Etiology of Drug Abuse: A Narrative Analysis

Abstract

and Aim
. Further gains in the prevention of drug abuse disorders require in-depth and holistic understanding of the risk factors of addiction from different perspectives. Lay persons and experts have different concepts of risk which could complement each other. The purpose of this study was to elaborate drug abuse risk factors through the story of individuals who had become drug dependent.
Design and Methods
. In this qualitative research, 33 individuals attending treatment centres for drug abuse were interviewed about the story of their addiction in Kerman, Iran. Interview questions were around the story of the participants.
Results
. All participants were male and in the age range of 18–40 years. Narrative analysis identified five themes as the main risk factors: family factors, peer pressure, the effect of gateway drugs (especially waterpipe), individual characteristics, and the community factors. More emphasis was placed upon the role of family factors, peer influence, and gateway effect.
Discussion and Conclusion
. This study elicited information from drug dependent subjects regarding the risk factors of drug abuse. According to drug dependent individuals’ views, more attention should be devoted to family and peer influences by policy makers, in developing culture-based preventive strategies.

Full text

Research Article
Etiology of Drug Abuse: A Narrative Analysis
Nadjme Jadidi1and Nouzar Nakhaee2
1St.VincentHospital,St.VincentHealth,Melbourne,Australia
2Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
Correspondence should be addressed to Nouzar Nakhaee; nakhaeen@yahoo.com
Received 5 May 2014; Revised 18 August 2014; Accepted 19 August 2014; Published 26 August 2014
Academic Editor: Jennifer B. Unger
Copyright © 2014 N. Jadidi and N. Nakhaee. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Introduction and Aim. Further gains in the prevention of drug abuse disorders require in-depth and holistic understanding of
the risk factors of addiction from dierent perspectives. Lay persons and experts have dierent concepts of risk which could
complement each other. e purpose of this study was to elaborate drug abuse risk factors through the story of individuals who
had become drug dependent. Design and Methods. In this qualitative research, 33 individuals attending treatment centres for drug
abuse were interviewed about the story of their addiction in Kerman, Iran. Interview questions were around the story of the
participants. Results. All participants were male and in the age range of 18–40 years. Narrative analysis identied ve themes as the
main risk factors: family factors, peer pressure, the eect of gateway drugs (especially waterpipe), individual characteristics, and the
community factors. More emphasis was placed upon the role of family factors, peer inuence, and gateway eect. Discussion and
Conclusion. is study elicited information from drug dependent subjects regarding the risk factors of drug abuse. According to
drug dependent individuals’ views, more attention should be devoted to family and peer inuences by policy makers, in developing
culture-based preventive strategies.
1. Introduction
According to the UNODC report, approximately 5% of the
world adult population have used illegal drugs at least once
in 2010 and 0.6% of people are considered “problem drug
users” [1]. Drug abuse will impact various aspects of one’s
life including physical, mental, and social aspects. In addition
to more than 200,000 deaths per annum due to heroin and
cocaine abuse, drug abuse could lead to delinquency, early
sexual activity, family disintegration, and increased risk of
HIV [1,2]. Although the rate of drug abuse is reported to be
steady in some countries, it has shown an increasing trend
in many developing societies [1]. Iran is facing an increasing
number of drug abusers that have negative social and health
impacts [3].
Over the past century, many theories have been proposed
to describe the aetiology of drug abuse [2,3]. ese theories
are categorised in 3 main subgroups of social, psychological,
and biological subgroups [4]. Although multiple theories
would help in better understanding of the aetiology of addic-
tion, this multiplicity could convey the lack of consensus
around aetiology of drug abuse [2] and, according to Spooner,
scientic evidence in this area is inadequate [5].
