WHO Drugs Booklet 5

5 SOCIOECONOMIC CHARACTERISTICS
AND DRUG USE DISORDERS
2020
© United Nations, June 2020. All rights reserved worldwide.
ISBN: 978-92-1-148345-1
eISBN: 978-92-1-005047-0
United Nations publication, Sales No. E.20.XI.6
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PREFACE
This is a time for science and solidarity, as United countries, are deprived of access to controlled drugs
Nations Secretary-General António Guterres has said, for pain relief and other essential medical uses.
highlighting the importance of trust in science and Governments have repeatedly pledged to work
of working together to respond to the global COVID- together to address the many challenges posed by the
19 pandemic. world drug problem, as part of commitments to
The same holds true for our responses to the world achieve the Sustainable Development Goals, and most
drug problem. To be effective, balanced solutions to recently in the 2019 Ministerial Declaration adopted
drug demand and supply must be rooted in evidence by the Commission on Narcotic Drugs (CND). But
and shared responsibility. This is more important data indicates that development assistance to address
than ever, as illicit drug challenges become increas- drug control has actually fallen over time.
ingly complex, and the COVID-19 crisis and Balanced, comprehensive and effective responses to
economic downturn threaten to worsen their impacts, drugs depend on governments to live up to their
on the poor, marginalized and vulnerable most of all. promises, and provide support to leave no one behind.
Some 35.6 million people suffer from drug use dis- Health-centred, rights-based and gender-responsive
orders globally. While more people use drugs in approaches to drug use and related diseases deliver
developed countries than in developing countries, better public health outcomes. We need to do more
and wealthier segments of society have a higher preva- to share this learning and support implementation,
lence of drug use, people who are socially and most of all in developing countries, including by
economically disadvantaged are more likely to develop strengthening cooperation with civil society and
drug use disorders. youth organizations.
Only one out of eight people who need drug-related The international community has an agreed legal
treatment receive it. While one out of three drug users framework and the commitments outlined in the
is a woman, only one out of five people in treatment 2019 CND Ministerial Declaration. The United
is a woman. People in prison settings, minorities, Nations Office on Drugs and Crime (UNODC) pro-
immigrants and displaced people also face barriers to vides integrated support to build national capacities
treatment due to discrimination and stigma. Of the and strengthen international cooperation to turn
11 million people who inject drugs, half of them are pledges into effective action on the ground.
living with hepatitis C, and 1.4 million with HIV. The theme for this year’s International Day against
Around 269 million people used drugs in 2018, up Drug Abuse and Illicit Trafficking, “Better Knowledge
30 per cent from 2009, with adolescents and young for Better Care”, highlights the importance of scien-
adults accounting for the largest share of users. More tific evidence to strengthen responses to the world
people are using drugs, and there are more drugs, and drug problem and support the people who need us.
more types of drugs, than ever. It also speaks to the ultimate goal of drug control,
Seizures of amphetamines quadrupled between 2009 namely the health and welfare of humankind.
and 2018. Even as precursor control improves glob- Through learning and understanding we find com-
ally, traffickers and manufacturers are using designer passion and seek solutions in solidarity.
chemicals, devised to circumvent international con- It is in this spirit that I present the UNODC World
trols, to synthesize amphetamine, methamphetamine Drug Report 2020, and I urge governments and all
and ecstasy. Production of heroin and cocaine remain stakeholders to make the best use of this resource.
among the highest levels recorded in modern times.
The growth in global drug supply and demand poses
challenges to law enforcement, compounds health
risks and complicates efforts to prevent and treat drug
use disorders. Ghada Waly
At the same time, more than 80% of the world’s Executive Director
population, mostly living in low- and middle-income United Nations Office on Drugs and Crime
1
Acknowledgements
The World Drug Report 2020 was prepared by the Research and Trend Analysis Branch, Division for
Policy Analysis and Public Affairs, United Nations Office on Drugs and Crime (UNODC), under the
supervision of Jean-Luc Lemahieu, Director of the Division, and Angela Me, Chief of the Research and
Trend Analysis Branch, and the coordination of Chloé Carpentier, Chief of the Drug Research Section.
Content overview Graphic design and production
Chloé Carpentier Anja Korenblik
Angela Me Suzanne Kunnen
Kristina Kuttnig
Analysis and drafting
Federica Martinelli
Maria Melchior
Administrative support
Editing
Iulia Lazar
Jonathan Gibbons
Review and comments

The World Drug Report 2020 benefited from the expertise of and invaluable contributions from
UNODC colleagues in all divisions.
The Research and Trend Analysis Branch acknowledges the invaluable contributions and advice
provided by the World Drug Report Scientific Advisory Committee:
Jonathan Caulkins Afarin Rahimi-Movaghar
Paul Griffiths Peter Reuter
Marya Hynes Alison Ritter
Vicknasingam B. Kasinather Francisco Thoumi
Charles Parry
The research for booklet 5 benefitted from the support of the Informal International Scientific
Network to the Commission on Narcotic Drugs, as well as of the Prevention, Treatment and
Rehabilitation Section of the Drug Prevention and Health Branch of the Division for Operations
of UNODC, which also funded it.
CONTENTS
EXECUTIVE SUMMARY, IMPACT OF COVID-19,

BOOKLET 1 CONCLUSIONS AND POLICY IMPLICATIONS
BOOKLET 2 DRUG USE AND HEALTH CONSEQUENCES
BOOKLET 3 DRUG SUPPLY
BOOKLET 4 CROSS-CUTTING ISSUES: EVOLVING TRENDS AND NEW CHALLENGES
BOOKLET 5 SOCIOECONOMIC CHARACTERISTICS AND DRUG USE DISORDERS
PREFACE...................................................................................................................... 1
EXPLANATORY NOTES............................................................................................... 5
SCOPE OF THE BOOKLET........................................................................................... 7
SOCIOECONOMIC CONDITIONS AND DRUG USE DISORDERS
AT THE MACRO LEVEL............................................................................................... 9
EVIDENCE REGARDING THE LINK BETWEEN SOCIOECONOMIC
CHARACTERISTICS AND DRUG USE DISORDERS..................................................... 11
Macro-level socioeconomic characteristics and drug use disorders............................................. 11
Relationships between community characteristics and drug use disorders................................ 14
Individual socioeconomic circumstances and drug use disorders .............................................. 17
MECHANISM UNDERLYING THE INTERACTION BETWEEN
SOCIOECONOMIC DISADVANTAGE AND DRUG USE DISORDERS.......................... 21
Genetic factors................................................................................................................................ 21
Family and peer dynamics.............................................................................................................. 22
Adverse life events, stress, lack of support networks and resources,
and their psychological consequences........................................................................................... 23
SOCIOECONOMIC CONSEQUENCES OF DRUG USE DISORDERS............................ 23
Community-level consequences..................................................................................................... 23
SOCIOECONOMIC INEQUALITIES IN ACCESS
TO EFFECTIVE DRUG TREATMENT........................................................................... 24
GROUPS PARTICULARLY IMPACTED BY SOCIOECONOMIC DISADVANTAGE........ 25
Women............................................................................................................................................ 25
Sexually diverse populations.......................................................................................................... 26
Indigenous and aboriginal peoples............................................................................................... 27
Ethnic groups and immigrants....................................................................................................... 28
Displaced persons............................................................................................................................ 29
People in rural settings .................................................................................................................. 30
GLOSSARY................................................................................................................. 31
REGIONAL GROUPINGS............................................................................................ 33
BOOKLET 6 OTHER DRUG POLICY ISSUES
3
EXPLANATORY NOTES
The designations employed and the presentation of The following abbreviations have been used in the
the material in the World Drug Report do not imply present booklet:
the expression of any opinion whatsoever on the
part of the Secretariat of the United Nations con- AIDS acquired immunodeficiency
cerning the legal status of any country, territory, city syndrome
or area, or of its authorities, or concerning the delim-
DALYs disability-adjusted life years
itation of its frontiers or boundaries.
Countries and areas are referred to by the names EMCDDA European Monitoring Centre for
that were in official use at the time the relevant data Drugs and Drug Addiction
were collected.
Since there is some scientific and legal ambiguity GDP gross domestic product
about the distinctions between “drug use”, “drug
misuse” and “drug abuse”, the neutral term “drug LGBTQI lesbian, gay, bisexual, transgender,
use” is used in the World Drug Report. The term queer or intersex
“misuse” is used only to denote the non-medical use
HIV human immunodeficiency virus
of prescription drugs.
All uses of the word “drug” and the term “drug use” MDMA 3,4-methylenedioxymetamphetamine
in the World Drug Report refer to substances con-
trolled under the international drug control OECD Organisation for Economic
conventions, and their non-medical use. Co-operation and Development
All analysis contained in the World Drug Report is
based on the official data submitted by Member UNAIDS Joint United Nations Programme on
States to the UNODC through the annual report HIV/AIDS
questionnaire unless indicated otherwise.
UNESCO United Nations Educational,
The data on population used in the World Drug Scientific and Cultural Organization
Report are taken from: World Population Prospects:
The 2019 Revision (United Nations, Department of UNODC United Nations Office on Drugs
Economic and Social Affairs, Population Division). and Crime
References to dollars ($) are to United States dollars,
unless otherwise stated. WHO World Health Organization
References to tons are to metric tons, unless other-
wise stated.
5
SCOPE OF THE BOOKLET
This, the fifth booklet of the World Drug Report define more vulnerable neighbourhoods. The influ-
2020, contributes evidence to support the interna- ence of individual-level circumstances and indicators
tional community in implementing operational of socioeconomic position on drug use and drug
recommendations on cross-cutting issues in relation use disorders are then addressed.
to drugs and human rights, youth, children, women The booklet subsequently discusses the possible
and communities, including the recommendations mechanisms that may explain how different factors,
contained in the outcome document of the special including genetic factors, psychological character-
session of the General Assembly on the world drug istics, family and peer dynamics, adverse life events
problem held in 2016. Many of these cross-cutting and stress, social networks and neighbourhood
issues are complex and their analysis would require dynamics, may contribute to the risk of developing
the mobilization of evidence that is not always read- drug use disorders. The next section addresses the
ily available. For this reason, this booklet focuses on negative consequences of drug use disorders on the
one issue in particular: the association between soci- socioeconomic status of individuals and the com-
oeconomic characteristics and drug use disorders. munities in which they live; it then discusses the
The booklet begins with a discussion of general con- impact that socioeconomic inequalities have on
cepts of population health in order to shed light on access to drug treatment services.
ways in which socioeconomic characteristics are The final section of the booklet reviews evidence on
associated with drug use disorders. Next it reviews subpopulation groups that may be impacted differ-
evidence regarding the association between socio- ently by drug use disorders, such as women, sexually
economic characteristics and drug use disorders, diverse groups, indigenous and aboriginal groups,
from those characteristics at the macro and popula- ethnic and immigrant groups, displaced persons,
tion levels to those at the community level that may and those living in rural settings.
Protective factors and risk factors for substance use

e
ectiv fa sk factor
ctor
Ri
s
Prot
• Safe neighbourhoods • Poverty

• Physical safety and social • Conflict/war
inclusion • Homeless, refugee status
• Quality school environment • Social exclusion and
• Access to health care inequality
• Caregiver involvement and • Neighbourhood disorders
monitoring • Peer substance use and
• Health and neurological skills: drug availability
- coping skills • Mental health problems
- emotional regulation • Trauma and childhood adversity
Positive physical, social Substance use Harmful use Substance

and mental health initiation of substances use disorders
7
Socioeconomic conditions and drug use disorders at the population level
5
Drug use disorders are multi-factorial and often and inequalities are analysed in the broader context
follow the course of a relapsing and remitting of drug use, on the assumption that drug use disor-
chronic disease. Socioeconomic inequalities, as well ders are at the end of a continuum of behaviours
as poverty, limited education and marginalization, that begins with drug initiation and ends with a
may increase the risk of developing drug use disor- drug use disorder.
ders and exacerbate their consequences. Conversely,
drug use disorders contribute to a number of con- SOCIOECONOMIC
sequences in an individual’s life, family and
community that have an impact on individuals’ CONDITIONS AND DRUG
academic, employment and income prospects, as USE DISORDERS AT THE
well as on their families and communities, thus MACRO LEVEL
fuelling a vicious cycle. This cycle may be further
exacerbated by the increased risk of exposure to Socioeconomic inequalities in relation to drug use
adverse psychosocial and environmental circum- disorders have mostly been studied in high-income
stances, which can be associated with depressed settings, where it has been shown that the socioeco-
socioeconomic conditions. Socioeconomic inequali- nomic conditions of individuals, neighbourhoods
ties may have a particularly strong impact on some and communities are associated with patterns of drug
groups and settings such as people living in urban use disorders. The rare studies conducted in middle-
areas, or people with minority status.1 Drug use income and low-income countries suggest that
disorder in people in those groups may increase the associations between socioeconomic disadvantage
stigmatizing attitudes surrounding them, which in and the risk of drug use disorders in such contexts
turn may further limit their accessibility to are, however, weaker.2
treatment.
Importantly, in high-income settings, the risk of
Drug use disorders are the primary focus of the pre- drug use disorders is not solely concentrated among
sent booklet. However, in some instances in the
discussion, data on socioeconomic characteristics Fig. 2 Socioeconomic gradient in opioid and
cocaine overdose risk, Luxembourg,
Fig. 1 Vicious cycle between socioeconomic 1994–2011
disadvantage and drug use disorders 0.40
Overdose mortality rate (percentage)
0.35
0.30
Poverty Conflict 0.25
0.20
0.15
Vicious 0.10
Drug use circle Limited

