Substance use disorders in refugee and migrant groups in Sweden: A nationwide cohort study of 1.2 million people

• Published in: PLoS medicine 2019-11, Vol.16 (11), p.e1002944
• Main Authors: Harris, Samantha, Dykxhoorn, Jennifer, Hollander, Anna-Clara, Dalman, Christina, Kirkbride, James B
• Format: Article
• Language: English
• Subjects: Adult; Aged; Authorship; Biology and Life Sciences; Cannabis; Cohort analysis; Cohort Studies; Comorbidity; Comparative analysis; Convergence; Diagnosis; Drinking (Alcoholic beverages); Drug abuse; Drug Overdose; Drug use; Emigration; Emigration and Immigration; Family; Female; Funding; Health hazards; Health sciences; Health Surveys; Humans; Income; Likelihood ratio; Male; Marijuana; Medical research; Medicine and Health Sciences; Mental disorders; Mental health; Middle Aged; Migrants; Migration; Morbidity; People and places; Population; Population density; Post traumatic stress disorder; Posttraumatic stress disorder; Prevalence; Proportional Hazards Models; Psychiatry; Psychosis; Public health; Refugees; Refugees - psychology; Registries; Risk Factors; Socioeconomic Factors; Studies; Substance abuse; Substance use; Substance-Related Disorders - epidemiology; Substance-Related Disorders - ethnology; Sweden - epidemiology; Transients and Migrants - psychology; Undocumented immigrants; Young Adult
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002944

Refugees are at higher risk of some psychiatric disorders, including post-traumatic stress disorder (PTSD) and psychosis, compared with other non-refugee migrants and the majority population. However, it is unclear whether this also applies to substance use disorders, which we investigated in a national register cohort study in Sweden. We also investigated whether risk varied by region of origin, age at migration, time in Sweden, and diagnosis of PTSD. Using linked Swedish register data, we followed a cohort born between 1984 and 1997 from their 14th birthday or arrival in Sweden, if later, until an International Classification of Diseases, 10th revision (ICD-10), diagnosis of substance use disorder (codes F10.X-19.X), emigration, death, or end of follow-up (31 December 2016). Refugee and non-refugee migrants were restricted to those from regions with at least 1,000 refugees in the Swedish registers. We used Cox proportional hazards regression to estimate unadjusted and adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) in refugee and non-refugee migrants, compared with Swedish-born individuals, for all substance use disorders (F10.X-19.X), alcohol use disorders (F10.X), cannabis use disorders (F12.X), and polydrug use disorders (F19.X). In adjusted analyses, we controlled for age, sex, birth year, family income, family employment status, population density, and PTSD diagnosis. Our sample of 1,241,901 participants included 17,783 (1.4%) refugee and 104,250 (8.4%) non-refugee migrants. Refugees' regions of origin were represented in proportions ranging from 6.0% (Eastern Europe and Russia) to 41.4% (Middle East and North Africa); proportions of non-refugee migrants' regions of origin ranged from 11.8% (sub-Saharan Africa) to 33.7% (Middle East and North Africa). These groups were more economically disadvantaged at cohort entry (p < 0.001) than the Swedish-born population. Refugee (aHR: 0.52; 95% CI 0.46-0.60) and non-refugee (aHR: 0.46; 95% CI 0.43-0.49) migrants had similarly lower rates of all substance use disorders compared with Swedish-born individuals (crude incidence: 290.2 cases per 100,000 person-years; 95% CI 287.3-293.1). Rates of substance use disorders in migrants converged to the Swedish-born rate over time, indicated by both earlier age at migration and longer time in Sweden. We observed similar patterns for alcohol and polydrug use disorders, separately, although differences in cannabis use were less marked; findings did not di