Migrants and drugs: health and social responses

Overview

Key issues

Migrants are a highly heterogeneous segment of the population, and the links between migration and drug use are complex.

On arrival, there is in generally a lower prevalence of drug use among migrants than is found in the host country. Nevertheless, some migrants may have already been using drugs prior to arrival and require drug-related medical care. Ensuring continuity of care for those receiving opioid agonist treatment and/or antiretroviral therapy is especially important, but there may be difficulties in determining medication equivalences and communicating the clinical management practices of the host country. 

Other migrants may be more vulnerable to problem substance use after arrival for a range of reasons, including trauma, unemployment and poverty, and the loss of family and social support. Drugs may be used by migrants to cope with trauma, boredom, and uncertainty and frustration in relation to their immigration status. Migrants’ vulnerability may be further aggravated by a lack of information about healthcare services and difficulties in accessing treatment. 

Data and literature on the prevalence and patterns of substance use among migrant populations in Europe are scarce, and this deficit inhibits a thorough assessment of the needs of this group (Humphris and Bradby, 2017; Blom et al., 2016).

Responses

Few interventions exist that focus specifically on drug use among migrants, and where such responses have been identified, little is known about their effectiveness. More commonly focused on is the broader issue of migrant health, or improving the accessibility of existing drug services for this group. Current responses include:

• interventions to facilitate and improve access to health services, including translating services and information materials, cultural mediation , cultural competency and training, peer work, gender-responsive assistance, and social integration;
• screening and needs assessment procedures suited to applicants for international protection and migrants in an irregular situation, specifically upon arrival;
• the provision of brief interventions in facilities housing migrants;
• engaging migrant populations through low-threshold services; and
• ensuring drug services are provided within integrated health services for migrants.

European picture

• There is currently no European overview of the availability of services responding to the health and social needs of migrants with drug-related challenges. At the national level, drug policies in EU countries rarely focus on the needs of migrants who use drugs, and, overall, studies suggest an under-prioritisation of the needs of migrants in areas such as mental healthcare, preventive care and treatment services. Nevertheless, recent years have seen the development of interventions in a number of countries, although data on their effectiveness, availability and coverage remain patchy. The majority of practices appear to be focused on reaching specific migrant populations, with only a few targeted drug-related interventions evident.

Key issues related to migrants and drug use

Responding appropriately to questions around migration has become an increasingly important concern for European policymaking over the past decade. Migration is a complex issue that requires proactive action to meet the challenges posed by recent migration from non-EU countries as well as intra-European migration flows. In addition, any examination of the subject should entail addressing the health needs of long-established migrant communities within the EU, where health and social inequalities are known to exist (De Kock, 2022). 

Recent developments, particularly the war in Ukraine, have also led to an increased recognition that there should be an equal focus on the mental health of migrants (Giacco et al., 2018) alongside their physical well-being. This includes issues related to substance use and the development of appropriate responses.

Migrants are a highly heterogeneous segment of the population (see Box Migrants in an EU context – who are we referring to?), and the links between migration and drug use are complex. There are often lower rates of substance use among migrants, especially recent migrants, than are recorded in their host communities, reflecting patterns of substance use behaviours in their countries of origin (Jane-Llopis et al., 2006; Harris et al., 2019). However, studies suggest that over time the prevalence of substance use in migrant communities becomes increasingly similar to that observed in the general population (Horyniak et al., 2016; Hurcombe et al., 2010; Priebe et al., 2016; WHO, 2018).

There are a number of known risk factors that migrants may experience that could lead to an increase in the prevalence of substance use. These include, but are not limited to, unemployment and poverty, loss of family and social support networks, and the move to a cultural setting where drug or alcohol use may be more socially tolerated. Other risk factors have been identified, including adverse socioeconomic living conditions (pre- and post-migration), traumatic experiences, low educational levels, family separation, family and socioeconomic status, work environment, stress and social exclusion (De Kock, 2022).

