He Won’t Agree to the Care We Know He Needs

Cwfranklin’s adult son smokes fentanyl. With his parents’ active support, he’s gone through various rounds of treatment. His recoveries have been substantial, but so far they haven’t lasted. Now his parents are considering “lines in the sand” to convince him to undertake a longer, multi-stage treatment plan. Allies CEO Dominique Simon-Levine suggests an alternative: CRAFT-informed engagement that returns responsibility to their Loved One, where it belongs. 

“Our 35-year-old son has been living with us for a few months trying to taper off his daily level of fentanyl smoking. He seems desperate to get off, but as with every other time in the past, he is worried about the disruption and pain of detoxing and the month or so of physical and emotional upheaval that is looming ahead for him. He is mostly financially dependent upon us as he has no job or place to live, and we are now back in the thorny dynamic of “demanding” that he be sober and moving forward with his life goals in order for us to support his efforts in getting his college degree, a job, etc. We’ve told him that his time here tapering has come to an end and he needs to go to detox and a comprehensive treatment program. He is fine with a one-month detox/inpatient, and has agreed to go in the next few days. But he is insisting we are completely off base to ask him to do the step-down month after that (a highly structured sober living house with full-time IOP).

Over the years, this added month in a longer-term program (two other times) has led to a much better chance of him having at least a 6 month period of sobriety. Every time he has gotten out of the one-month inpatient program and moved into a less structured sober house and a part-time IOP has led to him leaving after a few weeks or a few months, with a relapse within a few weeks. We want his “buy in,” but we think his addicted brain is not up to the task of thinking clearly….with addiction driving the show and making him terrified that the extra month(s) we are “requiring” will waste his life energy as he won’t be able to take “another program” that will only set his life back that much longer. It makes no sense as his life has been going nowhere during these months he has been living with us—but in spite of all the open-ended CRAFT-inspired conversations we have had with him, he is adamant in his belief that he can have a less structured living situation after the one-month program and be successful this time.

We have drawn the line in the sand that we aren’t going to support his plan, since we have done his less structured approach (maybe three or four times) in the past. It hasn’t been enough support, and he has ended up using and not following through on regular exercise, attending meetings and the other things he knows will support his long-term sobriety goals. He’s now saying that he will go to detox and the one-month program but then he will have to go his own way after—which to us means he will go back to hanging with his druggie friends (stealing, etc.) and getting back into fentanyl addiction. That makes us scared and sad, but we don’t want these emotions to drive our decision.  

We COULD just tell him to leave now as we aren’t going to continue to support his choices that we think will lead right back to addiction…or we could go along with his plan to just do the one-month program, hoping that he will be more reasonable once there and decide to do the second part of the program.  

We would love to hear your thoughts on how to approach this with more of a CRAFT philosophy.

Hi Cwfranklin

Your son is 35 and has been through a number of treatment programs over the years. In the past he has done better, defined by you as abstinent longer, when his inpatient stay was immediately followed by admission to a more structured setting for 30 days prior to moving to a recovery home. Your son is balking at your insistence that he repeat this path. Is it that he would rather go straight to a recovery home? Or does he think he can come home after that one month in an inpatient program?

Medication-assisted treatment (MAT) is too promising to ignore

A couple things jump out at me right away. What about medication-assisted treatment (MAT)? Has your son sworn-off taking Suboxone (buprenorphine) for instance? He is right to worry about the fentanyl causing physical and psychological difficulties when he stops taking it, but a good MAT treatment plan will be designed to help him through that process. A detoxification unit will probably titrate him down using something like buprenorphine.

Still, it’s true: he will probably not feel well for weeks into his inpatient stay. It makes sense that your son wants to be completely opioid free. With Suboxone, though, he wouldn’t have to go through the discomfort now. He could titrate off the Suboxone later, when his support systems and health are improved. And importantly, there’s a strong protective factor with Suboxone in that it lowers the risk of overdose by 50%. Leaving jail and leaving rehab are two high risks moments for people who use opioids. Suboxone would protect your son from the risk of relapsing fresh out of inpatient treatment, and from overdosing because he no longer has any gauge for his level of opioid tolerance.

Your son has had success staying free from opioids in the past, sometimes getting as much as six months drug free. That is wonderful, and needs to be marked in your dealings with him as the sign of strength and determination that it truly is. But it only happens when he spends longer in a more structured treatment program. When he gets to a recovery/sober home, things start to fall apart. I can see how this could be. One or even two months out from stopping opioids, the individual can still feel poorly—not sleeping, feeling low and lethargic, taking little interest in food.