0.05
0.00
disorder education Very Low Inter- High (>3)
low (>1 and mediate
(<=1) ≤ 2) (>2 and
≤ 3)
Limited
employment Relative socioeconomic position
Source: Alain Origer, Ethienne Le Bihan and Michèle Baumann,
“A social gradient in fatal opioids and cocaine related over-
doses?”, PLOS One, vol. 10, No. 5 (May 2015).
1 Andreas Heinz, Xudong Zhao and Shuyan Liu, “Implica- 2 Hui G. Cheng and others, “Social correlates of mental, neu-
tions of the association of social exclusion with mental rological, and substance use disorders in China and India: a
health”, JAMA Psychiatry, vol. 77, No. 2 (October 2019), review”, Lancet Psychiatry, vol. 3, No. 9 (September 2016),
pp. 113–114. pp. 882–899.
9
WORLD DRUG REPORT 2020 SOCIOECONOMIC CHARACTERISTICS AND DRUG USE DISORDERS
Fig. 3 Dahlgren and Whitehead model of socioeconomic conditions impacting on health
ic, cultural and environm

o n om enta
o ec l co
ls oci nd
era Living and working i �o
n ns
Ge condi�ons
mu
Work nd com nity netwo
environment ci al a rks Unemployment
So l lifestyle
i v i du a fac
Ind tor
s Water and
Educa�on
sanita�on
Health care
Agriculture services
and food Age, sex and
produc�on cons�tu�onal factors
Housing
Source: Göran Dahlgren and Margaret Whitehead, Policies and Strategies to Promote Social Equity in Health: Background Docu-
ment to WHO – Strategy Paper for Europe (revised) (Stockholm, Institute for Future Studies, 2007).
the most disadvantaged groups in society, but fol- living and working conditions and broad
lows a socioeconomic gradient: in comparison with socioeconomic, cultural and environmental factors.
the most affluent groups, people who belong to dis-
Socioeconomic characteristics at the individual,
advantaged groups have the highest relative level of
community and country levels can influence drug
risk of suffering from a drug use disorder, while
use and drug use disorder patterns either directly
those in middle-income groups have an intermedi-
(e.g. economic recessions and consequent increases
ate level of risk.3
in the level of unemployment have been found to
Several conceptual frameworks have described how be associated with increases in the level of drug use
socioeconomic inequalities in health integrate both disorders via psychosocial stress pathways)6 or by
individual and ecological socioeconomic means of intermediate mechanisms (e.g. income
characteristics. The concept developed by Margaret inequality at the neighbourhood level can be related
Whitehead and Göran Dahlgren,4, 5 which is one to levels of opioid overdose via the geographical
of the most widely applied, posits that the health of distribution of health-care facilities).7 In addition,
individuals is not only related to their biological, characteristics at the individual, family, community
demographic and constitutional characteristics, but and country levels can interact, making certain
also to lifestyle factors, which are partly shaped by groups of individuals especially vulnerable to the
social and community networks, and influenced by consequences of socioeconomic inequalities. For
example, although the prevalence of drug use dis-
3 Stéphane Legleye and others, “From cannabis initiation to orders is lower among women than among men,
daily use: educational inequalities in consumption behav- women who do suffer from such disorders appear
iours over three generations in France: transition to cannabis
daily use”, Addiction, vol. 111, No. 10 (October 2016), pp.
1856–1866. 6 Gera E. Nagelhout and others, “How economic recessions
4 Institute of Medicine, The Future of the Public’s Health in the and unemployment affect illegal drug use: a systematic real-
21st Century (Washington, D.C., National Academies Press, ist literature review”, International Journal on Drug Policy,
2003). vol. 44 (June 2017), pp. 69–83.
5 Göran Dahlgren and Margaret Whitehead, Policies and 7 Christopher Rowe and others, “Neighborhood-level and
Strategies to Promote Social Equity in Health: Background spatial characteristics associated with lay naloxone reversal
Document to WHO – Strategy Paper for Europe, (Stockholm, events and opioid overdose deaths”, Journal of Urban Health,
Institute for Future Studies, 1991). vol. 93, No. 1 (January 2016), pp. 117–130.
10
Evidence regarding the link between socioeconomic characteristics and drug use disorders
5
to be particularly vulnerable.8 Lastly, socioeconomic Fig. 4 Disability-adjusted life years lost due
inequalities in drug use unfold throughout the to drug use, by countries grouped by
course of a person’s life, with the experience of adver- national income level, 2017
sity from childhood onwards possibly influencing 1,000
Rate per 100,000 population

the risk of both drug use disorder and socioeconomic 900
disadvantage over the long term.9 This illustrates 800
the existence of a vicious cycle between socioeco- 700
nomic disadvantage and drug use disorders. 600
500
400
EVIDENCE REGARDING 300
THE LINK BETWEEN 200
100
SOCIOECONOMIC 0
CHARACTERISTICS AND Income level
DRUG USE DISORDERS High Upper middle Lower middle Low
Macro-level socioeconomic Source: Global Burden of Disease Study 2017.

characteristics and drug use Note: Countries are grouped according to the World Bank classifi-
cation of income levels.
disorders
Data on associations between country-level socio-
Fig. 5 Use in the past year of opiates and
economic conditions, such as overall national
cocaine and per capita gross domestic
income level and rates of drug use disorders, present
product, 2013
a somewhat paradoxical picture in which levels of
drug use tend to be highest in high-income coun- 3.0
tries in the Americas, Oceania and Europe, whereas
among the popula�on aged 15–64
the association in terms of injecting drug use and

Annual prevalence (percentage)
2.5
HIV is particularly strong in Eastern Europe and
West Asia.10 Moreover, higher country-level income
2.0
is associated with a higher prevalence of use and
1.5
8 Janni Leung and others, “A global meta-analysis of the
prevalence of HIV, hepatitis C virus, and hepatitis B virus
among people who inject drugs — do gender-based differ- 1.0
ences vary by country-level indicators?”, Journal of Infectious
Diseases, vol. 220, No. 1 (July 2019), pp. 78–90.
9 Seethalakshmi Ramanathan and others, “Macroeconomic 0.5
environment during Infancy as a possible risk factor for
adolescent behavioral problems”, JAMA Psychiatry, vol. 70,
No. 2 (February 2013); Shiyou Wu, Lisade Saxe Zerden and 0.0
Qi Wu, “The influence of childhood welfare participation 200 2,000 20,000 200,000
on adulthood substance use: evidence from the National
Per capita gross domes�c product
Longitudinal Study of Adolescent to Adult Health”, Ameri-
can Journal of Drug and Alcohol Abuse, vol. 42, No. 6 (April (dollars, logarithmic scale)
2016), pp. 657–670. Cocaine
10 World Drug Report 2019 (United Nations publication, Sales Opiates
No. E.19.8); Amy Peacock, Wayne Hall and Louisa Degen-
hardt, “Epidemiology of substance use internationally”, in Line of best ﬁt (cocaine)
Prevention of Substance Use, Zili Sloboda and others, eds.
(Cham, Switzerland, Springer, 2019); Fernando Salazar Silva Source: World Drug Report 2016 (World Bank (for per capita
and others, “Relationship between human development and gross domestic product (GDP)) and national data and estimates
drug use: human development index and drug use”, Salud based on responses to the annual report questionnaire and
Mental, vol. 37 (2014), pp. 35–39. other official sources (for drug use data)).
11
Fig. 6 Drug use in the past year among persons aged 15–64, by drug category and national
Percentage
Percentage
income level, 2013
0.4 Amphetaminesa 0.4 "Ecstasy"
1.0
0.9 0.7
0.9
Prevalence (percentage)
0.3 0.6 0.3
0.8
0.2 0.5 0.2
0.6
0.6 0.6
0.4
0.1 0.1
0.4 0.3
0.3 0 0.3
0.2 0
0.2 Low Lower Upper High 0.1 Low Lower Upper High
middle middle 0.5 middle middle
0.0 0.0 0.9
Percentage
0.0 0.0
Low Cannabis
Lower Upper High Low 0.4LowerOpiates
Upper High
8
0.9 middle middle middle middle
7 0.3 0.6
Income level 0.4 Income level
6
0.2
0.65 0.3 0.3
4 0.1
3 0.2
0.32 0
0.1 0.0
1 Low Lower Lower
Low Upper Upper
High
0.5
Percentage
0 0 middle middle
0.0 Low Lower Upper High
0.4 Income level
1.2 Low LowerCocaine
Upper High middle middle
0.9
0.3 middle middle

1.0 Income level
0.8 0.2 Global prevalence
0.6
Income level
0.6 0.1
0.4
0.3 0
0.2 Low Lower Upper High
0.0 middle middle
0.0
Lower Upper HighLow
Lower
middle Upper
middle High Low
middle middle
Income
Source: World Drug Report 2016 (World Bank level levels) and UNODC estimates based on responses to the annual report
(for income
questionnaire and other official sources (for drug use data)).
a Including prescription stimulants.
associated burden of disease, in terms of healthy In addition, dramatic changes in macroeconomic

years of life lost owing to disability and premature conditions, such as those arising from a political or
death (disability-adjusted life years (DALYs)).11 economic crisis, result in increases in poverty and
unemployment, which in turn influence individu-
Within individual countries, the degree of income
als’ socioeconomic prospects and stress levels, and
inequality is related to the prevalence of drug use12
may also lead to increases in rates of drug use.13,14
such that the countries with the highest levels of
In Eastern Europe, the interplay between macro-
socioeconomic inequality tend to have the highest
level socioeconomic and political changes, such as
prevalence of drug use disorders. Insufficient invest-
economic transitions during the 1990s, accompa-
ment in public policies and high levels of stress
nied by shifts from collective to more individualistic
among individuals accompany such income
disparities. 13 Tim Rhodes and others, “HIV infection associated with drug
injecting in the Newly Independent States, Eastern Europe:
11 World Drug Report 2016 (United Nations publication, Sales the social and economic context of epidemics”, Addiction,
No. E.16.XI.7), chap. 2, p. 65. vol. 94, No. 9 (September 1999), pp. 1323–1336.
12 Richard Wilkinson and Kate Pickett, The Spirit Level: 14 Robin Ghertner and Lincoln Groves, “The opioid crisis and
Why Greater Equality Makes Societies Stronger (New York, economic opportunity: geographic and economic trends”,
Bloomsbury Press, 2010). ASPE Research Brief (September 2018).
12
5
values, increases in population mobility, the diffu- Fig. 7 Country-level income inequality and drug use,
sion of drug cultures and the increasing demand on 2005
health-care systems resulted in the diffusion of drug
2.0
injection practices and the emergence of the HIV
epidemic.15 For example, in the Russian Federation
1.5
and Ukraine, the prevalence of injecting drug users
Country-level income inequality

