Environmental and Personal Factors Associated with Addiction Relapse in Referral Patients to Marand Treatment Centers

1. Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
2. Department of Nursing, Lectureship of Nursing, lslamic Azad  University, Marand, lran
3. Department of Nursing, Marand Center of Higher Health Education, Tabriz University of Medical Sciences, Tabriz, Iran
4. Research Committee, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran.
5. Marand Health Center, Tabriz University of Medical Sciences, Tabriz, Iran.

ARTICLE INFO		ABSTRACT
Original Article Received: 25 Nov 2017 Accepted: 15 Apr 2018		Introduction: The problem of relapse makes addiction treatment complicated because almost 80% of addicts relapse after treatment completion during the first six months. The purpose of this study was to determine the factors affecting relapse in addicts referred to addiction treatment centers in Marand. Methods: This study was a cross-sectional study that was performed on 306 patients in the city of Marand. The stratified sampling method was used. After collecting the questionnaire and determining its validity and reliability, questionnaires were distributed among an addicted group and as well as a non-addicted group. In the presence of the researcher, the patients answered the questions. Finally, the data were analyzed using statistical tests (chi-squared, independent t and ANOVA) applying SPSS software, version 21.0 for Windows. Results: In this study, the majority of participants in the addicted group and in the non-addicted group had a lower diploma and diploma respectively (90.2% and 90.8%). The mean age was the non-addicted group for 35.14 ± 8.23 years and in the non-addicted group and 32.72 ± 10.48 for the addicted group. According to the findings of this study, in the addicted group, the main reasons addiction relapse was family insistence (25.5% of cases). The non-addicted group mentioned the social conditions as the most common reason of success in the last quitting (22.9%). Based on the findings, a significant difference was found between the two variables including family size, employment status, smoking, family disputes, person's hopes and obsession to use drugs. Conclusion: For preventing and treating addiction, it is not enough to detoxify in treatment centers. It seems planning and interventions is necessary for preventing and reducing relapse, based on known major risk factors (such as employment status, smoking, family disputes, marriage, individual hope, and mental engagement with drug use).   Keywords: Addiction, Recurrence, Substance Abuse Treatment Centers
Corresponding Author: Tayebeh Rezaei tayebe.rezayi86@gmail.com

Introduction
Any problem which threatens the values of and spread throughout the society is called as a social problem. Addiction is one of the most important social issues which cause problems for the individual, family and society (1). It is the problem of all societies, both industrial and non-industrial societies (2). Addiction leads to physical and spiritual problems for the addict. Moreover, it causes economic, social, and cultural problems for the society (3, 4). It has been a century since the human beings have started trying to find a
solution for this problem due to its dangerous consequences. These include illnesses like AIDS-induced hepatitis due to intravenous infections, as well as long-term concerns about the harmful effects of pharmaceutical, social, legal and health-related substance abuse. The urgency of such issues catalyzes the push towards providing effective prevention strategies (5).
Addiction is such an important problem that Leuodic, a toxicologist, states that “apart from food, nothing more than drugs has been able to easily enter into the lives of human” (6). Due to the fact that Iran is a neighbor of Afghanistan, the biggest opiates producer in the world, the nation has become a big consumer of addictive substances (7). This issue forces policymakers to deal with it by using the internal information (9, 8). Although there has been much progress towards solving of this problem, but the relapse and rebounding of drug abuse are still common issues (10). Relapse is a complex and dynamic phenomenon which the psychological and biological issues can have effect on it. The studies have indicated that it is not possible to say that the addict does not rebound to consuming drugs. Moreover, the studies show that over 80% of addicts return to consuming drug in less than 6 months (11). In fact, the maintenance of an addict in treatment centers only results in his/her lack of access to the drug and causes detoxification and recovery during that period. After the addict is released, he or she rebounds to addictive substance (12).
