The Perceived Role of Family in Heroin Use Behaviors of Mexican American Men

Abstract

Background

The influence of the family is not well understood as it relates to drug use behaviors of Hispanic male adults. We examined the family’s influence on drug use behavior, as perceived by Hispanic men who use heroin.

Methods

One-time qualitative interviews were conducted with 21 current and former heroin users who participated in a larger study on long-term heroin use in Mexican-American men. Data were analyzed using a thematic analysis approach.

Results

Three main themes emerged: family as a supportive environment for heroin use; heroin as a family legacy; and, the family’s strategies for helping to stop using heroin. A sub-theme emerged on the paradox of family involvement, which spanned the three main themes.

Discussion

This research lays a foundation for future work to disentangle the risks and benefits of family involvement to inform culturally-centered therapies and cultural adaptations to traditional therapeutic approaches with Mexican American men who abuse drugs.

Background

Illicit drug use is a growing public health problem for the general population, despite its public perceptions as a youth or young adult issue only. In the past decade, drug use among individuals aged 50 to 59 more than doubled from 2.7% to 6.2% [1]. A similar trend has been found in the rates of drug-poisoning deaths involving heroin between 2000 and 2013 for U.S. [2]. While the rise in heroin-related deaths has been most dramatic among non-Hispanic white adults, it is a cause for alarm among U.S. Hispanic adults because of the growth in this sub-population. By 2050, approximately 20% of adults 65 years and older will be Hispanic, becoming the nation’s largest aging minority group [3]. By 2020, the number of persons aged 50 and older requiring substance abuse treatment will double to approximately six million [4]. Thus, the convergence of all these trends will likely present grave and unprecedented challenges for social service organizations serving Hispanic populations.

The family is an important context for drug use behaviors among Hispanic populations because of the prominence of familismo in Hispanic cultures. Familismo (loosely translated as “familism” in English) reflects a broad set of traditional and cultural values that shape family structures, norms, relationships, and expectations in Hispanic families. The prominence of reciprocity and interdependence between family members is life-long and multi-generational, and the family is seen as an extension of the self [5, 6]. Loyalty and commitment to family life, pride and cohesion of the family unit, and parental acceptance are also central tenets of familismo [7-9]. Thus, the drug use behaviors of Hispanic individuals may be in response to cultural scripts that support or oppose these behaviors. Cultural values have been shown influence both the initiation and cessation of drug use in this population [10].

There is mixed evidence on the influence of familismo on substance use behaviors [11] and decision-making concerning sobriety [12]. Results from a study of Hispanic day laborers found that families were a powerful motivator for changing alcohol use [13]. Other research on Hispanic male adolescents has suggested that a heightened level of family pride and support may play a key role in curbing marijuana use [14, 15]. Lower levels of familismo have been associated with a propensity toward greater alcohol use [16]. Thus, the family may serve as a protective factor against heroin drug use among the Hispanic population.

However, other research suggests that familismo may serve to reinforce unhealthy behaviors, such as long-term drug addiction and/or relapse, particularly when there has been a pattern of historical or intergenerational family drug use [17, 18]. One study found that in neighborhoods with concentrated poverty, parents or other family members with a history of drug use may inject heroin in close proximity to youth in the household, thus modeling poor decision-making and unhealthy behaviors. Another study found that visible drug use among family members may expose children to injection drug use at an early age, with the potential effect of normalizing such behaviors [19].

These mixed results suggest that the influence of the family is not well understood as it relates to drug use behaviors in Hispanic adults. Moreover, most research has focused on younger populations, and much less is known about the role of families for middle- and older-aged Hispanic drug users. To help fill this gap, we undertook the present study to examine the family’s influence on drug use behaviors, as perceived by Hispanic men who inject heroin. The aim of this paper is to describe the perceptions of the family’s role in starting and stopping drug use among a sample of Mexican American male heroin injection drug users.