was more than 1 per cent in 2017, while the preva-
lence of HIV among injecting drug users was 25.6 1.0
per cent in the Russian Federation in 2016 and 21.9
per cent in Ukraine in 2015 – a considerable increase 0.5
since the 1990s.16, 17 In Europe as a whole, overall
rates of injecting drug use have declined since 2000. 0.0
The rate of first admission for treatment was 4.03 0 5 10 15
per every 100,000 inhabitants in 2005, compared -0.5
with 2.74 in 2011, whereas an upward trend has
been observed in countries in Central and Eastern -1.0
Europe, in particular Czechia and Germany.18
-1.5
Recent research has examined the consequences of
the worldwide economic recession in 2008 on sub-
stance use in general, showing inconclusive results
for the use of controlled drugs and drug use disor- Source: Richard Wilkinson and Kate Pickett, The Spirit Level: Why
Greater Equality Makes Societies Stronger (New York, Bloomsbury
ders. A systematic review, which drew attention to Press, 2010).
the limited number of high-quality studies on this Note: The figure includes data points from 23 countries (16 countries in
West and Central Europe, and Australia, Canada, Israel, Japan, New Zea-
topic, reported a decrease in the use of drugs that land, Singapore and the United States of America).
had a higher cost (i.e. heroin and cocaine) and an
increase in the use of drugs that had a lower cost
associated psychosocial distress.20 Interestingly, when
(i.e. cannabis and methamphetamine) in Italy, pos-
asked about their reasons for increasing their level
sibly reflecting decreases in individual income levels.
of drug use during a period of economic recession,
By contrast, other countries such as Greece and
people who had used drugs in Catalonia (Spain),
Spain saw an increase in the use of controlled drugs,
England (United Kingdom) and Poland mainly
in particular among older people and people who
attributed their behaviour to having more free time
had become unemployed.19
on their hands,21 although that finding is not sup-
Increased unemployment appears to be a key expla- ported by a systematic review of the topic.22
nation for the increased levels of drug use during
In parallel, rapid economic growth and urbanization
periods of economic downturn, resulting from the
in some countries have gone hand in hand with
increases in levels of drug use or changes in the types
of drugs used. In Brazil, for example, the past-year
15 Mikko Lagerspetz and Jacek Moskalewicz, “Drugs in the
postsocialist transitions of Estonia, Latvia, Lithuania and prevalence of cocaine use among the population
Poland”, European Addiction Research, vol. 8, No. 4 (2002), aged 15–64 increased from 0.7 per cent in 2005 to
pp. 177–183.
16 World Drug Report 2019.
17 Rhodes and others, “HIV infection associated with drug
injecting in the Newly Independent States”. 20 Nagelhout and others, “How economic recessions and
18 Ana Sarasa-Renedo and others, “Technical report: estimating unemployment affect illegal drug use”.
trends in injecting drug use in Europe using national data 21 Geert Dom and others, “The impact of the 2008 economic
on drug treatment admissions” (June 2015). crisis on substance use patterns in the countries of the Euro-
19 Geert Dom and others, “The impact of the 2008 economic pean Union”, International Journal of Environmental Research
crisis on substance use patterns in the countries of the Euro- and Public Health, vol. 13, No. 1 (January 2016).
pean Union”, International Journal of Environmental Research 22 Nagelhout and others, “How economic recessions and
and Public Health, vol. 13, No. 1 (January 2016). unemployment affect illegal drug use”.
13
Fig. 8 Opioid use and opioid use disorders in 9,000 adolescents who participated in the National
India, 2017–2018 Longitudinal Survey of Youth 1997, Ramanathan
and colleagues found that increases in the unem-
1.2 ployment rate at the regional level during the
1.0
participants’ childhood were associated with
increases in cannabis use: an increase of 1 per cent
0.8 in the unemployment rate predicted an increase in
cannabis use by a factor of 1.08.25 Another study,
0.6 using vital statistics for the period 2005–2010 col-
0.4 lected in 366 metropolitan areas in the United
States, showed a 0.23 per cent increase in deaths
0.2 caused by drug overdoses for each point increase in
the unemployment rate.26 This effect appeared
0.0
Opium Heroin Pharmaceutical strongest among individuals aged 25–64, with the
opioids intention to commit suicide perhaps explaining a
fraction of those overdose deaths.
Any use Use disorder
Source: Atul Ambekar and others, Magnitude of Substance Relationships between
Use in India, 2019 (New Delhi, Ministry of Social Justice and
Empowerment, 2019).
community characteristics and
Note: The data reflect current use and problem use of opioids drug use disorders
among males aged 10–75 in India in the period 2017–2018.
Significant community and neighbourhood-level
socioeconomic characteristics associated with drug
1 per cent in 2016.23 However, the most significant use and drug use disorders include but are not lim-
increase was seen in the use of “crack” cocaine, from ited to poverty, violence, income inequality, low
a past-year prevalence of 0.1 per cent in 2005 to 0.3 levels of neighbourhood attachment and social capi-
per cent in 2016. tal, community norms favourable to drug use,
In India, the national household survey conducted firearms and crime, and the availability of alcohol
in 2019 showed that 2.1 per cent of the population and other drugs.27
aged 10–75 had used opioids in the past year, with
Poverty and violence
the use of heroin being more prevalent (1.14 per
cent) than the use of pharmaceutical opioids (1 per A study conducted in 10 cities in Spain between
cent) and opium (0.56 per cent). Estimated levels 1996 and 2003 found that people living in neigh-
of drug use disorders were: 0.1 per cent for opium bourhoods (i.e. census tracts) characterized by
use; 0.57 per cent for heroin use; and 0.23 per cent socioeconomic deprivation were up to seven times
for use of pharmaceutical opioids. Compared with more likely to die from a drug overdose than people
the estimates from an earlier survey conducted in living in more affluent areas.28 Another study, con-
the country in 2004, overall opioid use was esti- ducted among 2,400 people in Mexico, 1,600 of
mated to be more than five times higher in 2019.24A
25 Ramanathan and others, “Macroeconomic environment
Changes in labour market characteristics, such as during infancy”.
increases in unemployment rates, have been linked 26 Erin C. Strumpf and others, “Did the Great Recession affect
mortality rates in the metropolitan United States? Effects on
to increases in drug use and drug use disorders in a mortality by age, gender and cause of death”, Social Science
relatively consistent way. In an analysis of data col- and Medicine, vol. 189 (2017), pp. 11–16.
lected in the United States of America from almost 27 Susanne MacGregor and Anthony Thickett, “Partnerships
and communities in English drug policy: the challenge of
deprivation”, International Journal on Drug Policy, vol. 22,
23 UNODC, response to the annual report questionnaire sub- No. 6 (November 2011), pp. 478–490.
mitted by Brazil. 28 Mercè Gotsens and others, “Socio-economic inequalities in
24 Atul Ambekar and others, Magnitude of Substance Use in mortality due to injuries in small areas of ten cities in Spain
India, 2019 (New Delhi, Ministry of Social Justice and (MEDEA Project)”, Accident Analysis and Prevention, vol.
Empowerment, 2019). 43, No. 5 (September 2011), pp. 1802–1810.
14
5
Links between armed conflict and its consequences and drug use
disorders
Another macro-level factor related to drug use is vio- persons who were already using drugs prior to an armed
lent conflict. A systematic review and meta-analysis conflict, there is a risk of increase in the occurrence of
examining the findings of six studies showed an risky drug-related behaviours. The drug use survey in
increase in opioid use, as measured by comparing the Afghanistan reported that the majority of injecting drug
number of hospital admissions (in the Islamic Repub- users had initiated injecting while they were refugees in
lic of Iran and Lebanon) and drug-related deaths (in the Islamic Republic of Iran or Pakistan.d Indeed, there
Croatia) before and after situations of armed conflict, is evidence that, in the context of an armed conflict,
as well high levels of opioid use among persons dis- drug use could significantly contribute to increases in
placed as a result of armed conflict (in Pakistan and the breakdown of health-care structures, including dif-
Afghanistan).a The hypothesized mediating mecha- ficulties in accessing treatment and higher levels of HIV
nisms included lack of economic opportunities, transmission, resulting from increases in needle sharing.c
changes in social norms, and increases in the availabil-
ity of drugs as consequences of upheaval. In qualitative
a Helen Jack, Amelia Reese Masterson and Kaveh Khoshnhood,
research conducted in Libya, involving a study of 31
“Violent Conflict and opiate use in low and middle-income coun-
people, including 16 who used drugs, increases in drug tries: a systematic review”, International Journal of Drug Policy,
availability, the disruption of healthy recreational vol. 25, No. 2 (March 2014), pp. 196–203.
activities, and stress and trauma resulting from armed b Fauzi Muftah Elamouri and others, “Now drugs in Libya are
conflict and political unrest were the most frequently much cheaper than food: a qualitative study on substance use
cited reasons for cannabis or opiate use.b among young Libyans in post-revolution Tripoli, Libya”, Interna-
tional Journal of Drug Policy, vol. 53 (2018), pp. 23–31.
A study of 36 internally displaced adolescents and adults c Catherine Lee and others, “Mental health and psychosocial prob-
living in a camp in Kachin State in Myanmar reported lems among conflict-affected children in Kachin State, Myanmar:
a qualitative study”, Conflict and Health, vol. 12, art. 39 (Septem-
that drug use disorders had been spontaneously identi- ber 2018).
fied as one of the main concerns of displaced persons, d UNODC and Afghanistan, Ministry of Counter-Narcotics, and
who had directly attributed a lack of future prospects Ministry of Public Health, “Drug use in Afghanistan: 2009 survey
and depression to the armed conflict.c Moreover, among – executive summary” (Kabul, 2009).
whom lived in a town bordering the United States, results are consistent with data from quasi-experi-
found that area-level socioeconomic disadvantage mental research conducted among 172 people
influenced the rate of past-year drug use, in part relocated from a disadvantaged neighbourhood to
through exposure to violence and neighbourhood a more affluent one, which showed that the preva-
insecurity.29 A study conducted among 505 African- lence of weekly use of drugs in the sample decreased
American young people living in high-poverty rural from 36 to 17 per cent.31
areas in the United States showed that the experi-
ence of poverty and harsh parenting had led to a Neighbourhood poverty reflects residents’ socioeco-
lack of investment in the their future, which in turn nomic difficulties; it is therefore not always clear if
had increased the risk of drug use disorders.30 These it is the community characteristics or the individual
29 Guilherme Borges and others, “The relationship between stance abuse”, American Journal of Community Psychology,
social inequalities, substance use and violence in border and vol. 58, Nos. 3–4 (December 2016), pp. 422–433.
non-border cities of northern Mexico”, Drug and Alcohol 31 Hannah L. Cooper and others, “The aftermath of public
Dependence, vol. 2001 (2019), pp. 1–5. housing relocation: relationship to substance misuse”, Drug
30 Junhan Cho and Steve Kogan, “Risk and protective pro- and Alcohol Dependence, vol. 133, No. 1 (November 2013),
cesses predicting rural African-American young men’s sub- pp. 37–44.
15
characteristics that are more strongly linked to sub- Fig. 9 Rate of drug use disorder by level
stance use behaviours. of social capital and neighbourhood
deprivation, Sweden, 2003–2010
Income inequality, community 4.0
Annual age-standardized rate (percentage)

