COUNTRY REPORT: HARM REDUCTION IN MEXICO

DOCUMENT IN PROGRESS

Karen lvarez
E-mails: karen.alvarez@flacso.edu.mx
karen.alvarez@cij.gob.mx

ABSTRACT
This Country Report reviews the state of harm reduction in Mexico and provides a critical baseline in
terms of key developments and national actions as isolated programs guided by a response to drugrelated epidemics as HIV, Hepatitis B and C. It analyzes the deficiency of harm reduction in drug
policy in Mexico although these practices are one of the principles that guide the national policy on
HIV/AIDS. There are several NGOs providing harm reduction services as key part of a comprehensive
addiction care ensuring services for stigmatized and excluded people but there are no mandatory
technical standards for these practices because they are not stipulated in drug demand reduction
policy although the term is vaguely included in the Official Mexican Standard NOM-028-SSA2-20091
for addiction prevention, treatment and control. This legal vacuum is an important obstacle to design
and implement effective public health programs on harm reduction from an approach of drug abuse
and addiction and this structural failure raises a question about the Mexican governments success in
protecting the health of the particular segment of the population at risk of drug injection. This Country
Report advocates to improve the actual drug demand reduction policy towards a drug policy based on
human rights and public health.

KEYWORDS
Harm reduction, public policy, right to health protection, Mexico.

The update of the NOM-028-SSA2-1999 for addiction prevention, treatment and control.

ACKNOWLEDGEMENTS
The author recognizes the Directive Board of Centros de Integracin Juvenil, A.C. (CIJ) for their
contribution to the preparation of this Country Report. Especially, the author appreciates the trust of
two of the top specialists in addiction in Latin America: Ps Carmen Fernndez, director-general, and
Dr ngel Prado, deputy director-general, for their invaluable support by giving her the opportunity of
work in CIJ that has allowed to grow and to develop her understanding in harm reduction and to
recognize how this practice is essential in Mexican drug policy. The author wishes to thank also Dr
Eduardo Jaramillo, Senior Advisor to the Mexican Secretary of Health Mr Salomn Chertorivski
Woldenberg and expert in public health policy and legislation, for the time he spent answering relevant
questions and guiding the policy analysis. The author expresses gratitude to Dr Domitille Delaplace,
one of the best specialist in human rights and public policy in Mexico, for helping to build a rightsbased conceptual framework that is needed for the standardization of harm reduction programs in
addiction care. This Country Report is guided by the objective to make human rights principles central
to the formulation of good public policy on drug demand reduction in Mexico.
The information in this Country Report was gathered using reports from international organs and harm
reduction networks, useful epidemiological information at national level and the few existing data
sources on harm reduction in Mexico although there is a growing body of literature related to drug
injection and other blood-borne as human immunodeficiency virus (HIV). There several helpful
research papers on this theme, particularly those that are carried out in the northern frontier2, but there
is not a countrywide evaluation on harm reduction available except for work of the National Center for
HIV/AIDS Prevention and Control (CENSIDA).

Aside of Quintana Roo where Cancn and part of the southern frontier are located, historically the northern
border have the highest level of consumption. Tamaulipas has a cumulative incidence of 11.1%, Baja California
of 9.6% and Chihuahua of 8.2%. Chihuahua is the State with more heroin users around the country (30, 480).

