1. Background
Today, despite considerable advances in the treatment of addictive behaviors, opioid use remains a global concern, jeopardizing people’s physical and mental health (1, 2). Among all the studied factors, emotional wellbeing has attracted a great deal of attention in the etiology of opioid use in the recent years. According to previous studies, people with poor emotional wellbeing are more vulnerable to different types of addiction disorders, compared to their normal counterparts (3).
Craving or compulsory mental desire for drug use plays a crucial rule in the etiology and treatment of addictive behaviors. Apparently, craving has a close relationship with factors, which emotionally increase the risk of opioid use, such as stress, impulsiveness, attentional bias, and emotional dysregulation. Therefore, for a treatment to be effective in reducing opioid craving, it should consider the underlying factors. Meanwhile, self-control training, as a combination of cognitive therapy and assertive training (4), can teach people how to manage their emotions, predict their behaviors, and reward themselves to cope with craving (4).
2. Objectives
Despite some attempts, a few studies, especially in Iran, have examined the effect of this treatment on opioid use disorder. Therefore this study was performed to fill this research gap and to investigate the effects of self-control training on emotional wellbeing and opioid craving among men with opioid use disorder.
3. Materials and Methods
3.1. Study Design
In this study, a quasi-experimental design was applied.
3.2. Population and Sampling
The study population consisted of all male patients with opioid use disorder, admitted to drug treatment centers of district 6, Tehran, Iran. First, three centers were randomly selected from seven centers in the district. Among patients admitted to these centers (n, 104), 50 were selected, matched, and randomly assigned to experimental and control groups (25 subjects per group). For ethical considerations, informed consents were obtained from all the subjects. As participation in the study was completely voluntary, 16 subjects were absent for more than one session (based on the exclusion criteria) and were excluded from the study. The remaining 34 subjects (17 subjects per group) constituted the final sample.
Inclusion and exclusion criteria
The most important inclusion criteria were as follows: (1) male gender, (2) age range of 20 to 50 years old, (3) history of opioid use (at least two years) (4) withdrawal attempts (at least one attempt), (5) type of drug (opium, heroin, and crack), and (6) literacy (primary education at least). On the other hand, participants with any other physical or psychiatric disorders, as well as those, who were absent for more than one session, were excluded from the study.
3.3. Study Process
In the first step of the intervention, both groups were exposed to pretests. The experimental group participated in 10 weekly sessions of self-control training (45 minutes per session), while the control group remained on the waiting list for treatment. A week following the intervention, both groups were tested using the same instruments. In order to perform self-control training, a combination of lectures and role-play, as instructed by Leahy et al., was adopted (8).
The training included: (1) organizing the training groups and planning the sessions (first session), (2) prioritizing the treatment goals (second session), (3) teaching self-evaluation skills (third session), (4) teaching self-monitoring skills (fourth session), (5) teaching self-reinforcement methods (fifth session), (6) teaching self-guided training (sixth session), (7) teaching self-modeling (seventh session), (8) identifying the craving stimulants (eighth session), (9) teaching problem-solving skills (ninth session), and (10) reviewing and reappraising the treatment plans (tenth session).
3.4. Data Collection Tools
3.4.1. Diagnostic Interview
A diagnostic interview, based on the latest version of the diagnostic and statistical manual of mental disorders (DSM-5), was conducted in order to create a primary therapeutic alliance, identify the subjects, and ensure their addiction, poor emotional wellbeing, and high opioid craving. This interview was used to match the subjects and assign them to control and experimental groups.
3.4.2. Cognitive Emotion Regulation Questionnaire
The cognitive emotion regulation questionnaire (CERQ) was constructed by Garnefski and Kraaij in 2006 to measure positive and negative emotion regulation styles. This questionnaire includes 18 items, scored on a five-point Likert scale. The Cronbach’s alpha coefficient for reliability ranges from 0.78 to 0.83 (0.84 for all the scale) in this questionnaire (9). In the Iranian version, Cronbach’s alpha coefficients ranged between 0.68 and 0.86, while reliability and validity coefficients were estimated at 0.73 and 0.88, respectively (10).
3.4.3. Facial Expression Recognition Test
Facial expression recognition test (FERT), which was first developed by Ekman and Friesen (1987), contains 36 pictures and measures six major emotions. By looking at each picture, the respondent should recognize the conveyed emotion (11). The test-retest reliability coefficients (one-week interval) were measured at 0.85 and 0.71 in a study conducted in Iran (11). The content validity of this instrument was also reported to be satisfactory.
3.4.4. Emotional Processing Scale
Emotional Processing Scale is a 25-item self-report scale, first developed by Bakeret et al. to measure emotional processing styles (5). This instrument is scored on a five-point Likert scale and consists of four subscales, with higher scores signifying superiority in emotion processing (6). This scale has shown high internal consistency (0.88 to 0.92) and good test-retest reliability (12). In a study performed in Iran, Cronbach’s alpha coefficient for internal consistency was calculated as 0.92. In order to assess the validity, the instrument was correlated with emotional processing scale (EPS), and a significant negative correlation was observed between the instruments (r, 0.54; P < 0.05) (5).
3.4.5. Toronto Alexithymia Scale
Toronto alexithymia scale is composed of 20 items assessing alexithymia. This scale is scored on a five-point Likert scale (one to five) and has acceptable reliability and validity. In a study performed in Iran, Cronbach’s alpha coefficient for internal consistency was 0.85, and concurrent validity for the scale correlation with emotional quotient, emotional wellbeing, and psychological helplessness questionnaires was -0.80, -0.78, and 0.44, respectively (13); all these values were significant at 0.05.
3.4.6. Craving Beliefs Questionnaire
This 20-item instrument (scored on a seven-point scale), which was first designed by Beck et al. (1993), is a self-report questionnaire for the measurement of opioid craving. Discriminative validity was confirmed by comparing the findings of a craving beliefs questionnaire (CBQ) survey on alcohol addicts, social drinkers, and non-drinkers (14). In order to evaluate reliability, internal consistency of the questionnaire was determined (0.75). In a study performed in Iran, the content validity and reliability of the questionnaire (Cronbach’s alpha coefficient and test-retest methods) were reported to be satisfactory (0.84 and 0.81, respectively) (15).
3.5. Data Analysis
The obtained data were analyzed in SPSS version 18, using multiple analysis of variance (MANOVA) test.
4. Results
Based on the demographic information, the mean age of the participants was 33.25 ± 7.12 years in the control group and 35.20 ± 5.59 years in the experimental group. In total, 35.29%, 47.05%, and 17.64% of the subjects were taking crack, opium, and heroin in the control group, respectively, while the corresponding values in the experimental group were 47.05%, 29.14%, and 35.29%, respectively. Other descriptive data of the groups (including mean and standard division) are presented in Table 1.
Table 1.The Descriptive Data of the Study Groupsa
| Variables | Control Group | Experimental Group | ||
|---|---|---|---|---|
| Pretest | Posttest | Pretest | Posttest | |
| Negative emotion regulation | 31.56 ± 4.46 | 30.92 ± 4.48 | 29.27 ± 4.04 | 27.92 ± 3.93 |
| Positive emotion regulation | 18.59 ± 6.35 | 20.41 6.6± 6.6 | 23.73 ± 5.28 | 34.21 ± 4.56 |
| Emotion recognition | 27.58 ± 2.4 | 28.82 2.92± 2.92 | 27.09 ± 3.01 | 29.72 ± 1.87 |
| Emotion processing | 76.58 ± 13.28 | 78.88 ± 10.27 | 73.64 ± 14.45 | 80.64 ± 13.52 |
| Alexithymia | 65.53 ± 11.9 | 64.01 ± 12.98 | 64.13 ± 15.57 | 59.21 ± 14.05 |
| Craving | 83.82 ± 29.92 | 81.94 ± 34.45 | 83 ± 20.31 | 76.88 ± 32.12 |
aValues are expressed as mean ± SD.
Considering the normal distribution of data based on Kolmogorov-Smirnov test (P > 0.05), MANOVA test was applied to draw comparisons between the mean scores of the groups. Prior to that, Levene’s test was used to assess the homogeneity of variances. P value was not significant for any of the variables (Table 2).
Table 2.The Results of Levene’s Test
| Variables | F | Df1 | Df2 | P Value |
|---|---|---|---|---|
| Negative emotion regulation | 1.61 | 1 | 31 | 0.21 |
| Positive emotion regulation | 0.50 | 1 | 31 | 0.49 |
| Emotion recognition | 0.03 | 1 | 31 | 0.87 |
| Emotion processing | 0.04 | 1 | 31 | 0.84 |
| Alexithymia | 0.47 | 1 | 31 | 0.51 |
| Craving | 0.11 | 1 | 31 | 0.74 |
The results of Wilks’ Lambda test (Table 3) indicated that the difference between the control and experimental groups was significant for at least one variable (Wilk’s Lambda, 0.22; F, 15.67; P < 0.0001). As it can be inferred from partial eta squared, the interaction of dependent variables accounted for 78.3% of variance in the difference between the groups.
Table 3.The Results of Wilks’ Lambda Test
| Test | P Value | F | P Value | Partial Eta Squared |
|---|---|---|---|---|
| Wilks’ Lambda | 0.22 | 15.67 | 0.0001 | 0.783 |
As presented in Table 4, the results of MANOVA test were indicative of a significant difference between the mean scores of the groups for all the studied variables, including negative emotion regulation (F, 5.950; P = 0.002), positive emotion regulation (F, 1.474; P < 0.001), emotion recognition (F, 10.725; P = 0.002), emotion processing (F, 1.425; P < 0.001), alexithymia (F, 0.129; P < 0.001), and craving (F, 0.833; P < 0.001). Therefore, self-control training significantly augmented positive emotion regulation, emotion recognition, and emotion processing in the experimental group and substantially decreased their negative emotion regulation, alexithymia, and craving.
Table 4.The Results of Multiple Analysis of Variance Test
| Source of Variation/Dependent Variable | SS | DF | MS | F | P Value |
|---|---|---|---|---|---|
| Model | |||||
| Negative emotion regulation | 68.228 | 1 | 68.228 | 0.393 | 0.001 |
| Positive emotion regulation | 70.945 | 1 | 70.945 | 1.252 | 0.001 |
| Emotion recognition | 213.706 | 1 | 213.706 | 71.87 | 0.004 |
| Emotion processing | 831.531 | 1 | 831.531 | 35.87 | 0.004 |
| Alexithymia | 240.742 | 1 | 240.742 | 0.349 | 0.005 |
| Craving | 1367.872 | 1 | 1367.872 | 0.348 | 0.001 |
| Group | |||||
| Negative emotion regulation | 185.107 | 1 | 185.107 | 5.950 | 0.002 |
| Positive emotion regulation | 83.551 | 1 | 83.551 | 1.474 | 0.001 |
| Emotion recognition | 31.888 | 1 | 31.888 | 10.725 | 0.002 |
| Emotion processing | 98.440 | 1 | 98.440 | 1.425 | 0.001 |
| Alexithymia | 0.984 | 1 | 0.984 | 0.129 | 0.001 |
| Craving | 68.478 | 1 | 68.478 | 0.833 | 0.001 |
| Error | |||||
| Negative emotion regulation | 964.408 | 31 | 31.109 | ||
| Positive emotion regulation | 1756.691 | 31 | 56.667 | ||
| Emotion recognition | 92.173 | 31 | 2.973 | ||
| Emotion processing | 7186.529 | 31 | 231.824 | ||
| Alexithymia | 3405.985 | 31 | 109.870 | ||
| Craving | 6703.765 | 31 | 216.250 |
5. Discussion
The aim of the present study was to investigate the effects of self-control training on emotional wellbeing and opioid craving among people with opioid use disorder. One important finding of the present study was that self-control training could increase positive emotion regulation and decrease negative emotion regulation. These findings are in accordance with some previous studies (5, 6, 16, 17), which have shown that low levels of positive emotion regulation in people with opioid use disorder can be attributed to their inability to manage their emotions and effectively face their negative emotions, especially in the early stages of drug addiction (17).
Considering the fact that addicts cannot predict the possible consequences of drug addiction, particularly due to their impulsivity and irritability, improvement of emotion regulation skills through self-control training plays an essential role in the prevention of relapse; in fact, self-control training can reduce feelings of anger, impulsivity, craving, and cognitive bias (6).
The present study showed that self-control training could improve emotion recognition skills. This finding is in line with the results of a study by Marich (18). According to various studies, opioid addicts not only have less competence to identify (19, 20) or decode other people’s emotions (21), yet they also have problems communicating their emotions (19). These problems undermine their self-esteem to an extent that they cannot establish a healthy relationship with others (21). Self-control training, by providing a pleasant atmosphere for treatment, helps patients become more cognizant of their emotions and other people’s feelings. Moreover, it teaches them how to express their emotions and interact with others in order to establish a close interpersonal relationship without any negative thoughts or fear of rejection by others.
Moreover, the results of the present study showed that self-control training decreased alexithymia while increasing emotional processing, which is consistent with some previous studies (6, 7, 22). The positive effect of self-control training on emotion arises from at least three factors: First, self-control training provides some standards for a person with opioid use disorder; second, it helps the person pay attention to his/her behaviors; and third, it boosts one’s strength and ability to make the desired changes (7).
Finally, in line with some previous studies (7, 18), the present results showed that self-control training decreased craving for opioid use. The subjects’ increased awareness of tempting situations and their knowledge of how to respond to these situations are probably the most effective factors in reaching this conclusion (6). Techniques, such as the use of relaxation techniques at times of anxiety, knowledge of self-reinforcement methods, and diverting attention from opioid use, are also of paramount importance in decreasing craving.
Based on the mentioned findings, opioid use disorder is a health concern in Iran, as the most populous Persian Gulf country. Therefore, it is suggested to provide cognitive behavioral therapy to reduce this problem. Some studies have confirmed the effectiveness of cognitive behavioral therapy in reducing drug use problems (23-25); similar studies are suggested among opioid users of Iran.
5.1. Conclusions
Self-control training by combining different cognitive techniques and improving assertiveness in a relaxed atmosphere plays a pivotal role in increasing emotional wellbeing and decreasing craving for opioid use.
5.2. Limitations
Considering the time limitations of this study, no follow-up was performed. In addition, the study was confined to male participants and those solely living in Tehran, therefore, interpretation of the results may be limited. Further investigation of both males and females, along with a follow-up, is suggested in future studies.
