Exploring motivational factors for opioid treatment engagement among substance users in Kashmir: A qualitative study

Abstract

Background:

Substance use disorder is a significant public health challenge globally, especially in conflict-affected regions like Kashmir, where opioid dependence poses a severe health and social burden. Opioid substitution therapy (OST) with buprenorphine is increasingly used to address opioid addiction in Kashmir.

Aim:

To explore the reasons and motives of opioid users seeking buprenorphine treatment in a tertiary care center in Kashmir.

Materials and Methods:

This qualitative study was conducted at the Drug Deaddiction Center; 31 male opioid users were purposively sampled and interviewed. Inclusion criteria included individuals over 18 years with diagnosed opioid use disorder. Data were collected via in-depth interviews in Urdu or Kashmiri and analyzed using Braun and Clarke’s six-step thematic analysis.

Results:

Six primary themes and many subthemes emerged from the data analysis, namely, (1) Family Responsibility and Social Pressure, with subthemes highlighting concerns over family reputation and children’s wellbeing; (2) Regret Over Financial Consequences, particularly income loss due to addiction; (3) Emotional and Relational Impact, including familial disconnection and marital discord; (4) Desire for Self-Respect and Social Acceptance; (5) Personal Growth and Redemption, with a focus on aspirations for a drug-free future; and (6) External Influence, noting family encouragement for seeking treatment.

Conclusion:

Findings reveal that treatment motivations for opioid users are largely rooted in family and social considerations, financial impacts, and a desire for personal growth. These insights highlight the importance of family-centered support and socioeconomic interventions in enhancing the effectiveness of OST programs for opioid dependence in conflict regions like Kashmir.

Substance use disorder (SUD) is a common public health problem throughout the world, which accelerates psychiatric and medical morbidity and mortality. Approximately, 585,000 deaths have been estimated globally due to substances, with half of deaths attributed to hepatitis C.[1] In developing countries like India, it is becoming a prime concern, where illicit drugs like opioids are emerging as a new challenge for healthcare professionals.[2] In India, approximately 2.1% of the population reported using opioids with heroin use being the highest at 1.14%, followed by opium at 0.52% and other synthetic opioids at 0.96%.[3] One such territory of keen interest is Jammu and Kashmir, which has been an area of conflict for decades, predisposing the individuals residing here to engage in multiple substance use with multiple studies showing a higher prevalence of SUDs in conflict-ridden areas of Kashmir. It was noted that 87.33% of subjects were dependent on opioids, which was the most among other illicit substances.[4] Opioid use disorder imposes a significant healthcare burden and is often linked to unethical behaviors and criminality.[5,6,7] In the conflict-affected Kashmir valley, geopolitical instability and socioeconomic challenges have fueled substance use. Tertiary care centers in the region now offer opioid substitution therapy (OST), with buprenorphine as a primary treatment, showing promising results in improving patients’ physical, social, and occupational wellbeing.[8] However, understanding the motivations behind patients seeking buprenorphine remains crucial to enhancing treatment interventions in Kashmir. Understanding the motivations behind substance users seeking treatment is essential for improving patient prognosis, developing effective strategies for engagement and retention in addiction programs, and evaluating the effectiveness of existing policies. This study aimed to explore the reasons and motives of opioid users seeking buprenorphine treatment at a tertiary care center in Kashmir.

MATERIALS AND METHODS

This qualitative study was conducted among substance users and injecting drug users (IDUs) visiting the Drug deaddiction Center (DDC), Institute of Mental Health and Neurosciences Kashmir, in the month of August 2024. This study was accorded approval from the Institutional Review Board of Government Medical College, Srinagar, India. The study adopted a purposive sampling method to select participants who could provide in-depth insights into their experiences with substance use. The inclusion criteria of this study comprised (i) participants aged ≥18 years old, (ii) those who met criteria for opioid use disorder (as per The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition – DSM-5[9]), and (iii) those who provided written informed consent. Participants who refused to provide informed consent were excluded from the study.