ABBREVIATIONS AND ACRONYMS

AIDS
ART
CENSIDA

Acquired immunodeficiency syndrome

Antiretroviral therapy
Centro Nacional para la Prevencin y el Control del VIH/SIDA
(National Center for HIV/AIDS Prevention and Control of Mexico)
CIJ
Centros de Integracin Juvenil, A.C.
CONADIC
National Commission Against Addictions
(formerly known as National Council Against Addictions)
CICAD
Inter-American Drug Abuse Control Commission
DCF
Drug consumption facility
ENA
Encuesta Nacional de Adicciones
(Mexican National Addiction Survey).
GFATM
Global Fund to Fight AIDS, Tuberculosis and Malaria
HAT
Heroin assisted treatment
HBV
Hepatitis B virus
HCV
Hepatitis C virus
HIV
Human immunodeficiency virus
IDUs
Injection drug users
IHRA
International Harm Reduction Association
(currently Harm Reduction International)
INCB
International Narcotics Control Board
INPRF Instituto Nacional de Psiquiatra Ramn de la Fuente Muiz
(National Institute of Psychiatry Ramn de la Fuente Muiz)
MMT
Methadone maintenance treatment
MSIC
Medically supervised injection center
NGO
Non-governmental organization
NIDU
Non-injecting drug use
NOM
Official Mexican Standard
NSP
Needle and syringe exchange program
OST
Opioid substitution therapy
PAHO Pan American Health Organization (WHO)
PNEP Prison needle and syringe exchange program
SIF
Supervised or safer injecting facility
STI
Sexually transmitted infections
SSA
Secretara de Salud
(Secretariat of Health)
UNODC
United Nations Office on Drugs and Crime
USMBHC
United States-Mxico Border Health Commission
VCT
Voluntary HIV counseling and testing

INTRODUCTION
The World Drug Report 2011 states that some 210 million people use illicit drugs each year, and
almost 200,000 of them die from drugs. There continues to be an enormous unmet need for drug use
prevention, treatment, care and support, particularly in developing countries (UNODC, 2011: 8). The
United Nations Office on Drug and Crime (UNDOC) estimates the global average prevalence of HIV
among injecting drug users (IDUs) at 17.9% (2.8 million inhabitants aged 15-64) and of Hepatitis C is
at 50% (7.2 to 8.8 million of people who inject drugs aged 15-64). The UNODC affirms that each year
there are between 104,000 and 263,000 deaths related to or associated with the use of illicit drugs.
Over half of the deaths are estimated to be fatal overdose cases (UNODC, 2011: 14). Globally,
UNODC figures that there are approximately 15.9 million IDUs aged 15-643. The agency suggests
that close to 60% of all problem drug users worldwide inject drugs, and that injecting drug users
account for about 7.5% of all drug users worldwide (UNODC, 2011: 30). As reported by the Open
Society Global Drug Policy Program globally up to 10 percent of all HIV infections occur through
injecting drug use.
The Report of the International Narcotics Control Board (INCB) 2010 affirms that the abuse of certain
illicit drugs in Mexico has increased sharply (United Nations, 2011: 63). The government increased its
budget on addiction prevention of addiction, which rose from 135 million of pesos in 2006 to 400
million of pesos for 20114. The Mexican National Addiction Survey (ENA) of 2008 shows that illegal
drugs use (marijuana, cocaine and its derivatives, heroin, methamphetamine, hallucinogens, inhalants
and other drugs) increased from 4.6 to 5.2% in population in the population between the ages of 12
and 65. There are over than 3.5 million of people from 12 to 65 years old that have used a drug once
in their lifetime. As INCB affirms: One reason for the increased abuse of drugs is that drug trafficking
has resulted in drugs being more widely available in the country (United Nations, 2011: 71). The most
used drugs are marihuana and cocaine.
In relation to public perception, the ENA found that 50.2% of the polled people think from the
perspective of the stigmatizer that the individuals dealing with addiction problems should be sent to
the anexos5, granjas or casa hogar, which are expensive and crowded places where other
addicts, almost always in recovery, provide addiction care to the inmates based in violence: mental
abuse and physical torture are a common denominator. These private, unlicensed treatment centers
operate without implementing any of the regulations provided by Official Mexican Standard NOM-028SSA2-2009 of addiction prevention, treatment and control and the vast majority do not provide
evidence-based prevention and patient-friendly service. The report Treated With Cruelty: Abuses in
The Name of Drug Rehabilitation confirms this declaration: With public treatment facilities limited, and
ill-equipped, families and friends of drug users often turn in desperation to these private institutions.
Given the high demand for drug treatment, nearly anyone can set up shop and administer expensive
treatment with little to no oversight. Family members of stimulant users are not told that there is little
evidence that in-patient treatment is required (Open Society Foundations, 2011: 21). Unfortunately,
these centers also have become target for mass killings by drug gangs6.
About intervention needs, the ENA found that there are 428,819 people requiring specialized care
and 3,869,093 (people) that require brief interventions (ENA, 2008: 52-53). The INCB (2011)
3

Range 11.0 to 21.2 million of people.

