|Year : 2013 | Volume
| Issue : 2 | Page : 143-148
Relationship of reasons and fears of treatment with outcome in substance using population attending a de-addiction centre
Siddharth Sarkar1, Naresh Nebhinani2, Jasveen Kaur3, Kamalpreet Kaur3, Sandhya Ghai3, Debasish Basu1
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Postgraduate Institute of Medical Science, Rohtak, Haryana, India
3 National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||21-May-2014|
Department of Psychiatry, Postgraduate Institute of Medical Science, Rohtak, Haryana - 124 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Substance users approach a treatment facility for a variety of reasons as well as avoid or delay in help seeking due to perceived fears with treatment facilities. Sometimes these factors might be associated with treatment outcomes. Objectives: We studied the relationship of reasons and fears of treatment seeking with treatment outcome in substance users. Materials and Methods: One hundred subjects, attending the Drug Deaddiction and Treatment Centre, PGIMER, were prospectively recruited by purposive sampling. A semistructured proforma was used to gather sociodemographic and clinical data. Reasons of help-seeking and fear questionnaire, social support scale, and PGI locus of control scale were then applied. Followup data were available for 69 patients, which were classified into good or poor outcome based on relapse status. Results: At 6 months followup, 22 patients had relapsed, while 47 patients did not relapse. A higher degree of dysfunction due to substance at baseline was associated with relapsed status at followup. Parents or guardians coming to know about resuming substance and being unemployed for a long time were the reasons associated with relapsed status, while needing to consult a doctor immediately was significantly related to abstinent status at followup. Fear of not being able to meet substance using friends was associated with a poorer outcome in the form of relapse. Conclusions: Reasons for treatment seeking as well as fears related to treatment have significant implications on the clinical outcome of substance abusing patients. Addressing these could help in better patient outcomes.
Keywords: Fear about treatment, outcome, reasons of help seeking, substance dependence
|How to cite this article:|
Sarkar S, Nebhinani N, Kaur J, Kaur K, Ghai S, Basu D. Relationship of reasons and fears of treatment with outcome in substance using population attending a de-addiction centre. Ind Psychiatry J 2013;22:143-8
|How to cite this URL:|
Sarkar S, Nebhinani N, Kaur J, Kaur K, Ghai S, Basu D. Relationship of reasons and fears of treatment with outcome in substance using population attending a de-addiction centre. Ind Psychiatry J [serial online] 2013 [cited 2020 Mar 28];22:143-8. Available from: http://www.industrialpsychiatry.org/text.asp?2013/22/2/143/132929
Substance use disorders are amongst the commonest disorders worldwide.  These disorders affect a significant proportion of the adult population in India.  These disorders are associated with considerable morbidity and mortality. , Not only do they cause physical harm to the body, they are also implicated in the causation of many social problems.  The management of these disorders is fraught with many challenges including fluctuating motivation toward treatment. ,
Substance users approach a treatment facility for a variety of reasons. The reasons could range from 'hitting the bottom', life being out of control, familial and financial difficulties, physical problems, having mystical experiences, and wanting to regain self control. ,,,,, Such treatment seekers also harbour a variety of fears toward the treatment. The fears include those of failing treatment, of disappointing others, having a bad experience with treatment, uncertainty of treatment, embarrassment, and being afraid of seeing someone in treatment. ,,,
It has been observed that substance users have high rates of relapse. ,,, The relapses lead to a break in the treatment process, and result in recurrence of physical, psychological, and social problems associated with substance use. Avoiding and delaying such relapses help in improving patient outcomes.
The reasons for relapse can be manifold. Pretreatment factors have been implicated as predictors of outcomes; specifically as mediators of relapse. Such factors have been evaluated for many types of substances use disorders. ,,,,, Such factors have included high degree of stress, external drinking-related locus, poor social support, interpersonal factors, and drug related cues among others. In a study from our centre, those who have been following up regularly were less likely to have relapsed to substance taking behavior. 
We previously conducted a study looking at the various reasons and fears of coming for treatment in a substance using population.  We found that the common reasons cited for seeking treatment were becoming a habitual user, taking the substance for a long time and need to take it every day. The common fears about treatment were fear of disappointing others, loss of secrecy of substance use, and being considered a failure in life. 
