Introduction

Substance use disorder (SUD) is a chronic, relapsing condition that represents a major global public health challenge. Despite considerable advances in prevention and treatment, the prevalence of SUD continues to increase worldwide, contributing substantially to morbidity, mortality, and socioeconomic burden [1]. Relapse remains a defining characteristic of addiction, with many individuals returning to substance use even after successful treatment, thereby reducing the long-term effectiveness of rehabilitation programs [2].

Historically, Iraq maintained relatively low rates of substance abuse compared with neighboring countries because of strict legal regulations and limited drug availability. However, recent years have witnessed a marked increase in drug use, particularly among adolescents and young adults, making substance abuse an emerging public health concern in the country [3]. Although specialized addiction treatment services have expanded, many individuals experience difficulty accessing treatment, maintaining abstinence, and completing rehabilitation programs successfully [4].

Relapse is generally defined as a return to previous patterns of regular or uncontrolled substance use following a period of abstinence. It is recognized as one of the most significant obstacles to successful addiction treatment and sustained recovery [5]. Evidence indicates that relapse is particularly common during the first months after treatment, highlighting the need to identify the factors that contribute to renewed substance use and to develop targeted interventions that improve long-term recovery outcomes [6].

Previous studies have identified multiple determinants of relapse. Dawood reported that psychological craving, easy access to drugs, inadequate awareness of relapse risks, and family conflict were among the primary contributors to relapse among individuals recovering from substance dependence [7]. Similarly, Nunes et al. demonstrated alarmingly high relapse rates within the first six months following treatment, reaching 77% among patients receiving short-term inpatient treatment, 59% among those receiving long-term inpatient treatment, and 61% among individuals treated in outpatient settings. These findings emphasize the limitations of conventional treatment approaches in maintaining long-term abstinence [8].

Although considerable research has examined individual psychological determinants of relapse, comparatively fewer studies have explored the combined influence of personal, socio-cultural, and family-related factors, particularly in the Iraqi context. Understanding these multidimensional influences is essential for designing comprehensive relapse prevention strategies and improving addiction treatment outcomes. Therefore, the present study aimed to assess the factors associated with substance abuse relapse among recovering addicts in Maysan Governorate and to examine the relationship between relapse-related factors and selected demographic characteristics.

Aim of the Study

This study aimed to:

1. Assess the factors contributing to substance abuse relapse among recovering addicts from their perspective.
2. Examine the relationship between relapse-related factors and the demographic characteristics of addicted patients.

Methodology

Study Design

A descriptive cross-sectional study was conducted between 19 February and 29 June 2025 among patients receiving treatment at the Maysan Center for Treating Addicts and Psychotropic Substances in Maysan Governorate, Iraq.

Participants and Sampling

A purposive (non-probability) sample of 100 relapsed addicts was recruited. Eligible participants were inpatients who had previously undergone treatment for substance dependence and had experienced at least one relapse episode following treatment. Participation was voluntary, and informed consent was obtained from all participants.

Data Collection Instrument

Data were collected using a structured self-administered questionnaire adapted from the relapse assessment scale developed by Ngoepe [9]. The questionnaire consisted of three sections:

Section I: Socio-demographic characteristics, including age, sex, marital status, educational level, occupation, and monthly income.

Section II: Substance use history, including age at onset of substance use, type of substance used, duration of abstinence following treatment, and number of previous relapse episodes.

Section III: Assessment of relapse-related factors, comprising 26 dichotomous (Yes/No) items distributed across three domains:

• Personal factors and personal skills (10 items)
• Socio-cultural factors (10 items)
• Family factors (6 items)

Responses were scored as Yes = 2 and No = 1, with higher scores indicating greater perceived influence of relapse-related factors.

Statistical Analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participant characteristics and relapse-related factors. Inferential analysis was performed using the Chi-square test to examine the association between relapse-related factors and selected demographic characteristics. Statistical significance was established at p < 0.05.

RESULTS

A total of 100 relapsed addicts participated in the study. All participants were male, with the majority aged 18–25 years (59%). Most participants lived in urban areas (74%) and were employed (64%). Approximately one-third were married (35%), while 32% were divorced or widowed and 31% were single. The largest proportion had completed primary education (33%), whereas 42% had no formal education or were only able to read and write. More than half of the participants (59%) reported insufficient monthly income (Table 1).

Regarding substance use characteristics, most participants initiated substance use between the ages of 9 and 18 years (73%). Crystal methamphetamine was the predominant substance of abuse (78%), followed by alcohol (14%) and sedatives/anxiolytics (8%). Relapse most frequently occurred within the first six months after treatment (61%), and nearly three-quarters (72%) had experienced one previous interruption from substance use (Table 2).

The overall mean score for relapse-related factors was 1.69 ± 0.44, indicating a relatively high perceived influence of these factors. Within the personal domain, low self-esteem (85%) and the desire to experience pleasure (83%) were the most frequently reported causes of relapse. In the socio-cultural domain, availability of substances (86%) and lack of awareness regarding the risks of relapse (86%) were the leading contributors. Within the family domain, family conflict and frequent quarrels (71%) and difficulty coping with family problems (69%) were the most commonly identified factors.

Inferential analysis demonstrated a statistically significant association between educational level and relapse-related factors (p = 0.024). However, no significant relationships were found between relapse-related factors and participants' age (p = 0.614), marital status (p = 0.699), or occupation (p = 0.333) (Table 3).

