Substance use services for refugees

Bull World Health Organ 2019;97:246–246A | doi: http://dx.doi.org/10.2471/BLT.18.225086 Editorials 246 In 2017, a record number of 68.5 mil- lion people were living in forced dis- placement. Over one-third of these are refugees who crossed country borders in search of safety and protection, pri- marily into low- and middle-income countries.1 Becoming a refugee influ- ences risks for substance use disorders due to high levels of distress and mental health problems, disruption of protec- tive community networks, transforma- tion of social roles, changes in access to substances, and weakened enforcement of substance control policies.2 Epide- miological evidence corroborates the burden of substance use in forcibly- displaced populations, particularly among men and individuals with mental disorders.3–5 Addressing substance use disor- ders in refugee contexts falls within the mandates of various United Nations (UN) agencies. A new impetus for collaborative action is provided by the Global Compact on Refugees, which was recently adopted at the 2018 United Nations General Assembly and calls for joint action of multiple stakeholders to work together towards refugee protec- tion, assistance and solutions.6 Guidelines for the provision of humanitarian assistance recommend ac- tions to address substance misuse,7,8 but in practice few steps are being taken to monitor, prevent and treat substance use problems among displaced populations.9 A major reason for inaction is that available evidence on the effectiveness and implementation of substance use interventions in humanitarian settings is limited.9 The UN High Commissioner for Refugees commissioned a review to synthesize evidence on interventions for substance use among refugees in low- and middle-income countries and to identify promising strategies to inform operational research and pilot programming.10 The review identified six interventions evaluated among refu- gees and 29 interventions among other disadvantaged populations. Half of the refugee studies described screening and brief interventions to reduce hazardous substance use. Brief interventions are intended to prevent transition from hazardous use to disorder, while it is rec- ommended that individuals who meet criteria for severe substance use disorder also receive more intensive psychosocial and/or pharmacological intervention. Harm reduction was described in one refugee study, yet the evaluation focused on implementation challenges, not ef- fectiveness. The review did not identify studies describing promotion, universal prevention or selective prevention inter- ventions in refugee populations. Treatment studies identified in the review were not fully described or rigor- ously evaluated and had methodological limitations including non-experimental designs, non-validated measures, het- erogeneous outcomes and inconsistent recall periods. Particularly striking was the lack of studies on substances other than alcohol and on treatment options for people with severe substance use disorder. We argue that the gaps in knowl- edge and implementation should be addressed by operational research on substance use interventions among refugees. Such research should evaluate packages of interventions that bring together different approaches within a coherent frame. There will not be a single solution for addressing the com- plex public health problem of substance use disorder in refugee settings. Rather, various approaches that are known to work in non-refugee contexts should be implemented and studied in refugee settings while considering contextual as- pects. Such approaches include the role of gender, health and social problems, and structural factors, for example the criminalization of illicit drug use. Such a comprehensive package will likely consist of community-based approaches to raise awareness, promote primary prevention and reduce substance-related harm. Brief interventions delivered within an integrated primary health- care model to identify, manage, treat and appropriately refer (when possible) people with substance misuse, many of whom may be seeking care for health problems exacerbated by substance use, will also be needed. Capacity building including supervision for non-specialist providers is essential to ensure that interventions are implemented with fidelity and providers are confident in their ability to deliver this type of care. Last, clinical interventions for individuals with more severe substance use disorders should be provided to en- able these individuals to receive higher levels of care, including more intensive psychological interventions, medica- tion-assisted treatment and medically assisted withdrawal management. With the forcibly-displaced popu- lation growing, and with the increase in the burden of substance use disor- der globally,11 substance use among refugees must be considered a public health priority and addressed through concerted actions. Humanitarian non- governmental organizations often have insufficient research capacity and need to collaborate with research institutions and UN agencies. The limited available literature demonstrates that it is feasible to implement and evaluate substance use interventions in refugee populations. However, significant work needs to be done in overcoming implementation challenges and moving towards iden- tifying evidence-based substance use services for refugees living in complex, rapidly changing contexts.12 ■ Substance use services for refugees M Claire Greene,a Peter Ventevogelb & Jeremy C Kanea References Available at: http://www.who.int/bulletin/vol- umes/97/4/18-225086 a Johns Hopkins Bloomberg School of Public Health, John Hopkins University, 615 N Wolfe St, Baltimore, MD 21205, United States of America. b Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland. Correspondence to M Claire Greene (email: mgree116@jhu.edu). E itorials Editorials 246ABull World Health Organ 2019;97:246–246A | doi: http://dx.doi.org/10.2471/BLT.18.225086 References 1. Global trends - forced displacement in 2017. Geneva: United Nations High Commissioner for Refugees; 2018.Availbale from: https://www.unhcr.org/ globaltrends2017/ [2019 Feb 5]. 2. 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