In-depth interviews were conducted with 31 substance users, purposively selected participants who fulfilled inclusion criteria, in a private room inside DDC. The interviews were guided by a preformed interview guide to ensure consistency while allowing for flexibility in responses. All interviews were conducted in Urdu, with participants given the liberty to express themselves in Urdu or Kashmiri, based on their comfort. Before each interview, participants were provided detailed information about the study, and their written informed consent was taken. Interviews were conducted by the researcher who had prior experience in qualitative studies. The interviews were audio-recorded to ensure accurate data capture, with the minimum interview duration being 15 minutes and the maximum duration being 30 minutes. The interview concluded once the patient had answered all preformed questions as set in the preformed interview guide. Data saturation was achieved with 31 interviews. After the interviews, the recordings were transcribed verbatim into English. This process of transcribing and rereading the manuscript was performed till concepts, and themes were transformed into a list. The transcriptions were then transferred into Microsoft Word documents for further analysis. All interviews were conducted by Rajnish Raj (RR) and Shaheena Parveen (SP) to avoid bias and to maintain reflexivity. Thematic analysis was conducted by two researchers—the primary researcher, (RR), and Khalid Bashir (KB), an experienced qualitative researcher with an extensive background in qualitative research analysis, who ensured rigor in the analysis. To maintain intercoder reliability, the coding and theme development were cross-verified between RR and KB to reach a consensus. Data analysis was conducted following the six-step thematic analysis framework proposed by Braun and Clarke.[10] This included familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and finally producing the report. The inductive qualitative thematic analysis method was adopted. The thematic analysis allowed for a rich and nuanced interpretation of the participants’ experiences with substance use. Categorical variables were summarized as percentages and continuous variables as mean and standard deviation (SD). The duration of substance use was summarized as the median and interquartile range (IQR).

RESULTS

A total of 31 participants were included, with all male subjects. The mean age of the population was 26.29 years, with the median duration of substance use being 5 years. In substance history, the majority were opioid users, followed by nicotine and cannabis, whereas all were intravenous users. The rest of the sociodemographic and clinical details of the subjects are presented in Table 1.

Table 1.

Sociodemographic and clinical details of the participants

Variable	N (%)
Age, Mean (SD)	26.29 (5.47)
Gender, Male, n (%)	31 (100)
Education
Primary, n (%)	4 (12.90)
Secondary, n (%)	18 (58.06)
Senior secondary, n (%)	5 (16.12)
Graduate, n (%)	4 (12.90)
Marital status
Married, n (%)	21 (67.74)
Unmarried, n (%)	10 (32.25)
Duration of substance use, years, Median (IQR)	5 (4 – 7)
Substance History
Alcohol, n (%)	1 (3.22)
Opioid, n (%)	31 (100)
Cannabis, n (%)	26 (83.87)
Nicotine, n (%)	30 (96.77)
Codeine, n (%)	1 (3.22)
Tramadol, n (%)	3 (9.67)
Tapentadol, n (%)	10 (32.25)
Benzodiazepine, n (%)	2 (6.45)
Dicyclomine10 mg+ Paracetamol325 mg+ Tramadol50 mg, n (%)	2 (6.45)
Pregabalin, n (%)	1 (3.22)
Route of administration
Intravenous, n (%)	31 (100)
Chasing, n (%)	29 (93.54)
Smoker, n (%)	30 (96.77)
Tablet, n (%)	18 (58.06)

On thematic analysis, six themes and twelve subthemes evolved, presented in Table 2.

Table 2.

Themes and Subthemes details

Themes	Sub-Themes
1. Family Responsibility and Social Pressure	1.1 Concern about family reputation
	1.2 Avoiding shame for parents and siblings
	1.3 Ensuring family financial security
	1.4 Pressure to quit for the sake of children’s wellbeing
2. Regret Over Financial Consequences of Addiction	2.1 Earning being consumed by addiction
	2.2 Inability to contribute to household expenses
3. Emotional and Relational Impact	3.1 Disconnection from family and loved ones
	3.2 Marital conflicts stemming from drug use
4. Desire for Self-Respect and Social Acceptance	4.1 Stigmatization by neighbors and community
	4.2 Desire to rebuild self-confidence
5. Personal Growth and Redemption	5.1 Desire to move forward in life
	5.2 Ambition to stay drug-free and secure better opportunities
6. External Influence and Realization	6.1 Encouragement by family members
	6.2 Learning about treatment options through family

Theme: 1. Family Responsibility and Social Pressure

This theme highlights the critical role of family expectations and societal pressure in driving participants to seek treatment. Many felt their addiction could harm their family’s reputation and social standing, which motivated them to pursue treatment.

