The Conflict in East Ukraine: A Growing Need for Addiction Research and Substance Use Intervention for Vulnerable Populations

The conflict in Ukraine and its human toll since 2014 has reached over 13,000 deaths, nearly 3,000 of which were civilians lost largely to artillery and mines [1]. Recent statistics also estimate that there are over 1.5million internally displaced people or migrants as a result of the war (Figure 1). Efforts are being made in Ukraine by public and private organizations to improve the situation for Ukrainians who have been affected by the conflict. International support and aid have been increasing since 2014. For example, North Atlantic Treaty Organization (NATO) have increased projects and activities in Ukraine. Through the NATO Science for Peace and Security Programme, Ukraine has been featured in advanced research workshops, advanced training courses, and a larger cooperation with research and development projects. In 2018, Advanced Research Workshop on Health and Environment in Ukrainian Conflict Zones showcased various work in the fields of health, ecology, and economics, which included presentations on the growing concern of substance use arising from the conflict [2]. What may be undermeasured and left unexamined however, is the toll of substance and alcohol uses and addictions that may have been triggered by the conflict among the veterans, internally displaced peoples, and civilian survivors. Conflicts and wars are known to contribute to a higher burden of mental health problems among specific individuals who experience trauma as well as among those living in or near to conflict zones, even across generations [3-5]. Post-traumatic stress disorder is mostly recognized as the mental health burden; however, during conflict there is also significant disability from common mental health problems such as depression, anxiety, and substance misuse. From the Somalian conflict, these have been linked with the poverty associated with economic fragmentation and with a reduction of basic security functions and safety [6]. The link between armed conflict and the production and trafficking of illicit drugs has been noted in the literature, and recent research indicates a link between lootable resources, including opioids, and conflict duration [7]. As 2020 approaches, the conflict in Ukraine shifts to the emerging issues with substance uses and growing concern for mental health issues among the internally displaced population. As noted in a systematic review by Horyniak and colleagues (2016), forced migrants have commonly witnessed and personally experienced pre- and post-migration stress and trauma, including loss of homes and livelihoods, violence, and family separation [8]. Among this population, the prevalence of mental health disorders, specifically depression and post-traumatic stress disorder, are particularly high due to this lived experience [9-11]. In past studies, comorbidity between mental health and substance use disorders has been well documented in the general population [12-14]. An emerging literature has begun on substance use as a coping mechanism to document comorbidity among forced migrant populations [15-17].

Figure 1: Current map of UKRAINE since the 2014 conflict.

Also, forced migrants experience acculturation challenges, the process of cultural and psychological change that follows contact with a culture other than one’s own [18]. It has been hypothesized that migrants who are highly engaged in the host culture (‘assimilation’) may engage in substance use and addiction in order to adhere to mainstream norms and gain acceptance in their new communities [18-20]. Acculturation is an especially important factor for younger migrants, whose experiences are compounded by intergenerational conflict, and peer pressure as found in previous studies among Sudanese and Latino adolescents [19-23]. For example, in a study among ninth-grade adolescents, low levels of interest in maintaining their native culture alongside low levels of participation in their new culture, often due to discrimination and exclusion, has been associated with substance use [24]. Additionally, forced migrants, commonly experience social and economic inequality, marginalization and discrimination [25-28]. These factors have been shown to be important determinants of health, and could contribute to feelings of stress and powerlessness, which may contribute to substance use [29-31]. In addition, forced migrants could be exposed to illicit drugs as well through their residence in disadvantaged neighborhoods where drugs may be readily available leading to increased morbidity and mortality [32,33]. As a contributing factor, the HIV outbreak in Ukraine has spread throughout the nation. According to Public Health Center of the Ministry of Health of Ukraine, Ukraine continues to have high rates of HIV infection in Eastern Europe and Central and Eastern Asia [34]. According to the Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health of Ukraine, 25% of all Ukrainian people suffering from HIV prior to the beginning of the armed conflict were living in the Donbass area [35]. Prior to the conflict, the services to HIV-infected and high-risk groups of population for HIV infection in Donetsk and Lugansk regions included one of the largest networks of health facilities and nongovernmental organizations. Currently, little is known on how much of this network is still functioning after the conflict and how much of the epidemic is fully controlled. According to Public Health Center of Ministry of Health of Ukraine, “only every second HIVpositive person is aware of his or her positive status and applies to a medical institution” and cases of parent-to-child transmissions have not decreased [34]. As a consequence of increased substance and alcohol uses and addictions in Ukraine, the Ukrainian Monitoring and Medical Center on Drugs and Alcohol (UMMCDA) was established in 2015 as a government agency within the Ministry of Health of Ukraine. This Center leads activities related to monitoring the circulation of opioid medicines, illicit drugs, other psychotropic substances and precursors in Ukraine [36].

The understanding of substance addiction among the conflict zones in Ukraine especially among the forced migrants remains limited. Past and current research suggest a need to integrate substance use prevention and treatment into services offered to veterans, internally displaced peoples, and civilian survivors. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed. Further funding and research on substance and alcohol addiction from the 2014-2019 Ukrainian conflict should be examined. Are people from fragile states and conflict zones more susceptible to co-morbidity with substance abuse and addiction?.

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