How migrants risk becoming drug addicts along Balkan route

Even though the doctor at the facility had prescribed Hassan to take half a pill every eight hours, the packet of pills he shows is almost full.

"I received a medical examination without knowing what it was about. The doctor told me that Xanax was very suitable for my situation. But I did not understand why he thought I needed help. I had not reported any mental distress or asked for support," 45-year-old Hassan says.

Hassan decided to try the prescribed dose and, soon after that, he fell asleep for several hours. Once awake, he decided to look up information about the side effects of the medicine he had just taken — no one had explained them to him. "I typed the name of the drug online and found that half a pill could cause me to sleep for several hours. At that moment, I realised that if I kept taking it, I would spend my days sleeping. So I stopped, and I hoped that no one would check if I had continued taking the doses."

"The situation in the refugee camp was catastrophic. The people who did not take drugs were few. When I happened to cross paths with one, I immediately became his friend because usually, everyone around me was addicted," Hassan says. "Some people reach a very difficult situation and get to the point of taking the entire packet of drugs in a few hours."

Hassan today considers himself lucky to have managed to avoid addiction to psychotropic drugs. But many meet a different fate.

"I have seen with my own eyes what happens to people who can no longer do without these substances. Once I saw men cutting themselves in front of their kids," he says. "Had I not known about this problem, I would have continued to take Xanax, too, and maybe the same thing would have happened to me."

Over-prescription

The difficulties Hassan has faced along his migration journey mirror the experiences shared by thousands of others who, like him, have fled their countries and taken the Balkan route in search of a better future.

Sometimes, however, the pitfalls along this path to a better life can come not only in the form of physical violence — as in the case of border torture — but also psychological care based on the excessive use of psychotropic drugs.

The Balkan Route is one of the main migratory pathways into Europe. Starting from Turkey and Greece, it crosses all Eastern European countries — Bulgaria, Serbia, Kosovo, North Macedonia, Albania, Montenegro, Bosnia and Herzegovina — to end in Italy, Austria, and Hungary.

For decades, the path has been trodden by thousands of migrants. Yet, only since 2015, with the record entry of more than 764,000 refugees, have institutions and the media started to focus on it.

Every day, dozens of migrants face the challenging route to Western Europe — a challenge dubbed "the game" because of the great uncertainty and risk that weighs on those about to make it.

The route is full of obstacles, and although documentation of deaths in the Balkans is scarce, according to the NGO United for Intercultural Action, more than 2,100 people have lost their lives along this path in the last eight years.

"The Balkan route is hazardous, and lucidity is fundamental for those who intend to walk through it," explains Nawal Soufi, an independent activist who has been helping people in distress along the Balkan route for years. "Those who face this path under the influence of psychotropic drugs underestimate the risks along the way".

Mental health problems are the third most common cause of health interventions among refugees, according to a report published by the Serbian Red Cross.

However, the countries most affected by the influx of migrants — including Greece, Serbia, North Macedonia, Bosnia and Herzegovina, and Croatia — were never equipped with adequate facilities for the healthcare needs of those migrating through their territories.

"In the camps, if someone complains of a headache or insomnia, doctors immediately respond by giving them powerful antidepressants and anxiolytics [anti-anxiety medication]," says Soufi.

On paper, European institutions have attempted to guarantee people on the move the right to access health care.

However, those who have experienced the reality of refugee camps say that the level of assistance is deficient.

The main reason is that the migration crisis, in some cases, was intertwined with an already fragile socio-economic situation. A study has pointed out that in Greece, well before the surge in migration numbers, the healthcare system was already collapsing due to years of economic crisis.

Drug dependency

The most common drugs are benzodiazepines such as clonazepam, but also diazepam and pregabalin. The use of these medicines includes treatment for anxiety, epilepsy, and panic attacks.

"Prescriptions are in languages that people on the move don’t understand, and no one provides them with basic information about possible side effects," Soufi adds.

Soufi has been raising awareness of this problem for years. In the past, she rented houses to host migrants who were abusing psychotropic drugs to pull them out of the camps and drug dealing circuits, at least temporarily.

"In most cases, it is possible to completely fight addiction by ensuring that people have a safe place. When they began to feel better, I would ask them to help me with my volunteer activities, for example. Having plans for the day allowed them to have a daily goal," Soufi says.

Along migration routes, an excessive amount of free time can be dangerous.

