INTRODUCTION

According to the 2023 World Drug Report published by the United Nations Office on Drugs and Crime (UNODC), it is estimated that approximately 296 million people worldwide used drugs in 2021, and 31.5 million of the 60.3 million opioid users among these people used heroin. Opioid Use Disorder (OUD), which develops due to chronic use of opioids, continues to be a severe public health problem, with hundreds of thousands of deaths attributed to opioids every year worldwide. Therefore, effective strategies are still needed to prevent the development of addiction by identifying individuals at high risk of developing OUD.

Based on the information obtained from studies conducted to date, some individuals appear to be more prone to developing addiction than others due to various risk factors. Etiological studies investigating heterogeneous risk factors are increasingly focusing on the traumatic experiences an individual is exposed to at an early age to understand how addiction begins. Childhood traumas are known to be associated with many adverse life outcomes, including addiction, due to their both acute and long-term effects on the physical and mental health. Because traumatic experiences in childhood can affect a person’s emotional regulation, leaving them unable to modulate distressing emotions healthily and adaptively, opioids may be used as an attempt to cope and alleviate these emotions, which may explain the relationship between traumatic experiences and addiction. However, although many studies have shown that these experiences increase the risk of developing OUD, some studies suggest that these experiences do not correspond to stronger associations with the disease and that there may be possible protective factors that have not yet been addressed in this population. Therefore, during this period, there may be an opportunity to intervene with individuals at risk to prevent the development of situations that negatively affect the individual’s life, such as addiction.

Although trauma can predispose the individual to a wide variety of psychopathologies, addiction does not develop in every individual who has a negative experience in childhood. Both psychosocial and cultural factors may potentially provide key protective and risk characteristics that need to be assessed and intervened to prevent the development of OUD. Attachment theory may provide a helpful framework in this case, and insecure attachment may be an essential mediator between traumatic experiences in childhood and psychopathology in adulthood. According to Bowlby’s attachment theory, a close attachment bond is formed through the interaction between the infant and caregivers, and then child internalizes this bond. This situation affects the individual’s attachment styles, determines their relationships in adulthood, and is related to mental well-being. Nurturing relationships and robust social support systems may serve as protective factors of adverse health outcomes such as traumatic childhood experiences and substance use. On the other hand, those who experienced traumatic experiences in childhood have an insecure attachment style, which may predispose them to opioid use in adulthood. Although insecure attachment certainly does not predict the development of psychopathology, it can create vulnerability in the individual because it can create maladaptive strategies to interpret and interact with the world. In addition, people may turn to substance use to find a connection and fill the gap in their lives. Therefore, since attachment styles and childhood traumatic experiences can be among the critical factors explaining both vulnerability and resilience in response to mental distress, it is essential to analyze their roles in the development of OUD. Although previous studies have provided valuable information on how childhood traumatic exposure and attachment styles are individually associated with addiction, it is still unclear how these are associated with opioid use when multiple individual-level variables are considered together.

Impulsivity is critical to understand the initiation, maintenance, and relapse of substance use. While some researchers view impulsivity as an independent risk factor for psychiatric symptomatology, other researchers think that impulsivity may contribute to psychopathology when it interacts with some risk factors. Therefore, another critical aspect of this study is investigating the relationships between impulsivity and other variables, which negatively affect interpersonal relationships by disrupting a person’s quality of life and functionality.

Given the severe clinical course in OUD patients, it is essential to examine how various risk factors may be related to treatment outcome, defined as relapse. Both traumatic experiences, attachment characteristics, and impulsivity may affect the individual’s decisions and increase the likelihood of leaving treatment early. Our study also aimed to investigate the effects of various risk factors on treatment compliance and relapse.

Although these factors have been examined separately in the literature, to our knowledge, only a few studies evaluate these factors collectively in the same patient group. The primary purpose of this study is to investigate whether the childhood traumas, attachment styles, impulsivity levels, and quality of life of OUD patients in remission differ from healthy controls and to reveal the relationships between these parameters. H1 hypothesis of the study: Childhood traumas, impulsivity, fearful attachment and preoccupied attachment style are more common in OUD patients. Moreover, these parameters are interrelated and predict OUD.

MATERIAL AND METHODS

Study Sample and Procedure

The study enrolled patients who applied to Akdeniz University Alcohol and Substance Addiction Research and Application Center Outpatient Clinic between September 2021 and March 2022 who were diagnosed with OUD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria and who were in remission for at least one month. Remission was confirmed by urinalysis in all patients in the study. In our clinic, all OUD patients are subjected to a urinalysis at every outpatient clinic visit. Patients with any substance detected in urinalysis were not included in the study. Inclusion criteria for the OUD group; being between the ages of 18–65, and being at least a primary school graduate. Exclusion criteria for the OUD group; using a substance other than opioids, presence of a psychiatric comorbidity other than OUD in the psychiatric history (psychotic disorder, mood disorders, etc.), presence of alcohol use disorder, presence of organic disease (liver disease, kidney disease, asthma, cardiovascular disease, cancer, etc.), having a history of neurological disease (e.g., head trauma, epilepsy, central nervous system disease, etc.), pregnancy for female patients, mental retardation, using medication other than buprenorphine-naloxone (antidepressant, antipsychotic, mood stabilizer, etc.). Criteria for inclusion in the control group; being between the ages of 18–65 and being at least a primary school graduate. Exclusion criteria for the control group; Having a history of substance use, having a history of alcohol use disorder, having a psychiatric disease, having an organic disease. In addition, the control group was selected from people similar to the OUD group in terms of age and sex. The control group was randomly selected. A face-to-face interview was also held with the control group. Those who met the inclusion and exclusion criteria were included in the study. Some of them were hospital employees. Some of them were randomly selected individuals living in Antalya province by the researcher. The researchers conducted all interviews with the patient and control group participants face-to-face. This study was conducted according to the latest version of the Declaration of Helsinki and approved by the Akdeniz University Faculty of Medicine Clinical Research Ethics Committee (18.08.2021- Decision No: 595).

Measurement and Assessment Tools

All participants completed the Sociodemographic Data Form prepared by the researchers. We used the Structured Clinical Interview for DSM-5 Disorders Clinician Version (SCID-5/CV) form to determine participants’ current psychopathology and confirmed the diagnosis of OUD. To question participants’ childhood traumatic experiences, we used the Childhood Trauma Questionnaire (CTQ), which includes questions that retrospectively evaluate emotional, physical, and sexual abuse and neglect experienced before the age of 20. In addition, we administered the Relationship Scales Questionnaire (RSQ), which evaluates people’s attachment styles in 4 subscales (secure, fearful, preoccupied, dismissive), and the Barratt Impulsivity Scale (BIS-11), which determines impulsivity levels, to the participants. The World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) was used to evaluate the quality of life of the individuals. In addition, the Substance Craving Scale (SCS) was used to determine the level of substance use craving in the study’s patient group.

