“They either leave you or they get involved in it”: Familial factors influencing drug use amongst Appalachian people

Introduction:

The opioid crisis has gripped the United States with significant morbidity and mortality for over two decades.(Centers for Disease Control and Prevention (CDC), 2021) The Centers for Disease Control and Prevention (CDC) 2020 mortality data indicates that 187 people die daily from an opioid overdose (Centers for Disease Control and Prevention (CDC), 2021). Recent trends during the COVID-19 pandemic indicate the opioid epidemic worsened over the past few years, and opioid-related deaths continue to climb (Nair et al., 2022). The American Psychiatric Association defines opioid use disorder (OUD) as a problematic pattern of opioid use that leads to problems or distress along with two additional criteria such as cravings, increased tolerance, and social or personal problems (American Psychiatric Association, 2023). There are varying rates of OUD amongst states; however, the highest rates are found in rural Appalachia (Schalkoff et al., 2020). In particular, West Virginia, the only state entirely in Appalachia, is considered the epicenter of the opioid crisis (Merino et al., 2019). In 2021, CDC reported 1,501 people in West Virginia died of a drug overdose (Centers for Disease Control and Prevention (CDC), 2022). This rate of 90.9 (per 1000,00) is the highest in the country. Two other Appalachian states, Tennessee and Kentucky also had high rates of drug overdose and were in the top four states for drug over doses in the country in 2021 (Centers for Disease Control and Prevention (CDC), 2022). It is estimated that 49,619 people in West Virginia or 3.2% of the population have OUD (Clemans-Cope et al., 2021).

The high prevalence of OUD in West Virginia is attributed to many factors. For example, high prescription rates fueled by aggressive marketing by pharmaceutical companies, economic disparity, and sociocultural factors are known to contribute to the persistent opioid crisis in the state (Merino et al., 2019). For example, poverty rates in Appalachia remain high, ranging from 6.5% to 41%. The US average is 14.6% (Appalachian Regional Commission, 2019). The United States Census Bureau estimated that in 2021, 17.9% of people in West Virginia lived in poverty (United States Census Bureau, 2022b).Poverty has been associated with higher rates of prescription opioid overdose (Pear et al., 2019). These multiple and intersecting influences on opioid prescription and dependence form the basis of previous work by our group and others.

Development of OUD can begin with the introduction of prescription opioids to treat chronic pain or an injury/trauma (Pino & Wakeman, 2023). West Virginia is a state with a steep history of mining and timbering. These heavy manual labor jobs can cause painful injuries, often treated with opioids, which could contribute to opioid addiction (DEA United States Drug Enforcement Administration, 2017; Hodges et al., 2023). For people seeking illicit prescription opioids (meaning not prescribed for them), a family member or community contact is often cited as the source of the medication (Becker et al., 2011). There is evidence that children raised in families with a substance use disorder are more likely to develop their own substance use disorder later in life (Sheridan, 1995). However, there are a multitude of associations with the diagnosis of OUD. For example, adverse childhood events (ACEs) such as growing up in a family with mental health or substance use issues are associated with later development of OUD (Smith et al., 2021).

Children with ACEs experience stress which can impact brain development, leaving them vulnerable to chronic health problems and other adverse adult outcomes, including suicide (Thompson et al., 2019) and drug overdose (Wisdom et al., 2022). Additionally, the impact of poverty and food and housing insecurity contribute to and exacerbate the effects of ACEs (Jones et al., 2020) and can increase the risk of problem drug use as adults (Manhica et al., 2021) In West Virginia, it is estimated that 25% of children live in households below the poverty level (United States Census Bureau, 2022a) . A high level of opioid use coupled with one of the country's highest levels of child poverty suggests that families in WV are vulnerable to generational cycles of substance misuse. This study explores intergenerational and familial substance use in a sample of rural West Virginians who use opioids.

Methods:

Conceptual model:

This study is underpinned by a social-ecological framework (Jalali et al., 2020). This framework focuses on the interconnectedness of social interactions and the environment through multiple levels including individual, relationship, community, and societal level. Development of OUD can be influenced on many levels as discussed above and proposed by Jalali et al.(2020). This study focuses on the individual and relational development of drug use, specifically the influence of intergenerational and family dynamics however the influence of community and societal factors are not disregarded.