There is a paucity of research looking at the relationship of reasons or fears about treatment and treatment outcome. We did not come across any study examining specifically reasons or fears of treatment with treatment outcomes. Hence, in this follow up study, we attempted to find out whether any reason or fear about the treatment affected the short term outcome of the patient. Any such factor, if found to be significant, would help in identifying patients at risk of relapse, so that additional measures could be initiated to prevent such an outcome.
| Materials and methods|| |
The study was conducted at the Drug De-addiction and Treatment Centre (DDTC), Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh-a multispecialty teaching hospital. Most DDTC patients come through family or self-referral, and some are referred from other hospitals or other departments of the institute. The DDTC provides both outpatient services and inpatient facilities, catering to a variety of substance users. Therapeutic services involve pharmacological and nonpharmacological approaches.
The study was started after the approval of the institutional research ethics committee. The baseline data collection was started from 15 th June, 2011, and continued till 14 th July, 2011. Purposive sampling without a systematic bias was used. Substance using patients who gave valid written informed consent were included in this prospective study. Those patients who had any chronic physical illness, organic brain syndrome, or mental retardation were excluded from the study.
A semistructured proforma was used to assess demographic and substance use details. Overall impairment was explored in the domains of health, occupation, financial situation, legal issues, family relationships, marital life, and social functioning, and was graded from 0 to 3 in each domain. The overall score was calculated by dividing the total score of the patient by the total possible score. Thereafter, self-rated Hindi translated versions of the following instruments were administered: Reasons of help-seeking and fear questionnaire,  social support scale,  and PGI locus of control scale. 
The patients were then followed up after a period of 6 months. The follow up information was ascertained using case records and through telephonic interview. The outcome was graded as relapsed or nonrelapsed. Relapse was defined as resumption of substance taking behavior in the previous pattern and meeting ICD-10 criteria for dependence or harmful use, which was clinically assessed at follow-up. Any structured instrument or laboratory investigation was not used to ascertain relapse, as the study included patients with use of variety of substances where each combination of substances may have different noncomparable means for assessing relapse. Also, information about abstinence status is gathered regularly at follow ups from patients and other accompanying informants, giving the adequate data.
Analysis was done using SPSS version 14.0 for Windows (Chicago, Illinois, USA). Descriptive statistics were used for the demographic and clinical variables. Nonparametric tests were applied to determine the relationship between nominal and ordinal data. Parametric tests were applied for the continuous variables. The outcome variable was relapse status. The dropouts were not included in the analysis. Since all of the patients were abstinent when enrolled in the study and there was only one follow up assessment, last observation carried forth (LOCF) method for missing data was not used as it would have inflated the number of abstainers. A P value of less than 0.1 was considered significant (as it was an exploratory rather than confirmatory study design, it was decided to keep a less conservative cut-off P value than the more traditional 0.05). Multivariate logistic regression was carried out to find independent predictors of abstinent outcome and potential confounders were controlled.
| Instruments|| |
Reasons of help-seeking and fear questionnaire 
This is a self-rated instrument which looks into the reasons for seeking treatment and the fears associated with treatment in substance users. The original scale was developed by Sheehan et al. and comprised of 54 reasons and 27 fears of treatment. The adapted instrument in this study comprised of 40 questions of reasons of treatment and 23 questions regarding fears about treatment. The scale encompasses a broad variety of reasons and fears, and a subject can endorse as many options as applicable. 
Social support scale 
It is a scale developed as an Indian adaptation of social support questionnaire developed by Pollack and Harris.  This scale is available in Hindi and is self-rated. The scale assesses the extent of social support in studied subjects, and has been validated in the Indian population. The test is short, simple, and easy to administer and consists of 18 questions, each question being rated on a 4-point scale. Eleven items are reverse scored. The overall score can vary from 18 to 72. Higher scores suggest that more social support is available to the patient. The test retest reliability of the modified version is 0.91 with high concurrent validity with social support questionnaire. The scale has been used in many studies , and has been found to be a reliable and valid measure of social support.
