Background

Problematic substance use is a term that refers to the use of psychoactive drugs, which may result in psychological, legal, occupational, academic, or physiological dysfunction (WHO, 2018). Lindeman et al. (2022) described it as ‘a complex problem’ that poses considerable health concerns with an increased mortality risk. Drug use has, in the recent past, become a subject of interest and concern among researchers and the public. Its effect transcends various aspects of the users’ life, family, and community. In most cases, the family and relatives of those using drugs seek help and treatment for them, while those on the drugs may seem oblivious to the effects of the drugs on their life and general well-being, as they often give reasons for their usage (Chang et al., 2021). Irrespective of rehabilitative efforts from the family or the health care providers, the ability to desire change or to be motivated towards change has been identified as a significant determinant of the retention rate (commitment) to treatment (Oji et al., 2017). Thus, Fernández-Artamendi et al. (2017) report that adolescents who use cannabis experience psychological and other psychosocial problems, are less motivated for change, and are less likely to seek professional help.

In a study on the prevalence of problematic drug use by Chang et al. (2021), they observed that 5.8% (n = 23) of the participants reported having substance abuse issues, and 10.6% (n=42) of the participants reported improper usage of drugs with and problematic alcohol use. More males were identified to have issues with substance than females, and individuals with more severe psychotic symptoms were more likely to have issues with substance use than those with less psychotic symptoms.

In trying to evaluate the motivation for change among young people who abuse cannabis, their reasons for change, and perceived barriers to seeking professional help, Fernández-Artamendi et al. (2017) studied 261 cannabis users aged 16–21. They found that more adolescent users who are ready to stop abusing cannabis are significantly less than those who are not ready to stop using. The study also identified factors that determine intention to change as drug-related

problems, paranoid symptomatology, and more significant concern about the consequences of use. Also, Oji et al. (2017) studied stages of change, readiness, and treatment among 140 participants divided into retention and relapse groups. The study found that motivation for change was higher in the retention group than in the relapse group (P < 0.001).

Problematic drug use is a global pandemic, with the number of young users in Nigeria seeming to be higher than the global average. Many Nigerian youths have been noted to depend on different substances such as amphetamines, opioids, alcohol, and cannabis. Moreover, this trend is prevalent in all 36 federation states (Omolola et al., 2021). For instance, the spread of substance usage in Nigeria is estimated to be 37.5%- northwest, 17.3% - southwest, 13.5% - southeast, 11.7% - north central, and 8.5% -northeast (Oliha, 2014). To identify the reasons for substance use among this population, a Nigerian study using 140 undergraduate participants (substance abusers) reported that participants listed these reasons for abusing substances: peer influence (20.7%), curiosity (11.4%), emotional instability (9.3%), academic-induced frustration (6.4%), the portrayal of the unwholesome lifestyle of celebrities/music artists by the social media and the media (7.9%), lack of parental care (14.3%), coping mechanism from low self-esteem (5.7%), ignorance (4.3%), boredom for some in private universities (20%). Given the prevalence/spread of problematic substance use among individuals in Nigeria, with its attendant consequences, researchers have increasingly examined factors necessitating and sustaining drug use and relapse, such as social and psychological factors and mental illnesses. However, many of these studies have not looked at the perceptions of users and the supposed benefits they internalize, as these perceived benefits may affect their motivation toward change, even when they are already in a rehabilitation or mental health facility.

This study examined users' perception as a determinant of motivation to change and treatment compliance among individuals with substance use problems already in a facility. Specifically, it examines the roles and supposed benefits users claim to derive from substances and how the supposed benefits could affect their willingness to accept treatment. The different drugs of use are classified in this study as stimulant drugs (such as amphetamines, ecstasy, or cocaine) and Depressants (such as alcohol or cannabis, opioids).

Reviewing the characteristics of motivation toward behavioral change, some studies on motivation for behavioral change have suggested that motivation is a progressive, dynamic social construct that is not static. It is an internal and external active factor or force that triggers and induces behavioral change, “producing a behavior's initiation, direction, intensity, and persistence. Thus, motivation for treatment can be defined as the whole set of forces that determine entry, commitment, and perseverance in treatment” (Simoneau & Bergeron, 2003, p.1220). The implication is that motivation for behavioral change is not an event but a process that sometimes occurs in stages.