e majority of studies in drug dependency have a
quantitative approach that compares some of the factors in
drug abusers with those of the nonusers [6,7]. Considering
lack of adequate knowledge about predisposing factors for
addiction, experts recommended the use of “new models
of risk factor research” [7]. Due to the complex nature of
drug dependency, qualitative studies could be benecial in
exploring the process of addiction [3,8]. rough deeper
understanding of drug abusers, qualitative studies could
throw light on why some people abuse drugs [8]. Narrative
enquiryisarelativelynewmethodinqualitativestudies
mainly used in the eld of social science [9]. In this method,
data collection is done through story telling [10]. Story is a
rich source to obtain better insight into the social process
[11]. rough learning how people become addicted, one
could probably better understand “why they engage in these
unhealthy behaviours” [12]. Narrative analysis has been used
to discover the circumstances surrounding events such as
injuries and maternal death [13]. To the best of our knowledge
Hindawi Publishing Corporation
Journal of Addiction
Volume 2014, Article ID 352835, 6 pages
http://dx.doi.org/10.1155/2014/352835

2Journal of Addiction
this method has not been used in the eld of addiction
etiology. Nevertheless, hearing people’s story of their addic-
tion could give us some cultural information and also assist
us in prioritizing preventative activities as a supplement to
research and hence it could increase the practicality of our
ndings. Solvic, in his famous article “Perception of risk”
with more than 4500 citations, believes that the layperson’s
opinion should be considered in the design of preventative
interventions as their opinion is frequently regarded as a
supplement to the experts’ view [14]. He even states that “their
basic conceptualisation of risk is much richer than that of
the experts” [14]. e purpose of this study was to expand
on the existing body of literature by exploring the interview
narratives of drug abusers.
2. Methods
e study was approved by the ethics committee of Kerman
University of Medical Sciences. Subjects were individuals
referred for detoxication or maintenance therapy to addic-
tion treatment centres in Kerman city, the capital city of
the largest province in Iran. e reason these subjects were
chosen was that the focus of our study was on explanation
of drug abuse risk factors rather than drug use. It was
expected that individuals who experienced drug abuse would
be able to provide richer accounts of “drug abuse” risk factors
comparing to those with infrequent “drug use” [15]. is
distinction should be considered by the researchers working
on the aetiology of addiction [6]. All participants had already
passed the detoxication phase and were in a stable condition.
e sampling technique was purposive sampling.
Interviews were conducted aer obtaining informed con-
sent and ensuring condentiality and anonymity. Interviews
were performed in a private and quiet room. Each interview
took between 30 and 90 minutes. All interviews were tape-
recorded and then transcribed. Interviews started with a
general question and then carried on according to the
participants’ responses.
Interview questions were around the story of the partic-
ipants’ drug abuse from the experimental stage through to
abuse. e interview was started with a question about their
own background and then a follow-up question, “Tell me
about your rst experience with drugs?” ree dimensions
of the metaphoric narrative inquiry were considered by
the interviewer (Nouzar Nakhaee). ose three dimensions
of drug abuse were place, time sequence, and social and
personal interaction [9].
Narrative analysis was constructed through pragmatic
method as the purpose of narrative inquiry was not to
create story for the outcome of research but to extract and
categorise risk factors for drug abuse based on the content
of the story [16]. Risk factor is dened as “an individual
attribute, individual characteristic, situational condition, or
environmental context that increases the probability of drug
use or abuse or a transition in level of involvement in drugs”
[17].
Transcriptswerebrokenintosmallunitsthroughanalysis
of the content of the stories [18,19]. We used Labov’s method
of transcription to construct a text from the interviews [20].
ismethodisoneoftheapproachesfororganizingnarrative
data which is useful for understanding major events in the life
histories [20]. Primary codes (risk factors) were categorised
based on similarity and formed into subcategories. Finally,
the main themes were identied through making dierent
subcategories.
3. Results
irty-three interviews were conducted. All participants were
male and in the age range of 18–40 years. Only 2 participants
had university qualications. Findings were categorised in 5
themes as follows.
3.1. Family Relationships and Structure. Parental discipline
style was one of factors that participants focused on.
“MyfatherusedtobeatmeandIwasstubborn
and would come home even later at night. en
hewouldbeatmeharderandIbecamemore
stubborn.”