Statistical Analyses

We performed statistical analysis using the data of 200 patients in the patient and control groups and terminated the study. As a result of the post hoc power analysis performed on the last data collected, we calculated the power of the study to be approximately 92%. We performed the power analysis with the G*Power 3.1.9.7 for the Windows package program. We gave descriptive statistics for continuous (numerical) variables as mean ± standard deviation or median, minimum, and maximum, depending on the distribution. We summarized categorical variables as numbers and percentages. We checked the normality of numerical variables with Shapiro-Wilk and Kolmogorov-Smirnov tests. In comparing two independent groups, We used the Independent Samples T-Test in cases where numerical variables were normally distributed and the Whitney U test in cases where numerical variables were not normally distributed. In non-parametric tests, we evaluated the differences between groups with the Dwass-Steel-Critchlow-Fligner test. In examining the relationships between numerical variables, we used Spearman’s Rho correlation coefficient in cases where the variables were not normally distributed. We applied multiple logistic regression analysis to identify factors that may predict OUD risk. We performed statistical analyses with IBM Statistical Package for Social Sciences (SPSS) program version 26.0 (IBM Corporation, Armonk, NY, USA). We accepted the statistical significance level as p<0.05.

RESULTS

Descriptive statistics of the sociodemographic data of the study participants are summarized in Table 1. Clinical data of the patient group are summarized in Table 2. Comparisons between the patient and control groups for CTQ, RSQ, BIS-11, and WHOQOL-BREF scores are summarized in Table 3.

Table 1.

Comparison of sociodemographic data of opioid use disorder (OUD) and healthy control group

Table 2.

Clinical characteristics of patients with opioid use disorder (OUD)

Table 3.

Comparison of scale scores of opioid use disorder (OUD) and control group

We made some sub-comparisons on sociodemographic data. We found statistically significantly higher SCS scores in patients with OUD, those with low-income family relationships, and those who attempted suicide (p=0.018 and p=0.029,respectively). Considering the CTQ scores, sexual abuse scores were higher in women than in men, and emotional abuse and neglect scores were higher in individuals living in families where there was no parental cohabitation (p<0.001 for each). Patients with low-income family relationships had higher fearful attachment scores (p=0.025). In contrast, male patients who did not have other substance use individuals in their families and who did not smoke had higher secure attachment scores (p=0.032, p=0.014,respectively). Patients with suicide attempts had significantly higher unplanned impulsivity scores than patients without suicide attempts (p=0.044). Patients who smoked had lower physical and psychological health scores (p=0.003 and p<0.001,respectively). Patients with poor family relationships had lower psychological and social relationship scores (p=0.005 and p<0.001, respectively). The social relations scale scores of OUD patients who had a family member who used substances were significantly lower (p=0.038).

Inter-scale correlations were analyzed. In the patient group, negative correlations were found between SCS and WHOQOL-BREF subscale scores (respectively: r=-0.362, p<0.001; r=-0.355, p<0.001; r=-0.362, p<0.001; r=-0.359, p<0.001; r=-0.375, p<0.001). There was also a significant positive correlation between the emotional abuse scores of the patients and their preoccupied and dismissive attachment scores (r=0.207, p=0.038; r=0.260, p=0.009). There were significant negative correlations between emotional neglect scores and WHOQOL-BREF subscores (respectively: r=-0.354, p<0.001; r=-0.310, p=0.002; r=-0.371, p<0.001; r=-0.362, p<0.001; r=-0.512, p<0.001). There were significant positive correlations between sexual abuse scores and attentional impulsivity and unplanned impulsivity scores (respectively: r=0.363, p<0.001; r=0.395, p<0.001), whereas negative correlations were found between WHOQOL-BREF general health and environment sub-scores (respectively: r=0.316, p=0.001; r=0.400, p<0.001).

The results of the multivariate multiple logistic regression analysis conducted by including the variables of age, smoking and alcohol use, emotional abuse and neglect, physical abuse and neglect, and unplanned impulsivity, which were significant in the univariate model according to the univariate logistic regression analysis conducted to determine the risk factors for OUD, are shown in Table 4. Age, smoking, physical neglect, and unplanned impulsivity remained significant factors in the model.

Table 4.

Multiple logistic regression analysis to identify factors that increase the risk of opioid use disorder

DISCUSSION

Identifying the mechanisms underlying OUD and individual variables in this process is critical to developing more effective therapeutic and preventive interventions. In this regard, our study examined the relationship between childhood trauma, attachment styles, and OUD and whether various sociodemographic or clinical characteristics mediate this relationship. In our study, CTQ total score, emotional abuse, physical abuse, physical neglect and emotional neglect scores were found to be higher in the OUD group. Attachment styles are similar in both groups. When WHOQL-BREF scores were compared, general health, physical health and social relations subscale scores were found to be lower in the OUD group. BIS-11 unplanned impulsivity subscale scores were found to be higher in the OUD group than in healthy controls. Age, smoking, physical neglect and unplanned impulsivity significantly predicted OUD.

In the present study, childhood traumatic experience scores in the patient group were significantly higher than in healthy controls. So, foremost, the results of this study support the literature that traumatic experiences in childhood are associated with OUD in adulthood. Our finding showing that physical neglect, one of these experiences, has a stronger relationship with OUD than other traumatic experiences stands out among other studies in the literature. Considering that not every person with a traumatic childhood experience develops OUD, we also examined other variables that may predict individual differences in this relationship. Indeed, some individuals may be at greater risk for OUD due to sociocultural stressors, negative behaviors of the caregiver, poor upbringing, or lack of social support. Studies in the literature show that there are differences between genders in the rates of exposure to and being affected by trauma. In the OUD patients in our study, sexual abuse scores were significantly higher in women than in men. We think that women with OUD may have been exposed to more sexual abuse during childhood than men. In this respect, we believe that studies with very large samples should be conducted, especially evaluating women with OUD.

In addition, the study represents an investigation of attachment styles in a sample of OUD patients. An individual’s attachment style develops in infancy and affects adulthood. As attachment is replaced by individual freedom during adolescence, adolescents are more likely to engage in risky behavior. Relationships between attachment style and addictions have been reported in the literature. In a study conducted in our country, significant relationships were found between substance use and dismissive and preoccupied attachment styles. Likewise, in a study conducted in our country, the average avoidant attachment score of individuals with alcohol use disorder was found to be higher. However, in our study, attachment styles in OUD patients were found to be similar to healthy controls. Although only the dismissive attachment score was slightly higher in the control group in our study, the p value of 0.049 makes its significance extremely insignificant. In other words, we can say that attachment styles are similar in both groups. This situation seems incompatible with the existing literature. This can be explained by the fact that many psychosocial and cultural variables can affect attachment styles in a complex way. The emphasis on family ties in various cultures can serve as a robust support system and thus be a protective factor against adverse health outcomes such as substance use. On the other hand, the same situation can also be a risk factor for increased substance use by contributing to mood dysregulation among individuals who have problematic relationships with their parents. The fact that there was no difference between the attachment styles of the groups in our study may be related to the strong family ties in our country. The fact that parents in both sample groups were sensitive to their children’s needs and established an ideal and safe relationship with them and that similar child-rearing styles were common in society may have affected this situation. Again, regression analyses in our study did not reveal a strong relationship between attachment styles and OUD. On the other hand, in our study, it is seen that there are strong relationships between individuals who experienced emotional neglect and abuse in childhood and fearful attachment styles in adulthood. In other words, attachment style alone may not be a risk factor for substance use.