disorganization and low social capital 3.5
Although there are no global studies on the associa- 3.0
tion between income inequality, community 2.5
disorganization, low social capital and drug use 2.0
disorders, research conducted in high-income coun- 1.5
tries suggests that, in addition to low levels of 1.0
individual resources, neighbourhood- or commu- 0.5
nity-level characteristics other than poverty can
0.0
further influence drug use disorder patterns. Low Moderate High
Research conducted in New York City shows that neighbourhood neighbourhood neighbourhood
people living in neighbourhoods with high levels deprivation deprivation deprivation
of income or educational inequality are more likely Low social capital
to use cannabis than those who live in areas with Moderate social capital
more socioeconomic equality, even when control- High social capital
ling for individual socioeconomic position.32
Source: Jan Sundquist and others, “Neighborhood linking
One of the mechanisms hypothesized to explain social capital as a predictor of drug abuse: a Swedish national
cohort study”, Addictive Behaviors, vol. 63 (2016), pp. 37–44.
this association between socioeconomic inequality
at the city or country level and drug use disorders
is social capital, defined as the extent to which Similarly, a study in the United States, based on a
people in a community trust and support one national survey from 2000, carried out among
another and the institutions that govern them. 19,430 adolescents aged 12–17, showed that those
Social capital can be ascertained in surveys in which living in neighbourhoods characterized by social
participants are asked to describe their neighbour- disorganization (i.e. those with a high occurrence
hood and the extent to which they trust other of crime, drug sales, abandoned buildings and graf-
people or the institutions that govern them, but it fiti, and a transient population), or low social capital
is also sometimes measured using proxies, such as (ascertained on the basis of residents’ limited social
the level of voter participation in local elections. A networks) had a higher prevalence of opioid use
study conducted between 2003 and 2010 among than adolescents living in more stable areas.34
all residents of Sweden aged 15–44 included Community norms regarding drug use
1,700,896 men and 1,642,798 women. In neigh- and drug and alcohol availability
bourhoods where there was a low level of voter
turnout in local elections, which was interpreted as Neighbourhood disorganization can be a source of
a sign of low community social capital, rates of stress and can shape individuals’ social networks and
diagnosed drug use disorders recorded in the norms regarding drug-related behaviour.35 For exam-
national health insurance register were 1.5 times ple, in disadvantaged neighbourhoods that are
higher than in neighbourhoods with a high voter
turnout, even after accounting for socioeconomic capital as a predictor of drug abuse: a Swedish national
deprivation at the area and individual levels.33 cohort study”, Addictive Behaviors, vol. 63 (2016), pp.
37–44.
32 Sandro Galea and others, “Neighborhood income and 34 Jason E. Ford, Sarah Ann Sacra and Alexis Yohros, “Neigh-
income distribution and the use of cigarettes, alcohol, and borhood characteristics and prescription drug misuse among
marijuana”, American Journal of Preventive Medicine, vol. adolescents: the importance of social disorganization and
32, No. 6 (June 2007), pp. S195–S202; Sandro Galea and social capital”, International Journal on Drug Policy, vol. 46
others, “Education inequality and use of cigarettes, alcohol, (2017), pp. 47–53.
and marijuana”, Drug and Alcohol Dependence, vol. 90, 35 World Drug Report 2018: Drugs and Age – Drugs and Associ-
Suppl. 1 (September 2007), pp. S4–S15. ated Issues among Young People and Older People (United
33 Jan Sundquist and others, “Neighborhood linking social Nations publication, Sales No. E.18.XI.9 (Booklet 4)).
16
5
characterized by low social capital and disorganiza- workers42 and health-care workers43) appear to be at
tion, individuals may consider engagement in risky a particularly high risk of drug use disorders. These
behaviour as normal, which is less likely to be the variations partly reflect the particular characteristics
case in neighbourhoods that are more organized.36 of people employed in certain trades, but there is
also evidence that workplace climate and permissive
Beyond place of residence, other important contexts
attitudes towards drug use in the workplace, or out-
in which people live are, with regard to young
side it, also influence drug-related behaviours.44
people, schools and universities and, with regard to
adults, workplaces. Representative studies of ado-
lescents in the United States and Sweden have shown
Individual socioeconomic
that, while levels of drug initiation and occasional circumstances and drug use
use appear to be highest among students in affluent disorders
schools, drug use disorder levels are highest among Most research on socioeconomic inequalities in rela-
students attending technical or vocational, as tion to drug use disorders has been aimed at
opposed to general, training institutions.37, 38 identifying relationships between individual-level
In adulthood, while the overall levels of drug use indicators of socioeconomic position and drug use
disorders are higher among people who are not patterns. Among adolescents, while high socioeco-
employed than among those who are,39 drug use nomic position appears to be associated with drug
disorder patterns can vary across occupations. In initiation and occasional use,45 those who come
particular, according to a national population survey from less advantaged backgrounds are more likely
from 2000, the prevalence of drug use disorders in to engage in polysubstance use46 or have drug use
the United States was highest among people work- disorders.47 Adolescents from disadvantaged back-
ing in food services (16.9 per cent in the preceding grounds may have higher vulnerability to drug use
12 months), construction (14.3 per cent), enter-
tainment (12.9 per cent) and the mining industry Environmental Medicine, vol. 71, No. 1 (January 2014),
(11.8 per cent).40 pp. 71–76.
42 Marta Regina Cezar-Vaz and others, “The use of illegal
Within the broad industry categories used in the drugs and infectious contagious diseases: knowledge and
survey, certain occupations (truck drivers,41 dock intervention among dockworkers”, International Journal of
Environmental Research and Public Health, vol. 13, No. 1
(January 2016).
36 Melissa A. Davey-Rothwell and others, “The role of neigh- 43 Bimala Panthee and others, “Prevalence and correlates of
borhoods in shaping perceived norms: an exploration of substance use among health care students in Nepal: a cross
neighborhood disorder and norms among injection drug sectional study”, BMC Public Health, vol. 17, No. 1, art.
users in Baltimore, MD”, Health and Place, vol. 33 (2015), No. 950 (December 2017); Andreas G. Franke and others,
pp. 181–186. “Use of illicit and prescription drugs for cognitive or mood
37 Rebekah Levine Coley and others, “Locating economic risks enhancement among surgeons”, BMC Medicine, vol. 11
for adolescent mental and behavioral health: poverty and (2013).
affluence in families, neighborhoods, and schools”, Child 44 Michael R. Frone, “Workplace substance use climate: preva-
Development, vol. 889, No. 2 (March/April 2018), pp. lence and distribution in the U.S. workforce”, Journal of
360–369. Substance Use, vol. 71, No. 1 (February 2012), pp. 72–83.
38 Gabriella Olsson and Johan Fritzell, “A multilevel study on 45 Andrea L. Stone and others, “Review of risk and protective
ethnic and socioeconomic school stratification and health- factors of substance use and problem use in emerging adult-
related behaviors among students in Stockholm”, Journal hood”, Addictive Behaviors, vol. 37, No. 7 (July 2012), pp.
of School Health, vol. 85, No. 12 (December 2015), pp. 747–775.
871–879.
46 Mariel S. Bello and others, “Poly-product drug use dispari-
39 Maria Melchior and others, “Unemployment and substance ties in adolescents of lower socioeconomic status: emerging
use in young adults: does educational attainment modify the trends in nicotine products, marijuana products, and pre-
association?”, European Addiction Research, vol. 21, No. 3 scription drugs”, Behaviour Research and Therapy, vol. 115
(November 2014), pp. 115–123. (2019), pp. 103–110.
40 Donna M. Bush and Rachel N. Lipari, “Substance use and 47 Stone and others, “Review of risk and protective factors
substance use disorder, by industry”, in The CBHSQ Report of substance use”; Fernando C. Barros and others, “Social
(Rockville, Maryland, United States, Substance Abuse and inequalities in mental disorders and substance misuse in
Mental Health Services Administration, 2013). young adults: a birth cohort study in southern Brazil”, Social
41 Edmarlon Girotto and others, “Psychoactive substance use Psychiatry and Psychiatric Epidemiology, vol. 53, No. 7 (May
by truck drivers: a systematic review”, Occupational and 2018), pp. 717–726.
17
Fig. 10 Drug use across industries in the United States, 2008–2012
Public administration
Educational services
Mining
Health care and social assistance
Agriculture, forestry, fishing and hunting
Transportation and warehousing
Utilities
Finance and insurance
Manufacturing
Wholesale trade
Professional, technical and scientific services
Retail trade
Real estate
Construction
Information
Management
Arts, entertainment and recreation
Accomodation and food services
0 5 10 15 20 25
Source: Donna M. Bush and Rachel N. Lipari, “Substance use and substance use disorder, by industry”, 16 April 2015.
disorders than those from more advantaged back- causality to run in either direction or from third
grounds. They may also be more likely to have a variables to influence both of those outcomes. For
family history of drug use disorders.48 Moreover, example, in a study conducted among 500 adoles-
research increasingly points to the role of other risky cents in Ibadan in south-west Nigeria, it was found
health behaviours such as “sleep disparity”,49 which that students earning low grades in school were over
could partly mediate the effects of socioeconomic three times more likely to use psychoactive sub-
inequalities in young people.50 stances than those with high grades.52
Considering the academic performance of students Among adults living in high-income countries, drug
as an indicator of their socioeconomic status and use disorders tend to be more prevalent among those
future prospects, research has consistently found who experience socioeconomic disadvantage, which
that young people who underperform have higher is most frequently measured in terms of low educa-
levels of drug use than those who obtain good aca- tional level, low income level or unstable employment
demic results,51 with obvious possibilities for status, or a combination of these factors. These soci-
oeconomic inequalities have been observed both in
48 Maria Melchior and others, “Parental alcohol dependence, the general population and in samples of high-risk
socioeconomic disadvantage and alcohol and cannabis
dependence among young adults in the community”, Euro-
populations. A review of studies conducted in Ger-
pean Psychiatry, vol. 26, No. 1 (January 2011), pp. 13–17. many found that low levels of educational attainment
49 Nirav P. Patel and others, “‘Sleep disparity’ in the popula- were associated with the use of cannabis and other
tion: poor sleep quality is strongly associated with poverty drugs among young adults.53 Similarly, a study of
and ethnicity”, BMC Public Health, vol. 10 (2010).
50 Judith Owens and others, “Association between short sleep
duration and risk behavior factors in middle school stu- 52 Olayinka Atilola, Olatunde O. Ayinde and Oluwaseun Ade-
dents”, Sleep, vol. 40, No. 1 (January 2017). itan, “Beyond prevalence and pattern: problematic extent
51 Samuel Tomczyk, Barbara Isensee and Reiner Hanewinkel, of alcohol and substance use among adolescents in Ibadan
“Latent classes of polysubstance use among adolescents: a South-West Nigeria”, African Health Sciences, vol. 13, No. 3
systematic review”, Drug and Alcohol Dependence, vol. 160 (September 2013), pp. 777–784.
(2016), pp. 12–29. 53 Dieter Henkel and Uwe Zemlin, “Social inequality and sub-
18
5
more than 2,000 young adults living in Australia in a study conducted among 1,000 people treated
found that non-completion of high school predicted for tuberculosis in South Africa, in which partici-
drug use.54 Similar data have been published in the pants who were experiencing poverty were more
Islamic Republic of Iran,55 Saudi Arabia56 and the likely to have drug use disorders than those who
United States.57 In a study conducted among 2,200 were not.62 Moreover, in a sample of 1,400 women
people in prison across seven provinces in the living with HIV in Canada, the experience of eco-
Islamic Republic of Iran, individuals who had a nomic hardship was significantly related to higher
drug addiction were, on average, less educated than levels of drug use.63
those who did not.58
Above and beyond an individual’s socioeconomic
In France, in a study conducted among 1,200 young position at a particular point in time, his or her
adults, the experience of unemployment predicted socioeconomic trajectory from childhood to adult-
an increase in the risk of cannabis use and abuse, in hood is also associated with the risk of drug use
particular among individuals who had a low level of disorder. In the study conducted in France men-
educational attainment and who may have had the tioned above, the level of cannabis use disorder
lowest employment prospects.59 Likewise, in Spain, among participants who experienced a persistently
the experience of unemployment has also been low socioeconomic position, or downward socio-
found to be associated with heavy cannabis use in economic mobility in relation to their parents’
both men and women.60 There is also evidence that circumstances, was double the level among those
low income levels and poverty are associated with who had enjoyed favourable socioeconomic cir-
drug use behaviours, both in the general popula- cumstances throughout their life course. 64
tion61 and in specific subgroups, as demonstrated Additionally, the experience of food insecurity,
which is related to an individual’s income level,
stance use and problematic gambling among adolescents has also been found to be associated with drug use
and young adults: a review of epidemiological surveys
in Germany”, Current Drug Abuse Reviews, vol. 9, No. 1 disorder risk, even when adjusting for other socio-
(2016), pp. 26–48. economic characteristics.65
54 Dianne Currier and others, “Socioeconomic disadvantage,
mental health and substance use in young men in emerging To date, most of the data on the relationship
adulthood”, Behavioral Medicine, (2019), pp. 1–9. between individual socioeconomic circumstances
55 Parissa Karrari and others, “Pattern of illicit drug use in and drug use have come from high-income coun-
patients referred to addiction treatment centres in Birjand, tries. Recent evidence from low- and middle-income
eastern Iran”, Journal of the Pakistan Medical Association, vol.
63, No. 6 (June 2013), pp. 711–716. countries suggests that socioeconomic disparities
56 Yasir Ibrahim and others, “Patterns and sociodemographic in relation to drug use disorders tend to be less sig-
characteristics of substance abuse in Al Qassim, Saudi nificant in such countries than in high-income
Arabia: a retrospective study at a psychiatric rehabilitation
center”, Annals of Saudi Medicine, vol. 38, No. 5 (October
countries. For example, in a representative popula-
2018), pp. 319–325. tion survey conducted in Brazil, individuals with a
57 Jennifer M. Reingle Gonzalez and others, “The long-term higher level of schooling were more likely to report
effects of school dropout and GED attainment on substance
use disorders”, Drug and Alcohol Dependence, vol. 158
(2016), pp. 60–66. (November 2018), pp. 656–659.
58 Mehdi Amiri and others, “The relationship between addic- 62 Goedele M. Louwagie and others, “Poverty and substance
tion and socio-demographic characteristics of Iranian new- use in South African tuberculosis patients”, American Journal
comer prisoners”, Global Journal of Health Science, vol. 6, of Health Behavior, vol. 38, No.4 (May 2014), pp. 501–509.
No. 2 (March 2013), pp. 168–174. 63 Mostafa Shokoohi and others, “Patterns of social determi-
59 Melchior and others, “Unemployment and substance use in nants of health associated with drug use among women
young adults”. living with HIV in Canada: a latent class analysis”, Addic-
60 Ester Teixidó-Compañó and others, “Differences between tion, vol. 114, No. 7 (July 2019), pp. 1214–1224.
men and women in substance use: the role of educational 64 Lucy Bowes and others, “Lifecourse SEP and tobacco and
level and employment status”, Gaceta Sanitaria, vol. 32, No. cannabis use”, European Journal of Public Health, vol. 23,
1 (2018), pp. 41–47. No. 2 (April 2013), pp. 322–327.
61 Giuseppe Carrà and others, “Poverty matters: cannabis use 65 Laura Pryor and others, “Food insecurity and mental health
among people with serious mental illness: findings from problems among a community sample of young adults”,
the United States Survey on Drug Use and Health, 2015”, Social Psychiatry and Psychiatric Epidemiology, vol. 51, No. 8
International Journal of Social Psychiatry, vol. 64, No. 7 (August 2016), pp. 1073–1081.
19
Fig. 11 Drug use in Brazil, by education level, 2017
Past 30-day drug use

