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in Drug Treatment
Centers in Puerto Rico
Acknowledgments
First of all, we thank the persons who courageously shared with us their stories of mistreatment and abuse so we could make
visible the injustices and human rights violations that are committed in the name of drug treatment in Puerto Rico. We thank Dr.
Carmen Albizu Garca, Mariana Nogales Molinelli, Esq., Rafael Anglada, Esq., Lidia Daz, Vernica Vlez-Acevedo, Esq. and all of
those who provided their feedback during the process of research, editing and production of this report. We are also grateful to
Dr. Alexander Bennett and Dr. Honoria Guarino for their comments and proofreading of the English translation of this report.
Intercambios Puerto Rico, Inc. is a community-based non-profit organization that promotes the social integration of
marginalized groups, including people who used drugs, people who are homeless and sex workers, from the science-based
perspective of harm reduction and through programs and activities that include direct services, education, advocacy and research.
Suggested citation
Upegui-Hernndez, D. & Torruella, R.A. Humiliation and Abuses in Drug Treatment Centers in Puerto Rico (Intercambios Puerto
Rico: Puerto Rico, May 2015).
Table of Contents
Table of contents
This report presents testimonies from participants of drug treatment services for psychoactive drug use disorders
in Puerto Rico that document the persistence of approaches based on a false premise that this condition is the
result of pathological personalities and individual moral deficiencies, requiring the use of confrontational and
degrading processes of re-socialization so that affected individuals may learn to conform to social norms that
establish abstinence as the only acceptable outcome. It describes experiences that lacerate the dignity, health and
security as human beings forcing us to ask ourselves: Why are these practices tolerated in a state whose
Constitution proclaims that the dignity of human beings is inviolable?, Why are they tolerated in a democracy
that possesses institutions charged with safeguarding the health of its citizens and ensuring that prevention and
curative health services are based on evidence of its benefits and do not cause harm? The authors cite official
statistics that corroborate the predominance of this type of programs among the meager supply of treatment
services for problematic drug use available in the island.
These data adds to the series of reports generated in the country over several decades that denounce the
enormous gap between supply and demand of services based on scientific evidence of effectiveness to treat
problematic drug use in Puerto Rico. This report puts a human face on the tragic situation endured by individuals
who enter through the revolving door of predominantly court mandated services under legal control in which the
criminal justice system and social and health services participate without assuming a critical analysis or position
about their consequences. Under these conditions, the individual affected is placed in a position of inequality and
subject to interventions implemented by personnel that assume legitimized authoritarian approaches that violate a
patients autonomy and facilitate abusive and even dangerous practices. After all, we are talking about a person
who suffers from a criminalized condition that is construed as the inevitable consequence of his/her inability to
exert personal control. For that reason, the role of the person in charge of the intervention is reduced to
confronting the individual with his/her deficiencies and to penalize him/her when these are reflected in the
individuals behavior. These programs result in poor retention rates of these programs and the progressive social
exclusion that turns individuals who need quality health and social services into social outcasts.
In this historic moment when we have evidence that these practices and degrading experiences ill-conceived as
treatment are not effective and we have tested interventions that generate better results, it is unacceptable that
the state allows this enormous inequity and continues to support a sector of services that has turned its back on the
development of knowledge about what is effective in the treatment of addictions and persists in degrading its
participants and conceiving them mainly as undeserving of being treated with dignity. We must consolidate our
demands for the state to guarantee a continuum of services options that satisfy the immediate needs of an
individual within his/her hierarchy of possibilities just as we do with other chronic health conditions that are not
stigmatized. Above all, as long as the state does not address the structural conditions that promote the exclusion
and mistreatment of individuals who suffer from a drug use disorder, we are strengthen those sectors that construe
the issue as essentially of a moral or criminal nature, and not as a health problem that can be managed by the social
and health services sector. I exhort readers to feel indignant and to consider the recommendations presented in
this report, which are based on fundamental human rights and evidence of treatment effectiveness agreed upon
and supported by the World Health Organization and other important international and national organizations, and
to demand that these be the ones that Puerto Rico support sand promotes.
