While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants’ self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms. PWUD), and particularly, people who inject drugs (PWID) live, exposing them to an enhanced risk of HIV/HCV transmission, drug overdose episodes and deaths, and related drug-related harms  had gathered a “stash”, but when it ran out, she started feeling the painful effects of heroin withdrawal. Anxious, she considered selling her bonsai tree, “the only thing of value that I had”, before her husband managed to find some money. When she arrived at the punto, she saw “a lot of people, traffic jams, desperate people. I saw things that I wish I hadn’t seen. But it was open, el Punto had not closed, it had been open all the time”.Others, such as Papo, were forced to seek a punto as soon as the hurricane passed: “I had nothing, and I was desperate. I thought: what do I do? I decide to do a run [to the punto] even though I had no money. I jumped through fallen trees and debris, until I saw the dealer, and I tell him, ‘Look, I have no money, I need the bag, I am sick.’ He said, ‘I can’t’, but I insisted, and he finally gave it to me”. Kiri had not prepared for Maria and ran out of his drug of choice almost immediately, but the following day he was able to find what he needed in the local punto. “El Punto never closes”, argues Freddo, explaining why Maria had no effect on drug availability. “There was no food, there was no water, but there were drugs”, noted another participant. In a veiled critique of the slow government response, Vitin, who in his youth had been a local bichote, a bigshot local drug dealer, claimed, “The drug sellers were better organized than the government”.Not all PWID in our study managed to find their drug of choice right away. Some puntos are located in smaller localities or are disrupted by police or conflicts with rival groups, forcing PWID to travel frequently in search of their drug of choice. Hurricane Maria seems to have exacerbated these issues in some places. Manny believes that the continuous problems in the drug supply in his town, which preceded Maria, are caused by the instability created by rival drug gangs: “After Maria, we went to Caguas and Cidra [other towns] because here there was nothing for months at a time. There it’s the same people running the puntos, the same connection. Here they are destabilized. They are from out of town, from another location, and besides, they are always changing because the guys that were running it before are in jail now. Sometimes you go and it is good, everybody runs there, and then you came back a few days later and it’s not the same! It’s rubbish”.Miguelito, in another town, struggled to find a dealer because nobody knew where the punto, which had moved because of Maria, would open. “I had to chase them down. I couldn’t find the dealer, everybody was looking for him, and he was in hiding because of the police. It was not easy to buy the first couple of days, and yet the punto never shut down”. Chino, who lives in another location, decided to avoid his local punto and try his luck at a larger venue in a nearby town. Only one day after Maria struck, he found things “all normal, it didn’t lack anything. As if nothing had happened”. Speedball, heroin with a dash of cocaine, is the preferred drug of choice for PWID in rural Puerto Rico, but as it is a blend of two drugs, it often forces study participants to visit more than one punto. Pablito, who like most PWID in rural Puerto Rico uses speedball, struggled to find cocaine in his locality after Maria and was forced to visit numerous venues in nearby towns. “It’s messed up! You have to go here [for cocaine] and there [for heroin]”.Perhaps reflecting the fact that the drug supply was not significantly altered in the aftermath of Hurricane Maria, drug prices did not suffer any modification. All participants pointed out that in relation to price, things were “the same” and totally “normal”. However, while Maria offered opportunities to PWID to earn money in the informal economy, engaging in debris removal, construction, cleaning, or other activities, particularly in the days that followed Maria’s landfall, some participants struggled to afford their drug of choice. “I use what I can. In a bad day, I use less, what can I do?” (Kiri).PWID’s views on the effects of Hurricane Maria on drug quality are shaped by a number of factors, including previous perceptions of drug quality and the simultaneous arrival of fentanyl on the island. Some participants believe that heroin quality had decreased over the years, perhaps nostalgically imagining a mythical past when drug purity was much higher: “Fentanyl is killing people because before there weren’t so many deaths, there were not as many overdoses like today. Before, la droga [heroin] was the size of a tiny match head that cost only $3, got three people high, and you only needed to use only once y te curabas  for that day until the next day. That was quite something! Now, it is chemical stuff” (Miguelito). While fentanyl might have been present on the island before Maria, it was not widely distributed until a few months later. A participant that had been in jail before the arrival of fentanyl remembers his impressions of finding fentanyl in the drug supply for the first time: “It [drug quality] is very different now. Let me tell you something: I never thought that in that year and six months things would change so much. Everything changed because when I went to jail, there was no fentanyl. It’s like kissing the devil because it is much stronger. And it does not last much in the body either; you’ll need to use every fifteen to twenty minutes” (Fray). Study participants initially reacted negatively to the arrival of fentanyl, in part given the risk of overdose death. Some became habituated to its presence, while others sought to avoid it by entering treatment for MOUD or trying to quit “cold turkey”.caserio it is white; it doesn’t have fentanyl. When you put it in the cooker, it does not turn dark like the fentanyl” (Kiri).Yet, at least in the aftermath of Maria, some participants claimed it was possible to access heroin without fentanyl: “In the COVID-19′s effects on drug markets were not uniform. Some locations were more affected than others, and some study participants had difficulties finding their drugs of choice, while others did not. “No, I mean, in this area I don’t think it’s been, COVID hasn’t really been too bad, not like I can imagine it could be in other places” (Johanna). According to methamphetamine users, their drug of choice became harder to find, particularly in more rural or isolated locations: “It made it, made it so much harder to get meth because most people wanted it. So, it seemed like the heroin came, came in, like by the ton then, but meth wasn’t getting through to nobody and everyone was in fucking, like going off the chains, the fucking meth” (Sheila). Even Ralph, with extensive personal connections, had a similar experience: “Oh, yeah. It, it’s really dried up the sources, you know? I mean, it used to be pretty resilient. I mean, you could run around and talk to people, and bam, bam. You had some. Now it’s a major search. I say it’s harder to find.” .As with availability, participants’ perceptions of the effect of COVID-19 on drug quality are not uniform. Participants’ substance use trajectories and their previous views of drug quality tend to shape their assessments of the impact of the pandemic on the quality of their drug of choice: “The meth has definitely changed from when I first started doing it. When I first started doing it like I got as I told you I was taking the, I’m taking the Vicodins and at first, when I first started doing the meth at 22, it would calm me down and I could concentrate and shit like that but for the last year, I think, maybe two years the quality has changed. I mean, it’s good, but it’s a weird good, like too good. You know what I mean? Like I do just a little bit and be up for two weeks, three weeks at a time and just be absolutely fucking nuts” (Ric).Frequency of use also affects the perception of drug quality. Participants that use less frequently or that had stopped using for some time before resuming use might be more sensitive to the drug effects given their lowered tolerance: “Yeah, I think it’s gone way down in hell. You know, it’s hard to say because of my age. I feel, so, you know how that U-shape goes up on the using and then your tolerance comes back down. I believe my tolerance has come back down, and I, I think it was better. My, I just think the quality’s better. But it’s pricey” (Daisy).COVID-19 did not radically affect drug quality. Some changes, like the arrival of fentanyl, pre-existed the pandemic: “I was looking for heroin, but I mainly got fentanyl because it’s cheaper now than actual brown opium. The last thing I used was fentanyl and amphetamine. Amphetamine was cheaper than I’ve ever seen it. The quality of the amphetamine dropped considerably, but the fentanyl stayed fentanyl. I mean there was a little bit more cut in it but quality, not really, I mean it was actually better than the brown stuff I would get, so it’s actually what I ended up looking for. Other than your average amount of cut bags it was about the same” (Sam).While fentanyl had been present in the heroin supply for some time, the introduction of fentanyl into the methamphetamine markets is more recent. According to Paulie, fentanyl-laced methamphetamine produces a stronger effect, but it wanes faster: “They’re cutting it [methamphetamine] with fentanyl and all kinds of weird shit these days. Fentanyl keeps you high for a minute, up for a minute, and then you just come down, that’s what they do it for so they can make their money faster. It gives you a really good rush, and then you got to go get some more.” (Paulie).Other methamphetamine users perceive an unreliable drug quality, producing uneven effects: “It sucks, sometimes you do that because you might catch a buzz to some point, sometimes you do the same amount and it gets you the buzz was like too much. I mean you could do the same amount, it’s just the ingredient, I don’t know. You could do the same amount every time but the thing is, it just depends, I had a friend that told me you can go higher, but I do the same amount each time” (Sharon).Unpredictable effects or more intense cravings due to the introduction of fentanyl into the methamphetamine supply produced some nostalgia for a time when the supply was allegedly purer: “This shit is so badly cut. Back in the day, it was real good. Now it’s just even” (Anderson). Ron found the quality so bad that he stopped using: “The quality went down for sure. It was really expensive and really shitty. So, I quit smokin’ it”.As some participants recognize, quality during COVID-19 is also affected by access to trusted dealers, something that was also true before the pandemic, as Dora explains: “Some people you don’t want to buy from and some, yeah. You notice real quick who has some good ones and who doesn’t. And who you don’t want to buy from”.In response to the emergence of the pandemic, economic activity was brought to a halt, initially affecting the drug supply. Yet drug markets seem to have reacted quickly, reconstituting supply and distribution networks. After an initial supply shock, participants were able to find their drugs of choice: “Okay, well see, let me get more specific because at first when COVID started and they shut down the Mexican borders and stuff it got dry as fuck around here and it was impossible almost to find any [methamphetamine]. I was paying $400 dollars for an ounce, I mean it was insane. And so I was using it very sparingly and trying to hold on to it as long as I could, you know? But then it got a little bit easier as things have lightened up, and now I don’t have a problem at all finding it. Before it was worse than pulling teeth, man it was