This study investigated the prevalence and causes of drug abuse relapse as expressed by clients in NDLEA rehabilitation centers in North Central, Nigeria. The study also examined the influence of demographic variables of parental occupational status, educational attainment, marital status and age on respondents’ views.
The descriptive survey design was adopted for the study. Censors sampling method, that is, only the available clients or respondents at all rehabilitation centers in the North central region was used. A researcher-designed questionnaire on “Prevalence and Causes of Drug Abuse Relapse” was used to collect relevant data. The instrument had reliability co-efficient of 0.69 using test re-test method. Out of 175 questionnaire forms administered, 169 were retrieved and 159 were valid for data analysis. All the hypotheses were tested using t-test and Analysis of Variance (ANOVA) statistics at 0.05 level of significance.
Among other findings, the main findings of the study revealed that drug abuse relapse is moderately prevalent among clients in NDLEA rehabilitation centers in North Central, Nigeria and the main causes are easy availability of drugs, drug abuse environment, frequent passing through drug using site such as bar parlor and smoking joint, and being in companying of drug users.
Based on the findings of the study, it was recommended among others that counsellors should equip the relatives and families of clients with some social skills training such as human relation skills that they can employ in persuading their wards who have received treatment to avoid returning to the company of friends or environment that can still expose them again to the abuse of drugs.
Inhaltsverzeichnis
LIST OF TABLES
ABSTRACT
CHAPTER ONE
INTRODUCTION
CHAPTER TWO
REVIEW OF RELATED LITERATURE
CHAPTER THREE
METHODOLOGY
CHAPTER FOUR
RESULTS
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
References
Prevalence and Causes of Drug Relapse Questionnaire (PCDRQ)
DEDICATION
This study is dedicated to the Almighty Allah, the Creator of Mankind and Sustainer of the Universe.
ACKNOWLEDGEMENTS
I am grateful to God, the Almighty, for making it possible for me to write this dissertation successfully. I also appreciate Him for His protection and blessings over me and for making me to get this far in life.
I am indebted to my supervisor, Prof. Irene, A. Durosaro, for her advise and useful suggestions, which have helped me a lot in completing this dissertation. I also express my gratitude to the Head of the Department of Counsellor Education of University of Ilorin, Prof. Mary, O. Esere and all other lecturers in the Department for the high academic standard maintained in order to distinguish students of this Department from students of other institutions offering Guidance and Counselling. Other lecturers include, Profs. A. I. Idowu, A. A. Adegoke, Mary. G. Fajonyomi, L. A. Yahaya, A. O. Oniye, Drs. Falilat. A. Okesina, S. K. Ajiboye, Folukemi. N. Bolu-Steve, Mulikat. L. A. Mustapha, Aminat. A. Odebode, Mariam, B. Alwajud, Mr. A. Adegboyega, A. Adeboye, Mr. D. O. Adebayo, Mr. Muhammad, S. A. and Mr. K. Olagunju for their intensive academic and moral support. May Almighty Allah grant them all, long life to reap the fruit of their hard labour.
My special thanks and gratitude goes to Prof. Issa Baba of Department of Behavioural Science, University of Ilorin Teaching Hospital, Ilorin for reading through my manuscript and necessary corrections he made to make the work better. The State Commanders, the DDRD Heads and staffs of NDLEA in North Central Nigeria, for their permission and supports in administering the research questionnaires to clients in their respective commands.
My special thanks equally go to my research assistant, Mr. Akeem, A. Adigun and my course mates, whose support had saw me through the completion of this dissertation. Finally, I appreciate my wife, my children, as well as my siblings and all my family members for their enduring prayers and support during the course of my study. May God Almighty bless them all.
SANNI, Murtala Muhammed
October, 2019.
LIST OF TABLES
1. Population of Drug Addicts in North Central Senatorial Districts
2. Percentage Distributions of Respondents’ Demographic Characteristics
3. Percentage Distribution of Prevalence of Relapse among Clients in NDLEA Rehabilitation Centre in North Central
4. Mean and Rank Order of Respondents’ Responses on Causes of Drug Abuse Relapse
5. Mean, SD and t-test Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Parental Occupational Status
6. Mean, SD and t-test Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Parental Occupational Status
7. ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Educational Attainment
8. ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Educational Attainment
9. ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Marital Status
10. ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Marital Status
11. DMRT Showing the Group that Contribute to the Difference in Causes of Drug Abuse Relapse
12. ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Age
13. ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Age
14. DMRT Showing the Age Group that Contributes to the Difference in Causes of Drug Abuse Relapse
ABSTRACT
Despite sufficient research studies in the field of drug abuse, drug abuse relapse still remain one of the salient aspect that received less attention among research experts. This study thus investigated the prevalence and causes of drug abuse relapse as expressed by clients in NDLEA rehabilitation centres in North Central, Nigeria. The study also examined the influence of demographic variables of parental occupational status, educational attainment, marital status and age on respondents’ views.
The descriptive survey design was adopted for the study. Censors sampling method, that is, only the available clients or respondents at all rehabilitation centres in the North central region was used. A researcher-designed questionnaire on “Prevalence and Causes of Drug Abuse Relapse” was used to collect relevant data. The instrument had reliability co-efficient of 0.69 using test re-test method. Out of 175 questionnaire forms administered, 169 were retrieved and 159 were valid for data analysis. All the hypotheses were tested using t-test and Analysis of Variance (ANOVA) statistics at 0.05 level of significance.
Among other findings, the main findings of the study revealed that drug abuse relapse is moderately prevalent among clients in NDLEA rehabilitation centres in North Central, Nigeria and the main causes are easy availability of drugs, drug abuse environment, frequent passing through drug using site such as bar palour and smoking joint, and being in companying of drug users.
Based on the findings of the study, it was recommended among others that counsellors should equip the relatives and families of clients with some social skills training such as human relation skills that they can employ in persuading their wards who have received treatment to avoid returning to the company of friends or environment that can still expose them again to the abuse of drugs.
CHAPTER ONE
INTRODUCTION
Background to the Study
The phenomenon of drug abuse is not a new trend in the history of human race; it exists in every cultures, some religious practices and among people of different ages, with no respect to gender across the globe. It has become one of the health related problems that is of great concern to the Nigerian government and others stakeholders in the field of health and education. Drug has been defined variously by different authors and medical experts. For example, the Forensic Consulting (2004) defined drugs on three classifications of clinical, general and popular definitions. In a clinical term, a drug is a therapeutic agent; any substance other than food, used in the prevention, diagnosis, alleviation, treatment or cure of disease in man or animals. According to general definition, a drug is a substance other than food intended to affect the structure or function of a physiological system such as the human body. Drug is any chemical substance, other than food, which when taken affects one’s mood, behaviour and state of mind. Hence, any substance that changes the way the body or mind function (the way someone feels, thinks, sees, tastes, smells, hears or behaves) is a drug (Nigeria Drug Law Enforcement Agency, 2014). This implies that the meaning of drug transcend the medical boundaries.
The Nigeria Drug Law Enforcement Agency (2014) noted that drugs are all encompassing, ranging from the socially acceptable drugs (such as alcohol, caffeine and Nicotine), through prescription drugs (like Amphetamine, lexotan, valium) to the illicit drug (Cocaine, Heroin, Mariguana). Ballas (2006) classified drugs into legally approved and disapproved drugs. Legally approved drugs are drugs (tobacco and alcohol) which have through the years become part of the society, had remained open to public consumption. In some cultures, these drugs are not only tolerated, but their consumption is explicitly encouraged (Melgosa, 2005). On the other hand, the illegal drugs are drugs like heroin, cocaine and morphine, which are dangerous to physical, mental and social wellbeing of the users. Abuse of any of the two groups of drug affect the brain and its functions, leave harmful chemical remain in the body and create a habit (Melgosa, 2005).
In the light of the above, drug abuse can be defined as self-administration of drugs for non-medical reasons, in quantities and frequencies which may impart inability to function effectively and which may result in physical, social and/or emotional harm. Kwamanga, Odhiambo and Amukoye (2002) defined it as the unspecified use of a drug other than for legitimate purposes. According to the World Health Organization (2010), drug abuse is the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. It is the arbitrary over dependence or misuse of one particular drug with or without a prior medical diagnosis from qualified health practitioner. This follows that drug abuse is the misuse of medication, self-medication and the use of illegal substances.
Some drugs meant for treating diseases are now being abused or used inappropriately by the youth. For example, majority of Nigerian youth have turned benzodiazepines to which popular valium belongs, meant to treat organic and other related disorders, to drug of abuse (Okeowo, 2003); of which, high doses usage of these drugs might lead to dependence or addiction, that is, to continual use of the drug as a result of the difficulty to stop. Drug such as cocaine and ‘crystal meth’ are psychoactive substances which stimulate the path of the brain that releases dopamine; it gives the person a feeling of wellbeing and happiness (Seraphim, 2005).
When drugs impact an individual normal functioning and well-being, the user turns into an ‘abuser’. Fraser and Moore (2008) described abuser as an individual who has relinquished control over his/her life to psychoactive substances. This condition produces altered neurological functions, and changed perceptions, moods, consciousness and energy levels (King, 2008). Santrock (2001) highlighted some behaviours exhibited by drug abusers, these include; watering eyes and nose, being abnormally talkative or unusual quietness, unpredictable temper, concentration lapse, and loss of interest in education. Carelessness and neglect of one’s personal hygiene, general irresponsibility, high irritability, and hostility to close friends, wearing of dirty and tattered clothes and normally being in one clothe for many days are other attributes of drug abusers (Nyaga, 2001).
Drug abuse is more likely to be diagnosed among those who have just begun taking drugs and is often an early symptom of drug dependence. A long time use of drug may lead to dependence or desire for the drug. However, substance dependence can appear without substance abuse, and substance abuse can persist for extended periods of time without a transition to substance dependence (American Psychiatric Association, 2000). A person can become psychologically and physiologically dependent on a drug. According to King (2008), psychological dependence occurs when a person use the drug to satisfy an emotional need. Mild psychological dependence is called “habituation”. A person can be habituated to anything that gives a feeling of well-being. For example, a person can become habituated to the caffeine found in coffee, tea, cocoa and cola drink because it seems to provide a lift during the day. Physical dependence on the other hand, often results from tolerance. The body becomes used to a particular drug that it must have a certain amount in bloodstream and tissues all the time in order for the person to feel normal. Both psychological and physical dependence on drug are sometimes refers to as addiction.
Drug addiction is a chronic disease that affects millions of people around the world. The World Health Organisation (2003) defined drug addiction as a state, psychic and physical, resulting from the interaction between a living organism and a drug, characterized by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effect and to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug. Addiction is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, occurring any time. It is manifested by tolerance, withdrawal and other symptoms (Diagnostic & Statistical Manual of Mental Disorders, 2000).
The American Society of Addiction Medicine (ASAM, 2011) defined addiction as a primary, chronic disease of the brain. Dysfunction in these circuits can lead to biological, psychological and social manifestations of addiction. This means that a drug addict usually crave intensely for drugs and unable to control drug use despite negative consequences. However, not everyone who abuses drug becomes addicted, but it can happen to anyone, regardless of whether their drug of choice is a prescribed medication or an illicit drug. Like other chronic diseases, addiction often involves cycles of relapse and remission (American Society of Addiction Medicine, 2011).
Relapse is defined as the return to abusing a substance regularly and sometimes uncontrollably. Marlatt and Donovan (2005) defined relapse as a breakdown in a person’s attempt to change or modify any target behaviour. Relapse differs from a lapse. Lapse is considered a one-time slide into substance abuse and does not occur more than once. For example, If an individual drinks one beer or takes drug on one occasion, the person has had a lapse. But if he/she is abusing regularly and it is causing negative consequences on any aspect of one’s life, then, such an individual is having a relapse and need professional help.
Relapse following drug treatment is prevalent among people who use drugs. This has been reported globally even in countries with high rates of completion of impatient treatment, for example, 33% of relapse individuals in Nepal (Niraula, Chhetry, Singh, Negash & Shyangwa, 2006), 55.8% and in China (Tang, Zhao, Zhao & Cubells, 2006) relapsed into drug use between 1 month and 1 year after discharged from treatment programmes. Drug abuse relapse rates vary widely in clinical studies; a study showed that people who receive treatment experience short-term remission and are estimated to relapse in the long-term (Moos & Moos, 2006).
On average, between 25 and 50 percent of substance abusers will return to drugs or alcohol use within two years of receiving treatment (Fiorentene, 1999). Moreover, Habil, (2001) asserted that more than 70 percent of those attending drug rehabilitation centres would probably relapse. Reid, Kamarulzaman and Sran (2007) added that about 70 to 90 per cent of addicts who undergo rehabilitation would return to the habit within first year after been discharged if they are compelled and detained at the rehabilitation centres. Bidnas (2015) reported that 40-60% of all people who enter a rehabilitation facility will fall back into some level of substance abuse. Relapses is the return of addicts to the use of substance materials, after his success in dropping out of use for a limited period. Abstinence, or refraining from using the substance at all, is the only true way to prevent relapse. Addicts who remain abstinent for five years or more only have a 15 percent chance of relapsing, while those who were relieved for a year have a little more than a 50 percent chance and one-third of addicts who abstain for less than a year will maintain their sobriety (Manejwals, 2014). The Drug Demand Reduction Directorate of NDLEA, Kwara State command, in their 2015 report observed that between 50 to 70% of those treated and counselled returned to drug use after treatment.
Melemis (2015) suggested that relapse is a gradual process wherein a person in recovery returns to drug abuse. This means that relapse can begin weeks or even months before an individual first takes a drug again. According to Osborn (2017), drug relapse warning signs can be categorised into three classes, viz; emotional, mental and physical relapse. During emotional relapse, individuals are not consciously thinking about using, but they are setting themselves up for it. They remember what relapse feels like and are in denial about the possibility of it happening again (Melemis, 2015). During mental relapse, individuals are thinking about using drugs again, but they are at war with themselves. Part of them wants to use, and part of them does not. Eventually, this internal struggle wears them down. Physical relapse is when an individual finally returns to drug use and this is what some clinicians divide into lapse (initial drug use) and relapse (returning to uncontrolled using), which is the hardest to come back from (Osborn, 2017).
Varieties of factors can lead an addicts who have recieved treatment into relapse. Those factors are unavoidable or difficult to avoid and can either be internal or external in nature. Internal causes can be stress, depression, anxiety disorders and a genetic pre-disposition. Mattoo (2009) stated that comorbid psychiatric illness or personality disorder predicts poor outcome in substance abusers. Relapse can also be attributed to post-treatment incarceration, mental or other comorbid disorders, craving for drugs and withdrawal symptoms (Farrell, Growing, Marsden, Ling & Ali, 2005). External causes, on the other hand, are more hard to define, because they vary wildly from person to person, these include driving past a corner previously used to buy drugs or a chance meeting with an old friend an addict used to take drugs with. Factors such as stress, depression, anxiety, positive mood, social pressure, adverse life events, work stress, marital conflict, family dysfunction, and a lower level of social support have been reported as causes of relapse (Sinha, 2001; Mattoo, Chakrabarti & Anjaia, 2009).
Ibrahim and Kumar (2009) highlighted socio-demographic factors of peer group influence, family history of substance abuse, and poor family support along with young age at initiation, unemployment, singular status to be associated with relapse. Those with lower levels of education and who are under- or unemployed are at greater risk of relapse (Moos & Moos, 2006; Richardson, Wood, Montaner & Kerr, 2012).
These indicators can have a direct or indirect effect on an individual for his/her behaviour of drug addiction. Internationally, two thirds of patients with addiction have a coexisting mental health problem (Park & Kim, 2015). The relapse after treatment can influence the psychiatric symptomatology. The side-effects of drugs used by patients can change particular psychiatric symptoms (cocaine intoxication can increase irritability). Drug abuse relapse may also lead to environmental stressors, such as struggle with family and criminal acts, which may accelerate psychiatric symptoms (Tomlinson, Tate, Anderson, McCarthy & Brown, 2006). National Drug Law Enforcement Agency is the main organ of the Federal Government of Nigeria responsible for the control of illicit drug trafficking. It also play a leading role in drug abuse rehabilitation through its Drug Demand Reduction Units in all the 36 states commands and special area commands as well as the agency’s national headquarters in Abuja. It is against this background that this study investigated the prevalence and causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria.
