Family burden in injecting versus noninjecting opioid users.

BACKGROUND: A substance-dependent person in the family affects almost all aspects of family life that also impact the lives of the significant others and causes enormous burden.
OBJECTIVES: This study was aimed to assess the pattern of burden borne by the family caregivers of patients with opioid-dependence-injecting drug users (IDU) and noninjecting drug users (NIDU).
MATERIALS AND METHODS: A cross-sectional study was conducted with ICD-10 diagnosed-opioid-dependent subjects (IDU and NIDU, N = 40 in each group) and their family caregivers attending a de-addiction centre at a multispecialty teaching hospital in North India. Family Burden interview schedule was used to assess the pattern of burden borne by the family caregivers.
RESULTS: The IDU group was characterized by older age, longer duration of substance dependence, greater subjective and objective family burden in all the areas compared to NIDU group, and single status and unemployment were associated with severe objective burden. The family burden was associated neither with age, education, or duration of dependence of the patients, nor with family size, type of caregiver or caregiver's education in either group.
CONCLUSION: All caregivers reported a moderate or severe burden, which indicates the significance and need for further work in this area.

Indian communities are in transition amidst changing states of growth and development due to multiple influences such as globalization, migration, and industrialization.[1] These factors are contributing rapid increase in substance-related problems in modern communities. Substance use disorders, best conceptualized as chronic, noncommunicable diseases, are one of the top 20 risk factors to health worldwide.[2] It has great impact on the individual, family, and community at multiple levels.[2]

An illness adversely affects the individual as well as those around in terms of physical, emotional, and financial distress, and social and occupational dysfunction, which also impact the lives of the significant others and labeled as ‘burden’.[3] As family is the key resource in the care of patients including those with substance dependence,[4] this burden is also referred as ‘family burden’. The care giving family members are those who provide care to other family members who need supervision or assistance in illness or disability.[5] The family burden is largely determined by coping styles of family members.[6]

Substance dependence affects almost all aspects of family life, for example, interpersonal and social relationships, leisure time activities, and finances. Families of substance-dependent men have increased risk of stressful life events including emotional and physical abuse, medical and psychiatric disorders, and greater use of medical care services.[789101112]

A study[13] from India compared families of 30 subjects each with alcohol dependence, opioid dependence, and schizophrenia, in which burden was assessed by Family Burden Interview Schedule (FBIS).[14] Similar moderately-severe objective, and subjective burden was reported across alcohol, opioid, and schizophrenia groups.[13] Another study from India used FBIS to assess burden in wives of men with ICD-10 diagnosed opioid-dependence syndrome (N = 50); severe burden was more often reported on both subjective (56% vs. 44%) and objective assessment (74% vs. 26%).[15] A study from Nepal compared FBIS assessed family burden in 30 subjects each with intravenous drug use and alcohol dependence; the overall burden was higher with the former (66.7% vs. 46.7%) and, compared to other family caregivers, the spouses were more tolerant and reported a lower perceived burden.[16] A recent study by our group compared family burden among alcohol, opioid, and alcohol dependence with opioid dependence groups and found moderate or severe burden in all three groups.[17]

The limited data in this area provided impetus for the present research to study the pattern of burden borne by the family caregivers of men seeking treatment for opioid dependence injecting drug users (IDU) and noninjecting drug users (NIDU).

MATERIALS AND METHODS

This study was conducted at the Drug De-addiction and Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh – a multispecialty teaching hospital providing services to a major area of North India. This study had the approval of the institutional research ethics committee. The data collection lasted from 1st January 2010 to 30th August, 2011. A cross-sectional design was employed. The sample of convenience was recruited from the outpatient service by screening all the new registrants with opioid-dependence syndrome (as per ICD-10)[18] and their attendants to see if they fulfilled the inclusion and exclusion criteria. A written informed consent was obtained from both the patients and the caregivers taken up for the study.

The primary sample consisted of the care giving family members of the patients seeking treatment for opioid-dependence syndrome (as per ICD-10).[18] With this two groups were generated, family members of patients with injecting drug use (IDU) and noninjecting drug use (NIDU) (40 in each group). The family members accompanying the patients were included in the study if they were involved in their care and treatment-related assistance or supervision for ≥1 year and were living together with the patients. The ≥1 year cutoff for caring was taken for the sake of comparability – a majority of the studies from India have used this cutoff.[192021] In case of more than one family caregiver being available, the caregiver selected for the study was the one staying together longer and being involved in the care more, as agreed by a consensus among the patient, caregivers and the treating clinician. The caregivers were to be aged ≥18 years, of either gender, and healthy by general clinical assessment. The patients were to be males, aged ≥18 years, with opioid-dependence syndrome diagnosed as per ICD-10.[18] In both groups, 20 subjects were on medications for withdrawal management- Clonidine-NSAID-Nitrazepam combinations, while others 20 subjects were on Naltrexone maintenance treatment. The patients and caregivers were excluded from the study if they had any chronic debilitating physical disorder, organic brain syndrome, or mental retardation.