University degree Past-year drug use
Lifetime drug use
Education level
Complete middle-school or
incomplete university education
Complete elementary or
incomplete middle-school education
None or incomplete
elementary education
0 5 10 15 20
Source: Francisco Inácio Bastos and others, 3rd National Survey on Drug Use by the Brazilian Population (2017).
lifetime drug use, with the most prevalent sub- educational attainment and socioeconomic stand-
stances used being cannabis and cocaine, followed ing. Research conducted among adolescents has
by solvents. The prevalence of lifetime drug use was clearly shown that the use of psychoactive drugs
8.2 per cent among people who had not completed such as cannabis, in particular early on in life and
elementary education, compared with 16.6 per cent frequently, and/or in large quantities, can have det-
among those holding a university degree. However, rimental effects on school performance69 and
the relationship between the participants’ educa- educational achievement.70 For example, in the
tional attainment and recent drug use was not United States, data from a national study, in which
statistically significant.66 high school students were observed until adulthood,
show that frequent cannabis use (six or more times
A recent systematic review examining the relation-
in a month) predicts a lower probability of obtain-
ship between socioeconomic position and drug use
ing a university degree.71 This association could be
disorders in India reported only three studies show-
due to the biological effects of cannabis on brain
ing that workers in certain manual occupations
appear to be at high risk.67 A national drug survey,
conducted in Pakistan in 2013, found that, among 69 Madeleine H. Meier and others, “Associations of adolescent
people reporting regular opioid use, 35.7 per cent cannabis use with academic performance and mental health:
engaged in casual work (compared with 4.1 per cent a longitudinal study of upper middle class youth”, Drug and
Alcohol Dependence, vol. 156 (2015), pp. 207–212.
of casual workers who did not use opioids) and 39.8 70 Maria Melchior and others, “Early cannabis initiation and
per cent did not work (compared with 19.7 per cent educational attainment: is the association causal? Data from
who did not use opioids).68 the French TEMPO study”, International Journal of Epide-
miology, vol. 46, No. 5 (October 2017), pp. 1641–1650;
The studies mentioned above provide evidence of Jennifer L. Maggs and others, “Predicting young adult
degree attainment by late adolescent marijuana use”, Jour-
links between socioeconomic characteristics and nal of Adolescent Health, vol. 57, No. 2 (August 2015), pp.
drug use disorders without making a clear inference 205–211; W. Alex Mason, Amy L. Stevens and Charles B.
regarding cause and effect. However, drug use dis- Flemming, “A systematic review of research on adolescent
solitary alcohol and marijuana use in the United States”,
orders can have an effect on an individual’s Addiction, vol. 115, No. 1 (January 2020), pp. 19–31;
Edmund Silins and others, “Adolescent substance use and
66 Francisco Inácio Bastos and others, 3rd National Survey on educational attainment: an integrative data analysis compar-
Drug Use by the Brazilian Population (2017). ing cannabis and alcohol from three Australasian cohorts”,
67 Cheng and others, “Social correlates of mental, neurological, Drug and Alcohol Dependence, vol. 156, No. 1 (November
and substance use disorders in China and India”. 2015), pp. 90–96.
68 UNODC and Pakistan, Ministry of Interior and Narcotics 71 Maggs and others, “Predicting young adult degree attain-
Control, Drug Use in Pakistan 2013 (Islamabad, 2013). ment by late adolescent marijuana use”.
20
Evidence regarding the link between socioeconomic characteristics and drug use disorders /
Mechanisms underlying the interaction between socioeconomic disadvantages and drug use 5
functioning (i.e. decreases in memory, concentration For people who use drugs or who are diagnosed with
and attention), as well as to the progressive disinvest- a drug use disorder, experiences in the criminal justice
ment of adolescents in school, both of which may system can further influence their living circumstances
lead to academic failure. As educational attainment after they are released. Such experiences often worsen
is important in terms of long-term job prospects in their socioeconomic situation and increase their stress
many settings,72 the chances for adolescents with levels and their risk of not only continuing to use
drug use disorders to achieve socioeconomic integra- substances but also of being reincarcerated.78
tion can be permanently reduced.
In adults, persistent cannabis use has been shown MECHANISM UNDERLYING
to contribute to downward social mobility, finan- THE INTERACTION
cial difficulties and workplace difficulties in
midlife, even after accounting for socioeconomic BETWEEN SOCIOECONOMIC
adversity or family problems early on in life.73 A DISADVANTAGE AND DRUG
study conducted in China among 1,347 people USE DISORDERS
who injected drugs found low levels of education
and a high likelihood of criminal behaviour.74 Like- Following the theoretical model proposed by Dahl-
wise, a review of 130 studies published in 2011 gren and Whitehead,79 mentioned above, several
concluded that having a drug use disorder increases mechanisms may underline the interaction between
the chances of unemployment and job loss, and socioeconomic disadvantage and drug use disorders:
showed that unemployment increases the risk of genes, psychological characteristics, adverse life
relapse after drug addiction treatment, suggesting events and stress, social networks and neighbour-
a self-reinforcing circle.75 hood dynamics.
It is important to note here that the impact of drug
use disorders on socioeconomic prospects – in par- Genetic factors
ticular the increased risk of unemployment, poverty Several recent studies have found genetic contribu-
and homelessness – may be associated with stigma- tions to individuals’ educational attainment,80
tizing attitudes and, additionally, with consequences income81 or neighbourhood social deprivation,82 as
within the criminal justice system. Stigmatizing atti-
tudes contribute to a lack of access to health and social
harm reduction linked to non-fatal overdose amongst sex
services for people who use drugs, thus exacerbating workers who use drugs: results of a community-based cohort
the potential harms of substance use behaviours.76, 77 in Metro Vancouver, Canada”, International Journal of Drug
Policy, vol. 76 (2020).
78 Jason Schnittker, Michael Massoglia and Christopher
72 OECD, Data, “Employment by education level”. Uggen, “Out and down: incarceration and psychiatric disor-
73 Magdalena Cerdá and others, “Persistent cannabis depend- ders”, Journal of Health and Social Behavior, vol. 53, No. 4
ence and alcohol dependence representrisks for midlife (December 2012), pp. 448–464.
economic and social problems: a longitudinal cohort study”, 79 Dählgren and Whitehead, Policies and Strategies to Promote
Clinical Psychological Science, vol. 4, No. 6 (2016), Social Equity in Health.
pp. 1028–46.
80 James J. Lee and others, “Gene discovery and polygenic
74 Liu Liu, Wing Hong Chui and Ye Chen, “Violent and non- prediction from a genome-wide association study of educa-
violent criminal behavior among young Chinese drug users: tional attainment in 1.1 million individuals”, Nature Genet-
a mixed methods study”, International Journal of Environ- ics, vol. 50, No. 8 (July 2018), pp. 1112–1121; Aysu Okbay
mental Research and Public Health, vol. 15, No. 3 (March and others, “Genome-wide association study identifies 74
2018). loci associated with educational attainment”, Nature, vol.
75 Dieter Henkel, “Unemployment and substance use: a review 533 (2016).
of the literature (1990-2010)”, Current Drug Abuse Reviews, 81 Kenneth S. Kendler and others, “Genetic and family and
vol. 4, No. 1 (2011), pp. 4–27. community environmental effects on drug abuse in adoles-
76 Ali Ghaddar, Karine Nassar and Ghadier Elsoury, “Barriers cence: a Swedish national twin and sibling study”,
to access to sterile syringes as perceived by pharmacists and Am J Psychiatry, vol. 171, No. 2 (2014), pp. 209–17.
injecting drug users: implications for harm reduction in 82 W. David Hill and others, “Molecular genetic contribu-
Lebanon”, Substance Use and Misuse, vol. 52, No. 11 tions to social deprivation and household income in UK
(September 2017), pp. 1420–1428. Biobank”, Current Biology, vol. 26, No. 22 (November
77 Shira Goldenberg and others, “Police-related barriers to 2016), pp. 3083–3089.
21
well as their offspring’s educational attainment and Family and peer dynamics
well-being,83 possibly due in part to innate differ-
ences in cognitive ability and intelligence. There The family can influence an individual’s risk of using
also seems to be some overlap between the genetic drugs and being diagnosed with a drug use disorder,
risk of socioeconomic deprivation and substance partly via genetic but mostly via environmental
use disorders,84 although to date this has not been mechanisms. In families characterized by a low socio-
studied extensively in the context of the use of economic position and parental drug use, and
controlled drugs. perhaps by single parenting,89 a higher risk of sub-
stance use behaviours has been found. As evidenced
Genetic influences, which can heighten overall vul- by data from an international study of adolescents
nerability to drug use disorders, 85 become in Europe, parental supervision and monitoring,
increasingly evident throughout adolescence and which could be related to low levels of drug use
may play a role in propelling individuals from drug among young people,90 are less common among
initiation into more established patterns of use.86 families that experience socioeconomic difficulties
Lastly, evidence gathered in recent years indicating than among families that do not.91 A lack of pleas-
that interactions between genes and environmental urable, drug-free activities among young people
characteristics87 and epigenetic mechanisms88 play growing up in socioeconomically disadvantaged fam-
a key role in determining vulnerability to drug use ilies has also been found to contribute to higher levels
disorders, indicates that environmental characteris- of drug use.92 Moreover, among adults, members of
tics control the extent to which innate factors can groups characterized by socioeconomic disadvantage
influence the risk of drug use disorders. This implies tend to have more positive attitudes regarding drug
that protecting individuals from adverse experiences use, which could potentially contribute to higher
will reduce the likelihood of the genetic potential levels of drug use and related disorders.93
of drug use disorders becoming expressed.
89 Krzysztof Ostaszewski and Agnieska Pisarska A, “Youth risk