Introduction
Government (ASSMCA)
3.0%
3.8%
Private (community-based)
25
18.9%
39
29.5%
59
44.7%
TOTALS
132
100%
programs like Hogar CREA and in some faithbased or Christian centers. In the past, several
researchers have reported instances of cruel,
inhuman and degrading treatment in Puerto
Rico within treatment centers for drug
dependence.23, 24, 25, 26 In 1993, SantiagoNegron
described as follows the practices
conducted in centers under the guise of
treatment for drug users:
From religious exorcism to physical
and emotional punishments, such as
unconventional haircuts, verbal abuse
(hot chair), denial of access to
correspondence and visits, forcing
them to wear disposable adult diapers
and signs that ridicule the individual,
among other things. None of these
treatments are based on science;
they all proceed from arbitrary
speculations
by
countless
paraprofessionals,
self-proclaimed
experts in the field of drug addiction.
Many of these treatments become
fads, only to be abandoned as
arbitrarily as they were established
(i.e., some programs painted with
black dye the hands of the people who
were found masturbating).27
Almost 20 years after that, Perez-Torruella
(2010) documented the use of shaming
rituals in the treatment experiences received
by the interviewees in his study while they
were living in Puerto Rico. Perez-Torruella
interviewed Puerto Rican injecting drug users
living in New York about their past
experiences in treatment centers for drug
dependency in Puerto Rico. One of the
therapeutic practices performed in Hogares
CREA called Lea (a reference to the
firewood obtained from fallen trees) was
described as an emotional beating or
confrontation which consisted of the
following:
sitting in a little chair in the middle of
a room, being humiliated and insulted
by your peers who are clean. The
abuse escalated to the point where
One day I
forgot my
panties in the
bathroom, and
they made me
walk around the
program all day
wearing my
panties over
my head
Coerced Committal
11
Coerced Committal
I accepted it,
thinking that
they were going
to help me,
Right now, I
would rather be
in jail than
there they
took me to the
court house on
the second day,
and I was
throwing up
Coerced Committal
13
Rompiendo en Frio
They do not
have medicines
to kick the
habit. When I
was in the
Christian
centers there
was nothing
not even for
headaches
nothing all of
a sudden you
start kicking
the habit cold
turkey
Rompiendo en Frio
15
Although
involved in
treatment as an
alternative to
criminal justice
sanctions
Treatment should
not become a
form of
extrajudicial
punishment.
[United Nations Office on
Drugs and Crime]
16
17
hurts No, that is not useful at all because what it does is to create hatred
among people. If they speak ill [to]
you, if someone does that, if they insult
you, you would not hold this person in
high esteem I would hate their guts.
And I dont know what I would do in
the future if some day I suddenly run
into any of these people who have
offended me. Because in the street
things are completely different and I
would seek revenge. (Luis)
19
20
Degrading
treatment
encompasses acts
that are designed
to arouse in their
victims feelings of
fear, anguish and
feelings of
inferiority capable
of humiliating and
debasing them
and possibly
breaking their
physical or moral
resistance
[United Nations Special
Rapporteur]
21
Neither
detention nor
forced labor
have been
recognized by
science as
treatment for
drug use
disorders
(World Health Organization
and United Nations Office
of Drugs and Crime)
22
Figure 5. Hogar CREA residents must sell products and request donations in the streets
said, Well, because you have to pay
for a mechanic. Take it to the shop,
thats it. They told me I had to fix all
the trucks and buses from CREA. They
did not tell me that I had to fix the
directors car. I call the shots here. I
will show you who the boss is, he
replied. The next day I spent four hours
in the water. [At that moment, what I
wanted to do was] get the guy and kill
him. (Juan)
23
if you go to
treatment
I believe it is
because you
need treatment,
not to be
exploited
without any
pay .
25
Discharge or Desertion
Consequences
They make us fail exactly for that
reason, to bring you back in the
progression of the treatment (Angel)
26
Discharge or Desertion
Discharge or Desertion
27
Discharge or Desertion
There is
nothing worse
than facing
humiliation in
front of other
people that
they make you
feel less than
everybody else.
Because it is
a much stronger
pain, ..., and
psychologically
it stays with
you.
29
By denying
effective drug
treatment, State
drug policies
intentionally
subject a large
group of people
to severe physical pain, suffering
and humiliation.
[UN Special Rapporteur]
30
Inadequate Supervision
Drug treatment
under coercion is
only legally and
ethically justifiable
if the rights of the
individual are
protected by
procedural
guarantees and if
the treatment
provided is
effective and
humane.
[World Health Organization]
Conclusion
31
RECOMMENDATIONS
n light of this reality, the government and other public institutions must take measures to
remedy this situation and prevent these abuses from continuing to be committed, especially
under auspice of public funds.
32
Recommendations
1.
2.