For individuals who do not have a pre-established residency, an additional concern is that, on arrival in a host country, drugs may be used to cope with stress, boredom, and individuals’ uncertainty and frustration regarding their immigration status. A range of risk factors have been identified that may be associated with an elevated risk of experiencing substance use problems among this group, including: duration of time spent in immigration detention, the pending threat of deportation, and lack of access to health, education and social services (De Kock, 2022). Recent migrants may also be vulnerable because of a lack of information about, and potentially access to, treatment. Recently, for example, ensuring continuity of care has been identified as a priority in addressing the needs of migrants from the Ukraine as those who were receiving drug treatment within Ukraine were often found to be unaware of how to access suitable support or continue treatment within their host country.

There is also evidence to suggest that due to their experience of adverse events, some migrants may be particularly vulnerable to developing substance use problems Horyniak et al., 2016; Knipscheer et al., 2015; Lindert and Schimina, 2015; Bogic et al., 2012; Brendler-Lindqvist et al., 2014). Experiencing traumatic events pre- and post-migration, as well as during the migration journey itself, may for example, contribute to mental health stressors that could result in an increased risk of post-traumatic stress disorder (PTSD), depression or other mental health problems, which could, in turn, exacerbate the risk of developing substance use problems after migration. PTSD in particular has been identified as a risk factor for developing substance use problems (Knipscheer et al., 2015; Lindert and Schimina, 2015). These concerns are particularly elevated for refugees and applicants seeking international protection (Horyniak et al., 2016). 

In what is often a fast-moving and complex situation, effective service planning can be informed by an understanding of the prevalence of risk factors and patterns of substance use among both new and more established migrant populations. However, this information is often lacking (Humphris and Bradby, 2017; Blom et al., 2016; Bogic et al., 2012; Lindert and Schimina, 2011; Knipscheer et al., 2015; WHO, 2018; Priebe et al., 2016; Hurcombe et al., 2010; Horyniak et al., 2016; Harris et al. (2019), and there is no standardised data collection process which focuses on the migration status of people entering drug treatment or other drug services. 

Data collection and monitoring exercises can be challenging in some countries due to legal constraints regarding what data can be gathered on race, ethnicity and even in some circumstances nationality. There is thus an urgent need for developing approaches that can inform the targeting and planning of services to address the needs of migrant communities while also respecting national data protection alongside ethical rules and procedures. 

Barriers to accessing services

In considering the health needs of migrants it is particularly important to identify the barriers that may limit the ability of migrants to access both generic as well as more specialist health provision (Lindert and Schimina, 2011; Blom et al., 2016; Madeira et al., 2018). 

Migrants who need support with a drug problem may be unaware, for example, of the availability of treatment services, or have anxieties linked to disclosing drug use or seeking support related to fear of stigma and the possibility of experiencing adverse consequences, such as the risk of deportation, forfeiting residency rights or rights to accommodation and other privileges, or even losing custody of their children. Linguistic issues also represent a significant barrier to service access and delivery, as many migrants will not speak the language of the host country.

Other obstacles in the way of accessing specialised mental health or substance-use-related services among these populations include: different help-seeking behaviours; diverse cultural expectations regarding healthcare professionals; negative attitudes towards and by providers; long waiting lists; and cultural beliefs about mental health.

Responses to drug-related problems among migrants

In EU countries migrants may be entitled to emergency healthcare, but such provision varies between countries. In addition, generic approaches typically exist that support migrant health issues, and these may sometimes also include support for problems with substance use. Overall, however, there is an absence of services that have been specifically developed to address drug problems among migrants in Europe, although this situation is slowly changing with the launch of specialist services in recent years in a number of countries.

The interventions that have been developed to facilitate and improve access to general health services among migrant populations tend to focus on the following areas: increasing awareness and access to existing services; providing translation and interpretation services; making adjustments to service delivery models in order to be more sensitive to cultural differences or the specific needs of migrants; and employing liaison, referral or outreach staff to facilitate referral and service uptake (De Kock, 2022). 