135 million of pesos are over than 10 million USD and 400 million of pesos are over than 30 million USD.
5
Literally, anexo means next to, owing to the fact that such facilities are usually located right next to locations
for Alcoholics Anonymous meetings (Open Society Foundations, 2011: 23).
6
In June 7, 2011 a gang of heavily-armed men killed 13 patients and workers of a Center for Alcohol and Drug
Rehabilitation in Torreon, a city located in Coahuila at the north of Mexico. In the city of Chihuahua, a gunman
killed 19 people in a treatment facility in June 2010. In the same month, 9 people were killed in Durango.
4

declares that: In 2009, about 39,000 persons began receiving treatment for drug abuse in specialized
centers; that represented only a small proportion of the drug addicts in the country (United Nations,
2011: 72). As noted by Tena Tamayo (2011) "although the prevalence of consumption of drugs was
only 1% lower than in most countries and below the world average is 3.3% to 6.1%, we alerted the
upward trend in illegal drug use in relation to (....) 2002, but also worried that the percentage increase
was higher in the group under age 12 to 17 year " (Tena Tamayo, 2011).
The ENA states that there are 106, 939 heroin users in Mexico. The Secretary of Health of Mexico
City estimates an approximate number of heroin users based on the number of IDUs in Mexico. It
calculated 62,000 users in 2002 and 105,000 users in 2008 even though heroin use seems to be
steady since 1998. The following table demonstrates the potential exposure to injection drug use
among Mexican population:
Figure 1. Drugs that can dilute or dissolve drugs for injection used at least once in a lifetime in Mexico
Drug
%
Susceptible population being potentially
exposed to injection drug use7
Amphetamines
0.30 225,375
Cocaine
2.37 1,780,465
Crack
0.59 443,238
Heroin
0.14 105,175
Prescription drugs as morphine
1.03 773,789
3,328,042 chances of drug injection
Source: National Addiction Survey (ENA)

The ENA also revealed a high percentage of misinformation on HIV/AIDS: 29.5% of surveyed women
and 27.7% of surveyed men maintained that a person who looks healthy cannot have HIV. At the
beginning of the last decade, the government through CENSIDA began to implement a program to
reduce arising damages among IDUs by training health personnel and distributing injecting equipment
and educational material.

HARM REDUCTION IN THE REGULATORY FRAMEWORK OF DRUG

DEMAND REDUCTION IN MEXICO
Harm Reduction International8 states in its Global State of Harm Reduction 2010. Key issues for
broadening the response that there are explicit supportive reference to harm reduction in national
policy documents, needle exchange programs and opioid substitution programs (IHRA, 2010: 7) in
Mexico. CENSIDA is the federal agency that offers prevention, treatment and research on HIV/AIDS. It
also provides universal prevention of sexually transmitted infections (STI), voluntary HIV counseling
and testing VCT), antiretroviral therapy (ART) and harm reduction based on the Specific Program of
Action in response to HIV/AIDS and STI 2007-2012 of the Secretariat of Health (SSA), which also

This number is for IPO (Illustrative Purposes Only). The calculation is based on 75,125,112 Mexican total
population from 12 to 65 years old used in the ENA. Lozada (2008) based on the Epidemiology Vigilance
System of Addictions (SISVEA) has reported the following injected drugs by 2002: Rohypnol, amphetamines,
barbiturate, psychotropics, hallucinogens, basuco, marijuana, sedatives, crack, alcohol, morphine, crystal,
cocaine and heroin.
8
Formerly known as the International Harm Reduction Association (IHRA).