Statement of the Problem
Drug abuse is on the increase among the old and young ones in Nigeria and its associated problems are enormous. The World Health Organisation (2008) has reported that in 2008, tobacco smoking was estimated to have killed over 5 million people and by 2030, its death toll will exceed 8 million a year. Dependency or addiction to any type of drugs might lead to an increase in the development of drug related diseases such as cardiovascular disorders, lung cancer, stroke, chronic obstructive airways diseases, tumours of the mouth and larynx. This follows that the addicts need treatment in order to help them out of the situation. Drug abuse and relapse have a negative impact on the achievement of social development goals in developing countries, such as Nigeria and make serious demands on social work service delivery (Geyer & Lombard, 2014). Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death as Dennis, Funk, Laudet, Scott and Simeone (2011) noted that those suffering from drug addiction die an average of 22.5 years earlier.
The once peaceful traditionally conservative way of living of the people in Northern Nigeria is being threathened by the upsurge or increase in the number of youth who are into drugs abuse and addiction which may have serious implications in the future if not immediately addressed. The boys take hard drugs like cocaine, heroin, cannabis (wee-wee), tramadol and get “safer” and “soft” drugs like cough syrup with codeine “Stopcof, Cofflin, Totalin, Emzolyn” for girls (Suleiman, 2016).
Drug abuse relapse have devastating psychological effect on significant others like parents, children, spouse, siblings, friends, relations among others. Watching a loved one loosing control of his/her life to drugs and relapsing in and out of drugs against their expectations and plans create a great psychological problem for the family. Equally, the cost of each treatment episode is costly and time consuming. When a drug addict who undergoes treatment relapses, it puts the therapeutical team into confusion and burnout after exhausting all their counselling and clinical skills in assisting the drug addicts out of their problems.
Relevant studies have been carried out by different researchers in the field of drug use and abuse. Abiama, Abasiubong, Usen and Alexander (2014) investigated the prevalence of substance use and association with psychiatric illness among patients in Uyo, Nigeria. The findings of the study revealed that 48.4% of of the youths use substances and the current use of alcohol was 36.3%; cannabis 28.3%; cigarette 14.5%; cocaine 0.8%; snuff/fumes 2.4%; Pain killers and kola nuts 1.6%. Greene (2014) studied relapse among recovering addiction professionals: Prevalence and predictors. The findings revealed that high prevalence rates of relapse among the addicts. Respondents who relapsed had shorter histories of sobriety at the start of their careers and shorter periods of sobriety while in recovery.
Batool, Manzoor, Hassnain, Bajwa, Abbas, Mahmood and Sohail (2017) also examined the pattern of addiction and its relapse among habitual drug abusers in Lahore, Pakistan. Reasons for starting drug abuse were recreation, curiosity, and life-changing events. Reasons for relapse included association with former addicts, negative reactions from family, inability to manage the craving and work/social stress. None of the above studies have investigated the prevalence and causes of drug relapse except Greene (2014) but the study was conducted in United States. Perhaps, few studies exist in Nigeria on drug relapse among addicts. According to Umoru (2017), the northern geographical zone has the highest prevalence rate of drug abuse in Nigeria. Also, the personal observation of the researcher as a drug demand reduction officer in NDLEA indicated that addicts in the North Central Nigeria has the highest rate of relapse, these form part of the reasons this study investigated the prevalence and causes of drug relapse as expressed by immates in NDLEA Rehabilitation centres in North Central, Nigeria.
Research Questions
The following questions are raised for the conduct of the study:
1. How prevalent is relapse among inmates in NDLEA Rehabilitation Centres in North Central, Nigeria?
2. What are the causes of drug relapse among inmates in NDLEA Rehabilitation centres in North Central, Nigeria?
Research Hypotheses
The follwoing hypotheses are formulated to be tested in the study:
1. There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of parental occupational status.
2. There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central on the basis of parental occupational status.
3. There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of age.
4. There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeriaon the basis of age.
5. There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of educational attainment.
6. There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of educational attainment.
7. There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of marital status.
8. There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central Nigeria on the basis of marital status.
Purpose of the Study
The study investigated the prevalence and causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria. The study also examined the influence of moderating variables of parental occupational status, age, educational attainment and marital status on respondents’ expression of prevalence and causes of drug abuse relapse.
Signifcance of the Study
The findings of this study would be of immense benefit to the drug addicts, drug prevention agencies, counsellors, psychologists, government and future researchers. The findings of this study would be beneficial to the drug addicts. The findings would help them understand the rate of relapse among drug addicts and the likely factors that encourage them to go back to drug intake after passing through treatment in the rehabilitation centres.
The findings of the study would assists the Drug Demand Reduction Unit of NDLEA and other drug abuse rehabilitation centres to assess the prevalence of drug relapse among their treated clients and the likely causes, so that appropriate recovery programmes can be designed to help the addicts overcome their challenges.
Counsellors might also benefit from the findings of the study. The findings of the study would enable them understand the seriousness of relapse as well as the likely causes so that appropriate counselling intevention that could be used to help the addicts who return to drug use after treatment.
Psychologists would as well benefit from the findings of this study. The findings would assist the psychologists to understand the prevalence of relapse and the likely reasons behind addicts’ retun to drug abuse after treatment. This would assist them in designing and organising programmes that will help the addicts with relapse problem to totally stop using drugs.
The outcome of this study would help government and parents eveluate the financial implications of rehabilitating drug addicts and giude against resaons/factors that trigger relapse. This invariably would help them minimise their spending as well as the prevalence of relapse among treated addicts, this will contribute positively to the growth and development of the nation through vibrant and healthy youths free from drug addictions.
Future researchers would find the findings of this study beneficial. The findings of the study would serve as premise upon which future studies would be based by obeserving the gaps this study might not have covered, therefore, carrying out new study to fufill such existing gap.
Opertaional Definition of Terms
The following terms were opertaionally defined as used in the study:
Causes of relapse: Factors that influence people who have gone through rehabilitation process to return to abuse of drugs after treatment, at a particular period of time.
Clients: Those who have depended on drugs for their survival or to cope with life. They cannot do without taking drugs to perform one task or the other.
Prevalence of relapse: The rate at which relapse occur among drug addicts who have received treatment.
Relapse: An act of returning to drug abuse by an addict having pass through treatment process.
Rehabilitation Centres: Places where drug addicts are treated; for example, NDLEA counselling and rehabilitation centres.
Scope of the Study
This study was limited to the prevalence and causes of drug abuse relapse as expressed by inmates of NDLEA Rehabilitation Centres in North Central, Nigeria. The study also examined the influence of moderating variables of parental occupational status, age, educational attainment and marital status on respondents’ perception of prevalence and causes of relapse among clients in NDLEA rehabilitation centres. A questionnaire was used as instrument to collect data for the study. The questionnaire is tagged “Prevalence and Causes of Drug Abuse Relapse Questionnaire” (PCDARQ). The data collected were analysed using descriptive and inferencial statistics. Frequency and percentage was used for demographic data of respondents; while t-test and Analysis of Variance (ANOVA) were used to test the research hypotheses at 0.05 level of signifcance.
CHAPTER TWO
REVIEW OF RELATED LITERATURE
Preamble
Literature review deals with consultation of books, magazines, documents, reports, and on-line search on relevant topics of the study. In view of this, relevant literature will be reviewed under the folloing sub-topics:
- Concept of Drug Abuse and Addiction
- Concept of Drug Abuse Relapse
- Prevalence of Drug Abuse Relapse
- Causes of Drug Abuse Relapse
- NDLEA Counselling and Treatment of Drug Addiction
- Theories of Drug Abuse Relapse
- Empirical Studies on Prevalence and Causes of Drug Abuse Relapse
- Summary of Review of the Related Literature
Concept of Drug Abuse and Addiction
Drug abuse is the arbitrary usage of legal drugs or the use of illegal drugs without medical prescription or guide. It is an excessive and persistent use of a drug without adhering to culturally or medically acceptable patterns (Haladu, 2003). Odejide (2000) described drug abuse as the consumption of drug when it is not pharmacologically required, especially when it is used despite legal prohibition or when socially acceptable beverages are used disproportionately. According to Oshikoya and Alli (2006), many Nigerian youths ignorantly depend on one form of drug or the other to carry on with their various daily routine. In corroborating this, Oshikoya and Alli (2006) identified dependence and addiction as one of the major consequence of drug abuse, characterized by compulsive drug craving seeking behaviours even in the face of negative consequences.
According to the United Nations Office of Drug Abuse and Crime (UNODC, 2006), drug abuse is on the increase and causes adverse social, health and economic implications. The economic cost is estimated at between 0.5 to 1.3% of gross domestic product in many countries. The World Health Organization (WHO) indicated that the most widely used drugs are alcohol, tobacco, marijuana, opium and its derivatives, cocaine and hallucinogens. Others are khat (miraa), inhalants and volatile solvents like petrol and glue. Also, available are synthetic drugs mainly barbiturates. UNODC (2005) added that an estimated 30% of the general adult population worldwide uses alcohol, out of which 20% are men and 10% are women. Approximately 15.9 million people inject drugs worldwide, with the largest numbers found in China, America and Russia (Mathers, Degenhardt, Philipps, Weissing, Hickman, Strathdee, et. al., 2008).
Abiama, Abasiubong, Usen and Alexander (2014) examined the prevalence of substance use and association with psychiatric illness among patients in Uyo, Nigeria. The findings of the study revealed about 51.7% of the subjects used two or more substances. Substance use preceded first psychiatric episode in 29.6% of the participants; second in 42.9%; third in 50.0%; while 46.5% all relapses were preceded by alcohol/substance use. This study has shown that substance use is major risk factors for the development of psychiatric illnesses.
Drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences (Fraser, 2002). UNODC (2007) defined drug addiction as a complex illness characterised by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences. An addictive drug is a drug which is both rewarding and reinforcing, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioural and drug addictions, but not dependence (Malenka, Nestler & Hyman, 2009). Within the framework of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 2015), substance dependence is redefined as a drug addiction, and can be diagnosed without the occurrence of a withdrawal syndrome. It is now described accordingly: When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance addiction may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.
Drug addiction is a considerable social and personal problem which negatively influences not only the mind and body of the addict but also the health of a society concerning social, economical, political and cultural issues (Farjad, 2000). According to Mental Health Touches (2006), adolescent drug use is nowadays marked as a problem all over the world. Basically this does not raise any surprise since there has been moving statistics, highlighting this alerting social phenomenon. For instance, United Nations (2006) reported that 25 percent of addicts in Asia and eastern Europe are under the age of 20; also in the South Africa 80 percent of burglary and robbery cases had tight bounds to drugs and most of the convicts were between 12 to 17 years old age (Drakenstein Police Service, 2006). Addiction is a chronic illness, and like any other chronic illness, it must be managed over time.
Addiction is a chronic, often relapsing brain disease with compulsive drug seeking and using the drug despite harmful consequences. It is a brain disease because the drug leads to changes in structure and function of the brain. Initial decision of drug-intake may be voluntary but repeated drug exposure affects person’s self-control and ability to make sound decision (Batool, Manzoor, Hassnain, Bajwa, Abbas, Mahmood & Sohail, 2017). National Drug Intelligence Centre (2011) continues to use the term “addiction” to describe compulsive drug seeking despite negative consequences. According to Rehm, Mathers, Popova, Thavorncharoensap, Teerawattananon and Patra (2009), the American Psychiatrists Association updated the DSM, replacing the categories of substance abuse and substance dependence with a single category: substance use disorder. The symptoms associated with a substance use disorder fall into four major groupings: impaired control, social impairment, risky use, and pharmacological criteria (i.e., tolerance and withdrawal).
The substance is often taken in larger amounts or over a longer period than was intended; There is a persistent desire or unsuccessful effort to cut down or control use of the substance; A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects; Craving, or a strong desire or urge to use the substance; Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use; Important social, occupational, or recreational activities are given up or reduced because of use of the substance; and Recurrent use of the substance in situations in which it is physically hazardous. Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect; A markedly diminished effect with continued use of the same amount of the substance. Withdrawal, on the other hand, can be manifested by either of the following: The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance); The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms (Centres for Disease Control and Prevention, 2014).
The concepts of drug abuse and addiction or dependence exist together on a similar continuum; however, there is a distinction between the two. Drug abuse might eventually lead to an addiction but, as a non-clinical concept, ‘ abus e’ encompasses any use of illicit substances, or inappropriate use of medications (such as taking larger doses than were prescribed) (Centres for Disease Control and Prevention, 2014). It must be reiterated that not everyone that uses drugs (or abuses them) becomes addicted to them. On the other hand, addiction, by some accounts, begins as a result of using a substance (drugs or medications) that have a measurable impact on the reward centre of the brain, but it does not end there. The repeated stimulus of this reward centre is enough to effect a change in the functionality of the brain itself. Eating, sleeping, even sexual activity can take a back seat to obtaining and using drugs. There are various levels or stages of drug abuse problems and addiction, however, abuse always precedes addiction, and statistics bear out that many suffering from drug abuse do tend to progress to addiction (Condron, 2017).
Drugs that affect the brain, alter mood and behaviours are legally controlled substances and the most commonly abused drugs. These psychoactive drugs are usually abused by many Nigerian youths. They include; stimulants, depressants, hallucinogens, cannabis, narcotic and inhalants.
Stimulants: Stimulants are a group of drugs that excite or increase the activity of the central nervous system (CNS). Stimulant effects can be mild or strong depending on the kind of drug and the amount taken. Stimulants may cause an increase in alertness or give body a temperature, feeling of energy and wellbeing. Thus, the user feels uplifted and less fatigued. Example of stimulant drug include: caffeine, amphetamine and cocaine. These drugs have a high potential for psychological dependence and tolerance relatively quickly, but they are unlikely to provide significant physical dependence when judge by life threatening withdrawal symptoms. The important exception is cocaine which seems to be capable of producing psychological dependence and withdrawal so powerful that continued use of the drug is inevitable in some user (Gross, 2007).
Caffeine: The methylxanthines are family of chemicals that includes three compounds, caffeine, theophylline and theobromine. Of these, caffeine is the most heavily consumed. Caffeine is a tasteless drug found in coffee tea, cocoa, many soft drinks and several group of over-the-counter drugs. It is a relatively harmless Central Nervous System (CNS) stimulant when consumed in moderate amounts. Many coffee drinkers believe that they cannot start the day successfully without the benefit of a cup or two of coffee (Gross, 2007).
Amphetamines: These are stimulants that accelerate function of the brain and body. They come in pills or tablets. Prescription diet pills also fall into category of drugs. It street names are speed, uppers, dexies, bennies and are being used by swallowing, inhaled or injection. Amphetamines users get fast high, making them feel powerful, alert and energized. Uppers pump up heart rate, breathing, blood pressure and they can also cause sweating, shaking, headaches, sleeplessness and blurred vision. Excessive and prolonged use may cause hallucination and intense paranoid. Tragic highway accidents have occurred when a driver who has taken amphetamines to stay alert has swerved to avoid a danger that was not there at all, (Melgosa, 2005). Amphetamines are very addictive. Users who stop reported that they experienced various mood problems such as aggression, anxiety and intense craving for the drugs (Durani, 2012).
Crystal Methamphetamine: Crystal methamphetamine otherwisely called ice or speed, is the most recent and dangerous forms of methamphemine. When smoked the effects are felt in about seven seconds as a wave of intense physical and psychological exhilaration. This effects last for several hours until the user becomes physically exhausted. According to Kåver and Nilsonne (2002), Speed users experience a lack of appetite and weight loss as well as symptom of malnutrition. Muscles and joints ache and trembling occur. The effect of single dose may end in a depression so deep and intense that another dose seems the only cure.