Subtheme: 1.1, Concern about family reputation: Participants expressed anxiety about how their addiction might affect their family’s reputation, particularly in important life events like marriage. One participant said, “If my family found out about my drug habit, it would be a huge embarrassment. My sister’s marriage could suffer.”(Participant P01, age 24 years)

Another participant shared, “What will my family think if they discover I’m taking drugs? It will bring them shame.”(Participant P15, age 29 years)

Subtheme: 1.2, Avoiding shame for parents and siblings: Participants felt a sense of guilt about the potential embarrassment their addiction could bring to their parents and siblings.

“Even my parents will face shame because of this; what will society think?”(Participant P07, age 27 years)

Another remarked, “I don’t want my siblings to be embarrassed because of me.”(Participant P18, age 25 years)

Subtheme: 1.3, Ensuring family financial security: Many participants recognized that their addiction was affecting their ability to provide for their families, especially those who were the primary earners. One participant noted, “I am the only breadwinner, apart from my father who is a laborer and cannot support the family.”(Participant P11, age 29 years)

Another participant stated, “I need to provide for my family. They depend on me.”(Participant P21, age 26 years)

Subtheme: 1.4, Pressure to quit for the sake of children’s wellbeing: Some participants were motivated by concerns for their children’s future. “My children have asked me, ‘What are you smoking every day?’ It’s not cigarettes.” (Participant P03, age 32 years)

Another added, “I cannot let my children see me like this. I need to be a better father.” (Participant P19, age 28 years)

Theme: 2. Regret Over Financial Consequences of Addiction

Addiction placed a significant financial burden on participants, who regretted the money spent on drugs instead of contributing to household expenses. This financial strain became a motivating factor to seek treatment.

Subtheme: 2.1, Earning being consumed by addiction: Participants expressed regret that a large portion of their income was used to buy drugs.

“I earn 10 thousand rupees per month, and nearly 6 to 7 thousand goes on drugs.”(Participant P05, age 27 years)

Another said, “Most of what I earn is spent on drugs. There’s nothing left for anything else.”(Participant P14, age 31 years)

Subtheme: 2.2, Inability to contribute to household expenses: The financial consequences of addiction left participants unable to support their families. One participant mentioned, “I don’t have money to give to my family for household expenses.”(Participant P12, age 31 years)

Another echoed, “My family is struggling because of me. I can’t even help with the basics.”(Participant P22, age 28 years)

Theme: 3. Emotional and Relational Impact

Addiction severely strained relationships with family members and loved ones. Participants expressed a strong desire to repair these relationships, which motivated them to seek help.

Subtheme: 3.1, Disconnection from family and loved ones: Many participants felt emotionally distant from their families due to their addiction. One stated, “I’ve grown distant from my family, and I won’t do anything else to make them suffer.”(Participant P10, age 31 years)

Another reflected, “I miss being close to my family. My addiction has separated us.”(Participant P16, age 29 years)

Subtheme: 3.2, Marital conflicts stemming from drug use: Marital discord frequently arose as a result of addiction. Participants sought treatment as a way to restore their relationships. One explained, “My wife gets upset, and there are frequent fights. She said I should leave home.”(Participant P09, age 30 years)

Another said, “My relationship with my wife is strained. I don’t want to lose her because of this.”(Participant P27, age 31 years)

Theme: 4. Desire for Self-Respect and Social Acceptance

Participants sought treatment in part to regain their self-respect and acceptance within their communities as addiction had led to feelings of shame and low self-esteem.

