Converging Impact of the Ongoing Conflict and COVID-19 Pandemic on Mental Health and Substance Use Disorders in Ukraine

Abstract

Since the Russian annexation of the Autonomous Republic of Crimea and the subsequent occupation of parts of the Donetsk and Luhansk regions, Ukraine has been facing increasing security and healthcare challenges. The seven-year war in East Ukraine has led to a rise in substance and alcohol use and increasing addiction rates among veterans, internally displaced persons, and civilian survivors. This article examines the combined impact of the ongoing Russo–Ukrainian conflict and COVID-19 pandemic on substance use in Ukraine. It also gives an overview of the institutions in place to monitor and improve mental health in the country. The article highlights the urgent need for further funding and research on substance and alcohol addiction, with vulnerable populations affected by the conflict during the COVID-19 pandemic. Frontline healthcare workers in this region should anticipate an increased burden of patients suffering from substance use disorders who are in need of emergency management intervention and proper behavioral health referrals.

INTRODUCTION

This article examines how the conflict in Ukraine has led to mental health issues, including the use of maladaptive coping strategies through substance use disorders. The article also reviews the present public health infrastructures in Ukraine in place to monitor and address the ongoing mental health issues. It also identifies emergency management priorities and capacity needs in Ukraine to conduct harm reduction of substance use triggered by the conflict and the COVID-19 pandemic.

As of 2021, the economy of Ukraine has been affected by emerging issues with the COVID-19 response. The pandemic is pushing Ukraine toward its worst recession in decades, with devastating consequences for its most vulnerable people. Unemployment is surging, with more than 9 million people at risk of falling back into poverty (1). The combination of the conflict and the pandemic has led to growing concerns for the adoption of maladaptive coping strategies among the public. These behavioral strategies can lead to increased substance use disorders and mental health issues among veterans, civilians, and internally displaced persons (2,3). Recent studies have further documented how the COVID-19 pandemic has exacerbated the global opioid epidemic, alcohol use disorders, substance abuse and addictions (4,5). These escalating behavioral health issues can place a strain on an already fragmented healthcare system and under-resourced emergency management system. The compounded effects of the conflict and the COVID-19 pandemic on vulnerable populations represent a critical area of study as knowledge in this area will enable us to prepare for future scenarios where conflicts and external stressors intersect.

DISCUSSION

Conflict and War

The recent conflict in Ukraine has resulted in over 10,000 civilian casualties, many of which were due to artillery attacks and landmines. As of February 2021, an estimated 1.5 million Ukrainian citizens were internally displaced or became migrants as a result of the war (6). Many of them suffer from substance use disorders and have a growing need for social service and addiction health intervention programs (7). Conflicts and wars contribute to a higher burden of behavioral health issues among individuals across all generations who experience trauma as well as among those living in or near conflict zones (8, 9). Post-traumatic stress disorder is the most recognized mental health issue in these settings. During the conflict, there was also a significant increase in other common mental health problems such as depression, anxiety, and substance misuse. Underlying mental health problems are also potentially worsened following traumatic injuries, e.g., head trauma, limb loss, separation from family, and isolation from social contacts.

The significant influence of prior traumatic events in the twentieth century should not be ignored as they are still affecting the surviving elder population of Ukraine, which include the genocidal Great Famine of 1932 (Holodomor) killing 4 million Ukrainians, World War II (with over 8 million Ukrainian casualties), and chronic duress from over 70 years of Communist rule.

COVID-19 pandemic

The recent COVID-19 pandemic has deterred the ongoing addiction and substance use interventions and research. The country is also stretched thin in capacity building and necessary resources to meet the population’s behavioral health needs. The number of COVID-19 cases in Ukraine has been steadily increasing since the first official case in March 2020. According to the Ministry of Health of Ukraine (Center for Public Health), as of January 2021, there were 1,219,455 laboratory-confirmed cases, with 227,070 known fatalities (10). According to the Center for Public Health, data from the temporarily occupied territories of the Autonomous Republic of Crimea, the city of Sevastopol, the Donetsk and Luhansk regions are “missing” (10). The missing data impede further understanding of substance use and limit our ability to implement solutions to curbing substance use to help vulnerable populations in these conflict-affected areas.

The COVID-19 pandemic has also changed the medical care for patients undergoing substance abuse treatment. In March 2020, the Ministry of Health of Ukraine issued interim guidance, which was adopted in November 2020, for patients in Opioid Agonist Therapies (OATs), e.g., methadone and buprenorphine. As of January 2021, OATs were used by 14,800 patients. This guidance led to increased take-home dosing regimens for OATs, which has raised concern that there may be an increase in overdoses and more patients may drop out of treatment programs (11).

Mental health and emergency management infrastructure

The mental health infrastructure and emergency management system in Ukraine to support and assist vulnerable populations with substance use disorders are not keeping pace with increasing medical needs caused by the novel coronavirus pandemic. Emergency medical care in Ukraine is fragmented and underdeveloped and faces challenges such as lack of funding, shortage of proper medical equipment, and lack of standardization in emergency care training (12).