Key elements in these interventions may include:

• Translation services to improve the experience of foreign-language speakers in health services and their subsequent retention in and adherence to treatment programmes (Guerrero et al., 2012; Aelbrecht et al., 2012). Such responses address language barriers by making trained interpreters available to the relevant services, or using web-based applications, communication cards and telemedicine approaches. In addition to being translated, health communication materials may need to be adapted to specific audiences. While research in this area is underdeveloped, some studies suggest that the use of translators can improve adherence to substance-use treatment among migrants at high risk of dropout.
• Cultural mediation services, which may be offered alongside translation services, to facilitate communication between people speaking different languages and coming from a variety of cultural backgrounds (Guerrero et al., 2012). Cultural mediators are professionals who can provide information on different sets of values, assumptions and sociocultural conventions by clarifying culture-specific expressions and concepts that might give rise to misunderstandings. They can facilitate the adaptation of opioid agonist treatment protocols and procedures in the reception country that may differ from those in the country of origin, as well as addressing variations in drug laws and cultural or societal norms with regard to drug use in the host country.

• Cultural competency and training to encourage and empower health professionals to be culturally sensitive by (a) reflecting on their own cultural backgrounds and assumptions and how these may impact their clinical encounters with migrants, and (b) being more aware of the different beliefs and expectations of migrant populations when planning treatment at the individual and organisational level (Guerrero et al., 2012). Additionally, organisations and professionals may consider the structural and social factors that influence substance use and access to treatment for migrants and ethnic minorities.
• Peer work in the provision of targeted interventions, including the use of approaches that facilitate reaching migrant parents, training migrants to develop and disseminate prevention methods, and defining prevention priorities together with these populations.
• Gender-responsive services to suit the needs of particular groups. This is particularly important as European drug demand reduction services have often been developed in the context of a predominantly male service-using population, thus highlighting the need to refocus on both gender-relevant and gender-sensitive services. Consideration should be given to providing women-only, trauma-informed, non-stigmatising, gender-responsive treatment in which attention is also given to addressing childcare needs (see Women and drugs: health and social responses).
• Trauma-informed approaches that recognise the signs and symptoms of trauma in patients (and staff) and the role this can play in their lives; that avoid the repetition of trauma; and that restore feelings of safety and self-worth (Turrini et al., 2019; Wenk-Ansohn et al., 2018).

Interventions targeting migrants and drug-related problems

There is currently a limited but growing range of drug-related services and interventions in European countries specifically targeting migrants with drug problems. Importantly, however, where targeted interventions exist, little is known of their effectiveness.

The EU Drugs Strategy 2021-2025 focuses on the need to address barriers to accessing support services and treatment with respect to the key characteristics of the target group, such as demographic factors (including cultural background), situational factors (including migration) and personal factors (including mental health and well-being). It also acknowledges that migrants are among the specific groups of people who use drugs and who have drug-use disorders that may potentially have more complex or specific care needs.

Targeted interventions are developed in the context of screening and needs assessment procedures, brief interventions, continuity of care, integrated health services, and social reintegration.

Screening and needs assessment

It is important to establish screening and needs assessment procedures for applicants for international protection and migrants in an irregular situation, specifically upon arrival, and these should include measures to assess potential substance use problems. It is also vital that staff in any services, such as housing and drop-in facilities, are alert to potential problems.

Brief interventions

Some studies suggest that brief interventions offered within facilities housing applicants for international protection and migrants in an irregular situation may be useful in contributing to prevention strategies and as elements of community-based or multi-component approaches (Greene et al., 2019). Brief interventions in this context are usually intended to prevent the transition from recreational to high-risk substance use and from high-risk use to substance use disorders. However, more evidence is needed to determine their effectiveness here.

Continuity of care

A number of migrants will arrive with established opioid-use-related problems, and may need medical care for opioid dependence, in particular opioid agonist treatment, as well as support for the prevention or treatment of drug-related infectious diseases. Ensuring continuity of care for those patients receiving opioid agonist treatment and/or antiretroviral therapy is especially important as discontinuing care could result in relapse or other negative health consequences.

Possible challenges in ensuring continuity of care among those receiving opioid agonist treatment include: difficulties in determining equivalencies between the medication prescribed in the host country and the country of origin; having to switch the client to the prescribed medication available in the host country; and communicating clinical management practices that could differ from the country of origin (e.g., the requirement for urine testing).

Low-threshold services, with no or few access criteria, and which actively reach out to vulnerable populations, may be particularly attractive to applicants for international protection and migrants in an irregular situation.

