As defined by the United Nations (UN), an international migrant is someone who changes his or her country of usual residence, irrespective of the reason for migration or legal status (1). Refugees are also persons who are residing outside of their country of origin for reasons of feared persecution, conflict, generalized violence, or other circumstances that have seriously disturbed public order and, as a result, require international protection (2). There are around 272 million migrants globally, majorly labour migrants (3), and amongst these groups, nearly 26 million are refugees, and half of them are under the age of 18 (4). Migrants and refugees are a heterogeneous group. As a result of self-selection (e.g., health, level of education, wealth, ambition, etc.) and the exclusion of unhealthy individuals at immigration pre-screening level, international migrant populations may have a better health condition than the native population (5-7). Overall they do not necessarily exhibit a significantly higher prevalence of physical and psychological morbidities, especially substance use disorder (8, 9). However, refugees often face a number of resettlement stressors and acculturations that may be compounded by the previous violence of trauma exposure, which cumulatively might increase the risk for substance use disorder. More importantly, being kept in detention centers (10), the stress of relocation (11), lesser access to the necessary services (12), unemployment, difficult living conditions, problems with learning a new language (13), isolation, separation anxiety and division of the family, living in violent or poor neighborhoods which drugs are more likely to be available, exposure to different types of trauma (11), discrimination and exclusion (14-16) transformation of social roles, weakened enforcement of substance control policies (17) and the effect of cultural shaping of symptoms and illness behaviors are all risk factors that may make migrants and refugees more vulnerable to mental health problems and substance use disorder (18, 19).
Migrants may be particularly affected by income loss, isolation, lockdown, insecurity, social exclusion and lack of access to culturally and linguistically accessible services, compounding further the vulnerabilities that migrants face on a daily basis (20, 21).
Published evidence demonstrates that people with substance use disorder (PWSUD) are at increased risk of COVID-19 and its associated complications (22). On the other hand substance use disorder (SUD) is considered to get more complicated during the COVID-19 pandemic (25). Migrant and refugee PWSUD are doubly at risk of exclusion and stigmatization.
At the time of the outbreak of COVID-19 (and before the announcement of the pandemic by the World Health Organization (WHO)), the International Society of Addiction Medicine (ISAM) published a set of guidelines on supporting clinicians and policymakers to deliver an effective service for people with substance use disorders (PWSUD) (24). One of the important recommendations in this manuscript was the prioritization of specific populations at risk, including refugees and migrants in the context of competing health priorities. Additionally, a multi-phase global survey was conducted by the ISAM COVID-19 team in order to better understand the impact the acute stages of COVID-19 had on treatment and harm reduction services to PWSUD populations and their responses. The details of the methodology have been published as a study protocol (22). The participants consisted of nationally-representative informants from different countries who were experts in the field of addiction medicine and active in substance use treatment at different levels of policy and/or service during the pandemic. They were surveyed about the SUD treatment and harm reduction services for migrants and refugees collectively, during the COVID-19 pandemic in their country or region and the way it has been affected by the situation.
In total, 177 individuals from 77 countries participated in this ISAM survey. The survey results showed that in the first month of the pandemic announcement, substance use disorder treatment and harm reduction services were available and accessible in 59% of the participating countries. 88% of total respondents continued providing necessary medical and psychiatric care for PWSUD (20).
The availability and provision of SUD treatment and harm reduction services for refugees and migrants during COVID-19 pandemic in May 2020 is illustrated through a world map in Figure 1. The results of the first phase of the survey in March 2020 (the first month after the announcement of the pandemic by WHO), after excluding the unrelated responses which indicated lack of information or unwillingness to answer the question by the respondent, showed that only 12.9% (n=17) of respondents believed their countries’ services for the migrants and refugees with substance use disorders continued as usual. In this time, services for this population were reported to be unavailable by 29.7% (n=39) of the respondents. 57.2% (n=75) of the respondents claimed that services are available for migrants and refugees in their countries but with limited access (Figure 2). Survey responses on harm reduction and treatment services for general population PWSUD showed that 43% (n=74) of the respondents reported that service provision is limited and not enough, whereas 26% (n=45) believed that both harm reduction and treatment services for general population PWSUD are adequately available and with enough coverage. 23% (n=40) and 7% (n=13) of the respondents reported enough coverage and accessibility but only for treatment services, and only harm reduction services, respectively.
In May 2020, two months after the announcement of a pandemic situation, only 11.7% (n=8) of informant respondents of the second phase of the survey reported that the services for refugees and migrants with SUD got better in comparison to March 2020, whereas 11.7% (n=8) reported that these services in their country discontinued completely and 41.1% (n=28) believed they got worse in comparison to their first phase reports. 41.1% (n=24) of the respondents reported that services for migrants and refugees continued as usual despite the pandemic (Figures 3, 4). Respondents reported that service improvement rates were considerably lower for refugee and migrant subgroups relative to the whole population with SUD.
Although these findings were not derived from epidemiological data, they revealed that marginalized people, especially migrants and refugees, are among the groups that got most negative impact during COVID-19 even compared to the other vulnerable groups such as women, pregnant women, and children, this situation could be possibly due to higher risk of being neglected or even being sacrificed by policymakers and service providers.
Posselt et al (2017) (15) believed barriers of the services to refugees are related to four broad areas: 1- organizational and structural, 2- access and engagement, 3- treatment and service delivery and 4- training and resources (15) which all mutually influence each other (26). It is therefore important to improve the visibility of the needs of migrants and appropriate interventions to those with substance use disorders by:
- Raising awareness
- Considering this group in service providers’ business continuity measures,
- Allocating enough resources to support this population during crisis situations
- Enhancing collaboration and integration among various services
- Advocacy for access to substance use disorders service
- Reducing shame and stigma, and
- Integrating substance use disorders treatment into other health services.