Another important aspect of this study is that it investigates the relationship between impulsivity and other variables. There are relatively few studies that have comprehensively and simultaneously examined the relationship between impulsivity and such a variety of variables. Therefore, the data of this study may develop some approaches to prevent impulsive behaviors, which are among the diagnostic criteria of many psychopathologies. Our study found that motor and unplanned impulsivity scores were higher in the patient group than in the control group. Although there is a difference between groups in terms of motor impulsivity, the p value of 0.047 may indicate that the significance is low. The result should be evaluated from this perspective. Regression analyses also support this, showing that there is a strong relationship between unplanned impulsivity and OUD. Our study also found that motor impulsivity scores were significantly higher in men than women. Accordingly, it can be said that men have more difficulty in suppressing emotional, cognitive, and behavioral reactions than women and that they take action without thinking about the consequences. Perhaps this may be one of the reasons why OUD is more common in men. In addition, our research findings suggest that emotional and sexual abuse from traumatic experiences in childhood may be associated with motor and attentional impulsivity, and sexual abuse may be associated with unplanned impulsivity. We also found that patients with suicide attempts had higher unplanned impulsivity scores than those without suicide attempts.

Our study also investigated the relationship between various sociodemographic and clinical variables and quality of life by examining patterns of impairment in different quality-of-life domains between OUD patients in remission and healthy controls. Consistent with previous research, our study supports the idea that OUD patients have a lower quality of life than healthy controls. In our study, relationships were found between individuals’ quality of life and smoking, the presence of another member of the family who uses substances, loss of a parent, and the level of craving. Again, the correlation analysis detected negative significant relationships between childhood traumas and impulsivity and quality of life.

Craving, a diagnostic criterion and treatment target for OUD, is considered by some researchers to be predictive of future relapse. As a result of the correlation analyses we conducted in our study, we could not detect a significant relationship between craving scale scores and other variables, which suggests that craving is a complex structure and that more studies focusing on craving may be needed.

To the best of our knowledge, our study is one of the few studies that evaluate such a variety of sociodemographic and clinical characteristics in patients with OUD. However, readers should also consider some limitations when evaluating the results of this study. Firstly, a limitation of this study is that we evaluated the variables using self-report scales, and the patients answered the questions asked on some scales with retrospective recall. Additionally, since the sample was selected from a single center, the study has limitations regarding representing all OUD patients in Türkiye. While the early remission criterion for DSM-5 is at least 3 months, another limitation is that patients who were in remission for at least 1 month were included in our study.

As a result of our research, we can say that OUD patients have more childhood trauma and these patients are more impulsive. We can say that the attachment styles of OUD patients are similar to healthy controls, and their quality of life is worse in some areas. Correlations have been shown between patients’ emotional abuse scores and their preoccupied and dismissive attachment scores. We can say that there is no relationship between attachment style and OUD. We can also say that age, smoking, physical neglect and unplanned impulsivity independently increase the risk of OUD. We can say that childhood traumas and impulsivity are important risk factors for OUD that should be considered together. Prospective studies with larger samples are needed on this subject in the future.

INTRODUCTION

Globally, Opioid Use Disorder (OUD) presents a significant public health challenge. According to the 2023 World Drug Report, an estimated 296 million people worldwide used drugs in 2021, with 31.5 million of the 60.3 million opioid users specifically using heroin. Given that hundreds of thousands of deaths are attributed to opioids annually, effective strategies are necessary to prevent addiction development by identifying high-risk individuals. Research indicates that certain individuals are more susceptible to developing addiction due to various risk factors. Etiological studies increasingly focus on early life traumatic experiences to understand addiction's onset. Childhood traumas are associated with numerous adverse outcomes, including addiction, due to their profound and lasting effects on physical and mental health. Traumatic experiences in childhood can impair emotional regulation, potentially leading individuals to use opioids as a coping mechanism. While many studies confirm that these experiences increase OUD risk, some suggest inconsistent associations or point to the presence of unaddressed protective factors. This indicates an opportunity for intervention with at-risk individuals to prevent negative life outcomes such as addiction.

Despite trauma predisposing individuals to a wide range of psychopathologies, addiction does not manifest in every person exposed to negative childhood experiences. Psychosocial and cultural factors may provide critical protective and risk characteristics requiring assessment and intervention to prevent OUD. Attachment theory offers a valuable framework in this context, positing that insecure attachment may mediate the link between childhood traumatic experiences and adult psychopathology. According to Bowlby’s theory, early interactions with caregivers shape an internalized attachment bond that influences adult relationships and mental well-being. Nurturing relationships and robust social support systems can serve as protective factors against adverse health outcomes like traumatic childhood experiences and substance use. Conversely, individuals with childhood trauma may develop insecure attachment styles, increasing their vulnerability to opioid use in adulthood. While insecure attachment does not definitively predict psychopathology, it can create vulnerability by fostering maladaptive strategies for interpreting and interacting with the world. Moreover, some individuals may turn to substance use to find connection or fill perceived voids. Therefore, analyzing the roles of attachment styles and childhood traumatic experiences is crucial for understanding both vulnerability and resilience to mental distress in the context of OUD development. Although prior research has explored the individual associations of traumatic exposure and attachment styles with addiction, their combined association with opioid use, considering multiple individual-level variables, remains less clear.

Impulsivity is crucial for understanding the initiation, maintenance, and relapse of substance use. While some researchers view impulsivity as an independent risk factor for psychiatric symptomatology, others propose its contribution to psychopathology through interactions with various risk factors. Consequently, another significant aspect of this study involved investigating the relationships between impulsivity and other variables that negatively affect interpersonal relationships by disrupting an individual's quality of life and functionality. Given the severe clinical course observed in OUD patients, examining how various risk factors relate to treatment outcome, defined as relapse, is essential. Traumatic experiences, attachment characteristics, and impulsivity may all influence an individual’s decisions and increase the likelihood of early treatment discontinuation. This study also aimed to investigate the effects of these risk factors on treatment compliance and relapse. To the best of current knowledge, only a limited number of studies have collectively evaluated these factors within the same patient cohort. The primary purpose of this study was to investigate whether childhood traumas, attachment styles, impulsivity levels, and quality of life differ between OUD patients in remission and healthy controls, and to elucidate the relationships among these parameters. The study's hypothesis proposed that childhood traumas, impulsivity, and fearful and preoccupied attachment styles are more prevalent in OUD patients, are interrelated, and predict OUD.

MATERIAL AND METHODS

The study enrolled patients attending the Akdeniz University Alcohol and Substance Addiction Research and Application Center Outpatient Clinic between September 2021 and March 2022. Participants included individuals diagnosed with OUD according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria who had been in remission for at least one month, confirmed by urinalysis. Exclusion criteria for the OUD group included using substances other than opioids, a history of psychiatric comorbidities (e.g., psychotic or mood disorders), alcohol use disorder, organic diseases (e.g., liver, kidney, cardiovascular disease, cancer), neurological disease history, pregnancy, mental retardation, or use of medications other than buprenorphine-naloxone. The control group consisted of individuals aged 18–65 with at least a primary school education, free from any history of substance use, alcohol use disorder, psychiatric illness, or organic disease. Controls were matched for age and sex, with recruitment from hospital employees and random selection from the Antalya province. All interviews were conducted face-to-face by the researchers. The study received approval from the Akdeniz University Faculty of Medicine Clinical Research Ethics Committee (18.08.2021- Decision No: 595), aligning with the Declaration of Helsinki.

All participants completed a Sociodemographic Data Form prepared by the researchers. The Structured Clinical Interview for DSM-5 Disorders Clinician Version (SCID-5/CV) was used to determine current psychopathology and confirm OUD diagnoses. Childhood traumatic experiences experienced before the age of 20, including emotional, physical, and sexual abuse and neglect, were retrospectively assessed using the Childhood Trauma Questionnaire (CTQ). Participants' attachment styles were evaluated across four subscales (secure, fearful, preoccupied, dismissive) using the Relationship Scales Questionnaire (RSQ). Impulsivity levels were determined using the Barratt Impulsivity Scale (BIS-11). The World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) assessed quality of life. Additionally, the Substance Craving Scale (SCS) was administered to the patient group to measure substance use craving.