“I didn’t dare talking to my father to tell him about
my wishes. Our parents’ thoughts were focused
on earning money to buy a house, a car, etc.
rather than making time for their children and to
respecting their identity.”
Lack of a warm and emotionally rich environment at home
was another factor extracted from the participants’ stories.
“I can’t recall if my parents have ever hugged me.
I felt an emotional emptiness.”
“Anaddictwouldn’tintherstplacegotowards
drug abuse out of leisure. You don’t become an
addict if you were supported by the family.”
“I would rather play cards with my dad than my
friends.”
Another factor was noted as lack of supervision by parents.
“is wouldn’t have probably happened if my
parents hadn’t le me on my own.”
“If one day I had children, I would shadow them
all the time and not leave them on their own.”
Another risk factor was identied as copying parents espe-
cially the father.
“I remember my dad smoked opium and I wished
IcoulddothesamewhenIgrewup.”
“My father was an opium smoker. I thought he
isanadultsoheisdoingtherightthingssoif
I smoked opium like him, I would grow up and
become an adult like him.”
Disrupted/disintegrated family structure was another risk
factor.

Journal of Addiction 3
“Peace disappeared from our home when mum
died and dad re-married so I smoked opium to
keep calm.”
“When dad went to prison, there was no one to
look aer me, to keep an eye on me and to buy me
clothes, stationary, etc.”
Reviewing the content of stories, family relations were the
most prominent and frequent theme amongst all the themes
explored from the interviews.
3.2. Peer Inuence. Peer pressure was emphasised by the
interviewees as a main factor in experimenting drug abuse,
andespeciallyturningtoheavierdrugs.Someidentiedthat
peerpressureandengagingwiththewrongcrowdwouldstem
from their own personality that would innately attract this
type of people.
“Myaddictionstartedwithpartyingandnight
life.”
Some identied their linkage with the wrong crowd as an
accident.
“We had a new neighbour whose son was my
age. He was the rst person introducing me to
cigarettes and porn movies.”
Some mentioned being teased and criticised by friends as the
main factor for drug abuse.
“I didn’t want to smoke opium but my friends
wouldteasemeandsayyouareasook.Whydon’t
you smoke you little nerd?”
Some identied the main factor as positive expectation from
friends.
“One of my friends suggested I smoke heroin to
beat my competitor in Kong Fu matches.”
3.3. Individual Characteristics. In this study, individual char-
acteristics were identied as one of the risk factors. Starting
drug abuse at a young age was observed in many participants
in the way most of them reported their rst time use during
primary school. Particularly participants who started with
cigarettes or waterpipe identied pleasure being the main
reason for drug abuse.
“I met a girl and I stayed smoking opium to help
delay ejaculation.”
Some participants identied their personality problems as the
main risk factor in turning towards drugs.
“I was aloof and timid and I always saw myself less
than others.”
“I always looked for someone who would help me
with my loneliness.”
“I would feel like a man when I smoked cigarettes.”
“I wouldn’t take any advice and always wanted to
experience things myself.”
“I thought addiction was for others and I would be
able to control myself.”
Some individuals mentioned denial as a mechanism and a
reason to continue on their drug abuse.
“We, addicts, are the last ones who realise that we
have become dependent.”
Some identied hereditary factors.
“I feel this has been my fate because I had
addiction in my genes just like diabetes that shows
a few years later down the track.”
“If parents are addicted, the zygote is contami-
nated and the child would become dependent even
with minimal use over a short period of time.”
3.4. Gateway Eect. One concept extracted from the inter-
views was that problem drug abuse is a transition from lighter
use such as waterpipe, cigarettes, hashish, and alcohol. Some
individuals identied biological factors as the main risk factor
in this transition.
“My very rst time use was with waterpipe.
Waterpipe releases a code that is, you are no more
scared of smoking. Although it is only nicotine, it
would open the gate to other drugs.”
Some participants identied the gateway eect through social
factors.
“I started with waterpipe but then changed to
cigarettes as it was easier to hide.”
“Smoking waterpipe would predispose you to
smoke opium just for the sake of being around
together with others smokers.”