Study Design and Participant Recruitment:

The current work represents emergent themes discerned from participant interviews on the opioid epidemic and impacts of a new opioid prescribing law in West Virginia (Sedney et al., 2021, 2022). Briefly, this prescribing law placed limits on opioid prescribing, placed requirements for pain clinics, and included mandatory documentation of consent prior to initiating opioid medication (West Virginia Legislature 2018 Regular Session, 2018) The overarching study was a sequential, explanatory, mixed methods design and the current themes emerged during the qualitative component of the first study (Sedney et al., 2021). The study protocol was approved by the West Virginia University Institutional Review Board prior to the enrollment of participants. In depth semi-structured qualitative interviews were conducted by telephone on a convenience sample of 20 patients with chronic pain or opioid use disorder, 10 primary care physicians, 10 subspecialty physicians, and 10 pharmacists. Physicians and pharmacists were included as participants along with patients because of the social-ecological aspects of OUD various stakeholders could provide valuable insights. Sample size was estimated to achieve thematic saturation (Lincoln & Guba, Egon, 1985; Sandelowski, 1995) meaning no new themes are evident in the data (Guest et al., 2006).

The study research team partnered with the West Virginia Practice-Based Research Network (WVPBRN) for participant recruitment. The WVPBRN is a group of primary care clinicians who work in a partnership with researchers (West Virginia Clinical and Translational Science Institute, n.d.). This network of heath care providers has over 100 sites across West Virginia. The sampling plan was developed using county-level and specialty-level opioid prescription data (Sedney et al., 2021). Members of the PBRN in targeted counties were sent an email asking them to participate and recruit potential participants for the study. Interviews were conducted by a qualitative method trained research nurse (PD). Interview questions for all participants focused on their experience with prescribed opioids, understanding of the new opioid prescribing legislation, perceived impact of the legislation, and any impacts to personal practice or prescriptions.

Data collection:

Participants provided written informed consent before data collection, which were mailed and returned by mail during COVID restrictions. The study research nurse (PD) contacted participants and scheduled a telephone interview at a time convenient to the participant. Telephone interviews were completed from a private office location. Interviews were recorded and professionally transcribed verbatim, then uploaded into NVivo12 for data management. All interviews were completed between March and October of 2020. Audio recorded interviews ranged from 30 to 60 minutes each with average interviews lasting for 30.2 minutes. Participants were compensated with a $30 gift card to offset time and effort to take part in the study.

Data analysis:

The analytical orientation of this study is content analysis as described by Hsieh and Shannon (2005). Content analysis is the “subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” and is helpful for exploratory studies (Hsieh & Shannon, 2005). Our team has used this method successfully in other qualitative studies (Dekeseredy et al., 2021; Haggerty et al., 2022; Sedney et al., 2022). Three team members independently read transcriptions and collaborated to construct a codebook. The initial codebook focused on the implementation of the restrictive opioid prescribing law; however, emergent themes were evident describing intergenerational and familial use of drugs. Therefore, these emergent codes were expanded in the codebook. Text segments related to these themes were extracted based upon the codebook and further axial coding refined themes and concepts as all researchers explored the relationships between themes using memo-writing and group discussion with dialogue and mutual agreement between all researchers. The themes were examined in comparison and contrast to each other in a “constant comparative” paradigm. Reporting was crosschecked with the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Tong et al., 2007).

Findings:

Demographics of the participants can be found in Table 1.

Table 1.

Participant Demographics

	Male/Female	Number of West Virginia counties represented
Primary care physicians (PCP)	7 male/3 female	7
Specialist physicians*(SP)	5 male/5 female	7
Pharmacists (Pharm)	6 male/4 female	8
Patients who use opioids (PWO)	7 Male/13 female	10

^*surgeons, dentist, emergency medicine, palliative care, pain specialists

Three themes of relevance to the aim of the study were elucidated:

a. Drug misuse follows intergenerational relationships

Patient participants often noted illicit or non-prescribed drug use amongst both older and younger generations in their own families, and both pharmacists and physicians were aware of this phenomenon and the relational influence on drug use was mentioned most often by these groups. Often this was expressed in two specific ways chronologically: previous diversion or misuse of prescription substances was exemplified as the causative factor initiating dependence in these other generations by some participants but was generally referenced as a remote origin of addiction rather than a current one. In these accounts, often the medication was purposely diverted with the knowledge of the family member or sold for financial reasons.