PGI locus of control scale 
It has been found to be a quick, reliable, and valid scale to measure the internal-external control. The scale has been developed for the Indian population. The scale is administered in the form of a semistructured interview. It consists of seven items in Hindi, each item comprising of three choices. The score can range from 0 to 14, with higher scores reflecting higher internal locus of control. The test-retest reliability has been found to be 0.77 two weeks apart, while inter-rater reliability has been found to be 0.95. 
| Results|| |
A total of 100 patients were recruited in the study. Followup data were available for 69 patients. The baseline demographic and clinical data are presented in [Table 1]. The majority of the sample was male, married, employed, educated above 10 th grade and came from an urban background. There were no statistically significant differences in terms of marital status, employment status, educational level, religion, family type, and background between those for whom follow up information was available, and for whom follow up information was not available.
Of the 69 patients, 19 were dependent on alcohol, 31 were dependent on opioids, 10 were dependent on both, and 9 were dependent on other substances. The mean age of the sample was 33.7 years (±9.8 years). The mean duration of substance use was 6.9 years (±5.1 years). The mean scores on social support scale and locus of control scales were 50.9 (±6.7) and 11.5 (±2.0) respectively, reflecting moderate degree of social support and internal locus of control.
Forty-seven patients (68.1%) had a good outcome in the form of abstinence or use of substance not amounting to relapse at 6 months, while 22 patients (31.9%) had a relapse. [Table 2] shows the demographic and clinical characteristics of the patients across relapse status. It was seen that higher scores on dysfunction rating were significantly associated with relapse status (P = 0.002). Perceived social support and locus of control did not differ significantly between the groups of relapsed and non-relapsed outcome (P = 0.662 and P = 0.461, respectively).
|Table 2: Comparison of demographic and clinical variables in relapsed and not relapsed subjects|
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The reasons and fears of treatment across the treatment groups are depicted in [Table 3] and [Table 4] in descending order of occurrence. The number of reasons reported varied from 0 to 29 (median 15), while the number of fears reported varied from 0 to 21 (median 3). Parents or guardians coming to know about resuming substance and being unemployed for a long time was associated with relapsed status, while needing to consult doctor immediately was significantly related to abstinent status at followup. Fear of not being able to meet substance using friends was associated with a poorer outcome in the form of relapse.
A binary logistic regression analysis was conducted to find the reasons and fears of treatment which were independent predictors of abstinent status. At a cutoff of P = 0.05, only fear of not being able to meet substance using friends was significant predictor of outcome (B = 1.375, OR = 5.31, P = 0.021). The model generated however could explain only a limited degree of variability (Nagelkerke R Square = 0.106)
| Discussion|| |
The study finds that in short-term follow up, many of the patients of substance use disorders relapse to substance taking behaviors. From our study, it was seen that lower dysfunction scores were associated with abstinent status at followup. Similarly other studies have also found that higher dysfunction in various domains reflecting greater severity of substance use disorder has been associated with a risk of relapse. ,,
One of the reasons of treatment that was found to be significantly associated with abstinence was need to consult doctor immediately. This suggests that frail medical condition requiring intervention promoted abstinence, probably by serving as a grave warning to the patient. Another possible reason could be that medically precarious patients would be quite debilitated and hence would not be able to procure their substance of use. Parents or guardians coming to know about resuming substance and being unemployed for a long time were the other reasons associated with relapsed status. These two factors reflect the severity of substance use disorder, and are related to the outcome.
Fear of not being able to meet substance using friends was associated with poor outcome. This suggests that a perception of autonomy in the treatment process and allowing family and friends to meet may translate into better patient outcomes. Looking from another perspective, this may imply that those patients with poor motivation who are not willing to dissociate with substance using peers are greater risk of relapse. Previous studies have also shown that peer affiliation may have a significant role in substance use initiation and continuation. ,
This study is the first study across the continent looking at the relationship of reasons and fears of treatment with patient outcomes. Though relationship of lapse and relapse with respect to social support and locus of control were assessed, but significant associations were not found.
