Mexico's Drug Policy Reform: Cutting Edge Success Or Crisis in the Making? (Editorial)

In August 2009, Mexico's federal government took the bold step of passing a law partially decriminalizing possession of small quantities of drugs such as cannabis, cocaine, amphetamines, and heroin (Consejo Nacional contras las Adicciones, 2010). Concurrently, the law (known as the ‘ley de narcomenudeo’) also mandates that individuals found to be in possession of these drugs be diverted to addiction treatment, including methadone maintenance therapy (MMT) (Consejo Nacional contras las Adicciones, 2010). Specifically, individuals carrying illegal drugs under a threshold amount subject to the law who are stopped by police are released with a warning up to two times. However, upon a third drug-related infraction, individuals are either mandated to addiction treatment or jail (Consejo Nacional contras las Adicciones, 2010).

The intention of the narcomenudeo law was to reduce the burden on Mexico's criminal justice system as a result of policing and incarceration of individuals convicted of petty drug-related crimes, who were likely to recidivate because the current system of arrest and incarceration offered little to reduce drug-related harms and manage drug dependence (Moreno, Licea, & Rodriguez-Ajenjo, 2010). By adopting this law, Mexico was poised to join the vanguard of countries embracing cutting edge, health-focused drug policies, which also includes Switzerland and Portugal, both of which have experienced reductions in drug-related harms following the implementation of reform measures centered on public health approaches to drug harms (Greenwald, 2009; Hughes & Stevens, 2012; Killias, Aebi, & Ribeaud, 2000; Klingemann, 1996; Nordt & Stohler, 2006).

However, since the passage of the narcomenudeo law over four years ago, and despite a number of institutional target dates for the scale-up of addiction treatment in urban centers facing high levels of drug-related harms, the treatment and policing landscape in Mexico continues to face serious challenges to ensure the meaningful implementation of the intended reforms. For instance, according to Mexico's 2011 National Household Survey, only 18% of persons that meet the criteria for dependence were in treatment (Secretaría de Salud, 2011). Survey data also show that heroin use expanded throughout the 2000s from Mexico's northern border to other regions. In 2008, Mexico's National Household Survey reported that treatment centers were reporting heroin use in 17 states, 11 of them in the central and southern region of the country; by 2009, only four states in Mexico did not report cases of heroin use at treatment centers (Secretaría de Salud, 2009).

In Baja California, located in Mexico's northwest, between 31% and 36% of patients seeking addiction treatment reported needing help for heroin dependence (Tena et al., 2011; CIJ, 2011; Secretaría de Salud, 2012). In Tijuana alone, it has been estimated that a population of approximately 10,000 people who inject drugs (PWID) is beset by severe drug-related harms ((Beletsky, Lozada, et al., 2013; Brouwer et al., 2012; Brouwer et al., 2006; Kori, Roth, Lozada, Vera, & Brouwer, 2013; Patricia et al., 2008; Pollini et al., 2010; Strathdee et al., 2005; Ulibarri et al., 2013; Volkmann et al., 2011). A substantial proportion of this population is believed to be opioid-dependent (Strathdee et al., 2005; Strathdee, Magis-Rodriguez, Mays, Jimenez, & Patterson, 2012). However, only three MMT clinics are in operation, and two are private, for-profit enterprises. The third, while public, nevertheless charges individuals a fee for service (“Unidad de Tratamiento a Personas con Problemas del Consumo de Heroína Tijuana”, 2012). This has resulted in low levels of enrolment in MMT among PWID. For instance, a recent Tijuana-based study found that while over 80% of PWID participants reported opioid use at baseline, only 7.5% reported accessing MMT (Werb, Wagner, Beletsky, & Strathdee, 2014). This is of concern given that the narcomenudeo law specifically denotes that scale up of treatment centers is a key component necessary for reform implementation and success (Consejo Nacional contras las Adicciones, 2010). Given this slow scale up, as well as recent investigations of discretionary policing practices that likely reduce the capacity of PWID to access relevant health services (Beletsky, Lozada, et al., 2013; Volkmann et al., 2011), rates of MMT access in Tijuana are likely to remain woefully low (Syvertsen et al., 2010). Additionally, a survey conducted in Mexican federal prisons in 2012 reported that 60% of male and 80% of female inmates were sentenced due to drug related crimes, with 38% of all inmates arrested due to drug possession (CIDE, 2012). Research has also shown that Tijuana's PWID frequently interact with police in ways that have the potential to increase health and social harms (Beletsky, Lozada, et al., 2013; Strathdee et al., 2012). Research from other settings has also demonstrated that policing practices such as crackdowns, targeted patrols of harm reduction services, and syringe confiscation may reduce access to services and increase risky drug-related behaviors among PWID (Bluthenthal, Heinzerling, Martinez, & Kral, 2005; Maher & Dixon, 1999; Rhodes et al., 2004; Werb et al., 2008). As such, considerable effort is required to ensure a formal shift of emphasis in policing practices so that PWID are appropriately diverted from the criminal justice system and incentives are put in place to promote addiction treatment as an alternative to incarceration.