bad” (Sandy).The initial scarcity drove prices up, at least momentarily: “At first there was kind of a dry drought for a while, and people would go get it places from out of town, so they would charge more. And people pay it. I paid it one time, a little bit more” (Tim). Yet, some prices seem to have stabilized after an initial supply shock. Sheila provides an encompassing description of drug pricing during COVID-19: “[Methamphetamine’s price] is outrageous right now. That’s why heroin is becoming so much more popular. And I’m paying like you know, I was paying 150, 200 an ounce before, and now it’s up to fucking a thousand dollars. Yeah. It was outrageous for a little bit. Heroin got way cheaper and easier to get. I don’t know why that happened, but so did cocaine, too.” (Sheila).As Paul recognizes, price is not only a factor of supply and demand. What participants pay for their drug of choice is also affected by personal connections to the dealer: “Yeah, it varies, like depending on who I got up for or got it from.” (Paul).Findings show that while the drug markets might have been initially affected by the disruptions caused by Hurricane Maria in Puerto Rico and the lockdown implemented during the COVID-19 pandemic in the Midwestern United States, most effects were temporary. While drug availability, pricing, and quality might have suffered some initial fluctuations, they tended to stabilize as the drug markets absorbed the shocks caused by the lockdown measures. This finding is consistent with other studies of post-hurricane scenarios in the United States and also, more recently, of the severe lockdown measures adopted in early 2020 by New York City to curb the spread of COVID-19 .Rather than creating an entirely new market dynamic, “big events” like natural disasters or pandemics are superposed to pre-existing local markets. Studies based on self-reporting data about changes in the drug markets in the aftermath of Maria, COVID-19, or other big events should consider that participants’ views are not only rooted in their present experience but are also shaped by their histories and frequency of substance use. In turn, access to participants’ drugs of choice is driven by drug availability, and drug availability and price have shown some correlation although some of the effects might be provisional. One important result of this study is the arrival of fentanyl both in the Midwestern and Puerto Rican settings. Fentanyl seems to be present not only in the context of heroin but increasingly affects polysubstance users of stimulants like cocaine and amphetamine as well. The same trend has been documented elsewhere in the United States ,29. ThisBig events like Hurricane Maria and the global lockdown after the emergence of COVID-19 had only a temporary effect on drug markets, showing the limits of the strategy to curb the drug supply that has sustained the War on Drugs for more than fifty years. As other studies have shown, the War on Drugs has had the unintended effect of introducing ever more powerful and dangerous drugs into the market. In particular, the production and distribution of fentanyl and fentanyl-related analogs have recently exploded due to their low cost of production and high potency, yielding high returns for a relatively small volume and partially displacing the heroin trade .While this study is not the first to suggest the need to shift gears in drug policy, moving away from a punitive approach and into one based on harm reduction ,39,40,41Finally, collecting supply-side data in drug markets after big events is notoriously difficult. We suggest that self-reporting data on drug demand after natural disasters or pandemic events can be collected earlier and relatively quickly, offering an important picture of shifting drug markets. These studies might complement epidemiological or criminological data about drug-supply dynamics that are usually produced retrospectively, sometimes months or even years after the event has long passed. This study, based on self-reports of participants’ experiences accessing drug markets during big events has some limitations. While extremely valuable, these data can be affected by recall bias, but more importantly, since drug markets are local in nature, participants’ experiences are shaped by local conditions and, therefore, can be hard to generalize from. In addition, this study focuses on the demand side of the drug markets. While we believe that the perspective of PWUD reflects local market dynamics, other studies are needed to document the effects of big events on the drug supply. Yet despite this limitation, we believe that self-reporting data are critical in mapping sudden changes in drug markets in the aftermath of big events.Findings show that while the drug markets might have been initially affected by the disruptions caused by Hurricane Maria in Puerto Rico and the lockdown implemented during COVID-19 in the Midwestern United States, most effects were temporary. While drug availability, pricing, and quality might have suffered some initial fluctuations, they tended to stabilize as the drug markets absorbed the shocks caused by the lockdown measures. In preparation for future pandemics or natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also other drug-related harms.


The new revision of the ICD came into effect on January 1st, 2022, and significant changes have been introduced in the section related to substance use disorders.In the present work we describe the new ICD-11 section “Disorders due to Substance Use and Addictive Behaviors” and outline the innovations in classification and diagnosis introduced, with a view to addressing the most important issues in terms of new opportunities for identifying and caring for people in need of treatment.The main innovations introduced in the ICD-11 chapter of interest are the expanded classes of psychoactive substances, the introduction of single episodes of substance use, the introduction of harmful patterns of substance use and severity qualifiers for substance intoxication. Furthermore, the new category “Disorders due to addictive behaviors” has been added, including “Gambling disorder” and the new diagnostic category “Gaming disorder”.ICD-11 calls for renewed public health response and policies fostering the multi-professional and multidisciplinary management of alcohol and substance abuse treatment, giving to these forms of addiction new chances also towards the reaching of the UN 2030 Agenda Sustainable Development Goals. ICD-11 represents a new opportunity for those who are in need for treatment to be timely identified.ICD-11 allows to fill the existing therapeutic gap and increase the coverage of substance use disorders.ICD-11 pushes for necessary changes in the post-COVID era: an integrated approach aimed at using standard tools and training for adequate intervention.The new definitions adopted by ICD-11 are in line with the UN 2030 Agenda, aimed at ensuring healthy lives and promote well-being for all ages. The ICD is a collection of human disorders and related health conditions which is used from approximately 180 countries around the globe and is periodically revised from the World Health Organization (WHO). Disease classification and coding is crucial not only for accurate clinical diagnosis and effective communication between medical professionals, but also for epidemiological data gathering in order to monitor trends in disease prevalence and incidence, and for providing a basis for precision in research , and is the result of a wide international, multidisciplinary and participative process that involved many experts and stakeholders around the World, such as mental health professionals and users of mental health services . The WHOth revision was completed in 2013. The DSM covers all categories of mental health disorders and has a widespread importance and influence on how disorders are diagnosed, treated, and investigated. Although great efforts have been made to harmonize the ICD-11 with the DSM-5, the two systems do have some differences, also considering that they have, to some extent, different aims. While the DSM-5 aims at providing a common research and clinical language for mental health problems, the ICD-11 pays particular attention to issues of clinical utility in a broad range of settings, aiming at global applicability, and especially the area of ‘addictions’ has been handled by the latest revisions of the two systems with somewhat divergent approaches, that will be discussed later in this article , and the 5 article .The ICD-11 MBND chapter includes disorders related to substance use in the section “Disorders due to Substance Use and Addictive Behaviors” . Severalexpanded classes of psychoactive substances;introduction of single episodes of substance use;introduction of harmful patterns of substance use;severity qualifiers for substance intoxication;introduction of the category “Disorders due to addictive behaviors” that includes “Gambling disorder” (previously under “Habit and impulse disorders”) and the new diagnostic category “Gaming disorder”.Globally, the need for treatment for substance use disorders did not yet reach a satisfying level and the changes introduced in the ICD-11 have important implications for public health in terms of opportunities for improved monitoring, prevention and treatment and for restructuring of health services in such a way that patient-centered care is prioritized. Interventions must be supported from informed strategies and one of the main priorities in this respect is to provide health professionals with an effective tool for identifying people in need . TherefoChapter 6 of the ICD-11, “Mental, behavioral and neurodevelopmental disorders”, includes a new grouping of conditions in the 12th section called “Disorders due to Substance Use and Addictive Behaviors” see  which isDisorders due to substance use and addictive behaviors are mental and behavioral disorders that develop as a result of the use of predominantly psychoactive substances, including medications, or specific repetitive rewarding and reinforcing behaviors”  to 14, to comprehend contemporary patterns of use: alcohol, cannabis, synthetic cannabinoids, opioids, sedative hypnotics and anxiolytics, cocaine, stimulants including amphetamine methamphetamine or methcathinone, synthetic cathinones, caffeine, hallucinogens, nicotine, volatile inhalants, MDMA and related drugs, dissociative drugs including ketamine and phencyclidine . Other cIntroduction of single episodes of substance use and of harmful patterns of substance use are among the main features introduced in this version of the ICD for classification of primary diagnoses of substance use disorders (SUD): while with the ICD-10 these were only “Substance dependence” and “Harmful substance use” classifications, with the ICD-11 the primary diagnoses classes are “Substance dependence”, “Harmful Pattern of Psychoactive Substance Use” and “Episode of Harmful Psychoactive Substance Use”. One of these three diagnoses, or “Disorder due to substance use, unspecified” – when the use pattern in unknown at the time of evaluation – must be given when making a diagnosis of a disorder due to substance use . These cEarly identification and response of SUD can be eased from having different categories for harmful substance use and substance dependence as these can be addressed with different intervention schemes, for instance there are substance use patterns that may benefit from brief psychological interventions , while other require more extensive treatment (such as detoxification or agonist maintenance). In addition, the WHO considers harmful consumption categories to be very important for understanding the impact of substance use on public health in morbidity and mortality statistics .Furthermore, there are a number of diagnoses that can be added to the primary ones, which include “Substance intoxication”, “Substance withdrawal” and different “Substance induced mental disorders”. The manual includes also categories related to “Hazardous substance use”, which are classified in Chapter 24, ‘Factors Influencing Health Status or Contact with Health Services’, and not considered to be mental disorders and can be referred to in cases where no evident harm has occurred but the pattern of use increases the risk of harmful health consequences to the user, or to others, in a way that advice from health professionals is needed .Inclusion of the single episode of harmful substance use in the ICD-11 is noteworthy, as it allows for early intervention and prevention of increased use and worsening of the condition and harm. The diagnosis should follow an episode where damage has been caused to someone’s physical or mental health, not only referred to the user but also to others: this is an important added value of the ICD-11, where harm to the health of others is explicitly included . The epiThe harmful pattern of use definition, instead, indicates a case where interventions must be intensified, and refers to a situation where clinically significant harm to a person’s physical or mental health is evident, and can be due not only to the direct intoxicating effects of the substance, but also to secondary effects or harmful route of administration. The pattern can be further specified as episodic or continuous and should be detected for a period of at least one year for episodic use and at least one month for continuous use. Furthermore, harm to health should not be better accounted for by another medical condition or another mental disorder, including another disorder due to substance use, such as substance withdrawal or substance dependence. Harm caused by substance dependence can be similar to that observed in harmful pattern of psychoactive substance use, however, alcohol dependence also includes additional features of the diagnosis and requires at least two of three central features to be present at the same time: impaired control after substance use, substance use becomes an increasing priority in life, physiological features that indicate neuroadaptation to the substance, such a tolerance and withdrawal symptoms .Diagnosis of substance intoxication requires some essential characteristics, that include transient and clinically significant alteration – such as in behavior, consciousness or coordination – that appear during or shortly after substance use, the pharmacological effects of which must be compatible with the symptoms. Intoxication can last from only a few minutes or even several days after the episode of use. The effects of intoxication are limited in time and fade away as the substance is cleared from the body and symptoms are not better attributable to other medical conditions or mental disorders. The ICD-11 allows for specification of severity of intoxication, that can be classified as mild, moderate or severe, and depends on a variety of factors, such as the amount of substance used, its half-life and the route of administration, and of course individual susceptibility which can be influenced from body weight, tolerance or concurrent conditions such as kidney of liver impairment. Substance intoxication is considered mild if disturbances in psychophysiological functions and responses  are clinically recognizable but there is no – or little – disturbance in the level of consciousness. In moderate intoxication, instead, the above-mentioned disturbances are evident and the tasks that require psychophysiological functioning and response are substantially impaired. There is also some disturbance in the level of consciousness.Severe substance intoxication is a state in which motor coordination, attention and judgement are obviously impaired, as well as the level of consciousness. The person may not be capable of self-care or self-protection and may not be capable to communicate or cooperate with assessment and intervention. The intensity of intoxication decreases after reaching a peak of absorption of the substance, and the effects eventually disappear in there is no further use of the substance .th ICD-11 chapter, called “Disorders due to addictive behaviors”, includes “Gambling disorder”, which was previously listed in the category “Habit and impulse control disorders (ICD-10)”, and the new diagnostic category “Gaming disorder” (The new section introduced in the 6isorder” . DiagnosIn ICD-10 gambling was classified under the “Disorders of adult personality and behavior” section “Habit and impulse disorders” and was named “Pathological gambling”. Since recent evidence shows important phenomenological analogies between substance use disorders and disorders due to addictive behaviors, gambling has been associated, together with gaming, in the “Disorders due to Substance Use and Addictive Behaviors” section. This change is important also because a high co-occurrence has been detected within the phenomena, as well as the fact that they are both initially pleasurable and then followed by progression to loss of hedonic value and need for increased use. There is also some scientific evidence that disorders due to substance use and disorders due to addictive behaviors share similar neurobiology, especially activation and neuroadaptation within the reward and motivation neural circuits .th revision of the ICD, making a diagnosis for this disfunction a real possibility for patients and clinicians, where the issue is of such a nature and intensity that it results in marked distress or significant impairment in personal, family, social, educational or occupational functioning (Gaming disorder, either ‘digital gaming’ or ‘video-gaming’, is described as pattern of persistent or recurrent gaming behavior, which may be online or offline, characterized by impaired control over gaming in terms onset, frequency, intensity, duration, termination, and context. Furthermore, increasing priority is given to gaming in such a way that it takes precedence over other life interests and daily activities and, despite the occurrence of negative consequences, the disorder shows continuation or escalation of gaming . Solid ectioning . In factctioning . Unlike ctioning .The ICD and the DSM both have a substantial impact of psychiatric practice and research worldwide, and much effort has been made over the years to harmonize the two classifications and both the WHO and the American Psychiatric Association believe that the differences between the two systems should be minimized and maintained only if conceptually justified . NeverthThe ICD-11 paragraph “Disorders due to substance use and addictive behaviors” has a corresponding one in the DSM-5: “Substance-related and addictive disorders”. In order to facilitate data collection on their public health impact, some psychoactive substances have been added in the ICD-11 due to their increasing global importance : synthetDistinct categories for pattern of use included in the ICD-11 are discussed above, the DSM-5, instead, considers only one “Substance use disorder” category, and identifies three levels of severity depending on the number of recognized symptoms among a list of 11: two or three symptoms identify mild SUD, four or five symptoms identify moderate SUD, and six or more symptoms identify severe SUD. Furthermore, DSM-5 does not consider classification of SUD based on harm caused to the person’s physical or mental health or health of others.Although there is a noticeable similarity between the DSM-5 11 classifications for SUD and the three ICD-11 categories, a number of cases detected with DSM-5 would not find correspondence in the ICD-11: diagnosis of SUD in ICD-11 requires two out of three items, while in DSM-5 two out of 11. “Craving” and “Recurrent use in situations which are physically hazardous” are two items of DSM-5 that are not included nor have a correspondence in ICD-11. Furthermore, all the items related to a substance taking over in daily life activities described in the DSM-5: time spent using or obtaining substances, failure to fulfill role obligations, continued use despite social or interpersonal problems, important activities given up, and continued use despite physical or psychological problems, in ICD-11 are represented in only one category: “increasing precedence of substance use over other aspects of life” . All theAs for gaming disorder, some studies suggest that there might be noticeable differences between the two classification systems in gaming disorder cases detection, where prevalence of cases detected with the DSM-5 are much higher compared to ICD-11 . HoweverOverall, ICD-11 can represent a new opportunity for several harmful behaviors and for those who are in need for treatment to be timely identified, filling the existing therapeutic gap and increasing the coverage of alcohol and substance use disorders. ICD-11 also pushes for some needed changes, particularly in the post-COVID era , to supp


Self-medication represents a significant healthcare and health policy issue worldwide, both in developed and underdeveloped countries. Currently, the COVID-19 pandemic is considered a relevant context that could subtly trigger self-medication behavior because of limited access to health care services and the threat of infection with the SARS-CoV-2 virus. While the previous research conducted with quantitative methodologies reported a dramatically increased rate of self-medication around the world, qualitative inquiries on the subjective experience with self-medicine remain scarce in medical and related fields of study. For this purpose, a qualitative study with semi-structured interviews was undertaken to better understand how Romanian mothers (n = 18) applied self-treatment with their children by avoiding medical advice during the COVID-19 pandemic. The results showed that the COVID-19 pandemic did not affect the prevalence of self-medicine among the pediatric population as parents achieved a degree of awareness of self-treatment of their children due to the general context of the outbreak of the COVID-19 pandemic. Worldwide, more than 50% of all medicines are prescribed, dispensed, or sold inappropriately, while 50% of patients fail to take them correctly. One common source of irrational medicine use is inappropriate self-medication, often of prescription-only medicine .Self-medication (SM) is defined as “the taking of drugs, herbs or home remedies on one’s initiative, or on the advice of another person, without consulting a doctor” . Self-meThe key phenomena of self-medication has been widely quantified internationally. In the previous research, self-medication has been conceptualized and quantitatively measured by asking people to report how often they resorted to medication by avoiding medical or formally trained medical advice. For example, a high incident rate was reported in Slovenia 94.9%) and Bangladesh (100%). In European countries, the findings vary: in Czech Republic, the self-medication rate was reported to be approximately 31%, while it was 79% in Spain. In African countries the mean rate was below 67%, while in several Asian countries self-medication was also described as higher (79% in India and 78% in Saudi Arabia) .9% and B. In deveThe pandemic period is an opportunity to engage in an analysis of self-medication. The result of recent studies are mixed, with some data showing a dramatic increase in self-medication and other findings highlighting unchanged patterns of self-treatment of people with acute health problems. A recent systematic review on the prevalence and correlates of self-medication for the prevention and treatment of COVID-19 revealed the prevalence of self-medication with antibiotics is concerning, with anxiety about contracting the COVID-19 infection being the main trigger for self-medication .At the outbreak of the COVID-19 pandemic, in countries with a full lockdown , a partial (‘intelligent’) lockdown , and no lockdown , it was revealed that there were no relevant changes in people’s use of self-management strategies in the prevention of acute illness. Even though the number of people who consulted a medical doctor was low, all consultations were with health care providers for the treatment of COVID-19. The authors conclude that the COVID-19 pandemic did not seem to dramatical change behavior related to consultations with health care providers or the use of self-management strategies, such as dietary supplements and self-help techniques. Most of the respondents usually consumed natural remedies, dietary supplements, and/or self-management strategies but not for preventing or treating COVID-19 .A recent study of Google interest trends for self-medication during the COVID-19 pandemic shows an increase in the number of self-medication searches worldwide since the start of the COVID-19 pandemic, which indicates a higher prevalence of self-medication around the world . Self-meSelf-medication is more common in countries where healthcare systems tend to be less effective because of one or more factors: long waiting times in healthcare facilities, difficulty in obtaining physician appointments, insufficient stock of essential medicines, delay in attention, and an insufficient amount of available beds/space in healthcare facilities, . Probablit wasn’t a serious health problems; I was confronted with this in the past) and then to perceived doctor–patient barriers   at the time we did the test… Panic because we had my aunt at home, who was old and who was very afraid of being sick. It wasn’t easy at all…it took us a day to get back after the shock (patient 2). It was the unknown who I think marked us all, then a little bit of momentary panic, that we all experienced me my husband and child through the interaction with SARS-CoV-2.