Overall,outofall4drugs,therewasmoreemphasison
cigarette and waterpipe compared to alcohol and marijuana.
e majority of participants did not report their rst experi-
ence as being with opium and/or heroin.
3.5. Community Inuence. Some individuals identied more
environmental risk factors such as poverty, type of neigh-
bourhood, lack of leisure facilities, and normalised attitude
towards drug abuse.
“We didn’t have facilities for healthy activities so
we would gather together in a vacant house and
drink alcohol.”
“Drugs were easily available around our neigh-
bourhood just like lollies. How could you not get
aected?”

4Journal of Addiction
“I got involved with drugs when my father was
prisoned and we became poor and had to deal
with poverty.”
“Many restrictions in the society such as the police
being strict on the single male population in the
parks and on the streets would make us go and
gather in quiet places.”
“I always envied having a nice school bag or a
proper outt.”
“Peopletoldmethathey,everyonesmokes,why
you don’t? How long do you want to live?”
4. Discussion
is research elicited information from lived experience of
drug dependent individuals of Iran regarding the risk factors
of drug abuse. In this study, we categorised drug dependency
risk factors in 5 main themes of which 3 were common in
most of interviews, that is, role of the family, peer pressure,
and starting drug abuse with lighter items such as cigarettes,
waterpipe, and alcohol. e major limitation of this study
was the fact that generalizability to other settings especially
Western culture may be problematic and its main advantage
was the ability to illuminate the inner life and live experiences
of drug abusers.
Prevention is the most cost-eective method to address
drug abuse [20] and recognition of drug abuse risk factors is
required to design preventative interventions [3,7]. However,
some countries have built up their main services focusing
on harm reduction or war on drugs [21]. In order to extract
and interpret the risk factors, it is important to know that
risk factors are not in isolation from each other and they do
notworkinavacuumbutareratherrelatedtoeachother
so we should be careful not to have a narrow, parochial, and
dogmatic approach in identifying and interpreting those risk
factors [6].
On the other hand, we need to be aware that designing
preventative interventions for drug abuse would probably be
unsuccessful without considering the drug dependent popu-
lation’s views [22]. Qualitative studies are good at nding the
blind spots of some phenomena through in-depth interview.
ese blind spots are usually not detectible through quan-
titative studies. In this study, narrative analysis was used to
explore the risk factors of engaging in unhealthy behaviours
from the drug abusers’ point of view. Furthermore, these risk
factors exist within the culture of a society in which drug
abusers live. Given the numerous theories and risk factor
overload, this study was helpful to rene the more important
risk factors in a culture-based framework.
In this study, all participant identied family as the most
important and crucial risk factor for drug abuse in the youth.
Amongst all the family risk factors, some were more promi-
nent such as physical punishment, lack of a safe and warm
environment at home, weak attachment between children
and the parents, role modelling of the parents, and loss of
a parent. Lack of supervision and monitoring of children
by the parents were also identied amongst the risk factors
extracted from the interviews. Overall, family relationships
had a more signicant role than that of the family structure.
Family can play a role in development of drug abuse in
dierent ways. Lack of a warm and supportive environment
wouldincreasetheriskofdisruptiveandunhealthybehaviour
in children [6]. History of adverse childhood event especially
before the age of 5 can substantially increase the risk of
drug dependence in adolescents [23,24]. Also, neglectful
parents do not supervise their children’s choice of friends
[6]. Weak parent-child attachment would lead to strong
bonding with friends resulting in peer pressure in youth
[4]. Owing to modernization, integration of women in the
work world, and reduction of family size, Iranian family
is passing through a fast transition that is becoming more
similar to Western family. Family’s educative function has
been delegated to television, internet, school, and other
institutions so the supportive role of families seems to be
fading. All these factors may provoke the risk of drug abuse by
adolescents due to a lack of strong bond between parents and
child.
According to theories of social learning and social con-
trol, the stronger the family cohesion and parental moni-
toring are, the less probable the drug abuse and turning to
gateway drugs are. Parents role modelling, also identied by
the participants, has been proved in various studies [7,25].