Subtheme: 4.1, Stigmatization by neighbors and community: Many participants experienced social isolation due to the stigma surrounding drug use. One shared, “People at home and in the neighborhood look at me like I’m committing a crime.” (Participant P03, age 32 years)

Another said, “People talk about me behind my back, and it hurts. I just want them to treat me normally again.”(Participant P10, age 31 years)

Subtheme: 4.2, Desire to rebuild self-confidence: The participants’ addiction had eroded their self-esteem. One mentioned, “I want to regain my self-confidence, which will help improve my sense of self-worth.”(Participant P09, age 30 years)

Another participant said, “I don’t feel like myself anymore. I need to regain control over my life and my self-esteem.”(Participant P15, age 29 years).

Theme: 5. Personal Growth and Redemption

Participants expressed a desire for personal growth and redemption, recognizing that addiction had hindered their progress in life. Treatment was seen as a means to regain control and pursue a more fulfilling future.

Subtheme: 5.1, Desire to move forward in life: Participants viewed treatment as an opportunity to leave their addiction behind and rebuild their lives. One explained, “I want to focus on my career now. I’ve had to quit jobs because of my addiction.”(Participant P07, age 27 years).

Another said, “I’ve wasted enough time. It’s time to start moving forward in life.”(Participant P12, age 31 years)

Subtheme: 5.2, Ambition to stay drug-free and secure better opportunities: Participants believed that staying drug-free would open new opportunities. One shared, “By leaving that bad company behind, I’ll regain control over my choices.”(Participant P04, age 28 years)

Another added, “Quitting drugs will help me find new job opportunities and rebuild my life.”(Participant P11, age 29 years)

Theme: 6. External Influence and Realization

Family members played a crucial role in encouraging participants to seek treatment. Participants often cited family support as a major factor in their decision to get help.

Subtheme: 6.1, Encouragement by family members: Family support, especially from spouses and close relatives, motivated participants to pursue treatment. One participant mentioned, “My wife has been convincing me to quit drugs for a long time.”(Participant P13, age 33 years)

Another said, “My family told me I need to quit for my good, and they support me.”(Participant P06, age 28 years).

Subtheme: 6.2, Learning about treatment options through family: Some participants were unaware of available treatment options until family members researched and introduced them to buprenorphine.

One explained, “I didn’t know there was a way out of this addiction until my brother found out about treatment.”(Participant P05, age 27 years).

Another said, “My cousin told me about buprenorphine treatment and how it could help me quit drugs.”(Participant P14, age 31 years).

DISCUSSION

This study highlights the unique treatment-seeking behaviors of opioid users in conflict-affected Kashmir, shaped by sociocultural dynamics and traditional values. Unlike quantitative studies, this qualitative exploration reveals motivations rooted in lived experiences, such as family responsibilities, financial pressures, and aspirations for self-improvement. Key drivers include the desire to uphold family honor, alleviate economic burdens, and mend strained relationships, reflecting Kashmiri culture’s collectivist ethos. Financial challenges, emotional distress, and addiction-related stigma further motivate individuals to seek recovery as a pathway to rebuild trust, restore self-respect, and reconnect with loved ones. These findings highlight the need for culturally tailored interventions addressing stigma, family influence, and personal recovery aspirations. Participants exhibited a deep commitment to family and societal expectations. In the collectivist society of Kashmir, family reputation plays a pivotal role, and addiction often brings a sense of shame, motivating individuals to seek treatment to restore their family’s social standing and honor. Our findings align with earlier studies that highlight the effectiveness of family-based interventions, especially in culturally sensitive environments where family members are incorporated into the therapeutic process. A study by Esteban et al.[11] demonstrated that family-involved treatments significantly enhance treatment retention and recovery rates in similar sociocultural contexts. Based on these findings, deaddiction interventions in Kashmir could benefit from integrating family-centered strategies, such as counseling sessions that involve family members, to boost treatment engagement and retention.