Methods

Study Design

This study was part of a larger study that investigated the drug career trajectory and health of 227 adult Mexican American men who were long-term heroin injectors in a major metropolitan area in the Southwestern United States. The parent study is described in detail elsewhere [20]. The selection criteria of the parent study included: Mexican American (by self-identification) males who were 45 years or older, and currently or formerly used heroin via injection. We chose this age criterion because of the high rates of morbidity and mortality in this population caused by sustained drug use [21]. In this regard, this population can be seen as a prematurely aging group. A field-intensive outreach methodology [22] enhanced with respondent-driven sampling [23] was used to recruit from this hard-to-reach, hidden population.

Sample

The present study analyzed the data of 21 participants from the parent study who also consented to participate in a one-time qualitative interview. The study participants were mostly long-time drug users with low-incomes and education levels. The mean age of participants was 58 years, and the mean age of heroin injection initiation was 19.6 years, and all but three had previously gone through drug treatment. The majority of participants did not complete high school, were unemployed, retired, or disabled, and had income of less than $5,000 in the past six months. Two participants reported being homeless. Only four participants married, and the rest were either divorced or in unstable relationships.

Data Collection

The Institutional Review Board of the University of Houston's Committee for the Protection of Human Subjects (CPHS) approved all study protocols and materials. After obtaining consent, in-depth interviews were conducted using an interview guide that covered five domains, not including sociodemographic information: (1) family life and relationships; (2) social networks; (3) experiences of drug use; (4) sexual/medical history; and, (5) Mexican culture. Questions were open-ended, supplemented by probing questions to elicit a richer set of responses for each topic. Table 1 shows sample questions in the domains germane to the present study. Due to the hidden nature of this population, we deemed our sample size (N=21) was adequate for substantive thematic analysis [24] and consistent with other qualitative approaches [25, 26].

Table 1.

Sample Primary Interview Questions and Probing Areas by Domain

Domain	Areas for Probing
Primary Questions	Areas for Probing
Family Life and Relationships
I know all families have different problems and issues, and in order to understand you better, I want to hear about some of the problems and events in your family while you were growing up and currently. Tell me about your parents. How was their relationship? Did you always live with them?	Family life and household structure Past and current relationships with significant others (parents, siblings, extended kin, children, partners, etc.) Chronology of important events in the life cycle of respondent Positive/traumatic life events and ways in which individual responded/coped Concept of family/street family/friendships Role of family/friendships/street networks in the life and daily habits of individual Level of family involvement in criminal activities and/or drugs
Social Networks
Who do you hang out with usually? How often do you see your friends and acquaintances? What do you do when you kick back with your friends?	Where, how and with whom participant spends time Ethnicity of networks Meanings of relationships and symbiotic nature Significance of social networks and role of reference groups on values, norms, sexual behaviors, drug behaviors, etc. Types of material and emotional support provided by and given to network members Types of relationships/roles of individuals in social networks, sexual networks, and drug networks Overlap/fluidity of networks
Experiences of Drug Use
Now, I want you to tell me what drugs you have used in the past, starting with the first time you used any illegal drug. How old were you, who were you with, where were you and how did each one make you feel? How has your drug use pattern changed over time with regards to drugs used, who you use them with, how you use them, and how much you use?	History of drug use Current drug use Drug use specific to heroin Treatment experiences Drug buying/selling Experiences with law enforcement
Mexican Culture
Acculturation How long ago did you or your family leave Mexico? Do you think of yourself as a Mexican American or just American? Cultural norms and Values about Heroin Users	Language use Extent of ethnic contact (kinship ties, social networks, work relations, etc.) Relatives living in neighborhood Ethnic identification Participation in ethnically-identified activities

The interviews ranged from 1-2 hours and were conducted by a research team knowledgeable about the population and trained in qualitative interviewing methods. Interviews were conducted in the language preferred by participants. In most cases, participants spoke interchangeably in English and Spanish, and the interviewers followed the lead of the participants. The interviews were audio-recorded and transcribed verbatim, in their original language(s) to preserve the cultural nuances and linguistic integrity of the language(s).