Trans-theoretical model (Prochaska & DiClemente, 1983)

The trans-theoretical model (TTM) was propounded by Prochaska and DiClemente in 1983. This theory posits that behavioral change is not a once-off event but a process that involves stages. It describes the propensity of individuals to maneuver effectively through five different stages of behavioral changes. The four main concepts of the trans-theoretical model are stages of change, self-efficacy, decisional balance, and change processes. This model describes the stages of how individuals choose an adaptive health choice. The stages were detailed as the (a) pre- contemplation stage- where the individual does not see any need or benefit to change; (b) the contemplation stage- where the individual is considering and weighing his options and benefits of change; (c) the preparation stage- here the person starts making little changes towards the goal to change, (d) the action stage- the individual goes all out to pursue and engage in activities that

promote the needed change/outcome he desires, and (e) the maintenance stage- where the gained outcome is sustained over a significant time frame. This theory further deduced that different individuals may be at different stages of change and readiness at different periods and that such individuals may progress further in the stage of change, regress to an already surpassed stage of change, or even remain in a stage of change, for an undeterminable amount of time (Hashemzadeh, 2019).

Health Belief Theory (Rosenstock, 1974)

The health belief theory was expounded by Rosenstock (1974), who attributed the model to the studies done by Hochbaum in 1958. The health belief model (HBM) was developed to describe and forecast health-related behaviors. It proposes that an individual’s beliefs about health issues, perceived advantages of action and the hindrances to the action, and self-efficacy can be used to understand the reason for the engagement of health-seeking behavior. Beliefs surrounding the gravity of a health threat, an individual’s susceptibility to the threat, the effectiveness of the medication, and the side effects of the medication are all interpreted as the perceived rewards and shortcomings of action, which consequently determine the strength of the individual’s health- seeking intention (Abraham & Sheeran, 2015). The Health Belief Model is beneficial for classifying thoughts prior to health behaviors. Knowing the origin of health thoughts/beliefs is instrumental in treating the disease. Demographics and socio-psychological and structural variables form a person’s beliefs and attitudes (Siddiqui, 2016).

The health belief model implies that the possibility that an individual will choose a particular health behavior is assumed to be related to four main principles- the perceived understanding of the person’s susceptibility to the illness, the seriousness of the illness, what they stand to gain health-wise if they choose a particular health option and the cost of the health option (cost analysis) (Feinstein et al., 2006). The model suggests that healthcare behavior is a determinant of the cost-benefit analysis, where the individual assesses the viability and benefits that can be gotten from the chosen healthcare option, as against the cost.

Methods

Participants

The study participants are Forty-nine (49) clients (47 male, 2 female) between the categorical age of 18 to 57. They were all poly-substance users of alcohol, cannabis, amphetamines, ecstasy, and cocaine, who were already admitted into National Drug Law Enforcement Agency (NDLEA) Rehabilitation facility Aba, Abia State Nigeria. They were purposively selected for this study. The inclusion criteria are all clients brought in for rehab with or without their full consent and who had spent a day to four weeks in the facility at the time of this research. The exclusion criteria were those who did not consent to participate and those who had spent up to five weeks, two to three months, and were about to be discharged. They were excluded because the psychologist working with the facility had already provided psycho-educational services, built motivation for change, and taught them positive coping skills to deal with life anxieties and other stressors of life.

Instruments

The semi-structured interviewer-administered questionnaire, explicitly developed for the study was used, which helped the researchers to elicit clients' different drugs of use, perceptions of use, reason for use, awareness of the problem, and how they viewed their coming to rehabilitation (need for treatment). During data collection, demographic variables such as age, sex, education, marital status, and occupation of participants were recorded and presented in a table.