Demographic and clinical data for the caregivers and the patients were collected by the first author in the outpatient clinic. The selected family caregivers were assessed on family burden interview schedule (FBIS).[14] FBIS is a semistructured interview schedule, which covers six areas: Financial burden, disruption of family routine activities, disruption of family leisure, disruption of family interaction, effect on physical health of others and effect on mental health of others. It has 24 items, each rated on a 3-point scale (details are mentioned in appendix). Inter-rater reliability for all items is 0.78 and validity is 0.72. The scale was developed for Indian population socioeconomic and cultural conditions and has been widely used in India with the families of patients with mental retardation, chronic physical, alcohol use, and schizophrenic, affective, and neurotic disorders).[192021] One question to assess the global subjective burden was also included.

The data were analyzed using SPSS version 14.0 for Windows (Chicago, Illinois, USA). Descriptive data were analyzed by percentage, mean, and standard deviation. Group comparison was done by independent t-test for the continuous normally distributed variables and by Chi-square test the discrete variables. Binomial logistic regression analysis was employed to find out the predictors of severe objective or subjective family burden.

RESULTS

Patients

Demographic profile

Compared to NIDU group, the IDU group was older (34.27 ± 8.36 years vs. 28.12 ± 7.06 years, P < 0.01). Both groups were comparable for education, income, religion, marital status, occupation, family type, family size, and rural–urban location [Table 1].

Table 1

Sociodemographic profile of patients

Clinical profile

Compared to the NIDU group, the IDU group had longer duration of opioid dependence (8.81 ± 5.36 years vs. 5.82 ± 4.39 years, P < 0.01) [Table 1]. Psychiatric comorbidity was present in 5% IDU patients (depression-1, anxiety disorder-1), and 10% NIDU patients (psychosis-2, bipolar disorder-1, depression-1). Compared to NIDU group, physical comorbidity was higher in IDU group (25% vs. 7.5%, P = 0.03). In the IDU group, 10 patients had physical disorder – hepatitis (3), ulcer (2), seizure disorder (1), Gout (1), deep vein thrombosis (1), pancreatitis (1), and diabetes mellitus (1) and in NIDU group three patients had physical disorder - hepatitis (1), and seizure disorder (2). Family history of substance dependence was comparable in NIDU and IDU groups (40% vs. 35%).

Caregivers

Mean age (42.7 ± 11.6 vs. 47.3 ± 13.1 years), education (9.52 ± 3.82 vs. 10.27 ± 3.35 years), and proportion of working caregivers (30% vs. 37.5%) were comparable in IDU and NIDU groups. Compared to NIDU group, the IDU group had higher proportion of caregiver being the wife (45% vs. 27.5%).

Burden

IDU group had significantly greater severe objective (70% vs. 5%, P < 0.001) and subjective burden (80% vs. 50%, P < 0.01) compared to NIDU group. For the different areas of burden under consideration, IDU had significantly greater burden severity in all the areas compared to NIDU group [Table 2].

Table 2

Burden scores

In terms of objective burden severity scores, the scores were significantly higher in IDU group than NIDU group [Table 3]. For objective and subjective burden the differences were not significant for the duration of substance dependence of <5 years vs. ≥5 years and as reported by wives vs. other caregivers.

Table 3

Objective burden scores

Significant association was found between financial domain and physical comorbidity (severe burden in 100% patients with physical disorder vs. 50% patients without physical disorder, χ2 = 8.0, P = 0.005) and family leisure domain and physical comorbidity (severe burden in 90% patients with physical disorder vs. 50% patients without physical disorder, χ2 = 5.0, P = 0.025). Significant association was not found between burden domains/scores and psychological comorbidity and family history of substance dependence. Demographic and clinical variables of IDU and NIDU group (N = 40 each separately) with severe vs. moderate subjective or objective burden were compared by Chi-square test. In the IDU group, higher proportion of single subjects (87.5% vs. 58.3%, χ2 = 3.88, P = 0.049) compared to married and unemployed subjects (85.7% vs. 52.6%, χ2 = 5.19, P = 0.023) compared to employed reported severe objective burden. When similar comparison was made for various areas of burden then IDU group had significantly higher severe burden of disruption of family leisure in unmarried compared to married subjects (81% vs. 45.8%, χ2 = 5.01, P = 0.025) and unemployed compared to employed subjects (76% vs. 42%, χ2 = 4.82, P = 0.028).

