonable person could be so certain that they try to dismiss, censor and discredit others by questioning their ethics, intelligence and motives.

Opiate-addicted Parents in Methadone Treatment: Long-term Recovery, Health and Family Relationships

I recently came across this 10 year follow-up of parents in methadone treatment and their children from 2011.

Here’s a review of their outcomes.

First, here’s their definition of recovery:

Recovery status was based on recent drug use, history of drug problems, and history of incarceration. Long-term recovery was defined as no recent drug use (self-report or urinalysis [UA]) and no drug problems or incarcerations for at least 10 years (LHC data). Moderate recovery was defined as no recent drug use and no history of drug problems or incarcerations in the past 5 years.

Here are the outcomes for their definition of recovery:

Of the 144 parents in the original study, 34 (24%) had died. Nineteen (13.2%) appeared to meet our criteria for recovery for at least 10 years. Another 14 (9.7%) met these criteria for 5 to 10 years. Ten (7%) could not be characterized on recovery because they could not be located or contacted. The remaining 46% of the original sample did not meet our criteria for recovery because they experienced continuous or intermittent drug use or incarceration.

If that definition of recovery is a little too muddy for you, here’s some of the data on drug use.

Of the parents who reported no drug problems in the past 10 years (n = 37), over a third (n = 16) self-reported using illegal drugs in the previous 30 days and did not consider this a problem. Forty-nine percent of parents interviewed reported some illegal drug use in the past 30 days

Did they stay in treatment over the 10 years?

Forty-one percent of the parents reported participating in some form of drug treatment every year, and 32% were in methadone treatment every year. Methadone treatment was intermittent for 43% of the sample.

What about criminal justice involvement?

Arrests and convictions were common (90% had some WA state criminal record in the past 10 years), and periods of incarceration over the last 10 years were reported by 54% of parents interviewed, compared to a lifetime prevalence rate of arrests in the United States of 3%.

Mortality?

Mortality among the addicted parents was high. Thirty-two (25%) of the 130 families experienced the death of the addicted parent, and in 2 cases both parents had died before the long-term follow-up interview (34 deaths total). For comparison, mortality in the general population of Washington State was 7.5% ²⁵in 2005 and 14.8% among heroin users in the Seattle metropolitan area.

Mental health?

Mental health was also compromised. Forty-eight percent met DSM III criteria for a major depressive disorder in the last 10 years. . . .  Twenty-one percent felt their mental health was not good every day (mean days = 12.47, SD = 11.53). This is a high compared to the general population in Washington (mean days of mentally unhealthy days = 3.3).

Employment?

Unemployment was common. At the time of the interview, 52% reported no employment in the past year (55% of women and 40% of men, NS), compared to the unemployment rate for Washington State, which was 5.5% in 2005.²⁹ Forty-one respondents (35 women, 6 men, NS) reported no time in the past 10 years in which they were employed more than 30 hrs/week for at least 9 months.

Stable housing?

Thirty-six percent reported at least one year in which they did not have a regular place to live. There were no differences by gender. Four parents reported being homeless during the entire 10-year period and were homeless at the time of the long-term follow-up interview. Parents in long-term recovery were less likely to report homelessness (5.3%) compared to those in shorter term recovery (35.7%) or those still using (44.8%, X² = 10.0, p = .007).

The experience of the kids?

Overall, however, this study fills an important gap in the literature by providing a window into the lives of parents struggling with drug addiction. Our study shows similar negative long-term outcomes for opiate-addicted parents in methadone treatment as other studies have found for more general populations of drug addicts and methadone clients.

. . .

Very few of the children were doing well at the long-term follow-up. As previously reported,⁹ only 24% of the children met criteria for functional resilience by being constructively engaged in school or work, not having abused drugs, and avoiding criminal charges in the last 5 years.

Keep in mind that this is the treatment frequently referred to as the “most effective” treatment. You should ask, “Compared to what? And, as for what outcome measure?”

Further,  recent media coverage of the issue paints anyone who raises these kinds of questions as out-dated, moralistic, simple-minded and one-wayers. Some coverage comes close to implying that anyone who questions ORT is enabling overdose deaths.

I’m not saying a reasonable person could not reach a different position than I have. But, I have a hard time understanding how a reasonable person could be so certain that they try to dismiss, censor and discredit others by questioning their ethics, intelligence and motives.