Procedure

The researchers submitted a copy of ethical proposal letter declaring their intention and how they intend carrying out the research using clients in Abia state Rehabilitation center. The letter was submitted to the Abia State commander narcotics and drug demand reduction, through the Deputy State Commander Drug demand reduction unit (DDRU) in the facility. The letter indicated that no ethical rules will be violated, that the names, file numbers, and personal data that could identify clients will not be used. The commander gave his approval by signing approved, on the letter and given a copy to the researches. Upon receiving the ethical approval letter, the researchers proceeded to the clients, selected the inclusive criteria through the help of a staff who has their data, debriefed them about the purpose of the research, and handed them over the questionnaire with a copy of written informed consent form pinned in front of the questionnaire. Respondents gave their consent by ticking on the “I Agree” box on the form. The form highlighted the purpose of the study, the confidentiality, and informed respondents of the voluntary nature of their participation and that they are free to withdraw or quit without any penalty. It ended with appreciation of their valued time and willingness to participate. 

Design and statistics

The study adopted exploratory qualitative method, using semi-structured in-depth interviews among individuals already admitted into a Rehab facility (NDLEA, Aba). A qualitative method was necessary because it allowed the researchers to explore drugs of use, thoughts, perceptions, awareness of the problem, reasons for use, and motivation toward change. It also explores the broader reality experienced by the respondents while revealing hidden information about how they see and interpret their use and rehabilitation. The data were collected, coded, and analyzed using thematic analysis.

	Variables	Frequency	Percentage (%)
Distribution of respondents by gender	Female	2	4.1%
	Male	47	95.9%
	Total	49	100%
Distribution of
respondents by age range
	18-27 years	4	8.2%
	28-37 years	26	53.1%
	38-47 years	15	30.6%
	48-57 years	4	8.2%
	Total	49	100.0
Distribution of
respondents by
occupation
	Business	18	36.7%
	Hand Work	11	22.4%
	Networking	20	40.8%
	Total	49	100.0
Distribution of
respondents by marital
status
	Single	45	91.8%
	Married	4	8.2%
	Total	9	100.0
Distribution of
respondents by
educational level
	Secondary	8	16.3%
	Undergraduate	21	42.9%
	Graduate	20	40.8%
	Total	49	100.0
Distribution of
respondents based on
substance usage
**	Tobacco	17	34%
	Alcohol	49	100%
	Marijuana	40	81.6%
	Cocaine	13	26.5%
	Amphetamines	35	71.4%
	Tablets (Opioids)	25	51.0%

** All the respondents used at least two other substances including Alcohol

Table I above shows that greater percentage of the respondents are male (95%, female 4.1%). It also showed that more respondents fall within the age range of 28-37 (53.1%), followed by 38-47 (30.6%). Their occupation was mostly Networking (40.8%). An indication that they were mostly undergraduates (42.9%), followed by graduates (40.8%), and mostly single (91.8%).

They were all poly substance users, as indicated by the distribution on the table. Tobacco 34%, Alcohol 100%, Marijuana 81.6%, Cocaine 26.5%, Amphetamines 71.4% and Tablets 1.0%.

Table II: Themes, Frequency and Percentage scores of Respondents’ Reasons for use, Perception, and motivation for change.

 

Perception of use (functional benefits)                 Perception of Problem (perceived disadvantages of usage)         Respondents’ view about others people’s perception of a drug user       Respondent’s readiness to quit   Perceived need for Treatment

Themes   To keep Awake and focus To deal with my Depression To increase Energy for work To deal with Anxiety and increase boldness To catch Fun and relaxation To maintain my space I do not see my drug use as a problem I am not Addicted to Drugs I see my Drug usage as a problem   I am seen as useless   People don’t trust me   Loss of opportunities   I am not Ready I am not certain I will cut down on my usage I am Ready to quit I do not need this treatment I need treatment

Frequency   31 22 38 45   47 30 37 17 12   11   44   30   18 33 12 7 25 17

Percentage   63.3% 44.9% 77.6% 91.8%   95.9% 61.2% 75.5% 34.7% 24.5%   22.4%   89.8%   61.2%   36.7% 67.3% 24.5% 14.3% 51.0% 34.7%

Table II above showed various themes, Frequency and Percentage of Respondents that came out from the open-ended questions. All the Respondents gave various combination of functional benefits for their use of substances, 95.9% of them reported that substances help them to catch fun and relax. 75.5% do not see their substance use as a problem, and where either not ready to quit or uncertain.

