Addiction is a behavior that refers to any activity, substance or object that becomes the major focus of a person’s life; during which person withdraws from other activities [1]. Addiction is a craving for something intensely, loss of control over use, and continuing involvement despite negative consequences [2]. Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. The study of addiction is important because people suffering from addiction can be helped to better understand what they are going through. The aims of the study explore the reasons of relapse in Substance related Addictive Disorder [2].

Addiction do not only include physical things that consume, such as drugs or alcohol, but may include virtually anything, such abstract things as gambling to seemingly harmless products, such as chocolate; in other words, addiction may refer to a chemical addiction (e.g. drug addiction) or behavioral addiction (e.g. gambling addiction). Some researchers speak of two types of addictions: (for example, alcoholism, drug abuse, and smoking); and process addictions (for example, gambling, and spending, shopping, eating and sexual activity) [3]. The disease model describes substance dependency as primary, progressive, chronic relapsing disease that is either genetically transmitted or acquired through excessive consumption [4,5]. Initial drug use occurs voluntarily. As repeated drug use changes neural and brain function, however, the user progressively loses control over their initial voluntary behavior to the point that further drug seeking and use become acts of compulsions, not choice [6,7]. Thus, getting drug users who are in the early or later stages of an addiction into treatment with medical experts often represents their best hope for arresting but never curing the addiction [8].

The alternative model describes addiction as a motivated choice. Here, drug taking is at all times something individuals to voluntarily, usually when life is going badly or to avoid coping with problems in living [9]. When these problems in living are resolved, individuals normally find that the addiction resolves with them, while other individuals mature out of their addiction in time [10] or learn to control their consumption [11]. In this way, addiction is seen as more to do with the environments people live in than with brain pharmacology [3,5,12].

According to genetic model humans are all a product of their parents. If parents have addiction struggles, chances to susceptibility to addiction. That’s why drug addiction is more common in some families than in others. Drug addiction causes one generation to pass it on to the next [2].

Aside from the inherited factors, some people have a personality that is more likely to become drug dependent. People wanted to feel good, and by nature impatient. Drugs give an instant gratification that other things do not. Even some common personality characteristics, such as aggression, may be a factor. Children who do not have confidence, healthy self-esteem may be prone to turning to drugs to fill the void [2].

We are all wired to have relationships, and sometimes those relationships cause us to give in to something we otherwise would avoid in order to maintain the relationship. Peer pressure is huge and nowhere is greater than during our teenaged years. Kids want to be cool. It begins as a social action to take the drugs to be part of the group to be accepted. It’s not just teensgers, as peer pressure takes so many different forms. There is social etiquette, for example, to take drink during a party. “I am social drinker”. How many times have you heard that? Some people actually believe that drug addiction causes you to be accepted and part of the ‘popular’ group [6].

If someone wants to get drugs, he has to look far because they are everywhere. High school students can tell about this. Drug addiction causes people to sell drugs to the most vulnerable population, children. It’s not just the stereotypical poor sections of the inner city that serve as the hotbed for drugs. Drugs are found in suburban shopping malls, rural schools, and well-to-do private school, on the job in factories, offices and remote job sites [6].

Social control theorist focus on why only relatively few people engage in deviant behavior such as crime and drug abuse, and their answer is that the strength of an individual’s bond to society is the determining factor. Youths who maintain strong attachments with and commitment toward parents and school are less likely to engage in deviant behavior. According to control theorists deviance “results when an individual’s bond to society is weak or broken” [13]. According to social control theory, deviants are poorly socialized, and the family is the basic unit for socialization. Thus, whether they are conceived of in terms of psychology or sociology, internal constraints are linked to the influence of the family [13].

According to cognitive model people who face persistent difficulties and anxieties in their lives and who are not prepared to cope with them may resort to analgesic drugs for comfort. “While enabling them to forget their problems and stress, the pain killing experience engendered by such drugs actually decreases the ability to cope. This is because such drugs depress the central nervous system and the individual’s responsive capacity” [4].

Behaviorist can be explained behavior of taking drug by learning theory. The use of cocaine, for example, can be quite rewarding: it elevates mood and provides a sense of well-being, strength and energy whereas discontinuing use provides negative reinforcement in the form of psychological depression, or the “coke blues”. Likewise heroin use can be quite rewarding to the addict: it significantly reduces perceptions of physical and psychological pain, stress, and anxiety and provides a sense of euphoria, whereas discontinuing use provides negative reinforcement in the form of uncomfortable physical and psychological withdrawal symptoms [11].

Narcotics Anonymous is a 12-step program that was developed in the early 1950’s following the introduction of Alcoholics Anonymous in 1939. The first Narcotics Anonymous meetings were provided in Los Angeles, California but today NA meetings can be found throughout the country in every state as well as around the world. The Narcotics Anonymous 12-step program was first describes as, “NA is nonprofit fellowship or society of men oe women for whom drugs had become a major problem.”