A substantial theme in our study was the financial strain faced by participants, many of whom were the primary earners for their families. The economic impact of opioid addiction led many to seek treatment to regain their roles as providers. In line with our findings, previous literature illustrates that financial empowerment programs, such as job placement and vocational training, not only facilitate economic reintegration but also strengthen self-efficacy, which has been linked to reduced rates of dependency relapse.[12] Thus, incorporating economic reintegration programs within deaddiction services in Kashmir could be especially impactful, given the compounded effects of unemployment and economic instability due to ongoing regional conflict. Another important motivator for treatment was the emotional strain addiction placed on family relationships, particularly with spouses. Participants highlighted that strained relationships amplified psychological distress, motivating them to pursue treatment. Studies have consistently shown that chronic opioid use can lead to isolation, exacerbating psychological conditions such as depression and anxiety. Research by Ahluwalia et al.[13] supports the notion that therapeutic interventions that focus on familial and spousal relationships are effective in reducing these psychological impacts as they help to rebuild social support systems. Implementing couple-based interventions in Kashmir may be valuable in addressing relational conflicts, thereby enhancing family stability and reinforcing the recovery process. Social stigma emerged in our study as both a motivator and barrier for treatment-seeking. In Kashmir, addiction is seen not only as a violation of law but also as a moral transgression, leading to significant social isolation. Participants noted that social stigma and self-stigmatization lowered their self-worth and contributed to increased psychological distress, creating a complex barrier to recovery. Our findings align with Smith and Peyson,[14] which highlights the importance of stigma-reduction strategies, including community education and peer support, in reshaping societal attitudes and normalizing treatment-seeking behavior. Implementing community support networks and education programs could mitigate stigma’s negative impact, facilitating reintegration and supporting sustained recovery. A central theme among participants was their intrinsic motivation for a better life, encompassing personal growth and self-respect. This desire aligns with self-determination theories, which suggest that intrinsic motivation, rather than external pressure, is a strong driver of behavior change.[15] Participants aimed for stability, employment, and positive family roles, which they believed treatment could help them achieve. Interventions that encourage personal development, such as cognitive-behavioral therapy (CBT) and vocational training, could reinforce these internal motivations, giving participants tools for lasting recovery. These approaches have been substantiated by a study indicating that self-improvement-focused therapies lead to higher recovery rates and lower relapse incidences.[16] Family involvement plays a pivotal role in treatment engagement, with participants often relying on family for encouragement and logistical support. Many were introduced to deaddiction resources by family members, aligning with prior studies,[17,18,19] confirming the impact of family support on long-term recovery. Our findings suggest that deaddiction centers in Kashmir should implement structured family education programs to enhance support for patients.

Our study comes with these limitations. The study’s findings are based on a single drug deaddiction center in Kashmir, limiting their generalizability to other regions or populations with different sociocultural contexts. The cross-sectional design captures participants’ experiences at a specific time, missing potential changes over time that longitudinal studies could reveal.

This study offers valuable insights into the treatment-seeking behaviors of opioid users in Kashmir, a conflict-affected region. In-depth interviews facilitated nuanced perspectives, while the use of local languages (Urdu and Kashmiri) encouraged open expression. Thematic analysis ensured rigorous interpretation, and data saturation with 31 participants bolstered credibility. The focus on cultural, familial, and socioeconomic factors provides a basis for context-specific interventions in addiction care.

CONCLUSION

The study highlights the need for a culturally adaptive framework prioritizing family-centered care, economic reintegration, and stigma reduction. Tailored treatment protocols and policies, including financial aid and community-based interventions, can improve adherence and recovery outcomes. By addressing Kashmir-specific cultural and socioeconomic challenges, this study provides valuable insights into context-specific drivers of treatment-seeking, offering a foundation for culturally sensitive addiction care interventions.

Abbreviations

SUD: Substance use disorder

OST: Opioid substitution therapy

DDC: Deaddiction center

IMHANS-K: Institute of Mental Health and Neurosciences – Kashmir

SMHS: Sri Maharaja Hari Singh

CBT: Cognitive Behavioral Therapy

Authors’ contributions

R.R. conceptualised the study and H.K. and R.R. prepared the manuscript. S.P. and R.R. performed data collection. K.B. performed data analysis. A.K., Z.A.W., S.M.W. and Y.H.R. performed manuscript correction. All authors reviewed the manuscript.

Data availability statement

Data will be made available on reasonable request

Ethics approval and consent to participate

The Institutional Review Board of Government Medical College, Srinagar (IRBGMC-SGR/Psy/620; dated 27/07/2024), approved the study protocol, ensuring adherence to ethical guidelines. Informed consent was taken from all participants.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.