Book Review: It Takes a Family

I just finished Debra Jay’s new book, It Takes a Family: A Cooperative Approach to Lasting Sobriety and wanted to share a few thoughts with you.

Bill White was one of the first people I heard challenge our failure to distinguish between treatment and recovery. Jay picks up this theme and details the limitations of treatment–that treatment is good at stabilization, but in most cases it’s not designed to provide long term recovery support and monitoring. Where White’s focus is challenging treatment providers to develop systems and services to provide long term recovery monitoring and support, Jay’s focus is on giving families and addicts the information and tools to develop their own systems of long-term recovery monitoring and support.

Jay identifies Physician Health Programs as the gold standard for addiction treatment and outlines eight elements that they share:

1. Positive rewards and negative consequences
2. Frequent random drug testing
3. 12 step involvement and an abstinence expectation
4. Viable role models and recovery mentors
5. Modified lifestyles
6. Active and sustained monitoring
7. Active management of relapse
8. Continuing care approach

She proceeds with chapters on addiction as a disease, why our emphasis on motivation is misplaced, an inventory of the behaviors associated with successful recovery (suggesting that relapse is not random), a new look at enabling and the toll that addiction takes on families–adults and children.

All of these chapters are extremely well done and concise, however, two chapters stand out to me.

The chapter on the disease model takes some very complex information and conveys it in a manner that is very clear and concise. Rather than just describing neurological mechanisms, Jay describes addiction as it is experienced by the addict and those who love them. It’s not frothy emotional appeal, but it’s description is emotional and experiential as well as intellectual.

The chapter on enabling is unlike anything I have ever read on the topic. It is nonjudgmental and conveys and unparalleled level of empathy for the addict and the family. It explores the chronic stress associated with living with addiction and the impulse to protect not just the addict, but also the family–detaching and letting the addict hit bottom often means that the family hits bottom with the addict. In the absence of a viable alternative, fear of losing the family rules decision-making. That alternative is Structured Family Recovery. Structured Family Recovery provides a path to enabling recovery.

The second half of the book is a step-by-step guide to implementing Structured Family Recovery.

So, what is Structured Family Recovery? It’s a way for families and addicts to try to construct their own version of the same gold standard that addicted physicians get. It’s a commitment from the family for each family member to develop a recovery plan of their own and attend a weekly family meeting (via conference call) in which all family members are accountable to each other. The focus is not of the addict, rather it is on the family as a whole. Jay provides several checklists for families and 52 weeks of outlines for the family meetings. There is a lot about the model that excites Jay, but one of the most interesting is the family’s new-found empathy for the addict. When the family member is accountable for working a recovery program of their own they develop greater empathy, understanding and respect for how difficult this is for the addict.

The first chapter of this section continues the refreshing and startling level of insight and empathy for all parties, with sections about how to talk to your addict and how the addict can talk with their family. These sections sensitively and impressively speak to the nuanced, conflicted and powerful feelings and thoughts experienced by everyone–the addict’s ache to get the spotlight off themselves and family member’s fear, anger, hope and relief.

Professionals who view Physician Health Programs as the gold standard have been searching for ways to emulate elements of the model for all of our clients in a voluntary and sustainable manner. Jay has done an enormous service to addicts, families and the field in offering a potentially free approach for achieving this goal. This will be invaluable for clinicians who are looking for ways to extend support and monitoring. More importantly, this book empowers families and addicts to do it themselves.

Debra Jay and her husband (Jeff) are renowned and respected interventionists who serve a lot of high-powered families and individuals. However, the thing I respect and admire most about them is their generosity in sharing their knowledge, experience and tool kits with the rest of us. Love First gave us step-by-step instructions for interventions and helped families decide if they could do it on their own. It Takes a Family continues their open source tradition by giving families Jay’s entire model and helps them decide whether they are capable of doing it on their own.

For less that $11 (relatively) intact families who are committed to working together to support recovery and heal their family now have a detailed road map written in a confident and reassuring voice that makes the reader feel like Debra is right next to you and understands exactly what you’re going through.

My Dad Will Never Stop Smoking Pot

sad girl by .indigo

The Atlantic published an personal essay about the impact of her father’s marijuana addiction on herself and her siblings.

Then there’s my sister, the baby, the one who struggled harder than any of us. She tried so desperately to finish high school, a rare feat in my family. Then she tried community college. As we sat outside at a café this year, talking about my dad’s temper and his rambling mind, she told me how she herself has started to smoke.