We demand that the licenses to provide treatment for drug dependence be revoked
from institutions that do not comply with the standards of evidence-based treatment provided by a multidisciplinary team of health professionals until they are able to demonstrate
their compliance with the standards of treatment established by the World Health Organization (WHO) and the Substance Abuse and Mental Health Services Administration
(SAMHSA) that were incorporated in Law No. 408 of 2000, as amended on 2008.
3.
The Legislature of Puerto Rico must eliminate article 13.02 of Law No. 408 of 2008 of Mental Health of Puerto Rico, as amended on 2008, which allows community-based and faithbased organizations to continue providing their services according to their historical,
traditional and ordinary practices, given that those practices constitute human rights
violations and violate the rights established by the Bill of Rights of Mental Health Patients.
4.
The government of Puerto Rico must supervise and carry out adequate, regular evaluation
of the processes that occur inside these institutions including regular compulsory visits that
check for compliance with Law No. 408 of 2000, as amended on 2008, ensuring that the
rights of patients are respected and that minimum standards of evidence-based treatment
and best practices accepted by the mental health professional community are adhered to.
5.
The government of Puerto Rico must actively work to provide more treatment
alternatives that are evidence-based and must not divert prisoners to private institutions that do not provide treatment based on scientific evidence and treat their residents
in a cruel, inhumane and degrading manner violating their integrity and dignity as human
beings.
6.
The government of Puerto Rico must investigate violations of patients civil and human
rights and must take legal action against those persons and/or institutions that
committed these violations by action, omission and/or negligence.
7.
ASSMCA, as the regulating entity charged with ensuring compliance of Law No. 408 of
2000, as amended on 2008, must keep records and follow up all drug treatment patients
that participate in legal diversion programs in public and/or private centers to ensure
quality of services and compliance with the standards of the law.
8.
We must decriminalize drug users in Puerto Rico. Only when we stop viewing drugs users
as criminals and persons outside the law will it be possible to eliminate stigma and
discrimination against them. By labeling drug users as criminals and persons who are
breaking the law, we allow for their dehumanization and create the conditions whereby
violations of their human rights no longer cause public outrage; at the same time,
criminalizing drug use prevents us from approaching this issue from a public health
perspective.
METHODOLOGY
Methodology
33
ENDNOTES
1.
Roy Walmsley, World Prison Population List, 10th ed. (London: International Centre for Prison Studies,
2013), available at: http://www.prisonstudies.org/sites/prisonstudies.org/files/resources/downloads/
wppl_10.pdf.
2.
United Nations Office on Drugs and Crime (UNODC), Global Study on Homicide (Vienna: UNODC,
2011), available at: http://www.unodc.org/unodc/en/data-and-analysis/homicide.html.
3.
Centers for Disease Control and Prevention, Incidence and Diagnoses of HIV Infection --- Puerto Rico,
2006, Morbidity and Mortality Weekly Report 58, no. 21:589591 (2009), available: at http://
www.cdc.gov/mmwr/preview/mmwrhtml/mm5821a3.htm.
4. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias
y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico] (Puerto
Rico: ASSMCA, 2009). Table 12. Available at: http://www2.pr.gov/agencias/assmca/Documents/
EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%20USO%20DE%
20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%20%E2%80%93%
202008.pdf
5.
6.
7.
The effect of xylazine among injectable drug users in Puerto Rico has been documented by Torruella,
R.A. Xylazine (veterinary sedative) use in Puerto Rico. Substance Abuse Treatment, Prevention, and
Policy, 6, (2011). Available at: http://www.substanceabusepolicy.com/content/6/1/7
8.
The term problematic drug use was introduced by the current DSM-5 (APA 2013) and is the most
appropriate term for referring to the health condition associated with severe substance use that has
negative consequences for an individuals functionality. This classification distinguishes between
problematic use and non-problematic use (which goes along a continuum from mild, moderate or
severe according to the level of dysfunction). Before this newest edition of the manual, DSM-IV
utilized the categories of use, abuse and dependence. The categories of abuse and dependence are
contained within the term problematic use. For the purpose of this report, we use the DMS-IV and
DSM-5 terminology interchangeably. We decided to not eliminate the language of dependence
because we understand that this term is more known by the public and it is used in much of the
literature on drug use. The term problematic use is still rather unknown in many circles.
9. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias
y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico] (Puerto
Rico: ASSMCA, 2009). Table 28. Available at: http://www2.pr.gov/agencias/assmca/Documents/
EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%20USO%20DE%
20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%20%E2%80%93%
202008.pdf
10. ASSMCAs Households Survey 2008 utilized the DSM-IVs classification for substance use disorders
with the categories of use, abuse and dependence. The DSM-5 was introduced in 2013.
11. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico]
(Puerto Rico: ASSMCA, 2009). Table 39. Available at: http://www2.pr.gov/agencias/assmca/
Documents/EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%
20USO%20DE%20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%
20%E2%80%93%202008.pdf
12. Rafael A. Torruella, All en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of
Drug Users from Puerto Rico to the United States. Doctoral Dissertation, City University of New York
34
Endnotes
Endnotes
35
ENDNOTES
21. Campaign to Stop Torture in Health Care. Treated with Cruelty: Abuses in the Name of Drug Treatment Rehabilitation, Open Society Foundations, edited by Roxanne Saucier, et.al. (2011). Available at:
http://opensocietyfoundations.org/sites/default/files/treatedwithcruelty.pdf.
22. Saucier, R. & Wolfe, D. Privatizando la Crueldad Tortura, Trato Inhumano y Degradante en Centros
de Rehabilitacin por Consumo de Drogas a cargo de Organizaciones No Gubernamentales. Torture in
Healthcare settings: Reflections on the Special Rapporteur on Tortures 2013 Thematic Report .
Center for Human Rights & Humanitarian Law: Anti-torture Initiative, American University Washington College of Law (Washington, DC 2014), Pp.123-132.
23. Santiago-Negrn, S. Alternativas al modelo prohibicionista en el tratamiento de la adiccin a drogas
[Alternatives to the prohibitionist model for treating drug addiction]. Revista Ciencias de la Conducta,
Vol.7, Numbers 1 y 2, pp. 7-38 (1993).
24. Perez-Torruella, R.All en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of Drug
Users from Puerto Rico to the United States. Doctoral Dissertation, City University of New York
(2010), available at : https://www.academia.edu/306628/
_Alla_En_Nueva_York_Todo_Es_Mejor_A_Qualitative_Study_on_the_Relocation_of_Drug_Users_From_
Puerto_Rico_to_the_United_States.
25. Rivera-Suazo, S. Stigmatizing Practices in Addiction Treatment Settings: Participants Perspectives.
Paper presented at panel Stigma Manifestations towards Drug Users in the SUD Treatment Sector
and Its Implications for Public Health Policies, at the 60th Puerto Rican Psychology Association
Convention, Ponce, PR. (November, 2013)
26. Rivera-Suazo, S. Albizu, C.E., Salvador, S. & Perez, C. Stigmatizing Experiences while in Drug Treatment: A Qualitative Exploration of Clients Perceptions. Poster presented at the College on Problems
of Drug Dependence Annual Conference. (June, 2014)
27. Santiago-Negrn, S. Alternativas al modelo prohibicionista en el tratamiento de la adiccin a drogas
[Alternatives to the prohibitionist model for treating drug addiction]. Revista Ciencias de la Conducta,
Vol.7, Nmbers 1 y 2, pp. 7-38. (1993) Page 16.
28. Perez-Torruella, R. All en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of Drug
Users from Puerto Rico to the United States. Doctoral Dissertation, City University of New York
(2010), available at: https://www.academia.edu/306628/
_Alla_En_Nueva_York_Todo_Es_Mejor_A_Qualitative_Study_on_the_Relocation_of_Drug_Users_From_
Puerto_Rico_to_the_United_States.
29. Costa, A. Drug Control, Crime Prevention and Criminal Justice: A Human Rights Perspective Note by
the Executive Director. Commission on Narcotic Drugs, 53ava session, UN Doc. E/CN/.7/2010/CRP.6-E/
CN.15/2010/CRP.1 (March 3, 2010) paragraph 46 available at: http://www.unodc.org/documents/
commissions/CCPCJ/CCPCJ_Sessions/CCPCJ_19/E-CN15-2010-CRP1_E-CN7-2010-CRP6/E-CN15-2010CRP1_E-CN7-2010-CRP6.pdf.
30. World Health Organization. Neuroscience of Psychoactive Substance Use and Dependence. (WHO:
Geneva, 2004).
31. Costa, A. Drug Control, Crime Prevention and Criminal Justice: A Human Rights Perspective Note by
the Executive Director. Commission on Narcotic Drugs, 53ava session, UN Doc. E/CN/.7/2010/CRP.6-E/
CN.15/2010/CRP.1 (March 3, 2010) paragraph 40 available at: http://www.unodc.org/documents/
commissions/CCPCJ/CCPCJ_Sessions/CCPCJ_19/E-CN15-2010-CRP1_E-CN7-2010-CRP6/E-CN15-2010CRP1_E-CN7-2010-CRP6.pdf.