According to Fredrick et al. (1988), only 20% to 50% stop consuming addictive substance after a year (13). In another study by Xie over a ten-year period, the results showed that 25% of the addicts in the first year and 75% in the tenth year return consuming addictive substance (14). According to Fadayi, in the best conditions and treatments 95% of the addicts return consuming addictive substance after a year, and the 5% return using it in the next two years (15). It is for these reasons that some of the experts use the expression “chronic and recurrent disorder” for addiction (16). Drug addicts who visited treatment centers usually are admitted more than 2 to 3 times (17). The factors which cause the relapse can be divided into three categories: the micro level factors, such as the individual; the middle factors, such as the family; and the macro level factors, such as the society, policy, and economy (18). Falahzadeh and Hosseyni believe that some factors such as addicted friends, family aloofness, and returning to the previous locations can have effects on the returning to use of an addictive substance (19). Sadegiye Ahari, in his research, spoke of family disputes, social problems, and short periods of not using drugs as a cause of relapse (20).
Health policymakers play an important role in community member for health (21, 22). Identifying effective factors in the return and relapse can be reduced by implementing policies, preventive measures and controlling the percentage of return (23). Despite the importance of the issue, no study has been conducted in the northwest of the country. Considering the importance of the issue of addictive substances and return to drug abuse, and the lack of adequate studies on the rate of relapse in Eastern Azerbaijan and its causes, this study aimed to determine the factors influencing the relapse of addiction using the point of view of addicts referring to addiction treatment centers in Marand city.
Methods
This study was a cross-sectional study
that was conducted by Tabriz University of Medical Sciences with the ethics code
of TBZMED.REC.2015.156. The statistical population of this study was all addicts referred to addiction treatment camps (three addiction treatment camps), as well as non-addict people referring to them. In fact, the study compared the associated factors between addicted and non-addicted groups. Being in addicted or non-addicted group was done based on the list of treatment centers.
Sample size calculation was based on the previous study, Solati et al. (24) Based on a confidence level of 95%, a power of 90%, two tailed test utilizing G-Power software, at least a total of 306 subjects were calculated to recruit in the study (the sample size in each group was calculated to be at least 153).
The instrument to collect the data was a standard questionnaire with a validity of 0.8, validity and reliability of the questionnaire was done in men referred to treatment centers in Tehran (25). The questionnaire consisted of two sections. Section one was included demographic information such as age, marital status, family affairs (number of people living together), and number of times that they have stopped using drugs. Section two was included other factors associated with the relapse such as individual, family, occupational and economic factors based on a Likert scale: (very low, low, moderate, high, very high), multiple options and two options (yes, no).
The criteria for including the study in the addicted group was to have at least one recorded period of at least three weeks from the start of the current treatment. In the non-addicted group, those who completed the treatment successfully and at the time of the study, at least one year had elapsed since the completion of their treatment.
After preparing the last version of the instruments and getting the necessary research certifications from the Tabriz University of Medical science, the researcher has visited the camps and after stated the aims of the study the questionnaire was distributed among addicted group (an addict person who had stopped using drugs at least one time either in the governmental or private centers and now refer to the camps and three weeks elapse from his.her treatment). Moreover, the questionnaire was distributed among the non-addicted group (a person whose treatment was successfully done in the treatment centers and after one year the person return to the camp based on sampling was selected) and the participants provided their responses to the questionnaire in the presence of the researcher. It should be stated that the data analysis was done by using the chi-squared test, and independent t-test.
Results
In this study, the majority of the participants both in the non-addicted and addicted groups had diploma and less than diploma degrees (90.2% and 90.8%, respectively) Furthermore, 28.8% of the addicted group and 14.4% of the non-addicted group were unemployed (Table 1). The results also revealed that 57% of the addicts in the addicted group and 43% of the non-addicted group had family disputes. 28.1% of the addicted group and 34% of the non-addicted group reported more than five attempts to stop drug abuse. 56.7% of the addicted group and 43.3% of the non-addicted group expressed that after they stop drug abuse their mental engagements were. 54.5% of addicts' families were not hopeful about the ability of their addicts to stop drug using.
Furthermore, the findings of this study (using the chi-squared test and independent t-test) indicated that there was a significant difference among the variables such as family household, employment status, smoking, family disputes, marital status, person’s hope, Mental engagement of the addicts in the addicted and the non-addicted groups (Table 2). However, the variables such as age status, level of education, duration of drug abuse, family hope, and presence of addict in the family did not indicate any statistically significant differences between the addicted and the non-addicted groups.