Culture-based family education programmes to reveal the
pivotal role of families in prevention of youth drug abuse
wouldhavepotentialbenetsforcommunity[23,24].
In this study, peer pressure has been identied so strongly
that most of participants mentioned the stereotype statement
“I wouldn’t become addicted if I didn’t have bad friends.”
Almost all studies agree on the impact of peer-related factors
[7],butsomewouldclearlyrecogniseitasthestrongestrisk
factor for drug abuse in youth [26,27].
Regarding how an individual adolescent would go on a
socialization pathway through a friend, some experts believe
that potential drug abusers do not accidentally fall into peer
clusters, but they are attracted through their common rules
and similar attitudes known as “selective recruitment” [4].
However, some regard this as a casual process and identify
the main factor being lack of supervision by parents in
the process of friend nding which leads to adolescents
beingdeceivedbytheirpeers[20,28]. is study was
more in line with the latter. Our study revealed that peer
variables are among the strongest predictors of adolescents’
drug abuse and parental neglect and lack of supervision
may have a crucial role in triggering the peer inuences
[3,27,28]. As a whole, the role of peer factors needs to
be emphasized in teaching programmes for both youth and
parents.
In general, family and friend factors always interact, but
it could be speculated that, in developing countries with less
modernisation eect, children are more strongly bonded with
thefamilysotheywouldbemoreimpactedbythefamilyin
both positive and negative ways [3].
Most of participants reported the experience of transition
from drug abuse to problem drug abuse, that is, from lighter
drugs such as cigarette, waterpipe, and alcohol to heavier

Journal of Addiction 5
drugs. Unlike the general consensus on the role of family and
peer pressure, there was not an agreement on the gateway
eect [4,6] and some even recognised it as a cultural myth
[7].
In our study, waterpipe has been mentioned as an
important gateway drug which could be due to high rates
of waterpipe use in Iranian young population [29] while
in the western countries there is more focus on cannabis
abuse due to its higher prevalence [4]. In terms of the
importance of gateway drugs, Markwood has stated in his
comprehensive theory of drug abuse prevention as a result
of a holistic evaluation of all drug abuse risk factors, “in
essence, the only way to achieve true primary prevention of
abuse of postgateway drugs is to succeed at preventing or
stopping use of gateway drug” [30]. According to growing
popularity of waterpipe smoking among Iranian population
more attention should be devoted to this epidemic by health
policymakers.
Individual characteristics were also mentioned by the
participants as one of drug abuse risk factors. In various
etiological studies on addiction especially studies with an
individualistic approach, there has been an emphasis on the
role of personality, age of starting drug abuse [2,6], and
hereditary and genetic factors [26]. However, some believe
that genetics is more involved with drug abuse rather than
recreational drug abuse [31]. Culture-based research to give
a clearer picture of personality traits of drug abusers is
warranted.
Roles of the community and macroenvironment have
also been noted in the interviews as risk factors of drug
abuse. Poverty, neighbourhood, living in poor and polluted
suburbs, and low level of leisure facilities have been identied
as impacting factors.
In conict theory of abuse, the role of social class, income,
andlocalehavebeenrevealedindrugabuseespeciallyheavy
drugssuchasheroinandcocaineasitismentionedin
“just say poverty: what causes Crack and Heroin Abuse” [4].
However, some experts regard the neighbourhood eects as
minimal [32].
Overall, considering the factors extracted from the stories
of participants, we are able to report that identied risk fac-
torsaremoreinlinewiththeprinciplesmentionedinthe
social development theory [33] which states that youth would
attach to drug-using peers if they did not have a strong
enoughbondingwiththeirparents.istheoryfocuseson
the concept of protective factors and risk factors, and it
recognises a role for all levels of individual, family, peers,
community, and the neighbourhood.
Amongst all the risk factors for drug abuse, this study
has highlighted some based on the participants’ story of
their addiction. e impacts of family, peer pressure, and
gateway drug abuse were identied as the most important of
all factors.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
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