behavior prevention based on positive relationships: Warsaw
83 Timothy C. Bates and others, “Social competence in par- adolescent study”, in The Cambridge Handbook of Inter-
ents increases children’s educational attainment: replicable national Prevention Science, Moshe Israelashvili and John
genetically-mediated effects of parenting revealed by non- L. Romano, eds. (New York, Cambridge University Press,
transmitted DNA”, Twin Research and Human Genetics, 2017), pp. 896–928.
vol. 22, No. 1 (February 2019), pp. 1–3.
90 Lioney Tornay and others, “Parental monitoring: a way to
84 Toni-Kim Clarke and others, “Polygenic risk for alcohol decrease substance use among Swiss adolescents?”, European
dependence associates with alcohol consumption, cogni- Journal of Pediatrics, vol. 172, No. 9 (September 2013), pp.
tive function and social deprivation in a population-based 1229–1234.
cohort, Addiction Biology, vol. 21, No. 2 (March 2016), pp.
91 Jean-Sébastien Fallu and others, “Preventing disruptive boys
469–480.
from becoming heavy substance users during adolescence:
85 Kora-Mareen Bühler and others, “Common single nucleo- a longitudinal study of familial and peer-related protective
tide variants underlying drug addiction: more than a decade factors”, Addictive Behaviors, vol. 35, No. 12 (December
of research”, Addiction Biology, vol. 20, No. 5 (September 2010), pp. 1074–1082.
2015), pp. 845–871
92 Jungeun Olivia Lee and others, “Developmental pathways
86 J. H. Baker and others, “Sex differences and developmental from parental socioeconomic status to adolescent substance
stability in genetic and environmental influences on psy- use: alternative and complementary reinforcement”, Journal
choactive substance consumption from early adolescence of Youth and Adolescence, vol. 47, No. 2 (February 2018),
to young adulthood”, Psychological Medicine, vol. 41, No. 9 pp. 334–348; Nafesa Andrabi, Rubin Khoddam and Adam
(September 2011), pp. 1907–1916. M. Leventhal, “Socioeconomic disparities in adolescent
87 Jacqueline M. Vink, “Genetics of addiction: future focus substance use: role of enjoyable alternative substance-free
on gene × environment interaction?”, Journal of Studies on activities”, Social Science & Medicine, vol. 176 (2017), pp.
Alcohol and Drugs, vol. 77, No. 5 (September 2016), pp. 175–182.
684–687. 93 Davey-Rothwell and others, “The role of neighborhoods in
88 Amber N. Brown and Jian Feng, “Drug addiction and DNA shaping perceived norms”; Phillip L. Marotta and Dexter R.
modifications”, in Neuroepigenomics in Aging and Disease, Voisin, “Testing three pathways to substance use and delin-
Raul Delgado-Morales, ed., Advances in Experimental quency among low-income African American adolescents”,
Medicine and Biology Series, vol. 978 (Cham, Switzerland, Children and Youth Services Review, vol. 75 (2017), pp.
Springer, 2017), pp. 105–125. 7–14.
22
Mechanisms underlying the interaction between socioeconomic disadvantages and drug use /
Socioeconomic consequences of drug use disorders 5
Adverse life events, stress, later in life,97 suggesting that the relationship
between early life adversity and later risks could at
lack of support networks and least in part be mediated via biological pathways.
resources, and their psychologi-
cal consequences
SOCIOECONOMIC
The impact of socioeconomic inequalities on drug
use disorders can also be examined from the per-
CONSEQUENCES OF DRUG
spective of heightened exposure to adverse life USE DISORDERS
events (e.g. emotional and physical abuse and
neglect, and community violence) and chronic The relationship between socioeconomic inequality
stress.94 These life experiences can shape an indi- and drug use is not deterministic. In addition to the
vidual’s perception of his or her environment and direct effects of socioeconomic circumstances on an
fuel psychological processes such as impulsivity and individual’s patterns of drug use disorders, it is also
fatalism,95 which in turn can contribute to the risk important to take note of the finding that drug use,
of developing drug use disorders. particularly if frequent and in high amounts, can
have negative consequences for an individual’s socio-
Moreover, it has also been suggested that the expe- economic status and community.
rience of poverty has a direct, negative impact on
cognitive functions, thereby narrowing an individ- Community-level consequences
ual’s decision-making skill development.96 The
experience of socioeconomic adversity in early life In addition to having negative consequences for indi-
has been shown to shape brain structures associated viduals, a high prevalence of drug use disorders can
with the regulation of emotions, which could also have an impact on communities and neighbour-
be involved in an elevated risk of drug use disorder hoods. In particular, negative outcomes among
children and young people growing up in families
and communities characterized by drug use disor-
ders have been documented.98 Two ecological studies
94 Verônica Morais Ximenes and others, “Drugs and poverty: conducted in the United States found that rates of
interfaces of oppression in the capitalist world”, in Drugs
and Social Context: Social Perspectives on the Use of Alco-
drug-related arrests99 and hospital discharges related
hol and Other Drugs, Telmo Mota Ronzani, ed. (Cham, to opioid overdoses were associated with rates of
Switzerland, Springer, 2018); Cédric Galéra and others, child maltreatment.100 It was also observed that the
“Hyperactivity-inattention symptoms in childhood and
substance use in adolescence: the youth gazel cohort”, Drug
and Alcohol Dependence, vol. 94, Nos. 1–3 (April 2008), pp. 97 Pilyoung Kim and others, “Effects of childhood poverty
30–37; Cédric Galéra and others, “Disruptive symptoms in and chronic stress on emotion regulatory brain function in
childhood and adolescence and early initiation of tobacco adulthood”, Proceedings of the National Academy of Sciences
and cannabis use: the Gazel Youth study”, European Psychia- of the United States of America, vol. 110, No. 46 (November
try, vol. 25, No. 7 (November 2010), pp. 402–408; Cédric 2013), pp. 18442–18447; Michael D. De Bellis and Abigail
Galéra and others, “Attention problems in childhood and Zisk A. B., “The biological effects of childhood trauma”,
adult substance use”, Journal of Pediatrics, vol. 163, No. 6 Child and Adolescent Psychiatric Clinics of North America,
(December 2013), pp. 1677–1683; Jason E. Strickhouser vol. 23, No. 2 (April 2014), pp. 185–222; Elizabeth Cuervo
and Angelina R. Sutin, “Family and neighborhood socio- Tilson, “Adverse Childhood Experiences (ACEs): an impor-
economic status and temperament development from child- tant element of a comprehensive approach to the opioid
hood to adolescence”, Journal of Personality, in press. crisis”, North Carolina Medical Journal, vol. 79, No. 3 (May/
June 2018), pp. 166–169.
95 Silvia Chwartzmann Halpern and others, “Child maltreat-
ment and illicit substance abuse: a systematic review and 98 Angélica Meinhofer and Yohanis Angleró-Díaz, “Trends in
meta-analysis of longitudinal studies: child maltreatment foster care entry among children removed from their homes
and illicit substance abuse”, Child Abuse Review, vol. 27, because of parental drug use, 2000 to 2017, JAMA Pediat-
No. 5 (September/October 2018), pp. 344–360; Howard rics, vol. 173, No. 9 (July 2019), pp. 881–883.
Dubowitz and others, “Child maltreatment, relationship 99 Bridget Freisthler, Barbara Needell and Paul J. Gruenewald,
with father, peer substance use, and adolescent marijuana “Is the physical availability of alcohol and illicit drugs
use”, Journal of Child and Adolescent Substance Abuse, vol. related to neighborhood rates of child maltreatment?, Child
28, No. 3 (2019), pp. 150–159. Abuse and Neglect, vol. 29, No. 9 (September 2005), pp.
96 Anandi Mani and others, “Poverty impedes cognitive 1049–1060.
function”, Science, vol. 341, No. 6149 (August 2013), pp. 100 Jennifer Price Wolf and others, “Are community level pre-
976–980. scription opioid overdoses associated with child harm? A
23
increase in overdoses caused by prescription opioids treatment (defined as four or more sessions with a
between 2001 and 2011 in the United States coin- mental health and/or general practice physician and
cided with a 2 per cent increase in hospital discharges six or more sessions with a non-medically trained
related to child maltreatment and a 1 per cent professional), the same study reported an average
increase in those related to child injury.101 access rate of 7.1 per cent, with significant dispari-
ties across regions: 10.3 per cent in high-income
Lastly, drug use may influence the socioeconomic
countries, 4.3 per cent in upper-middle-income
characteristics of neighbourhoods. The illicit drug
countries and 1 per cent in low- to lower-middle-
market provides economic opportunities that can
income countries. The insufficient availability of
lead individuals to disengage from the legal labour
treatment services is the main explanation for such
market and discourages official businesses, thereby
country-level differences in access.
perpetuating a cycle of poverty and social disor-
ganization that can fuel further drug use Moreover, access to HIV interventions, including
disorders.102 anti-retroviral therapy, is limited in several countries.
For example, a systematic review found that, in 2017,
needle and syringe programmes had distributed just
SOCIOECONOMIC 33 needles and syringes per person per year to inject-
INEQUALITIES IN ACCESS ing drug users, and only 16 per cent of injecting drug
TO EFFECTIVE DRUG users had access to medication-assisted therapy.
TREATMENT Less than 1 per cent of injecting drug users lived
in countries where the coverage of both of these
Estimates suggest that only one out of every eight key interventions was high. Furthermore, in most
people with a drug use disorder worldwide has access of the 54 countries reporting data to the Joint
to treatment, although there are large geographical United Nations Programme on HIV/AIDS, the
disparities in that regard.103 Access to treatment for coverage of needle and syringe programmes and
drug use disorders tends to be more limited in coun- opioid substitution therapy remained low between
tries with a low or intermediate level of economic 2014 and 2018.105, 106
development than in those with higher levels of At the individual level, a lack of, or insufficient,
development, which may be the result of a combi- health insurance coverage,107 low income108 and
nation of ignorance about drug use disorders and educational levels are also associated with low levels
inadequate access related to limited financial resourc- of access to drug use treatment.109 Moreover, indi-
es.104 For example, global mental health surveys
show that, among people who meet the criteria for 105 Sarah Larney and others, Global, regional, and country-level
a drug use disorder, 43.1 per cent of those in high- coverage of interventions to prevent and manage HIV and
hepatitis C among people who inject drugs: a systematic
income countries, 35.6 per cent of those in review”, Lancet Global Health, vol. 5, No. 12 (December
upper-middle-income countries and 31.5 per cent 2017), pp. e1208–e1220.
of those in lower-middle income countries reported 106 UNAIDS, Health, Rights and Drugs: Harm Reduction,
needing treatment. Decriminalization and Zero Discrimination for People Who
Use Drugs (Geneva, 2019), figure 2.
Examining actual access to minimally effective 107 Namkee G. Choi and others, Adults who misuse opioids:
substance abuse treatment use and perceived treatment
need”, Substance Abuse, vol. 40, No. 2 (2019), pp. 247–255;
spatial analysis of California zip codes, 2001–2011”, Drug
Eunice Park-Lee, Rachel N. Lipari and Sarra L. Hedden,
and Alcohol Dependence, vol. 166 (2016), pp. 202–208.
“Receipt of services for substance use and mental health
101 Ibid. issues among adults: results from the 2016 National Survey
102 Bruce D. Johnson and others, “Drug abuse in the inner city: on Drug Use and Health”, NSDUH Data Review (Septem-
impact on hard-drug users and the community”, Crime and ber 2017).
Justice, vol. 13 (1990), pp. 9–67. 108 Atilola, Ayinde and Adeitan, “Beyond prevalence and
103 See Booklet 2 of the present report. pattern”.
104 Louisa Degenhardt and others, “Estimating treatment cover- 109 S. Evans-Lacko and others, “Socio-economic variations in
age for people with substance use disorders: an analysis of the mental health treatment gap for people with anxiety,
data from the World Mental Health Surveys”, World Psychia- mood, and substance use disorders: results from the WHO
try, vol. 16, No. 3 (October 2017), pp. 299–307. World Mental Health (WMH) Surveys”, Psychological
24
Socioeconomic inequalities in access to effective drug treatment /
Groups particularly impacted by socioeconomic disadvantage 5
viduals who experience incarceration may have
particular difficulties in accessing treatment, as sug- GROUPS PARTICULARLY
gested by a study conducted in Canada among 2,700 IMPACTED BY SOCIO-
people who injected drugs,110 which showed that
the existing treatment options were insufficient to
ECONOMIC DISADVANTAGE
meet existing needs.
Women
Stigmatizing attitudes represent one of the barriers Although the prevalence of drug use disorders is
preventing people with drug use disorders from gain- generally lower among women than men,115 women
ing access to health and social services. Such attitudes who do have a drug use disorder appear to be par-
may be further exacerbated by the additional stigma ticularly vulnerable.116 First, compared with men,
attached to low socioeconomic status or association women who have a drug use disorder are more likely
with the criminal justice system. For example, a to have a co-morbid psychiatric disorder. For exam-
qualitative study conducted among a sample of ple, in a study conducted among 226 women who
homeless people in Kingston, Ontario, Canada, were injecting drug users in five different countries
showed that those with drug use disorders frequently in Europe (Austria, Italy, Poland, Spain and the
reported having experienced stigmatizing and sham- United Kingdom of Great Britain and Northern
ing experiences when in contact with health-care Ireland (Scotland)), 87 per cent had a psychiatric
services. This in turn could lead them to forego or co-morbidity (mainly depression, panic disorder
abandon access to care.111 Other research, conducted and post-traumatic stress disorder) and 68 per cent
in Nigeria, showed that 40 per cent of people who had experienced interpersonal violence in their cur-
self-identified as participating in high-risk drug use rent or most recent intimate relationship in the
behaviours wanted treatment but were unable to preceding 12 months.117 Second, women face par-
get it, with a lack of financial resources and available ticular risks in terms of sexual and reproductive
treatment services and fear of stigma being the main health, as well as the experience of sexual violence,
barriers to accessing such treatment.112 particularly in contexts of poverty and drug use.118
Sometimes, even when they do access appropriate A study conducted in Delhi found that women who
health services, people with drug use disorders who injected drugs had difficulty using contraceptives
have a low level of education or income or insuffi- reliably, owing to gender imbalances and difficul-
cient health insurance coverage have difficulty ties in imposing their will, which could lead to a
accessing quality, evidence-based treatment or have limited capacity to act and heighten the risk of
difficulty adhering to the treatment regimen.113 This exposure to violence.119
may be the case in particular when the health-care
system is fragmented and therefore difficult for indi- lenges and opportunities”, Journal of the American Academy
of Child and Adolescent Psychiatry, vol. 49, No. 7 (July
viduals to navigate.114 2010), pp. 637–646.
115 Louisa Degenhardt and others, “The epidemiology of drug
Medicine, vol. 48, No. 9 (July 2018), pp. 1560–1571. use disorders cross-nationally: findings from the WHO’s
110 John D. Koehn and others, “Impact of incarceration on Mentl Health Surveys”, International Journal of Drug Policy,
rates of methadone use in a community recruited cohort of vol. 71 (2019), pp. 103–112.
injection drug users”, Addictive Behaviors, vol. 46 (2015), 116 UNODC, Guidelines on Drug Prevention and Treatment for
pp. 1–4. Girls and Women (Vienna, 2016).
111 Eva Purkey and Meredith MacKenzie, “Experience of 117 Judit Tirado-Muñoz and others, “Psychiatric comorbidity
healthcare among the homeless and vulnerably housed a and intimate partner violence among women who inject
qualitative study: opportunities for equity-oriented health drugs in Europe: a cross-sectional study”, Archives of Women’s
care”, International Journal for Equity in Health, vol. 18, Mental Health, vol. 21, No. 3 (2018), pp. 259–269.
No. 1 (July 2019).
118 Catherine Embersin-Kyprianou and others, “Grossesses non
112 UNODC, Drug Use in Nigeria 2018 (Vienna, 2019). prévues, violences sexuelles et contraception chez les femmes
113 Perrine Roux and others, “Predictors of non-adherence to consommant du cannabis ou d’autres substances psychoac-
methadone maintenance treatment in opioid-dependent tives illégales en Île-de-France: données du Baromètre Santé
individuals: implications for clinicians”, Current Pharmaceu- 2016”, Revue d’Epidémiologie et de Santé Publique, vol. 68,
tical Design, vol. 20, No. 25 (August 2014), pp. 4097–4105. No. 1 (October 2019).
114 Stacy Sterling and others, “Access to treatment for adoles- 119 Vartika Sharma and others, “Women and substance use:
cents with substance use and co-occurring disorders: chal- a qualitative study on sexual and reproductive health of
25
Women who have a partner who also has a drug use Sexually diverse populations
disorder can suffer as a result of the partner’s addic-
tion, as well as its consequences. For example, a study In general, the relationship between belonging to
conducted among women whose partners were incar- lesbian, gay, bisexual, transgender, queer or intersex
cerated, in many cases for drug-related reasons, found (LGBTQI) groups and levels of drug use disorders
that the women who had been “left behind” had is not well described globally.
seen their financial resources decrease significantly, Studies of sexual minorities in a few countries have
leading them to engage in transactional sex.120 shown that adolescents and adults who have sexual
Women who are mothers are additionally vulner- relations with people of the same sex or who identify
able because their children’s welfare can also be as lesbian, gay, bisexual transgender, queer or inter-
affected by their drug use.121 In particular, there is sex are more likely to have drug use disorders than
evidence that, among women who use psychoactive people who identify as heterosexual.124
drugs, the likelihood of loss of child custody is In the United States, according to a nationally rep-
related to low socioeconomic status and involve- resentative monitoring study of youth, 50 per cent
ment in the criminal justice system (i.e. problems of high school students who identified as non-het-
with the police or a history of incarceration).122 erosexual had used cannabis, compared with 35 per
This may reflect the effects of an accumulation of cent of those who identified as heterosexual; when
stresses and difficulties among mothers who use asked about current cannabis use, 30 per cent of
drugs and who have socioeconomic or criminal non-heterosexual students responded positively, as
justice-related problems in parallel, which alto- compared with 19 per cent of heterosexual students.
gether impedes their parenting abilities. Lastly, Similar patterns were observed for other controlled
being a mother can reduce the chances of success- drugs: 11 per cent versus 6 per cent for lifetime use