Ritalin: Ritalin is a drug prescribed to elementary-age children who are hyper-active or cannot concentrate to help focus attention. Although Ritalin has not historically been considered a significant drug of abuse, the recent surge in the prescribing of Ritalin for children and teens has become a subject of debate (Kaver & Nilsonne, 2002).
Cocaine : Cocaine is the primary psychoactive substance found in the leaves of the South American Coca plant. Cocaine is a powerful and illegal stimulant which its abuse has become a major health problem in the society. Cocaine create a feeling of exhilaration and a burst of energy, followed by depression as the drug wears off (the effects of cocaine last only briefly from five to thirty minutes). When users take more of the drug to relieve depression, they become dependent on it. Cocaine also makes the user crave for more of it (Gross, 2007). Cocaine is injected into the blood stream, smoke or sniffed the powder up their noses in its most powerful forms. Cocaine users come from many age groups.
Depressants: Depressants (or sedatives) calm nerves and relax muscle i.e it slows down the CNS function. Drugs include in the category are alcohol bartiturates and tranquilizers. Depressants produce tolerance in abuser, as well as strong psychological and physical dependence. The concept of alcohol shall specially be addressed as being the commonly and popularly abused drugs across different ages in our society. Thus, here we shall focus on other category of depressants (Kaver & Nilsonne, 2002).
Barbiturates : Barbiturates sometimes called sleeping pills are used to cause sleep. Barbiturates showed reactive, reduced mental functioning and memory, slurred speech, loss of inhibition, causes drowsiness and sleep. High doses of barbiturates can lead to coma and death (Melgosa, 2005). The danger of death from barbiturate abuse multiplies when taken with alcohol because both have similar effects. According to Gross (2007), the combined effect of these drugs is greater than simply adding the effects of the two drugs together. It is as if one and one added up to three or more instead of two. Unless medical care is given in time, the person will die from lack of oxygen.
Seizures, delusion, hallucinations, convulsion, collapse of cardiovascular system and death are some of the withdrawal syndrome from barbiturate use. Kåver and Nilsonne (2002) suggested that withdrawal must occur gradually by reducing the amount of the barbiturate. Withdrawal from barbiturate dependence should be done only under medical supervision.
Tranquilizers : Tranquilizers are depressant for managing stress and reduce anxiety and relax muscle. They are specifically not designed to produce sleep but rather to help people cope during their waiting hours. Such tranquilizers are termed minor tranquilizer of which diazepam (Vallium) and chlordiazepoxide (Librium) may be the most commonly prescribed example (Kåver & Nilsonne, 2002). Some tranquilizers are designed to control hospitalized psychotic patient who may be suicidal or who are potential threat to others. These major ones permit them to regain consciousness and subdue people physically. Hallucination and convulsion can result from sudden withdrawal from tranquilizers.
Rohypnol : Rohypnol is a prescription drug manufactured in South America, Mexico, Europe and Asia and illegally transported into the United States. It is a low cost increasingly popular drug because it often comes in pre-sealed bubble packs; many teens think that the drug is safe. Its street names are roofies, roach, forge-time pill, date rape drug. This drug is swallowed, sometimes with alcohol or other drugs. Rohypnol is a prescription anti-anxiety medication that is ten times more powerful than valium (Durani, 2012). It can cause the blood pressure to drop, as well as cause memory loss, drowsiness, dizziness and an upset stomach. Rohypnol has received a lot of attention because of its association with date rape. Many girls report having been raped after having rohypnol slipped into their drinks. The drug also causes “anterograde amnesia”. This means it is hard to remember what happened while on the drug, like a blackout. Because of this, it can be hard to give important details if a young woman wants to report rape (Durani, 2012)
Hallucinogens: Hallucinogens also called psychedelic drugs, or phantasticants are drugs that cause great changes in the way a person feels and interprets things. As the name suggests, hallucinogenic drugs cause hallucinations perceived distortion of reality. i.e it becomes difficult for the mind to distinguish fact from fantasy. Hallucinogenic drug include laboratory produced Lysergic Acid Diethylamide (LSD), mescaline (from the peyote cactus plant) and psilocybin (from a particular genuse of mushroom) (Gross, 2009. Hallicinogen consumption do not produce physical dependence but mild level of psychological dependence, no withdrawal symptoms, however, tolerance could be developed. All hallucinogens produce similar reactions but the intensity of the reaction varies according to the kind and amount used.
Hallucinogens users experience synesthesia, a sensation in which users report hearing a color, smelling music or touching a taste. Moods may swing from completely joy to absolute terror. A dreamlike period may become horrifying night mare. This is called “bad trip”. Recurrence of hallucinations without having taken new dose of the hallucinogen may results to “flash back”- the unpredictable return to a psychedelic trips that occurred months or even year earlier. Flash back are thought to result from the accumulation of a drug within body cells. Some users have been frightened that this is a sign of insanity and as a result have committed suicide (Kåver & Nilsonne, 2002).
LSD : The best known and most powerful of all hallucinogen is Lysergic Acid Diethylamide (LSD). It is a lab-brewed hallucinogen and mood changing chemicals. LSD is odourless, colourless and tasteless. It is otherwise called acid, blotter, doses microdots. LSD is licked or sucked off small squares of blotting paper. Capsule and liquid forms are swallowed. Paper squares containing acid may be decorated with cute cartoon characters or colourful designs. Hallucination occurs within 30 to 90 minutes of dropping acid. The effects are unpredictable depending on how much LSD is taken and the use.
Designer Drugs: Designer drugs are drugs produced by chemist in their home laboratories. These are illegal drugs similar to the controlled drugs but are sufficiently different so that they escape governmental control. Designer drugs are said to produce effects similar to their controlled counterparts. It is a great risk using this type of drug because its manufacturing is unregulated. The neuro-physiological effects of these home-made drugs can be quite dangerous. Experts are particularly concerned that designer drugs can produce strong psychological dependence and can deplete serotonin, an important excitatory neuro-transmitter associated with a state of alertness (Melgosa, 2005). Permanent brain damage is possible.
Phencyclidine : Phencyclidine (PCP, “angel dust”) is unique because it produces multiple effects. It acts not only as hallucinogenic but also as analgesic, a depressant, a stimulant and an anesthetic. This makes the typical PCP experience impossible to predict or describe. After consumption, the physical effects of PCP begin a few minutes and continue for four to six hours. PCP was studies for years during 1950s and 1960s and was founds to be a suitable animal and human anesthetic (Gross, 2007).
PCP come in tablet or powder form and can be injected, inhaled, taken orally or smoked. Some of it effects are euphoria, bizarre perception, paranoids feeling and aggressive behaviour. It’s over dose can cause convulsion, cardiovascular collapse and damage to the brain respiratory centre (Durani, 2012). Authorities have difficulty in limiting it availability because PCP is easily and cheaply manufactured in home laboratories
Cannabis: Cannabis (marijuana) is a wild plant (cannabis sativa) whose fibers were once used in the manufacture of hemp rope. It grows wild in nearly every part of the world. The leaves and flowering tops of the hemp plant are dried to obtain marijuana. Hashish (commonly smoked in pipe) is obtained by collecting the sticky substance that comes from the flowers of the hemp plant. Marijuana produces hallucinogenic effect caused by the determination of the percentage of active ingredient tetrahydrocainabinol (THC), present in the product (Kåver & Nilsonne, 2002).
Narcotics: strong painkillers that cause sleepiness are called narcotics; they are sometimes called opiates because most come from the seed pods of the opium poppy. It is an addictive drug subject to illegal use e.g opiate, morphine, heroin etc. it depresses brain function. It induces stupor and insensibility. It causes dependence and tolerance (Melgosa, 2005).
Alcohol: Alcohol is a drug that is produced by a chemical reaction in fruit, vegetables and grains. That is, alcohol is created from the fermented grain, fruits or vegetable. Fermentation is the process that uses yeast or bacteria to change the sugar in the food into alcohol. Fermentation is used to produce many necessary items everything from cheese to medications. Alcohol has different forms and can be used as a cleaner, an antiseptic, or a sedative (Durani, 2012).
Unconventional Substances: Sanni (2017 listed several unconventional substances being used that are not scheduled by law to include; suck and die (chloroform), rubber solution, paint tinner, correction fluid, petrol, pit latrine, datura (zakami/gegemu), lizard excreta, mai-sulhu, shai gadage, skushes among others. Individuals may get addicted to using of the above discussed drugs categories.
Causes of Drug Abuse and Addiction
While the specific causes of drug addiction are not known, genetic, psychological and environmental factors are thought to play a significant role. Rather than a single cause of drug abuse and addiction, it is likely that multiple factors lead to drug abuse and addiction in any given person. Some drug addicts also identify drug use and ignorance as a cause of drug abuse and addiction. Often, if a person is dealing with pain-management issues, the drug they receive, like oxycodone, can be very addictive (Natacha, 2017). The ignorance of the drug’s addiction potential, along with the physical pain of the condition, becomes a cause of drug abuse and addiction. In view of this, the following factors are discussed as the causes of drug abuse and addiction among youth.
Biological / Genetic Factor: The genes that people are born with account for about half of a person’s risk for addiction. Drug abuse and addiction tends to run in families, indicating genetics may have a role in causing drug addiction (National Institute of Drug Abuse, 2015). Genetic causes of drug abuse and addiction appear to involve multiple gene sequences and science has not yet been able to pinpoint all the genes involved. However, it is known some genes, like those involved in brain receptors of nicotine, contribute to the cause of drug addiction. Gender, ethnicity, and the presence of other mental disorders may also influence risk for drug use and addiction (Andrei, 2017).
Psychological Causes: While biological causes of drug abuse and addiction have been suggested, many people still believe psychological factors comprise the bulk of what causes drug addiction. Some of the psychological causes of drug abuse and addiction appear to stem from trauma, often when the drug addict is young. Sexual or physical abuse, neglect, or chaos in the home can all lead to psychological stress, which people attempt to ‘self-medicate’ (decrease the stress’s pain through drug use). This self-medication becomes a cause of drug addiction (Natacha, 2017). Other psychological causes of drug addiction include: A mental illness such as depression; inability to connect with others, lack of friends; poor performance at work or school; poor stress coping skills.
Environmental Factors: A person’s environment includes many different influences, from family and friends to economic status and general quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress and parental guidance can greatly affect a person’s likelihood of drug use and addiction. Drug addiction is more common in environments where drug abuse is seen or where it is seen as permissible. Children who grow up in homes with drug addicts often become drug addicts themselves. Because most drug use starts in adolescence. Those with inattentive, abusive or neglectful parents are more prone to drug abuse. One cause of drug addiction can be the combination of drug experimentation with the lack of parental oversight (National Institute of Drug Abuse, 2015). Other environmental factors that can be causes of drug abuse include: Participation in a sport where performance-enhancing drugs are encouraged; a peer group that uses or promotes drug use; people of lower socioeconomic status are at greater risk of drug addiction; gender and ethnicity contribute to addiction of some drugs.
The family factors comprised the parental behaviour, family relationships (fathermother or parent-child), the atmosphere within the family, and the family’s economic standing. In particular, Glynn (1981) found that parental substance use was itself the most significant predictor of drug abuse, which may be attributable to the modeling of parental behaviours as explained by the social learning theory. The stronger the parentchild relationship, the greater the parental influence on the child in which case, if the parent is a substance user, there is a greater chance that the child would follow the parent’s footstep. This is further supported by Andrews, Hops, and Duncan’s (1997) study which investigated substance use in adolescents. They found that adolescents tended to model themselves on their father’s marijuana use and mother’s cigarette’s use if there was a close parent-child relationship.
Human Development (Interaction between gene and the environment) : Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction risk. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to addiction. This is particularly problematic for teens. Because areas in their brains that control decision-making, judgment, and self-control are still developing, teens may be especially prone to risky behaviours, including trying drugs (National Institute of Drug Abuse, 2015).
Concept of Drug Abuse Relapse
Addiction treatment is an essential component in bringing down the number of drug addict. However, while treatment is beneficial for addicts’ recovery and overall wellbeing, it is not uncommon to relapse after a period of sobriety. In fact, some schools of thought viewed drug abuse relapse as a normal part of the recovery process. According to the New England Journal of Medicine (2002), relapse acts as an impetus for learning more about what a person needs to sustain long-term recovery. In its simplest terms, a relapse is when one starts using drugs again after a period of abstinence (Becker, 2017). Heavy cravings or obsessive thoughts about drugs taking can feel impossible to ignore in the early days of recovery, especially if individuals are experiencing stress or feel unhappy in their life. Despite their efforts to stay clean and sober, they may turn to drug as a familiar coping mechanism and relapse. Relapse happens, in part, because of the chronic nature of the disease of addiction. According to the National Institute on Alcohol Abuse and Alcoholism (1989), evidence showed that roughly 90% of people with alcoholism relapse within 4 years after completing treatment.
Several authors have described relapse as complex, dynamic and unpredictable (Marlatt, 1996; Buhringer, 2000). Whereas according to Mahmood (1996), relapse means, usage, intake or misuse of psychoactive substances after one had received drug addiction treatment and rehabilitation, physically and psychologically. Relapse is generally considered to be the return to substance use after a period of abstinence. According to Foster (2012), relapse has different definitions. Some defined it as a return to any amount of substance use, while others would described it as a return to heavy use. Hence, a relapse is a return to destructive or heavier use of drugs or any substance.
Fauziah and Kumar (2009) described drug relapse as complex, vibrant, and volatile process. They labelled drug relapse as “usage, intake, or misuse of psychoactive substance after one had received drug addiction treatment and rehabilitation, physically, and psychologically”. Identifying risk factors can help reduce the likelihood of relapse. These can be both internal and external, so avoiding them entirely is not usually possible. Learning to deal with these situations is the only way to avoid relapse.
According to National Institute on Drug Abuse (2002), relapse prevalence rate are determined by: (1) the definition of relapse used, For example, a therapist who believes that drug abuse is a chronic, relapsing disease will treat a patient who has relapsed differently from one who views drug abuse as a secondary symptom of underlying psychopathology. A clinical researcher who accepts a theory of inherited Endorphin deficiency will design and test treatments for relapse differently from a researcher who believes that drug abuse is learned behaviour. (2) the method of detecting relapse vary widely. In drug treatment outcome research, an interview with the subject combined with urine testing to validate current drug use is a common method of assessing relapse. A final variation in computing relapse rates is in the handling of missing data. Since investigators are unable to contact all subjects in followup studies, assumptions must be made about subjects lost to followup. They may be assumed to have relapsed, or they can be “replaced” by subjects who could be located. The method of handling missing data is often not overtly specified in reports of relapse rates; yet, it can account for considerable variance.
Prevalence of Drug Abuse Relapse
Substance abuse is a chronic, relapsing illness. It is believed that drug abuse is viewed as a chronic disorder; however, relapse is considered as the natural section of the recovery process, which is defined when subjects return to even a single usage of a drug, same as the condition prior to treatment (Sau, Mukherjee, Manna & Sanyal, 2013). Relapse, or the return to heavy alcohol use following a period of abstinence or moderate use, occurs in many drinkers who have undergone alcoholism treatment. Relapse is considered a full blown return to the addiction. A lapse or a slip is just a temporary return, picking back up rather quickly, getting back on the horse metaphorically and getting back on with life. Relapse is the return to drug use after an attempt to stop. Relapse indicates the need for more or different treatment. Relapse needs to be viewed as a process or a series of maladaptive responses that eventually lead to the act of taking drugs (Gautam, 2012). Changes at the levels of thought and feeling, shifts in attitudes and behaviour patterns can be noticed before the clients actually take drugs again.