Statistical analyses were performed on data from 200 patients across the patient and control groups, yielding a post hoc power of approximately 92% calculated using G*Power 3.1.9.7 for Windows. Descriptive statistics for continuous variables were presented as mean ± standard deviation or median, minimum, and maximum, contingent on distribution. Categorical variables were summarized using numbers and percentages. Normality of numerical variables was assessed with Shapiro-Wilk and Kolmogorov-Smirnov tests. For comparing two independent groups, the Independent Samples T-Test was applied for normally distributed numerical variables, while the Whitney U test was used for non-normally distributed variables. In non-parametric tests, differences between groups were evaluated with the Dwass-Steel-Critchlow-Fligner test. Relationships between numerical variables were examined using Spearman’s Rho correlation coefficient for non-normally distributed variables. Multiple logistic regression analysis was employed to identify factors predicting OUD risk. All statistical analyses were conducted using IBM Statistical Package for Social Sciences (SPSS) program version 26.0, with statistical significance set at p<0.05.

RESULTS

Descriptive statistics for the sociodemographic data of the study participants are summarized in Table 1. Clinical data for the patient group are presented in Table 2. Comparisons of Childhood Trauma Questionnaire (CTQ), Relationship Scales Questionnaire (RSQ), Barratt Impulsivity Scale (BIS-11), and World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) scores between the patient and control groups are detailed in Table 3.

Analysis of sociodemographic data revealed statistically significantly higher Substance Craving Scale (SCS) scores in OUD patients with low-income family relationships and a history of suicide attempts. Regarding CTQ scores, women exhibited higher sexual abuse scores than men, while emotional abuse and neglect scores were higher in individuals from families without parental cohabitation. Patients with low-income family relationships reported higher fearful attachment scores. Conversely, secure attachment scores were higher in male patients without other substance-using individuals in their families and those who did not smoke. Patients with suicide attempts showed significantly higher unplanned impulsivity scores. Lower physical and psychological health scores were noted in smokers, and poor family relationships correlated with lower psychological and social relationship scores. The social relations scale scores of OUD patients with a family history of substance use were significantly lower. Inter-scale correlations revealed negative associations between SCS and WHOQOL-BREF subscale scores in the patient group. Significant positive correlations were observed between emotional abuse scores and preoccupied and dismissive attachment scores. Emotional neglect scores had significant negative correlations with WHOQOL-BREF subscores. Sexual abuse scores showed significant positive correlations with attentional and unplanned impulsivity scores, while negatively correlating with WHOQOL-BREF general health and environment sub-scores.

The results of the multivariate logistic regression analysis, which included age, smoking, alcohol use, emotional abuse and neglect, physical abuse and neglect, and unplanned impulsivity from the univariate model as significant variables, are presented in Table 4. Age, smoking, physical neglect, and unplanned impulsivity remained significant factors in the final model for predicting the risk of OUD.

DISCUSSION

The identification of mechanisms underlying Opioid Use Disorder (OUD) and associated individual variables is critical for developing more effective therapeutic and preventive interventions. This study investigated the relationship between childhood trauma, attachment styles, and OUD, and explored how various sociodemographic or clinical characteristics might mediate these relationships. Key findings indicated that the OUD group had significantly higher total Childhood Trauma Questionnaire (CTQ) scores, including emotional abuse, physical abuse, physical neglect, and emotional neglect scores, compared to healthy controls. Notably, physical neglect showed a stronger association with OUD than other traumatic experiences. While trauma is a recognized risk factor, individual differences in vulnerability exist, influenced by factors such as sex, with women in the OUD group reporting higher rates of sexual abuse. These results align with existing literature indicating a strong link between childhood traumatic experiences and OUD in adulthood.

While attachment styles are known to develop in infancy and influence adult relationships and mental health, this study found no significant differences in attachment styles between OUD patients and healthy controls, which contrasts with some existing literature. This outcome may be influenced by strong family ties and similar child-rearing practices prevalent in the study's cultural context, potentially serving as protective factors. Although direct regression analysis did not establish a strong predictive relationship between attachment styles and OUD, strong associations were observed between childhood emotional neglect and abuse and fearful attachment styles in adulthood, suggesting attachment may act as a mediator rather than a primary risk factor in this population.

Impulsivity emerged as another significant factor, with OUD patients exhibiting higher scores in motor and unplanned impulsivity compared to controls. Unplanned impulsivity, in particular, was strongly associated with OUD. Furthermore, men showed higher motor impulsivity than women, potentially contributing to the higher prevalence of OUD among men. The study also identified links between specific childhood traumatic experiences (emotional and sexual abuse) and various aspects of impulsivity. Consistent with previous research, the quality of life was generally lower in OUD patients than in healthy controls, with negative correlations observed between quality of life and factors such as smoking, family substance use, parental loss, childhood traumas, and impulsivity.

The study acknowledged craving as a complex diagnostic criterion and potential predictor of relapse in OUD; however, in this investigation, craving did not show significant correlations with other variables, suggesting the need for more focused research on this aspect. Limitations of the study include its reliance on self-report scales and retrospective recall, the single-center recruitment limiting generalizability to the broader Turkish OUD population, and the use of a one-month remission criterion, which is shorter than the three-month criterion specified by DSM-5 for early remission.

In conclusion, the findings indicate that individuals with OUD experience more childhood trauma and higher levels of impulsivity. While attachment styles were similar to healthy controls, and a direct link between attachment style and OUD was not established in this study, correlations between emotional abuse and certain insecure attachment styles were observed. Age, smoking, physical neglect, and unplanned impulsivity were identified as independent factors increasing the risk of OUD. The study underscores childhood traumas and impulsivity as crucial and interrelated risk factors for OUD, emphasizing the need for future prospective studies with larger and more diverse samples to further elucidate these complex relationships.

INTRODUCTION

Opioid Use Disorder (OUD) remains a significant global public health concern. In 2021, an estimated 296 million people worldwide used drugs, with 31.5 million of the 60.3 million opioid users consuming heroin. OUD develops from chronic opioid use and contributes to hundreds of thousands of deaths annually. Consequently, effective strategies are still necessary to identify individuals at high risk for OUD and prevent addiction development.

Research indicates that certain individuals are more susceptible to addiction due to various risk factors, with increasing focus on traumatic experiences during early life. Childhood traumas are known to be associated with numerous negative life outcomes, including addiction, due to their immediate and long-term impacts on physical and mental well-being. Traumatic childhood experiences can impair emotional regulation, making it difficult for individuals to manage distressing emotions constructively. Opioids may then be used as a coping mechanism to alleviate these feelings, which could explain the link between trauma and addiction. However, while many studies show that these experiences increase OUD risk, some suggest the association might not always be stronger, and potential protective factors could exist. This period may offer opportunities for intervention to prevent negative outcomes like addiction in at-risk individuals.