Integrated health services

The development of integrated health services and coordination with housing and social services is likely to be an important element in providing an effective response to the health needs of migrants (Roberts et al., 2015). This is because, both in the general population and among migrants, problem substance use is often associated with mental health disorders and adverse social conditions. These sorts of problems may be particularly acute among applicants for international protection and refugees.

There are few practices in substance use treatment specifically targeted at migrants that have been robustly evaluated, but a number of trials have been conducted in relation to trauma-focused methods. Cognitive behavioural therapy for reducing substance use has also found to be beneficial in non-refugee migrant populations (Turrini et al., 2019). These and other mental health interventions could support efforts to tackle the underlying reasons behind problem substance use. 

Other interventions aimed at improving the mental health of persons with a migration background include raising awareness of cultural and contextual backgrounds in therapy, or developing links between facilities housing newly arrived migrant and mental healthcare services (De Kock, 2022).

Social reintegration

Social reintegration services can also be important in facilitating the integration into the host community of migrants who use drugs (Priebe et al., 2016). Social reintegration typically focuses on housing, education and employment, and may play a role in reducing the prevalence of mental health disorders and lowering the barriers to accessing treatment, as well as supporting recovery for people who use drugs. 

European picture: availability of drug-related interventions for migrants

There is currently no European overview of the availability of services responding to the health and social needs of migrants with drug-related problems (De Kock, 2022). At the national level, drug policies in EU countries do not often specifically feature the needs of migrants who use drugs, and, overall, studies suggest an under-prioritisation of the needs of migrants in Europe in areas such as mental healthcare, preventive support and long-term care (De Kock, 2022). This situation is changing slowly and in recent years a number of countries have developed interventions, but data on their effectiveness, availability and coverage remain scant (De Kock, 2022).

Access to general healthcare and specialised services, such as mental health and substance use treatment, depends on the organisation of individual countries’ healthcare systems – on how they approach the issue of healthcare inclusion with regard to different migrant groups as well as their capacity to design and implement medical support for refugees and applicants for international protection in view of their specific circumstances and needs (IOM, 2016, 2018).

A number of actionable recommendations have been developed by SEMID-EU, a project funded by the European Commission. This initiative aims to fill gaps in knowledge and practical experience regarding drug use and migration in Europe in order to improve the well-being and health of vulnerable migrants who use drugs. SEMID-EU recently carried out a three-stage Delphi study to develop consensus statements and recommendations among civil society experts in Europe on drug use and access to care services for vulnerable migrants in the European Union. The study reached high levels of agreement on 20 statements and 15 recommendations. These recommendations focused on increasing the availability of reliable data, developing supporting materials, strengthening collaboration between EU Member States, and eliminating barriers in accessing drug-related services (see Box Recommendations for action to improve access to drug-related services for migrants who use drugs) (van Selm et al., 2023). Future outputs of the project include a mapping exercise with regard to local needs among migrant groups in Amsterdam, Athens, Berlin and Paris, and the development of toolkits and practical guidelines.

Many European countries grant access to healthcare for refugees, although limits may be imposed on the care provided. These limitations may be even greater for applicants for international protection and migrants in an irregular situation. However, some countries have been working to improve access to healthcare for these populations. Spain for instance has reinstituted universal access to the national health system for everyone in the country, regardless of their administrative situation. In Latvia, a new law grants stateless persons the right to receive state-funded minimum medical care assistance. In Cyprus, a co-funded government project covers the medical costs of third-country nationals, including applicants for international protection (EMN, 2019).

There are a number of interventions in European countries that attempt to overcome language barriers in healthcare, including drug services. Approaches used include promoting cultural competency and offering translation services as well as the multilingual dissemination of information materials on substance use through means such as leaflets and online videos or smartphone applications (De Kock, 2022).

For example, in Belgium, cultural mediators are employed in hospitals to overcome linguistic and cultural barriers in a variety of healthcare contexts (Verrept, 2019), and in Sweden a telepsychiatry service is available nationwide to facilitate refugees’ access to mental health services (WHO, 2018). In Germany, one particular project provides online videos that draw attention to the possible consequences of using alcohol, cannabis or prescription medication. These videos are available in German, English, Arabic, Dari and Tigrinya, and can be used by professionals working with these migrant populations (Mittel et al., 2018). In Belgium a smartphone application tailored to refugees was developed to provide an overview of welfare, mental health and other services (Mascia, 2020).