The regression test was used in this study.
Table 3 displays predictors of addiction relapse, according fourteen variables (age, marital status, education, family size, having a job, housing, income, smoking, family disputes, chronic physical pain, mentality toward substance use, how hopeful the individual and family members are, and the presence of another addict in the family). Marital status, family size, having a job, smoking, family disputes, mentality toward substance use and hope status factors were significantly associated with addiction relapse (Table 3). All factors associated with addiction relapse in Table 3 entered to a separate logistic regression analyses. Table 4 shows the final model of factors predicting the development addiction relapse.

The non-addicted  group(153)		The addicted group (153)		Variable
percent	number	percent	number
35.14± 8.23		32.72± 10.48		mean ± deviation	Age
34	52	39.9	61	Married	Married
52.3	80	39.2	60	Single
13.7	21	20.9	32	Isolated and dead wife
90.8	139	90.2	138	Diploma and lower	Level of education
9.2	14	9.8	15	Top diploma
14.4	22	28.8	44	Unemployed	Employment
85.6	131	71.2	109	Employed
32.7	50	18.3	28	Personal	housing situation
18.3	28	32	49	Renting out
49	75	49.7	76	Paternity
22.9	35	37.9	58	Weak	Income status
64.1	98	58.2	89	medium
13	20	3.9	6	Good

Chi-square test	Witness		addicted		group variable
	percent	number	percent	number
0.029	66	73	60.1	92	Non-married	Marital status	demographic information
	34	80	39.9	61	Married
0.845	90.8	139	90.2	138	Diploma and lower	education
	9.2	14	9.8	15	Higher than diploma
0.001	82.4	126	96.7	148	has it	smoking
	17.6	27	3.3	5	does not have
0.001	62.1	95	82.4	126	has it	Family disputes	Family factors
	37.9	58	17.6	27	does not have
0.261	25.5	39	29.4	45	has it	The presence of another addict in the family
	74.5	114	70.6	108	does not have
0.001	69.9	107	91.5	140	has it	Mentality toward substance use	Individual factors
	39.1	46	9.5	13	does not have
0.203	53.59	82	61.4	94	has it	chronic physical pain
	46.41	71	38.6	59	does not have
0.001	52.28	80	71.2	109	has it	Hope status
	47.72	73	28.8	44	does not have
0.276	83.66	128	80.39	123	has it	Hope status of the individual's family
	16.44	25	19.61	30	does not have
0.001	22.9	35	37.9	58	Weak	Income status	occupational and economic factors
	64.1	98	58.2	89	medium
	13	20	3.9	6	Good
0.002	85.6	131	71.2	109	has it	having a job
	14.4	22	28.8	44	does not have
0.178	35.14±8.23		33.72±10.04		(Mean standard deviation)	Age status	demographic information
0.003	4.08±2.31		4.89±2.39		(Mean standard deviation)	Family size
0.812	94.21±64.47		96.05±75.44		(Mean standard deviation)	Duration of use

p-value	95% C.I.for EXP(B)		OR	variables
	Upper	Lower
0.178	1.042	0.992	1.017	Age
0.03	2.600	1.051	1.653	Marital status
0.620	1.129	0.816	.960	Education
0.001	0.933	0.768	0.846	Family size
0.003	4.256	1.357	2.404	having a job
0.1	1.0411	0.611	0.811	housing
0.120	1.247	0.975	1.103	income
0.000	16.957	2.373	6.343	smoking
0.000	4.834	1.679	2.849	Family disputes
0.166	2.174	0.875	1.379	chronic physical pain
0.000	9.003	2.381	4.630	Mentality toward substance use
0.457	1.438	0.446	0.801	Hope status of the individual's family
0.000	1.835	1.230	1.502	Hope status
0.442	1.358	0.496	0.821	The presence of another addict in the family

		B	S.E.	Wald	df	Sig.	Exp(B)
Step 1a	Marital status	.116	.361	.102	1	.749	1.122
	Hope status	.583	.282	4.269	1	.039	1.792
	having a job	-.808	.351	5.303	1	.021	.446
	Smoking	1.990	.555	12.857	1	.000	7.315
	Family disputes	.823	.309	7.074	1	.008	2.278
	Mentality toward substance use	.942	.396	5.656	1	.017	2.565
	Family size			9.567	4	.048
	1	.709	.453	2.452	1	.117	2.031
	2	1.064	.468	5.182	1	.023	2.899
	3 & above	1.332	.529	6.348	1	.012	3.789
	0	.239	.501	.227	1	.634	1.269
	Housing			12.644	3	.005
	Personal	-.170	.700	.059	1	.808	.844
	Renting out	-1.463	.733	3.984	1	.046	.232
	Paternity	-.200	.673	.089	1	.766	.818
	Constant	-4.324	1.202	12.932	1	.000	.013
Step 2a	Hope status	.573	.280	4.181	1	.041	1.774