"People wait for an answer for weeks or even months, brooding all day about the violence they suffered at the border. They feel ashamed of their living conditions," she explains. In such a context, taking medicine is a way to forget reality.

A large rehabilitation centre in Athens, funded by the Greek ministry of health, has been organising programs for refugees who abuse drugs and other substances for the past few years.

During an informal interview, a spokesperson of this centre, who wanted to remain anonymous, confirmed the existence of poorly controlled distribution of psychotropic medicines in the camps.

But at the same time, the source stressed the little information they have about it and the difficulties in understanding at which stage of the migration route the abuse begins.

It is estimated that, in 2019, there were about 20,000 refugees on the island of Lesvos. Most of them lived on the streets in dire conditions, and it was particularly hard to take care of them. "A very small staff had to take care of people who had been travelling for years, who may have already started taking substances in Turkey, or even earlier," the source said.

The same person added that in the reception facilities, in most cases, doctors give psychotropic drugs to those who have already bought them on the black market.

Likewise, many start asking for pills because they cannot sleep, or they are given medicines by a friend and then start selling or buying them on the side.

’Keep people as calm as possible’

According to data provided by the EU border agency Frontex, over one million irregular migrants entered the Western Balkans from 2015 to 2022 — mainly from Syria, Afghanistan, Pakistan, Iran, and Iraq.

The head of an NGO — who prefers to remain anonymous, fearing retaliation — who worked for several months on the Greek islands explained that "one of the main consequences of the high number of migrants was the overcrowding of reception facilities."

"Over time, camps designed to host no more than 800 people were crowded with more than 3,000 people. Tranquilisers were distributed regardless of the patient’s condition because the real goal was to avoid fights and keep people as calm as possible," the source said.

One of the most-used substances was a pregabalin-based drug used to treat epilepsy and neuropathic pain. "The boxes of this drug were scattered on the ground everywhere. In some cases, it was the migrants themselves who requested it, and the doctors, partly due to lack of time, gave them without doing further investigation," the NGO official said.

"Clinics in the camps are constantly understaffed, and one single professional has to deal with dozens of people. How is it possible to do accurate analysis under such conditions and timing? We should point the finger at the whole system and not at doctors."

The problem is not only the shortage of medical staff in the camps but also the need for more preparation.

"Foreign NGOs, to get assignments on the ground, have to make agreements with local hospitals. These pacts always involve hiring local doctors — it is a way to boost employment in countries where labour is scarce," an activist said. "These professionals, however, are hardly prepared to deal properly with patients with severe trauma. This results in a tendency to solve problems with the copious use of psychotropic drugs."

Migrants who receive or become familiar with psychotropic drugs along the Balkan route also try to obtain them in Trieste, the Italian city on the border with Slovenia that is considered one of the final stops along the route.

"Some people asked me for psychotropic drugs or medications that could reduce their agitation and anxiety or because they knew about them. In some cases, I can confirm the conditions to prescribe that medication. But in many other cases, migrants ask for them because they see in the drug the possibility of solving their problems, whether they are psychological, mental or physical," explains Andrea Collaretta, a volunteer doctor for Donk, an association in Trieste that provides health care to people who cannot access the Italian National Health Service.

Looking at prescriptions that some people had received in the Balkans and had kept on their cell phones, Collaretta found that "the most frequently used psychotropic drugs are the different forms of benzodiazepines. Predominantly, they are old benzodiazepines that cost little and have a significant effect anyway. However, in some cases in Italy, they are not even prescribable as anxiolytics.

In Italy, the abuse of psychotropic drugs mainly takes place in detention centres for repatriation, the pre-removal detention centres, also called CPRs, intended for foreigners awaiting deportation.

Elsewhere, the problem affects the country less than Balkan countries, because of a more sensitive approach to mental health. A study by the Lancet found that, despite the challenges, the Trieste model of mental health care is recognised by the World Health Organisation as a world standard for community psychiatry.

Loneliness

However, in some states in the Balkan region, little attention is paid to mental health, and the overuse of antidepressants is deeply rooted in the social fabric.

According to a 2021 study, Greece had the highest level of antipsychotic drug consumption among all the included countries and regions, while in Europe, the use of tranquilisers was highest in Serbia. This trend affects both citizens and migrants but the consequences of abuse can be more severe for the latter because of the traumatic experiences they suffered in their countries of origin and along their journey to a safe destination.