Although trauma can predispose individuals to various mental health conditions, not every person who experiences childhood adversity develops addiction. Both psychosocial and cultural factors can offer crucial protective or risk characteristics that require assessment and intervention to prevent OUD. Attachment theory may provide a useful framework for understanding this, as insecure attachment could mediate the link between childhood trauma and adult mental health issues. According to Bowlby’s attachment theory, an infant forms a close bond with caregivers, which the child internalizes. This internalized bond influences adult attachment styles, determines relationships, and affects mental well-being. Supportive relationships and robust social support systems can act as protective factors against adverse health outcomes like the effects of traumatic childhood experiences and substance use. Conversely, individuals with traumatic childhood experiences may develop an insecure attachment style, potentially predisposing them to opioid use in adulthood. While insecure attachment does not definitively predict mental health conditions, it can create vulnerability by fostering maladaptive ways of interpreting and interacting with the world. Furthermore, individuals may turn to substance use to seek connection or fill a void in their lives. Therefore, analyzing the roles of attachment styles and childhood traumatic experiences is crucial, as they can explain both vulnerability and resilience in response to mental distress and in the development of OUD. Previous studies have offered valuable information on how childhood trauma and attachment styles are individually associated with addiction, but their combined association with opioid use, considering multiple individual-level variables, remains unclear.

Impulsivity is a critical factor in understanding the initiation, maintenance, and relapse of substance use. Some researchers view impulsivity as an independent risk factor for psychiatric symptoms, while others believe it contributes to mental health conditions when interacting with specific risk factors. Thus, another important aspect of this study is investigating the relationships between impulsivity and other variables that negatively affect interpersonal relationships by disrupting a person's quality of life and functionality.

Given the severe clinical course in OUD patients, it is essential to examine how various risk factors may relate to treatment outcomes, specifically relapse. Traumatic experiences, attachment characteristics, and impulsivity can influence an individual's decisions and increase the likelihood of early treatment discontinuation. This study also aimed to investigate the effects of various risk factors on treatment compliance and relapse.

Few studies have examined these factors collectively within the same patient group. The primary purpose of this study is to investigate whether childhood traumas, attachment styles, impulsivity levels, and quality of life differ between OUD patients in remission and healthy controls, and to uncover the relationships among these parameters. The study's hypothesis is that childhood traumas, impulsivity, and fearful and preoccupied attachment styles are more common in OUD patients, and these parameters are interrelated and predict OUD.

MATERIAL AND METHODS

Study Sample and Procedure

The study enrolled patients from Akdeniz University Alcohol and Substance Addiction Research and Application Center Outpatient Clinic between September 2021 and March 2022. Participants were diagnosed with OUD according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and were in remission for at least one month. Remission was verified by urinalysis for all patients. Patients with any substance detected in urinalysis were excluded. Inclusion criteria for the OUD group included being between 18–65 years old and having at least a primary school education. Exclusion criteria for the OUD group involved using substances other than opioids, having psychiatric comorbidities (e.g., psychotic disorder, mood disorders), alcohol use disorder, organic diseases (e.g., liver, kidney, heart disease, cancer), neurological disease history (e.g., head trauma, epilepsy), pregnancy, intellectual disability, or using medications other than buprenorphine-naloxone (e.g., antidepressants, antipsychotics). The control group inclusion criteria included being between 18–65 years old and having at least a primary school education. Control group exclusion criteria included a history of substance use, alcohol use disorder, psychiatric disease, or organic disease. The control group was age and sex-matched with the OUD group and randomly selected. Face-to-face interviews were conducted with all participants. Some control participants were hospital employees, others were randomly selected individuals from Antalya province. The study adhered to the Declaration of Helsinki and received approval from the Akdeniz University Faculty of Medicine Clinical Research Ethics Committee (18.08.2021- Decision No: 595).

Measurement and Assessment Tools

All participants completed a Sociodemographic Data Form prepared by the researchers. The Structured Clinical Interview for DSM-5 Disorders Clinician Version (SCID-5/CV) confirmed current psychopathology and OUD diagnosis. Childhood traumatic experiences were assessed using the Childhood Trauma Questionnaire (CTQ), which retrospectively evaluates emotional, physical, and sexual abuse and neglect experienced before age 20. The Relationship Scales Questionnaire (RSQ) evaluated attachment styles across four subscales (secure, fearful, preoccupied, dismissive). The Barratt Impulsivity Scale (BIS-11) determined impulsivity levels. Quality of life was assessed using the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF). For the patient group, the Substance Craving Scale (SCS) measured substance craving levels.

Statistical Analyses

Statistical analysis was performed using data from 200 participants (patient and control groups), after which the study concluded. A post hoc power analysis on the final data indicated a study power of approximately 92%, performed with G*Power 3.1.9.7 for Windows. Descriptive statistics for continuous variables were presented as mean ± standard deviation or median, minimum, and maximum, depending on their distribution. Categorical variables were summarized using numbers and percentages. Normality of numerical variables was checked using Shapiro-Wilk and Kolmogorov-Smirnov tests. For comparing two independent groups, the Independent Samples T-Test was used for normally distributed numerical variables, and the Whitney U test for non-normally distributed variables. In non-parametric tests, the Dwass-Steel-Critchlow-Fligner test evaluated group differences. Spearman’s Rho correlation coefficient examined relationships between non-normally distributed numerical variables. Multiple logistic regression analysis identified factors predicting OUD risk. Statistical analyses were conducted using IBM Statistical Package for Social Sciences (SPSS) program version 26.0. A statistical significance level of p<0.05 was accepted.

RESULTS

The study's sociodemographic data are summarized in Table 1, clinical data of the patient group in Table 2, and comparisons of scale scores (CTQ, RSQ, BIS-11, and WHOQOL-BREF) between patient and control groups in Table 3. Specific sub-comparisons on sociodemographic data revealed statistically significantly higher SCS scores in OUD patients with low-income family relationships and those who attempted suicide (p=0.018 and p=0.029, respectively). Regarding CTQ scores, women had higher sexual abuse scores than men, and individuals from single-parent families had higher emotional abuse and neglect scores (p<0.001 for each). Patients with low-income family relationships exhibited higher fearful attachment scores (p=0.025). Conversely, male patients without other substance users in their families and who did not smoke had higher secure attachment scores (p=0.032, p=0.014, respectively). Patients with suicide attempts showed significantly higher unplanned impulsivity scores than those without (p=0.044). Smokers reported lower physical and psychological health scores (p=0.003 and p<0.001, respectively). Patients with poor family relationships had lower psychological and social relationship scores (p=0.005 and p<0.001, respectively). OUD patients with a family member who used substances reported significantly lower social relations scale scores (p=0.038).

Inter-scale correlations were analyzed. In the patient group, negative correlations were found between SCS and WHOQOL-BREF subscale scores (r=-0.362, p<0.001; r=-0.355, p<0.001; r=-0.362, p<0.001; r=-0.359, p<0.001; r=-0.375, p<0.001). A significant positive correlation existed between patients' emotional abuse scores and their preoccupied and dismissive attachment scores (r=0.207, p=0.038; r=0.260, p=0.009). Significant negative correlations were observed between emotional neglect scores and WHOQOL-BREF subscores (r=-0.354, p<0.001; r=-0.310, p=0.002; r=-0.371, p<0.001; r=-0.362, p<0.001; r=-0.512, p<0.001). Significant positive correlations were found between sexual abuse scores and attentional impulsivity and unplanned impulsivity scores (r=0.363, p<0.001; r=0.395, p<0.001), while negative correlations existed between sexual abuse scores and WHOQOL-BREF general health and environment sub-scores (r=0.316, p=0.001; r=0.400, p<0.001).

The results of the multivariate multiple logistic regression analysis, including age, smoking and alcohol use, emotional abuse and neglect, physical abuse and neglect, and unplanned impulsivity (identified as significant in the univariate model), are shown in Table 4. Age, smoking, physical neglect, and unplanned impulsivity remained significant factors in the model.