36
Endnotes
Endnotes
37
ENDNOTES
49. Law of Mental Health in Puerto Rico, Law No. 408, October 2, 2000, as amended by Law No. 183,
August 6, 2008. Secretariado de la Conferencia Judicial y Notarial del Tribunal Supremo. It includes
amendments made until November 2010.
50. Melndez Nieves, V.M. Melendez Nieves, V.M. Salas Especializadas y la Justicia Teraputica
[Specialized Drug Courts and Therapeutic Justice] . Escuela Graduada de Administracin Publica
Roberto Sanchez Vilella, Recinto de Rio Piedras, Universidad de Puerto Rico. Master in Arts Thesis
(2009).
51. United Nations Office on Drugs and Crime. From Coercion to Cohesion: Treating Drug Dependence
through Healthcare, not Punishment. Discussion Paper (UNODC: New York, 2010) Prologue.
52. Ibid. page. 6.
53. Personal communication with the former director of the Puerto Rico Mental Health and Addiction
Services Administration [ASSMCA] (2013-2014), Dr. Salvador Santiago-Negron, August 5, 2014.
54. World Health Organization. Neuroscience of Psychoactive Substance Use and Dependence. (WHO:
Geneva, 2004), page 234.
55. Mendez, Juan. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading
treatment or punishment, Center for Human Rights & Humanitarian Law: Anti-torture Initiative,
American University Washington College of Law (Washington, DC, 2014), AR/HRC/22/53, page 316,
paragraph #74 (299-321).
38
Endnotes
Dbora Upegui-Hernndez is a social psychologist, researcher and author of the book Growing Up
Transnational: Colombian and Dominican Children of Immigrants in New York City (2014). She has taught
at the University of Puerto Rico, Rio Piedras Campus and Carolina Campus, St. Peters College in New
Jersey and Baruch College in New York and was a Research Associate at National Latina Institute for
Reproductive Health in New York. Dr. Upegui-Hernandez has work on several research projects about
immigration, education, social justice and the experiences of Latinas/os. Upegui-Hernandez has authored
several reports for the Latino Data Research Project at CUNYs Center for Latin American Caribbean and
Latino Studies, journal articles in Encyclopedia of Critical Psychology, Feminism and Psychology, Journal of
Pacific Rim Psychology and chapters in Navigating Multiple Identities and Diversity in Mind and Action:
Volume IMultiple Faces of Identity. She holds a doctorate in social and personality psychology from the
CUNY Graduate Center and received several awards from CUNYs Center for Latin American, Caribbean
and Latino Studies, the Humbolt University Summer Research Program, the Spencer Social Justice and
Social Development Fellowship and the Center on Philanthropy and Civil Society's Interdisciplinary Seminar
on Civil Society, Government, and Governance of the CUNY Graduate Center.
Rafael A. Torruella is executive director of Intercambios Puerto Rico, Inc, a non-profit community based
organization that provides harm reduction services in the northeast of Puerto Rico. He is also the director
of Descriminalizacion.org, a drug policy change campaign and board member of New York Harm
Reduction Educators (NYHRE), a New York harm reduction community based organization. His research
and advocacy work has focused on understanding processes and issues related to drug use in Puerto Rico
and New York, advocating for evidence-based services and treatment for drug users, and developing drug
policy that is respectful of drug users human rights and improves their quality of life and wider
community. His doctoral tesis All en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation
of Drug Users from Puerto Rico to the United States explores the relocation of drug users from Puerto Rico
to the United States with the goal of receiving drug treatment.. Dr. Torruella holds a doctorate in social
and personality psychology from the CUNY Graduate Center and was awarded pre and post-doctoral
fellowships by the National Institute on Drug Abuse (NIDA) to conduct behavioral research with drug users
at the National Development Research Institute (NDRI). He also received a fellowship from the
Interdisciplinary Research Training Institute (IRTI) on Hispanic Drug Abuse. He has authored journal
articles in the Journal of Social Issues, Substance Use & Abuse, Substance Abuse Treatment Prevention &
Policy, and el Centro Journal and was recently recognized by Drug Policy Alliance as a Latino Drug Policy
Reformer during 2015 Hispanic Heritage Month.
39