promotes prison needle and syringe exchange program (PNEP)9.Since CENSIDA dispense needles
among IDUS, in 2008 published the Handbook of HIV/AIDS prevention in injecting drug users (IDUs)
and hand out leaflets about the inherent risk that is substantially increased when drug users share
needles. Furthermore, Mexico has applied for the round 9 Strengthening the National Response to
HIV for MSM and male and female IDUs in Mexico of the Global Fund to Fight AIDS, Malaria and
Tuberculosis (GFATM) and received a grant that will finish in late 2013. But it seems that harm
reduction in Mexican policy has a one-sided and simplistic approach: it is just a useful perspective to
prevent the spread of infections including HIV/AIDS.
Tolerance of harm reduction interventions has been the posture of Mexican government based on the
idea that primary prevention is the ideal tool to prevent drug use, but abstinence as highly desirable for
particularly those who inject or consume. As Laws (1996) indicates, this is a zero-tolerance position
and can be a conspicuous failure in drug demand reduction programs. Therefore harm reduction as an
integral part of drug demand reduction strategy is almost invisible in Mexican public policy as it is
shown below.
Political Constitution of the United Mexican States
The current constitution of Mexico declares in its article 4 that Every person has the right to health
protection. The law shall not only define the guiding criteria regulating the access to health services
but also establish concurrent activities to be carried out by the States and Mexico City, they are
responsible in organizing public health services but they have to accomplish all federal observances.
General Law on Health
Article 184 bis of this Law creates the "National Council Against Addictions, which aims to promote
and support the public, private and social actions aimed at the prevention and control of your health
problems caused by addictions (...) and propose and evaluate programs" (General Health Law, 2011:
58). This Council is currently the National Commission against Addictions (CONADIC). The CONADIC
is chaired by the Secretary of Health, heads of the agencies related and representatives of civil
organizations that fight addictions. CONADIC mission is "To promote and protect the health of
Mexicans, by defining and conducting national policy in matters of research, prevention, treatment,
training and human resource development for the control of addiction, with the purpose of improving
the quality of individual, family and social life" (CONADIC, 2011). This mission is aligned with the
expressions in both the National Development Plan 2007-2012, as in the National Health Program for
the same period. The Chapter IV of the eleventh title of this Law contains the Program against Drug
Addiction that is implemented by the SSA and the General Health Council and has three lines of
action: "I. The prevention and treatment of drug and, where necessary, rehabilitation of drug addicts;
II. The education about the effects of the use of drugs and other psychotropic substances responsible
to produce dependence and its consequences for social relations; III. The education and instruction to
the family and the community on how recognize symptoms of addiction and take appropriate
measures for its prevention and treatment (General Health Law, 2011: 60). Note that all information
on addiction received by the population "should be based on scientific studies and a clear warning
about the effects and physical and psychological harm of drug and psychotropic substances" (General
Health Law, 2011: 60).The SSA should develop a national program for prevention and treatment of
drug dependence, and will be implemented in coordination with agencies and entities in the health
sector and governments of the states.
National Health Program 2007-2012
It its remarkable that this public policy tool has as a line of action the reinforcement of care policies for
addiction caused by abuse of alcohol, tobacco, medical non-prescription drugs and illegal drugs within
9

Since 2009, CENSIDA has guidelines for PNEP implementation in penitentiaries for man based on the official
guidelines on HIV prevention for staff working in prisons, jointly developed by the Secretariat of Health (SSA)
and the Secretariat of Public Security (SSP) in 2007.

