From 2011 to 2024, the Syrian government and various factions fought. The conflict internally and externally displaced millions and injured or killed hundreds of thousands of civilians. Crucial infrastructure was destroyed, and remaining medical facilities struggle with a lack of staff, supplies, and funding [1]. The earthquakes in February 2023 further damaged the remaining infrastructure [2]. This destruction destabilized economic and social structures, limiting opportunities for engaging in traditional income-generating activities. This pattern is exemplified in Azaz, Syria, which is the geographical focus of this study. It is an area previously controlled by opposition forces with a population of 4·5 million; 2·9 million are internally displaced, and 3·7 million are food insecure [3]. Azaz’s population was 30,000 before the conflict, but an influx of internally displaced populations buoyed the number. At the time of the study, roughly 165,000 internally displaced people were estimated to be in Azaz, though these numbers may be outdated. In Syria, currency depreciation, high inflation, and commodity price increases have placed additional economic stress on a vulnerable population that may be forced to rely on alternative sources of income, including the production and/or sale of substances.

Substance use disorders (SUDs) include problematic use of substances like alcohol, nicotine, amphetamines, or other illicit materials. SUDs involve the use of these substances, which results in the impairment of an individual’s ability to function [4]. Development of tolerance and repeated failed attempts to quit constitute a cornerstone of the disorder. Medications, therapy, and neuromodulation can be used to treat SUDs. However, providing these treatments often necessitates the availability of specially trained healthcare workers and facilities. In countries with a history of significant conflict, internal displacement, and insufficient or destroyed medical infrastructure, there are complex risk factors and significant barriers to care affecting patterns of substance use. In Afghanistan, a nationally representative, cross-sectional survey found that the prevalence of any substance use was 5·03% with a sedative use prevalence of 6·71% [5]. Furthermore, individuals with previous experience of any traumatic event were more likely to use any substances compared to their peers. Those with depression, PTSD, and generalized anxiety disorder were also more likely to use any substance compared to their peers without psychiatric disorders. This association between a significant trauma burden and increased risk of substance use was similarly found in Lebanon, a country with the largest per capita number of refugees in the world, and its history of civil conflict and violence [6]. Furthermore, Palestinian refugees born in Lebanon had a higher lifetime rate of substance use than Palestinians and Syrians recently displaced from Syria [7]. The existing body of literature, while limited, suggests that refugees in countries in the Middle East with a history of conflict have an increased rate of substance use compared to non-displaced peers. This underscores potential associations between complex social factors, including trauma, conflict, displacement, and substance use.

Given the ongoing political and economic instability of Northwestern Syria, there has been a growing concern that substance use is rising. Seizures of amphetamines in the region reached a record high of 86 tons in 2021, double that of 2020 [8]. This suggests growing production and potential use of substances in the area. However, limited data is currently available on use patterns in Northwestern Syria. Previous studies sought to identify sources of drugs, the prevalence of use, demographics of users, reasons for the spread of drugs, and the impact of this spread on Syrians [9]. Previous efforts also sought to open and assess the need for an addiction treatment center in Azaz (opened with Physicians Across Continents (PAC) on 28 August 2022) and train Green Crescent Syria team members on mental healthcare and addiction. In the Afrin region, a study was conducted in collaboration with Turkish intelligence, the Activists’ Body, and National Army Factions to assess the prevalence of drugs and methods of trafficking between April 2021 and April 2022. A study in Damascus with Raba Al-Nahhas at the Syrian International Academy for Training and Development sought to analyze the impact of drug use and trafficking on homeless children. These previous studies could not fully elucidate substance use patterns due to methodology, scope, and structure issues. Developing an SUD unfolds as a complex interplay of personal, economic, and systemic socio-political factors, along with an individual’s social network and, in the aggregate, prevailing larger-scale conditions. This study seeks to elucidate patterns of substance use in Northwestern Syria and, subsequently, outline potential changes to increase care.

Funding for this study was obtained through the World Health Organization (WHO), and MedGlobal, an international NGO, coordinated logistics. Institutional research approval was obtained from Baylor College of Medicine. This study employed a multi-pronged recruitment approach, utilizing questionnaires and focus group discussions to systematically gather insights from community members and service providers regarding 1- the prevalence of substance use and SUDs, 2-their societal and public health impacts, and 3- perspectives on treatment availability and obstacles. This paper summarizes the data from these questionnaires.

This study utilized the 2008 Field Guide and Rapid Assessment of Alcohol and Other Substance Use in Conflict-Affected and Displaced Populations used by the WHO [10] and United Nations High Commissioner for Refugees (UNHCR) [11]. The substance use thematic group in Northwest Syria worked on translating, developing, and adapting the survey forms from this guide to the Syrian context. While formal psychometric validation was not feasible due to field constraints, the adaptation process included expert review and pilot testing The questionnaire forms consisted of 92 questions covering demographics, socio-political issues, use patterns in the area, positive or negative perceptions regarding substance use, personal use, attempts to quit, the presence of IV drug use, the presence of HIV, and sexual relations due to substance use. All questionnaires were conducted in Arabic by trained personnel.

All subjects were recruited from Azaz, part of Aleppo’s governorate in Northwest Syria. MedGlobal organized the recruitment of participants in coordination with the PAC organization, the local health directorate, and other stakeholders.

A snowball sampling method was applied: Recruitment of community members was done by verbal invitations by NGO staff, followed by an email if indicated. We asked participants to reveal who else we may contact who might be willing to participate in the study.