(Patient 3)I was scared when my husband got the virus because he has certain health problems. He had, if I recall correctly, two heart attacks, and I was scared. Fortunately, it evolved very, very well. I mean, he did lose his smell and taste but didn’t have any other symptoms to aggravate his health. After all, it passed smoothly, he didn’t have a serious form of the disease and, as far as I read and understood, people who lose their smell and taste have the light form of the disease compared to the people who start suddenly with fever or…but I’m not sure, no…I just read to be informed but I don’t think anybody knows for sure.(Patient 16)Participants referred to the lack of assessment of chronic diseases and the conversion of hospitals in COVID-19 support health centers as a life-threatening situation. However, many of the participants had a positive relationship with their family doctors. Most of the interviewees pointed out that they were in contact with their family doctor via mobile phone or WhatsApp. Regardless of the situation, participants in the study did not resort to self-medication because, as they declared, telemedicine allowed them to solve the situation. There were situations where parents attended the doctors’ office and requested health care and vaccine delivery even if there were a COVID-19 state emergency. And I called the doctor and went to her office. Matei was crying very badly, and I didn’t know why he was crying. His belly seemed to be hurting, he seemed to be unable to move.(Patient 1)I was really in July and August, for vaccines….(Patient 8)I know my doctor for many years now. I am her patient since I was a student and I allow myself to call or write a message to her even if it’s something mundane, not serious, I mean, I ask for an appointment. I don’t take antibiotics without a prescription just because…if it’s something easy, I ask my mother who used to be a chemist and she can help with, I don’t know, with something simple like a headache, a toothache, something that doesn’t require antibiotics or powerful drugs. I always ask for medical advice when it comes to using drugs..(Patient 8)We didn’t interact much lately; I mean if my little one wasn’t sick, I didn’t call or contact my GP… (Patient 6).Some participants placed themselves at the opposite pole of their relationship with the doctor: They did not interact with the doctor or request health care because they did not face medical problems. When we ran the interviews, we also surveyed what type of information sources patients consulted in the medical field, if they asked a family doctor/doctor or turned to other sources. In all situations, the advice of the family doctor was considered very important. Some mothers preferred to access websites to read medical leaflets, to obtain information regarding the diversification of children, or to read about the experiences of other mothers.Two of the interviewees (patients 10 and 11) claim that they do not search Google because they do not trust the posts, while others (patient 6) considered the online health information posted on Facebook parenting groups as useful: Of course, until we came to talk to doctors, to clarify, we read on the Internet and terrified us, …, so I do not recommend that, rather, you speak to a specialist. And we are trying to refrain from doing so.(Patient 3)I: Tell me if you you’re interested in certain health conditions or if your child was diagnosed with a simple virus, from where do you get the medical information? P6: On the Internet mostly (Patient6). I: Do you search on certain websites you use? P6: No, no. Just Google search. I also have two Facebook groups where I used to ask some questions when my child was a baby. I: But the information was useful? P6: Yes, it works most of the time.I also ask my mother who was a pharmacist and can help us (Patient 8).In the case of a medical emergency, friends or relatives working in medical or related fields were considered sources of information: Three hypothetical situations were presented to the respondents to assess parents’ attitudes toward pediatric self-medication: first, a friend contacts the survey respondent to ask for her advice because her child had a fever; the second situation assumes that a child had a fever of 39 °C and his mother administered to him an antipyretic (paracetamol/ibuprofen) according to the leaflet; and in the last situation the child had fever of 39 °C and the mother administered an antibiotic (amoxicillin-clavulanic acid). We have used the technique of non-directive questions to get honest answers from the subjects and, above all, for methodological reasons, to avoid the respondents’ bias. When the participants assessed the first situation, the most often advice was to contact the family doctor, but interviewees also advised their friends to use medication first and to contact their doctor or go to the emergency room if the situation did not change:Before the pandemic, I would certainly apply a classic treatment when my child was ill, in the sense that I gave him Paracetamol® (paracetamol) because I know that the Paracetamol® (paracetamol) works. I would have waited a day or two, and if I had seen that nothing happens, certainly I would call my family doctor.(Patient 19)As I always do, I tell them to ask the pediatrician or the GP. In our case, it happened that the GP is also a pediatrician, but the answer is to ask the pediatrician. As far as I’m concerned, I can give some advice from experience regarding food or clothing, but drugs no, because in my case, I wouldn’t medicate as others did, using their dosage or a certain drug even if the disease seems similar. I always ask the doctor first and then I follow his instructions.I: Have you never interfered with a treatment on your own?P8: No, no, and it happened with our friends. They have a baby girl, one or two months older than our child, and she had the same disease as our little one, with fever, and a little rash, but I also told them to ask their doctor. I mean, I can tell them what we used for treatment, but it is not recommended, every child is different, the fever can be higher or lower, and his general state can be different. I also told them first to ask the doctor and follow his instructions and I explained the course of the disease, that after the fever, he will have a small rash/bump and that we didn’t use anything to treat it, they healed on their own. My friends were out of town, and I shared that information with them to calm them down, but that was all I said, I don’t give any advice on medicating, I’m not trained in this field.(Patient 8)For example, when the symptoms start very suddenly. For a runny nose, I don’t think that I must go to the doctor. Well, now it’s a special situation, but I don’t think that I must visit my GP for a runny nose. I take a pill of Paracetamol® (paracetamol) and I monitor my condition; I drink hot tea or something like that and if it gets worse and I don’t feel well, I will assume that it’s something different and I stop my treatment.(Patient 16)The next situation that was evaluated by the parents was where the child had a fever of 39 °C and the mother administered them paracetamol/ibuprofen according to the prospectus. The responses received can be classified into two categories. The first category made up of participants who claimed that a temperature of 39 °C was high and required the advice of a doctor and the dose of paracetamol/ibuprofen based on the minor’s weight.As far as we know, I don’t think he ever had a high fever, past 39 °C, but I know that you treat low fever, 37 °C, 38 °C, with Ibuprofen®(ibuprofen), but if he has a high fever, 39 °C and past, he should be seen by a doctor because high fever can be a symptom for a serious disease that needs antibiotics and using Ibuprofen®(ibuprofen) will just attenuate the symptom but not treat it. So, yes, I think that for a fever of 39 °C, you should at least ask the doctor and confirm the high fever. For a fever of 37 °C, I have Ibuprofen®(ibuprofen) to my little one when he was teething and had passed 36 °C, 37 °C, and 37 °C +, but after I asked the doctor and was told that if he continues to have a fever, when he’s teething, to give him a dosage of 2.5 mL or 5 mL, according to age. He had his first tooth when he has 6 months old, so I gave him a dosage of 2.5 mL. But for high fever, hoe you describe, 39 °C, no, I wouldn’t treat him with Ibuprofen®(ibuprofen) so at least I wouldn’t treat after my own opinion.(Patient 8)39 °C fever for a child is high. The first step is to lower his fever and for that, you need to use an antipyretic, but you also must ask for medical advice. So yes, I’m thinking that fever of 39 °C for a child is a high fever.(Patient 16)Before a pandemic, I would use the classical treatment, the one I know my child reacts to, so I would give him Paracetamol® (paracetamol) because I know it has the effect I expect, I would monitor his condition for a day or two and if nothing happens, for sure I would contact my GP, as a first step. After a consult, if the doctor says that is something more serious than she expected, she recommends pulmonology or other specialties, if the case requires. My baby girl is predisposed to bronchiolitis and when she’s sick, it manifests very suddenly, or it used to, lately, we didn’t have any problems of this sort, so I would start with the classical cold treatment, which we give to a ten-year-old child,Paracetamol® (paracetamol) a hot bath.(Patient 19)The child is under the weight that they give in the leaflet and know that doses are calculated, and then I think it is better to call the doctor and give you advice, to give you precise advice, than to experiment on the child.