fully entering treatment for a drug use disorder, of hallucinogenic drugs; 8 per cent versus 4 per cent
owing to conflicting demands, a lack of adequate for lifetime cocaine use; 18 per cent versus 7 per
child-care services provided by the health-care facil- cent for lifetime inhalant use; 9 per cent versus 3
ity, or fear of loss of child custody.123 per cent for lifetime methamphetamine use; 9 per
cent versus 3 per cent for lifetime MDMA
(“ecstasy”) use; and 6 per cent versus 1 per cent for
lifetime heroin use.125
Similar trends were observed in a study conducted
in eight European countries, where 15-year old chil-
women who use drugs in Delhi, India”, BMJ Open, vol. 7, dren who reported being attracted to young people
No. 11 (November 2017).
of the same sex, or to both those of the same and
120 Kelly M. King, Carl A. Latkin and Melissa A. Davey-
Rothwell, “Love on lockdown: how social network charac- those of the opposite sex, had levels of cannabis use
teristics predict separational concurrency among low income nearly two times higher than those who were only
African-American women”, Journal of Urban Health, vol. 92, attracted to young people of the opposite sex.126 In
No. 3 (March 2015), pp. 460–471.
adulthood, these differences in drug use persist: a
121 Freisthler, Needell and Gruenewald, “Is the physical avail-
ability of alcohol and illicit drugs related to neighborhood study conducted in the United States found that
rates of child maltreatment? ”; Daniel Max Crowley and
others, “Considering the child welfare system burden from 124 Erin M. Kahle and others, “Functional and structural social
opioid misuse: research priorities for estimating public support, substance use and sexual orientation from a nation-
costs”, American Journal of Managed Care, vol. 25 (2019), ally representative sample of U.S. adults”, Addiction, vol.
pp. S256–S263. 115, No. 3 (March 2020), pp. 546–558.
122 Martha Canfield and others, “Maternal substance use and 125 Laura Kann and others, “Youth risk behavior surveillance
child protection: a rapid evidence assessment of factors asso- – United States, 2017”, Morbidity and Mortality Weekly
ciated with loss of child care”, Child Abuse and Neglect, vol. Report, Surveillance Summaries, vol. 67, No. 8 (June 2018),
70 (2017), pp. 11–27. pp. 1–114.
123 Rebekah J. Savage and others, “The adverse effects of 126 András Költő and others, “Romantic attraction and sub-
motherhood on substance use treatment program outcomes stance use in 15-year-old adolescents from eight European
among adolescent women”, Journal of Addiction Medicine, countries”, International Journal of Environmental Research
vol. 9, No. 6 (November/December 2015), pp. 478–484. and Public Health, vol. 16, No. 17 (August 2019).
26
Groups particularly impacted by socioeconomic disadvantage
5
overall rates of drug use disorder were 50 per cent than among those who identify as heterosexual132
higher among non-heterosexual persons than among – may compound the risk of drug use disorders.
heterosexual persons, with the difference between
those rates being greater for women.127 In these stud- Indigenous and aboriginal
ies, this increased risk of drug use disorders appeared peoples
to be higher among women who were not hetero-
sexual than among men;128 it was also elevated There is extensive evidence documenting the
among individuals who were transsexual.129 increased risk of drug use disorders among individu-
als who are members of indigenous and aboriginal
Transgender people represent another group at high peoples. For example, in the United States and
risk of drug use: data from 406 transgender study Canada, cannabis use disorders are 20–50 per cent
participants in Canada showed a prevalence of use more common among indigenous peoples than
of controlled drugs of 12.3 per cent, a prevalence among Caucasians.133 In terms of mortality, up until
of cocaine use of 7.3 per cent (compared with 1.3 2010, Native Alaskans represented the ethnic group
per cent in the general population) and a prevalence in North America with the highest rate of drug-
of amphetamine use of 1.3 per cent (compared with related deaths (15.6 per 100,000 population).134
0.3 per cent in the general population) in the past The elevated risk of death among indigenous peoples
year.130 This increased risk of drug use among indi- in North America seems to be particularly related
viduals who belong to LGBTQI groups may be to psychostimulant use; importantly, this rate has
explained in part by the stigma and discrimination, increased in recent years.135
whether real or perceived, that such individuals often
face from an early age.131 The experience of socio- In Australia and Oceania, mental and drug use dis-
economic disadvantage among people who belong orders are the leading cause of non-fatal burden of
to LGBTQI groups and – a situation that appears illness among people belonging to indigenous
more commonly among people who identify as bisex- groups.136 It has also been suggested that the rates
ual or who are not sure about their sexual orientation of use of certain drugs such as inhalants are elevated
among the native populations of Alaska and the
Arctic.137 Review studies suggest that this increased
127 Kahle and others, “Functional and structural social support,
substance use and sexual orientation”. 132 Bradley T. Kerridge and others, “Prevalence, sociodemo-
graphic correlates and DSM-5 substance use disorders and
128 Amelia E. Talley and others, “Sexual minority youth at risk
other psychiatric disorders among sexual minorities in the
of early and persistent alcohol, tobacco, and marijuana use”,
United States”, Drug and Alcohol Dependence, vol. 170
Archives of Sexual Behavior, vol. 48, No. 2 (January 2019),
(2017), pp. 82–92.
pp. 1073–1086.
133 Frederik S. Stinson and others, “Cannabis use disorders
129 Sari L. Reisner and others, “Global health burden and needs
in the USA: prevalence, correlates and co-morbidity”, Psy-
of transgender populations: a review”, Lancet, vol. 388, No.
chological Medicine, vol. 36, No. 10 (October 2006), pp.
10042 (July 2016), pp. 412–436; Siyan Yi and others, “HIV
1447–1460; Nolan K. Hop and others, “The prevalence of
prevalence, risky behaviors, and discrimination experiences
distress, depression, anxiety, and substance use issues among
among transgender women in Cambodia: descriptive find-
Indigenous post-secondary students in Canada”, Transcul-
ings from a national integrated biological and behavioral
tural Psychiatry (October 2019); Sana Shahram, “The social
survey”, BMC International Health and Human Rights, vol.
determinants of substance use for aboriginal women: a sys-
17, No. 14 (2017).
tematic review”, Women and Health, vol. 56, No. 2 (October
130 Ayden I. Scheim, Greta R. Bauer and Mostafa Shokoohi, 2015), pp. 157–176.
“Drug use among transgender people in Ontario, Canada:
134 Karin A. Mack, “Drug-induced deaths: United States,
disparities and associations with social exclusion”, Addictive
1999–2010”, Morbidity and Mortality Weekly Report, Sup-
Behaviors, vol. 72 (2017), pp. 151–158.
plements, vol. 62, No. 3 (November 2013), pp. 161–163.
131 Nicholas A. Livingston and others, “Ecological momentary
135 Mbabazi Kariisa and others, ”Drug overdose deaths involv-
assessment of daily discrimination experiences and nicotine,
ing cocaine and psychostimulants with abuse potential:
alcohol, and drug use among sexual and gender minority
United States, 2003–2017”, Morbidity and Mortality Weekly
individuals”, Journal of Consulting and Clinical Psychology,
Report, vol. 68, No. 17 (May 2019), pp. 388–395.
vol. 85, No. 12 (December 2017), pp. 1131–1143; Katie
McLaughlin, Mark L. Hatzenbuehler and Katherine M. 136 Fiona J. Charlson and Holly E. Erskine, “Burden of mental
Keyes, “Responses to discrimination and psychiatric disor- and substance use disorders in Indigenous Australians and
ders among black, Hispanic, female, and lesbian, gay, and Oceania”, Australasian Psychiatry, vol. 23, No. 6 (2015), pp.
bisexual individuals”, American Journal of Public Health, vol. 13–16.
100, No. 8 (August 2010), pp. 1477–1484. 137 Venla Lehti and others, “Mental health, substance use and
27
risk may be due to disadvantaged socioeconomic dom, black and “mixed-race” people are also at higher
circumstances138 and high levels of stress and poor risk of cannabis use than white people, but this risk
family cohesion.139 is low among people who originate from South-East
Asia, particularly women.145 Despite the dearth of
Ethnic groups and immigrants data from other settings, it is important to note that
The data relating to ethnic differences are particu- levels of drug use have been found to vary across
larly complex. For example, in the United States, ethnic groups in other countries; for example, they
compared with their Caucasian counterparts, rates appear to be elevated among young people belong-
of cannabis use among African-American adoles- ing to hill tribes in northern Thailand.146
cents, in particular female adolescents, tend to be Differences in drug use disorders across ethnic and
lower. However, these trends tend to converge upon immigrant groups may in part reflect differences in
reaching adulthood140 and over time.141 The level socioeconomic difficulties, as well as the general
of opioid mortality is also lower among African- experience of stigma and discrimination. For
Americans than among Caucasians,142 but the instance, a study conducted among 2,315 African-
levels of cocaine use and cocaine use disorder are American and white college students in the United
higher among African-Americans than among States showed that African-American women who
other ethnic groups.143 reported having experienced discrimination in the
In other settings, variability in levels of drug use dis- past were more than three times more likely than
orders across ethnic groups has also been observed. those who did not to report recent cannabis use.147
In Germany, the level of cannabis use tends to be In parallel, the rate of cannabis use was also elevated
higher among Turkish-German young people than among black women who reported being homo-
among young people who do not have an immigrant sexual, suggesting that discrimination associated
background.144 Similarly, in the United King- with different types of minority status identities can
accumulate and potentially synergize, consistent
with the intersectional framework of health.148
suicidal behaviour among young Indigenous people in the
Arctic: a systematic review”, Social Science and Medicine, vol. Although findings regarding the elevated risk of drug
69, No. 8 (October 2009), pp. 1194–1203. use and drug use disorder across ethnic groups are
138 Shahram, “The social determinants of substance use for mixed and generally come from high-income coun-
aboriginal women”. tries, there is clear evidence that, in cases of drug
139 Christian Young and others, “Psychosocial factors associated
with the mental health of indigenous children living in high
use disorder, people from ethnic groups are less likely
income countries: a systematic review”, International Journal to receive optimal health care. For instance, a study
for Equity in Health, vol. 16, No. 153 (August 2017). conducted among 789 opioid users, recruited across
140 Katherine M. Keyes and others, “Racial/ethnic differences in
use of alcohol, tobacco, and marijuana: is there a cross-over
from adolescence to adulthood?”, Social Science and Medi- 145 Karen Rodham and others, “Ethnic and gender differences
cine, vol. 124 (2015), pp. 132–141. in drinking, smoking and drug taking among adolescents in
141 Ava D. Hamilton and others, “Age, period and cohort England: a self-report school-based survey of 15 and 16 year
effects in frequent cannabis use among US students: 1991– olds”, Journal of Adolescence, vol. 28, No. 1 (February 2005),
2018”, Addiction, vol. 114, No. 10 (October 2019), pp. pp. 63–73.
1763–1172. 146 Chalitar Chomchoei and others, “Perceived factors influenc-
142 Monica J. Alexander, Mathew V. Kiang and Magali Barbieri, ing the initiation of methamphetamine use among Akha
“Trends in Black and White opioid mortality in the United and Lahu youths: a qualitative approach”, BMC Public
States, 1979–2015”, Epidemiology, vol. 29, No. 5 (Septem- Health, vol. 19, No. 1 (December 2019).
ber 2018), pp. 707–715. 147 Milkie Vu and others, “Mental health and substance use
143 William S. John and Li-Tzy Wu, “Trends and correlates of among women and men at the intersections of identities
cocaine use and cocaine use disorder in the United States and experiences of discrimination: insights from the inter-
from 2011 to 2015”, Drug and Alcohol Dependence, vol. 180 sectionality framework”, BMC Public Health, vol. 19, No. 1
(2017), pp. 376–384. (January 2019).
144 Carolin Donath and others, “Substance consumption in 148 Kimberle Crenshaw, “Mapping the margins: intersectional-
adolescents with and without an immigration background: ity, identity politics, and violence against women of color”,
a representative study–what part of an immigration back- in The Public Nature of Private Violence: The Discovery of
ground is protective against binge drinking? ”, BMC Public Domestic Abuse, Martha Albertson Fineman and Roxanne
Health, vol. 16, No. 1157 (November 2016). Mykitiuk, eds. (New York, Routledge, 1994).
28
Groups particularly impacted by socioeconomic disadvantage
5
the United States, found that, two years after the tion can be passed down to the next generation: in
initiation of treatment, accounting for other char- particular, a recent systematic review and meta-anal-
acteristics including sociodemographic factors, ysis found that the children of immigrants who are
participants who were Hispanic or African-American left behind when their parents emigrate are 1.24
were less likely to receive buprenorphine than those times more likely to use psychoactive drugs than the
who were white.149 Some of the most common bar- children of non-immigrants.153
riers observed were lack of health insurance coverage,
In addition, immigrant status can compound risks
difficulties in access and high prices. Other research
associated with unfavourable socioeconomic cir-
has confirmed that access to and completion of treat-
cumstances. For example, among women engaged
ment for opioid use also vary across ethnic groups.150
in sex work on the border between Mexico and Gua-
Studies conducted among immigrant populations, temala, there is evidence that those with immigrant
who tend to experience high levels of socioeconomic status have a higher likelihood than non-immigrants
difficulty, provide additional insights into the socio- of engaging in drug use.154 Similarly, several studies
economic and contextual factors that can influence suggest elevated levels of risky drug-related behav-
drug use patterns. For example, a study comparing iours among immigrants who use drugs, for
a small sample of young Brazilians living in Brazil instance, those who have migrated from the former
(n = 161) and the United Kingdom (n = 164) found Soviet Union to Germany155 or from Myanmar to
that levels of drug use were higher among the latter China.156 Naturally, there is great heterogeneity
group. Moreover, patterns of drug use reported by among immigrant populations, their contexts and
the Brazilians living in the United Kingdom were their drug use risks, and there are still large gaps in
shaped by socioeconomic characteristics, such as related research. There is a need to study these
low educational level, which did not seem to be the aspects in detail in specific settings in order to yield
case among those living in Brazil.151 information that is relevant for policy and pro-
gramme design, as well as the implementation of
In other research, based on observations conducted
effective health services.
on the border between the United States and Mexico
in San Diego and Tijuana, it has been reported that
immigrants are at high risk of drug use in circum-
Displaced persons
stances where they mix with the local population, Displaced persons are people who have been forced
if they also experience unfavourable socioeconomic to leave their homes because of armed conflict,
circumstances.152 Moreover, the impact of migra- generalized violence, human rights violations or
environmental disasters, and who have moved to
149 Elizabeth A. Evans and others, “Effects of access barriers another area within their own country (internally
and medication acceptability on buprenorphine-naloxone
treatment utilization over 2 years: results from a multisite
randomized trial of adults with opioid use disorder”, Journal among migrant populations: a narrative review”, Substance
of Substance Abuse Treatment, vol. 106 (2019), pp. 19–28. Use & Misuse, vol. 53, No. 9 (July 2018), pp. 1558–1570.
150 Rebecca E. Cantone and others, “Predictors of medication- 153 Gracia Fellmeth and others, “Health impacts of parental
assisted treatment initiation for opioid use disorder in an migration on left-behind children and adolescents: a system-
interdisciplinary primary care model”, Journal of the Ameri- atic review and meta-analysis”, Lancet, vol. 392, No. 10164
can Board of Family Medicine, vol. 32, No. 5 (September (December 2018), pp. 2567–2582.
2019), pp. 724–731; Gerald J. Stahler and Jeremy Mennis, 154 Teresita Rocha-Jiménez and others, “The influence of migra-
“Treatment outcome disparities for opioid users: are there tion in substance use practices and HIV/STI-related risks of
racial and ethnic differences in treatment completion across female sex workers at a dynamic border crossing”, Journal of
large US metropolitan areas?”, Drug and Alcohol Dependence, Ethnicity in Substance Abuse (February 2019), pp. 1–18.
vol. 190 (2018), pp. 170–78; Ben Lewis and others, “Race 155 Lineke Derks and others, “Risk behaviours and viral infec-
and socioeconomic status in substance use progression and tions among drug injecting migrants from the former Soviet
treatment entry”, Journal of Ethnicity in Substance Abuse, vol. Union in Germany: results from the DRUCK-study”, Inter-
17, No. 2 (April/June 2018), pp. 150–166. national Journal on Drug Policy, vol. 59 (September 2018),
151 Martha Canfield, Marcia Worrell and Catherine Gilvarry, pp. 54–62.
“Determinants of substance use amongst Brazilians resid- 156 Xin Chen and others, “Burmese injecting drug users in
ing in the UK: the role of acculturation”, Drug and Alcohol Yunnan play a pivotal role in the cross-border transmission
Review, vol. 36, No. 6 (November 2017), pp. 751–760. of HIV-1 in the China-Myanmar border region”, Virulence,
152 Jason S. Melo and others, “Injection drug use trajectories vol. 9, No. 1 (2018), pp. 1195–1204.
29
displaced persons), or to another country Similar results have been observed in Australia,
(refugees).157 Although a review published in 2012, where people who use drugs residing in rural areas
based on data collected between 1971 and 2007 in are less likely to access information and services for
Afghanistan, Bosnia and Herzegovina, Croatia and the prevention of adverse health consequences of
Pakistan, found weak evidence of elevated levels of drug use and treatment of drug use disorders than
drug use among displaced persons,158 more recent those living in urban settings.163
data suggest that forced displacement is related to
drug use disorders. A study conducted in Colombia
found a high lifetime prevalence of use of cannabis
(11 per cent), cocaine (3.5 per cent), coca paste (2
per cent), inhalants (2.3 per cent) and injected drugs
(0.7 per cent) among persons who were displaced.159
Factors that are likely to increase the risk of drug
use among displaced persons include exposure to
trauma160 and lack of economic opportunities.161
Access to drug treatment for displaced persons is a
major challenge, in particular for those who migrate
to a different country.
People in rural settings

