By Michael Ascher, M.D. and Elana Rosof, Ph.D.
As addiction professionals in private practice, we evaluate and treat patients with varying degrees of opioid use disorders and motivation to participate in treatment. In fact, having fluctuating degrees of motivation and commitment to treatment is expected. Ambivalence about fully engaging in treatment is something we embrace, normalize, and explore with our patients. Working with families to help a loved one with an opioid use disorder enter treatment is another significant part of our practice. Coaching and guiding families to focus on their own self care, setting healthy limits, learning to communicate in a nonjudgmental way, and empathizing with the ambivalence that their loved one faces is an effective approach and improves the chances the child will enter treatment (more fully discussed in a previous article “10 Effective Tips to Help Your Loved One Seek Treatment for a Substance Use Problem”). There are times, however, when things in the family are so destructive, dangerous, and chaotic that the family must ask the substance using child to leave the home. This should be a last resort when there is a physical and/or emotional/psychiatric safety concern and after all other attempts including the utilization of nonconfrontational approaches such as Community Reinforcement and Family Training (CRAFT) have repeatedly failed to help the substance user to enter treatment. Three must read resources that help families to learn CRAFT include “Parents 20-Minute Guide: A Guide for Parents About How to Help Their Children Change Their Substance Use,” “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening,” and “Beyond Addiction: How Science and Kindness Help People Change.” Additionally, Cadence Online has created an extremely helpful video series for parents to learn CRAFT. This article discusses important considerations for the family once the decision to ask your son or daughter to leave the home is made. The importance of all parental figures in the home sending a consistent message to the substance user is vital.
1. Deliver the message in a way that is calm and communicates to the person that this request to leave the home is out of love (even if it is not met with calm in return). This is not the time for anger but the time to express that the addiction is creating a situation at home that is no longer livable. It may also be helpful to write a note explaining how much you love your child and want them to live a fulfilling and meaningful life. Remind them that you have your own personal limits and that the current situation is intolerable, and you will be there for them 100% if they choose to enter treatment. Explain to your child that a substance use disorder is not a moral defect but rather a medical condition that needs to be treated like every other chronic medical condition. Explain that they deserve the chance to get to the root of their relationship with substances and to treat co-occurring anxiety, depression, trauma, and attentional difficulties as well.
2. Offer treatment choices such as an inpatient detoxification, inpatient rehabilitation hospital, outpatient methadone clinic, supervised buprenorphine (Suboxone) treatment, long-acting injectable naltrexone (Vivitrol), sober living with an intensive outpatient program, etc. It is worth asking your son or daughter once again at that moment if they are willing to seek treatment for their opioid addiction. Remind your child that you will always be on the side of him getting treatment and let him know that you will always be available for help in that way.
3. Make it financially and logistically difficult for them to obtain drugs. This is going to be very uncomfortable for your son or daughter. That’s okay. Sometimes that increase in discomfort tips the ambivalence scale in favor of a decision to enter treatment. Make sure you cut off all credit cards and debit cards. It may be prudent to call one of the three national credit bureaus (Experian, Transunion and Equifax) and place a “fraud alert” on your credit reports. Fraud alerts can stop your child from opening additional accounts in your name, and you will be contacted before any new account is opened or an existing account is changed. Any forms of cryptocurrency including Venmo, Apple Pay, Paypal and Bitcoin linked to your credits cards or checking accounts should be deleted. Lock up your personal valuables such as cash, jewelry, digital cameras,and family heirlooms. Make sure you retrieve your child’s cell phone and contact the phone provider to deactivate their cell phone. Take their computer. Take your car keys back from them and lock up any forms of transportation that they might take such as a bike.
4. Harm reduction is a helpful approach when you know your loved one is probably going to be engaging in high risk behaviors. You may pack a bag for them that includes some clean syringes and condoms. Also be sure to pack any medications for chronic health conditions (diabetes, hypertension, seizure disorder, asthma, etc.) or contraceptive medication that your loved one takes regularly. Explain that if they run out of medications, they should inform the pharmacist to call you directly and you will pay for those medications directly via a credit card. You may offer to drop them off at a local Salvation Army so they have a bed for the evening.
5. Provide your loved one with resources for help and notify any existing medical providers of the crisis. Write down the phone numbers and addresses of local shelters, detoxification facilities and hospitals. Make it clear that you will certainly engage with your loved one if they decide to get help. Include phone cards that can be used to call you at home. Explain that if alcohol or benzodiazepines medications (such as valium, xanax, ativan, or klonopin) have been used habitually, the risk of withdrawal can be deadly if stopped abruptly. Encourage your child that they should report to the nearest emergency room for detoxification so that they can safely come off of these substances. This is also the time to inform any of your child’s existing mental health care providers and prescribing clinicians that your child is in crisis.
6. Inform friends and loved ones that your child may try to reach out to them by explaining that your child has significant mental health issues, is using drugs and is a danger to themselves. Communicate that you are here to help your child with open arms if treatment is accepted. Instruct your friends and loved ones not to be manipulated by your child and to also calmly explain that everyone is here to help them if treatment is accepted. Explain that your child was given multiple choices in terms of next steps and is “homeless by choice.” Also, educate them about naloxone (Narcan), an FDA approved medication designed to rapidly reverse potential opioid overdose.
7. Obtain your own mental health support. This will likely be excruciating and heart-breaking for you and your family. Find support for yourself and family members. If there are younger children in the house, they may need support too. If you have your own substance use issues, address them. This is a time to take care of the people at home.
8. Finally, do not let your child come back home unless they have started the process of obtaining treatment which includes an inpatient or outpatient detoxification (withdrawal management) program. Inpatient detoxification is usually necessary if there are major medical concerns and/or your child has a co-occurring benzodiazepine or alcohol use disorder. Once withdrawal management is completed, your child should be on a relapse prevention medication such as (Vivitrol, supervised Suboxone or Methadone). If things turn violent, be prepared to call 911. When your child has left the home, clean out his or her room and remove any drug paraphernalia or drugs that are found. Undoubtedly, you have given your child many opportunities to follow through with their intentions to seek help. Here you are setting a limit that you have come to after many other tried interventions. It was not impulsive and you are doing it for a reason. Probably several reasons. Good reasons. Stick to it.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches.