Addiction and substance dependence are among the most significant social issues of modern times, with global prevalence and consequences including psychological, physical, familial, cultural, economic, and social disorders. In its literal sense, addiction means inclining towards something (Dehkhoda). However, nowadays, due to the inadequacy of the term “addiction” and also substance dependence, the term “substance abuse” is used. The concept of this term is that a person becomes dependent on a substance both physically and psychologically due to its misuse, so that they feel calmness and pleasure with drug use and experience restlessness and discomfort when the drug is unavailable. According to this definition, any drug can be considered addictive. Therefore, the World Health Organization recognizes anyone suffering from any type of drug or psychological dependence on drugs as addicted, with the main components of this dependence being a strong need for use, a desire to continually increase consumption, and physical and psychological dependence on the drug (Faridkian, 2010).

The World Health Organizations annual report in 2005 indicates that there are approximately 200 million opioid addicts worldwide, and the number of substance users increases every day. According to the announcement of the head of the Research Center of the Anti-Drug Headquarters in 2012, 1,325,000 Iranians are involved in drug use (Sadeghi et al., 2013).

As the capital of Iran, Tehran has witnessed various urban, social, and economic transformations in recent decades and has borne a larger share of social problems such as addiction compared to other cities. Although unofficial estimates suggest a higher population of drug users, what is unanimously agreed upon is the decreasing age of addiction onset and the presence of risky addiction-related behaviors due to unawareness and limited access to basic health conditions, leading to both individual and societal harm. The first institution affected by the harms of addiction and substance abuse is the family. Family factors have been identified as influential in both susceptibility to addiction and in quitting addiction in many studies. Domestic violence, child abuse, divorce, etc., are considered social consequences of addiction that initially affect the family and then society as a whole. On the other hand, after addiction sets in, one of the most important components of support for quitting addiction is the family. Given that the current research examines the role of social support in the recovery of addicted individuals, it investigates to what extent family support guarantees the improvement of addicts. For this purpose, two groups of substance users were studied: the first group living with their families, and the second group consisting of homeless individuals and social outcasts. They were assessed based on general health indices, hope scale, and loneliness scale to measure the impact of social support on their improvement.

Statement of the Problem

Various methods are employed for treating addiction. The aim of addiction treatment is for individuals to be able to cease substance use and achieve a substance-free lifestyle while functioning effectively in their families, workplaces, and society. Addiction is treatable, but its treatment is not simple and requires simultaneous attention to personal, social, and biological aspects (Noroozi et al., 2011). The role of the family in accompanying the addicted individual throughout the treatment process is crucial for providing psychological and social support and preventing relapse. In our country, addiction treatment is approached in several ways. Narcotics Anonymous (NA) associations and NGOs, which advocate abstinence and are based on certain principles, rehabilitation camps that keep addicts collectively in a specific location for a certain period of time (residential treatment), the Sixty Congress, methadone maintenance treatment (MMT) centers, and Harm Reduction Centers (also known as Drop-in Centers [DIC]) providing services such as MMT and health and nutrition services to homeless addicts are among these methods.

Among these methods, methadone maintenance treatment (MMT) is one of the important measures taken towards reducing harm, especially in reducing the risks associated with injections. This method provides the opportunity to prevent illegal drug use for patients and reduces the use of risky addiction methods such as injection, unlike detoxification methods, which aim to quit addiction, its goal is to reduce the harms of substance use and improve the quality of life (Moradi et al., 2015). Various studies have shown that methadone reduces drug use, especially heroin (Arefnasab et al., 2007). MMT services in our country are provided in two forms. In the first form, there are addiction treatment centers where individuals are placed under methadone maintenance treatment by registering their personal information and substance use status. This group usually attends these centers with their families or with the encouragement of their families. The second form consists of Harm Reduction Centers (DIC), which are located in areas of cities with high social harm related to addiction and receive substance users daily who have been expelled from their families, and are colloquially referred to as homeless. Addiction in the second category is accompanied by other harms such as committing street crimes, using shared needles and equipment, AIDS, hepatitis, etc., all of which are consequences of family expulsion and lack of social support in the latter group. Active participation of the patient and the patients family in the treatment process leads to an increased sense of belonging and responsibility, changes in individual behavior, and improvement in the quality of health services, which in turn leads to greater hope for the patients recovery (Fathi & Mousavifar, 2016).