	having a job	-.807	.351	5.288	1	.021	.446
	Smoking	1.994	.555	12.932	1	.000	7.348
	Family disputes	.825	.309	7.118	1	.008	2.282
	Mentality toward substance use	.953	.394	5.841	1	.016	2.593
	Family size			11.966	4	.018
	1	.749	.434	2.978	1	.084	2.116
	2	1.123	.430	6.828	1	.009	3.075
	3 & above	1.399	.486	8.280	1	.004	4.052
	0	.304	.458	.440	1	.507	1.355
	Housing			12.605	3	.006
	Personal	-.150	.697	.046	1	.830	.861
	Renting out	-1.436	.728	3.893	1	.049	.238
	Paternity	-.203	.673	.091	1	.763	.816
	Constant	-4.210	1.147	13.464	1	.000	.015

Discussion
The current study was an attempt to investigate the view of addicts referring to Marand treatment centers.
The results of the study indicated that there was no statistical significant difference between the two groups (the addicted and the non-addicted groups) regarding age variable. In the current study the age mean of the non-addicted group was three years more than that of the addicted group. The findings of this study are in line with that of Fallahzade whose relapse had 32.5 year-of-age and Seraji (26) with relapse age of 32.8. Moreover, Jackson indicated that, while there had no relationship between the age and treatment success of males it had a very weak relation exists regarding the female (18). In the Xie’s study, no relationship was detected between age and relapse (14).
Based on the findings of this study, there was a significant difference between the two addicted and non-addicted groups regarding household size. That is, the higher the household size, the higher the probability of the relapse, which was consistent with Rimaz’s study (25). In Rimaz’s study there was a significant difference between the two addicted and non-addicted groups in terms of household size. Perhaps the reason is that in high-income families, factors such as anxiety, life stress, family disputes, and parents’ neglect of children can cause tension and anxiety after recovery and as a result of the relapse is inevitable (25, 27). Therefore, for treatment, in the first step, it is necessary to reduce the tensions in such families and, as long as the severity of these pressures is not reduced, there may obtain no success in the treatment.
The findings of the current study also indicated that there was a significant difference between the two groups in terms of marital status, and those who were single were more likely to return to addiction. These findings are in line with that of the study of Washton (28). However, this finding contradicts some studies. Maureen’s study showed that marital status has no role in relapse (29). Zhou also showed that there is no relationship between marital status and return to smoking (30).
The results showed that there is a significant difference between the two groups (addicted and non-addicted) in terms of employment; employed patients has a greater chance of recovery. In the Seraji’s study, unemployment has been the strongest indicator of relapse (26), as various state. Furthermore, the unemployed are more likely to be addicted than those who work.
In fact, unemployment can lead to various deviations, especially addiction. Unemployment is not only due to lack of economic life and material and spiritual well-being for family members but also through disturbances in personality building, moral stability, dignity, and hope for the future and individual authority lead to various deviations such as addiction. Having job skills plays an important role in predicting the survival rate of treatment for those who have recovered from addiction. Regarding the important role of oppression in preventing the return to drug abuse, emphasis is placed on the need to create job opportunities to prevent the return to the addiction cycle (31). The variable duration of drug abuse (addiction duration), there was no significant difference between the two addicted and non-addicted groups, which was consistent with the Rimaz and Mattoo studies (25, 32).
