Addiction used to be considered a moral failing, and the family was blamed for keeping the relative with addictions sick, through behaviors labeled “codependency” and “enabling.” The opioid epidemic can take credit for putting a serious dent in these destructive and stigmatizing notions. When psychiatrists actively include families as educated treatment partners, fatalities are less likely, and the havoc created by addiction on families is mitigated.
Genes and addiction
What causes addiction? Statistics show that Native Americans fare the worst of all minority groups, with death by opiates in whites and Native Americans double or triple the rates of African Americans and Latinos. Reasons put forward for Native American deaths are their vulnerability related to systemic racism, intergenerational trauma, and lack of access to health care. These “reasons” are well known to contribute to poor overall health status of impoverished communities.
Among impoverished white communities, the Monongahela Valley of Pennsylvania has been studied by, as an example of postindustrial decay ( ). Once a global center of steel production, the exodus of jobs, residents, and businesses since the early 1980s is thought to contribute to the high numbers of opioid deaths. A qualitative study of the people with addiction in the deteriorating mill city of McKeesport, Pa., characterized a risk environment hidden behind closed doors, and populated by unprepared, ambivalent overdose “assistants.” These people are “co-drug” users who themselves are reluctant to step forward because of fear of getting in trouble. The participants described the hopelessness and lack of opportunity as driving the use of heroin, with many stating that jobs and community reinvestment are needed to reduce fatalities. This certainly resonates with the Native American experience.
People with the AA variant of OXTR also have been shown to have less secure adult attachment and more social anxiety (). Comparing people with OXTR variants, the AA genotype was associated with a perceived negative social environment and significantly increased PTSD symptoms, whereas the GG genotype was protective.
However, for many decades, psychological theories about the defects of individuals and their moral failing have prevailed. In the family, aspersions have been cast on the family’s deficits in terms of setting limits and their enabling behaviors, mostly focusing on wives and mothers. The social mantra has been that since not all people get addicted, the strong resist and the weak succumb. Psychiatry has focused on providing psychotherapy to correct the personal deficits of the weak and addicted and, from a family perspective, on correcting negative personality traits in the caregivers, classified as codependency.