NA is non-religious program in which each member is encouraged to cultivate their own understanding of the various spiritual principles that govern the program. These principles may be religious for the individual but the goal is to apply the spiritual principles to everyday life [2].

• We admitted that we were powerless over our addiction, that our lives had become unmanageable.

• We came to believe that a Power greater than ourselves could restore us to sanity.

• We made decision to turn our will and our lives over the care of God as we understood Him.

• We made a searching and fearless moral inventory of ourselves.

• We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

• We are entirely ready to God remove the defects of our character.

• We humbly asked Him to remove our shortcomings.

• We made a list of all persons we had harmed and became willing to make amends to them all.

• We made direct amends to such people wherever possible, except when to do so would injure them or others.

• We continued to take personal inventory and when were wrong promptly admitted it.

• We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of his will for us and the power to carry that out.

• Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.

The NA program works by breaking the recovery process into small sets of changes and acceptances that must be made. The 12-steps begin with accepting that there is an addiction and that there has been a wrongdoing. Throughout the process, the individual uses the guiding principles of the 12-steps to guide themselves to a spiritual awakening in which recovery and freedom from addiction is finally found.

The drug is carried to the brain by the bloodstream. It goes everywhere in the brain, but some drugs effect parts of the brain in different ways and became the cause of certain changes in behaviors and disorders like depression, anxiety, psychosis etc.

Addiction treatment

For most, people doing again and again the same behavior or taking a specific drug is a purely recreational activity. But for some, it offers a relief from other problems and for others; it may be a symptom of problems rather than a cause. If someone is concerned about others who are taking drugs he needs to focus on their feelings, behavior, and personal circumstances, and not on their drug use in isolation. The most effective way of supporting a drug user who is having mental health problems is to see the drug as just one element affecting them and not necessarily the major one. Their own feelings about their drug use the reason for it and its consequences need to be understood before any action is taken. If the person decides that their drug use is a problem and they want to do something about it. Treatment of addiction involves Behavioral method, Psychological methods and pharmacological methods among all psychological methods (i.e. AA meeting, NA meeting, Intervention) are the most common and effective now a day with the combination of pharmacological methods [14].

Intervention is a psychological method to treat addiction. An intervention is a caring and deliberate attempt by members of the family and loved ones to help the alcoholic or drug addicted person get help for his or her problem. Interventions are a structured and loving process organized and facilitated by a trained professional who guides a meeting between family members, friends and the prospective client [2].

The study supported the hypothesis that the population of individuals with substance use and psychiatric disorders has a high prevalence of smoking and a consequent increase in taboo-related morbidity and mortality when compared to the general population [5].

A study conducted on comparative study of characteristics distinguishing drug addicts from non addicts among students. Fifty students were selected among which twenty five were known addicts and 25 were non addicts. The results revealed that adjustment and drug addiction are not interdependent [8].

A study conducted on drugs in use and abuse in the city of Lahore, with special reference to drugs primarily used for psychiatric ailment. The major objective of the study was to find out the drugs which are commonly used or abused at present in the city of Lahore. To find the effects of social changes on the drug use, an interview schedule was prepared by the researcher. The results revealed that the most common and popular abused substance at present appeared to be opium and charas. It was also found that the pleasant experience of the first drug leads to drug dependency [15].

Salik and Najma (1990) conducted a study on factors leading addiction among children. A sample of 100 boys was interviews from jails and different areas of Lahore and Bahawalpur. According to results peer group, family conflict, curiosity, and escape from problems were found to be significant risk factors leading to drug addiction.

A study conducted on psycho-social factors affecting the drug abuse and addicts in the city of Lahore. The psychosocial factors the affecting the drug abuse by addicts was statistically analyzed by using a sample of 100 drug addicts. The confirmatory psychosocial factors such as easy availability, peer pressure, parental disharmony and escape or refuge from life problems were found to be acceptable representation of the observed data according to both statistical analysis and personality tests [16].

A study conducted on neuropsychological functioning of drug addicts. Neuropsychological functioning inventory was used for assessment. Results revealed that heroin addicts showed significant impaired neurological functioning. It was also found that drug addicts showed depressive symptom, somatic deficits, memory and attention deficits and impairment in communication [17].

The research is guided following research questions: what was the age of participant at the time of first intake? What was the reason of first intake? What did he feel after first intake? Why he has to continue for intakes? What is the mode of intake? How many admissions in the hospital for quitting drugs? What were the reasons of relapse? Now what are the reasons of taking treatment?