DISCUSSION

Identifying the mechanisms underlying OUD and individual variables involved in this process is crucial for developing more effective therapeutic and preventive interventions. This study examined the relationship between childhood trauma, attachment styles, and OUD, and whether various sociodemographic or clinical characteristics mediate this relationship. The study found that total CTQ scores, along with emotional abuse, physical abuse, physical neglect, and emotional neglect scores, were higher in the OUD group compared to healthy controls. This finding supports existing literature indicating that traumatic experiences in childhood are associated with OUD in adulthood, with physical neglect notably showing a stronger relationship than other traumatic experiences. However, not every person with a traumatic childhood experience develops OUD; sociocultural stressors, negative caregiver behaviors, poor upbringing, or lack of social support may increase individual risk. Gender differences in trauma exposure and impact were also observed; OUD women in this study had significantly higher sexual abuse scores than men, suggesting a need for larger studies specifically evaluating women with OUD.

This study also investigated attachment styles in a sample of OUD patients. An individual's attachment style develops in infancy and influences adulthood. While some literature reports relationships between substance use and dismissive or preoccupied attachment styles, this study found attachment styles in OUD patients to be similar to healthy controls. Although the dismissive attachment score was slightly higher in the control group, its statistical significance was marginal (p=0.049). This finding appears inconsistent with some existing literature and might be explained by the complex interplay of psychosocial and cultural variables, such as strong family ties, which can act as a protective factor against substance use. However, problematic family relationships can also increase mood dysregulation, becoming a risk factor. Regression analyses in this study did not reveal a strong relationship between attachment styles and OUD. Yet, strong relationships were observed between individuals who experienced emotional neglect and abuse in childhood and fearful attachment styles in adulthood, suggesting attachment style alone may not be a risk factor for substance use.

Another significant aspect of this study is its comprehensive examination of impulsivity and its relationship with other variables, an area with limited prior research. The study found that motor and unplanned impulsivity scores were higher in the OUD group than in the control group. Although a difference in motor impulsivity existed, its significance was low (p=0.047). Regression analyses further supported a strong relationship between unplanned impulsivity and OUD. Men in the study exhibited significantly higher motor impulsivity scores than women, potentially contributing to the higher prevalence of OUD in men. Research findings also suggest that emotional and sexual abuse from childhood traumatic experiences may be linked to motor and attentional impulsivity, with sexual abuse specifically associated with unplanned impulsivity. Additionally, patients with suicide attempts had higher unplanned impulsivity scores.

The study also investigated the relationship between various sociodemographic and clinical variables and quality of life, examining impairment patterns in different quality-of-life domains between OUD patients in remission and healthy controls. Consistent with previous research, OUD patients had a lower quality of life than healthy controls. Relationships were found between individuals’ quality of life and smoking, the presence of another family member who uses substances, parental loss, and craving levels. Correlation analysis also detected significant negative relationships between childhood traumas, impulsivity, and quality of life. Craving, a diagnostic criterion and treatment target for OUD, is considered by some researchers to be predictive of future relapse. However, correlation analyses in this study did not detect a significant relationship between craving scale scores and other variables, suggesting that craving is a complex construct requiring further focused studies.

This study is one of few that evaluate such a variety of sociodemographic and clinical characteristics in OUD patients. However, some limitations should be considered when evaluating the results. Firstly, the use of self-report scales and retrospective recall by patients may introduce bias. Additionally, selecting the sample from a single center limits its representativeness of all OUD patients in Turkey. Another limitation is including patients in remission for at least one month, whereas the DSM-5 early remission criterion is at least three months.

In conclusion, OUD patients tend to have experienced more childhood trauma and exhibit higher impulsivity. Their attachment styles appear similar to healthy controls, though their quality of life is worse in certain areas. Correlations were observed between patients’ emotional abuse scores and their preoccupied and dismissive attachment scores. This study suggests no direct relationship between attachment style and OUD. However, age, smoking, physical neglect, and unplanned impulsivity independently increase the risk of OUD. Childhood traumas and impulsivity are important risk factors for OUD that should be considered together. Future prospective studies with larger samples are needed to further explore these relationships.

INTRODUCTION

Around the world, an estimated 296 million people used drugs in 2021, and over 31 million of these individuals used heroin. Opioid Use Disorder (OUD), a condition that develops from ongoing opioid use, remains a serious public health concern, contributing to hundreds of thousands of deaths each year globally. Therefore, effective methods are still needed to prevent addiction by identifying people who are at high risk of developing OUD.

Research shows that some individuals are more likely to develop addiction due to various risk factors. Studies are increasingly looking at traumatic experiences in early life to understand how addiction begins. Childhood traumas are known to be linked to many negative life outcomes, including addiction, because they have both immediate and long-term effects on physical and mental health. Traumatic experiences in childhood can affect a person's ability to manage emotions, making it hard to cope with distress in healthy ways. People might then use opioids to try and lessen these feelings, which could explain the link between trauma and addiction. While many studies confirm that these experiences increase OUD risk, some suggest that the link isn't always strong and that protective factors might exist. This highlights an opportunity to help individuals at risk and prevent negative outcomes like addiction.

While trauma can make someone vulnerable to various mental health conditions, not everyone who has a negative childhood experience develops addiction. Social and cultural factors can offer important protective or risk characteristics that should be considered. Attachment theory, which describes how early relationships shape adult connections, can be a useful framework. Insecure attachment may connect childhood trauma to mental health issues in adulthood. Strong, caring relationships and social support systems can protect against negative health outcomes, including the effects of childhood trauma and substance use. However, those with traumatic childhoods may develop insecure attachment styles, which could increase their risk of opioid use later in life. While insecure attachment does not guarantee mental health problems, it can create a vulnerability by leading to unhealthy ways of interpreting and interacting with the world. Some people may also turn to substance use to find a connection or fill a void in their lives. Understanding the roles of attachment styles and childhood traumatic experiences is crucial because they can explain both vulnerability and resilience to mental distress and OUD.

Impulsivity, or acting without thinking, is key to understanding why substance use begins, continues, and leads to relapse. Some researchers see impulsivity as a separate risk factor for mental health symptoms, while others believe it contributes to problems when combined with other risk factors. This study also investigates how impulsivity relates to other factors that negatively affect a person's quality of life and relationships.

Considering the serious nature of OUD, it is important to examine how different risk factors might affect treatment success, particularly relapse. Traumatic experiences, attachment characteristics, and impulsivity may all influence a person's decisions and increase the likelihood of leaving treatment early. This study also aimed to explore how these risk factors affect treatment adherence and relapse. While these factors have been studied separately, few studies have looked at them together in the same group of patients. The main goal of this study is to compare childhood traumas, attachment styles, impulsivity levels, and quality of life in OUD patients who are in recovery with healthy individuals, and to identify the relationships between these factors. The study predicted that childhood traumas, impulsivity, and certain insecure attachment styles would be more common in OUD patients, and that these factors would be connected and could predict OUD.