Oral and written consent was obtained from all participants before enrollment in the research study. Names or identifying information were not collected. Questionnaires were administered in person by trained, Arabic-speaking staff. Before the study, staff received training in the appropriate protocol for administering the survey and recording participant responses. Staff administered the survey orally and recorded responses due to concerns for participant literacy differences affecting data collection. This paper summarizes the results of these surveys.

This study provides comprehensive results about the demographic patterns of substance use within Azaz, an area whose composition is representative of Northwest Syria, where a confluence of political, environmental, and social disruptions has contributed to a rise in substance use. These results demonstrate a high prevalence of substance use, with the most common substances used being H-booz (methamphetamines), Captagon, Hashish, and Tramadol. Findings suggest that users predominantly use alone and are the only users in their household. While a small percentage of the sample acknowledged personal substance use, a larger percentage of the sample responded in detail about community use in such a way that suggests a significant level of awareness and, potentially, unreported personal use. This discrepancy demonstrates the impact of non-response and social desirability bias on this data set.

Additionally, this discrepancy further reinforces the social stigma surrounding substance use and potential barriers to accessing treatment for SUDs. Further surveys should explore this finding as a possible cause of a discrepancy noted in our results: non-users detailed reporting information about substance use. The types of substances used do not align fully with news/media reports of captagon use as the primary substance, but rather highlight more prevalent methamphetamine (hbooz) and hashish use. There are two ways to view our results, and the authors presume stigma surrounding substance use may be involved: looking strictly at those who reported personal use, rates are congruent with those in other countries. However, when information about substance patterns is compiled regardless of the user/non-user dichotomy, the picture obtained is that of a population with a high SUD burden.

Furthermore, analysis of the predictors of use within this recruited sample revealed patterns of vulnerabilities consistent with trends observed globally, particularly in countries like Afghanistan and Lebanon [5, 7]. Forced migration consistently emerges as a risk factor for substance use [12, 13]. Similarly, the strong protective role of education reinforces cross-cultural evidence that higher educational attainment serves as a buffer against SUDs across various populations [14, 15]. The pronounced risk gradient between displaced individuals with limited education and their higher-educated, non-displaced counterparts reflects the intersectional vulnerabilities documented internationally and in this sample, suggesting that the displacement amplifies existing disparities in substance use patterns across diverse sociopolitical contexts.

The vast majority (98.04%) of those acknowledging substance use reported intravenous drug use, potentially highlighting that milder levels of SUDs are less reported. However, a limited proportion had been tested for bloodborne pathogens like HIV; there is a noted discrepancy between reported counseling and testing for HIV. In light of how many users in our sample reported IV drug use, the lack of counseling and testing is alarming. This information stresses the importance of public health interventions targeted at intravenous drug users, including increased information about the potential for blood-borne diseases like HIV and safe needle use.

The lack of accessibility to treatment for substance use is highlighted by several findings of our questionnaire, including the lack of specialized centers for SUD treatment or medical doctors and the reliance on community or religious leaders who may not have specialized training for SUD treatment and prevention. As mentioned above, the lack of diagnostic options and care for co-occurring disorders and exposure to previous traumatic experiences is highlighted by questionnaire results, as users and non-users report that unresolved issues/trauma are antecedents to SUD. Even without available treatment, those who are using are reflecting on reasons for use, which indicates the severity of their use, as this represents an aspect of the pre-contemplative mindset for stopping or changing substance use patterns. Additionally, given the high rate of use of tramadol in the region, treatment options available should ideally include medication-assisted treatment (MAT). MAT is more efficacious than therapy alone [16]. However, MAT requires a functional medical infrastructure for initiating medication and maintaining long-term monitoring. In Northwestern Syria, there is currently limited or no access to MAT for substance abuse disorders.

Reported suggestions for improvement include expanding on themes found in this study and repeating this study, given recent changes in the sociopolitical situation in Syria. The end of the civil war represents an opportunity to repeat this survey to generalize better use patterns nationwide. Questions concerning vulnerable populations like women and children should be added to ascertain connections between substance use, conflict, and human trafficking. Due to the high reported rate of intravenous drug use, future studies may investigate how users acquire their needles and if any measures are taken to ensure that these supplies are safe. For this type of study, bilingual fluency is required. Therefore, for the reproduction and expansion of these findings, both linguistic and cultural fluency are a requirement.

There is a general lack of awareness of systemic factors' influence on SUD in the questionnaire. A plethora of published reports describe associations of substance trafficking with war and human trafficking, but our questionnaire found mostly awareness of financial issues and “bad company”/interpersonal influences. Prevention and treatment programs should carefully consider the balance of personal versus systemic interventions and the limitations of person-focused treatments in areas with such high socio-political conflict.

Limitations to this study include the nature of the data collected, the difficulty in obtaining information about individuals' substance use, social desirability bias, and significant barriers to recruiting participants. The data collected was primarily descriptive, including the characteristics of those responding to the questionnaire and their shared observations and experiences with substance use in the community.

The majority of individuals refused to answer questions regarding personal substance use history or whether they knew others who used substances. This may have been due to social desirability bias- SUDs remain difficult to discuss or acknowledge, and this attitude was evident beyond the individual level. Due to stigma, universities did not allow students to be recruited or surveyed on their campuses, which altered initial recruitment plans. Questionnaires had to be held in other settings with the assistance of the local health government. This suggests that there was a significant element of stigma that may have prevented participation in the study and deterred participants from being forthcoming about the true nature of substance use in the region. There was also a significant skew in the number of individuals who could be recruited and consented to participate in this study: the majority were male. As 480 participants were recruited, this is the most extensive study investigating patterns of substance use in Northwestern Syria [17].