(Patient 7)The second category includes people who agree with the administration of the paracetamol/ibuprofen, and they declare that they applied self-medication because they experienced a similar situation with their first child and the self-treatment worked. These responses show that mothers sometimes give up medical advice and resort to oversimplification based on their own previous experience in healing their children.Responses varied on their experience in applying self-treatment. Mothers that had two or more children of 3–4 years old did not recommend the administration of paracetamol/ibuprofen at the first signs of disease. The other respondents claimed that they gave this advice from their own experience, which means that self-medication is still recurrent in cases of a medical emergency. In one case, a mother mentioned the possibility of using alternative medical methods to decrease fever, namely, a wet cloth wrapping, which according to her experience, works in decreasing a fever.I would recommend them to speak to their family doctor, and if it is not possible or I know… depending on what the value is the fever, give Paracetamol®/Ibuprofen®/(paracetamol/ibuprofen)that’s what I do.(Patient 9)I would give him treatment for the fever, and if continued after a day, I would call my family doctor.(Patient 16)When evaluating the last situation, where a child has a 39 °C fever and the mother administers amoxicillin-clavulanic acid, the responses indicate that all mothers are aware that amoxicillin-clavulanic acid, which is an antibiotic and can be administered with physician’s instructions. None of them would recommend or have applied such medication.I would not administer antibiotic because I know that antibiotic is administered only in certain cases, for certain infections, and I do not agree to administer this to the child without a prescription.(Patient 3)I don’t use antibiotics without knowing exactly what it is.(Patient 6)I would certainly not give the child antibiotics, without knowing what it is all about and without a prescription from the doctor, that is, telling me exactly: Administer the antibiotic x in dose d at I don’t know how many hours, that is, I wouldn’t risk, at least at the first child, no.(Patient 8)I believe so, yes. I think I have experienced a few times the situation where I needed an antibiotic fast, the one that I knew I react to or my child does, and because I didn’t have it at home, I asked a friend for help, a friend who works in a pharmacy or other medical field. And now, for example, with azithromycin, I didn’t find it the first day I needed it, and the next day, when I had the prescription, I took it from the pharmacy I usually buy my pills, near my building. The family pharmacy to say so, where, in time, you create certain connections/bonds.(Patient 19)The purpose of this study was to explore if, how, and why Romanian mothers resorted to self-treatment of their children during the COVID-19 pandemic. Similar to previous studies ,10,20, oMothers resorted to self-treatment of their children and refused to access health services when they perceived that the health problem of their children was mild or when they had a contact at the pharmacy. As past study ,25,26,27Mothers use antipyretic or traditional methods, and they use it as a routine in case of flu. Depending on the fever value, they may prefer immediate medical assessment, delayed delivery of the medicine, or administration for two days with subsequent evaluation in case of persistence. This pattern is also described by Fallah Tafti B et al.  and DruiBased on the findings of the present study, many of the participants had a positive relationship with their family doctors. The importance of the relationship with the doctor is also encountered in other studies ,33,34,35In our study, some participants reported that access to health services via telemedicine allowed them to solve the situation and to gain more health literacy on how and when to use medicines. Reduced access to care, surgeries, and other hospital services, combined with fear of exposure to the virus, led to a significant drop in health access. Thus, many diseases that develop symptoms have been managed by using telemedicine. Telemedicine has surged as a feasible tool to maintain patient care; to reduce the risk of COVID-19 exposure to patients, healthcare workers, and the public; to improve health outcomes; and to reduce emergency department visits, including fewer hospitalizations ,39,40.Evidence suggests that information about coronavirus and lockdown, fear of infection in health centres and poor accessibility to them, emergency illness, delays in receiving hospital services, distance to the health facility, and proximity of the pharmacy are the reasons for adoption of self-medication ,41,42,43Nevertheless, a limit of the current research consists in the homogeneity of respondents and their socio-demographic traits: higher-educated mothers from urban areas. However, how this type of urban population uses self-medication and resorts to self-treatment of their children remains an issue of interest for medical and other related fields of study. Further, a qualitative study could also interview male populations, single-parent families, or chronic patients in order to observe other vulnerable social groups and their patterns related to self-medication.Based on our findings and discussion, we derive the main conclusions of the qualitative study.Firstly, regarding the occurrence of self-medication in the pediatric population during the COVID-19 pandemic, parents managed to avoid self-medication due to medical authorities’ guidelines during the pandemic, which led parents to consult with GP in case of specific symptoms. In the meantime, the threat of SARS-CoV-2 infection enhanced medical services, especially those of the GPs. Consequently, with the overseeing of the GPs, parents cope with their children’s common health problems and prevent self-medication.Secondly, we observed a high degree of awareness of the self-administration of antibiotics probably due to the current legal regulations in Romania. However, self-medication occurs when a pharmacist facilitates self-medication by ignoring their duties and selling a product in the absence of the client’s medical prescription.Thirdly, during the COVID-19 pandemic, doctor–patient interaction mediated by telephone and telemedicine eased the uptake of parents’ right therapeutical conduct in case of their children’s health problems and helped them to avoid self-treatment of their children. In light of our data, we can say that structural factors also sustain the correct use of medicine among the public during the COVID-19 pandemic, especially in Central and Eastern Europe, where the role of family medicine could be increased in the general health system . The impFourthly, the presence of a fever is the most common symptom that triggers mothers to apply a specific self-medicine, that is, the administration of antipyretics to their children without medical advice.Overall, the findings of our research indicate that the COVID-19 pandemic did not affect the prevalence of self-medicine among the pediatric population and parents achieved a certain degree of awareness of applying self-treatment to their children because they become more health-conscious in the general context of the outbreak of the pandemic.This section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript.


Words are the building blocks of language. OK, but what are words? Are they universal? Where and how are they stored, represented and organized in the human brain, i.e., mental lexicon ? These are important questions, and their answers are far from simple. Hence our motivation for this Research Topic.words: Let us consider them as textual items delimited by a space, or as headwords  listed in a dictionary. They both are words, but they are not the same. This is even more true when we consider words in the human brain, or the ML.Concerning Words in dictionaries are building blocks, i.e., raw material, appearing there in a standardized form (lemma), out of context, and devoid of morphosyntactic information revealing tense, number, or the word's actual role . Unlike the ML, which is limited in size and highly personal, dictionaries contain the lexical competency of a very large community. Having been built by a team of experts, they are more precise and larger than anyone's personal lexicon. Yet, being disconnected from the real world , they can tell us only part of the story. Take any entry, say “dog.” Its definition is only a poor substitute for the pet a child has in mind when referring to Ginger, its beloved animal.multi-word expressions , or the impact of the writing system. Having grown up in a culture that uses an alphabet, you will have no trouble to recognize words, even in a foreign language, as long as the writing is the same (sound to grapheme mapping). The situation is quite different though for a language like Chinese which uses a logographic-, or, more precisely, a morpho-syllabic writing system. By comparing a given message in Chinese and English—我的泰勒很有 (Wo de tàilēi hěn you qián) vs. “My tailor is rich”—, you will realize that it is not easy to recognize words in Chinese. Indeed, out of seven characters only five are words: 我,的,泰勒,很,有.There are other problems like 1° concept :  ⇒ 2° abstract word : horse  ⇒ 3° concrete form = h rc s/horse. This is why psychologists prefer to use the term “activation” to refer what lexicographers call the “look up” of a word. Some see words as the result produced by a word factory (brain), while others consider them as existing entities, stored in a database. One last point: the human mind does not make any distinction between the lexicon, the thesaurus, topic maps, named entities, episodic- or encyclopedic knowledge. They all are integrated into a single resource, called upon depending on the momentary cognitive state or knowledge need.The situation is even more complex when we compare lexical entries and words in the ML. In dictionaries, they are holistic entities, i.e., objects (word forms), available at any time. In the brain they are decomposed, their elements being distributed. Yet, if any of them lacks energy, the word's full form may not be accessible anymore. Words in the brain are only virtual entities, i.e., abstract patterns that become “realized” over time: A lot of work has been devoted to the ML, but given our current knowledge state it is hardly more than a fascinating metaphor. For example, we do not have a clear idea concerning its topology, nor do we know how to build this map. This is what motivated our Research Topic, and here are some of its goals: (a) clarify the notion of mental lexicon; (b) consider its value for building navigational tools to support word finding (c) conceive a strategy to build the map, (d) draw attention to work in other disciplines to foster cross-fertilization.This Research Topic contains seven papers. The first two focus on the notion of the ML.In the manifesto Zock tries to answer the question raised in the title. Being interested in the development of brain-compatible software, he offers some guidelines for the development of a tool to help authors to overcome the tip-of-the-tongue problem. Observing that people resort to different resources  depending on their knowledge state, which is variable and unpredictable, he suggests integrating all of them into a single resource.Libben tries to give more substance to the notion of the ML. To this end he introduces two innovative principles of lexical organization: morphological transcendence (key ⇒ keyboard ⇒ turnkey) and lexical superstates Taking inspiration from Quantum Physics, McCrae et al. address the question of how to determine the number of senses words have. They tackle this problem by comparing the strengths and weaknesses of formal, cognitive, distributional and intercultural approaches. Their work provides a detailed case study for “fish” and “wing.” As there are substantial variations concerning the number of senses identified with each approach, the authors show how they might be unified.Aguirre-Celis and Miikkulainen explored the changes of the conceptual representation of a word. If a given word occurred in different contexts, its meaning changes would be signaled via different brain-level representations. The word's meaning may change dynamically in the ML, the actual meaning depending not only on the concept's inherent features but also on contextual information.Hofmann et al. could show to what extent semantic and syntactic factors affect word access in the ML. By predicting single fixation, gaze and total viewing duration for reading, the authors showed that n-gram and recurrent neural network representations of words allow for better performance than topic models or cloze probability.Going beyond word length and frequency effects, Yang et al. show that a simple segmentation model inspired by Zipf's principle of least effort can simulate the acquisition of such assorted lexical materials, and account for their use by readers of a connected text.The ML is understood to “contain” not only morphologically simple words, but also inflected and derived forms, compounds, light verb construction, collocations, idioms, social routine clichés and pre-compiled routinized chunks maximizing processing opportunities. Jacobs and Kinder discuss the potential and limitations of distributed semantic models (DSM) to account for the gain of knowledge (apperceptive mass) to enrich the ML, via reading books. The results show that performance increases with age, and that DSMs, while promising, are nevertheless still far from perfect.In the final paper While the here-presented papers look promising, more work is needed. Describing the structure and functioning of the ML is bound to keep the research community busy for quite some time.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