The limitations of the study include purposive sampling for recruitment of the subjects and a limited sample size. The information about relapse was collected based on patient's self-reports which at times could not be corroborated from other informants. The followup information was available for a subset of the total cohort. It is possible that many of the patients did not follow up and relapsed, but information could not be ascertained about them. This combined with a shorter duration of follow up could have resulted in the overall low relapse rates in the patient population. Also, this study was conducted amongst treatment seekers at a specialized deaddiction centre and caution needs to be exercised while interpreting findings in the context of primary care or community setting. The sample also had negligible number of females, which is in keeping with the pattern of treatment seekers in DDTC and the country. ,
This study assesses the outcome of substance users in relation with key demographic and clinical factors. It also takes a look into the reasons and fears of treatment that were related to patient outcome terms of abstinence from substances of use. Assessing these reasons and fears, and addressing patient's needs accordingly would help in modifying treatment to improve long-term outcomes. Especially fears about the treatment of substance use disorder that may be considered coercive in some situations  can help in building a better therapeutic relationship. Focusing on individual's fears with goal-directed counseling and family's involvement may help allay anxieties and encourage better participation of the patient in formulating personal goals from treatment. Also, keeping in view the reasons of presentation of the patient to treatment may help in better prognostication and increased efforts in situations where relapse is more likely. Larger studies with multiple followup points can further establish the role of these reasons and fears of treatment, and also the moderating influences of other factors like social support.
| References|| |
|1.||United Nations Office on Drugs and Crime. World Drug Report 2010. New York: United Nations; 2010. |
|2.||Ray R, Mondal A, Gupta K, Chatterjee A, Bajaj P. UNODC-ROSA-Publications-The Extent, Patterns and Trends of Drug Abuse in India-National Survey. 2004. Available from: http://www.unodc.org/india/national_Survey.html. [Last accessed on 2012 Sep 05]. |
|3.||McGinnis JM, Foege WH. Mortality and morbidity attributable to use of addictive substances in the United States. Proc Assoc Am Physicians 1999;111:109-18. |
|4.||Single E, Robson L, Rehm J, Xie X. Morbidity and mortality attributable to alcohol, tobacco, and illicit drug use in Canada. Am J Public Health 1999;89:385-90. |
|5.||Lyman MD, Potter GW. Drugs in Society: Causes, Concepts and Control. Elsevier; 2010. |
|6.||Korcha RA, Polcin DL, Bond JC, Lapp WM, Galloway G. Substance use and motivation: A longitudinal perspective. Am J Drug Alcohol Abuse 2011;37:48-53. |
|7.||DiClemente CC, Bellino LE, Neavins TM. Motivation for change and alcoholism treatment. Alcohol Res Health 1999;23:86-92. |
|8.||Ludwig AM. Cognitive processes associated with "spontaneous" recovery from alcoholism. J Stud Alcohol 1985;46:53-8. |
|9.||Oppenheimer E, Sheehan M, Taylor C. Letting the Client Speak: Drug misusers and the process of help seeking. Br J Addict 1988;83:635-47. |
|10.||Brooke D, Fudala PJ, Johnson RE. Weighing up the pros and cons: Help-seeking by drug misusers in Baltimore, USA. Drug Alcohol Depend 1992;31:37-43. |
|11.||Cunningham JA, Sobell LC, Sobell MB, Gaskin J. Alcohol and drug abusers' reasons for seeking treatment. Addict Behav 1994;19:691-6. |
|12.||Chung YY, Shek DT. Reasons for seeking treatment among young drug abusers in Hong Kong. Int J Adolesc Med Health 2008;20:441-8. |
|13.||Smith DC, Cleeland L, Dennis ML. Reasons for quitting among emerging adults and adolescents in substance-use-disorder treatment. J Stud Alcohol Drugs 2010;71:400-9. |