67.3% of the respondents were not certain if they want to quit, while 14.3% reported not ready to quit. 51.0% reported not needing the treatment that their family choose for them.

Discussion of Thematic Analysis as presented on the table.

a. Use of substance, perception of substance use and the need for treatment.

The study found that various clients accepted their substance use, indicating no negative perception of their use and no need for treatment. For instance, a male client forced into treatment by family members explained:

“I do not have a problem; I am not addicted and few that admitted that they have problem that requires treatment”.

Further investigation showed that most participants agreed they were using not just one but a combination of substances. Either to stop the effect of one or to increase the impact for a “better

result.” However, the majority claimed that their substance use is not a problem. Instead, it was for a good reason (functional) that they started using substances and claimed they were not addicted to drugs. This reflects and is consistent with the results of previous qualitative studies on the perceived benefits of substance use among most substance users (El Kazdouh et al., 20180). This finding is echoed in the statements credited to an adult female participant:

“I am not an addict, I use substance, but I don’t have problem with that. I can control my use. But because people around me do not understand me, they feel I have problem with drugs. I only use when I want to use, and nobody has the right to dictate my life for me. So, this rehabilitation is not for me.

Another said.

“I know I am using substance, and to non-user, I may look like an addict. For me, I can control my use, although I know sometimes, I lost control but that is my life which my family has no right to punish me”.

However, few acknowledged that substance use was becoming a problem for them, and they wished to cut down on their use or stop the use of substances. A participant explained below:

“I know I was using for a reason, but at this stage in my life, I think it is beginning to affect my relationship with family, and my business; so, I think I should do something about it.”

The implication is that some clients are at the contemplative stage of change as they recognize the negative impacts of their substance use. In a study conducted by Raihan, 2023, p.14, the results show that the contemplative stage “…is marked by awareness and acknowledgment of the problematic behavior with serious consideration to change. However, the person is uncertain if the problem behavior is worthy of correcting. Therefore, this internal approach-avoidance conflict results in no commitment to taking the necessary steps toward change”.

b.  Other People’s Perception of their Use of substance.

When asked to explain how others view them and their use, themes like uselessness, lack of trust, and lack of opportunities arose. All the participants reported that when an individual is seen as a drug user, people do not care to know their pain. They always talk about the use and see the person as not serious-minded and may not trust the person. A client in a pre-contemplative stage of recovery indicated his frustrations with how non-addicts around him are viewing him:

“People always see a drug user as a junky! As someone that cannot be trusted. For me, that is error in social perception. They don’t really understand.”

Also expressing frustration about how her family members are treating her because of her substance use, another participant explained:

“My family did not know what I was going through. They contributed to my use of substance. So, I think they are the ones that need this rehabilitation more. But because they want to punish me, they brought me here.”

She continued by explaining that:

“It got so bad that my father cannot believe anything I said but would want to verify from my younger sister. It is so disheartening. That even made me more depressed, and I used more drugs. I know I have lost some money because of my drug life; I was no longer taking my business seriously.”

Another who said he is a designer said.

“I lost my costumers. Because sometimes, I will use the advance money they paid me for substances and may not have enough money to complete the job. That led to frequent disappointment and loss of money.”

The above narration manifests the fact that many substance users are being perceived from a negative lens by the general population. This is consistent with previous studies like that of Yang et al., 2017, p. 1, which “indicated that the public holds very stigmatized views towards individuals with substance use disorders and that the level of stigma was higher towards individuals with substance use disorders than towards those with other psychiatric disorders.”

c. Functional Reasons for Substance Use.