Although global data on this issue are lacking, people
living in rural areas may face specific challenges in
accessing adequate treatment in cases of drug use
disorder. For instance, a study conducted among
more than 1,600 people registered as drug users in
Hunan Province, China, found that those residing
in rural settings were generally less likely to report
past participation in drug treatment than those
living in urban settings (2.8 per cent versus 6.8 per
cent).162
157 UNESCO, Social and Human Sciences, Fostering rights,

inclusion and non-discrimination, Migration and inclusive
societies, International migration, “Glossary of migration-
related terms: displaced persons/displacement”. Available at
www.unesco.org/.
158 Nadine Ezard, “Substance use among populations displaced
by conflict: a literature review”, Disasters, vol. 36, No. 3
(July 2012), pp. 533–557.
159 Guillermo Castaño and others, “Trastornos mentales y
consumo de drogas en la población víctima del conflicto
armado en tres ciudades de Colombia”, Biomédica, vol. 38
(2017), pp. 77–92.
160 Danielle Horyniak and others, “Epidemiology of substance
use among forced migrants: a global systematic review”,
PLOS One, vol. 11, No. 7 (2016).
161 Ezard, “Substance use among populations displaced by
conflict”. 163 Carolyn Day and others, “Patterns of drug use and associ-
162 Qijian Deng and others, “Drug use in rural China: a pre- ated harms among rural injecting drug users: comparisons
liminary investigation in Hunan Province”, Addiction, vol. with metropolitan injecting drug users”, Australian Journal
107, No. 3 (March 2012), pp. 610–613. of Rural Health, vol. 14, No. 3 (June 2006), pp. 120–125.
30
GLOSSARY
amphetamine-type stimulants — a group of sub- problem drug users — people who engage in the
stances composed of synthetic stimulants controlled high-risk consumption of drugs. For example,
under the Convention on Psychotropic Substances people who inject drugs, people who use drugs on
of 1971 and from the group of substances called a daily basis and/or people diagnosed with drug use
amphetamines, which includes amphetamine, meth- disorders (harmful use or drug dependence), based
amphetamine, methcathinone and the on clinical criteria as contained in the Diagnostic
“ecstasy”-group substances (3,4-methylenedioxym- and Statistical Manual of Mental Disorders (fifth edi-
ethamphetamine (MDMA) and its analogues). tion) of the American Psychiatric Association, or
the International Classification of Diseases and Related
amphetamines — a group of amphetamine-type Health Problems (tenth revision) of WHO.
stimulants that includes amphetamine and
methamphetamine. people who suffer from drug use disorders/people with
drug use disorders — a subset of people who use
annual prevalence — the total number of people of drugs. Harmful use of substances and dependence
a given age range who have used a given drug at are features of drug use disorders. People with drug
least once in the past year, divided by the number use disorders need treatment, health and social care
of people of the given age range, and expressed as a and rehabilitation.
percentage.
harmful use of substances — defined in the Interna-
coca paste (or coca base) — an extract of the leaves tional Statistical Classification of Diseases and Related
of the coca bush. Purification of coca paste yields Health Problems (tenth revision) as a pattern of use
cocaine (base and hydrochloride). that causes damage to physical or mental health.
“crack” cocaine — cocaine base obtained from dependence — defined in the International Statistical
cocaine hydrochloride through conversion processes Classification of Diseases and Related Health Problems
to make it suitable for smoking. (tenth revision) as a cluster of physiological, behav-
cocaine salt — cocaine hydrochloride. ioural and cognitive phenomena that develop after
repeated substance use and that typically include a
drug use — use of controlled psychoactive substances strong desire to take the drug, difficulties in control-
for non-medical and non-scientific purposes, unless ling its use, persisting in its use despite harmful
otherwise specified. consequences, a higher priority given to drug use
fentanyls - fentanyl and its analogues. than to other activities and obligations, increased
tolerance, and sometimes a physical withdrawal
new psychoactive substances — substances of abuse, state.
either in a pure form or a preparation, that are not
controlled under the Single Convention on Narcotic substance or drug use disorders — referred to in the
Drugs of 1961 or the 1971 Convention, but that Diagnostic and Statistical Manual of Mental Disorders
may pose a public health threat. In this context, the (fifth edition) as patterns of symptoms resulting
term “new” does not necessarily refer to new inven- from the repeated use of a substance despite expe-
tions but to substances that have recently become riencing problems or impairment in daily life as a
available. result of using substances. Depending on the
number of symptoms identified, substance use dis-
opiates — a subset of opioids comprising the various order may be mild, moderate or severe.
products derived from the opium poppy plant,
prevention of drug use and treatment of drug use dis-
including opium, morphine and heroin.
orders — the aim of “prevention of drug use” is to
opioids — a generic term that refers both to opiates prevent or delay the initiation of drug use, as well
and their synthetic analogues (mainly prescription as the transition to drug use disorders. Once a person
or pharmaceutical opioids) and compounds synthe- develops a drug use disorder, treatment, care and
sized in the body. rehabilitation are needed.
31
REGIONAL GROUPINGS
The World Drug Report uses a number of regional of Korea, Indonesia, Japan, Lao People’s
and subregional designations. These are not official Democratic Republic, Malaysia, Mongolia,
designations, and are defined as follows: Myanmar, Philippines, Republic of Korea,
• East Africa: Burundi, Comoros, Djibouti, Eritrea,
Singapore, Thailand, Timor-Leste, Viet Nam,
Hong Kong, China, Macao, China, and Taiwan
Ethiopia, Kenya, Madagascar, Mauritius, Rwanda,
Province of China
Seychelles, Somalia, South Sudan, Uganda,
United Republic of Tanzania and Mayotte • South-West Asia: Afghanistan, Iran (Islamic
• North Africa: Algeria, Egypt, Libya, Morocco,
Republic of ) and Pakistan
Sudan and Tunisia • Near and Middle East: Bahrain, Iraq, Israel,
• Southern Africa: Angola, Botswana, Eswatini,
Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi
Arabia, State of Palestine, Syrian Arab Republic,
Lesotho, Malawi, Mozambique, Namibia, South
United Arab Emirates and Yemen
Africa, Zambia, Zimbabwe and Reunion
• West and Central Africa: Benin, Burkina
• South Asia: Bangladesh, Bhutan, India, Maldives,
Nepal and Sri Lanka
Faso, Cabo Verde, Cameroon, Central African
Republic, Chad, Congo, Côte d’Ivoire, • Eastern Europe: Belarus, Republic of Moldova,
Democratic Republic of the Congo, Equatorial Russian Federation and Ukraine
Guinea, Gabon, Gambia, Ghana, Guinea, • South-Eastern Europe: Albania, Bosnia and
Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Herzegovina, Bulgaria, Croatia, Montenegro,
Nigeria, Sao Tome and Principe, Senegal, Sierra North Macedonia, Romania, Serbia, Turkey
Leone, Togo and Saint Helena and Kosovo164
• Caribbean: Antigua and Barbuda, Bahamas, • Western and Central Europe: Andorra, Austria,
Barbados, Cuba, Dominica, Dominican Republic, Belgium, Cyprus, Czechia, Denmark, Estonia,
Grenada, Haiti, Jamaica, Saint Kitts and Nevis, Finland, France, Germany, Greece, Hungary,
Saint Lucia, Saint Vincent and the Grenadines, Iceland, Ireland, Italy, Latvia, Liechtenstein,
Trinidad and Tobago, Anguilla, Aruba, Bonaire, Lithuania, Luxembourg, Malta, Monaco,
Netherlands, British Virgin Islands, Cayman Netherlands, Norway, Poland, Portugal, San
Islands, Curaçao, Guadeloupe, Martinique, Marino, Slovakia, Slovenia, Spain, Sweden,
Montserrat, Puerto Rico, Saba, Netherlands, Sint Switzerland, United Kingdom of Great Britain
Eustatius, Netherlands, Sint Maarten, Turks and and Northern Ireland, Faroe Islands, Gibraltar
Caicos Islands and United States Virgin Islands and Holy See
• Central America: Belize, Costa Rica, El Salvador,
Oceania (comprised of four sub-regions):
Guatemala, Honduras, Nicaragua and Panama
• Australia and New Zealand: Australia and
• North America: Canada, Mexico and United
New Zealand
States of America, Bermuda, Greenland and Saint-
Pierre and Miquelon
• Polynesia: Cook Islands, Niue, Samoa, Tonga,
Tuvalu, French Polynesia, Tokelau and Wallis and
• South America: Argentina, Bolivia (Plurinational
Futuna Islands
State of ), Brazil, Chile, Colombia, Ecuador,
Guyana, Paraguay, Peru, Suriname, Uruguay,
• Melanesia: Fiji, Papua New Guinea, Solomon
Venezuela (Bolivarian Republic of ) and Falkland Islands, Vanuatu and New Caledonia
Islands (Malvinas) • Micronesia: Kiribati, Marshall Islands, Micronesia
• Central Asia and Transcaucasia: Armenia,
(Federated States of ), Nauru, Palau, Guam and
Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Northern Mariana Islands
Tajikistan, Turkmenistan and Uzbekistan
164 All references to Kosovo in the World Drug Report should
• East and South-East Asia: Brunei Darussalam,
be understood to be in compliance with Security Council
Cambodia, China, Democratic People’s Republic resolution 1244 (1999).
33
Vienna International Centre, PO Box 500, 1400 Vienna, Austria
Tel: +(43) (1) 26060-0, Fax: +(43) (1) 26060-5866, www.unodc.org
Presented in six separate booklets, the World Drug Report 2020 provides a wealth of
information and analysis to support the international community in implementing
operational recommendations on a number of commitments made by Member
States, including the recommendations contained in the outcome document of the
special session of the General Assembly on the world drug problem, held in 2016.
5
Booklet 1 provides a summary of the five subsequent booklets by reviewing their
key findings and highlighting their policy implications. Booklet 2 focuses on drug
demand and contains a global overview of the extent of and trends in drug use,
including drug use disorders, and its health consequences. Booklet 3 deals with drug
supply and presents the latest estimates and trends regarding the production of and
SOCIOECONOMIC CHARACTERISTICS
trafficking in opiates, cocaine, amphetamine-type stimulants and cannabis. Booklet
4 addresses a number of cross-cutting issues, including the macrodynamics that are
AND DRUG USE DISORDERS
driving the expansion and increasing complexity of the drug markets, and describes
some of the rapidly evolving drug-related concerns: the latest, multifaceted global
opioid crisis; rapid market changes; the market for new psychoactive substances;
the use of the darknet for supplying drugs; and developments in jurisdictions that
have measures allowing the non-medical use of cannabis. Booklet 5 looks at the
association between socioeconomic characteristics and drug use disorders, including
at the macro-, community and individual levels, with a special focus on population
subgroups that may be impacted differently by drug use and drug use disorders.
Finally, booklet 6 addresses a number of other drug policy issues that all form part
of the international debate on the drug problem but on which in-depth evidence is
scarce, including access to controlled medicines, international cooperation on drug
matters, alternative development in drug cultivation areas, and the nexus between
2020
drugs and crime.
As in previous years, the World Drug Report 2020 is aimed at improving the
understanding of the world drug problem and contributing to fostering greater
international cooperation in order to counter its impact on health, governance and
security.
The accompanying statistical annex is published on the UNODC website:

wdr.unodc.org
ISBN 978-92-1-148345-1

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5 SOCIOECONOMIC CHARACTERISTICS

AND DRUG USE DISORDERS

This publication may be reproduced in whole or in part and in any form

Comments on the report are welcome and can be sent to:

Division for Policy Analysis and Public Affairs

Review and comments

EXECUTIVE SUMMARY, IMPACT OF COVID-19,

BOOKLET 2 DRUG USE AND HEALTH CONSEQUENCES

BOOKLET 3 DRUG SUPPLY

BOOKLET 4 CROSS-CUTTING ISSUES: EVOLVING TRENDS AND NEW CHALLENGES

BOOKLET 5 SOCIOECONOMIC CHARACTERISTICS AND DRUG USE DISORDERS

BOOKLET 6 OTHER DRUG POLICY ISSUES

Protective factors and risk factors for substance use

• Safe neighbourhoods • Poverty

Positive physical, social Substance use Harmful use Substance

Drug use circle Limited

Fig. 3 Dahlgren and Whitehead model of socioeconomic conditions impacting on health

ic, cultural and environm

Rate per 100,000 population

Macro-level socioeconomic Source: Global Burden of Disease Study 2017.

the association in terms of injecting drug use and

0.3 middle middle

associated burden of disease, in terms of healthy In addition, dramatic changes in macroeconomic

Country-level income inequality

Annual age-standardized rate (percentage)

Fig. 10 Drug use across industries in the United States, 2008–2012

Fig. 11 Drug use in Brazil, by education level, 2017

Past 30-day drug use

89 Krzysztof Ostaszewski and Agnieska Pisarska A, “Youth risk

People in rural settings

157 UNESCO, Social and Human Sciences, Fostering rights,

The accompanying statistical annex is published on the UNODC website:

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