It is hard to hang on, day in, day out. A sober/recovery home is far less structured than an inpatient setting, and allows for more and easier opportunities to get and use drugs. That second month probably helps him recover more of himself before returning to a community setting and thus, as you noted, he is able to hang on longer. With two months of structure under his belt, your son perhaps gains more momentum and strength to push on in recovery once he’s again based in the community.

He’s the one who must choose

At 35, your son has probably been using drugs addictively for years. You have been there for him, engaging him into inpatient treatment and helping him access step-down programs and homes. He knows what it’s like to break down and use. He knows what to do so that this doesn’t happen—he’s been six months abstinent in the past. And yet he eventually slips. He knows the score.

It’s not for me or for you as his parents to dictate the treatments he chooses to engage with. I would like to see MAT on board; you would like to see him transition to a more structured program before entering a recovery home. You can encourage both these things by ensuring they are available to him, and building your relationship and trust with him so that he’s more likely to feel like listening. That’s it.

Again, by this point, your son knows what it takes to remain abstinent. He’s done it before. The need for repeated treatment episodes is unfortunately common. I would recommend you see this next admission as a brand-new start for your son, one that can lead to a more profound decision not to use. He has your support. The doors to treatment have been opened, thanks to you. Let him and his treaters decide next steps.

The past isn’t necessarily prologue: things really can change.

From our viewpoint (and surely that of many of our members) you’re in an enviable place. Your son is willing to go to treatment, and that’s huge. Now is not the time to negotiate how he should proceed through that treatment.

You are scared for him and for yourselves if he doesn’t stay abstinent. Should he relapse, the whole cycle could start again. He could land back home, or homeless and jobless. Everyone knows and fears this score, this seemingly black-or-white choice. Yet the reality would likely be a lot more gray.

Pressure can backfire in serious ways

It’s hard not to pressure your son to do what seems obvious to you. But pressure, such as threats not to pay for treatment or to cut off support for school and so on, will almost certainly feel to him like punishment. It will put a wedge between you, and may weaken your connection. CRAFT teaches us that this connection is critical for both you and your son.

We hope the connection you have right now has grown deeper through the use of CRAFT skills and methods. Your respect for his decisions are exceptionally important. Rather than trying to force your son into a single track, I would suggest you get more collaborative with him by discussing what should happen if it doesn’t go well. What will be different this time? Let him talk; you just listen. This is not about convincing him to do something. He can and will be the one choosing. You are on the record about your fear of what happens when he goes directly from inpatient to recovery home living.

Boundaries are part of supporting him—and yourself

After listening to him justify his chosen course, you set your boundaries. You can decide what you will need before considering letting him come home again. This can include MAT or six months abstinence. It can include things like a job or taking a class, regular maintenance of his recovery, mutual aid groups—whatever he agrees is helpful and recovery oriented—a phone call when late, etc.

These are your boundaries. You’re not talking about his drug use behavior, his personal affairs, his need for housing or income. When your son steps over a boundary, you note it, and go back to the CRAFT basics. The trouble will come to light earlier as well because you know how to recognize his signs and patterns (Module 3). But you’ll also know how best to respond to that trouble: how to communicate and listen better (Module 4), and when to step closer when he’s not using (Module 5) and away when he is (Module 6). You will be better at seeing and assessing what is going on in front of you, in the moment. You’ll be less reactive, and more effective overall.

Your boundaries can also include what you will pay for and support should he not be able to come home. This can include more treatment, and maybe some limited help with living expenses (but not cash that might go to drugs).

While you’ve probably said or thought all of this before, you’ll be presenting it very differently to your son. “This is what I (Mom) am willing to do going forward, and what I cannot do. You’re in the driver’s seat, son.” Because ultimately, he is, and we want him to feel it. You have shifted the responsibility onto him with your boundaries, and away from Mom trying to force the action you are looking for.

If things fall apart again after this treatment episode, I would suggest you look at your home and resources through the CRAFT lens of rewards (Modules 5 and 6). Perhaps he’s not permitted to come home if he’s continuing to get high. Perhaps he is welcomed in your home for a short while with a boundary like that suggested above. We worked out one CRAFT example that reduces housing to an almost daily reward we call the daybed and locker.

CRAFT provides science-backed principles on which to make a lot of difficult decisions when it comes to our Loved Ones with addiction, and you know best what can work. Our job here at Allies is to show you ways to apply those CRAFT principles to your situation. It’s a powerful combination. Thanks for writing in. Let us know how things progress.