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‘ In his early twenties he was arrested and faced the choice of avoiding the expulsion of his family by registering as a " volunteer " for deployment in Syria.’ from our foreign correspondent

In Germany, refugees from Syria, Iraq, Iran and Afghanistan already traumatised by war and upheaval are seeking treatment for substance dependence. What are the lessons for the UK, asks Dr Chris Ford

I WAS LOOKING FORWARD to hearing my friend and colleague, Hans-Guenter, talking about the issues of caring for refugees who have already been traumatised by war, violence and upheaval when they presented seeking help with their substance depend- ence. When Hans had told Mr A’ s story there was complete silence in the room.‘ Mr A was in his mid-20s and was born and raised in Iran. His family was originally from Afghanistan, from where they had fled to the neighbouring country. When Mr A was 17, the family was expelled by the Iranian authorities and returned to Afghanistan. There the father was killed and the mother once more battled her way with the children to Tehran. At this time Mr A began to consume theriac, as opium is called in this part of the world, and then after a while to smoke heroin. In his early twenties he was arrested and faced the choice of avoiding the expulsion of his family by registering as a " volunteer " for deployment in Syria. There he fought in the Iranian military units on the side of the Assad

government. When the heroin supply he brought along was getting low, his comman- der supplied him with morphine. After a shrapnel injury he returned to Iran, continued taking heroin and, for the first time, metha- done. He took some methadone with him when he fled to Europe, where some months after arriving in Hamburg he relapsed and came to our clinic and asked for treatment.’

Hans-Guenter explained that over the past 25 years the clinic in Germany had seen people from at least 50 countries, including migrants and asylum seekers from Afghanistan, Iran and Turkey, partisans from the mountains of Kurdistan, refugees from the Balkan wars and from the conflicts in the former republics of the USSR.

He explained that many were treated, and had been able to establish new roots and become members of the community in Hamburg. From January 2015 to August 2016, however, one million people applied for asylum in Germany – two out of three were from Syria, Iraq, Iran and Afghanistan, and many of the men had grown up in an opium / theriac / heroin culture.

How did Hamburg cope with this large influx of refugees? It responded quickly, setting up a model system, which included consultation hours in the refugee reception centres, uniform screening for all and special places reserved for children and women.

All departments are working together, with prevention available in key languages and the police supportive. Sadly the situation isn’ t like this in other areas of Germany.

Hans-Guenter then posed a number of questions, which I now pose to you: Can we manage to gain transcultural competence in treating refugees? Do we need special teams? When is it the right time to take a detailed medical history of traumatic experiences? How can we bring trauma therapy and addiction medicine together? How can we reach the female refugees with a substance problem from these countries? In the context of migration, should integration be defined as the fifth pillar of drug policy? Should we develop recommendations, guidelines and best practice models for treating refugees with substance use disorders?

And in the UK: what do you provide in your area for refugees? Which are the main groups you are seeing? How do you manage with translation? What additional skills would you like?

Dr Chris Ford, IDHDP with Dr Hans- Guenter Meyer Thompson, Hamburg

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