The Confluence of Human Trafficking, Drug Trafficking, Militias, and Substance Use

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TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we see depression through the lens of an asylum seeker. This story is a reminder of the devastating impact of substance abuse, human trafficking, and conflict on individuals and communities. It underscores the importance of understanding the sociological aspects of drug use, including the need for structure, protection, and a sense of belonging. It highlights the critical role of trauma-informed care and policy interventions in addressing these complex challenges. This intersection between human trafficking, drug trafficking, ongoing conflict, and substance use exists in many parts of the globe. To understand this situation globally, one must consider the general principles underlying each phenomenon and leading to their confluence. In this piece, we look at the socio-economical background where the symptoms of interest developed, rather than the individual patient picture. Further, we wish to remind readers that militia, gang violence and human trafficking models share profound similarities across all countries and cultures.

Case Study

You see “Layla” in your outpatient clinic for depression. Her story stayed with you, as she softly cried recalling how she was able to seek asylum. Layla, a widowed mother of 2, struggled to make ends meet. The war had taken everything from her—her husband, her house, and her sense of security. They had fled and were internally displaced inside their home country of Syria.

When she met “Amir,” a seemingly kind man, she felt relief. He promised to take care of her. He said that he loved her. One day, when overwhelmed by the memories of the home she had left behind, the life she once had, Amir offered her a white tablet and told her that it would help her relax. It did not take long for Layla to become dependent on it. Amir gave it to her willingly at first, then he changed.

Amir told Layla that in order for him to keep giving her the tablets she had become dependent on, she needed to find other women who would work for him. Using the substance as both a lure and a means of control, Amir coerced Layla into recruiting other women. Whenever she had gone a while without using, she began to feel sick, and thought she had no other options. She complied. Layla found herself trapped in a vicious cycle of addiction and exploitation, her life spiraling out of control. One day, while wandering the streets, Layla stumbled upon a group of orphaned children. They, too, had fallen victim to the chaos, using gasoline to get high. Layla's heart ached for them, as she saw her own children reflected in their eyes. As she escaped her situation, years later, she remains depressed and bitter over her experiences, and sought care for those feelings.

Substance Use Disorders and Trauma Usage

Substance use, impairing an individual’s ability to function,¹ can destabilize the lives of users as they experience increasing financial and social pressure to maintain and to conceal their disorder. Treatment options require a functional system for the diagnosis and treatment of users.² Medications, therapy, and neuromodulation can be used to treat substance use disorders (SUDs). Medication assisted treatment (MAT) has been shown to be more efficacious than therapy alone.³ However, MAT requires a functional medical infrastructure for initiation of medication as well as long-term monitoring and maintenance. This medical infrastructure may be inaccessible to victims of human trafficking or patients in a zone experiencing conflict. In regions afflicted by both, those resources are effectively nonexistent.

Research has shown that those who have experienced trauma are also more prone than others to SUDs. SUDs may in turn promote situations or lifestyles that are likely to result in further traumatic experiences. Many have proposed a self-medication hypothesis, suggesting that patients may utilize substances in order to ameliorate symptoms of posttraumatic stress disorder, to attempt to fall asleep better, to escape painful memories, or to reduce anxiety.^4,5 For others, more stimulating medications might help to decrease feelings of anhedonia that are common after trauma, resulting in euphoria or the ability to enjoy pleasurable activities. Thus, an individual’s substance use patterns may be connected to their past traumatic experiences and ongoing substance use may make them vulnerable to an increased trauma burden and inhibit their ability to seek treatment for their SUD or a comorbid mental health disorder.

Patterns of drug trafficking can be seen in the Figure.

Figure. Routes of Drug and Human Trafficking

Cultural and Sociological Considerations

The cultural and social context of a given region greatly impacts substance users’ behavior and access to treatment. In many regions, cultural conceptions concerning substance usage affect access to care, identification of users, and adequate allocation of social resources to address these issues.

In one study of individuals with SUDs, their families, and associated providers in Iran, women who used substances were more likely to be accused of engaging in sex work as a means of supporting their addiction. This stigma served as a deterrent for women seeking treatment.⁶ Primary care providers in Southeast Brazil were also found to negatively judge the use of tobacco, marijuana, and alcohol. Users of these same substances experience the highest rate of rejection in health care settings.⁷ Thus, cultural attitudes may shape barriers to care and differ across socioeconomic, geographical, and cultural contexts.

Cultural conceptions surrounding substance abuse may also hinder researchers’ ability to interview individuals with a SUD, their families, or individuals in at-risk populations. These cultural barriers inhibit the ability to fully understand the scope of SUDs and, subsequently, may inhibit the ability to push for policy changes and the provision of resources to address the issue.