The findings of this study indicated that there was a significant relationship between cigarette smoking after recovery and relapse. In the study conducted by Rahmati, it was shown that about 91.4% of drug addicts had simultaneous cigarette smoking (17). Hser reported that the deaths of opium addicts who were smokers were 4 times higher than those who did not smoke. Moreover, the smokers who were addicted to heroin will return to addiction after their recovery. However, people who do not smoke will tend less to return addiction. Furthermore, recovery from of nicotine addiction reduces many temporary abusive disturbances which are caused by drug abuse, including being worry, drowsiness, depression, concentration problems, impatience, and intolerance (33). Marcle also showed that people who smoke regularly and those who stop using alcohol or marijuana and start to smoke had a higher chance of returning to the drug abuse. In those people, the chances of returning to alcohol are significantly higher than those who left smoking. Moreover, those who are constantly smoking as well as people who have recently started smoking, the period of relapse of marijuana occurs quite faster. (34) As previously reported, the drug abuse in behavioral and physiological aspects are the causes to use other drugs. (34) The results of current study are in line with the results of the studies showing the relationship between consumption and stopping the use of tobacco and the outcome of drug treatment (35). The drug abuse, alcohol and tobacco using in adolescents aged 11 to 18, especially in high school, is still a major problem in different countries (12). Therefore, addressing educational and awareness strategies in preventing drug abuse in the school can be an effective step in this field.
According to the findings of this study, there is a statistically significant relationship between family disputes and the return to addiction. Thus, it can be concluded that those who stop using drugs and experience family disputes tend to relapse more to addiction than those who stop using drugs after dispute. This finding is in line with that of Rimaz, Chong and Golestan (25, 36, 37). In the study of Seraji, also, 52.5% of returnees have had family disputes with their father or spouse (26). The results of the study by Jackson also showed that there was a relationship between family disputes and the success rate of treatment (18). In the study conducted by Madu et al. it was approved that family disputes are the causes of returning to drug addiction in opioids (38). It is likely that other members of the family will be anxious due to the addiction of the members of the family and it will cause
tension. A study of family members can help to investigate the causes of addiction; many studies have identified families as one of the most important factors in determining the risk of drug abuse among children (39).
Based on the findings of this study, there was a significant relationship between income and return to addiction, which is probably due to the high unemployment rate in the addicted group and the presence of patients with a high probability job, which led to successful control in the non-addicted group with more unemployed people being exposed to many of the risk factors associated with relapse of drug abuse, there is a higher incidence of addiction (12, 32, 39).
The results of the current study also revealed that there is a statistically significant relationship between the hope status and return to addiction. Thus, based on this, it can be concluded that those who stop using drugs and who are more hopeful about their recovery than those who are stop using and are less hopeful tend to return to addiction with less tendency. This find is consistent with that of Scott’s study (40), while in Jackson’s study, there was no relation between the hopeful and the treatment success.
Moreover, in the men’s and women’s groups, those with less hope were reported to enter the treatment with less rate of participation. Given that Taylor et al. suggested that hopeful thought has a relationship with spiritual health (41).
The results of this study showed that from the perspective of another addict in the family, there is no statistically significant difference between the addicted and non-addicted group. However, in the study of Matto, there was a relationship between the family experience of addiction and relapse, especially if the addicted person is currently using drug.
Conclusion
The results of this study showed that the individual, social, psychosocial, occupational and economic variables are factors influencing the relapse of substance abuse. Identifying the factors associated with the recurrence of substance abuse can be helpful in designing prevention and treatment programs for the relapse of drug use. Perform interventions is necessary based on identified key risk factors (such as employment status, smoking, family disputes, marital status, individual hope, etc.).
Limitation of the study
One of the limitations of this study was all participants were men. This was due to the fact that there was no recovery camp for the women in Marand. Another limitation was the self-reporting method of the patients.