Interventions and resources developed to improve cultural competency are available in a number of Member States, although there are no data on their coverage and implementation. Often these measures include training and coaching for professionals working with migrants and ethnic minorities, the development of guidebooks on how to increase cultural competence, and forging links between different services needed by these populations (De Kock, 2022). 

Targeted interventions

Across Europe there are a number of initiatives in operation designed specifically for migrants, or particular migrant populations, often including different components, such as health assessments, brief interventions, and residential and outpatient treatment.

For example, in Greece, REFRAME responds to emergency needs and fosters the empowerment of refugees and other migrants. It consists of systematic needs assessment and awareness-raising with respect to substance use (De Kock, 2022). Prevention and early intervention groups for families, parents, children and young people are also offered, as is counselling for people who use drugs and referral to other services as needed. REFRAME also trains professionals and volunteers working in accommodation sites and shelters to identify problems related to substance use and potential referrals.

In Berlin, a residential treatment programme targets clients from diverse cultural backgrounds. It provides intercultural individual and group therapy, mediation with relatives, and support with migration and social issues (De Kock, 2020). Similarly in Greece, Kethea Mosaic offers intercultural counselling and other services to facilitate social integration and relapse prevention among migrants who use drugs, albeit in a low-threshold non-residential programme (De Kock, 2022). 

Implications for policy and practice

Basics

• Substance use prevalence rates among migrants upon arrival are generally lower than those of the host populations, but migrants may be more vulnerable to substance use problems for a range of reasons, such as trauma, unemployment and poverty, loss of family support, boredom, and uncertainty and frustration with regard to their immigration status.
• The vulnerability of this population may be aggravated by a lack of information about or access to drug services.
• Language difficulties can represent a significant barrier in assessing the needs of migrants and in facilitating their access to care.

Opportunities

• Targeted services to address the needs of migrant groups are being developed in a number of countries and promising examples of practice should be shared.
• Routine monitoring and needs assessments could be developed to increase the understanding of priorities in this area. 

Gaps

• There is limited knowledge on the extent and nature of the drug problems among new migrants in Europe.
• Few national drug policies currently address migrant health. Interventions need to be expanded to explore and address cultural barriers, translation and interpretation needs, and the requirements for increasing staff competence in working with different migrant populations. 
• Interventions in this area need to be evaluated so that the current limited evidence base can be expanded.

Further resources

EMCDDA

• Responsiveness and preparedness in addressing drug-related needs of displaced Ukrainians in EU countries bordering Ukraine, Trendspotter briefing, 2022
• Displaced people and EU preparedness and response — lessons from Ukraine, Webinar, 2022
• Responding to drug-related problems among migrants, refugees and ethnic minorities in Europe, Commissioned paper, 2022
• Migrants, asylum seekers and refugees: an overview of the literature relating to drug use and access to services, Commissioned paper, 2017

Other sources

• EUAA 2022, Critical incident management in the field of asylum and reception
• EUAA 2021, Consultations with applicants for international protection on mental health
• FRA 2015, Cost of exclusion from healthcare: the case of migrants in an irregular situation 
• UNHCR 2018, Addressing alcohol and substance use disorders among refugees: a desk review of intervention approaches
• WHO 2019, What are the roles of intercultural mediators in health care and what is the evidence on their contributions and effectiveness in improving accessibility and quality of care for refugees and migrants in the WHO European Region?
• WHO 2018, Health of refugees and migrants: regional situation analysis, practices, experiences, lessons learned and ways forward
• WHO 2016, Public health aspects of mental health among migrants and refugees: a review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region 

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About this miniguide

This miniguide provides an overview of what to consider when planning or delivering health and social responses for migrants who use drugs, and reviews the available interventions and their effectiveness. It also considers implications for policy and practice. This miniguide is one of a larger set, which together comprise Health and social responses to drug problems: a European guide.

Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2023), Migrants and drugs: health and social responses, https://www.emcdda.europa.eu/publications/mini-guides/migrants-and-drug….

Identifiers

HTML: TD-02-23-181-EN-Q
ISBN: 978-92-9497-953-7
DOI: 10.2810/123920