The present research was conducted in accordance with APA ethical guidelines and it was approved in Punjab Institute of Mental Health. Prior to taking part all participants were fully informed as to the purposes of this study.

Method

In Study I sample of 8 participants was interviewed with age range of 25-38 years and they were recruited from Punjab Institute of Mental Health. To analyze the interview data IPA and content analyses was used. Demographic data sheets and a form of semi structured interview protocol were used for the participants. The interview protocol consisted of eight questions. After informed consent the formal interview lasted around 25-50 minutes. The key question for every participant was “Tell me about when you were taking first time drugs.” This open-ended question was followed by further questions that focused on circumstances reasons, mode of intake, feeling after in taking drugs how many admissions for the purpose of quitting drugs, what are the reasons of drugs and now what are the reason of taking treatment.

Each interview was transcribed and analyzed using Interpretative Phenomenological Analysis (IPA) in an idiographic and systematic manner. The transcripts were read and re-read several times. Two main themes were identified, these were named, poor relationship with family and common views of participants regarding relapse. The sub themes were allocated to these main themes. The themes were extracted from each interview and researchers using consensual approach made sense of these interpretations. The guidelines were followed as per earlier qualitative studies [18].

Study II was based on focus group for this purpose same eight male participants was called in focus group panel. Procedure was followed as the first author moderated and recorded the discussion, and also took notes. The duration of focus group discussion was about 50 minutes. The focus group protocol consisted of four questions; what are the reasons of taking drugs, reasons of relapse, how much amount used on drugs and what are the reasons of taking treatments. Transcribing was done with the help of notes and recorded discussion. The transcript was read and re-read, each line was searched for a sentence or phrase that related to a broad theme and these were highlighted with similar colour and marked with a code. These codes were then combined under sub-themes and the sub-themes under main themes [19]. The findings from focus group discussion was found three main themes that emerged and found the reasons of relapse that were peer pressure, social rejection and lack of assertiveness. Sub themes of peer pressure were (bad company, easy availability of drugs, fashion and environmental problems). Sub themes of lack of assertiveness was unable to say no to drugs and the last major theme of this study was social rejection and the subthemes of this study was lack of family support and failure of love which leads the reasons of relapses (Table 1).

Table 1: Content analysis.

Content analysis

The main themes that emerged have been illustrated in Figures 1 and 2. lack of relationship with family lack of sharing, less control of parents on their children, less warmth and less affection. And the second theme was common view of participants regarding reasons of relapse and that were family disapproval, same friends (peer pressure), low socio economic status, and same environment [20].

Figure 1: Relationship of family with drug addicts.

Figure 2: Common views of participants regarding relapse.

Findings from focus group discussion

The three main themes that emerged and found the reasons of relapse that were peer pressure, social rejection and lack of assertiveness. Sub themes of peer pressure were (bad company, easy availability of drugs, fashion and environmental problems) [21]. Sub themes of lack of assertiveness was unable to say no to drugs and the last major theme of this study was social rejection and the subthemes of this study was lack of family support and failure of love which leads the reasons of relapses (Table 2).

Table 2: Themes.

This study sought to gain some basic information on the reasons of relapse in Substance related addictive disorder. The findings of interview and focus group revealed that the major issues of their multiple admissions in hospital for quitting drugs are peer pressure, lack of assertiveness, lack of family belief and easy availability of drugs [22]. As a participant reported:

“My friends force me to take or taste drugs their forceful insistence makes me weak and I started to take drug which is cause my relapse”.

A participant reported about the easy availability of the drugs as:

“Cigarette and opium is very easy to found and it is very cheap to get especially from darbars and back side of Shahi Qila”.

If someone wants to get drugs, he has to look far because they are everywhere. High school students can tell about this. Drug addiction causes people to sell drugs to the most vulnerable population, children. It’s not just the stereotypical poor sections of the inner city that serve as the hotbed for drugs. Drugs are found in suburban shopping malls, rural schools, and well-to-do private school, on the job in factories, offices and remote job sites [2].

Present findings suggested that perpetrators were mostly rejected by their parents and close relatives. A participant reported as:

“Family and friends do not trust me they said he cannot leave the drugs they have lack of trust on me which leads me addict once more time”.

Another participant reported that:

“I was belong to a middle class family and sometimes used to take cigarette just for enjoying friends company during this period I was in love with my class fellow truly but she was rejected me due to my socioeconomic status her rejection made my addict and I feel relax after intake of drugs ”.

Social Control Theory focus on why only relatively few people engage in deviant behavior such as crime and drug abuse, and their answer is that the strength of an individual’s bond to society is the determining factor [23]. Youths who maintain strong attachments with and commitment toward parents and school are less likely to engage in deviant behavior. According to control theorists deviance “results when an individual’s bond to society is weak or broken” [13]. According to social control theory, deviants are poorly socialized, and the family is the basic unit for socialization. Thus, whether they are conceived of in terms of psychology or sociology, internal constraints are linked to the influence of the family [13].