Data Analysis

Three bilingual researchers independently coded the transcripts, using a thematic analysis approach [24]. The text was organized by linking, coding, searching and theorizing textual units in three successive rounds of coding [27]. First, transcripts were coded line by line to develop initial codes and broad categories for thematic direction. The coders met after this first round of open coding to debrief on the meanings and concepts assigned to initial codes and categories. A second round of coding formulated core categories and sub-categories that represented the emerging constructs on the perceptions of the family’s involvement or influence on drug use behavior. The debriefing process was repeated in the second round of coding, leading to the final round of coding, at which point we finalized the thematic content. Coding agreement was calculated between all three coders, and the average percentage agreement between pairs of coders was 90% or higher [28]. The analysis was conducted in NVivo 10® software.

Results

Three main themes emerged from our analysis of the interview data: family as an inadvertent environment for heroin use; heroin as a family legacy; and the family’s strategies for helping the addicted family member stop using heroin. Additionally, a sub-theme emerged on the paradox of family involvement, which spanned the three main themes.

Family as an Inadvertent Environment for Heroin Use

The first theme that emerged was the environment families created inadvertently to encourage the initiation, continuation, and relapse of heroin use. The majority of study participants indicated having had at least one family member who was involved in their drug use; these included siblings, cousins, brothers-in-law, and intimate partners (e.g. spouses, girlfriends, and prostitutes). Participants described their families as helping them to stay addicted by obtaining drugs. As one participant explained, he connected with family relatives to obtain drugs after relocating to a new city and not knowing the existing drug market: “It wasn’t like I was solo looking for it. It was the family… you didn’t have to go out there to locate it or nothing.” Another participant shared a prevailing sentiment: “I can score heroin wherever I want, because I come from a family of heroin addicts, you follow?”

All but two participants indicated that they became involved in broader heroin user networks through a male relative around their same age, primarily cousins, brothers, brothers-inlaw, and in one case, a stepson. For those who were able to stop using drugs for a period of time, family relatives with a similar drug problem were often the catalyst to relapse. For example, Hector was released from prison and had remained “clean” for a year or two when he watched his brother-in-law Ivan use heroin, which triggered his desire to inject. He stated, “I started again [when] I saw [Ivan] preparing his fix; [at] first I didn’t want it, then I did.”

Our analyses revealed that family members appeared to directly and indirectly support participants’ drug use, including providing money or tangible goods that could be sold or pawned to purchase drugs. Sammy described how his wife Loretta directly supported his drug habit:

I got her to look at it this way, “I’m broke. Loan me a hundred dollars.” She will go to the bank and give me a hundred dollars... She’s real good to me man. I can’t say nothing about her, man. She has been with me 48 years. Is she crazy or I am?

Julio disclosed that his mother supported his habit by providing him money to buy heroin when he was experiencing a withdrawal (malias). Julio described how he would tell his mother he was “sick” and she would give him money to “go get well.” Other participants mentioned that their rucas (slang for intimate partners) helped them with their heroin use. For example, Raul and Manuel characterized their relationships with their rucas Gloria and Anita as mutual and lasting. Raul stated, “I met me another junkie like me. Me and her [Gloria] used to do drugs and stuff all the time until I got locked up.” Similarly, Manuel noted that he started using heroin with his ruca Anita, after which their relationship and heroin use continued for five years.

Whereas some family members engaged in actions that explicitly supported the continued use of heroin, other family members engaged in more implicit or passive actions, which achieved the same result. Angel, a current user at the time of interview, indicated that his ruca Martha tolerated his life of heroin use and stayed with him through a five-year incarceration term for drug possession. He expressed his surprise with her loyalty and commitment to remain in their forty-eight-year relationship even when he received a lengthy prison sentence:

I don’t know why [Martha] never divorced me, I don’t know why man. I did five years … “What the hell is wrong with you?” I told her. “Are you brain dead or something? What the (expletive) are you waiting for me for?” She answered, “Well, I think personally you’ll change.” I said, “Who told you that (expletive) lie?” You know … I never thought that she would wait, never in my life, never.