Therefore, in the present research, the impact of social support on two groups of substance users, one group living with their families while being an addict, and the other group expelled from their families and are homeless, was investigated. Both groups are under methadone maintenance treatment and have their own centers to attend, and family support is a variable that distinguishes these two groups. In this study, three questionnaires of general health, hope scale, and loneliness scale were used to measure the extent of the impact of social support on these three variables. The first group consists of addicts who have visited MMT centers in central Tehran for addiction treatment along with their families, and the second group consists of homeless addicts who visit the DIC center in Shoush Square on a daily basis to receive methadone and health services.

Research Question and Hypotheses

Question: To what extent does the presence or absence of social support affect the recovery of addicts under family support versus addicts who are expelled from their families and are homeless?

Hypothesis 1: There is a difference in hope between the two groups, those under family support and the homeless.

Hypothesis 2: There is a difference in loneliness between the two groups, those under family support and the homeless.

Hypothesis 3: There is a difference in general health between the two groups, those under family support and the homeless.

Research Background

Studies in the field of social support and addiction have primarily focused on the role of family in the development or exacerbation of addiction, with less emphasis on investigating the impact of social support on the recovery process of substance users.

Fathi and Mousavifar, in a qualitative study titled “Investigating Addicts Experiences Regarding Social and Family Support as Facilitating Factors in Quitting Addiction,” concluded that individuals addicted to substances require material, emotional, and social support from family members and society. They emphasized the need for changing the attitudes of families and society towards addiction so that instead of exacerbating dependence, they guide individuals towards improvement and returning to the family fold during their addiction period (2016).

Amini, Afshar Moghadam, and Mahyar Azar highlighted the necessity of interpersonal relationship education and empathy towards addicts and their families, as well as lifestyle changes in addicts, in their study titled “Investigating the Social and Environmental Factors Associated with the Repeated Relapse of Addicts to Opioid Use”. Family factors were distinguished for single and married addicts. Key factors for the first group (single addicts) included inappropriate family confrontation, discrimination, and family overcrowding, while bad spouse-child relationships, a spouses lack of commitment to marriage, and sexual function disputes were among the most significant exacerbating factors for addiction in the second group (married addicts) (Amini et al., 2000). In a comprehensive analysis comparing individual and environmental factors affecting relapse into addiction after drug withdrawal in 2014 by Hajataghayi et al. environmental factors, primarily social factors, were found to be more influential than individual factors in relapse. Family conflicts, family pressure and neglect, social rejection, and lack of social support were identified as factors that significantly contribute to addiction exacerbation and relapse, with subsequent recommendations focusing on changing social attitudes with an emphasis on social support as a crucial measure towards improving the addicted individual (Hajataghayi et al., 2014). Additionally, in a study titled “The Effectiveness of Bowen Family Therapy on Differentiation and Family Functioning in Families with Addicted Children” conducted by Ghaffari and her colleagues, the results demonstrated the impact of receiving systemic family therapy on the improvement of the addicted family member. Although this study specifically compared regular systemic family therapies with Bowen Family Systems Therapy, the importance of family roles and social support remains noteworthy (Ghaffari et al., 2009).

In the ever-evolving field of child development and family support, several recent studies have made significant contributions. Among them is the work of Hadiloo and Heydari, (2023) which provides a comprehensive examination of the positive impact that empowering families of exceptional children has on improving the quality of life for these children and the broader society. Their study, published in the European Journal of Medical and Health Sciences, delves into the multifaceted challenges these families face and highlights the transformational effects of providing essential support services, including early interventions and specialized therapies (Hadiloo & Heydari, 2023).

Furthermore, Heydari and Hadiloo, (2023) have expanded on this foundation by exploring the specific realm of recovery and quality of nursing care for disabled children. Their detailed analysis outlines the manifold challenges within the healthcare system and proposes innovative solutions for managing care effectively. By offering a clear framework and management strategies, their research contributes to the ongoing conversation on enhancing care quality for disabled children in medical settings (Heydari & Hadiloo, 2023). In another vein, Hadiloo, (2023) shifts the focus toward the psychological development of children with disabilities. Her research emphasizes the profound influence that environment and family dynamics have on fostering psychological well-being. The study published in the European Journal of Medical and Health Sciences argues that a nurturing environment and strong family support can significantly enhance the developmental trajectories of children with disabilities, empowering them to reach their full potential (Hadiloo, 2023). Complementing these perspectives, Saki and Ahmadis, (2022) anthropological study published in Culture & Psychology provides a unique lens on mental suffering and cultural practices of healing. By examining the phenomenon of spirit possession among the Turkmens of Iran, their research sheds light on cultural-bound syndromes and the traditional methods of theurgic flight used for treatment. This study broadens the understanding of mental health and therapy by situating it within a specific cultural context, thus adding a valuable dimension to the discourse on mental health practices (Saki & Ahmadi, 2022).

