Addressing opioid use disorder: Mexico's step backwards

Methadone and buprenorphine are considered Essential Medicines by the World Health Organization. Both are highly effective medications for treating opioid use disorder (MOUD) that significantly reduce morbidity and mortality among persons with opioid use disorder (OUD). Although access to MOUD is sub-optimal in many countries, some face unique challenges imposed by external events. In the USA, the aftermath of 9/11 and Hurricanes Katrina and Rita led to methadone dispensing interruptions that led many patients to undergo sudden opioid withdrawal and subsequent drug relapse.^1,2 When Russia annexed Crimea in 2014 and assumed control over the region, methadone was immediately banned in accordance with Russia's federal law on narcotic and psychotropic substances which prohibits its use. This sudden policy change immediately affected over 800 people who use drugs (PWUD) in Crimea who were receiving MOUD.³ A small number moved to neighbouring Ukraine to continue treatment, but the majority who could not leave rapidly underwent forced detoxification. Within a year, an estimated 80–100 people had died, some due to overdose or suicide.⁴

Another tragedy is unfolding, this time in Mexico. In February 2023, Mexico's federal government closed the country's only methadone manufacturing plant, Psicofarma, following concerns about quality control.⁵ In Mexican-U.S. border cities, such as Ciudad Juarez, Mexicali, and Tijuana, where the prevalence of OUD is among the highest in the country, methadone clinics are turning new clients away as they run out of medication, limiting doses, providing doses only on alternate days, or not dosing altogether. Although there are no accurate estimates of the number of persons with OUD in Mexico, a national survey in 2016 suggested that 23,251 people had used heroin in the past year.⁶ In 2020, 2.2% (n = 2217) of the persons that sought drug treatment in public clinics reported opioids as the main substance used, representing 42% of cases among persons who inject drugs (PWID).⁷ Both are likely gross under-estimates.

Although the impact of the closure of Mexico's methadone manufacturing plant has yet to be fully realized, the potential consequences are dire for methadone clients who may be required to undergo rapid detoxification or are suddenly cut-off altogether. People receiving MOUD who relapse experience a higher risk of fatal overdose due to their reduced tolerance.^1,2 The infiltration of illicitly manufactured fentanyl in Mexico further exacerbates the risk of overdose among those who experience relapse, since fentanyl is approximately fifty times more potent than heroin.

Mexico's problems with OUD and the lack of MOUD are not theirs to bear alone. Mexico and the USA share a 2000-mile border and a binational community. Among PWID living in San Diego, California, one in six travelled to nearby Tijuana to purchase and use drugs where they are cheaper and easier to purchase.⁸ In north-western Mexico, pharmacies catering to drug tourists sell opiates and counterfeit drugs contaminated with opiates.⁹ If Mexico's OUD related problems worsens, it will almost certainly affect the USA, which continues to face rising numbers of opioid overdose deaths.

The sudden closure of Mexico's only methadone manufacturing plant lies bare the fault lines in its treatment of substance use disorders across the country. In 2021, there were only eleven clinics offering methadone across the country,¹⁰ with each treating approximately 400 methadone clients per year who may be affected, as well as countless others who are being turned away from services. Although the federal government had planned to expand methadone maintenance programs as part of their drug policy reform that embraced harm reduction,¹¹ this has fallen dramatically short of expectation. Meanwhile, syringe services programs lack sufficient supplies to help PWID avoid becoming infected with HIV or viral hepatitis. The Mexican government's official statement is that the opioid overdose reversal medication, naloxone, is “irrelevant” in Mexico given the small number of persons with OUD and that it will only benefit interest groups supporting a neoliberal agenda. Although Mexico lacks official estimates on the numbers of people with OUD and opioid overdose deaths, they are neither invisible nor negligible.

During the COVID-19 pandemic, barriers to MOUD access in the USA were sometimes overcome by relaxing restrictions on take-home doses and scaling up telehealth. Mexico should seize this opportunity to not only rectify its MOUD shortages but improve drug treatment and harm reduction services to ensure a constant supply of methadone by importing it from international suppliers, and making available other drugs for treatment of OUD, such as buprenorphine. In the interim, Mexico could maintain people on other long-acting agents such as sustained release oral morphine or hydromorphone. The international community should assist Mexico in identifying alternative sources of MOUD to reduce morbidity and mortality. Thousands of lives depend on it.

Contributors

SAS drafted the commentary. DG and CR edited the commentary and provided assistance with the literature review.

Declaration of interests

Authors declare no conflicts of interest.