the Strategy 2 Strengthen and integrate the actions of health promotion and disease prevention and
control. This goal is based in making stronger the provision of care services for addicts and their
families. This is an opportunity to insert more harm reduction services provided by the government.
There are only two methadone maintenance treatment (MMT) facilities supported by the government
in Mexico as it is explained in the next section of the Report. In the forum of public consultation of
Health in the Northern Frontier of Mexico, the term of harm reduction was ignored.
Specific Program of Action Prevention and Treatment of Addiction (PAE). Update 2011-2012
The PAE states that public policy of the current federal administration "are intended to encourage
people in the decision not to start smoking or to quit, to prevent and reduce the harm associated with
alcohol, and reject the use of illegal drugs or non-prescribed medical, to reduce and to mitigate the
severe damage they cause and the wear observed in the family, labor, educational, cultural and social
areas" (SSA, 2007: 11). This program of the SSA is mainly focused in universal and selective
prevention. The only reference to harm reduction is when the PAE explains that the Centers Nueva
Vida of the CONADIC have a directory of contacts for timely referral to harm reduction, showed as
the last subsection of the treatment category.
Official Mexican Standard NOM-028-SSA2-2009
In the NOM 2009, addiction care services fundamentally embody activities of prevention, in
emergency, treatment, rehabilitation and social reinsertion, risk reduction and harm reduction,
teaching and training, and research. In the section of treatment in this Standard, harm reduction is
defined10 as the set of strategies, programs and measures to avoid or reduce risk situations and limit
damage associated with psychoactive substance use, consequently it is necessarily interconnected
with prevention and treatment (and it) not necessarily expects withdrawal (NOM, 2009: 21). In the
next paragraph, this definition is closely related to HIV/AIDS and there is a longer explanation of what
harm reduction is as the safest and most effective way to limit HIV transmission among injection drug
users (NOM, 2009: 21). Harm reduction falls in the category of alternative and/or complementary
treatment and the facilities that provide it must meet the requirements of the NOM as well as being
registered and certified by the CONADIC in addition to the official operation notice issued by the
authorities. The programs of harm reduction are obliged to be based on evidence and certified by the
CONADIC. Also, in the section of teaching and training call to involved parties, federal agencies and
NGOs certified by CONADIC, to support the development of comprehensive prevention, investigation,
treatment, harm reduction, smoking rehabilitation and control, alcoholism, alcohol abuse and drug
dependence as well as raising the quality of such actions and encourage the exchange of experiences
and knowledge (NOM, 2009: 23). But then again there is substantial inconsistency in the definition
when according to the NOM harm reduction must have as final purpose to coming off drugs and
withdrawal or reduction of the consequences.
Position papers
There are references of harm reduction in position papers prepared by a Joint Commission of Experts
on Health11 as Injecting Drug Use and HIV/AIDS in Mexico. A Public Health Problem12 (2003) and

10

Harm reduction was not included the past Mexican Official Standard for addiction prevention, treatment and
control (NOM 028-SSA2-1999).
11
This Commission is composed by the National Center for HIV/AIDS Prevention and Control (CENSIDA),
Centros de Integracin Juvenil, A.C. (CIJ), National Commission Against Addictions (CONADIC) and National
Institute of Psychiatry Ramn de la Fuente Muiz (INPRF). All of them are part of the Secretariat of Health
(SSA). The United States-Mxico Border Health Commission (USMBHC) participed as expert in the position
paper Injecting Drug Use and HIV/AIDS in Mexico. A Public Health Problem (2003). The National Center for
Planning, Analysis, and Information in Combating Crime (CENAPI) of the Office of the General Prosecutor
(PGR) participed as expert in the Position paper of Mexican policy on harm reduction (2009).
12
This position paper is only avaliable in Spanish: El consumo de drogas inyectadas y la epidemia del
VIH/SIDA en Mxico. Un Problema de Salud Pblica. Documento de Posicin.

Position paper of Mexican policy on harm reduction (2009)13. The first document is more extended
than the second one and is focused on the association between drug use and blood-borne viruses
such as HIV, HBV and HCV. It also clarifies that the proportion of AIDS cases attributable to injection
drug use was not large by 2003 (1.5% of cases at national level) but there was an undeniably
escalation over the years. This position paper is merely an informative paper that is not decidedly
encouraged on advocate harm reduction but it recognizes that it is essential to implement special
programs adapted to target populations and local conditions in order to prevent both the increase of
injected drug use in the statistics and to reduce the harm associated with the same (CONADIC et al,
2003: 7). The poorly disseminated, shorter and inadequate Position paper of Mexican policy on harm
reduction supports some strategies for reducing drug use consequences focused on special groups
of drug users that are in vulnerable circumstances, have an advanced addiction and hardly can be get
into treatment. The strategies in reducing consequences are the window of opportunity for an
intervention with those people that has the total and sustained abstinence as the final purpose
(CONADIC et al, 2009: 1). This position paper is repetitive, does not have references and is less
elaborated than the first one of 2003.

