1. Introduction
The intersection of war, chronic instability, and substance use disorders creates a syndemic that threatens both individual recovery and the public mental health infrastructure. This editorial examines the neurobiological and psychosocial mechanisms through which conflict environments may perpetuate addiction.
Wars have played a significant role in the history of psychiatry (1). Armed conflict has a catastrophic impact on mental health and well-being, devastating communities and families and often disrupting the socioeconomic development of nations (1).
Research involving humans also highlights the complex relationship between the social environment and substance use (2). The World Health Organization estimates that, in war situations, approximately 10% of individuals exposed to traumatic events will experience severe mental health problems, while an additional 10% will exhibit behaviors that impair their ability to function effectively (3).
Conflict zones and regions of chronic instability can serve as powerful precipitating factors within a diathesis-stress framework (4). War not only increases exposure to trauma-related disorders but also fundamentally alters the socio-environmental conditions required for recovery from addiction (5, 6).
2. The Neurobiology of Trauma and Substance Use
In unstable environments, chronic activation of the hypothalamic-pituitary-adrenal axis can induce neurobiological changes that lower the threshold for substance use (7, 8). Conflict-induced trauma may also contribute to persistent epigenetic modifications, particularly in genes involved in reward circuitry and stress-response pathways. These alterations have been implicated in changes in emotion regulation, stress reactivity, and vulnerability to substance use; however, the precise causal relationships in humans remain complex and require further investigation (9, 10).
3. The Cycle of Self-Medication in Instability
In the absence of stable social safety nets or professional mental health care, substances may be used as a form of self-medication (11). Alcohol, opioids, and stimulants may be used to reduce hyperarousal or induce sleep in environments in which safety is absent (12). However, substance use can disrupt the neuroplasticity required for emotional regulation and may consequently exacerbate underlying psychiatric symptoms (13).
4. Beyond Neurobiology: Psychoanalytic Perspectives on Addiction in War and Chronic Instability
Beyond neurobiological mechanisms, psychoanalytic theories offer a complementary perspective for understanding the psychological effects of prolonged war and chronic instability. Contemporary addiction science has shown that trauma and chronic stress can alter reward pathways, stress systems, and neuroplasticity. However, biological changes alone cannot fully capture the subjective experiences of individuals living under critical conditions, including fear, grief, helplessness, and emotional burden, all of which can shape efforts at psychological survival.
Freud's reflections on war and civilization provide an early framework for understanding this psychological disruption. In "Thoughts for the Times on War and Death," Freud described war as an experience that challenges fundamental assumptions about safety, morality, and social order. War forces individuals to confront mortality, loss, and primitive anxieties that are normally contained by the structures of civilization (14). Later, in "Civilization and Its Discontents," Freud argued that human beings rely on social structures and psychological processes to endure frustration, postpone immediate gratification, and regulate instinctual drives (15). War can create conditions in which these stabilizing structures collapse, and repeated exposure to danger, uncertainty, displacement, and grief may overwhelm the capacity for emotional regulation.
From a psychoanalytic perspective, substance use in wartime settings may therefore be understood not merely as maladaptive behavior but also as an attempt to obtain relief from psychological experiences that feel unbearable. For a person living with constant threat, loss, or traumatic memories, alcohol or other substances may temporarily provide emotional distance from fear, sadness, intrusive thoughts, or feelings of powerlessness. Substances may become a rapid but ultimately harmful means of calming an overwhelmed internal world when other forms of emotional processing, interpersonal support, or social protection are unavailable. This perspective is consistent with the self-medication hypothesis of substance use disorders, which proposes that individuals may use substances, at least in part, to regulate painful emotional states that are difficult to tolerate through ordinary coping mechanisms (11).
Bion's concept of containment provides another lens through which addiction in conflict settings can be understood. According to this concept, psychological development depends on the presence of a person or relational environment capable of receiving and processing overwhelming emotional experiences and helping transform them into experiences that are comprehensible and tolerable. In wartime, however, the systems that normally provide emotional containment and stability for families, communities, and social institutions may themselves be damaged or destroyed. Experiences of terror, grief, humiliation, and helplessness may remain unprocessed because no stable relational space is available in which they can be expressed and assimilated. Under these circumstances, substances may serve as an external and temporary substitute for emotional regulation.
Winnicott's concept of the "holding environment" further highlights the importance of safety, continuity, and reliable relationships in maintaining psychological stability (16). Human beings need a sense of security and emotional support not only during childhood but throughout life, particularly during periods of extreme vulnerability. War disrupts many of the structures that provide this psychological holding: families are separated, communities are fragmented, identities are threatened, and access to supportive health care becomes limited. In the absence of these protective environments, substances may offer a temporary sense of relief, control, or escape from overwhelming emotional experiences. Although this relief is ultimately harmful and may contribute to dependence, understanding its psychological function is essential for developing compassionate and effective interventions.
5. Clinical Challenges and Epigenetic Persistence
Substance use disorders have been associated with epigenetic changes that may contribute to persistent alterations in stress regulation, reward processing, and emotional functioning. The misuse of alcohol and other substances can produce extensive alterations in the epigenome and gene activity within the central nervous system, thereby interfering with essential functions such as reward processing and emotional control. These changes in gene regulation may persist beyond the period of substance use and may contribute to triggering or exacerbating psychiatric disorders (17).
The clinical management of addiction in post-conflict or unstable settings is hindered by perpetuating factors (18). The epigenetic footprint of chronic stress and substance use may reduce responsiveness to traditional therapeutic modalities. Alterations in reward pathways may contribute to treatment resistance, which is particularly difficult to address in resource-depleted settings.
6. Reframing Addiction in Conflict Settings: From Individual Disease to a Socially Embedded Disorder
The prevailing clinical approach to addiction has traditionally emphasized individual vulnerability, behavioral control, and pharmacological treatment. Although these components remain essential, they may be insufficient for populations exposed to prolonged conflict, in which social disruption, trauma exposure, and loss of health care infrastructure become major determinants of addiction risk (19-21). In conflict-affected settings, the environment itself, through persistent chronic stress, insecurity, grief, and social instability, can become a factor that sustains substance use.
Addressing addiction should therefore include cognitive, analytical, and pharmacological strategies aimed at building resilience in individuals at risk while also addressing the environmental and social factors that perpetuate substance use in conflict-affected settings (22).
7. Conclusions
Addiction in conflict settings should not be conceptualized primarily as an individual failure of self-control or merely as a conventional psychiatric disorder; rather, it should be understood in the context of the neurobiological and social consequences of prolonged exposure to violence, instability, and environments that disrupt recovery. Mental health policy and addiction care in conflict-affected regions, therefore, require trauma-informed, harm reduction-based, and systems-level interventions.