Human Trafficking

The presence of individuals who are vulnerable secondary to conflict, socioeconomic status, or legal status may predispose a region to having more trafficking activity.

The intersection between human trafficking and substance abuse patterns is significant both theoretically and geographically. The overlap between forced labor and substance trafficking may be a contributing factor to the geographical overlap of drug trafficking and human trafficking routes. Human trafficking routes can also be seen in the Figure.

Trafficking has several phases. In some cases, the recruitment stage is initiated by the trafficker feigning romantic interest in the victim. The trafficker may then begin to supply substances and facilitate the acquisition of these substances under certain conditions (ie, If the victim performs sex work or recruits additional victims to perform work for the trafficker). The travel-transit stage may involve confiscating documents and the initiation of violence. The exploitation phase involves the restriction of movement and poor working and living conditions as well as physical, sexual, and psychological violence. During this phase, detention or retrafficking may occur. Individuals who exit the exploitation stage without being retrafficked may reintegrate into their home country or integrate into the society of the host country.⁸ Understanding this framework is valuable to providers attempting to identify victims of trafficking, as victims may present for medical care at different points in this conceptual framework.

Substance usage and human trafficking are intertwined as those trafficking substances may also engage in human trafficking and/or use victims as labor to support drug trafficking activities. Traffickers also often use substances as a coercion tool. Drug addiction and the threat of withdrawal may be used as a tool to coerce labor or sex.⁹ Victims of human trafficking may also develop SUDs as a means of coping with exploitation and trauma.¹⁰ Understanding the interactions between these phenomena may allow providers to identify more accurately patients at risk for human trafficking and increase assessment for comorbid SUDs.

Groups, Conflict, and the Trafficking of Substances

For organized groups, income generated from direct involvement in the sale and/or production of substances or taxation of such activities may be funneled into funding ongoing conflict via payment of combatants or acquisition of supplies.¹¹ In Columbia, the FARC rebels funded their conflict with the government through the sale and trafficking of locally grown cocaine.¹² Synthetic substances, especially, offer an opportunity for manufacturing drugs without the need for large tracts of land. As seizures of amphetamines in the Middle East reached a record high of 86 tons in 2021, double that of 2020,¹¹ the United States sanctioned 2 relatives of a sitting president for their involvement in the production and exportation of Captagon.¹³ This development stresses the increasing importance of the production and trafficking of synthetic substances to fund the operations of the organized structures. The pattern of organized groups involved in conflict converting proceeds of illegal narcotic trafficking into operational funds is one which has occurred in many different regions of the globe throughout history.

Increased access to substances may also serve as an incentive to fight for a given group. Historically, there is precedent for heads of armed groups giving substances to combatants to incentivize them to fight or enhance their fighting ability. Hasan-l Sabbah in the 11th century gave Hashish to his fighters, the Hashisheen, and then showed them an exquisite garden to entice them to fight for him.¹⁴ In this case, joining a fighting force provided access to substances. Drug consumption may also be used to fuel soldiers during combat. During World War II, both Allied and Axis powers distributed methamphetamines to soldiers for use as performance enhancers.¹⁵ Use of stimulants can lead to psychosis and poor judgment as well as create a dynamic in which combatants become addicted to a given substance. This may increase their reliance and allegiance to the group for which they fight.

Organized groups who use trafficked substances to fund their operations contribute to the further traumatization of communities in conflict zones as violence secondary to drug trafficking further destabilizes these environments.¹⁶ Noncombatants may be lured into involvement in trafficking substances after being given the substances, as an alternative source of income after being displaced due to conflict,¹⁷ or as a coping mechanism. The illegal trafficking of substances by organized groups is a complex phenomenon which further damages communities in conflict zones.

Concluding Thoughts

The linkages between trauma, substance use, and human trafficking are complex and one cannot be fully understood in isolation from another. Practical implications for approaching the confluence of these issues should be considered by providers and regulators. Local health workers should be trained in trauma informed care due to the widespread political and economic instability. Policy changes should consider the interplay between trauma, substance use, and human trafficking. Providers should consider the overlapping phenomena which may lead to a patient using substances, having a trauma history, and experiencing trafficking. Overall, those seeking to tackle these issues and treat patients like Layla need to be cognizant of the economic, social, and cultural environment which shape patient’s experiences and interfere with their treatment and recovery.

Ms Draper is currently completing an MBA at Rice University between her third and fourth year of medical school at Baylor College of Medicine. She will be applying to psychiatry residency and is interested in global mental health, community psychiatry, and addiction psychiatry. Dr Albaba is a chief resident in psychiatry at Baylor College of Medicine.

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