“I’m so sorry,” she kept repeating. “But it’s really not that bad, is it? And it’s relaxing. It makes everything okay for a while. Don’t be angry, please don’t be angry.”

I can’t be angry. I understand the appeal of marijuana: its soothing properties, its potential to help chronic pain sufferers, its medical implications. I also believe it should be legalized. In a world where alcohol and nicotine can be purchased at most corner shops, the argument against bringing pot sales out into the open is a weak one.

Yet I can be sad. So very little is understood about how marijuana impacts families. I can’t help but thinking that the cool, carefree users of today will be the parents of tomorrow.

My dad will never stop smoking pot. Sometimes I wonder about the man he might have been, and the lives we all might have had, if he’d never started.

via My Dad Will Never Stop Smoking Pot – Leah Allen – The Atlantic.

Gratitude

Happy Thanksgiving!

Here are a few things I’m grateful for:

Recovery – 23 years ago I was 4 weeks abstinent (not in recovery) and 1 week away from being coerced into a psych unit because my therapist was convinced I was going to kill myself in the coming weeks. He was right. The patients (not the doctors) in the psych unit told me that my main problem was my alcoholism and that I should go to the meetings in the cafeteria. They were right. After I was released (4 weeks later), I was fortunate that my therapist was humble enough to recognize that his ability to help me was limited and that the long term solution to my problem was outside his office. He encouraged me to keep going to meetings, though he frequently expressed disgust at the smoking at meetings.

Community – I was welcomed into the recovering community in a way I had not been welcomed anywhere for some time. My first time at my first home group, Dan F. insisted that I take his seat (The meeting was too big for the small meeting space and did not have enough seats. This meant that he would have to stand or sit on the floor. He was in his 60s and needed a knee replacement.) Ron S. made sure that I never had to leave my seat for coffee, refilling my cup frequently. John M. told me that he was an atheist and that there was room for him in this program and that there was room for me. Dave H. told me that he had faith that things would get better for me and said, “if you can’t believe that things will get better, just believe that I believe things will get better for you.” Bill C. who had sponsees stop by my place to invite me to go to meetings with them. Today, my home group is a wonderful group of people who are patient, kind and generous with newcomers and people who struggle to find stable recovery. We support each other through blessings and trials.

Family – My parents were supportive and patient through the ups and downs of early recovery. (I still cringe when I think of how self-absorbed and thoughtless I could be.) Today, I have very good relationships with them and I’m very grateful for their continued support. I’m grateful for a wife who supported me in pursuing this vocation when I was on the fence about a MSW or law school. I’m grateful for two wonderful kids who expose me to new things every day and whose creativity, joy, kindness, generosity, thoughtfulness and energy challenge me to cultivate more of those traits in myself. When I got sober, I didn’t want a family and, now, I can’t imagine life without them.

Work – I’m grateful to work in a place that understands and respects recovery. We accept addicts for who they are and who they can become. In return, we get to play a small part in miraculous transformations of people who were once hopeless into healed, whole people who are fully engaged in their families and their communities–often helping others stumble through the same transformation.

Bill White did a good job summing up this experience in the context of the history of addiction treatment: “So what does this history tell us about how to conduct one’s life in this most unusual of professions? I think the lessons from those who have gone before us are very simple ones. Respect the struggles of those who have delivered the field into your hands. Respect yourself and your limits. Respect the addicts and family members who seek your help. Respect (with hopeful but healthy skepticism) the emerging addiction science. And respect the power of forces you cannot fully understand to be present in the treatment process. Above all, recognize that what addiction professionals have done for more than a century and a half is to create a setting and an opening in which the addicted can transform their identity and redefine every relationship in their lives, including their relationship with alcohol and other drugs. What we are professionally responsible for is creating a milieu of opportunity, choice and hope. What happens with that opportunity is up to the addict and his or her god. We can own neither the addiction nor the recovery, only the clarity of the presented choice, the best clinical technology we can muster, and our faith in the potential for human rebirth.”

Beyond the work we do together, I’m also very grateful to work with such a great group of fun, supportive, nice and passionate people. I enjoy time off work, but I miss seeing the people I work with when I’m away.

I recently read the following and thought how glad I am to work with so many people share my gratitude for being part of something bigger than ourselves that really makes a difference in the lives of addicts, their families and the larger community.