|14.||Chung YY, Shek DT. Fears about treatment among young drug abusers in Hong Kong. Int J Adolesc Med Health 2011;23:141-5. |
|15.||Rapp RC, Xu J, Carr CA, Lane DT, Wang J, Carlson R. Treatment barriers identified by substance abusers assessed at a centralized intake unit. J Subst Abuse Treat 2006;30:227-35. |
|16.||Hunt WA, Barnett LW, Branch LG. Relapse rates in addiction programs. J Clin Psychol 1971;27:455-6. |
|17.||Milkman H, Weiner SE, Sunderwirth S. Addiction relapse. Adv Alcohol Subst Abuse 1983-4;3:119-34. |
|18.||Brandon TH, Vidrine JI, Litvin EB. Relapse and relapse prevention. Annu Rev Clin Psychol 2007;3:257-84. |
|19.||Hendershot CS, Witkiewitz K, George WH, Marlatt GA. Relapse prevention for addictive behaviors. Subst Abuse Treat Prev Policy 2011;6:17. |
|20.||Kivlahan DR, Donovan DM, Walker RD. Predictors of relapse: Interaction of drinking-related locus of control and reasons for drinking. Addict Behav 1983;8:273-6. |
|21.||Unnithan S, Gossop M, Strang J. Factors associated with relapse among opiate addicts in an out-patient detoxification programme. Br J Psychiatry 1992;161:654-7. |
|22.||Brown SA, Vik PW, Patterson TL, Grant I, Schuckit MA. Stress, vulnerability and adult alcohol relapse. J Stud Alcohol 1995;56:538-45. |
|23.||Miller WR, Westerberg VS, Harris RJ, Tonigan JS. What predicts relapse? Prospective testing of antecedent models. Addiction 1996;91:S155-72. |
|24.||Noone M, Dua J, Markham R. Stress, cognitive factors, and coping resources as predictors of relapse in alcoholics. Addict Behav 1999;24:687-93. |
|25.||Mehta SH, Sudarshi D, Srikrishnan AK, Celentano DD, Vasudevan CK, Anand S, et al. Factors associated with injection cessation, relapse and initiation in a community-based cohort of injection drug users in Chennai, India. Addiction 2012;107:349-58. |
|26.||Singh SM, Mattoo SK, Dutt A, Chakrabarti K, Nebhinani N, Kumar S, et al. Long-term outcome of in-patients with substance use disorders: A study from North India. Indian J Psychiatry 2008;50:269-73. |
|27.||Nebhinani N, Sarkar S, Ghai S, Basu D. Reasonsforhelp-seeking and associated fears in subjects with substance dependence. Indian J Psychol Med 2012;34:153-8 |
|28.||Tipirneni SK, Varma VK, Malhotra A. A study of reasons for help seeking and associated fears in psychoactive substance users with special reference to drug use and psychosocial variables. 1994 [Thesis submitted at Postgraduate Institute of Medical Education and Research, Chandigarh]. |
|29.||Nehra R, Kulhara P. Development of a scale for assessment of social support: Initial tryout in Indian setting. Ind J Soc Psychiatry 1987;4:353-9. |
|30.||Menon DK, Wig NN, Verma VK. Manual for P.G.I. Locus of Control Scale. Varanasi: Rupa Psychological Corporation; 1988. |
|31.||Sheehan M, Oppenheimer E, Taylor C. Who Comes for Treatment: Drug misusers at three London agencies. Br J Addict 1988;83:311-20. |
|32.||Pollack L, Harris R. Measurement of social support. Psychol Rep 1983;53:466. |
|33.||Boschloo L, Vogelzangs N, van den Brink W, Smit JH, Beekman AT, Penninx BW. Predictors of the 2-year recurrence and persistence of alcohol dependence. Addiction 2012;107:1639-40. |
|34.||Hubicka B, Laurell H, Bergman H. Psychosocial characteristics of drunk drivers assessed by the Addiction Severity Index, prediction of relapse. Scand J Public Health 2010;38:71-7. |
|35.||Hoffmann NG, Miller NS. Perspectives of effective treatment for alcohol and drug disorders. Psychiatr Clin North Am 1993;16:127-40. |
|36.||Andrews JA, Tildesley E, Hops H, Li F. The influence of peers on young adult substance use. Health Psychol 2002;21:34957. |
|37.||Tsering D, Pal R. Role of family and peers in initiation and continuation of substance use. Indian J Psychol Med 2009;31:30-4. |
|38.||Grover S, Irpati AS, Saluja BS, Mattoo SK, Basu D. Substance-dependent women attending a de-addiction center in North India: Sociodemographic and clinical profile. Indian J Med Sci 2005;59:283-91. |
|39.||Shah R, Basu D. Coercion in psychiatric care: Global and Indian perspective. Indian J Psychiatry 2010;52:203-6. |
[Table 1], [Table 2], [Table 3], [Table 4]