Similar to Angel’s experience with Martha, Alfred was using heroin currently at the time of interview, and he described how nothing changed in his home life even after his mother discovered drugs in his room. He shared:

She just straightened up [and] asked me, “Sit down I want to talk to you.” “Orale (Sure) what’s on your mind?” She goes, “You.” And I go “What’s on your mind about me?” She goes, “You doing drugs, yes or no, that’s all I want to know?” “Yep.” Y asina se quedó (and that’s how it ended), it just stayed like that. She never hounded me, she never asked me what kind of drug I was doing. She never…she didn’t love me any less or any more. I just told her the truth, yeah I’m on drugs…that was the end of that.

Whether family members actively or passively supported study participants’ drug use, they were instrumental in participants’ patterns of behaviors that persisted over many years.

Heroin as a Family Legacy

The second theme that emerged was the perception that heroin was a family legacy. For the majority of study participants, a clear pattern of multigenerational drug use emerged in their descriptions of their experiences with drugs. The majority of participants described having had relatives who used heroin solely or in combination with other illicit drugs. Study participants’ family legacies of heroin use included a parent, siblings, and cousins.

Participants explicitly stated that a significant reason for initiating their own drug use was watching the drug use behavior of those close to them. On such participant was Joseph who grew up with his older brothers doing drugs:

I used to know about them [sibling brothers] doing it. I guess that was one of the reasons why [I started using heroin], you know? I knew that they were doing it so I thought it was cool and that’s one of the reasons why [I started using drugs and heroin].

Another participant described how the use of heroin by family members influenced him to start using heroin: “I’ve always thought that was the thing to do… that’s what some of my cousins were doing, too, so I started doing it, too, myself.”

Further analysis revealed that family legacies appeared to fall along gender lines despite having had multiple family members with a history of substance abuse. Specifically, the legacy was maintained predominantly by male family members; few participants identified female family members (e.g. mothers or aunts) as having had a heroin problem. The influence of fathers was particularly instrumental for study participants. One such participant was Rico, who stated simply, “My father, he was a heroin addict [so] my mom ran him off … [so] I didn’t meet my father until I was 15.” When asked if he was aware of his father’s history of drug addiction while growing up, Rico responded:

… [We all knew] pretty much cause my Dad would always be getting in trouble and he had traffic [drugs] at the house and then he’d take off and he would never come back. He was high. I knew something was wrong with him.

When asked if other members in his family used heroin, another participant stated, “A lot of them [in my family] were doing it before I was… My dad used to do drugs… I got a sister that does drugs too.”

In summary, a multi-generational pattern of injection heroin use emerged from our analysis, with many participants identifying male relatives as having been addicted to injecting heroin, which highly influenced their own drug use.

Families’ Strategies to Support Drug Cessation

The third theme that emerged from our analysis was the family’s varied strategies to support or encourage drug cessation. Study participants described two main ways that their families dealt with their drug use: discouragement and punishment.

Discouragement

The majority of study participants reported that various family members, including fathers, mothers, siblings, and intimate partners, strongly discouraged their drug use. The type of discouragement varied in severity and intensity. Family members implored some participants to stop their drug addiction. For instance, one participant, Jim, recalled his mother telling him, “You have to stop, son.” Other participants described interactions with their families that were much more confrontational than Jim’s experience. For example, one participant explained that when his mother found a marijuana joint while washing his shirt, she “threatened to call the cops and every damn thing.” For another participant, his older sibling discovered his addiction and admonished him for his deviant behavior:

You got life messed up, dude. Guess what you’re gonna do now? You’re gonna work. You don’t go to school, you’re gonna work and you’re gonna work the rest of your life. You don’t want to, you’re gonna get out of here. Mom’s not going to support you and I’m not gonna support you.