Even though many of us have numerous occasions to feel grateful in both our personal and professional lives, we often miss out on opportunities to express gratitude, especially at work. A recent survey of 2,000 Americans released earlier this year by the John Templeton Foundation found that people are less likely to feel or express gratitude at work than anyplace else. We are not even thankful for our jobs, which tend to rank dead last when asked to list the things we’re grateful for in our lives.

Gratitude itself – On last thing. I’m grateful that Rob M. instructed me to practice gratitude on a daily basis. It was so unnatural and difficult for me. It also challenged my worldview that was colored with self-pity and pessimism about human nature and the human condition. The gratitude he taught me has kept me humble (most of the time) and free from (extreme) bouts of self-pity.

Related articles

• Six Habits of Highly Grateful People (blogs.berkeley.edu)

Indescribable horror turned into advocacy

Bill White appears to have started blogging!

His most recent post touches upon an issue that is close to my heart.

People in recovery and their family members are leading what is rapidly becoming an international recovery advocacy movement, but there are faces and voices notably absent from the frontlines of this movement:  the families who experienced death of a loved one from addiction before recovery was achieved.  These family members are now seeking each other out for mutual support and are adding their voices to calls for enhanced access and quality of addiction treatment and recovery support services in local communities.

He then introduces a video made by a bereaved father, Jim Contopulos, in memory of his son, Nick.

The following is attributed to Jim and reportedly from his eulogy for Nick.

For those of us here today, who have had a “front  row seat” to this disease over these past 13 years, or even to those sitting further back and have continued,  as it were, to hear “reports form the front line” we can confirm without any hesitation that addiction is truly a “cunning, powerful and baffling” disease.

Some of us sitting here today know nothing of Nick other that this courageous struggle, and it is my hope that as we allow Nick to “speak” through the songs he loved; the movies he loved; his love for animals; his love for children, especially his love for his daughter Hailey; his irreverent humor; his love and admiration for his sister Vanessa, his mom and myself; his strong desire for justice as well as his struggles with addiction coupled with mental illness, what’s known as a dual diagnosis, that you will have a much larger context for his life.

Perhaps with this better understanding, Nick would ask you simply to love, rather than judge; the addict, the mentally ill the diseased, the imprisoned, the homeless, the poor, the unlovable and the lonely, because Nick himself was, at one time or another, all of these.

None of us sitting here today wants only to be remembered for our failures and certainly not Nick, which is why he so loved the final verse to the song “These Days” by Jackson Browne, which says. “don’t confront me with my failures, I have not forgotten them”.

The worst part of this work is the terrible loss of life, often young lives. Among the parents that are left behind are some of the bravest and most admirable men and women I have ever met.

Diane Montes turned the loss of her son, Brian, into a mission to prevent deaths and support families going through a similar loss.

It was the evening of June 29, 2006, when Diane Montes returned home from work and went to her son’s room to speak with him. When she opened his bedroom door, she witnessed “an indescribable horror.” Brian Montes, a 22-year-old education major at Michigan State University, was lying dead on his bed. Police told the grieving mother that her son died from heroin use.

The family later learned that the fatal dose was mixed with the pain-killer Fentanyl, which caused respiratory failure. Brian’s family had not been aware he had a drug abuse problem. They later found out he had only been using heroin for 6 weeks when he died.

After Brian’s death, Diane and her husband Andy learned that there were more Livonia teenagers and young adults using heroin than they had ever imagined. Diane talked to a number of people who said they knew of young heroin users who either died, were hospitalized, or sent to drug rehabilitation. In addition, it was reported that Livonia police suspected the drug could have played a role in a dozen deaths in Livonia over the previous year.

Diane looked for information and support in Livonia but found little. She learned of the Royal Oak Save Our Youth Task Force, a group of school, police, medical and political leaders focused on spreading word about the dangers of heroin and other drugs and how users and families can find help. The Royal Oak group formed in response to a number of drug deaths in that community.

On October 18, 2006, Diane convened a community meeting to try and build community support for a Livonia Save Our Youth Task Force. Over 140 people with questions and stories to share attended that initial meeting. From that meeting, a group formed and the first meeting of the Livonia Save Our Youth Task Force was held on November 15, 2006.

Since 2006, Livonia Save Our Youth continues to grow and expand. In 2012, the name was changed from “Task Force” to “Coalition” to reflect the longevity of the group and intent to continue its mission and activities in the community.

I’ve called on Diane over and over again to ask if she’d be willing to speak with a parent who just lost a child. She’s never hesitated to make her self available to them.