Population, Sample, and Sampling Method:

The statistical population in the present study consists of two groups of individuals undergoing methadone maintenance treatment. The first group has referred to an MMT center and, in addition to receiving methadone, benefits from the support of their families. These individuals typically enter the treatment program with the encouragement of their families and live with their families during the treatment. MMT centers, from which the data were collected, are located in the central area of Tehran. The second group comprises of homeless addicts who have been expelled from their families and communities and live on the streets. The latter group initiates methadone treatment and receives health services by visiting a DIC in Shoush Square, Tehran. Given the limitations in studying the addicted population, purposive sampling was employed in this research. Purposive sampling provides information from specific individuals or groups, i.e., particular types of individuals who can provide the desired information or meet certain criteria established by the researcher. For this purpose, 80 participants, divided into two groups of 40, responded to the designated questionnaires. Additionally, for addicts who were unable to focus on completing the questionnaires, their responses to orally read questions were recorded on the questionnaires. The questionnaires used in this study include the General Health Questionnaire (GHQ), the Hope Scale, and the UCLA Loneliness Scale. The GHQ consists of a 28-item self-report questionnaire covering four subscales: somatic symptoms, anxiety and insomnia, social dysfunction, and depression. The Hope Scale, developed by Snyder, Harris, Anderson, Holleran, Irving, and Sigmon (1991), consists of 12 questions aimed at evaluating the level of hope in individuals. It is scored on a 4-point Likert scale. This questionnaire is designed for individuals aged 15 and above and includes 4 items for measuring agency thinking, 4 items for measuring pathway thinking, and 4 distractor items. The UCLA Loneliness Scale (Version 3), created by Russell, Peplau, and Ferguson in 1978 at the University of California, measures the degree of loneliness and provides a way to address measurement issues.

The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS), employing independent t-tests and multivariate analysis of variance (MANOVA).

Descriptive statistics showed that in terms of the loneliness variable, the family-supported group had a higher mean of 60.52 compared to the homeless individuals. Regarding the hope variable, the mean of 35.77 favored the family-supported group. 

Table 1: Descriptive statistics of addicted individuals under family support and homeless individuals in hope and loneliness scales.

As shown in Table 1, addicted individuals under family support have achieved better scores in the scales of loneliness and hope compared to homeless addicted individuals, and the damage in these areas is less in the group undergoing treatment with family support, leading to a better improvement trend subsequently. In terms of the general health variable, the group under family support had a higher average, which was equal to 70.4.

Table 2: Descriptive statistics of addicted individuals under family support and homeless individuals in the general health index and its four subscales (physical health, anxiety, and sleep disorders, social functioning, and depression). 

In other words, Table 2 indicates that addicts who receive support from their families have better overall health compared to homeless addicts. The scores suggest better physical health, fewer anxiety and sleep disorders, better social functioning, and less depression in the first group.

Research Hypothesis Testing

Hypothesis 1: There is a difference in hope scale between the two groups, those supported by their families and the homeless. Due to the non-normality of the hope variable data, the independent non-parametric Mann-Whitney U test was used to determine whether there is a difference between the two groups at a 95% confidence level (alpha = 0.05). 

Table 3: Mann-Whitney U Test for Hope Scale. 

The Mann-Whitney U test showed that there is a significant difference between the two groups of addicts, those under family support and homeless addicts, in terms of hopefulness at the 95% confidence level. The z-value was -3.29. The effect size was 0.041, which, according to Cohens criteria (1988), is small.

Hypothesis Two: There is a difference between the two groups, those under family support and homeless addicts, in terms of loneliness. For the above hypothesis, due to the normality of the loneliness variable data, an independent t-test was used to determine whether there is a difference between the means of the two groups at the 95% confidence level (alpha = 0.05). Variance homogeneity was examined with Levenes test, and no homogeneous variances were observed.