In 2017, the Cabinet of Ministers of Ukraine adopted the Concept for the Development of Mental Health Care with a commitment for support up to 2030. The Concept for the Development of Mental Health Care highlights behavioral health problems in Ukraine and guides the government to create an “Action Plan,” which would entail specific ways to address mental healthcare problems. For example, the provision of care to support patients with mental disorders and substance use issues is deemed to be the critical area of focus (13). In January 2021, the Action Plan was passed by the official public discussions and is now in process of approval by all ministries.

The Center for Mental Health and Monitoring of Drugs and Alcohol of the Ministry of Health of Ukraine (Center for Mental Health), a state-level mental health infrastructure established in 2006, monitors the prevalence of opioid and alcohol misuse disorders (14). One of the positive contributions of the Center for Mental Health has been the implementation of statistical analysis for psychiatric care in Ukraine, especially the creation of a database of psychiatric care facilities. As shown in Figure 1, the Center for Mental Health has mapped all public facilities and its networks in Ukraine from which people with substance use disorders can seek social services and healthcare.

Figure 1.

Network of facilities providing psychiatric care to people with substance use disorders In Ukraine.

Map: Oleksii Sukhovii. Source: Center for Mental Health and Monitoring of Drugs and Alcohol MoH of Ukraine (https://www.datawrapper.de/_/Yjcfv/)

The Center for Public Health in Ukraine is a healthcare and state institution, established in 2015, whose primary functions include monitoring and improving the health status of the Ukrainian citizens, social and hygienic monitoring of diseases, epidemiological surveillance and biological safety, group and population prevention of diseases, epidemic control and strategic management in public health. The Center for Public Health coordinates opioid maintenance therapy (OMT) to assist populations, including those in the conflict regions of Ukraine. The Center for Public Health has been monitoring OMT on a monthly basis since 2014 and publishes the data as an online resource. Figure 2 is a map documenting the individuals receiving OMT throughout Ukraine.

Figure 2.

Map of persons receiving opioid maintenance therapy in Ukraine. Map: Oleksii Sukhovii. Source: Center for Public Health MoH of Ukraine (https://www.datawrapper.de/_/109ME/).

Additionally, the National Health Service of Ukraine is funding OMT programs with an open-access database to the public. Supporting such government institutions in Ukraine will lead to short-term and long-term successes in improving opioid-induced harm reduction during the COVID-19 pandemic. The Center for Public Health and the Center for Mental Health have both grown over the years at the government level and continue to help vulnerable populations gain better access to facilities and treatment. As the novel coronavirus spreads in Ukraine, building capacity with access to emergency healthcare and vaccination distribution programs at these government institutions will be vital to improve the country’s overall health. In January 2021, the Ukrainian government announced the schedule for a state-funded COVID-19 vaccination campaign. Ukraine was scheduled to receive 117,000 doses of Pfizer-BioNTech vaccines in February via COVAX, a facility coordinated by the World Health Organization (WHO) to support lower-income countries in accessing vaccines (15) As of June 1, 2021, 1,047,894 people in Ukraine have received their first dose of a COVID-19 vaccine, and 132,508 have received two doses (16).

International efforts have been made in Ukraine by governmental, public, private, nongovernmental, and international organizations to effectively treat conflict-affected Ukrainians with substance use disorders. Global support and aid have been increasing since 2014. The WHO, United Nations Children’s Fund (UNICEF), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), United Nations Office on Drugs and Crime (UNODC), European Union Action against Drugs and Organised Crime (EU-ACT), North Atlantic Treaty Organization (NATO), the World Bank, United States Agency for International Development (USAID), Swiss Agency for Development and Cooperation (SDC), and Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) are largely contributing to enhance mental health services, especially for people with mental and behavioral disorders due to psychoactive substance use.

RECOMMENDATIONS

1. A reliable system for national data acquisition is of paramount importance. Further funding and research on substance and alcohol addiction due to the conflict in Ukraine and the COVID-19 pandemic should be prioritized. What may be under-measured is the toll of substance and alcohol addictions on vulnerable individuals triggered by the pandemic among veterans, internally displaced persons, and civilian survivors. Particular emphasis and interventions are needed in the conflict region of East Ukraine.

2. There is a critical need to ensure there are an adequate emergency management hospital-based infrastructure and a reliable prehospital system to reach the individuals with substance use disorders caused by the conflict and the COVID-19 pandemic. This includes underserved areas throughout the country and especially the conflict region in East Ukraine.

3. A national COVID-19 vaccination program should be implemented rapidly throughout the country in urban, rural, remote, and conflict settings.

CONCLUSION

It is essential to understand the compounded effect of the East Ukraine conflict and the COVID-19 pandemic on substance addiction rates in Ukraine, especially among displaced persons and veterans, to gain a complete picture of mental health in Ukraine. The COVID-19 pandemic deters support programs and interventions that were previously in place during the conflict. Additionally, there is an urgent need for a national emergency healthcare system and COVID-19 vaccination program in urban, rural, remote, and conflict settings. Past and current research suggest a need to empower and implement coping strategies and integrate substance use prevention and treatment services offered to vulnerable populations as part of crisis response efforts. Efforts to develop and evaluate interventions to treat substance use and reduce related harm are critical. Finally, frontline healthcare workers in this region should anticipate an increased burden of patients suffering from substance use disorders who need emergency management intervention and proper behavioral health referrals.