Mark Rudolph also lost his son, Ryan, in 2007 and has been relentless in building a coordinated community response to the problem of addiction in his “safe” suburban community.

He made this video in memory of Ryan. (The voice mail he included at the end is heartbreaking and horrifying.)

More recently, I met Mark S. who lost his son, Andrew, just one year ago.

He’s been sharing his difficult journey on his blog and in his podcast. He recently marked Andrew’s birthday with a 12 hour podcast to raise money to provide treatment for others.

Here’s his introduction to that 12 hour podcast.

[audio http://traffic.libsyn.com/talktherapy/Hour_1_of_12_Hour_Podcast_Mark.mp3]

These are just a few of the people I’ve met who have turned their tragedy into a heroic journey. Sadly, we’re in the midst of another wave of overdoses.  I hate this part of the job but I am so grateful to have met people like Diane, Mark and Mark.

Mark and Ryan’s story

UPDATE: Mark pulled the video. Hopefully it’s only temporary.

My job allows me to meet some really wonderful people. Sadly, I meet some of them under really terrible circumstances. Mark Rudolph is one of those people. He lost his son to opiate addiction 5 years ago and has chosen to make meaning of it by educating others about opiate addiction in the “safe” suburbs and supporting families dealing with addiction.

He just shared this video with me:

Family meals appear to be protective for girls

family dinner by Daniel Bachhuber

Promoting family meals is a popular prevention strategy. A recently published study looks at its impact:

Family meals were associated with reductions in alcohol and tobacco consumption in girls but not boys. Alcohol consumption was also associated with reductions in the frequency of meals among girls, but not boys. Results supported the assertion that family meals protect some girls from substance abuse but suggest meals may have little impact on existing users.

Negotiating Recovery

 

boundaries by joiseyshawaa

An Addict In Our Son’s Bedroom touches upon a very important issue for loved one’s of addicts:

We’ve all done it. Seldom, if ever does it work. We make deals, we are willing to sell our soul, our dignity and our future to an addict in an effort to stop the madness.

My efforts to negotiate recovery involved buying things, providing gifts, paying for medical treatment, rehab and rents. All this in a fruitless attempt to bargain away the addiction from my son. This all happens while we enable our addicts and deny the reality.

I’ve been working with more parents over this issue comes up over and over again, both when parents begin renegotiating their boundaries or when they are upset with us for maintaining our boundaries. We need up having a conversation about:

• the importance of choosing our boundaries carefully;
• knowing the purpose of our boundaries (Care of self, family and home. Not to manipulate the addict into recovery);
• that the time to re-negotiate boundaries is not after they have been broken.

Families aren’t alone in facing this challenge. Professional helpers struggle with this too. This is a big part of why we use a team approach and talk constantly about boundaries, our motives and the reasons behind them.

Mom and Dad at An Addict In Our Son’s Bedroom reached a similar conclusion:

So what’s the answer? You must live in the world of a reality that involves seeing the picture as it is not how you want it to be. Stepping back and taking in the holistic nature of this disease and how it not only affects the addict but all those that they touch is the first step. From that place I was able to see that negotiating was hopeless. Then it came down to figuring out where I actually stood in relationship to the disease and my relationship with my addict.

At that point I began to understand what boundaries meant. At that point there is no negotiating. The only thing left is deciding where you can go and where you cannot go.

 

a family disease

Guinevere Gets Sober has a great post unpacking some of her thoughts about the new ASAM definition of addiction and what it means for the common expression that addiction is “a family disease.”

When I woke around 6 this morning I started to wonder: if addiction is an illness inside the addict’s neurological system, then how can we “adult children of alcoholics” consider ourselves to be affected by addiction? I’ve heard people in Al-Anon meetings say, “I’m the same as the alcoholic—I just don’t drink.” (I can tell you: for my mother, that was true. She WAS a dry-drunk.)

This reminded me of something I’d read years ago that described 4 tasks of treatment and recovery:

• Recovery from the other genetic, biochemical, social, psychological, or familial influences which initially contributed to the development and trajectory substance problems
• Recovery from the adverse psychosocial consequences of the substance use
• Recovery from the pharmacologic effects of the substances themselves
• Recovery from an addictive culture

Note that family are likely to share at least some of the first and second, and possibly, the fourth.

The more I think about this new definition, the more I like it. It really captures the primary nature of the illness and acknowledges the secondary problems that can result from it. This has important implications for treatment and understanding the constellations of problems that people initiating recovery often experience.