Acknowledgments
The authors wish to acknowledge the education and research assistance of Tabriz University of medical science. The authors also thank all
those who have cooperated in this research, for their kind participation. This study with code of ethics (TBZMED.REC.1394.156).
Conflict of interest
The authors have no conflicts of interest to report.

References
1. Termorshuizen F, Krol A, Prins M, et al. Prediction of relapse to frequent heroin use and the role of methadone prescription: an analysis of the Amsterdam Cohort Study among drug users. Drug and Alcohol Dependence. 2005; 79(2): 231-240.
2. Hunt WA, Barnett LW, Branch LG. Relapse rates in addiction programs. Journal of Clinical Psychology. 1971; 27(4): 455-456.
3. Skiba D, Monroe J, Wodarski JS. Adolescent substance use: reviewing the effectiveness of prevention strategie. Social Work. 2004; 49(3): 343-353.
4. Mohammadpoorasl A, Fakhari A, Akbari H, et al. Addiction relapse and its predictors: a prospective study. Journal of Addiction Research and Therapy. 2012; 3(1): 1-3.
5. Assarian F, Omidi A, Akbari H. Psychological and personality characteristics of young addicted subjects in Kashan, 1379. Feyz Journal of Kashan University of Medical Sciences. 2004; 8(1): 37-42 [Persian].
6. Shargh A, Shakibi A, Nisary R, et al. Survey of related factors with relapse of drug addiction in centers of drug addiction in Western Azarbaijan. The Journal of Urmia University Medical Sciences. 2012; 22(2):129-136 [Persian].
7. Mirzaei T, Ravary A, Hanifi N, et al. Addicts' perspectives about factors associated with substance abuse relapse. Iran Journal of Nursing. 2010; 23(67): 49-58 [Persian].
8. Rahimi MA, Sharifi V, Mohammadi M, et al. Researches on substance use in Iran; 3 decades evaluation. Hakim Health Systems research journal . 2006; 8(4): 37-44[Persian].
9. Tol A, Azam K, Shahmirzadi SE, et al. Relation between empowerment of diabetes control and adoption of self-management behaviors and its related factors among type 2 diabetic patients. Razi Journal of Medical Sciences. 2012; 19(98): 11-18[Persian].
10. McKay JR, Franklin TR, Patapis N, et al. Conceptual, methodological, and analytical issues in the study of relapse. Clinical Psychology Review. 2006; 26(2): 109-127.
11. Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. American Psychologist. 2004; 59(4): 224-235.
12. Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005; 293(12): 1453-1460.
13. Friedmann PD, Saitz R, Samet JH. Management of adults recovering from alcohol or other drug problems: relapse prevention in primary care. JAMA. 1998; 279 (15):1227-1231.
14.          Xie H, McHugo GJ, Fox MB, et al. Special section on relapse prevention: substance abuse relapse in a ten-year prospective follow-up of clients with mental and substance use disorders. Psychiatric Services. 2005; 56(10): 1282-1287.
15. Fadayi F. Percent of addicts after 6 months return to addiction. Iranian National Drug Control Headquarters. 2008.
16. Brown BS. Drug Use–Chronic and Relapsing or a Treatable Condition? Substance Use & Misuse. 1998; 33(12): 2515-2520.
17. Rahmati M M. The Factors Affecting Drug Abuse Among Addicted Women. Journal of Research on Addiction. 2002; 1;131-150 [Persian].
18. Jackson R, Wernicke R, Haaga DA. Hope as a predictor of entering substance abuse treatment. Addictive Behaviors. 2003; 28(1): 13-28.
19. Fallahzadeh H, Hosseini N. The Study of the Causes of Relapse in Addicts Referning to Behzisti of Yazd,1381. Toloo-e-Behdasht Journal. 2007; 5(1-2): 67-73 [Persian].
20. Sadeghieh Ahari S, Azami A, Barak M, et al. Factors Affecting the Relapse among the Patients Referring Voluntarily to Addiction-abandoning Centers, 2000. Journal  of Ardabil Medical University. 2004; 4(2):36-41[Persian].
21. Rezakhani Moghaddam H, Habibi A, Fezollahi E, et al. An investigation of mental health and its relationship with social capital among the students of Islamic Azad University-Khalkhal. Archives of  Hygiene Sciences. 2014; 3(4):177-183.