Table 1. Demographic Characteristics of the Participants (N = 100)

Substance use characteristics

Highest-ranked relapse factors

The present study investigated the factors associated with substance abuse relapse among recovering addicts in Maysan Governorate. The findings demonstrated that all participants were male, with the majority aged between 18 and 25 years. This demographic profile likely reflects cultural and social norms in Iraq, where males generally have greater social mobility and exposure to high-risk environments, whereas substance use among females remains largely concealed because of social stigma. Similar findings were reported by Dawood, who found that all participants in his study were male [7]. Furthermore, most participants had only primary education, were married, and reported insufficient monthly income, which is consistent with the findings of Mousali et al., who identified low educational attainment and poor socioeconomic status as common characteristics among individuals experiencing relapse [10]. These findings suggest that socioeconomic disadvantage may increase vulnerability to recurrent substance use.

The majority of participants initiated substance use between the ages of 9 and 18 years, emphasizing adolescence as a critical period for the development of substance dependence. Neurodevelopmental immaturity, peer influence, and increased risk-taking behaviors during adolescence may contribute to early substance experimentation and subsequent addiction. Moreover, most participants relapsed within six months after treatment, supporting previous evidence that the early recovery period is associated with the highest risk of relapse [7,11]. Crystal methamphetamine was the predominant substance used by participants, which is consistent with the findings of Sighaldeh et al. [12]. The high prevalence of crystal methamphetamine use may be attributed to its strong addictive potential, rapid development of dependence, and increasing availability within Iraq.

Among the personal factors, low self-esteem emerged as the strongest predictor of relapse. Individuals with diminished self-worth often have limited confidence in their ability to cope with stress and resist drug cravings, increasing their susceptibility to recurrent substance use. This finding is supported by Xia et al., who demonstrated that low self-esteem significantly increases relapse tendency among individuals with substance use disorders [13]. Similarly, Habibi et al. reported that interventions aimed at improving self-esteem reduced relapse rates and enhanced recovery outcomes [18]. The desire to experience pleasure was also frequently reported, highlighting the persistent psychological reinforcement associated with addictive behaviors.

Within the socio-cultural domain, easy access to drugs and inadequate awareness of relapse risks were identified as the most influential contributors to relapse. The widespread availability of illicit substances facilitates re-exposure to drug-related cues and increases opportunities for recurrent use. At the same time, insufficient knowledge regarding relapse triggers and prevention strategies may reduce patients' ability to maintain abstinence after treatment. These findings emphasize the importance of community-based prevention programs and continuous patient education following discharge from treatment facilities.

Family-related factors also played a substantial role in relapse. Frequent family conflict and difficulties coping with family problems were the most commonly reported family-related triggers. Dysfunctional family environments may increase emotional distress and reduce the availability of social support, encouraging recovering individuals to use substances as a maladaptive coping mechanism. These findings are consistent with those reported by Hamerbacher and Lyvers, who identified interpersonal conflict and poor family relationships as important predictors of substance use relapse [14]. Strengthening family support systems should therefore be considered an essential component of relapse prevention programs.

Regarding demographic characteristics, educational level was the only variable significantly associated with relapse-related factors. Participants with lower educational attainment appeared to experience greater exposure to relapse triggers, possibly because of limited health literacy and reduced access to information regarding addiction recovery. Similar associations have been reported by Sau et al. and Mousali et al. [16,20]. In contrast, no significant associations were observed between relapse-related factors and age, marital status, or occupation. These findings agree with Haghighi et al., who also found no significant relationship between age and relapse [15]. Although previous studies have reported conflicting findings regarding marital status and employment [15,17,19], the present results suggest that psychological, environmental, and family-related factors may exert a stronger influence on relapse than demographic characteristics alone.

The present study demonstrated that substance abuse relapse among recovering addicts is influenced by a complex interaction of personal, socio-cultural, and family-related factors. Most participants initiated substance use during adolescence, primarily abused crystal methamphetamine, and experienced relapse within the first six months following treatment. Low self-esteem was identified as the leading personal factor associated with relapse, whereas the availability of drugs and inadequate awareness of relapse risks were the most influential socio-cultural factors. Family conflict and poor coping with family problems were the predominant family-related contributors. Educational level showed a significant association with relapse-related factors, while age, marital status, and occupation were not significantly associated. These findings highlight the need for comprehensive relapse prevention strategies that extend beyond medical treatment to include psychological support, patient education, family involvement, and community-based interventions.

RECOMMENDATIONS

1. Develop comprehensive relapse prevention programs that integrate psychological counseling, self-esteem enhancement, coping-skills training, and continuous follow-up after discharge from treatment centers.
2. Strengthen public awareness campaigns through television, radio, social media, and community outreach programs to increase knowledge about substance abuse, relapse risk factors, and available treatment services.
3. Incorporate evidence-based drug prevention and health education programs into school and university curricula to reduce early initiation of substance use among adolescents.
4. Improve accessibility and quality of addiction treatment and rehabilitation services by implementing multidisciplinary, patient-centered approaches that include psychological, social, and family support.
5. Establish family-based counseling and support programs aimed at improving communication, reducing family conflict, and strengthening the home environment to facilitate long-term recovery.
6. Conduct longitudinal and multicenter studies involving larger and more diverse populations to further investigate relapse determinants and evaluate the effectiveness of relapse prevention interventions in Iraq.