MATERIAL AND METHODS

Study Sample and Procedure

The study included patients seen at Akdeniz University's Alcohol and Substance Addiction Research and Application Center Outpatient Clinic between September 2021 and March 2022. Participants were diagnosed with OUD based on official criteria and had been in recovery for at least one month, confirmed by urine tests at every visit. Patients with any substance detected in their urine were not included. To be included, OUD patients had to be between 18 and 65 years old and have at least a primary school education. They were excluded if they used substances other than opioids, had other psychiatric conditions (like psychotic or mood disorders), had alcohol use disorder, suffered from an organic disease (like liver or kidney disease, cancer), had a history of neurological disease (like head trauma or epilepsy), were pregnant, had intellectual disabilities, or were using medications other than buprenorphine-naloxone. The control group had similar age and education requirements, but were excluded if they had any history of substance use, alcohol use disorder, psychiatric illness, or organic disease. Control group members were randomly selected, some being hospital employees and others residents of Antalya province. All interviews with both patient and control groups were conducted face-to-face by the researchers. This study followed ethical guidelines and was approved by the Akdeniz University Faculty of Medicine Clinical Research Ethics Committee.

Measurement and Assessment Tools

All participants completed a form about their personal and demographic information, prepared by the researchers. A clinical interview form was used to confirm mental health diagnoses, including OUD. To assess childhood traumatic experiences, the Childhood Trauma Questionnaire (CTQ) was used, which asks about emotional, physical, and sexual abuse and neglect before age 20. The Relationship Scales Questionnaire (RSQ) assessed attachment styles (secure, fearful, preoccupied, dismissive), and the Barratt Impulsivity Scale (BIS-11) measured impulsivity levels. The World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) evaluated overall quality of life. For the OUD patient group, the Substance Craving Scale (SCS) measured the intensity of substance craving.

Statistical Analyses

Statistical analysis was performed using data from 200 participants (patients and controls), after which the study concluded. A power analysis indicated that the study had approximately 92% power. Numerical data were described using averages and standard deviations, or medians and ranges, depending on their distribution. Categorical data were summarized using counts and percentages. Standard statistical tests were used to check if numerical variables were normally distributed. To compare two independent groups, appropriate tests were used based on whether the data was normally distributed. Relationships between numerical variables were examined using a correlation coefficient. Multiple logistic regression analysis was applied to identify factors that might predict the risk of OUD. All analyses were conducted using IBM SPSS software, with a statistical significance level set at p<0.05.

RESULTS

The initial overview of participant backgrounds is shown in Table 1. Clinical information for the patient group is summarized in Table 2. Comparisons between the patient and control groups regarding scores on the CTQ, RSQ, BIS-11, and WHOQOL-BREF are presented in Table 3.

Table 1.

Comparison of sociodemographic data of opioid use disorder (OUD) and healthy control group

Table 2.

Clinical characteristics of patients with opioid use disorder (OUD)

Table 3.

Comparison of scale scores of opioid use disorder (OUD) and control group

Further comparisons were made based on sociodemographic data. Patients with OUD, those from low-income families, and those who had attempted suicide showed significantly higher substance craving scores. Regarding childhood trauma scores, women had higher sexual abuse scores than men, and individuals whose parents did not live together had higher scores for emotional abuse and neglect. Patients with low-income family backgrounds had higher fearful attachment scores. In contrast, male patients who did not have other family members using substances and who did not smoke had higher secure attachment scores. Patients who had attempted suicide had notably higher unplanned impulsivity scores. Patients who smoked reported lower physical and psychological health scores. Patients with poor family relationships had lower psychological health and social relationship scores. OUD patients with a family member who used substances reported significantly lower scores in social relations.

Relationships between different scale scores were analyzed. In the patient group, higher craving scores were linked to lower quality of life scores across various areas. There was also a notable connection between patients' emotional abuse scores and their preoccupied and dismissive attachment scores. Higher emotional neglect scores were associated with lower scores on various quality of life measures. Sexual abuse scores showed a link to higher attentional and unplanned impulsivity scores, while being negatively related to general health and environment quality of life scores.

The results of the statistical analysis, which included variables like age, smoking, alcohol use, types of childhood abuse and neglect, and unplanned impulsivity, are shown in Table 4. Age, smoking, physical neglect, and unplanned impulsivity remained important factors in predicting OUD risk.

Table 4.

Multiple logistic regression analysis to identify factors that increase the risk of opioid use disorder

DISCUSSION

Understanding the factors that contribute to Opioid Use Disorder (OUD) is vital for developing more effective treatments and prevention strategies. This study examined the connections between childhood trauma, attachment styles, and OUD, and how various personal or clinical characteristics might influence these relationships. The study found that OUD patients had higher scores for overall childhood trauma, including emotional abuse, physical abuse, physical neglect, and emotional neglect, compared to healthy individuals. While attachment styles were similar between the two groups, OUD patients reported lower scores in general health, physical health, and social relationships on quality of life assessments. Additionally, OUD patients had higher scores for unplanned impulsivity. Age, smoking, physical neglect, and unplanned impulsivity were strong predictors of OUD.

The findings confirm that traumatic experiences in childhood are associated with OUD in adulthood. Notably, physical neglect showed a stronger link to OUD than other traumatic experiences. Since not everyone with a traumatic childhood develops OUD, the study also explored other factors that might explain individual differences. Sociocultural stress, negative caregiver behaviors, poor upbringing, or a lack of social support can increase someone's risk for OUD. The study also observed gender differences: women with OUD had significantly higher sexual abuse scores than men. This suggests a need for larger studies focusing on women with OUD.

The study also investigated attachment styles in OUD patients. A person's attachment style develops early in life and influences adult relationships. While previous research has linked dismissive and preoccupied attachment styles to substance use, this study found that attachment styles in OUD patients were similar to healthy individuals. The slight difference in dismissive attachment scores was not statistically significant. This finding might differ from other studies due to the complex influence of psychosocial and cultural factors on attachment styles. For example, strong family ties in certain cultures can act as a protective factor against substance use. However, these same ties could also be a risk factor if family relationships are problematic, leading to difficulty managing emotions. The similarity in attachment styles between the groups in this study might be related to strong family bonds and common parenting styles in the country where the study took place. The analysis did not find a strong relationship between attachment styles and OUD by themselves. However, it did show strong connections between childhood emotional neglect and abuse and fearful attachment styles in adulthood, suggesting that attachment style alone may not be a risk factor for substance use.

Another important aspect of this study was its exploration of the link between impulsivity and other factors, a relationship not often studied comprehensively. The findings could lead to new ways to prevent impulsive behaviors, which are part of many mental health diagnoses. The study found that OUD patients had higher motor and unplanned impulsivity scores than the control group. The connection between motor impulsivity and OUD was less strong, however, and requires further consideration. The analysis also supported a strong link between unplanned impulsivity and OUD. Furthermore, men had significantly higher motor impulsivity scores than women, suggesting men may have more difficulty controlling their emotional, mental, and behavioral reactions and may act without considering the consequences. This might partly explain why OUD is more common in men. The research also indicates that emotional and sexual abuse during childhood trauma may be connected to motor and attentional impulsivity, and sexual abuse specifically to unplanned impulsivity. Patients who had attempted suicide also showed higher unplanned impulsivity scores.

The study also examined how different personal and clinical factors relate to quality of life in OUD patients in recovery compared to healthy individuals. Consistent with prior research, OUD patients generally reported a lower quality of life. The study found links between individuals’ quality of life and smoking, having another family member who uses substances, losing a parent, and the level of craving for substances. Additionally, the analysis detected negative relationships between childhood traumas, impulsivity, and quality of life.

Craving, a symptom and treatment target for OUD, is sometimes considered a predictor of future relapse. However, this study did not find a significant relationship between craving scores and other variables, suggesting that craving is complex and needs more focused research.