Studies have shown that all psychoactive substances produce some feelings of pleasure in the human brain. As the use continues, the brain adapts to the euphoric feelings surge. Thus, “these brain adaptations often lead to the person becoming less and less able to derive pleasure from other things they once enjoyed, like food, sex, or social activities” (NIDA. 2018, p.2). Substance users often perceive they must cope with specific life stressors to function in society with substances. (Iswardani et al., 2022). In this study, some participants gave many functional reasons for their substance use, such as to keep awake/focus, deal with depression, increase energy for work, deal with anxiety and boldness, have fun and relax, and maintain their space.

For example, a client who is into the dry-cleaning business shared:

“I am a dry cleaner; I use substance to chill out after the day’s work. The quantity I use is dependent on how stressful the day’s job was. Like I said, I am not an addict! But because of social view of substance users, so when I have this troublesome customer, who I am ready to insult when they want to take me for a ride, people will say, I am a drug user. So, my family decided to bring me here without knowing why I display some aggressive behaviors.”

Many who claimed they were in the networking business reported that drugs, especially methamphetamines, provided them the alertness, focus, and wisdom to carry out their business without distractions. For instance, a client in web business noted:

“I am a web developer, so I always need concentration and focus. Use of ice has been helpful in this regard. When I want to do night work, when network will be stable, I use meth. It makes me to be happy, full of concentration and ready to bomb.”

In addition, another client in a car business explained:

“I started using when I was depressed. It helped me deal with my depression because it was giving me a sense of euphoria that I needed. I lost a relationship. So, I lost trust in any form of relationship, my coping anytime I feel depressed is to use substance to be happy and maintain my personal space without needlessly offending anyone.”

Although all the participants gave various and varied functional reasons for their continuous use of substances, few acknowledged that it could solve their problems temporally; it has added more problems to their lives. This affirms results from studies that showed although substance users experience some temporary positive feelings, users also acknowledge some long-term adverse effects ("NIDA. 2022; Flores-García et al., 2019).

d. Motivation to Remain Sober After Treatment.

The study also found that most participants showed unwillingness to change, while others reported that they would cut down because they were not sure of stopping; few indicated the motivation for change. For instance, a client who is in a pre-contemplative stage of change explained:

“Because my parents brought me here without my knowledge and proper understanding of what led me to substance, I have made up my mind not to stop. Let them spend this

money. I will stop when I am determined on my own to stop.”

On the other hand, a client in a contemplative stage of changed noted:

“I am not sure of complete stopping because I know I benefit from my substance use, which any non-user will not understand. Nevertheless, I also know I started using too much at some point. So, I will use this time in the rehab to learn how to reduce my use."

The above statements from clients at different stages of change speak to the various elements and characteristics of clients at different stages. Each stage of change has different motivating factors toward change. For instance, pre-contemplative clients are motivated to enter the change process by "extrinsic sources of motivation." On the other hand, clients at the contemplative stage of change display signs of ambivalence toward change (U.S. Department of Health and Human Services, 2019, p. 65).

The present study examined the perception of substance use as a determinant of motivation for change among individuals diagnosed with problematic substance use in an NDLEA Rehabilitation facility in Aba, Abia State Nigeria. Results from the 49 participants studied indicated that more males (95.9%, n 47) abuse substances than females (4.1%) and that problematic substance use was more prevalent among individuals within the age range of 28-37 years (53.1%, n=26), followed by 38-47years (30.6%, n=15) with people aged 18-27 years and 48-57years having the lowest prevalence of problematic substance use (8.2%, n =4 respectively). Alcohol (100%), marijuana (81.6%), and amphetamines (71.4%) were the most abused substances. Most respondents (91.8%).

listed 'having fun and relaxation' (functional benefits) as the reason for their abuse; and a significant number (75.5%) of them 'did not see' their drug use as a problem, and only 24.5% 'saw' it as a problem. This finding agrees with Chang et al., (2021), whose study concluded that more males experienced problematic substance use than females and that a significant number of substance users seem oblivious to the effects of the drugs on their lives and general well-being as they often give reasons for their usage.

Fernández-Artamendi et al., (2017) also corroborated this finding in their study, where they observed that the participants (adolescent users) who were ready to stop using cannabis were significantly less than those who were not ready to stop using.