HARM REDUCTION PRACTICES AS

ADDICTION CARE SERVICES IN MEXICO

PART

OF

COMPREHENSIVE

The last published inform on harm reduction of CENSIDA dates from 2008 and described that 25 of 31
states and a Federal District (Mexico City) reported harm reduction activities.
Methadone maintenance treatment (MMT)
Lozada and Strathdee (2005) declare that there are 22 MTM facilities nationwide. In Tijuana, there are
2 private clinics that monthly care for 1,800 people. Centros de Integracin Juvenil (CIJ)14, an NGO
that receive support from the government, has a developed a methadone maintenance treatment
(MMT) in Ciudad Jurez, Chihuahua from 2000 and in Tijuana since 3 years ago15. There are 300
benefited patients per day. This is the only MMT program financed by the government. Mexico City
has a program on morphine supplementation with a very low coverage: 20 patients until 2005. There
are no programs based neither on levo--acetylmethadol (LAAM) nor Naltrexone.
Needle and syringe exchange programs (NSP)
Aside CENSIDAs NSP, in 2009 1316 of the 113 Units of CIJ started to distribute 3,500 needleexchange kits with 3 alcohol prep pads, 3 containers of distilled water, 5 condoms, 3 sterile syringes
that contains insulin aspart, an informative leaflet and one interchangeable ticket for other kit. Seven
NGOs were contacted to collaborate with this project but only 3 accepted to participate. The target
population of this program was the drug users of liquid heroin and the coverage was low: only 431
(12.3%) of the total number of kits were taken and used by the approached people. Population
Services International (PSI) also has NSP in collaboration with CENSIDA. Lozada (2008) states that is

13

This position paper is only avaliable in Spanish: Posicin de Mxico sobre las polticas para la <<reduccin
del dao>>
14
CIJ makes programs and projects of prevention, treatment, social reintegration, research and human
resources development (HRD) in the field of addictions for 41 years in Mexico.
15
Buprenorphine was used sometime.
16
Hospitalization Units of Culiacn (Sinaloa), Tijuana (Baja California) and Zapopan (Jalisco); MMT Units in
Ciudad Jurez (Chihuahua) and Tijuana Soler (Baja California), and the Treatment and Prevention Centers of
Chihuahua (Chihuahua),Ciudad Jurez Norte (Chihuahua), Mexicali (Baja California), Nogales (Sonora),
Tecomn (Colima), Tijuana Guaycura (Baja California) and Zapopan Norte (Jalisco). Lozada (2008) reports NSP
in Guanajuato too since 1999.

even is legal to buy syringes, the addicts are arrested anyway. There are not dispensing machines in
Mexico.
Heroin assisted treatment (HAT).
Prescriptions for heroin are not legal in Mexico.
Drug consumption facility (DCF) or Medically supervised injection center (MSIC)
These services are unavailable in Mexico.

POLICY RECOMMENDATIONS
Harm reduction practices are a pending issue in Mexican drug demand reduction public policy
because it is not standardized national drug policy. The harm reduction programs are focused to IDUs
and are just to prevent the spreading of HIV/AIDS and other viruses. There are not intended to prevent
an overdose or to reduce the harmful consequences associated with recreational drug use and other
high risk activities. There are DCF as supervised safer smoking facilities for crack users, i.e. The harm
reduction services should be part of drug demand reduction policy because they have positive effects
in reducing the adverse health, social and economic consequences, not only drug users but also for
the community . Without a consensus on a concrete expression of harm reduction, there will be more
obstacles to apply effective programs. It is extremely urgent to tune drug demand reduction policy with
the context and broaden policy options in harm reduction. Also, there is necessary an evaluation
system with proper indicators because with better data you can enrich policy. A comprehensive and
integrated approach on harm reduction based on human rights depends on the political will of the
Mexican government to directly address the problem of drug use and the provision of financial
resources. The absence of harm reduction in drug demand reduction policy calls to reinforce the
promotion of a health-oriented approach to drug dependence and in line with ethical standards. The
government must ensure that drug demand reduction services are committed to the right to health
protection, the obligation of the Mexican State. Mexican State shall incorporate and implement harm
reduction services in its domestic drug care system because its commitment to protecting the right of
health as a legal obligation under international human rights law.
The Report would make recommendations that address the lack of these practices in the normative
framework of public policy in drug demand reduction that would set standards to meet when providing
these services to fulfill the right to health protection of Mexican drug users.

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