Clearly, the slow scale-up of a coordinated system to provide evidence-based addiction treatment in Mexico has the potential to critically delay the meaningful adoption of the country's drug policy reform and its potential future success. While the ‘law on the books’ directs police and judges to divert drug-dependent individuals to addiction treatment, this can only occur in settings where treatment is both physically and financially accessible. To that end, it is heartening that Mexico's federal government has recently moved to incorporate existing addiction treatment clinics into a certification model overseen by a government health agency to ensure a minimum standard of care (Instituto de Psiquiatria del Estado de Baja California, 2014). However, experiences in other settings have demonstrated that when discretionary policing practices are exercised on PWID it can compromise health and addiction treatment service access even in settings where these services are brought to scale (Bluthenthal, Kral, Lorvick, & Watters, 1997; Wagner, Simon-Freeman, & Bluthenthal, 2013). Relatedly, observers have noted that discretionary policing practices continue in Mexican settings such as Tijuana despite the fact that they are no longer sanctioned (Beletsky, Lozada, et al., 2013).

While scale-up of addiction treatment services is a key pillar of Mexico's reform, it is also clear that this effort must rely on law enforcement to properly identify and connect drug-dependent individuals with needed services. Without the participation of and ‘buy in’ from law enforcement community, the effectiveness of Mexico's drug policy reform is likely to be severely hampered. It is noteworthy that police and public health partnerships have been successfully implemented in urban centers in countries such as Switzerland and Canada; in both settings these partnerships have resulted in a reduction of drug-related harms among PWID populations (DeBeck et al., 2008; Monaghan & Bewley-Taylor, 2013). As such, police education programs are needed to ensure full implementation among first responders at the street level. Such education programs should have two areas of focus: first, education regarding the components of the drug reform law and its obligations; and second, education regarding the impact of addiction treatment access on improving public order. With respect to the first area of focus, surprisingly no formal programs currently exist to ensure that Mexican law enforcement officers understand the legally-binding components of the new law reform. With respect to the second area of focus, research from other settings has demonstrated that PWID who are provided with access to evidence-based addiction treatment such as MMT have a significantly lower risk of criminal recidivism and in some cases reductions in public drug use (Amato, Davoli, Ferri, & Ali, 2002; Mattick, Breen, Kimber, & Davoli, 2009). Furthermore, evidence shows that by bundling harm reduction education with occupational safety, police attitudes have been shifted to become more accepting of a community policing approach grounded in public health in diverse settings experiencing heightened drug-related harms (Beletsky et al., 2011; Beletsky, Thomas, Shumskaya, Artamonova, & Smelyanskaya, 2013; Davis & Beletsky, 2009; Silverman et al., 2012).

Mexico continues to experience a range of severe harms related to its geographic position as a key transit point for drug trafficking into the United States (Willoughby, 2003). These harms include high levels of injection drug use and its associated health-related harms and behaviors in Mexico's northern border regions (Beletsky et al., 2012; Strathdee et al., 2012). In this context, the country's drug policy reform has the potential to meaningfully reduce risky drug use and drug-related disorder by referring drug-dependent individuals to addiction treatment. However, beyond the necessary scale up of addiction treatment, the fulcrum of this reform effort is the active participation of drug law enforcement in facilitating greater uptake of addiction treatment, as opposed to traditional practices focused on incarceration for drug-related infractions. This can only occur systematically if law enforcement are aware of the conditions of the new law and are educated on the benefits to public order that can result with increased uptake of addiction treatment across a population of drug-dependent individuals. A dual scale up of both treatment centers and police education programs therefore appears to be crucial in ensuring the success of Mexico's bold and potentially game-changing drug policy decision. Without these steps, Mexico's cutting edge reform may soon slide into a crisis of implementation.