Getting stuff from old people. It’s a shame, they may be in pain, but they sell it to get other meds and groceries, pay their electric, you know, which is sad.

(PWO 03)

Having a parent with drug use issues was seen as an influence or predictor towards a person’s own drug use.

He came from it in life, his dad and mom all use and things so I didn't come from that and he did and I can't blame him.

(PWO 15)

And participants’ children’s drug use had broader consequences for participants, as an additional stressor during times when they were often struggling with their own addiction issues. Some participants were estranged from their children because of episodes of stealing or relapse. One participant noted that her daughter was no longer allowed at her house due to stealing her buprenorphine. Worry for their children’s lives in the face of possible overdose was frequently expressed, as well as a sense of helplessness over impacting that fear.

I'm having a hard, hard time with her. My biggest fear is I'm going to get that phone call that she OD'd, she's hurt. She knows to reach out and get the help. She knows.

(PWO 15)

Participants strongly desired their children involved in drug use to “get help,” and oftentimes the participants expressed the desire that their children could be forced into recovery, such as through carceral drug programs.

He's in prison now and he's calmed down a lot, but if people-- How many times are you going to write a ticket to someone, before you say enough is enough and you put them in jail?

(PWO 16)

Further complicating the lives of participants was the burden of caring for the health issues of their own children or parents because of drug use, or in childcare of grandchildren because of children’s drug use. This additional stressor impacted the ability of families to maintain custody of the children and impacted participant’s own attempts at sobriety.

Whenever my youngest daughter has her twins, of course, she can't even keep them. I had them, they gave me custody of them, and I had them for seven months. Of course, they were drug babies. This other woman went behind my back and told the HR woman that I couldn't take care of them because she was coming and getting them every weekend to give me a break.

(PWO 06)

b. Partner drug use as factor for escalation of use or relapse

Romantic partners and spouses were significant influence on illicit drug use and relapse. In spite of the significant impact of this phenomenon as described by patient participants, it was not prominently discussed by pharmacists or physicians. Occasionally male patient participants discussed that girlfriends or female romantic partners initiated or escalated illicit drug use, but the vast majority of such relationships were characterized by female participants and detailed as their male romantic partners initiating or escalating use.

Like I said, my ex father-in-law, he got prescribed Oxycontins so I'd get them [snaps fingers three times] pretty much snap of the finger. My ex-husband would get them and I didn't inject them then, at first. He started injecting them so then I started injecting them.

(PWO 16)

Often this relationship or exposure was very early in life and described as recreational in nature.

I met my husband when I was 14 and somebody close to him sold Oxycontin, 80s. Those were the real ones before they put rubber and stuff in them. I loved it, I loved how I felt. I wanted to do it everyday. When I wasn't high I wanted to be high.

(PWO 20)

Similar to the potentiation of addiction problems described amongst intergenerational drug users, participants with partners who used drugs described the stress and struggle of caring for a loved one suffering from addition while struggling with their own addiction.

I almost felt like a hypocrite for leaving my husband. I put him in rehab three times. I came out of rehab and I went right back to it. I did try to deal with the situation, but then it got to a Saturday, he was violent, getting violent, threatened with my kids and threatened them if I didn't getting money for him and stuff like that.

(PWO 08)

In spite of the difficulty and threat of violence of such relationships, they were seen as inevitable when one partner was engaged in illicit drug use, as described by one participant:

…when you're buying stuff off the street and that's your income and it's this whole kind of lifestyle, yes, the people that you bring into your life get involved. They either leave you or they get involved in it.