Relapse varies in intensity, however, studies have shown that a large proportion of individuals who have been treated for addiction tend to re-use drug shortly after treatment (Walton, Blow, Bingham & Chermack, 2003; Xie, McHugo, Fox & Drake, 2005). Some may reach out for help after a single incident of drug use, while others may go back to regular use, with some or all the drug related problems of the past (Gautam, 2012). Relapse is the biggest problem for recovering addicts; an addict can be forced to abstain from using drugs while they are admitted in a treatment clinic, but once they leave the clinic they are at risk of relapse (Ranganathan, 2005). Some researches, related to methadone maintenance programmes in treatment centres, showed that although treatment with methadone can be efficient for risk factors such as decreasing the crime-associated incidents, employment increase and the improvement of quality of life for addicts, many subjects continue drug abuse with concurrent use of methadone (Chaney, Roszell & Cummings, 1982).
In a large national study in USA, of relapse among cocaine users, Simpson and associates (1999) showed that 23.5% of their sample had returned to weekly cocaine use in the year following treatment admission, and an additional 18% were readmitted for treatment. In their 5-year follow-up report, 26% of the participants reported weekly use, 26% had positive drug screens for cocaine, and 18% reported having been arrested in the follow-up period in New York. The 5-year mark tends to be an important time for sobriety, as not only evidenced but also in the National Treatment Outcomes Study by Gossop, Marsden, Stewart and Kidd (2003) found that the use of drugs such as heroin and benzodiazepines significantly decreased. Crack and powder cocaine use rates were not significantly different between admission and 4- to 5-year follow-up benchmarks.
Greene (2014) investigated the prevalence and predictors of relapse among recovering addiction professionals. The study findings showed that an estimated 14.7% of RAPs relapsed over their career lifespan. There was no evidence of relationship between relapse and gender, race, or educational level. Lower likelihood and rates of relapse were associated with mutual aid group affiliation and attendance at meetings. RAPs (Recovering Addiction Professionals) who relapsed had shorter histories of sobriety at the start of their careers and shorter periods of sobriety while in recovery.
Kassani, Niazi, Hassanzadeh and Menati (2015) studied the survival analysis of drug abuse relapse in addiction treatment centres. The findings of the study revealed that the relapse rate was 30.42%, mean and median of the time to relapse (survival time) were 27.40 ± 1.63 months and 25 ± 2.25 months, respectively. In the first six months, the cumulative survival rate was 83%, while in the 24th month it was 46% and the following time was consistent. Job status, marital status, family size and age were statistically significant in Cox regression model.
Bhandari, Dahal and Neupane (2015) worked on factors associated with drug abuse relapse: A study on the clients of rehabilitation centres. The findings of the study indicated that most of the respondents (94.7 percent) were relapsed in drugs after abstinence. The average number of times relapse in drugs is 3.29 times per person.
The treatment and after-care unit of NDLEA is in charge of treatment and provision of follow-up services for the drug addicts persons in Nigeria. In 2011, a total of 4,162 drug addicts were treated. Out of this number, the North-West accounted for 1,389 (38%) addicts, South-West were 992 (23%), South-South recorded 713 (17%), North-Central were 490 (12%), and North-East with 427 (10%). In 2012, 4,136 were treated, out of which, North West took precedence 1,409 (34%), South-West accounted for 543 (16%) addicts, South-South recorded 644 (15%), North-Central with 528 (13%), North-East with 483 (12%), while South-East recorded 429 (10%).
The NDLEA (2014) reported that about 3,415 drug addicts were conuselled in the various state commands of the Agency across the nation. Out of this population, 12 were reffered to treatment centre and 137 were undergoing treatment as at 31st Dec., 2014. Specifically, based on geo-geographical zone, the North-West zone took the lead with 1,523 (45%), followed by South-West 457 (13%), North-East and South-East 404 (12%) each, South-East 337 (10%) and North-Central 281 (8%). In 2015, a total of 4,106 addicts were counselled. The North-Western region with 1,468 (36%), South-West 778 (19%), North-Central 646 (16%), South-South (13%), South-East 424 (10%) and North-East 240 (6%). This implies that drug relapse might likely to be more prevalent in North-West region of the country.
Causes of Drug Abuse Relapse
Relapse is a formidable challenge in the treatment of all behaviour disorders (Witkiewitz & Marlatt, 2004). According to Manejwals (2014), addict stops substance use for a variety of reasons to undergo treatment or be forced to leave as a result of external circumstances, such as moving to a new environment where the drugs are not available. Where it was noted that those who are forced to leave the substance are more likely to relapse than those who drop out of conviction, also it noted that those who are undergoing treatment are less likely to relapse than those who leave the drug without medical assistance. It decreases with the increasing likelihood of relapse time. Whatever the reason for stopping the use of substance abuse, the person remains vulnerable to a relapse.
Golestan, Abdullah, Ahmad and Ali Anjomshoa (2010) worked environmental factors influencing relapse behaviour among adolescent opiate users in Kerman (A Province in Iran). Results indicated that there were significant relationships between these factors with relapse in adolescents. In a prospective study, Mohammad-poorasl, Fakhari, Akbari, Karimi, Bostanabad, Rostami and Hajizadeh (2012) examined addiction relapse and its predictors. After six months follow-up, it was found that the relapse rate was 64.0%. The results of logistic model indicate that smoking, having a drug user in the family, unemployment and stay connected with drug user friends after quitting were factors associated with relapse. This study similar to other studies showed a high relapse rate and determined some of its risk factors among addicts.
Environmental causal factors of relapse: Environmental factors that can increase the risk of relapse include increased availability and accessibility of drugs, poverty and unemployment, and encountering people, places and paraphernalia associated with earlier drug use. Availability of drug has an important role to increase the high rate of relapse after detoxification. In today’s schools the variety of drugs and their availability is prevalent (Mokri, 2002). The supply and demand for drug is very high (National Institute on Drug Abuse, 2006). So, adolescents that quitted using drugs will return to environments like school and society where drug is easily available and there exist the risk of returning to drug use or relapse.
Bain (2004) suggested that the prevalence of drug use by young people escalates as the variety of drugs available increases. Environmental cues play an important role in the process of relapse (Bain, 2004). Simply returning to the place where the drug(s) was taken can trigger a relapse even months after abstinence commenced (Bain, 2004). Cami and Farrè (2003) added that environmental stimuli associated with drug use itself can produce withdrawal and craving in the absence of the drug. For Hyman and Malenka (2001) environmental cues elevate the risk of a relapse when addicts encounter people, places or paraphernalia associated with earlier drug use.
Peer p ressure: In addition to availability of drugs, the effects of peer groups seem to have the largest effect on adolescent drug using behaviour (Chen, Sheth, Elliott & Yeager, 2004). The main factor involved in the risk of drug use is having friends who suffer behavioural problems (Fraser, 2002; Brandt & Delport, 2005). Peer pressure generally is the reason for using drugs. If the people in a social group use drugs, they will influence each other directly or indirectly (National Institute on Drug Abuse, 2006). Mahmood, et al. (1999) found 50% of old friends influenced former addicts to pick up the drug taking habit after they were discharged from rehabilitation centres. The research also showed that 76% of the old friends assist rehabilitated individuals to get the needed supply of drugs.
These situations further induced the relapsed addiction amongst former addicts who has been getting rehabilitation treatments. However, the above research is different from findings by Chuah (1990). He found peers support could help former addicts from not getting back to the old habit. He concluded that high emotional and spiritual support will indirectly increase the addicts’ self confidence and decrease the risk towards relapsed addiction. Gregoire and Snively (2001) reported that addicts who have discharged from rehabilitation centres and living in drug-free social environments could be linked with higher abstinence rates and low in relapse of drug use.
Unemplo y ment and Economic Crises: Poverty and unemployment are also perceived as reasons for drug abuse (Ramlagan, Peltzer & Matseke, 2010). Employment opportunities are limited in South Africa and lack of education is also a contributing factor when employment is sought (National Treasury, 2011). Seeing that employment opportunities are limited, becoming demotivated when employment is not found is a high-risk situation. Mc Coy and Lai (1997) associated inability to get jobs amongst former addicts who were discharged from rehabilitation centres coupled with lack of financial supports, caused the addicts to go back to addictions. Yunos (1995) asserted that employers always took advantage on the former addicts by paying low salaries without taking into consideration their qualifications and experience, causing dissatisfactions amongst the former addicts that eventually caused them to quit their jobs.
Ineffective Rehabilitation Programmes: Yahya and Mahmood (2002) found that the treatment and rehabilitation programmes being conducted in any country would faced various challenges. The effectiveness of drug rehabilitation programmes is also one of the factors, associated with relapsed addictions amongst addicts. This is because some researchers found drug rehabilitation programs conducted on addicts are less effective to jolt them to awake (Mokhtar, 1997, Wellish & Prondergast, 1995). Many research found that the traditional treatment and rehabilitation models failed to help in reducing relapse addiction to drug use (Habil, 2001; O’Brien, 2006 ; Reid, 2007).
Social causal factors: Interpersonal factors relates to relationships or communication between people. Campos (2009) stated that individuals in recovery often have substance-using peer groups that model continued drug use, or do not possess the skills to help in managing high-risk situations. Depending on the influence from the peer group, relapse is probable upon returning to the same drug-abusing peers. Wadhwa (2009) included peer pressure as one of the most frequent high-risk situations for relapse. McCrady (2001) is of the opinion that deliberate steps need to be taken to detach drug-dependent people from a social network that is supportive of drug use and to access new social networks that support new behaviour. Doweiko (2006) postulated that the individual’s access to strong social support systems during times of craving seems to contribute to continued abstinence.
O’Connell and Bevvino (2007) noted that during drug use conflict is dealt with in dysfunctional ways - the psychological consequences of conflict may have been muted and diluted by the presence of drugs in the system. Alternative healthy strategies and conflict-resolution styles need to be adopted by, amongst others, the young African adult in order to be able to deal with conflict constructively.
Intrapersonal causal factors: Intrapersonal factor refer to aspects that are taking place or existing within the mind. Wadhwa (2009) postulated that some of the most frequent high-risk situations for relapse are when negative emotions are experienced. Such negative emotions include boredom, loneliness, sadness or depression, disappointment, anger, resentment and stress (Sinha, 2001; Wadhwa, 2009). Drug users tend to use drugs to modify and change troublesome emotions and supplant them with at least temporary feelings of pleasure and happiness (O’Connell & Bevvino, 2007). Wadhwa (2009) affirmed that the use of drugs is the central coping mechanism for day-to-day life for addicts, but it is necessary for individuals to identify specific coping mechanisms for different thoughts, feelings or moods, and situations. O'Connell and Bevvino (2007) believed that appropriate coping responses must be learned to cope with emotions and high-risk situations. Doweiko (2006) stated that a craving in itself is a poor predictor of relapse, which may be triggered by drug-use cues (smells, the sight of the drug, sounds, etc.) and trigger moods and memories that predispose the individual to substance use. Larimer, Palmer and Marlatt (1999) testify that on-going cravings may erode the person’s commitment to maintaining abstinence as the desire for immediate gratification increases. This process may lead to a relapse.
Physical causal factors: Physical risk factors that can increase the risk of relapse include physical dependence on drugs, withdrawal from drugs and being in a negative physical state. Physical dependence refers to the fact that the body has adapted physiologically to the chronic use of a drug(s) (Schuckit, 2006). Simultaneously, people also develop tolerance for the drug where they need higher doses to achieve the same effects (Schuckit, 2006). Withdrawal refers to the physiological and psychological symptoms that present when drug-taking is decreased or suddenly terminated (Kring, Davison, Neale & Johnson, 2007). Furthermore, Doweiko (2006) asserted that a person experiencing a negative physical state such as illness, postsurgical distress or injury might face an elevated risk for relapse. The debate now shifts to the characteristics of young African adults and how these characteristics relate to relapse among this vulnerable group.
Personal and Family factors: Attitude and poor knowledge on drug abuse been reported to be contributing factor of relapsed addictions among drug addicts (Abdullah & Iran, 1997). Besides, less support from family members and the community by large towards former addicts highly promote the relapsed addiction tendency after treatment (Brown et al., 1995; Miller et al.,1999; Miller, 1992; Moos & King, 1997). Research by Mohd Taib, Rusli and Mohd Khairi (2000) on family communication patterns amongst addicts’ family and non addicts’ family, showed weak communication patterns and less effective interactions amongst former addicts’ family is one of the high probable factors toward drug addiction. Indeed, family support is much needed to ensure the rehabilitation process success and issues like “don’t care attitude” and ostracizing former addicts would only failed the rehabilitation process and in the long run caused the former addicts to relapse (Daley & Marlatt, 1992).
Self-Efficacy: Other relapse promoting factor is self-efficacy, defined as a degree to which an individual feels confident and capable performing a certain behaviour in a specific situational context (Bandura, 1977). As described in the cognitive-behavioural model of relapse (Marlatt, Bear & Quigley, 1995), high levels of self-efficacy are predictive of improved alcoholism treatment outcomes (Rychtarik, Prue, Rapp & King, 1992; Greenfield et. al., 2000). The situation is different from the results of research done on 60 alcoholics, which found that individuals who have high self-efficacy after going through rehabilitation treatment, are most unlikely to be addicted again (Allsop, Saunders & Phillips, 2000). Chuah (1990), in his research found that drug addicts who have low self-efficacy would be back to addiction after their release from getting treatment and rehabilitation. Other previous studies have also point out that improvement in self-esteem positively lead to success in rehabilitation programmes and it assist in curbing drug addictions (Mahmood, 1995; Mahmood et al., 1999).
Psychological Factors: Various studies have examined the effects of psychosocial factors towards relapse among drug and alcohol dependence. Moos (2007) contended that psychological factors are supposition to contribute to relapse among drug addicts after abstinence. Consistently, anxiety has been linked to increased relapse risk among marijuana addicts (Arendt et al., 2007; White et al., 2004). To Rasmussen (2000), relapse occurred because of the building up of additional crisis such as to look trivially on certain problem, stress, weak or failed forecast, the pessimistic thinking that all issue cannot be resolved and immature actions. Relapsed addicts also be confused and overreact due to the inability to think clearly, unable to manage feelings and emotions, the difficulty to remember things, unable to control their feelings and easily angered.
NDLEA Counselling and Treatment of Drug Addiction
Treatment of drug addicts in Nigeria usually takes place mainly in psychiatric hospitals, although some private hospitals, non-governmental organizations (including faith-based groups) and traditional healers also offer services (Onifade, 2011). Since the early 1960s, federal and state psychiatric hospitals have provided care for persons who present cannabis-induced psychotic behaviour. In March 1983, the first specialised Drug Addiction Research and Treatment Centre was established at the Neuropsychiatric Hospital, Aro, Abeokuta. Since then, more treatment centres have become available, mostly situated within the confines of psychiatric hospitals, though some others are located in general hospitals and the medical units of teaching hospitals (Onifade, 2011). Available reports from these government-funded treatment centres showed that treatment methods used follow strictly the orthodox pattern comprising:
(i) An assessment of the patient for physical, mental and social deficits;
(ii) Detoxification, usually offered as an integral part of the treatment service;
(iii) Various forms of psychotherapy and drug-free counselling; and
(iv) Educational, occupational and social rehabilitation that is initiated at the start of treatment with active participation of family members (Lawal, Adelekan, Ohaeri & Orija, 1998).
Treatment is aimed at total abstinence and there is no evidence that any treatment facility offers other type of drug treatment, such as drug substitution. In-patient and limited outpatient services are offered in most hospitals and drug units. These facilities often use the services of part-time psychiatrists, medical practitioners and psychologists. They offer a range of services including counselling, vocational and occupational rehabilitation, and, in a few centres, psychotherapy (Onifade, 2011). Informal treatment programmes based on religion also exist.
The NDLEA is a Federal Government Agency established through the promulgation of Decree 48 of 1989 now Act of the National Assembly known as NDLEA Act Cap N30 LFN 2004 as amended.
The Agency is saddled with the responsibilities to:
- Eradicate illicit trafficking in narcotic drugs & other substances of abuse.
- Suppress the demand for illicit drugs & other substances of abuse.
