Violent conflict and opiate use in low and middle-income countries: a systematic review.

BACKGROUND Violent conflicts disproportionately affect populations in low and middle-income countries, and exposure to conflict is a known risk factor for mental disorders and substance use, including use of illicit opiates. Opiate use can be particularly problematic in resource-limited settings because few treatment options are available and dependence can impede economic development. In this systematic review, we explore the relationship between violent conflict and opiate use in conflict-affected populations in low and middle-income countries. METHODS We searched MEDLINE, PsychINFO, SCOPUS, PILOTS, and select grey literature databases using a defined list of key terms related to conflict and opiate use, screened the results for relevant and methodologically rigorous studies, and conducted a forward search of the bibliographies of selected results to identify additional studies. RESULTS We screened 707 articles, selecting 6 articles for inclusion: 4 quantitative studies and 2 qualitative studies that examined populations in 9 different countries. All study participants were adults (aged 15-65) living in or displaced from a conflict-affected country. Data sources included death records, hospital records, and interviews with refugees, internally displaced persons, and others affected by conflict. Overall, we found a positive, but ambiguous, association between violent conflict and opiate use, with five of six studies suggesting that opiate use increases with violent conflict. Five key factors mediate the conceptual relationship between opiate use and violent conflict: (1) pre-conflict opiate presence, (2) mental disorders, (3) lack of economic opportunity, (4) changes in social norms or structure, and (5) changes in drug availability. CONCLUSIONS The strength and direction of the association between opiate use and violent conflict and the proposed mediating factors may differ between contexts, necessitating country and population-specific research and interventions. Prevalence of opiate use prior to the start of conflict was common to all populations in which conflict induced a change in opiate use, suggesting that interventions to reduce opiate use and future research should focus on such populations. Population-based, longitudinal studies that use systematic measures of exposure to conflict and opiate use are needed to further explore this association and its mediating factors.