All interviews were conducted via telephone and online and were transcribed and analyzed using Colaizzi's phenomenological method. The study does, however, identify four primary themes and 13 supporting themes, including (1) experience in a new working environment , (2) diagnosis , (3) recovery days , and (4) post-COVID-19 . This study is important for healthcare policymakers because it helps them design healthcare management systems that take Bangladeshi society's social context into account. This study also recommends that long-term behavioral change programs be implemented by national policymakers to lessen societal stigma. At the same time, it suggests that the government should help lessen the barriers to health care services that persons with lower socioeconomic status confront.Many countries, including Bangladesh, have conducted research on the mental health of frontline workers and their challenges in adjusting to their new workplaces. However, the authors are unaware of any studies on their real-life experiences as COVID-19-positive patients in Bangladesh. This study intends to investigate the lived experiences of Bangladeshi frontline workers who were isolated as a result of the COVID-19 infection and tested positive for the virus. We used a qualitative methodology and a semi-structured interview guide to conduct ten interviews between July 26 and August 12, 2020. The participants were recruited  The SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) virus, which causes COVID-19, is highly contagious and pathogenic. It has sparked a global pandemic that has resulted in a large number of deaths around the world. Although there is debate about the exact origin and source of the virus, Wuhan- an emerging economic and commercial hub in China initially saw an outbreak of a new coronavirus by the end of 2019 that killed over 1,800 people and infected over 70,000 individuals in the first 50 days of the COVID-19 epidemic. In 2003 a viral infection caused by the SARS coronavirus broke out in southern China's Guangdong province . According to the Bangladesh Medical Association, about 8,890 frontline healthcare workers tested positive among the infected, and 87 died  from various sources, including a social media campaign and personal contact. We adopted the required number of participants by interviewing those who met the following inclusion criteria until the data was saturated and no new themes were generated.The inclusion criteria included:Of those who had contracted COVID-19 after a diagnosis,Those who had undergone at least a 2-week isolation independently or in a hospital, andThose who had formally agreed to participate in the study after being informed of its goals.We developed the interview outline after reviewing pertinent literature and getting feedback from group members at numerous meetings. The interview subjects were asked the following questions: (1) What was your earlier life before infection? (2) How did you come to know about your infection? (3) What were your initial responses after identifying yourself as a COVID-19 patient? (4) What were your experiences during the isolation days? (5) How did you cope with this situation? (6) What aspects of life changed after your recovery from COVID-19?An email including a consent form and an interview guide was sent to participants who indicated an interest in participating in this study. After the participants gave their consent, an interview was scheduled and held whenever it suited them. The five research team members  conducted each interview. Due to the pandemic, the interviews were carried out over the telephone and on online platforms . Each interview lasted 35–60 min and was conducted in Bangla. With the participants' consent, all interviews were audio recorded.Within 24 h of each interview, the team translated the audio recording from Bangla to English. The first two authors (SA and TR) then read each transcript several times to identify significant statements. Next, they took the meaning units from these statements and provided codes. After creating a preliminary list of themes that emerged from the diversity of transcripts, the connections between themes (cluster meaning) were established. The research team then engaged in frequent online meetings to extrapolate themes and subthemes from the coding. Finally, divergent opinions on the content of the topics were addressed and resolved by a professor with experience in qualitative research. We also conducted another interview with the participants to share the study's findings for validation.This study followed the ethical agreement of the Helsinki declaration. The study participants had the right to withdraw from the research at any time. In gathering the data we maintained objectivity and built strong bonds with the individuals. Each participant's name was changed to a pseudonym to protect their identity. We kept all the information in a password-protected Google Drive storage system that was only available to us.Our study comprised three medical frontline workers and seven non-medical frontline workers who had been diagnosed as COVID-19 patients and were between the ages of 28 and 45. Their average age was 34 years. Three of them (30%) provided healthcare services, three (30%) worked in law-enforcement agencies and bureaucracy, and the remaining four (40%) worked in the financial sector and print media industries. Moreover, 30% of respondents were single, whereas 70% were married. In addition, seven respondents received treatment at home, while three others were admitted to COVID-19-dedicated hospitals. The duration of treatment lasted between 14 and 32 days. The participant's characteristics are outlined in However, we analyzed the lived experiences of COVID-19-positive frontline workers in Bangladesh using phenomenological techniques. Four significant themes and 13 subthemes emerged from Frontline workers in the COVID-19 situation encountered numerous challenges in a new work situation that impacted their physical, psychological, and social wellbeing. This theme consisted of three subthemes: workload and adaptations; maintaining health protocol and social distance, and the fear of being infected by others.None of the frontline workers in this study had worked in a pandemic environment like the current COVID-19 pandemic in Bangladesh. Therefore, they had to adapt to the new working situations and policies. Specially, medical frontline workers had to face dire conditions due to their direct involvement in treating COVID-19 patients in the corona unit. In addition, because of the increasing number of COVID-19 patients in Bangladesh, non-medical frontline workers were deployed and assigned to different places outside their routine work.Since I am a government employee, I had to go to different places to perform official duties at the beginning of the corona infection in Bangladesh. I started working to ensure social distancing from the period when the government announced that no more than 10 or 15 people could gather in a place. Control of public gatherings at various institutions, wedding houses, religious and social functions, to ensure the home quarantine and isolation of expatriates and those who came from outside the district, etc., were my prime official duties during that time” (R2).“I have been on the field since the beginning of Corona, highlighting the plight of patients in hospitals, including the mismanagement of sample collections, the neglect of unsuspected people, and the corporate propaganda called ‘corona drug.' While other stations shut down their crime investigation programs, Searchlight did not shut down for a single episode” (R7).“Most of the frontline workers in this study expressed that they always tried to follow the health rules of the Directorate General of Health Services (DGHS) and World Health Organization (WHO) properly. Initially, medical frontline healthcare workers in Bangladesh had shortages of personal protective equipments and they had to work long hours in COVID-19 dedicated isolation units with corona patients. So maintaining health protocols were challenging at the beginning. But gradually this situation improved. However, for non-medical frontline workers it was very difficult to work with complete personal equipment (PPE) and maintain a social distance because of their nature of work in diverse areas and people.When I went to bury Corona suspicious person's body, I wore full PPE . However, when I went to the work court or other work, I used a mask, gloves, and head cover. It is tough to ensure social distance in Bangladesh due to the people's indifference. I tried but could not always maintain it” (R9).“Because of the severity of the virus, misinformation, data, nature, and workload, the survivors experienced fear of contracting the virus. In addition, most participants feared spreading the virus to their families and close ones.As I was the only earning member of my family, I always feared being affected by the virus.“ So, I tried to maintain necessary precautions like wearing a mask, washing my hands frequently, and trying to maintain distance as much as possible” (R4).“Another participant involved in financial services (bank) closely observed a patient with COVID-19 symptoms who were not granted leave by the authorities. As a result, she feared going to the office every day. According to her statement,I was afraid of going to the office regularly. One incident in my office that I want to mention here. One of our colleagues was suffering from a cold during the lockdown situation. Although she applied for leave, she was not granted it. As a result, she frequently met all of us, and we became horrified” (R5).“This theme centered on survivors' experiences of being infected and the diagnosis center. Three subthemes emerged from this, such as the origin of infection, physiological symptoms, and experiences in the diagnosis center.Those frontline workers whose duty was to provide public services and welfare amidst the severity of COVID-19 believed that they had been infected because of their frequent visits to public places and contacts.The way both of us (couple) have done our professional work in dealing with the Corona situation, we assumed today or tomorrow we would be infected because we did not have the opportunity to stay at home” (R7).