- Recover ill-gotten wealth believed to be proceeds of or acquired from illicit drug trade.
- Protect, enhance & maintain the good image of Nigeria & Nigerians both at home & abroad.
The agency carry out these responsibities through the following directorates:
- Directorate of Operations and General Investigation
- Directorates of Drug Demand Reduction
- Directorate of Prosecution and Legal Services.
- The Drug Demand Reduction Directorate
In order to sensitize and create awareness to the general populace and especially the youths, the School Based Programmes, that is, Preventive Drug Education were infused into the school curricular at the primary and secondary school levels of education. Drug Free Clubs were launched in Primary and Secondary Schools across the country. Anti drug abuse and trafficking lectures are delivered in schools across the country. Printing and Distribution of Public Enlighment Materials: in form of posters, handbills, stickers, and notebooks. Collaboration with NGOS/Other Stakeholders was made among others (NDLEA, 2016).
The NDLEA, through its DDR Directorate, offers counselling services across the state and special area commands. While staff members are dedicated to the DDR function, training is ongoing to improve capacity (National Drug Control Master Plan 2015-2019) to enable staffs meet minimum standards for the well-being of clients. Also, as part of the implemention of the National Drug Control Master Plan 2015 – 2019 capacity building effort, all counselling officers working with NDLEA has been trained on the Standard Operating Procedures (SOPs) which should be followed at the counselling centres of NDLEA, this is expected to bring about a degree of standardization and uniformity of the services provided by the NDLEA Counselling centres across the country (Ambekar & Swati, 2015). Ambekar and Swati (2015) stated that these SOPs are primarily meant for all the personnel managing the counselling centres of NDLEA (for the purpose of implementation) as well as for the senior officials of NDLEA (for the purpose of monitoring and evaluation).
The following are the plans put in place by the NDLEA for effective treatment and rehabilitation of drug addicts:
Infrastructure : All the counselling / DDR centres working with NDLEA must possess adequate infrastructure for provision of counselling services to the clients. This includes the following types of rooms: Intake room/Office space/counselling room; waiting area; activity room /group discussion room; residential area/ward; and toilets. It is an established fact that there is a dearth of building / space at NDLEA centres, and more specifically for the counselling/DDR activities. Thus, all attempts must be made to accord due priority for counselling/DDR activities in allocation of infrastructure; efficiently utilize the available infrastructure for counselling/DDR activities; and intake room/office space/counselling room. This room will be primarily utilized by the counsellors for:
- Conducting their office work
- Interviewing the clients and family members during intake
- Conducting individual counselling sessions with the clients and family members
The room possesses adequate furniture, storage space (for the records), computer and printer among others (NDLEA, 2016).
Staff: Every counselling centre should have at least one trained counsellor. The ideal ratio would be one counsellor for 10 residential clients. For more number of clients the centre should attempt for provision of more counsellors correspondingly. In ideal situations there should be a doctor available with the counselling centre. The doctor may be a part-time doctor who is expected to devote at least three hours, twice a week in each of the counselling centre. In addition there should be an arrangement of calling the doctor in situations of medical emergency (or shifting the client to the emergency department of the nearest health facility). In addition there is a need of support staff in the form of attendants / care takers / housekeeping staff etc. The counsellor should have undergone specific training on counselling for people who use drugs and should possess the necessary documentation for the same.
Service Delivery: The services provided at the NDLEA counselling and DDR centres would include; assessment and intake of clients; home-based counselling intervention (for clients and family members); residential counselling intervention; after care services; referral services; and recreational and occupational rehabilitation services. A brief description of each of these services are as follows.
Assessment and intake of clients: Every client reaching the counselling centre must undergo the assessment (as per the process explained in the chapter “Assessment”).
Home-based counselling intervention (for clients and family members): These counselling interventions can be scheduled as per the convenience of clients and counsellors. In general, the counsellors should be able to decide the specific time-slots for various activities (counselling for home-based clients, counselling for residential clients, office-work etc.). These timings should be prominently displayed at the centre.
Residential counselling intervention: These counselling interventions are meant for the clients who are receiving residential care and hence are expected to be (a) more intensive in nature and (b) provide more flexibility of timings for the counsellors. The specific types of counselling interventions (as well as their frequency) would be guided by the requirements of individual cases.
After care services : In case of residential clients, even after discharge, it is not necessary to assume that the treatment is complete and that the client no longer requires services from the centre. After discharge, the counsellors can encourage the clients to maintain contact with the centre and keep visiting to receive after-care counselling services (the exact types of these counselling interventions to be decided upon the specific requirements of the individual case).
Referral services: All the NDELA centres are essentially ‘stand-alone’ facilities. People Who Use Drugs on the other hand have multiple needs and requirements. The NDLEA counselling centres are not realistically expected to meet all the requirements of all the clients. Thus it is necessary for all the centres to maintain a network of various services to which the NDLEA clients can be referred. These referrals may include to following types of services:
- Health care services
- Legal aids and services
- Social welfare services
- Educational or vocational services
- Financial services
- Religious / spiritual services
It would be helpful to maintain a Directory of referral services, from where it would be very convenient for a counsellor to find out the details of various service providers and refer the clients.
Recreational and occupational rehabilitation services: All NDLEA centres should strive for providing some Recreational and occupational rehabilitation services, especially to the residential care clients. The recreational services may include healthy indoor games, readings of books, magazines and newspapers, television or movies. Similarly occupational rehabilitation services ay may include short-term vocational trainings (with the aid of other agencies / organizations).
Record Maintenance : A simple and user-friendly record maintenance system is being recommended which would ensure that all the client-related activities of the centre are recorded and aids in delivery of efficient services as well as in monitoring and evaluation. Reporting, Monitoring and Evaluation : All the NDLEA counselling and DDR centres would be expected to prepare their monthly reports and submit it by 10th of every month. All these reports could be submitted in the online version (as an email attachment or an online format) but additionally should be submitted to the NDLEA headquarter in the hard copy format too. Reports from all the centres would be compiled and collated every month and would be used for reviewing and implementing policy-level decisions. In addition, a system of on-site monitoring and evaluation could be put in place whereby senior DDR officials may visit the centres, and conduct the following activities:
- Inspection and observation of the centre
- Interaction with the staff
- Interaction with the clients (residential and home-based)
- Review of records
Based upon the observations, the evaluating officers could submit specific recommendations to improve the functioning of the given centre.
Theories of Drug Abuse Relapse
The main theory adopted for this study is the Transtheoretical Model propounded by Prochaska and DiClemente (1977). The theory is otherwise known as the “Stages of Change Model”. Prochaska and DiClemente believed that individuals change behaviours gradually in a cyclical series of phases. Drug addicts often times denie their addiction for a period of time in order to rationalise the problem at hand. It is an ego defense mechanism to reject the fact that they are not experiencing drug addiction problem or to ward off discomfort caused by repeated emotional injuries. This usually results into poor treatment outcomes and is a major obstacle in diagnosis. It is a hostile shield, and certainly not a long-term solution for any problem (Barthwell, 2015).
Addicts in the above status, are usually not motivated to change; but Prochaska and DiClemente emphasised that intentional change is key to changing habitual behaviours; that is, addicts must want and be ready to change their behaviour. In the addiction field, this means that drug users need to want to stop using before they can continue through the rest of the recovery process. There are six theoretical stages of change as postulated by Prochaska and DiClemente (1972) and they include: precontemplation, contemplation, preparation/determination, action, maintenance, and relapse. Determining which stage of change a person is in can help clinicians to decide which therapies and treatment methods should be applied. The “ideal” stage of change is maintenance, though it should be noted that it is quite common to cycle through the stages multiple times before settling in to a new habitual behaviour (Barthwell, 2015).
Precontemplation Stage: Individuals in the Precontemplation Stage have no intention of changing in the foreseeable future, which Prochaska and DiClemente define as “within the next six months.” The person is often in denial or legitimately unaware that his or her behaviour is problematic. They are inwardly focused and predominantly think about how changing their behaviour will negatively affect their lives. They put no consideration into the idea that change might bring about positive effects.
That is, the user is not considering change, is aware of few negative consequences, and is unlikely to take action soon. As the old saying goes, “You cannot help someone who does not want to help themselves”. So, individuals in this stage are unlikely to benefit from a rehabilitaion programme. It is helpful in this stage to approach the addict gently. No one should try to force their loved ones to take action. As Diclemente wrote, “We cannot make precontemplators change, but we can help motivate them to move to contemplation.”
Contemplation Stage: Drug addicts in the contemplation stage are no longer in denial about their behaviour. They recognize that it is problematic, and contemplate the positive and negative effects equally. They intend to reform their behaviour in the foreseeable future, though they may be unsure about the decision. They begin to contemplate their habit and the effects that it’s having on their life. Oftentimes, they will “get ready” to make a change. However, during the contemplation stage, addicts don’t commit to treatment. They may not even express their concerns out loud. Some addicts stay in this stage for long periods of time. They may move back and forth between precontemplation and contemplation before moving onto the next stage (Barthwell, 2015).
Preparation (Determination) Stage: Individuals in the Preparation (Determination) Stage are ready to take action and plan to do so within 30 days. They start making small steps toward change and genuinely believe that behavioural adjustment is a positive step. They are determined to take action, but not yet doing so.
Some drug addicts may say things like, “I have to do something about my life,” or, “I have a serious problem”. They might reach out to friends and family for help. They may even call clinics and research rehabilitation programmes to decide which path to take. But, they still continue to use drugs or drink alcohol. In order for therapists to consider an addict in the preparation stage, the addict must be willing to take tangible steps toward changing their behaviour within 30 days (Prochaska & DiClemente, 1972).
Action Stage: Individuals in the Action Stage have initiated behavioural change and plan to continue moving forward. They modify their lifestyle to add healthy actions and subtract problematic ones. They are no longer engaging in the problem behaviour and are actively changing for the better. They have come to terms with the fact that their habit is destructive to their wellbeing. They also decide to take action in order to end it. This stage may include things like detox, rehab, drug counselling, group support meetings, and participation in other forms of treatment (Barthwell, 2015).
Unfortunately, this stage carries the highest risk of relapse. Because the addict probably still has traces of their favorite drug still in their system, along with the fact that they are dealing with the emotional effects of addiction, they can easily fall prey to temptation. However, as long as the addict commits to getting sober, they should be able to cycle back to stage four. Some practitioners of Prochaska’s Stages of Change model believe that the best course of action is complete abstinence. However, that view is slightly outdated. It ignores that fact that the “cold turkey” approach does not work for everyone.
Maintenance Stage: Individuals in the Maintenance Stage have refrained from engaging in their problem behaviour for more than six months. This is the ideal stage of change; positive behaviour is being maintained and the negative behaviour is kept at bay. It is important for addicts in this stage to actively work to prevent relapse back to earlier stages of the cycle.
This stage rarely ever ends (Barthwell, 2015). In order for an addict to stay sober, they must manage drug cravings and triggers for the rest of their lives. Of course, the cravings dissipate over time. But, the temptation to relapse remains. The body never forgets the way it felt when it was addicted. So, it takes immense self-control to maintain one’s sobriety. During this stage, the addict does not experience the rapid changes that they experience in previous stages. Ideally, they will find a rhythm that helps them to stay sober. Occasionally, it is necessary to make adjustments in order to avoid relapse. The longer they stay sober, however, the easier it is to maintain sobriety.
Relapse Stage: Individuals in the Relapse Stage have broken the period of maintenance and started to engage in their problem behaviour again. People in this stage are usually overwhelmed with negative emotions and tend to return to some form of comfort zone. It is important to recognize that relapse is not synonymous with failure; cycling through the stages multiple times is an accepted and normal part of creating lasting change (Prochaska & DiClemente, 1977).
According to the transtheoretical model, relapse is a sad reality of addiction. While some addicts are able to get clean on their first attempt, others are not. As a result, most psychotherapists encourage their patients to see relapse as a learning experience. If the client is committed to recovery, they are allowed to re-enter the cycle at the beginning and move through the stages once again. While the addict works through the stages, the doctor helps them to identify what went wrong on their first attempt. Both parties work to pinpoint unidentified triggers, answer unanswered questions and devise new solutions for managing cravings (Darnton, 2008).
It is important for addicts to understand that relapses happen. Just because someone relapses does not mean that hope is lost. One of the strengths of this model is that it allows space for addicts to re-enter recovery after a relapse. While the theory certainly has its critics, many doctors believe that the transtheoretical model is the most effective approach to addiction treatment. These doctors find the model effective because of the way it treats recovery as a slow process instead of a quick one (Prochaska & DiClemente, 1977).
“The true power of this model really becomes apparent when the stages are recognised, sequential and conditional,” (Prochaska & DiClemente, 1977). In other words, this model works because it approaches recovery as a step-by-step process. Unless the doctor sees evidence that the patient is ready to progress onto the next stage, they won’t rush the addict into treatment. According to Lickerman (2012), the best thing about the Stages of Change Model is that it helps the addict to recover in small increments. That way, they are not overwhelmed by the prospect of recovery. “Focus on reaching the next stage rather than the end goal,” he advised, that “Sobriety may seem too far away and therefore discourage one from even starting on the path towards it.”
As it was pointed out above, Prochaska and DiClemente’s theory is not perfect. It was developed in another era before scientists understood much of what they know about the brain today. As a result, some see the Transtheoretical Model as an outdated tool as a result of the following reasons (Ling, 2012).
Rigid Timelines: The original Model assigns timelines to each Stage of Change. For example, the developers believed that the Preparation Stage should take no longer than six months. This is one of the biggest points of contention with critics. It does not account for the fact that everyone is different and may take longer to move to the next stage.
Blurred boundaries: Some argue that the Stages are not as clearly defined as Prochaska and DiClemente believed. Robert West argues this point in a research paper. “It has to draw arbitrary dividing lines in order to differentiate between the stages,” West writes. In order for TTM to work, therefore, therapists must have specific benchmarks that signify the beginning and end of each stage.
Ignores Addict’s Needs: Some people argue that the Model ignores addicts who lack the desire to change. Because it lumps all pre-contemplative behaviour into the first Stage, the Model could encourage addicts to keep using. In the worst case scenario, an addict might overdose simply because their doctor does not want to suggest rehab too early. Ultimately, many doctors believe that this model is an ineffective way to view and treat addiction (Darnton, 2008).
Metabolic Theories: In the early 1960s, Dole and Nyswander were studying the metabolic kinetics of morphine when they observed improvement in subjects’ functioning in response to substituting methadone for morphine. Long before the discovery of narcotic receptors, endorphins, or enkephalins, Dole and Nyswander postulated that repeated exposure to narcotic drugs might induce metabolic changes in neurons (Dole & Nyswander, 1967, p. 22). Methadone corrected the metabolic change. Since methadone was meeting a metabolic need of the patient, replacement methadone therapy, perhaps lifelong, was rational and the treatment fit a medical model (i.e., like exogenous insulin for a diabetic). The hypothesis that exposure to narcotics produces metabolic alterations is supported by more recent work with opiate receptors, beta-endorphin, and enkephalins. After the discovery by Goldstein in 1971 that some neurons had specialized recognition sites on the cell’s membrane for opiates, scientists searched for an endogenous substance with opioid activity that would bind to the receptor. Several endogenous substances meeting the criteria were subsequently found: beta-endorphin, a fragment of beta-lipotropin; and two pentapeptides, methionine-enkephalin and leucine-enkephalin.
Goldstein (1978) speculated that a relationship existed between beta-endorphin levels and heroin addiction. He hypothesized that the use of heroin would suppress endorphin production, analogous to feedback regulation of other hormones. Further, persistent opiate withdrawal symptoms would result from endorphin deficiency, and protracted narcotic withdrawal symptoms could help account for the high relapse rate among opiate addicts. Ho et al. (1980) provide empirical support for Goldstein’s hypothesis that betaendorphinlevels are abnormal in opiate addicts. They compared plasma levels of endorphins in heroin addicts and nondrug-using controls and found that the mean level of immunoassayable plasma endorphin activity, which reacts with beta-endorphin and beta-lipotropin, was reduced in the heroin addicts to about one-third the level of the nonaddict controls.