The present study found that reasons of relapse of substance in take is same friends and same environment they face after seeking treatment, sometimes family shows lack of trust and emotion [24].

“After seeking treatment when we go back to home we get same environment same people same friends so it is very hard to stick on the treatment phase so we get back and start to take drugs”.

The study also found that the mode of taking drugs 5 participants like to sniff, 2 participants like to inject and 1 participant like to drink and smoke.

Among them all one participant reported that:

“Sniff is the easiest way to intake drugs without getting any pain and achieve gratification/pleasurable effects and getting relax within few seconds”.

In this study we explore the reason of seeking treatment after the relapse the findings of the reason of treatment is revealed that 4 participants come their treatment for health purposes, 5 for social acceptance and 2 participants want family approval and their trust on them [25].

A participant reported that:

“Drugs makes man sick and lethargic so I came here for make me healthy person”.

Another participant reported that:

“I came here for quitting drugs only for getting the approval of my family and want to be socially accepted and desirable person of the society”.

It can be concluded that the reasons of relapse of substance related addictive disorder is peer pressure, failure of love, rejection of society, easy availability of drugs, and lack of trust of family and reasons of first intake and relapse has same. Previous literature and theories also support the present study [26].

It is limited in scope due to only male participants but the purpose of study is accomplished. Further studies should include adult females as substance abuse among females is as common. However, the present findings have important implication for substance abusers. Pakistan is today notorious for many things, but in the last 20 years addiction has increasingly become just one of them. The issue of addiction is often overshadowed by many of other development problems, such as poverty, illiteracy and lack of basic health care. But the fact is addiction. People with an addiction do not have control over what they are doing, taking or using. Their addiction may reach a point at which it is harmful. The purpose of the present study is to provide guideline to the families and people suffering from addiction; so they get to know what they are going through and can be helped in better way [27]. It is suggested that parents need to give proper time to their children, love them unconditionally trust them, but also give them good parenting not so harsh, neglecting and over protecting make them children ease and make them good and stable personality. Must assure about their peers, discuss about their routine asking about their spending time. Make friendly relationship with them. Good parenting can overcome this evil which is spreading day by day in every home. Secondly, there are number of rehabilitation centers for the drug addicts privately and very few in governmental level and the centers of government sectors are not working very effectively due to little number of trained psychologists. Government should provide the free training courses for psychologists so they trained in particular field and help them out the needy motivated people as well as make motivated to unmotivated people [28].

Addiction has been spreading in Pakistan at a first rate since the late Seventies. It has now become a serious social problem, which is probably going to stay. Addiction designate a complex illness characterized by repeated, compulsive, at times uncontrollable behavior that persists even in the face of adverse social, psychological, and/or physical consequences [4]. Addiction is a behavior that refers to any activity, substance or object that becomes the major focus of a person’s life; during which person withdraws from other activities [1]. Addiction do not only include physical things that consume, such as drugs or alcohol, but may include virtually anything, such abstract things as gambling [3]. Different perspectives, theoretical framework and conceptual models explained addiction as a disease rather than a life style choice; and explained risk factor for addiction that are peer pressure, social groups, personality type and inheritance [4,13]. Selfhelp support groups (Alcoholic Anonymous AA and Narcotics Anonymous NA) and intervention following 12-step program as the most common and effective treatment of addiction now-a-days with the combination of pharmacological methods [2]. Previous researches reveal chronic and relapsing nature of addiction and explained that addiction is related with bio, psycho, social and spiritual aspects of human life [16]. According to indigenous researches pleasant experience of the first drug leads to drug dependency and peer group, family conflict, curiosity and escape from problems are risk factors leading to drug addiction [12]. Research also portrayed that neurological functioning like depressive symptom, somatic deficits, memory and attention deficits and impairment in communication are caused by the use of addictive substances [17]. Addiction has now become a serious social problem which is probably going to stay. There is no pushbutton solution for control and eradication. Over simplification of the problem is not likely to solve the complex issue of some specific type of addiction. It requires concentrated and continuous struggle on the part of all concerned: governmental and non-governmental organizations, politicians, religious leaders and all the liable members of the society.

Pakistan is today notorious for many things, but in the last 20 years addiction has increasingly become just one of them. The issue of addiction is often overshadowed by many of other development problems, such as poverty, illiteracy and lack of basic health care. But the fact is addiction. People with an addiction do not have control over what they are doing, taking or using. Their addiction may reach a point at which it is harmful. The purpose of the present study is to provide guideline to the families and people suffering from addiction; so they get to know what they are going through and can be helped in better ways.