This study is one of the few that comprehensively evaluates such a variety of personal and clinical characteristics in OUD patients. However, some limitations should be considered. Firstly, the variables were assessed using self-report questionnaires, and patients relied on their memories to answer some questions. Secondly, because the sample was taken from a single location, the findings may not fully represent all OUD patients in the country. Additionally, while the standard for early OUD recovery is at least three months, this study included patients who had been in recovery for at least one month.

In conclusion, OUD patients experience more childhood trauma and are more impulsive. Their attachment styles appear similar to healthy individuals, but their quality of life is worse in certain areas. Connections were found between patients' emotional abuse scores and certain insecure attachment styles. While there appears to be no direct relationship between attachment style alone and OUD, age, smoking, physical neglect, and unplanned impulsivity independently increase the risk of OUD. Childhood traumas and impulsivity are important risk factors for OUD that should be considered together. Future research with larger groups and long-term follow-up is needed in this area.

Introduction

About 296 million people around the world used drugs in 2021. From this group, about 31.5 million people used heroin. Opioid Use Disorder (OUD) is a serious problem that happens when someone uses opioids a lot over time. Each year, many people around the world die because of opioids. Because of this, we need good ways to stop addiction from starting. This means finding people who are more likely to get OUD.

Studies show that some people are more likely to get addicted than others. This is because of different risk factors. More and more, studies look at bad experiences people had when they were young. These childhood traumas can cause many bad things later in life, like addiction. This is because trauma can make it hard for a person to deal with sad feelings in a good way. So, people might use opioids to feel better. Some studies show that these bad experiences make OUD more likely. But other studies suggest that some things might protect people. This means there is a chance to help people at risk before addiction starts.

Trauma can make someone more likely to have many mental health problems. But not everyone who has a bad experience as a child gets addicted. Things about a person's life and their culture can also protect them or put them at risk for OUD. A special idea called "attachment theory" can help here. It says that strong loving bonds with caregivers when a baby is young affect how a person forms relationships as an adult. Good relationships and strong support from friends and family can protect people from bad health problems, like using drugs after bad childhood experiences.

On the other hand, people who had trauma as children might have trouble feeling safe in relationships. This could make them more likely to use opioids when they grow up. While not feeling safe does not always mean someone will have mental health problems, it can make them weaker. It can make it hard for them to deal with the world. Also, some people might use drugs to feel connected or to fill a gap in their lives. So, it is important to look at how childhood traumas and ways of attaching to others play a part in OUD. We need to see how these things work together with other personal facts.

Acting without thinking (impulsivity) is very important to understand why people start using drugs, keep using them, and start again. Impulsivity can be a risk on its own, or it can cause mental problems when it mixes with other risks. People with OUD often have serious problems. So, it is important to see how different risk factors might affect how well treatment works. This means if someone starts using drugs again. Things like trauma, how a person attaches to others, and impulsivity might make people stop treatment too soon. This study looked at these issues. Our main goal was to see if OUD patients doing better (in remission) are different from healthy people in terms of childhood traumas, attachment styles, how impulsive they are, and their quality of life. We also wanted to see how these things are linked and if they can tell us if someone will have OUD.

Material and Methods

This study looked at patients who visited a special clinic for addiction at Akdeniz University. These patients were told by doctors that they had Opioid Use Disorder (OUD) and had not used opioids for at least one month. We made sure they had not used drugs with urine tests. People could join the study if they were between 18 and 65 years old and had at least finished primary school. We did not include people who used other drugs, had other mental health problems, or had serious physical health problems.

We also had a group of healthy people who did not use drugs, did not have mental health problems, and did not have physical health problems. This group was chosen to be similar in age and sex to the OUD group. All people in the study had face-to-face talks with the researchers. This study followed rules to keep people safe and was approved by the medical ethics board.

We used special forms and talks to gather information. This included a form about age and schooling, a doctor’s talk to check for mental health problems, and forms to ask about childhood traumas, how people attach to others, how impulsive they are, their quality of life, and how much they craved drugs. We then looked at all the numbers from these forms using special computer programs to see what the information told us. We wanted to see if the results were real and not just by chance.

Results

We compared people with OUD to healthy people in our study. People with OUD had much higher scores for craving drugs, especially if they had low-income families or had tried to harm themselves. Women in the OUD group had higher scores for sexual abuse. People whose parents did not live together had higher scores for emotional abuse and neglect. Patients from low-income families also showed more fearful attachment. Men who did not have other family members using drugs and who did not smoke had more secure attachment. Patients who had tried to harm themselves scored higher for acting without planning. Patients who smoked had worse scores for physical and mind health. People with poor family relationships had worse scores for mind health and social life. OUD patients whose family members used drugs had worse social relations scores.

When we looked at how different things were linked, we found some connections. Higher drug craving scores meant lower quality of life scores. Patients who were emotionally abused had certain ways of attaching to others (preoccupied and dismissive styles). Also, the more emotional neglect people had, the worse their quality of life was. Sexual abuse was linked to acting without thinking or planning. People who had been sexually abused also had lower general health and environment quality of life scores.

We also looked at what factors might increase the risk of OUD. We found that age, smoking, physical neglect, and acting without planning were important factors. These factors on their own strongly showed who might have OUD.

Discussion

Understanding how OUD works and what personal things are involved helps us find better ways to treat and stop it. In our study, we looked at how childhood trauma and how people attach to others are linked to OUD. We found that people with OUD had higher scores for overall childhood trauma, emotional abuse, physical abuse, physical neglect, and emotional neglect. This agrees with other studies that show bad childhood experiences are linked to OUD later in life. Our study also showed that physical neglect was a strong link to OUD. Not every person with a bad childhood experience gets OUD. Other things like stress from society, bad ways parents acted, or not having good support from others can also put people at risk. We also found that women with OUD had more sexual abuse scores from childhood than men.

We also looked at how OUD patients attach to others. How a person attaches to others starts when they are babies and affects them as adults. Other studies have found links between how people attach and addiction. But in our study, we found that OUD patients had similar attachment styles to healthy people. This might be because strong family bonds in our country can protect people from bad health problems like drug use. Our findings suggest that how someone attaches to others might not be a risk factor for drug use on its own. However, we did find strong links between people who had emotional neglect and abuse as children and being scared in relationships as adults.

Another important part of our study was looking at how acting without thinking (impulsivity) is linked to other things. We found that patients with OUD had higher scores for acting without thinking or planning. Our findings show that acting without planning is strongly linked to OUD. We also found that men had more trouble stopping their actions without thinking than women. This might be one reason why OUD is more common in men. Also, emotional and sexual abuse from childhood trauma seemed linked to acting without thinking. People who had tried to harm themselves also scored higher for acting without planning.

Our study also showed that people with OUD have a lower quality of life than healthy people. We found links between a person's quality of life and if they smoke, if another family member uses drugs, if they lost a parent, and how much they crave drugs. Bad childhood experiences and acting without thinking were also linked to a lower quality of life. We also looked at drug craving, which is a sign of OUD and a goal for treatment. Our study did not find a strong link between craving and other things, which means craving is complex and needs more study.

There are some things to keep in mind about our study. We used forms where people answered questions about themselves, and they had to remember things from the past. Also, the study was only done in one place, so it might not show how all OUD patients are in Turkey. And while medical rules say someone is in remission from OUD after at least 3 months, our study included people after only 1 month. Despite these points, what we found is that OUD patients have more childhood trauma and are more impulsive. How OUD patients attach to others is similar to healthy people, but their quality of life is worse in some areas. Childhood traumas and impulsivity are important risks for OUD that should be looked at together. We need more studies with many more people in the future to learn more about this.