Counselling Implications for Treatment: The metabolic theory of opiate dependence supplies support for opiate dependency as a disease. Reduced endorphin levels of narcotic addicts provide plausible medical reason for a relapse. Metabolic theories bolster the medical disease model of narcotic drug abuse and provide a medical foundation for narcotic maintenance therapy (e.g., methadone and LAAM). The endorphin deficiency model also has an implication about the duration of methadone treatment. If one supposes that the addict inherited an endorphin deficiency, analogous to insulin deficiency in diabetics, then “replacement” could be lifelong. Many providers of methadone maintenance do not use this model. They view the need for methadone maintenance to be temporary and the appropriate use of methadone to be to provide a time-limited period of psychosocial stabilization while rehabilitation occurs. Widespread acceptance of this latter perspective has led to legislation that prohibits maintenance therapy of unlimited duration. Typically, in the United States, opiate addicts are provided methadone maintenance for periods of 1 or 2 years.
Conditioning Theory: Wikler (1961, 1965, 1973) proposed the conditioned withdrawal syndrome to explain why formerly addicted persons who appear to be “cured” of their addiction while in treatment or in jail return to opiate use when no longer physically dependent. According to Wikler, environmental and social stimuli formerly associated with actual withdrawal and drug-seeking became classically conditioned stimuli for a conditioned withdrawal syndrome. Wikler and Pescor (1967) demonstrated a conditioned withdrawal syndrome in rats. Rats that were no longer morphine dependent showed signs of narcotic withdrawal (e.g., “wet shakes”) when they were returned to the cage in which they had previously suffered narcotic withdrawal. With Ludwig, Wikler extended the conditioned withdrawal model to alcohol relapse (Ludwig & Wikler, 1974). Over time, craving and other alcohol withdrawal phenomena become conditioned to environmental and emotional stimuli through temporal continuity. Once conditioned, exposure to the same or similar stimuli would cause an abstinent alcoholic to experience withdrawal.
Some evidence of conditioned abstinence in intravenous heroin addicts was found by Sideroff and Jarvik (1980). Eight addicts who were completing a l4-day detoxification program were shown a 6-minute videotape depicting scenes of heroin being prepared for injection and being injected. Compared to a control group of two heroin users who snorted heroin and six patients who were not drug dependent, the intravenous heroin users, while watching the videotape, developed greater increases in anxiety, depression, drug cravings, galvanic skin resistance, and heart rate. These investigators propose that the psychological and physiological changes they observed demonstrated conditioned withdrawal.
Implications for Treatment: A direct application of classical conditioning is aversion treatment of alcoholism with emetine. Patients have sessions in which they are given emetine, which produces severe nausea and sometimes vomiting, while being allowed to smell or taste their preferred alcoholic beverage. With repeated pairings of alcohol with nausea, instead of the usual pleasurable feelings, alcohol loses its appeal. To prevent relapse to narcotic use, Wikler (1980) proposed active extinction of the classically conditioned abstinence syndrome and the operantly conditioned drug-seeking behaviour by eliciting the abstinence syndrome while preventing the reinforcing effects of opiates. He predicted that repeated elicitation of the conditioned withdrawal syndrome while the reinforcer (i.e., the relief obtained from the narcotic) is blocked with an orally effective, long-acting narcotic antagonist (such as naltrexone) should eventually extinguish the conditioned withdrawal syndrome, and the drive for self-administration of narcotics should cease.
Social Learning Theories: Social learning models of addiction and relapse acknowledge the role of classical and operant conditioning; however, they focus on cognitive-mediated processes in the acquisition, maintenance, and modification of behaviour. The various social learning theories complement conditioning theory by focusing on the cognitive processes occurring between stimulus and behaviour. A general model of relapse in a social learning framework has three components: first, the patient encounters a high-risk situation during abstinence; second, the patient has expectations about whether the situation can be handled without use of drugs; and third, the patient has a limited repertoire of behaviours and skills to cope with the high-risk situation.
What follows the high-risk situation depends on whether the situation resulted in drug use. The model holds that avoiding use leads to heightened expectations about personal control, mastery, and continued abstinence. Using a drug in response to the high-risk situation can lead to feelings of failure and guilt, which can precipitate further use. Consequences of relapse have been discussed by Bandura (1978) and Marlatt and Gordon (1980). “Catastrophizing” (Bandura 1978) is an exaggerated or extreme response to an occasion of use. Persons who doubt their ability to control their use, e.g., those with low efficacy expectations, are likely to overreact or “catastrophize” the consequences of a single lapse and view lapse as a global failure. The Marlatt and Gordon (1980) abstinence violation effect (AVE) is a similar construct. It has two components: cognitive dissonance (having a selfimage as a nonuser which conflicts with the actual drug-using behaviour) and personal attribution of the transgression as a sign of weakness and failure. Although the AVE varies in intensity, its occurrence will increase the probability of repeating the drug use since the dissonance and the attribution of weakness will drive behaviour to reduce the dissonance.
Implications for Treatment: The work of social learning theorists contains specific formulations regarding relapse prevention. Treatment derived from social learning theories attempts to prevent relapse by intervening at different points in the chain of behaviours, beginning with antecedents to the high-risk situation and extending through actual relapse. The interventions are tailored to the particular stage in the sequence and to the particular person. Social learning theorists agree that a critical point of intervention is at the time of experiencing a situation of risk. Treatment goals include fostering recognition of the situation as one of risk, maximizing expectations of efficacy in handling the situation, and enhancing the behavioural repertoire to cope with the situation. The person is taught to recognize his or her high-risk situation and to practice coping skills needed to avoid drug use should the situation be encountered. Following a slip or a relapse, interventions include teaching clients how to limit or contain an episode of drug use and how to apply cognitive restructuring. Cognitive restructuring involves conceptualizing the episode of use as a limited slip rather than a major disaster; analyzing the high-risk situation; and learning new coping skills.
Empirical Studies on Prevalence and Causes of Drug Relapse
Several empirical studies have been carried out on drug relapse both at national and international level. For example, Walton, Castro and Barrington (1994) examined the role of attributions in abstinence, lapse, and relapse following substance abuse treatment. Ninety-seven participants were recruited from an inpatient treatment centre for substance abuse and completed an interview 6 months after leaving treatment. Findings revealed that lapsers and relapsers were similar regarding their internal/external attributions following a return to drug use: predictions were supported as relapsers made more stable and global attributions as compared to lapsers. Also, as predicted, abstainers made more internal, stable and global attributions regarding their abstinence (as compared to lapsers following their slip). Abstainers’ attributions for their success in remaining abstinent tended to be similar to the attributions made by relapsers for their failure to remain abstinent (i.e for their relapse).
Sinha (2001) explored how stress increase the risk of drug abuse and relapse. The study examined empirical evidence on how stress may increase the vulnerability to drug abuse, and explored whether chronic drug abuse alters the stress response and coping in addicts, thereby increasing the likelihood of drug seeking and relapse. The study was an experimental study carried out among 52 addicts in Delhi. A pre-test, posttest method was employed using Stress Induces Factors Scale. The findings of the study showed that stress, in addition to drug itself, plays a key role in perpetuating drug abuse and relapse. However, the mechanisms underlying this association in humans remain unclear. A greater understanding of how stress may perpetuate drug abuse will likely have a significant impact on both prevention and treatment development in the field of addiction.
Walitzer and Dearing (2006) investigated gender differences in alcohol and substance use relapse. The study explored gender differences in relapse and characteristics of relapse events in alcohol and substance use among 23 drug addicts in psychiatric centre in New York. The study showed that for alcohol, relapse rates were similar across gender. Although negative mood, childhood sexual abuse, alcohol-related self-efficacy, and poorer coping strategies redicted alcohol relapse, gender did not moderate these effects. Gender did moderate the association between marriage and alcohol relapse. For women, marriage and marital stress were risk factors for alcohol relapse; among men, marriage lowered relapse risk. This gender difference in the role of marriage in relapse may be a result of partner differences in problem drinking. Alcoholic women are more likely to be married to heavy drinking partners than are alcoholic men; thus, alcoholic women may be put at risk of relapse by marriage and alcoholic men may be protected by marriage. There are fewer studies ocumenting gender differences in substance abuse relapse so conclusions are limited and tentative. In contrast to the lack of gender differences in alcohol relapse rates, women appear less likely to experience relapse to substance use, relative to men. Women relapsing to substance use appear to be more sensitive to negative affect and interpersonal problems. Men, in contrast, may be more likely to have positive experiences prior to relapse.
Moos and Moos (2006) investigated the rates and predictors of relapse after natural and treated remission from alcohol use disorders. A 461 sample who initiated help-seeking was surveyed at baseline and 1 year, 3 years, 8 years and 16 years later. Participants provided information on their life history of drinking, alcohol-related functioning and life context and coping. It was dicovered that compared to individuals who obtained help, those who did not were less likely to achieve 3-year remission and subsequently were more likely to relapse. Less alcohol consumption and fewer drinking problems, more self-efficacy and less reliance on avoidance coping at baseline predicted 3-year remission; this was especially true of individuals who remitted without help. Among individuals who were remitted at 3 years, those who consumed more alcohol but were less likely to see their drinking as a significant problem, had less self-efficacy, and relied more on avoidance coping, were more likely to relapse by 16 years. These findings held for individuals who initially obtained help and for those who did not.
Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), Dawson, Goldstein, and Grant (2007) conducted a more sophisticated study and one of the only studies examined relapse within the context of both abstinent and nonabstinent remission. The first wave of the study identified 2109 people as having met DSM-IV criteria (American Psychiatric Association, 1994) for alcohol dependence, but who were currently in full remission. Type of remission was divided into three groups: asymptomatic risk drinkers, low-risk drinkers, and abstainers. These categories were based on pattern and volume of alcohol use. Asymptomatic risk drinkers and low-risk drinkers still met criteria for full remission as abstinence is not a criterion for remission from an alcohol use disorder (AUD). Three years later, 1772 individuals were reinterviewed. Examining the relationship between remission status and relapse, this study found that 51.0% of asymptomatic drinkers experienced relapse to an AUD, 27.2% of low-risk drinkers experienced relapse, and 7.9% of abstainers experienced relapse.
Ibrahim and Kumar (2009) carried out a study on factors affecting drug relapse in Malaysia. 400 drug addicts on relapse cases were selected from eight drug rehabilitation centres throughout Peninsular Malaysia which examined factors influencing the relapsed addiction to drug use. The study found that self-efficacy, family support, community support and employers support were identified as main factors that influenced the relapsed addictions tendency amongst addicts.
Jone, Sells and Rehfuss (2009) study was tagged “how wounded the healers? The pevalence of relapse among addiction counsellors in recovery from alcohol and other drugs”. This descriptive survey, designed to ascertain frequencies of relapse among drug and alcohol counsellors recovering from addictions to alcohol and/other drugs studied 657 male, 580 female, and 2 transsexual professionals ranging from 18 to more than 70 years of age. The 20-item instrument was administered online. A total of 1,239 usable responses were received, documenting an overall relapse rate of 37.777%. Outlines for further research were suggested. The study concluded that overall relapse rates approaching 38% mandate a reassessment of relapse within the addictions profession itself and the development of policies promoting destigmatization and enlightened intervention among practitioners.
Chepkwony, Chelule and Barmao’s (2013) study focused on the prevalence and factors contributing to relapse among alcoholics in selected rehabilitation centres in Nairobi County, Kenya. The study adopted an ex-post facto causal comparative research design. The target population was all the relapse cases in the 14 rehabilitation centres registered by NACADA in Nairobi. A random sample of 109 alcoholics and 8 counsellors drawn from 4 purposively selected rehabilitation centres were involved in the study. Data was collected through the administration of two sets of self-structured questionnaires to the selected respondents. The results of study shown that relapse was influenced by the interaction of past-risks within the individual and environmental situations and level of preparedness to cope with these past-risks to resist drinking.
Maehira, Chowdhury, Reza, Drahozal, Gayen, Masud, et al. (2013), in a prospective study, examined the factors associated with relapse into drug use among male and female attendees of a three-month drug detoxification–rehabilitation programme in Dhaka, Bangladesh. The findings of the study showed that a greater proportion of female than male subjects relapsed over the study period (71.9% versus 54.5%, p < 0.01). For men, baseline factors associated with relapse were living with other PWUDs, living alone and not having sex with non-commercial partners; whereas for women these were previous history of drug treatment, unstable housing, higher earnings, preferring to smoke heroin and injecting buprenorphine/pethidine. After discharge, relapse for men was associated with unstable housing, living alone, higher earnings and buying sex from sex workers. Women’ relapses were associated with not having children to support and selling sex. The relapse rate was higher for female PWUDs. For both male and female subjects the findings highlight the importance of stable living conditions. Additionally, female PWUDs need gender-sensitive services and active efforts to refer them for opioid substitution therapy, which should not be restricted only to people who inject drugs.
Lian and Chu (2014) embarked on a qualitative study on drug abuse relapse in Malaysia: Contributory factors and treatment effectiveness. The study examined the contributory factors of drug relapse among drug addicts and the treatment effectiveness of a centre in Malaysia. Methods/Study Design: An in-depth qualitative interview which was flexible, nondirective, and semi-structured was employed. There were 17 drug addicts and 3 administrative staffs being selected from the Malaysian Private Rehabilitation Centre for interview. Findings indicated that peer influence and curiosity were the top two significant factors contributing to drugs abuse. Treatment provided in the centre was highly effective as majority of the participants have a very low intention to relapse after recovered.
Deepti, Kaur and Kaur (2014) condcuted a study on drug relapse and its associated factors among cases admitted in Swami Vivekanand drug de-addiction Centre, GMC, Amritsar. The cross-sectional study was conducted over 50 drug relapse cases admitted in Swami Vivekanand Drug De-addiction Centre, Government Medical College, and Amritsar to find the various factors contributing to relapse after the de-addiction. Prestructured proforma was applied to study the socio-demographic profile, factors responsible for initiation of drug use, to seek treatment and relapse. The relevant data was collected and analyzed. The study found that out of all the participants, majority were male (98%), married (56%) and were from rural background (54%), while 60% of the respondents were of upper lower socio-economic status. Initiation of drug intake was in adolescence period, under the peer pressure being friends as motivator. In relapse also, major factor for initiation was friends.
Chong and Lopez (2014) studied the predictors of relapse for American-Indian women after substance abuse treatment. The study described the predictors of substance use relapse of American Indian (AI) women up to one year following substance abuse treatment. Data were collected from AI women in a 45-day residential substance abuse treatment program. Predictors include distal (in time) proximal (recent), and intrapersonal factors. Results indicated that intrapersonal factors showed the strongest relationship with relapse, followed by proximal and distal factors. Negative messages about using alcohol or drugs from the client’s father while growing up may have had an impact on whether the client used alcohol at 6 months. Conflicts with other people and being in the company of alcohol or drug users were highly predictive of relapse. While craving was highly predictive of substance use at follow up, self-efficacy was highly predictive of no substance use. Knowledge about predictors of relapse among this population should be used as a guide toward individual treatment planning.
Bhandari, Dahal and Neupane (2015) worked on factors associated with drug abuse relapse: A study on the clients of rehabilitation centres. The study made use of 114 drug addicts in Lalitpur and Chitwan districts. According to the findings, the main causes for the drugs relapse were peer pressure and the family relations. The age of the respondents is associated with the drugs relapse (P<0.029). Educational level of the respondents is associated with the drug relapse (P<0.004). It was concluded that medium and higher economic background, type of family, job holder, lower education level have more chance to be relapsed. Relapsed can be prevented by providing support, care, positive attitude and rehabilitation for the behavioural treatment of the drug users.