22. Shahrabadi R, Moeini B, Roshanai GH, et al. Assessing Hamadans nurses perceptions of patient safety cultures dimensions. Journal of Hospital. 2014; 12(4): 83-90 [Persian].
23. Meysamie AP, Faramarzi B, Naieni KH. How addicts think about addiction and community problems?. Tehran University Medical Journal TUMS Publications. 2006; 64(5): 34-43 [Persian].
24. Solati Dehkordi K. Relationship between drug abuse and dependence on drugs with mental disorders family members. Journal of Shahrekord University of Medical Sciences. 2004; 6(2): 1-8 [Persian].
25. Rimaz S, Dastoorpour M, Merghati khoii e, et al. Demographic variables associated with relapse in women and men referred to the selected addiction treatment centers in Tehran, 2009: A case- control study. Razi Journal of Medical Sciences. 2013; 20 (107): 63-72 [Persian].
26. Seraji A, Momeni H, Salehi A. The investigation of factors affecting dependence on narcotics and reappearance of drug usage in narcotics anonymous population in Khomein. Arak Medical University Journal. 2010; 13(3): 68-75.
27. Aghabakhshi H. Addiction and Pathology of Family: A Social Work. Tehran: University of Social Welfare and Rehabilitation Sciences 1998 [Persian].
28. Washton AM. Structured outpatient group therapy: In: Lowinson JH, editor. Substance abuse: a comprehensive textbook. 3rd ed Baltimore: Lippincott Williams & Wilkins; 1996: 215-217.
29. Walton MA, Blow FC, Booth BM. A comparison of substance abuse patients' and counselors' perceptions of relapse risk: Relationship to actualrelapse. Journal of Substance Abuse Treatment. 2000;19(2):161-169.
30. Zhou X, Nonnemaker J, Sherrill B, et al. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addictive Behaviors. 2009; 34(4): 365-373.
31. Tarrahi M, Ansari H, Heydari K, et al. Viewpoint of care providers and self-reported substance drug addicts referring to withdrawal centers about etiology of re-addiction in Khoramabad, 2010. Journal of Rafsanjan University of Medical Sciences. 2013; 12(4): 299-308 [Persian].
32. Mattoo S, Chakrabarti S, Anjaiah M. Psychosocial factors associated with relapse in men with alcohol or opioid dependence. Indian Journal of  Medical Research. 2009; 130(6): 702-708.
33. McCarthy WJ, Collins C, Hser YI. Does cigarette smoking affect drug abuse treatment?. Journal of Drug Issues. 2002; 32(1): 61-79.
34. de Dios MA, Vaughan EL, Stanton CA, et al. Adolescent tobacco use and substance abuse treatment outcomes. Journal of Substance Abuse Treatment. 2009; 37(1): 17-24.
35. Kurst-Swanger K, weather DS. Maintaining addiction: tobacco cessation policy and substance abuse treatment for youth. Journal of Child & Adolescent Substance Abuse. 2003; 12(3): 71-86.
36. Chong J, Lopez D. Predictors of relapse for american Indian women after substance abuse treatment. American Indian and Alaska Native Mental Health Research: The Journal of the National Center. 2008; 14(3): 24-48.
37. Golestan S. The Role of Family factors on the Relapse Behaviour of Male Adolescent Opiate Abusers in Kerman. Asian Culture and History. 2010; 2(1): 126-131.
38.  Madu S, Matla M. Correlations for perceived family environmental factors with substance useamong adolescents in South Africa. Psychological Reports. 2003; 92(2): 403-415.
39. Marlatt GA, Donovan DM. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York London: Guilford Press; 2005.
40. Carvajal SC, Clair SD, Nash SG, et al. Relating optimism, hope, and self-esteem to social influences in deterring substance use in adolescents. Journal of Social and Clinical Psychology. 1998; 17(4): 443-465.
41. Colvin CR, Block J. Do positive illusions foster mental health? An examination ofthe Taylor and Brown formulation. Psychological Bulletin. 1994;116(1): 3-20.