Simple binary logistic regression analysis with enter method was used to study the relationship among independent variables which were more frequently present in IDU and NIDU groups with severe objective and subjective burden. Unemployment was the only significant predictor of severe subjective burden with odds ratio of 5.4 (β=1.68, SE = 0.775, Wald = 4.74, CI 1.18–24.64, P = 0.029).

DISCUSSION

The maximum impact of a psychiatric disorder including substance dependence is usually borne by the family and often leads to financial burden and physical and mental health problems of the family members. For substance dependence in particular a lot of money is spent on procuring the substances, managing complications like accidents and crime, and seeking treatment.[10] Thus, the study of family burden in substance dependence is of paramount importance as the implicated factors may predict the outcome of the problem. This is also useful in designing the individual and family interventions to deal with substance dependence and associated problems.

As a small attempt in this context, our study used a hospital based population of caregivers’ of treatment seeking opioid substance dependent (IDU vs. NIDU) subjects to assess the burden experienced by the caregivers. The demographic and clinical profile of our IDU and NIDU groups were generally similar to that reported in earlier studies from our centre[1322] and other centers.[1516] However, compared to a study from another centre in North India,[15] our NIDU opioid group was more educated (school completers 55% vs. 10%), and more unemployed (52.5% vs. 26%); and fewer urban subjects in our study (72.5% vs. 98%), could be the effect of the other centre being located in a metropolis. Compared to IDU group, NIDU group had greater psychiatric comorbidity which was also an important reason for treatment seeking in addition to drug dependence.

Compared to other Indian studies,[1315] in our study the objective burden in NIDU group was more often moderate (95% vs. 44% to 63%) than severe (5% vs. 23% to 56%). Shyangwa et al.16 reported severe burden more commonly than moderate burden. Similarly objective burden in terms of total score (17.12 vs. 23.03) and burden areas scores were also lesser in our NIDU subjects compared to earlier studies from our centre[13] and a different centre. Our study found moderate and severe subjective burden in equal proportion (50% each) in the NIDU group, while earlier Indian studies have reported excess of either moderate[13] or severe subjective burden.[16]

The objective and subjective burdens, and different areas of burden in our IDU group were comparable to an earlier study conducted in a similar population in Nepal.[16] That study reported greater family burden severity in IDU compared to patients with alcohol dependence.[16] We also found significantly greater burden severity in IDU compared to the NIDU opioid-dependent group.

Our findings of greater objective burden in unmarried and unemployed IDU subjects is understandable in that the subjects with severe dependence are more prone for not getting a partner as well as job, which further increase the financial burden and disturbed family functioning. Higher disruption of family interaction might be a common factor for both the subject remaining single as also his family caregiver perceiving greater burden. Unemployment was the only significant predictor of severe objective burden in IDU group (OR 5.6). Poor social support was reported as significant predictor for greater family burden in a study on women substance abusers.[23]

We found more disruption of family leisure in singles in comparison to the earlier study from our centre that reported married subjects to be more burdened especially for domains of finance, disruption of family routine, and effects on mental and physical health.[13] That study also reported higher burden being associated with severe dependence while our research did not find such an association. Also, that study reported the burden for financial domain to be higher in rural population and disruption of family leisure to be more in married, elderly and female caregivers.

Our study is limited by a small sample size from hospital setting. Assessments of burden were cross-sectional and nonblind and other sources of burden like other stressors, and life events etc., were also not assessed. All information was obtained from a single family care giver and several mediators such as coping, appraisal, expressed emotions and social support were not assessed. Structured instrument was not employed to ascertain caregivers’ psychological status.

Within these limitations our study found that substance dependence is associated with substantial burden for the family members especially in the IDU group, more objective burdens in single and unemployed IDUs. These findings suggest directions for further research in this area. Future research should be conducted in a large sample with prospective design to further study the exact effects of substance and other mediators such as family type, and other demographic parameters, other stressors, life events, coping, and social support on the family burden. It should also be supplemented with structured evaluation of physical and psychological disorders among patients and caregivers and their contribution in family burden.

Family plays a complex role in substance dependence. Hence, there is vital need to improve communication between families and health providers and active involvement of families in the therapeutic process. Providing services to the whole family and addressing family burden can improve treatment effectiveness.[24]