Osama and Muhammed (2016) studied the relationship between personality disorders and relapses among 45 sample of substance abuse patients. Pearson Correlation Coefficient showed that there are statistically significant relationship between Antisocial Personality Disorder (APD), Borderline Personality Disorder (BPD), Avoidant Personality Disorder (AVPD) and Dependent personality disorder (DPD) and substance abuse relapses. Also, the result showed that there are no statistically significant relationship between Paranoid personality disorder (PDD), Schizoid personality disorder (SPD), Schizotypal personality disorder (STPD), Histrionic personality disorder (HPD), Narsistic personality disorder (NPD) and Obsessive-Compulsive personality disorder (OCPD) and substance abuse relapse. The Regression and Prediction Coefficient (stepwise) was also used and showed that the Dependent personality disorder, Borderline personality disorder and Antisocial personality disorder predicts substance abuse relapses.
Batool, Manzoor, Hassnain, Bajwa, Abbas, Mahmood and Sohail (2017), in a cross-sectional survey, explored the pattern of addiction and its relapse among habitual drug abusers in Lahore, Pakistan. Nonprobability purposive sampling was done to collect a sample of 119 participants. A structured questionnaire and in-depth interviews were used for data collection. Out of 119 participants, 71.4% were in the age group 15–35 years. Educational levels were low in the majority, with 68.1% below secondary education. Unmarried (51.3%) and unemployed (44.5%) participants were at the greatest risk of using drugs. The age of addiction in 45% of patients was 5 years. Reasons for starting drug abuse were recreation (37%), curiosity (34.5%), and life-changing events (14.3%). Reasons for relapse included association with former addicts, negative reactions from family, inability to manage the craving and work/social stress.
The studies explored under the empirical review showed that majority of the studies are foreign based, perhaps, few studies have been carried out in Nigeria, they are probably not published and were less wide in scope. This suggests that there is need for carrying out a robust empirical study of this nature on prevalence and causes of drug abuse relapse among the victims in Nigeria.
Summary of the Reviewed Related Literature
The review of related literature begins with the concept of drug abuse and addiction. Drug abuse is misuse of licit and illicit drugs. Drug addiction was defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioural and drug addictions, but not dependence. Addiction, by some accounts, begins as a result of using a substance (drugs or medications) that have a measurable impact on the reward centre of the brain, but it does not end there. The repeated stimulus of this reward centre is enough to effect a change in the functionality of the brain itself - as the process of stimulating the reward circuitry, so to speak, becomes of paramount importance above all other aspects of an otherwise ‘normal’ life.
Some of the causes of addiction were also identified in the review. They include; genetic, psychological and environmental factors. Genetic causes of drug addiction appear to involve multiple gene sequences and science has not yet been able to pinpoint all the genes involved. Some of the psychological causes of drug addiction appear to stem from trauma, often when the drug addict is young. Sexual or physical abuse, neglect, or chaos in the home can all lead to psychological stress, which people attempt to ‘self-medicate. Environmental factors are peer pressure, physical and sexual abuse, early exposure to drugs, stress and parental guidance can greatly affect a person’s likelihood of drug use and addiction among others.
The concept of drug abuse was also discussed as described by different experts. Drug relapse was described as a complex, vibrant, and volatile process. They labelled drug relapse as “usage, intake, or misuse of psychoactive substance after one had received drug addiction treatment and rehabilitation, physically, and psychologically”. Identifying risk factors can help reduce the likelihood of relapse. Some studies have noted that drug relapse is unavoidable in addicts and it is prevalent in many situations. For example in Nigeria, the National Drug Law Enforcement Agency reported that drug relapse varies across the states in the country, however, it is more prevalent in North-West region of the country.
Some of the causes of drug relapse as revealed in the literature review were availability and accessibility of drugs, poverty and unemployment, and encountering people, places and paraphernalia associated with earlier drug use. Effect of peer pressure, unemployment, poverty, economic crisis, coping with other life challenges, family factors, low self-esteem and self-efficacy among others were also noted. In view of the above, relevant empirical studies were cited to establish the genuiness of the focus of this study.
CHAPTER THREE
METHODOLOGY
Preamble
This chapter presents the detail process and procedure adopted in carrying out this study. It focuses on the research design, population, sample and sampling procedure, instrumention (including its psychometric properties – validity and reliability), procedure for instrument administration and data collection, procedure for scoring and method of data analysis.
Research Design
The study investigated the prevalence and causes of drug relapse among inmates in NDLEA rehabilitation centres in North Central, Nigeria. In this regard, descriptive survey design was considered appropriate for this study as it collected relevant information on prevalence and causes of relapse using questionnaire. Henry and Smith (2001) defined survey as a research procedure which aims at determining incidence, perception and attitude towards sociological and psychological variables. Descriptive survey research usually focuses on people, their knowledge, beliefs, opinion, practices, perceptions, attitudes and behaviours. Hence, the survey research design was considered most appropriate for study of this nature.
Population, Sample and Sampling Procedure
The population for this study comprises all drug addicts in NDLEA rehabilitation centres in North Central, Nigeria. Newman (2011) described a population as the abstract idea of a large group of many cases from which a researcher draws a sample and to which results from the sample are generalised. According to NDLEA (2019), 568 inmates are currently receiving treatment at different rehabilitation centres in North Central Nigeria. The following is the breakdown of the estimated population of addicts in at different rehabilitation centres in North Central Nigeria
Table 1: Population of Drug Addicts in North Central Senatorial Districts
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Source: NDLEA (2019)
Based on the above population, the researcher made use of a census to account for the sample of the study. Census in the sense that only the inmates supplied or provided by the NDLEA officers to the researcher were allowed to participate in the study. Hence, 169 respondents participated in the study. These are the respondents available for the conduct of the study.
Instrumentation
Instrumentation is the process of selecting or developing measuring devices and methods appropriate to a given evaluation or research problems (Okeowo, 2003). The main instrument used for data collection was a questionnaire tagged “Prevalence and Causes of Drug Abuse Relapse Questionnaire (PCDRQ)” which consists of three sections A, B and C. Section A of the questionnaire elicits the personal information of respondents. Sections B and C deal with the prevalence and causes of drug abuse relapse respectively. They were patterned in line with the Four Point Likert-type rating scale format. For section B; Very Often = VO; Often = O; Less Often = LO; and Not at All = NA were adopted, while Strongly Agree = SA; Agree = A; Disagree = D; and Strongly Disgaree = SD were used for section C.
Psychometric properties of the instrument
Validity: Validity is the extent to which an instrument or test measures what is purports to measure. Validity is the most critical criterion and indicates the degree to which an instrument measures what it is supposed to measure. In other words, validity is the extent to which differences found with a measuring instrument reflect true differences among those being tested (Kothari, 2004). In order to ascertain the validity of the instrument, the questionnaire was submitted to the researcher’s supervisor and four other experts (lecturers) in the Department of Counsellor Education, University of Ilorin for appraisal and assessment. Also, medical experts in the field of drug and NDLEA specialists make necessary adjustment and corrections on the designed questionnaire. All the corrections and suggestions made by the experts were implemented in making the final copy of the instrument. The content validity of the instrument was thus established based on this procedure.
Reliability of the instrument: Reliability deals with consistency and stability of an instrument or test score. It is the degree of consistency with which an instrument measures behaviour over time. Reliability is also described as the consistency, accuracy, stability and trust worthiness of a measuring instrument or score obtained, that is, how far the same instrument would give the same score on different occasions or with different sets of equivalent items under the same condition (Abiri, 2007). In order to establish the reliability of the instrument, splipt-half method was adopted. The instrument was at once administered on 20 respondents or clients in NDLEA rehabilitation centre in North-East who were not part of the study. The scores were splited into two categories (even and odd) and Cronbach Alpha statistics was used to compute the two set of scores. A reliability coefficient of 0.82 was therefore obtained. This coefficient indicates that the instrument is reliable.
Procedure for Instrument Administration and Data Collection
A preliminary visit was made to each of the NDLEA rehabilitation centres across the North Central geo-political zones, Nigeria, in order to obtain permission and co-operation of the administrators. Dates were fixed for the administration of the scheduled questionnaire. Copies of the questionnaire were taken to the different rehabilitation centres at the appointed time for the respondents to fill. The cooperation of the respondents was sought by explaining to them the purpose of the study and by assuring them of confidentiality. This went a long way in facilitating accurate and sincere responses. The researcher was assisted by four (4) trained research assistants.
Procedure for Scoring the Instrument
Section A of the questionnaire was scored by requiring the respondents to indicate the most applicable options to them. Section B and C deal with items on prevalence and causes of drug relapse were scored as follows: For section B.
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In determining the prevalence of drug relapse, percentage was used. The highest score is 80 (4 * 20 items); while the lowest score is 20 (1 * 20 items). Hence, scores between 60-80 was regarded as high prevalence of drug relapse, scores between 41-59 was rated as moderately prevalence of drug relapse, while scores between 20-40 was considered low prevalence. On the other hand, the causes was rated using mean and rank order. The highest score for any respondents is 4, while the lowest score is 1 the average score is therefore 4+3+2+1 = 10/4 = 2.5. Hence, score of 2.5 and above was considered the major causes of drug relapse, while scores below 2.5 was considered less significant causes of drug relapse.
Method of Data Analysis
The data obtained was analyzed using descriptive statistics (percentages) for the demographic data section. The hypotheses postulated were tested using inferential statistics of student t- test and Analysis of Variance (ANOVA) to compare the mean scores of respondents. Adana (1996) considered t-test as a parametric test often used by researchers to compare the means of two groups, while ANOVA as inferential statistics is used to compare mean scores from three or more variables. Hence, all hypotheses were tested at 0.05 level of significance.
CHAPTER FOUR
RESULTS
Preamble
This chapter presents the analysis of data collected. It discussed the results of the study with its interpretations. One-hundred and seventy-five (175) questionnaires were distributed to the respondents, but 169 were retrieved and 159 questionnaire forms were valid for data analysis. The results are presented as follows, viz: demographic characteristics of the respondents, answers to the research questions, hypotheses testing and summary of findings.
Demographic Chracteristics of the Respondents
Percentage was used to present the demographic profiles of the respondents as follows:
Table 2: Percentage Distributions of Respondents’ Demographic Characteristics
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Table 2 shows that 159 respondents took part in the study. The respondents’ parental occupational status indicated that 99 (62.3%) of their parents were employed; while 60 (37.7%) have parents who were unemployed. This means that more than 50% of parents of the victims of drug abuse relapse were working-class individuals. The educational attainment of the respondents showed that 34 (21.4%) of them were primary school certificate holders, 54 (34.0%) have secondary school certificates, 35 (22.0%) were ND/NCE certificate holders, 28 (17.6%) have HND/First Degree certificate; while 8 (5.0%) were postgraduate certificate holders. The marital status indicates that 94 (59.1%) were single, 52 (32.7%) were married; while 13 (8.2%) were divorced. This suggested that majority of the respondents were not married.
The age distribution of the respondents indicated that 21 (13.2%) were between 13-22 years, 75 (47.2%) were between 23-32 years, 54 (34.0%) were within 33-42 years age range; while 9 (5.7%) were 43 years and above. This showed that majority of people with drug abuse relapse in this study were youth (within the age range 23-32 years). In terms of age at first use of substance, 44 (27.7%) of the respondents started using drugs at 10-15 years, 82 (51.6%) used drugs at 16-20 years, 21 (13.2%) started at 21-29 years; while 12 (7.5%) used drug at 30 years and above. 99 (62.3%) of the respondents indicated that they have received treatment before the conduct of this study; while 60 (37.7%) have not being receiving any treatment. Similarly, 88 (55.3%) of the respondents reported that they have received treatment at 1-3 times, 55 (34.6%) have received it between 4-6 times, 14 (8.8%) have received treatment at 7-10 times; while 2 (1.3%) indicated 11 times and above.
Answers to Research Questions Raised in the Study
Research Question 1: How prevalent is relaspe among clients in NDLEA Rehabilitation Centres in North Central, Nigeria?
Table 3: Percentage Distribution of Prevalence of Relapse among Clients in NDLEA Rehabilitation Centre in North Central
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Table 3 shows that out of the 159 respondents, 63 (39.6%) scored between 1-40 score range on the prevalence of drug abuse relapse scale, 94 (59.1%) scored between 41-59 score range on the prevalence of drug abuse relapse scale; while 2 (1.3%) scored between 60-80 on the scale. This indicated that drug abuse relapse is moderately prevalent among addicts in NDLEA rehabilitation centres in North Central, Nigeria.
Research Question 2: What are the causes of drug relapse among clients in NDLEA Rehabilitation centres in North Central, Nigeria?
Table 4 : Mean and Rank Order of Respondents’ Responses on Causes of Drug Abuse Relapse
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Table 4 shows that 13 out of the 23 items have mean scores that are above the average (benchmark) mean value of 2.50 for determining the main causes of drug abuse relapse among the addicts. However, items 1, 21, 2, 13 and 22 took precedence over others, with mean values of 2.86, 2.77, 2.74, 2.74 and 2.70 and were ranked 1st, 2nd, 3rd, 4th and 5th respectively. This indicated that the main causes of drug abuse relapse among addicts in NDLEA rehabilitation centres in North Central, Nigeria are easy availability of drugs, drug abuse environment, frequent passing through drug using site e.g bar palour and smoking joint, being in companying of drug users and easy accessibility to substance.
Hypotheses Testing
In the study, eight null hypotheses were formulated in line with the research questions. The hypotheses were tested using inferential statistics of t-test and Analysis of Variance (ANOVA) at 0.05 level of significance. In view of this, results of the hypotheses tested are presented as follows:
Hypothesis One:
There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status.
Table 5 : Mean, SD and t-test Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Parental Occupational Status
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Table 5 shows that for a degree of freedom (df) of 157, the calculated t-value of 0.60 is less than the critical t-value of 1.96 (p = 0.259 > 0.05). This indicates that there is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status; hence, the hypothesis was retained. Therefore, parental occupational has no influence on respondents’ expression on the prevalence of drug abuse relapse.
Hypothesis Two:
There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in the North Central on the basis of parental occupational status.
Table 6 : Mean, SD and t-test Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Parental Occupational Status
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Table 6 shows that for a degree of freedom (df) of 157, the calculated t-value of 0.33 is less than the critical t-value of 1.96 (p = 0.736 > 0.05). This indicates that there is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status; hence, the hypothesis was retained. Therefore, parental occupational has no influence on respondents’ expression on the causes of drug abuse relapse.
Hypothesis Three:
There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment.
Table 7 : ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Educational Attainment
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Table 7 shows that for a degrees of freedom (df) of 4 and 154, the calculated F-value of 1.98 is less than the critical F-value of 2.34 (p = 0.100 > 0.05). This indicates that there is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment; hence, the hypothesis was retained. Therefore, difference in educational attainment has no influence on respondents’ expression on the prevalence of drug abuse relapse.
Hypothesis Four:
There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment.
Table 8 : ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Educational Attainment
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Table 8 shows that for a degrees of freedom (df) of 4 and 154, the calculated F-value of 1.29 is less than the critical F-value of 2.34 (p = 0.275 > 0.05). This indicates that there is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment; hence, the hypothesis was retained. Therefore, educational attainment difference has no influence on respondents’ expression on the causes of drug abuse relapse.
Hypothesis Five:
There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status.
Table 9 : ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Marital Status
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Table 9 shows that for a degrees of freedom (df) of 2 and 156, the calculated F-value of 1.45 is less than the critical F-value of 2.34 (p = 0.236 > 0.05). This indicates that there is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status; hence, the hypothesis was retained. Therefore, variation in marital status of the respondents has no influence their expression on the prevalence of drug abuse relapse.
Hypothesis Six:
There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status.
Table 10 : ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Marital Status
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* Sig. at p < 0.05
Table 10 shows that for degrees of freedom (df) of 2 and 156, the calculated F-value of 4.46 is greater than the critical F-value of 3.00 (p = 0.011 < 0.05). This indicates that there is a significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status; hence, the hypothesis was rejected. Therefore, difference in marital status of the respondents has no influence on their expression on the causes of drug abuse relapse. In view of this, Duncan Multiple Range Test (DMRT) was used to identify the group that contributes to the difference.