Table 4: Independent t-test of Loneliness. 

The difference between the means of the two groups in terms of the loneliness variable became significant at the 0.05 level. With 95% confidence, the difference between the means is between 12.39 and 20.75. The eta-squared value is 0.48, indicating that approximately 48% of the variance in the dependent variable is explained by the independent variable, which is considered a large effect.

Hypothesis Three: There is a difference between the two groups, those under family support and homeless addicts, in terms of general health. For the above hypothesis, due to the non-normality of the general health variable data, a non-parametric independent t-test, namely the Mann-Whitney U test, was used to determine whether there is a difference between the two groups at the 95% confidence level (alpha = 0.05) in terms of general health.

Table 5: Mann-Whitney Test of General Health. 

The Mann-Whitney test indicated a significant difference in general health between the two groups of addicts under family support and homeless addicts at the 95% confidence level. The value of z was -5.605. The effect size was 0.07, which, according to Cohens criteria (1988), is considered small.

The aim of this study was to investigate the effect of social support on the recovery of addicts. To compare the impact of social support in these individuals, two groups of addicts, one with social support and the other without, were assessed. Due to the limitations of sampling, questionnaires were distributed at different centers (DIC and MMT), where addicts under family support and homeless addicts seek maintenance therapy with methadone. To assess the improvement level of the two groups of addicts, three questionnaires on general health, hope scale, and loneliness scale were administered. The research hypotheses suggested that addicts under family support would experience less loneliness, have greater hope, and have better physical and mental well-being compared to addicts who have been ostracized from their families and society. The results supported the research hypotheses, indicating that addicts receiving family support who had opted for methadone replacement therapy experienced less loneliness and had better hope compared to their counterparts without family support. Additionally, they were physically healthier, experienced fewer anxiety and sleep disorders, had better social functioning, and suffered less from depression. Therefore, in describing the research objective, the issue of social support and its impact on substance users can be explained as follows: Addiction involves family issues and familial relationships, and one of the damages experienced by an addicted individual is the lack of social support. Every relationship we engage in is a social relationship, and in many social relationships, we seek social support. Therefore, whenever part of our social relationships encounters difficulties or disappears, we experience varying degrees of loneliness, abandonment, and loss of social support (Cohen, 2000).

The concept of social support is defined by the degree of kindness, assistance, and attention from family members and other individuals (Sedghpour et al., 2010). Social support is a mechanism of interpersonal relationships that protects individuals from the negative effects of stress and is defined by the degree of kindness, companionship, and attention from family members, friends, etc. (Decker, 2007). It is not far-fetched to say that with the risk of losing family network support and social relationships, the physical and mental health of the addicted individual, who is already exposed to the adverse effects of substance abuse, is further jeopardized. That is why successful treatments in the field of addiction attempt to address the multifaceted damages experienced by the addicted individual to minimize the risk of relapse into substance abuse. Methadone maintenance treatment is one of the most common methods prescribed for drug addicts in our country. However, methadone maintenance treatment alone cannot guarantee the improvement of the addicted individual, as the addicted individual, in addition to the physical suffering caused by substance dependency, experiences isolation, loneliness, and a lack of a suitable perspective for their future. Hence, in the present study, the physical and mental conditions of addicts living with their families and undergoing substance abuse treatment were significantly better than those of individuals completely estranged from their families and society. However, it is worth mentioning that raising awareness among society and those working in the addiction field about the multifaceted dimensions of addiction-related damages in our country is still in its early stages, and through multiple research studies, a better perspective for addiction treatment can be outlined. Educating families and teaching them how to deal with addiction issues and the addicted individual can strengthen social support and minimize intra-personal and inter-personal damages caused by substance abuse. Moreover, integrating social work components into various institutions providing services to homeless addicts can create a conducive environment for their return to families and reduce social problems.

F.S. conceptualization, methodology, investigation, writing-original draft. R.S. writing-review editing. A.M. visualization, data curation, formal analysis. All authors who are involved in this research read and approved the manuscript for publication.

We are grateful to all the dear professors for providing their information regarding this research.

The authors of this manuscript declare their agreement with the statements and have no conflict of interest.