Relapse in Substance Use Disorder and Its Relation to Stigma: An Outpatient Based Cross Sectional Study

Background: One of the most crucial but discouraging features of the outcome of substance use disorder is relapse. The factors predicting this event must be understood to be considered for future interventions. Aim: This study aimed to assess factors related to relapse and stigma among patients with substance use disorder. Methods: A sample of 53 relapsed patients were recruited from the outpatient clinic of the addiction unit at Mansoura university hospital. Tools of data collection: Structured questionnaires were utilized. It included 3 parts. Part I: to assess socio-demographic characteristics. Part 2: Questionnaire about factors related to relapse among substance use disorder patients. Part 3: the perceived stigma of substance abuse scale. Results: It was found that relapse dimensions represented from the greatest to the lowest mean score as the following: unpleasant emotions, craving, good feelings, disruption of relationship, physical pain, peer pressure, and family problems, which was estimated as the following; 12.81±3.52, 5.94±3.15, 4.36±2.38, 10.21±5.45, 14.23±4.19, 11.00±4.00, 4.21±1.47, 10.13±3.06. A statistically significant positive correlation between stigma score and (craving, loss of control, peer pressure, pleased emotions, non-pleased emotions, physical pain, and disturbed relationship) domains of relapse scale. Conclusion: It


Introduction
Substance use disorder (SUD) is a chronic and relapsing disorder, with different biological, psychological, and social factors affecting its initiation and continuation.Relapse in SUD is a universal phenomenon and the main challenge in the management of SUD is the treatment of addictive behaviors.It mostly impacts adolescent life and puts huge burdens on them in their productive years [1].SUD is not a personality flaw but rather an enduring medical disorder that comprises a maladaptive pattern of drug-seeking behavior that significantly impairs functioning [2].According to Abolhasan et al. (2016), addiction is a primary, chronic disease of the reward, motivation, and memory-related circuits of the brain.Due to the country's rapidly expanding and evolving substance use 99 patterns, SUD is a significant issue.SUD accounts for 10% of the population in Egypt.ElQahra, Sohage, and El-Monefia are the three governorates in Egypt with the highest addiction rates, respectively.When a patient continues to take drugs despite cognitive, behavioral, and physical side effects, they are said to have a substance use disorder [3].In Egypt, the general rates of substance use vary significantly by location.However, with only small variations, the demographic risk factors are extremely constant across areas.Young and middle-aged males, those with less education, those in technical or commercial occupations, those who have experienced a failed marriage, and those who live in urban regions have higher lifetime prevalence of substance use and addiction [4].According to Mohammed (2009), the word "relapse" is derived from the Latin word "relapi," whose meaning is to slip or slide back into a former undesirable state or pattern of behavior, particularly into disease after a partial recovery.Relapse is a setback that occurs during the process of behavioral change, such that progress towards the maintenance of the goal of behavioral change (e.g., abstinence from drug use) is interrupted by a reversion to the previous behavior.It can be defined as the process of recurrence of alcohol or drug dependency behaviors in an individual who has previously achieved and maintained abstinence for a significant period beyond the detoxification period.From the same perspective, relapse is viewed as an ongoing process in which the decision to start using drugs again is the culmination of a series of maladaptive reactions to either internal or external cues and stimuli [5].The likelihood of relapse among individuals with substance use disorders following treatment has been estimated to be up to 90% within the first year [6].According to Mohammed (2009), relapse is associated with the following factors: urge, craving, and drug temptation; negative or positive emotional state; negative physical state; testing of personal control; conflicts in families or other relationships; peer and social pressure to use drugs; and treatment-related obstacles.The definition of stigma according to a mainstream dictionary is "a mark of disgrace connected to a situation or quality of an individual."The stigmatized person is viewed as being inferior to others.Most stigmas have underlying presumptions or misconceptions.This word influences people with substance use disorders, medical professionals, researchers, policymakers, and society at large [7].Language is a collection of words and phrases that activate cognitive scripts and generate human schemas, which in turn typically influence human behavior.The terminology used to describe psychiatric disorders and SUD has changed over time as we have come to understand the power that words have.Thankfully, we have now moved past labels for those with mental illnesses like "insane asylums," "lunatics," "idiots," or "retards" [8].Still, there is room for improvement.Progress is crucial in the field of substance use disorders in particular.An individual's reality is created by his or her thoughts, behaviors, and values, all of which are expressed through language.Language influences how society views problems.The terminology used for SUD is currently more updated than that used for other standards.Words have power.We can comprehend and interpret the world around us thanks to our language.Regardless of the outcome, they transmit meaning.We can assist in the reduction of stigma by using our words correctly [9].The study aimed to assess factors correlated with relapse among substance use disorder patients including stigma.