Table 11: DMRT Showing the Group that Contribute to the Difference in Causes of Drug Abuse Relapse
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Table 11 shows that the group 1, 2 and 3 have mean values of 67.69, 61.10 and 54.59 respectively. This indicates that respondents who are divorced contributed to the difference found in table 10. Thus, divorced status aids respondents’ involvement in relapsing towards drug abuse. This might have resulted from the negative psychological imbalance associated with divorce among couples.
Hypothesis Seven:
There is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age.
Table 12 : ANOVA Result Comparing Respondents’ Expression on Prevalence of Drug Abuse Relapse Based on Age
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Table 12 shows that for a degrees of freedom (df) of 3 and 155, the calculated F-value of 1.41 is less than the critical F-value of 2.60 (p = 0.242 > 0.05). This indicates that there is no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age; hence, the hypothesis was retained. Therefore, difference in age range has no influence on respondents’ expression on the prevalence of drug abuse relapse.
Hypothesis Eight:
There is no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age.
Table 13 : ANOVA Result Comparing Respondents’ Expression on Causes of Drug Abuse Relapse Based on Age
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* Sig. at p < 0.05
Table 13 shows that for degrees of freedom (df) of 3 and 155, the calculated F-value of 2.82 is greater than the critical F-value of 2.60 (p = 0.041 < 0.05). This indicates that there is a significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age; hence, the hypothesis was rejected. Therefore, age difference has an influence on respondents’ expression on the causes of drug abuse relapse. In view of this, Duncan Multiple Range Test (DMRT) was used to identify the age group that contributes to the difference.
Table 14: DMRT Showing the Age Group that Contributes to the Difference in Causes of Drug Abuse Relapse
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Table 14 shows that the groups 1, 2, 3 and 4 have mean values of 70.22, 59.47, 56.47 and 51.57 respectively are significantly different from one another. However, the table showed that the expression of respondents within 43 years and above contributed to the difference found in table 13. Thus, addicts with old age are stronger in their view as regards the causes of drug abuse relapse. This might have resulted from their high level experience in relapsing to drug abuse.
Summary of Findings
It can be deduced from the results of this study that:
- Drug abuse relapse is moderately prevalent among clients in NDLEA rehabilitation centres in North Central, Nigeria.
- The main causes of drug abuse relapse among clients in NDLEA rehabilitation centres in North Central, Nigeria are easy availability of drugs, drug abuse environment, frequent passing through drug using site; for example, bar palour and smoking joint, being in companying of drug users and easy accessibility to substance.
- There was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status.
- There was no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status.
- There was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment.
- There was no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment.
- There was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status.
- There was a significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status.
- There was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age.
- There was a significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age.
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
Preamble
In the conduct of this study, two major research questions were answered, while eight null research hypotheses were tested at 0.05 level of significance. This chapter thus focuses on the discussion of findings, conclusions, recommendations based on the findings of the study and suggestions for further studies.
Discussion
The finding of this study revealed that drug abuse relapse is moderately prevalent among clients in NDLEA rehabilitation centres in North Central, Nigeria. This means that drug abuse relapse is not too widespread in the society; indicating that the rehabilitation programme of NDLEA in North Central, Nigeria is functioning as more victims of drug addicts were able to overcome addictions and adjust effective to their respective environment. This finding also suggests that many addicts of drugs rarely attend rehabilitation centres or being referred for adjustment; indicating that multitude of drug addicts are in the society without receiving any treatment to overcome their addictive behaviour. The moderate level of prevalence of drug abuse relapse could have resulted from the fact that great effort has been put in place by the NDLEA through its DDR Directorate, in offering of counselling services across the state and special area commands. The finding of this study is in contrast with the findings of Reid, Kamarulzaman and Sran (2007) added that about 70 to 90 per cent of addicts who undergo rehabilitation would return to the habit within first year after been discharged if they are compelled and detained at the rehabilitation centres. Also, the NDLEA (2015) report showed that there is high prevalence of drug abuse relapse among the respondents, where 50 to 70% of those treated and counselled returned to drug use after treatment in Nigeria. The difference of the finding of this study from the previous studies is that the society in which it was conducted was different and the categories of the respondents are different from those used in this study.
The main causes of drug abuse relapse among clients in NDLEA rehabilitation centres in North Central, Nigeria are easy availability of drugs, drug abuse environment, frequent passing through drug using site such as bar palour and smoking joint, being in companying of drug users and easy accessibility to substance. Easy availability of and accessibility to drugs/substances is most likely to enhance drug abuse relapse among addicts. Addicts under treatment in rehabilitation centre who are in a society with easy availability of and accessibility to drugs/substances will perhaps relapse to drugs/substance having undergone treatment. This is becauses the seeing of the drugs in the environment becomes appealing and chaming for the addicts thus motivating them towards taking the drugs again and again. The findings of this study is similar with the findings of Mokri (2002) and Ibrahim and Kumar (2009) which revealed that drug abuse environment, easy availability of drugs and easy accessibility to substance are some of the causes of drug abuse relapse. This suggests that addicts’ exposure to the identified factors will consequently lead them to take drugs/substances after being treated in the rehabilitation centres.
The finding of this study also showed that being in the companying of drug users can make addicts return to drug abuse after undergone rehabilitation programmes. The influence of friends is enormous on the individuals’ behaviours. Somebody who accompanying him/herself with those that promote prosocial behaviours will be trenghtning and equipped against returning to drugs/substance abuse after rehabilitation; while someone who associates with people that uphold anti-social behaviours are more susceptible to drug abuse relapse having undergone rehabilitation programmes. Also, frequent passing through drug using site such as bar palour and smoking joint will as well encourage drug abuse relapse among the addicts. These are the environments which expose addicts to the use of drugs/substances after being exposed to rehabilitation programmes. The findings of this study are in line with the findings of Bain (2004) and Mohammad-poorasl, Fakhari, Akbari, Karimi, Bostanabad, Rostami and Hajizadeh (2012) which revealed that accompanying with group of friend that engage in drug/substance use can lead addicts to abuse after he/she had undergone rehabilitation.
The first hypothesis tested revealed that there was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status. This means that the perception of the respondents was similar on the prevalence of drug abuse relapse despite the differences in their parental background. The finding of this study is in contrast with the finding of Ibrahim and Kumar (2009) which revealed that there is a significant difference in the addicts’ perception of prevalence of relapse irrespective of variations in their parental occupational background. The similarity in the respondents’ perception could have resulted from the fact that drug addiction is a severe condition that is very difficult to navigate irrespective of parental occupational background of the victims or clients.
The second hypothesis tested revealed that there was no significant difference in the causes of drug abuse relapse as expressed by addicts in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of parental occupational status. This means that the expression of the respondents was similar on the causes of drug abuse relapse despite the differences in their parental background. The finding of this study is disgress with the findings of Lian and Chu (2014); Deepti, Kaur and Kaur (2014) which showed that a significant difference exists in the respondents’ (addicts’) perception of causes of drug abuse relapse with regards to the difference in their parental occupational background. The finding of this study deviates from the previous study because it was conducted on the respondents that have different characteristics in different country. This suggests that parental background has influenced addicts’ return to drug abuse after receiving treatment in the rehabilitation centre.
Hypothesis three indicated that there was no significant difference in the prevalence of drug abuse relapse as expressed by addicts in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment. This implies that differences in the educational attainment of the respondents did not influence their expression on the prevalence of drug abuse relapse in the society. The finding of this study disregard the finding of Bhandari, Dahal and Neupane (2015) which revealed that a significant difference exists in the respondents’ perception of drug abuse relapse on the basis of educational attainment. Difference of this finding from the previous findings indicated that drug abuse relapse is more prevalent among addicts across all level of educational attainment in adavanced countries than Nigeria where this study is conducted.
Hypothesis four indicated that there was no significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of educational attainment. This implies that differences in the educational attainment of the respondents did not affect the expression of the respondents on the causes of drug abuse relapse in the society. The finding of this study is in tandem with the finding of Greene (2014) which revealed that differences in the educational background of the addicts did not influence their expression on causes of drug abuse relapse. This finding suggests that drug addicts with varying educational level can return to drug abuse after being treated from rehabilitation centers as a result of some of the identified reasons for relapse.
The fifth hypothesis also showed that there was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status. This means that the expression of respondents with different marital statuses was similar on the prevalence of drug abuse relapse. The finding of this study is in contrast with the finding of Kassani, Niazi, Hassanzadeh and Menati (2015) which revealed that a significant difference existed in the prevalence of drug abuse relapse among addicts in rehabilitation centres on the basis of marital status. This indicated that drug abuse prevalence is more persistent among a group of people than the other. The finding of this study deviated from the previous finding because because of difference in the locale of studies and variation on the policies and laws guiding drug abuse practices in the countries.
The sixth hypothesis revaeld that there was a significant difference in the causes of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of marital status. This means that there is difference in the respondents’ expression on the causes of drug abuse relapse with respect to differences in their marital status. The finding of this study corresponds with the finding of Mattoo, Chakrabarti and Anjaia (2009) which revealed that significant difference exists in the expression of the addicts on the causes of drug abuse relapse based on marital status. The result of the DMRT conducted showed that respondents who are divorced contributed to the difference found in their expression. This follows divorced status aids respondents’ involvement in relapsing towards drug abuse. This might have resulted from the negative psychological imbalance associated with divorce among couples.
The seventh hypothesis showed that there was no significant difference in the prevalence of drug abuse relapse as expressed by clients in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age. This implies that respondents’ expression was similar on the prevalence of drug abuse relapse irrespective of the differences in their age range. The finding of the study contradict the finding of Kassani, Niazi, Hassanzadeh and Menati (2015) which showed that drug abuse relapse prevalence varied among respondents with different age range. This finding is different from the previous finding because the difference in the locales and the time of study.
The eight hypothesis showed that there was a significant difference in the causes of drug abuse relapse as expressed by addicts in NDLEA Rehabilitation centres in North Central, Nigeria on the basis of age. This means that the expression of respondents on the prevalence was different with regards to variation in their age range. This finding is in tandem with the finding of Bhandari, Dahal and Neupane (2015) which revealed that no significant difference exists in the respondents’ expression on the causes of drug abuse relapse on the basis of age range. The finding of this study is similar with the previous study because the categories of respondents used were similar. However, the DMRT conducted in this study showed that the expression of respondents within 43 years and above contributed to the difference in respondents’ expresson. This might have resulted from their several experiences of drug abuse relapse.
Conclusion
The conclusion drawn from the results of this study is that stakeholders in drug abuse reduction, particularly the NDEA have been effective in curbing drug abuse menace among Nigeria youths; thus, the moderately prevalent of drug abuse relapse among clients in NDLEA rehabilitation centres in North Central, Nigeria. In the light of this, they should be intensified to prevent relapse among the clients under rehabilitation process and drastically reduce the population of youths who use or abuse drugs.
Implications of the Findings for Counselling
The findings of this study have some relevant implications for counselling as helping profession. Some of these implications are as follows: Counselling as helping profession which is part of the rehabilitation programmes and a section or units in the NDLEA should help clients who relapse to drug abuse with appropriate counselling interventions or the use of different counselling techniques such as cognitive restructuring, behaviour rehearsal, modelling, in-vivo therapy or systematic desensitization tha can save them from irrational thoughts or model positive behaviour in them; thereby, being able to develop positive adjustment strategies to combart all forms of temptation towards returning to drugs/substances abuse. Counsellors can as well through a group guidance or psychoeducational programmes expose to and equip clients or addicts (who relapse to drugs) with effective problem solving strategies, positive coping mechanisms, social skills and assertiveness training, as well as decision making skills that can help them sustain positive adjustment they have made through rehabilitation programmes; thereby, preventing relapsing to drug/substance abuse.
Recommendations
Based on the findings of the study, it was recommended that:
1. Counsellors also has the mandate of equipping the relatives and families of the clients with some social skills training such as human relation skills that they can employ in persuading their wards who have received treatment to avoid returning to the companying of friends or environment that can still expose them again to the abuse of drugs.
2. NDLEA should intense effort in identifying more addicts in order to take them through rehabilitation process so that they can adjust effectively to their environment and avoid going back to drug/substance use after receiving treatment.
3. The government through NDLEA and other drug prevention agencies should intensify their effort in providing adequate rehabilitation programmes and follow-up activities that help reduce the level of drug abuse relapse among the addicts after going through the rehabilitation process.
4. After rehabilitation, the NDLEA and rehabilitation agents should encourage or help the addicts to change their environment to such that will engage them in positive activities (such as sports) so that they can avoid being accessible to drugs/substances.
5. The NDLEA rehabilitation centres should work with the family and relatives of the addicts (who had being saved from drug abuse problems) by helping them to avoid mingling with bad companying that can encourage towards drug abuse again.
6. The government and all agencies for drug abuse prevention in Nigeria should not relent on their effort in making evacuating the drug availability and accessibility in the society so that addicts who had undergone rehabilitation programmes will not be forced or motivated towards returning to drug/substance abuse.
7. The escalation of bar palours and other related environments should be prevented or restricted to some specific society that can be adequately monitored by the authorities. This will prevent the rehabilitated addicts from relapsing to drug abuse.
8. The rehabilitation centres make provision for intensive follow-up services to monitor the change process of their clients and provide them with other necessary supports that can prevent them from returning to drugs/substance after treatment.
Suggestions for Further Studies
The study investigated the prevalence and causes of drub abuse relapse as expressed by clients in NDLEA rehabilitation centres in North Central, Nigeria. The study also examined the influence of demographic variables of parental occupational status, educational attainment, marital status and age on respondents’ expression. In view of this:
- Further research could be carried out on consequences of drug abuse relapse and counselling strategies help the victims.
- The number of sample can be increased to cover a wide range of addicts in NDLEA rehabilitation centres in Nigeria.
- Study of this nature should be extended to cover all addicts in Nigeria in order to increase the generalizability of its findings.
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UNIVERSITY OF ILORIN
FACALTY OF EDUCATION
DEPARTMENT OF CONSELOR EDUCATION
Prevalence and Causes of Drug Relapse Questionnaire (PCDRQ)
Dear Respondent,
This questionnaire is designed to collect information on prevalence and causes of drug relapse among drug addicts in Nigeria. Your responses will be used purely for research purposes and will be treated with utmost confidentiality. Hence, you do not need to indicate your name or give any information that could reveal your personality issue. Therefore, kindly respond sincerely and honestly to the statements in the questionnaire form.
Thanks.
Researcher.
Direction: Kindly respond to all the items in this questionnaire ticking (√) the columns that are applicable to you.
Section A: Demographic Data
Parental Occupational Status: Employed ( ); Unemployed ( ).
Age : 13-20 years ( ); 21-28 years ( ); 29-36 years ( ); 37 years & above ( ).
Educational Attainment : Primary ( ); Secondary ( ); ND/NCE ( ); HND/B.Sc ( ); Postgraduate ( ).
Marital Status: Single ( ); Married ( ); Divorced ( ).
Age at First Use of Substance: 10-15 years ( ); 16-20 years ( ); 21-29 years ( ); 30 years & above ( ).
Have You Received Drug Addiction Treatment Before: Yes ( ); No ( ).
Number of Times Received Drug Addiction Treatment: 4-6 times ( ); 7-10 times ( ); 11 times & above ( ).
Direction: Kindly respond to all the items in this questionnaire ticking (√) the columns that are applicable to you, using the following keys: Very Often = VO; Often = O; Less Often = LO; and Not at All = NA.
Section B: Prevalence of Drug Abuse
Abbildung in dieser Leseprobe nicht enthalten
[...]
- Quote paper
- Muritala Sanni (Author), 2019, Prevalence and causes of drug abuse relapse as expressed by clients in NDLEA rehabilitation centres in North central, Nigeria, Munich, GRIN Verlag, https://www.grin.com/document/538092
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