Punishment

Half of study participants reported that their family members punished them in some way for their addictive behavior. The most common form of punishment was avoidance. Study participants shared that their families avoided them in a number of ways, from telling them to leave their house, to limiting the time spent with them, to completely cutting off communication with them and/or withdrawing all financial or emotional support. For example, after serving time in prison, Richard (aka Flaco, translated as “Skinny”) resumed his heroin habit. Flaco shared how his family ended all contact with him as a result:

… Another thing about prison is prison’s not going to stop anything. So when I got out, I took prison with me and that’s when my whole family just disowned me…For over 25 years I wasn’t welcome in any of my family’s home.

Participants shared that they felt hurt emotionally as a consequence of their family’s avoidance of them. For instance, one participant described the changes in his family’s dynamics after they became aware that he was injecting heroin:

My sisters, they don’t look at me the same. They stay away from me … you know, they stayed away from me and my Mom knew. I thought I was hiding it pretty good but, you know … my father was an addict, so she knew the signs. My brother knew.

A less common form of punishment was corporal punishment. Some participants recalled that family members, regardless of gender, hit them as a way to discourage their heroin use. These participants viewed being hit as a form of love and/or caring by their families, and for some, a strategy of last resort. For example, Eddie recalled a time when he was younger when his brother hit him to get him to stop using drugs. He stated, “He [brother] whooped me up about 5 or 6 times when I was a kid. He didn’t just whoop me to whoop me. Tough love, you know.”

The Paradox of Family Involvement

Our analysis revealed a sub-theme woven through the three main themes. There seemed to be a paradoxical pattern in families’ discouraging and encouraging drug use. Several participants noted that members in their extended family networks continually implored them to stop using heroin or admonished or physically confronted them about their drug use while at the same time permitting or supporting their addiction. For example, Manny had been addicted to heroin for a long time, and his family constantly pleaded and argued with him to stop using drugs. However, they encouraged his addiction by giving him money or items to pawn. According to Manny:

Sometimes I ask my wife and tell her, “let me borrow some things [to pawn]. She responds, “You need to stop that shit.” She’s bitching about it but she still sometimes gives me money.

This quote illustrated the push and pull of the family toward and away from drugs for Manny and many other participants. This paradox between discouraging and encouraging use emerged mostly in situations where family members’ actions shielded participants from facing some of the consequences of their injection drug use. These situations included permitting participants to live at home to avoid homelessness, violence, and incarceration. Thus, while families routinely admonished participants’ use of drugs, families created or maintained conditions conducive to addiction.

Discussion

In this study, we examined the family’s perceived role in the drug use behaviors of Mexican American men who abused heroin. Overall, we found a consistent pattern of family members’ involvement in the users’ experiences of addiction that reflected aspects of familismo in unexpected, and perhaps, unintended ways. First, the passing down of drug addiction occurred from one generation to the next. Second, the intergenerational transmission of drug use behaviors suggested that addiction evolved into a normative expectation within the family environment. These findings are a seeming contradiction to the literature about familismo, which has depicted the concept as a protective factor for developmental outcomes in Hispanic youth [29, 30] and against drug use [14-16]. On the contrary, our findings suggest that familismo may actually pose as a risk factor for addiction. This finding is supported by other research showing that the family environment is a risk factor for heroin relapse [10, 18] and continuation of substance use [31]. Our finding on the paradoxical role of family in both encouraging and discouraging participants’ drug use further reflects the mixed nature of the current literature. Thus, our findings may reflect the fulfillment of familismo by both the men in this study and their families, which came at a very high cost for all those involved.

New Contributions to the Literature

Our study further advances the literature with respect to the gendered nature of support for continued drug use. First, men and women family members enabled participants’ addiction. Men were most notably the conduits for intergenerational transmission of drug use behaviors. However, women, particularly mothers and intimate partners, also were featured prominently in the drug experiences of the Mexican American men in this study. The women family members served as enablers of addiction by providing money or tangible goods that could be sold or pawned to purchase drugs, or by permitting participants to live in the family home to avoid homelessness, violence, and incarceration.