(PWO 03)

c. Children/parent dyads as influence towards recovery

Even as familial drug use made recovery harder for participants in this study, the influence of family on recovery was featured prominently in interviews. Again, this aspect of familial impacts on drug use was not recognized by healthcare providers in spite of its prominence for patients and active drug users. Participants frequently mentioned their children as a motivation for abstinence, and birth of a child or removal of a child from the home were frequently referenced as reasons for attempting abstinence (with abstinence specifically referenced by participants as opposed to other forms of recovery). Some feared not being present for their children’s lives.

They were having dreams mom OD'd and I don't want my kids to come see me in a casket because I overdosed and died. I want to be there to enjoy my grandkids growing up.

(PWO 17)

Participant’s whose children were still actively using drugs hoped that their children’s children might become a motivation for them as well.

I just hope she applies the life lessons she learned and start living for her children instead of being greedy towards herself. It's going to kill her.

(PWO 07)

Remorse about the impact of their drug use on their children’s lives was a common theme that both potentiated use, and motivated abstinence, which was the primary vision of recovery espoused by participants.

My son is 15 and he's brilliant, he truly is brilliant. He's very smart and he was finally candid with me and he told me-- because my ex-husband, his dad is a substance abuser too and in treatment now. He told me, he's like, "Mom, if you and dad would have just made a different choice, my life wouldn't be like it is right now".

(PWO 05)

…it's because I didn't have my son as much as I wanted to, that made my drug use more, but that pushed him away at the same time. At that point, I couldn't take it anymore, seeing him being so disappointed in me.

(PWO 05)

Dyadic relationships influencing drug use were bidirectional, and death of parents also impacted their children and triggered relapse. One pharmacist described how it was too late for one woman who confided that her son had been stealing her opioids for years. His overdose and death were what led her to recovery.

The story she relayed to me and I'll-I'll tell it to you now, is that her son had been stealing pills from her for years… She said that on October 30th, she quit her opioids because her son had overdosed and died the week before

(Pharm 01)

Discussion:

The participants in this study described how using opioids have impacted their lives, their family, and community. They recognized drug use was embedded along familial groups and influenced by significant others such as partners or peers. Parents described how children were a strong motivator for recovery and how they felt remorse for exposing their children to their drug use. The strength of family ties and the importance of extended family and life-long kinship bonds are core values in Appalachian culture (Helton & Keller, 2010). This influence, for better or worse, was often discussed by participants as fatalistic beliefs for the future of their community members. For example, the fear and helplessness expressed towards an overdose in the community or the belief that “he just comes from that,” so it is not his fault. However, this fatalism was not evident when participants talked about their children; instead, they expressed a strong desire for their children who use drugs to get help, even if it meant incarceration.

Participants struggled to begin or sustain recovery when a romantic partner or spouse continued to use in the house. Like other similarities couples might have, substance use is often a shared behavioral characteristic (Leonard & Das Eiden, 1999). As one participant described, they “either use with you or they leave you.” The women in our study described how it was the men in their lives who initiated drug use or facilitated their use. These findings are similar to Powis et al., who found that men are often instrumental in their female partner’s drug use, usually being the ones to introduce injecting heroin or cocaine (Powis et al., 1996). Additionally, women who use substances are also at a high risk of intimate partner violence, (Yu et al., 2019) which our female participants experienced.

The importance of non-marital family relationships in Appalachian health outcomes has been described (Roberson et al., 2023). According to Tang and Russ (2007), strong family ties characteristic of Appalachian culture may be strengthened because of historical the isolation from mainstream culture. This isolation is still present in a geographical sense within the rural state of West Virginia. Similarly, Brown and colleagues have found that “families (rather than communities) may be the primary pathway for the provision of… resources, scaffolding, and support” (Brown et al., 2009). Importantly, this finding is the opposite of what has been observed in non-Appalachian families (Leventhal & Brooks-Gunn, 2000). Some have cautioned about the application of “Appalachian Culture” when interpreting experiences within geographical boundary of Appalachia emphasizing the diversity that exists with the region (Denham, 2016). The participants in our study came from across the state, but over half (58%) were from ten different counties in the southern part of the state which have been hardest hit by the opioid crisis. They spoke of fear of not being in their children’s lives and not seeing their grandchildren grow up. References to multigenerational living was frequent, especially if it was jeopardized by substance use. Paradoxically, the strong family ties that Appalachian families share, present in numerous early ethnographic accounts (Hennon & Photiadis, 1979; Keefe, 1971; Schwarzweller et al., 1971), can also contribute to perpetuating problem behavior in future generations when substance use is involved (Peleg-Oren & Teichman, 2006).