“The same was true for another healthcare frontline worker who treated COVID-19 patients at a private hospital and experienced the tragic loss of three family members due to COVID-19.As I was taking care of my father, like taking him to the ICU when he developed severe respiratory problems, though I was doing everything with protection, of course, I thought that I should test myself. There was a likelihood that I may have transferred the germ to my other colleagues as I was working with them in the hospital” (R5).“When the respondents were interviewed the most reported symptoms were fever, neck pain, headaches, coughs, body aches, and loss of taste and smell, as indicators of their general weakness. The comments here include examples of the earlier symptoms that the front-line workers reported.I had no such symptoms except some minor neck pain. However, gradually, I developed other symptoms, and my physical situation worsened” (R1).“My wife and I tested a corona examination on May 11 at Bangabandhu Sheikh Mujib Medical University with symptoms of fever, headache, slight cough, and severe pain around the ears” (R7).“However, two respondents stated that they did not display any physical symptoms in their bodies in the initial stages of the disease or even after it was diagnosed. Even though everything about them was fine, they were listed as COVID-19-positive patients after the test.Even in my case, I was certain that I was carrying the germ and infected my wife, though I had no such symptoms to be sure of my disease” (R6).“When they went to the diagnosis center for a diagnosis, those frontline employees involved in government services  received tremendous support. However, even though they were not required to keep queues for providing samples in the medical center, one of the respondents described his encounter with the testing facility as follows:I did not need to pay any fees for my test, as it was free for all government officials. I also did not face harassment while doing tests standing in a queue or others. Instead, I went to the hospital, filled out a form with some information, gave a sample, and returned” (R1).“However, people from lower socio-economic backgrounds who worked in the private sector struggled in the diagnosis centers. Another one commented,When I went to the Upazilla health complex to do a blood test, the doctor left the hospital for having lunch” (R3).“This theme covers a significant area of the survivors' experiences after identifying themselves as COVID-19 positive. Their initial reactions after the test report, experiences in the isolation center/home isolation, and coping mechanisms are discussed here. This theme includes earlier reactions ; experiences in isolation center/home isolation ; and coping mechanisms .Some frontline workers experienced fear of death and anxiety after identifying themselves as COVID-19 patients. However, they informed us throughout our conversation that they were fully aware of how Bangladeshi family members and relatives consider the corpse of a corona patient as something unpleasant and unexpected.When I heard it, I felt that the whole sky had broken down on me. I might die soon. Life is very short. We are just like guests on this earth” (R1).“After getting the report, my whole situation changed. I became anxious. Suddenly, my hands and feet were shaking. I started thinking about death and afterward” (R2).“While being identified as COVID-19 patients after the test, most of the individuals in this study reported feeling depressed. In addition, some of them have started to experience emotional instability. Even one participant with no physical symptoms of illness developed psychological weakness. The reason for this is that after the disease was reported, they were worried about the severity of the virus and its burden.I was broken at first after hearing the news. Especially when Sayda hugged me and cried and said, We do not even have a baby” (R7).“However, a 35-year-old female assistant commissioner of Kishorgonj Upazilla who initially experienced depression later revealed that she gradually turned her depression into strength.I became a little depressed. However, I convinced myself that if I remained frustrated, I would die. So I had to convert my depression into mental strength” (R4).“I tested only to be sure of my situation but I was astonished seeing that I was also positive while I had no symptoms” (R6).At least two respondents who had no physical symptoms expressed surprise when they had identified themselves as COVID-19 positive. When we interviewed them they said that they had always kept a social distance, been extremely cautious from the beginning and adhered to health regulations (including PPE). They found it difficult to believe because they were certain they had followed the precautionary measure. One of the respondents said as “Nearly all participants admitted to becoming extremely concerned for their families after receiving confirmation of their infection. This is because they were the primary breadwinners in their household. As a result, they started to worry about what would happen to their families if the virus harmed them.At that time, the first thing that came to my mind was my family, especially my younger sister” (R2).“I became anxious about my family, especially about my little children” (R9).“Another respondent who was a non-medical frontline workers had to keep his sickness a secret from his family. He was far away from them and just did not want to upset them. According to him,I did not tell family members about my infection as I was far away from them. I did so because everyone was so afraid and anxious during that time of pandemic outbreak that if anyone was identified as a COVID-19 patient, people believed that that person would die soon or thought that he/she was very prone to death. So I decided not to inform my family and relatives because it could make them more sacred” (R1).“We also found a new situation after our interview. The majority of the frontline workers were panicked and became anxious, however, a 37-year-old frontline financial service provider kept her composure despite knowing she was sick. This is because, prior to becoming ill, her family had COVID-19 survivors. Therefore, she took mental preparation in advance of her infection as well as remained calm knowing the nature and severity of this virus. According to her,I was not afraid. You know, it is not a dangerous disease. I was conscious only of my smell problem. However, I got used to this situation because two more people had been infected in our house. I saw them closely” (R5).“Most of the frontline workers we have interviewed remained in isolation at home. Only three were admitted to hospitals designed explicitly for COVID-19, where they were isolated for a minimum of 14 days. They consequently experienced positive and negative interactions with the caregivers while in isolation. However, one of the respondents, a police officer, said that the hospitals provided adequate healthcare when we asked him about his hospital experiences.I was admitted to the district police hospital in Sylhet.” Moreover, three of my colleagues, who were also positive, remained in the room. The hospital authorities provided us with good treatment and everything that we required. They sent every necessary accessory as soon as we informed them over the telephone or mobile phone (R1).“On the other hand, another non-medical frontline workers shared his bitter experiences while receiving treatment at COVID-19 dedicated hospital. He was shocked that no one, not even physicians or nurses, had ever seen him physically during his 22 days of isolation in hospitals.During our 22 days of hospitalization, no doctors, nurses, or other medical staff ever visited us physically in the hospital, but only in some critical situations. Instead, they talked to us over the phone and provided only virtual advice. It frustrated me a lot to think that this is happening because we are COVID-19 patients” (R9).“At least two respondents described similar instances of self-isolation from family and friends. They internalized their condition and prioritized their family members' wellbeing. Even one of the responders could not go to his father's burial because he felt that other people would fall in danger of infection.I have grief for not attending my father's funeral, but I took the right step at the right moment because my presence could infect others in a way that I could never accept” (R6).“Almost all frontline workers experienced various forms of emotional distress in isolation, including dilemmas, insomnia, and fear of deaths. One of the frontline workers who was away from her house because of job obligations struggled to sleep and experienced death fears while alone in an isolation room at a government estate. She could not communicate with anyone because her home was kept in strict lockdown during her quarantine. She asserts,Since I had trouble breathing almost every night when I went to bed, I was afraid that I might not be able to get up in the morning. I was scared to death. I thought I had these psychological problems because I was living alone” (T2).“Another survivor, a well-known journalist, and author in Bangladesh experienced difficulty, uncertainty, and emotional stress during his mandatory home quarantine. According to him,The doctor advised us to avoid social media, especially Facebook, and suggested we be busy with housework and self-care. But unfortunately, I did not listen to the doctor but once or twice used Facebook. Later, I saw that it truly created anxiety and mental pressure on me. Especially when you see that everything in the world is running smoothly, nothing is stopped because of your illness” (R7).“Furthermore, a medical professional who cared for coronavirus patients in a private hospital in Dhaka shared similar worries with us.The doctor told us to follow the routine and to become worry-free.” But nevertheless, is it possible to remain worry-free after all of this? I was shocked that even a little gastric pain was short of breath! “Corona was such a mental torture” (R8).“The COVID-19 infection had an impact not only on the patients but also on their interpersonal and societal interactions. People purposefully avoid COVID-19 patients due to an overarching fear of infection. During their solitude, survivors allegedly experienced rejection and ostracism from those who were closest to them. At least two of non-medical frontline workers shared similar stories of denial from their colleagues and close ones when they caught COVID-19.The building where I live was completely locked down. I faced some social stigma. After I got sick, I heard many officers who worked with me were terrified. Many of my colleagues around me wanted to escape. For example, after hearing the news of my infection, the naib of my office went to his village. He was afraid I might order him to work for me, but I think I have faced fewer social vulnerabilities due to my social status than other survivors” (R2).“Even families of patients who tested positive for COVID-19 had to deal with unfavorable behaviors from their kin and neighbors Due to this stigmatization, a 38-year-old doctor who treated Corona patients in a private hospital in Dhaka had to endure severe repercussions. In his opinion:As frontline workers, we had to give service directly to the COVID-19 patients. When I returned from the hospital, I understood that they feared me. However, when four other members of my family and I were infected with the COVID-19 virus, they completely avoided us” (R6).“Another participant, a non-medical frontline workers who lost his father due to COVID-19 infection shared similar stories of being stigmatization by his neighbors. He also claimed that owing to stigma, he could not even convince anyone to hold the corpse after his father's death. The same rejection events occurred when he got infected. According to him:When the villagers learned about my father's disease, they started to treat us like wild animals. Even when my father died, none of my neighbors visited our home, and there was no one to hold the corpse bed. After that, they stopped coming to our pond to take a bath when I got infected“ (R4).