Setting
The present study was carried out at the outpatient addiction clinic of the psychiatry department affiliated to Mansoura university.; Real Estate Hints and Desire (15 things), such; when I recalled the taste... etc. Test your ability to control your abusive behaviour with these nine items (Dimension 2): "When I convinced myself that I was a new person I could be used to abuse...etc."Pressure from peers (Dimension 3) had seven items, such as: while I was with my pals and I was resolved to deal with them, etc. Dimension for Good Feelings, (18 items), At times when I was at ease and confident, etc. (Dimension 5); Unpleasant Feelings, (18 things), including times when I felt inferior to others, etc. Disruption of Relationships with Others, (15 Items), such as when I disagreed (Dimension 6); 15 items under "Disruption of Relationships with Others" include instances like when I clashed with a friend because I thought they didn't like me, etc. (Dimension 7) Family Issues (5 elements), such as when there were arguments at home; (Dimension eight) Mental, physical, and incapacitating pains (13 items), such as when I had trouble falling asleep, etc.

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Scoring Method: To assess the eight aspects that make up the elements associated with relapse: desire and real estate indications, an inability to control the abuse, peer pressure, situations that make you feel good or bad, the disruption of relationships with others, family issues, mental, physical, and incapacitating difficulties.The following ratings are given to the responses to the questions: Scored as 2, "applicable".Scored as 1, "Not applicable" Perceived stigma of substance abuse scale This scale was initially created and validated in a group of patients receiving treatment for issues connected to substance use in the United States.The scale was correlated with internalized shame, self-concealment, internalized stigma, and depression in the original development and validation study.The items were adapted from Link's perceived discriminationdevaluation measures, and content validity was evaluated by review from substance use stigma experts (Luoma et al., 2010).A four-point Likert scale is used to score each item on the scale (1 being strongly disagreed with and 4 being strongly agreed with).After reverse coding of the positively phrased items, a higher score denotes a higher amount of perceived stigma.

Study design A descriptive cross-sectional study Sample Size calculation
The calculated sample size of the study was 42 participants at 5% level of significance and 90% power of study, using the following formula.The sample size has been increased to 53 participants to compensate for incomplete data and to increase the study power.

Data Collection Procedure
This study started in Feb 2023, once permission was granted from IRB to conduct it, the researchers started to collect the data.The researchers introduced themselves and explained the purpose of the study to each relapsed patient with SUD, male participants with an age range from 18 to 60 were included in this research.Informed written consent was taken from each patient.The confidentiality of any obtained information was assured, and the patients were informed about their right to participate or not in the study.6 patients refused to participate and 3 gave us incomplete data so excluded from the final sheet, this led to a total of 53 patients as a sample size for this research.Each participant has been interviewed personally in the outpatient clinic for about 25-40 minutes.Data collection for this study was carried out in about three months from Feb 2023 to May 2023.The main investigator diagnosed all the participants as SUD patients, using SCID-I based on DSM 5 criteria, and by doing a urine test to screen for either opioid or cannabis use disorder patients.We also assisted all the patients in understanding the scales and read them aloud for illiterate subjects.1 showed that the age range of the studied group was between 18 to 50, 50.9% were single, 35.8% with 101 technical education, 58.5% were manual workers, 66% were rural,49.1% with average income,50.9%with no previous admission,71.7%with no legal problems,81.1% were heroin dependent,18.9%as cannabis dependent, 54.7% with onset less than one year and 71.7% were less than 5 years as a total duration of substance use disorder Table 3 showed a statistically significant difference between cannabis and opioid users regarding the stigma scale score and some of the relapse scale score (craving, non-pleased emotions, disturbed relation, family problems and physical pain).Table 4 showed a statistically significant association between marital status (single), occupation (nonworking), economic status (in debts), and total relapse score, also showed a statistically significant association between occupational status (employee) and total stigma score.