Migrants are also more vulnerable to abuse because of the lack of integration into the local community, which sometimes results in loneliness.

"When I escaped the Middle East, I wanted to start a normal life. But instead, I found myself abandoned," said Harun, a young man who still struggles with the problem of addiction to psychoactive drugs and other substances.

"When I think about it, I realise it would have been better not to leave at all and die in my country," he said. "I don’t believe in anything anymore. I am still alive only because I think about my mother, and I don’t want to hurt her. Still, I have already attempted suicide"

Challenging to document

Margherita Festini, an Italian doctor who volunteered with the No Name Kitchen association in a Serbian town, also noticed the widespread use of psychotropic drugs.

"In my experience, I saw that doctors didn’t prescribe psychotropic drugs necessarily to sedate people. I remember at least two cases of vulnerable boys whose doctors prescribed those drugs to cure them. But the doses were so massive that the curative effects were nullified. Instead, because there was no follow-up, people used the pills to get high," Festini said.

Sometimes, the problem lies not only in the dosage but also in the prescription.

"The most popular psychotropic drugs are pregabalin and clonazepam. Both are antiepileptic drugs, but they are improperly prescribed as antianxiety drugs and therefore to calm down or make people sleep," Festini continues. "People should not take them for more than ten days because they are addictive."

Some witnesses collected photographic material from within the camps that proves the existence of prescriptions for drugs such as Diazepam (benzodiazepine), Rispin and Zoxil (both antipsychotics), and Neurontin (neuroleptic).

This documentation, along with the accounts of migrants and activists, is the only evidence of the phenomenon. Currently, measuring the problem quantitatively is very complex, because there are no reliable reports on the figures of psychotropic drugs distributed in the camps and because the phenomenon also exists outside organised structures, such as within organised crime networks, in prisons, or through acquaintances.

No questions asked

Some pharmacies also contribute by selling antidepressants and tranquillisers without prescriptions, with migrants able to buy as many packages as they want and then sell pills at a markup.

In Athens, in the neighbourhood of Omonia, a well-known drug dealing area, a pharmacist sold us, without asking for a prescription, a box of Tramadol, a medicine belonging to the class of opioid painkillers. Migrants and activists we spoke with confirmed that this is common.

"It’s easy to get these pills inside pharmacies; you don’t need to have any prescription. You only need the money to pay for them," explains Gulhem, an asylum seeker.

"If you can prove that you suffer from psychological problems, you can get access into a vulnerable category," Gulhem said. "Many people start taking them to appear fragile and to avoid running the risk of having their asylum applications rejected."

Traffickers paid by migrants to arrange border crossings are also involved in selling psychotropic drugs. Vuk Vukovic, president of the Serbian NGO KlikAktiv, talked about cases of mothers forced to give their children tranquilisers to get through the migration route.

"It’s hard to not attract the attention of the police and hide if there’s a crying baby, so mothers are forced to put their children to sleep. If they don’t do that, smugglers threaten them that they won’t leave," he said. Every week, a team from KlikAktiv visits the Serbian north borders, where they assist people on the move who live in informal settlements — squats.

"The main goal of our work is to provide legal counselling and psychosocial support. The indiscriminate use of anxiolytics and tranquilisers is well-known by the organisations operating along the route. Still, for some strange reason, it is not considered that serious by international actors," Vukovic told us.

But the situation improves once migrants cross the Italian border.

This is also confirmed by Gianfranco Schiavone, president of Consorzio Italiano di Solidarietà, an association that offers assistance to refugees and is based in Trieste.

"Medicine can be often used as a tool of control," Schiavone said. "We all know this, although there is no data to prove it since no one wants to bring this up. However, the scenario changes when people realise they can access a healthcare system that works. This coincides with a drop in demand for psychotropic drugs."

Unfortunately, the future of people who want to leave Trieste to reach other EU countries isn’t always as bright as they’ve imagined. In several contexts, obstacles and inequalities to access healthcare services persist, and so does the misuse of psychotropic drugs.

Kochay, an asylum seeker we met in Trieste’s Square, hopes this will change. "There should be controls on young people’s use of these substances. I have seen so many people take them and find themselves in bad situations right afterwards, losing contact with family, with friends, losing all hope for the future."

Names of individuals have been changed

This investigation was supported by Investigative Journalism for Europe (IJ4EU)