“The majority of patients who received treatment at home altered their diet plans. They thought eating a lot would make them more prone to the illness. Some respondents stated that they also regularly engaged in breathing exercises, steamed hot baths, and sunbathing, all of which assisted their recovery from the infection.According to the doctor's advice, I ate nutritious foods like milk, eggs, fish, meat, lemons, and vitamin C daily. I also took hot water vapor and followed the hygiene rules” (R2).“Bangladesh has a large Muslim population. During times of isolation, faith in God and practicing religion were very effective coping mechanisms for the survivors. Nearly everyone we had a conversation claimed that their faith in God helped them find relief from their sufferings. According to one of the respondents,Most of the time of the day I prayed salah and recited dua. As I was free from all worldly activities, I concentrated more on religious activities that gave me relief ” (R4).“Another participant who received treatment at a COVID-19-dedicated hospital regularly listened to various religious lectures (Wazz) on YouTube, which provided him with moral support to recover.Most of the frontline workers admitted that they avoided social media sites while remaining in isolation because it created anxiety and mental pressure upon them. One of the non-medical frontline workers asserted that he became mentally more vulnerable when he found everything around him was okay except him while scrolling into Facebook. However, most of the frontline workers passed their isolation times by watching movies, reading books, and a few of them involved in gardening.I did not use social media. I read books, walked around the house, watched funny movies, and spent time gardening” (R2).“Netflix and Amazon Prime helped me overcome this challenge. In series like Breaking Bad, Picky Blinders, House of Cards, Walter-Jesse's Math Lab, Celian Murphy's outstanding performance, and the political intelligence of the Underwood family, I forgot I had a fatal illness” (R7).“Before this pandemic, the general people of Bangladesh were not comfortable with telemedicine services. But due to the shortage of COVID-19 designated beds in public and private hospitals telemedicine services became very popular among the patients who received care remaining at home. Three individuals in our study also regularly consulted with their doctors about their health related problems over the phone, which helped them recovering from this disease. According to one of the respondents:We decided to take treatment from home until the situation worsens.“ In that case, we need to be under the supervision of a specialist doctor. ”Doctor X provided us treatment via telemedicine regularly” (R8).“Due to the severity and concealed nature of COVID-19 at the initial stages of infection, Bangladeshi people, notably frontline workers, were more susceptible. In addition, a couple of the individuals we interviewed said that their family was their source of mental strength, aiding their recovery from this illness. One of the frontline worker who was kept in isolation in her government estate describe this situation as:I have done self-counseling by convincing myself that many people depend on me. So I have to live for my siblings and my family's future. This mental strength has inspired me to recover” (R2).“Almost all of the frontline workers received immense support from their family members and relatives, which helped them to recover quickly. Even if, in some instances, the family members were not physically present while they were in the hospital or home isolation, their support—such as food, comfort, and religious guidance—were tremendously helpful in enabling them to heal and cope.Although I was in a COVID-19 dedicated hospital in an isolation room, I received immense support from my family. Whenever I talked with my wife over the phone, she told me not to be afraid. She motivated me in such a way that I am going to recover very soon. Even she took care of my family, children, and business in my absence” (R4).“Some survivors also received much help from their colleagues, office managers, and friends, which was a huge help in their recovery. One of the respondents, who was admitted into a COVID-19 dedicated hospital along with four other colleagues, stated that because of their shared experiences, they could help one another and manage the situation even while remaining in a segregated unit. As (R1) said;... As we were living together in a hospital room, it was great to support us all. When we felt upset, we gossiped with one another, had fun and joked, and shared our grief to maintain social distance. It worked great to recover from our psychological hardship and effectively overcome our trouble. It had a tremendous impact on us that would not have been possible if I had stayed alone in a room.”“Although most frontline workers reported having their neighbors denied and rejected them, an author and journalist told us that his house owner offered adequate support and cooperation when the couple became infected. Due to their comparative higher social status and their connections with the power structure they were most privileged even in the age of COVID-19, but the general situation is completely different in Bangladesh. According to the respondents:We informed the homeowner at the outset so that no one got panicked.” He helped us a lot from the beginning. He provided us with food, fruits, and bottled water, in addition to the constant search. He also hired a doorman who would bring emergency supplies and take down the garbage can (R7).“Following their recovery, survivors also reported post-COVID-19 physiological and psychological issues, such as chest pain, sleep issues, anxiety, and shortness of breath, as well as specific social issues, such as financial loss. However, they also started to view life more optimistically. There are four subthemes under this main theme: excitement, fear and confusion, physiological problems, financial stress, and changes in philosophy.Survivors undoubtedly felt joy when they returned to normal life. Although, medical-frontline workers had to return to their previous job as there was scarcity of physicians and nurses in COVID-19 dedicated hospitals in Bangladesh. However, some participants concurred that they were afraid of spreading the virus to others after they were fully recovered. Therefore, they stayed away from places where the public congregates, like bazaars, tea shops, and playgrounds. When we questioned why they felt this way, they admitted that their test results had left them perplexed. During the pandemic, some private hospitals and clinics issued fake corona test results, which led to significant discrepancies. According to them:After recovery, I tried to avoid visiting public places like bazaars, tea stalls, or friends' houses because I was scared if someone would be infected by me again. So, I tried to maintain all medical rules when communicating with others” (R1).“When I fully recovered I could not believe in myself! I wanted to meet my friends and close ones. However, you know I was frightened of mixing with them. I have little trust in corona testing. So, I do not want to put anyone at risk” (R5).“Some survivors also experienced negative attitudes from their neighbors even after their recovery from the COVID-19 virus. Despite being healed, their bodies were marked as something to be afraid of. As a result, neighbors tried to avoid them for fear of contracting an infection. According to one of the respondents:Even after the report came back negative, many people stayed far away from me. So I do not know if it was for awareness or if people were scared of me”(R2).“The survivors experienced various physiological problems following their recovery. For instance, among the survivors breathing difficulties, respiratory issues, weakness, etc., were frequent. In addition, one survivor informed us that for a month, he could not move from one place to another owing to physical sickness.Even after recovery, I often had shortness of breath. I still have some respiratory problems and have also reduced my 4 kg weight” (R2).“Corona is a substantial financial burden on patients. Although, those frontline workers we interviewed were comparatively remained in a better socio-economic condition rather than the general population in Bangladesh, but they reported having some form of financial hardship to support their families after recuperation. One of the participants who was a doctor lost his job due to corona infection. To her surprise:There has been some economic loss. The prices of daily necessities, including masks, sanitizers, fish meat, and eggs, have increased significantly. As a result, family expenses have increased immensely” (R2).“I do not believe a mask can protect us from corona” (R8).The participants returned to their everyday lives when the swab test results were reported as negative. Corona improved most of the survivors' outlooks, but a few of them who were highly educated were still uncertain about their sources of infection and the importance of mask in preventing corona virus. This is against our general beliefs about those who are illiterate are more suspicious and superstitious about the severity of corona virus. One of the non-medical frontline workers assert as: “However, participants also claimed that they developed a stronger spiritual bond with God due to their COVID-19 experience. They prayed to God frequently while in the hospital and formed regular prayer routines. For example, one of the respondents who was agnostic now became a devoted follower of religion. According to him:Although from the beginning I was conscientious, I was infected.” It surprised me a lot, and “I realized it was Allah's will. Therefore, I have developed a firm belief in the almighty that led me to be involved in religious rituals during my hospital days” (R1).“We analyzed the lived experiences of Bangladeshi COVID-19-positive frontline workers in this study. We have identified four major themes and 13 subthemes from this study. In summary, our study showed that frontline workers in Bangladesh faced significant physiological, psychological, and social challenges while working in a new COVID-19 environment. Thus, when they contracted the infection and were isolated at home or in a hospital unit, they experienced anxiety, fear, wrath, frustration, and stigma. However, they could quickly deal with this adverse situation by altering their eating habits, relying on telemedicine for assistance, being self-motivated, having social support, and enjoying movies. The research also revealed that frontline workers continued to experience physical, emotional, economical, and social sufferings after fully recovered. In addition, when experiencing financial crisis and stigma they emphasized more on religiosity which in turn helped them to overcome those hardships. Similar themes emerged from another study on Indonesian frontline nurses who were kept in quarantine because of their infection , for example, non-medical frontline financial service workers had to regularly provide banking services to the general population . We also found that nurses in Saudi Arabia and Qatar considered changing their eating habits a solid coping mechanism against this virus  even after being fully recovered from the virus. Likewise, Guo et al., in their study, also found that fatigue, shortness of breath, fear, trauma, and stigma are common to many medical frontline workers after their recovery  in Bangladesh provided partial funding to the lead author for this study .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.