Statistical analysis Data were analyzed using the Statistical Package of Social Science (SPSS) program for Windows (Standard version 24
).The normality of data was first tested with one-sample Kolmogorov-Smirnov test.Qualitative data were described using number and percentage.Continuous variables were presented as mean ± SD (standard deviation) normally distributed data.The following tests were used; Independent t test was used to compare two quantitative variables while the ANOVA test was used to compare more than two groups.The threshold of significance is fixed at 5% level.The results was considered significant when p ≤ 0.05.The smaller the p-value obtained, the more significant are the results.

Discussion
The current study aimed to assess factors correlated with relapse among substance use disorder patients including stigma.The following relapse dimensions were found to have the highest to lowest mean scores among substance abuse patients: unpleasant emotions, craving, pleasurable feelings, relationship disruption, physical pain, peer pressure, and family problems, which were estimated to be 12.813.52,5.943.15,4.362.38,10.215.45,14.234.19,11.004.00,4.211.47,and 10.133.06.The study by Abdel al & Atta (2018) found that the following relapse dimensions represented from the greatest to the lowest mean score among patients with SUD: unpleasant feelings, good feelings, disruption of relationships with others, mental, physical, and debilitating pains, desire and real estate hints, test the ability to control the abuse.These results are somewhat consistent with our study.The findings partially agreed with the research conducted by Zywiak et al, which found that negative emotions from both the intrapersonal and interpersonal domains were the most important factor, followed by social pressure, and finally, the desire to get high, testing control, substance cues, and urges to drink [10].These results were also in line with the negative emotional states that a person goes through before relapsing, confirmed by our study.
The current study emphasized that peer pressure was one of the most significant contributing factors to relapse.Due to the potentially vast range of settings involving friendships and social networks, peer influence is a complex subject.Numerous studies have examined the influence of peer groups and reported that 50% of the former SUD patients' old companions persuaded them to start using drugs after they were released from treatment facilities [11].The same author also showed that 76 % of the old friends assist rehabilitated individuals to get the needed supply of drugs.It was indicated that the social context can serve either as a resource or an obstacle for behavioral change by the patient post-treatment.For example, "negative peer influences have been noted in the development of substance use behavior and the promotion of relapse [11].The findings of this study showed that patients from families with family conflicts had a higher risk of relapse.These findings also show that family disagreements may serve to perpetuate parental inconsistencies, poor parenting, and ineffective supervision system.These findings were corroborated by earlier research that found peer pressure and domestic abuse to be risk factors for substance use relapse in SUD patients [12].The majority (62.5%) of respondents did not feel accepted in society, according to the study's findings, and they experienced a variety of adjustment issues such as hatred (68%), a lack of trust by others (58.3%), a lack of communication (58.3%), and problems at work (37.5%) according to the analysis of the perceived stigma of substance abuse scale items.This conclusion is reinforced by a previous study, which found that 92% of respondents experienced a communication gap, 86% reported a lack of trust, 54% experienced difficulties at work, and 32% cited avoidance and a negative outlook as the two biggest challenges to adjusting to society [13].Additionally, there was a statistically significant correlation between stigma scores and the results of all relapse domains, which was in line with the findings of Mak et al. (2017) who provided the strongest evidence for such a direct relationship between stigma and a person's eventual recovery with the aid of treatment services [14].Another study done on similar vein also demonstrated a relationship between stigma and treatment adherence [15].While Schomerus et al.