Addiction research is limited on the cultural context that might underlie the motives for such behaviors. However, the research on gender roles in the family literature may provide some plausible explanations. Gender role differentiation and social role functioning have been shown to be important to the social organization of Mexican cultures and are embedded in the tenets of familismo [32]. Machismo and marianismo are roles occupied by the father and mother, respectively, in traditional Mexican families [33, 34]. Machismo is the concept of masculinity or manliness, which includes characteristics such as male dominance and drinking to excess, among others [35-37]. Marianismo is the concept of femininity in the traditional Mexican family, which involves traits of weakness and deference [38]. This female gender role is based on the emulation of the Virgin Mary in the Catholic religion and has been referred to as la madre abnegada [34], meaning “self-sacrificing mother.” As the mariana, the mother is expected to be completely submissive to her husband, acknowledge his authority, and perform self-sacrificing behaviors to benefit her family [34, 39, 40].

Although we did not specifically ask study participants for their views about machismo or marianismo, our findings suggest that family members were fulfilling these gender roles by either modeling risky and excessive behaviors to meet the social expectations of masculinity, or by nurturing addiction out of weakness or deference. For example, despite admonishing participants for their drug use behaviors, mothers gave them money and emotional support. This is consistent with prior research showing that men with heroin addiction often maintain a close relationship with their mothers and reside with their parents well into middle and/or late adulthood [41, 42]. Similarly, intimate partners continued their romantic relationships with participants even when they rebuked their drug use behaviors. These enabling behaviors may have also reflected women’s overall role as caretaker of the family to stabilize family dynamics or maintain the family structure [17, 43]. However, from the perspective of participants, the women in their lives seemed unwilling to take a strong stance against their drug use.

Our findings on discouragement and punishment as strategies to promote drug cessation are consistent with prior research. Previous research has found that verbal and physical confrontation are used as a coping response to drug-addicted behavior [44, 45]. A qualitative study in Mexico and England of family members of individuals with alcohol or drug problems found that they employed two main types of responses to substance abuse, “assertive with emotional coping,” such as critical challenges and emotional threats; and “emotional coping with an element of controlling,” which involved physical struggles [45]. Despite the discouragement from others, the participants in our study did not cease their injection heroin use, which suggested that they anticipated such confrontations and minimized them through their avoidance of family members. However, some of them also reported family members avoiding them, which seemed to have a greater impact on changing their drug use behaviors than discouragement. This finding suggests that promoting positive behavior changes in individuals with addiction problems might be better achieved by avoiding the individuals rather than confronting them. More research is warranted on the relationship of avoidance to drug use behaviors to develop best practices that can be incorporated into treatment approaches.

Several study limitations should be noted. First, women were not included in this study which prevented us from exploring how gender plays out in the addiction experiences of Mexican American individuals who abuse heroin. More research is needed to examine how the drug use experiences of women align with those of men, particularly with respect to the perceived influences of the family we identified in this study. Second, we only conducted one interview with each study participant. Follow up interviews would have provided richer data for analysis. Despite these limitations, our paper discussed the influence of family members from the perspectives of the addicted family member using a fundamental cultural construct that is often associated with Hispanic families but seldom clearly described in addiction research.

Conclusions

The Mexican family is an important cultural context that can have important implications for substance abuse treatment in the Mexican American population. Stopping long-term heroin injection behavior is a significant challenge for any individual, and thus the enabling role of families is particularly concerning, especially in families with a “legacy of drug use.” More research is needed to identify and disentangle the risks and benefits of family involvement to inform culturally-centered therapies and cultural adaptations to traditional therapeutic approaches with Mexican American individuals who abuse drugs and their families [46]. In particular, helping families understand the potential harm of their actions may be a critical component of an intervention plan. Additionally, we identified that women were prominently featured in men’s experiences in this study, and thus special attention should be given to how these family members’ influence can be successfully leveraged in existing drug treatment plans.