When asked about the perception of others towards their substance usage, most of the respondents (89.8%) reported that 'people do not trust them.' Interestingly, only 14.3% reported readiness to quit, and 67.3% were unsure about their readiness to quit substance use. Using the transtheoretical model (TTM) continuum of five stages of change by Prochaska and DiClemente (1983) to explain this phenomenon, it can be theorized that most of the studied individuals with problematic substance use are still in the pre-contemplation stage, and do not consider their substance use to be a problem, may be living in denial, may not have experienced a negative consequence as a result of their substance use or maybe deriving 'pleasant/functional benefits' from their usage (Keene, 2019). Irrespective of rehabilitative efforts from the family or the health care providers, the ability to desire change or to be motivated towards change has been identified as a significant determinant of the retention rate (commitment) to treatment (Oji et al., 2017).

The above results from the interview show that clients' perceptions of the functional benefits they get from substances tend to determine their willingness to change. Also, the study shows that clients at different stages of change perceive substance use differently regarding motivation toward change, the functional benefits, and the commitment to remain sober after treatment.Without proper analysis of those perceived benefits, they may resist help to change. Also, when people lack insight into the dangers of substance use, they remain in the pre-contemplation stage and resist change. The result also revealed that clients are not self-motivated to quit substance use when they still believe drugs are beneficial.

Conclusion & Recommendations

The crux of this study is examining the perception of substance use as a determinant of motivation for change among individuals with problematic substance use. Given the discussed submissions, the study observed that most individuals with problematic substance use are reluctant to change, do not want treatment, and do not see substance usage as a problem. This has far-reaching implications for substance use professionals treating individuals with substance problems. Intentional and consistent efforts should include motivation enhancement therapy, insight-oriented therapy, and substance use psychoeducation by drug addiction professionals in treating persons with problematic substance use. The efficacy of using just pharmacotherapeutic interventions (as is mostly used in Nigeria) has limited potential. Several studies and experiences have shown that including psychotherapy in managing addictions, such as problematic substance use, may offer better treatment outcomes in managing persons with substance use disorders.

Furthermore, there is a need for family therapy, as many of the studied participants felt that their families saw them as 'useless.' A collaborative effort with drug users' families is vital for a holistic and systematic approach to intervention.

The following recommendations were made based on the success of this study:

1. There is a need for intensive psychotherapeutic interventions using motivation enhancement therapy, insight-oriented therapy, and substance use psychoeducation by trained clinicians in all rehabilitation centers.

2. There is a great need for family therapy for almost all clients to resolve conflicts of interest arising from users' perceptions.

3. Government and policymakers should facilitate and implement drug education and harm reduction policies to help substance users eventually cease drug use.

List of abbreviations

National Drug Law Enforcement Agency (NDLEA)

World Health Organization (WHO)

Trans-theoretical model (TTM)

health belief model (HBM)

Drug demand reduction unit (DDRU)

Declarations

Ethical Approval 

The researchers submitted a copy of ethical proposal letter declaring their intention and how they intend carrying out the research using clients in Abia state Rehabilitation center. The letter was submitted to the Abia State commander narcotics and drug demand reduction, through the Deputy State Commander Drug demand reduction unit (DDRU) in the facility. The ethical approval letter granted by the National Drug Law Enforcement Agency (NDLEA) with ID number: NDLEA/ABSC/VOL. 1/1. Original pdf copy has been attached in the space provided in the submission process. The letter indicated that no ethical rules will be violated, that the names, file numbers, and personal data that could identify clients will not be used. The commander gave his approval by signing approved, on the letter and given a copy to the research. Upon receiving the ethical approval letter, the researchers proceeded to the clients, selected the inclusive criteria through the help of a staff who has their data, debriefed them about the purpose of the research, and handed them over the questionnaire with a copy of written informed consent form pinned in front of the questionnaire. Respondents gave their consent by ticking on the “I Agree” box on the form. The form highlighted the purpose of the study, the confidentiality, and informed respondents of the voluntary nature of their participation and that they are free to withdraw or quit without any penalty. It ended with appreciation of their valued time and willingness to participate.