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(2011) found a correlation between a stigma subscale and years of problem drinking, the study by Luoma et al. (2014) does seem to establish a relationship between stigma and treatment adherence.Three longitudinal studies that indicated that pre-treatment stigma did not predict post-treatment substance use cast doubt on the earlier findings [16].Even Link et al. (1997) argued that stigma scores did not change even as substance use symptoms improved.Only one longitudinal study agrees with Mak et al's findings, but its tool of assessing stigma (nonverbal shame behaviors) is unusual in research literature [17].The current study showed that there were significant positive correlations between all dimensions of relapse and marital status (being single), occupational status (unemployment), economic status (being in and previous admission.These results were partially in line with the findings of Abdel al & Atta, (2018), who showed that there were significant positive correlations between all dimensions of relapse and age, place of birth, level of education and economic status.These results partially agreed with Rimaz et, al., (2013) who explained that the financial poverty, life costs, and bankruptcy have a remarkable influence on the relapse of addiction, financial issues can serve as an influential factor on the relapse of addiction [18].The findings that relapse is positively correlated to previous admission is consistent with the views held by researchers, who reported that individuals may enter a treatment facility more than once following a relapse [19].In contrast, Amit et al., (2012) mentioned that unemployment, peer pressure, family and social stresses were factors that showed statistically significant associations with repeated admissions denying the effect of a previous admission.This study established an association between relapse and some personal, social and environmental factors, but the findings of our analysis revealed no differences in the average age of relapsed patients, despite the fact that various studies have shown a relationship between younger age and SUD relapse [20].Our findings demonstrated that relapse rates are equal across educational levels, in contrast to several research that identified an association between low literacy and relapse to SUD [21].The comparison of stigma scores between the two study sample groups (opioid use disorder and cannabis use disorder) was the most interesting part of this study.The findings showed that stigma scores were higher in the opioid group, which could be attributed to the widespread belief in society that cannabis is not addictive.Our results were in line with researchers, who looked at three dimensions of stigma (social distance, negative emotions, and forcing treatment) in relation to individuals using two illegal substances (marijuana and heroin) and found that heroin users experienced higher levels of stigma than marijuana users [22].According to Skliamis' argument, cannabis users did not encounter a significant amount of stigmatization, however, this was not in comparison to users of other drugs as in our study.

Conclusion
It was concluded that the following relapse dimensions were found to have the highest to lowest mean scores among substance abuse patients: unpleasant emotions, craving, pleasurable feelings, relationship disruption, physical pain, peer pressure, and family problems, also there was a significant positive correlation between all dimensions of relapse and socio-demographic characteristics such as single marital status, unemployment, in debt economic status, and previous admission.Recommendation: Develop future preventive programs for protection against substance abuse and stigma.
Structured questionnaires were utilized.It included three parts.Part I: to assess socio-demographic characteristics.Part 2: Questionnaire about factors correlated with relapse among substance use disorder patients.Part 3: the perceived stigma of substance abuse scale Questionnaire about factors correlated with relapse among substance Abusers (Hassan & Atta 2018) It has eight dimensions and 100 questions for determining relapse, the following are the eight different dimensions of the questionnaire:: (Dimension 1) The standard normal deviate for α = Zα = 1.96The standard normal deviate for β = Zβ = 1.28The expected correlation coefficient between desire, real estate hints, and weaning duration for the drug after treatment (r=0.644)(Abdel Aal and Atta, 2018) C = 0.5 * ln[(1+r)/(1-r)] = 0.7582 Total sample size = N = [(Zα+Zβ)/C]2 + 3 * 2= 42

Table 4
showed a statistically significant positive correlation between stigma score and (craving, loss of control, peer pressure, pleased emotions, non-pleased emotions and disturbed relationship) domains of relapse scale, negative correlation between onset of substance use and peer pressure domain of relapse score, negative correlation between previous admission and onset of substance use and disturbed relationship domain of relapse scale.102Figure1:

Scatter diagram for positive correlation between total relapse score and Stigma scoreTable 5 : Association between total relapse score, stigma and patients characteristics
: independent t test, F: ANOVA test , *significant p ≤0.05, ab: similar letters indicate significant difference between groups by post hoc LSD test. t