Children who grow up with a parent with substance use disorder face many challenges including continuing the intergeneration cycle of substance misuse (Sheridan, 1995). Our participants described how their children were impacted by their drug use including, being removed from the home as small children, having a substance use disorder, incarceration, overdose and death. Many expressed guilt, and a concern for future generations. The adverse effects associated with living with addiction and recovery require specialized programs that address the unique needs of parents to mitigate risk to their children (Hussong et al., 2022). Peer interactions also influence the exposure to and development of substance use disorder, particularly in adolescent substance use. A majority of adolescents and young adults receive opioids from peer interactions including friends and family (Hudgins et al., 2019). Similarly, our participants told us how early introduction to opioids, as teenagers for recreational use was their initiation to opioid use. Transitioning from prescription opioid use disorder to injection illicit drug misuse, such as heroin, has been associated with peer interactions providing support and encouragement to initiate injection (Barry et al., 2012).

Family dynamics in the milieu of drug use are complicated. Relationships with family members are often strained. Our participants expressed great concern for children and grandchildren because they knew the exposure to drug use increased the risk they would also use.. A pharmacist told us about his patient, how it was only after the death of her child from an opioid overdose that she “detoxed” herself and quit taking any opioids at all. This is consistent with other studies that found family concern can be a strong motivator for detox and drug treatment (Garrett & Landau, 2007).

The current study focuses on how social and family influences can contribute to OUD. However, this needs to be considered within the context of other social determinants of health and under the influence of wider social-ecological forces including the community and societal levels. The patients in our study are all from West Virginia, a state with high rates of poverty (United States Census Bureau, 2022b), lower education (United States Census Bureau, 2022b), unemployment (U.S. Bureau of Labor Statistics, 2023), and a lack of access to harm reduction and treatment programs for OUD (Sheppard et al., 2021) . There have been efforts to address the opioid crisis in West Virginia such as restrictive prescribing laws (West Virginia Legislature 2018 Regular Session, 2018) and enhancing preventions and education programs (West Virginia Department of Health and Human Resources, 2020). However, given the multiple factors at play, a comprehensive approach needs to consider the influence of economic and societal factors along with individual and family dynamics.

Our study has some limitations. Specific drug use characteristics of our patient participants, beyond being prescribed opioids, were not systematically collected. Although we had interview transcripts from 50 people, the intergenerational drug use was mostly referenced amongst the patient participants who volunteered their personal experiences. The lack of recognition of this same phenomenon amongst healthcare workers was notable and could be contributed to the interview guide and focus of the overarching study on the impact of the prescribing law. Additional focused studies on the experiences of pharmacists and physicians could provide more insight into the topic of study. This study was from a single Appalachian state and may not be generalizable to other states with different demographics and cultural values. Appalachia is a large and diverse area, and while there are generalizations regarding cultural characteristics, there are variations within West Virginia, and differences among the people also need to be considered when interpreting findings.

Conclusion:

The residents of rural Appalachia continue to experience a devastating opioid crisis. The people in this study described the long-term generational destruction of their families related to opioid use. They felt guilt and shame for the adverse effects their drug use was having on their family and children despite expressing strong feelings of concern and care for them. The strengths of Appalachian community and family values, such as closeness of kin, pride in where you come from, and looking after your own, can be valuable assets in implementing recovery and harm reduction programs to interrupt the risk to subsequent generations. Partnering with community leaders and prioritizing the family, not just the individual could leverage the strong ties characteristic of people in Appalachia. This study reinforces the importance of community engagement, parental support, and early identification of vulnerable young people to lessen the intergenerational continuance of substance use. Involving the communities with the support of the locals can be difficult, but without local buy-in, success will be challenging. Our study supports the guiding principles of previous public health initiatives that you must know your people, collaborate, involve the people, and meet them where they are.