Introduction

Patterns of drug consumption in Mexico are influenced by its proximity to the Unites States (U.S.) (Goodman-Meza et al., 2019), which may result in a higher prevalence of people who inject drugs (PWID), especially heroin (Bucardo et al., 2005; Villatoro et al., 2012). For example, Tijuana has high levels of intravenous drug use than the rest of Mexico and a high concentration of vulnerable populations such as sex workers and deportees from the U.S. PWID living along the northern border have higher rates of hepatitis C (HCV) and human immunodeficiency virus (HIV) (Güereña-Burgueño, Benenson, & Sepúlveda-Amor, 1991; Robertson et al., 2014). As the opioid epidemic rages in the U.S., some have suggested that overdoing may become an increasingly serious problem along the northern border. This phenomenon necessitates novel public health interventions (Beletsky et al., 2018) to protect PWID, particularly women (Pinkham, Myers, & Stoicescu, 2012). Such programs should be evidence-based, incorporating core principles of harm reduction, such as those established by the United Nations of Drugs and Crime and the World Health Organization, to minimize the negative consequences of substance use (Des Jarlais, 1995).

In Mexico, the Centro Nacional para la Prevención y Control del VIH (CENSIDA) has worked to implement and finance harm reduction programs and establish guidelines in coordination with local non-governmental organizations (NGOs) (Centro Nacional para la Prevención y el Control del VIH/SIDA, 2008). Interventions such as needle exchange and Opioid Substitution Therapy (OST) (Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz & CENSIDA, 2008) have been consolidated as necessary tools to reduce drug-related harms in Mexico, but approaches like Safe Consumption Sites (SCS) haven’t been considered yet. Successful implementation in other countries (Kerr, Wood, Montaner, & Tyndall, 2009) has demonstrated that SCS modify the public space by reducing street injection and syringe litter (MSIC Evaluation Committee, 2003) while protecting PWID from police abuse and increasing access to public health services in a cost-effective way (Bayoumi & Zaric, 2008; Irwin, Jozaghi, Bluthenthal, & Kral, 2017). For this reason, some have argued that interventions in SCS are a public health imperative for places like Tijuana (Beletsky et al., 2018).

The policy context for SCS in Tijuana is favorable because in 2009 Mexico depenalization the possession of a minimum amount of drugs for immediate and personal consumption (Arredondo et al., 2017). However, to succeed in Tijuana, a SCS intervention will need support from PWID and police officers alike. As part of an ad-hoc collaboration between UCSD and the Mexico’s Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz (INPRFM), this report leverages data from two parallel field studies on police (Strathdee et al., 2015) and PWID (Fleiz-Bautista et al., 2019) in Tijuana for the purpose of measuring attitudes regarding a potential SCS intervention in the city.

Method

Studies settings

In January 2015, the entire police force received training as part of Proyecto Escudo, a collaboration between the University of California San Diego (UCSD) and the Ministry of Public Safety of the City of Tijuana. The training covered occupational safety, current drug laws, and harm reduction strategies (excluding SCS). The design and conceptual framework of Proyecto Escudo have been described in detail elsewhere (Strathdee et al., 2015). A total of 771 officers who provided written consent were randomly selected for follow-up during a two-year period and completed surveys on knowledge, attitudes, and policing behaviors.

The INPRFM conducted a cross sectional study of heroin consumption patterns in northern Mexico. The current report uses only data collected in the city of Tijuana, Baja California (Fleiz-Bautista et al., 2019). Using rapid assessment, the investigators identified factors in the risk environment that increase harm of drug use among PWID (Rhodes, 2009). The “Heroin Use in the Mexican Northern Border Study: Context and Dimension” (Fleiz-Bautista et al., 2019) included quantitative interviews with 200 PWID in rehabilitation centers in Tijuana with a history of heroin consumption (People with Lived Experience – PLE). Inclusion criteria covered people who were 18 years and older, regular residents of the city, who seek treatment for heroin use disorder. A convenience sample of rehabilitation centers was selected using data from the Mexican Comisión Nacional Contra las Adicciones (CONADIC) and who agreed to collaborate with the study.

Survey design and data collection

The Escudo questionnaire was adapted from instruments used in previous PLE programs (Beletsky, Macalino, & Burris, 2005) and is described in detail elsewhere (Arredondo et al., 2017; Cepeda et al., 2017). The 24-month follow-up survey included attitudinal measures toward SCS among active police officers in Tijuana. Data was collected by trained interviewers between December 2016 and June 2018.

The INPRFM questionnaire covered patterns of substance use, risk behaviors, police, and treatment experiences among other topics and was conducted in Spanish. The survey also included similar questions to measure attitudes toward SCS. The surveys were administered by trained harm reduction staff from the NGO Prevencasa A.C., in Tijuana, between October 2017 and March 2018. All interviewers used the same graphic guide and text to introduce the topic of SCS among their respective populations. More details about the survey design and data collection can be found elsewhere (Fleiz-Bautista et al., 2019).

Measures and data analysis

The Escudo survey included the following items on SCS: 1. I would support a safe consumption clinic for drug users; 2. A safe consumption clinic could be successful in Tijuana; 3. My police colleagues would support a safe consumption clinic; 4. A safe consumption clinic could improve my occupational safety; 5. If there was a safe consumption clinic, I would refer drug users there. The study by the INPRFM included the following questions: 1. I would support a safe consumption clinic for drug users; 2. A safe consumption clinic could be successful in my city; 3. My peers would support a safe consumption clinic; 4. A safe consumption clinic could improve my health; 5. If there was a safe consumption clinic, I would use it.

The items were measured on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree”. All variables were dichotomized (strongly agree, agree vs other options). We present descriptive statistics and chi square test for these items.

Ethical considerations

The Escudo study was approved by the Institutional Review Boards of UCSD School of Medicine, USA, and Xochicalco University, Mexico. Similarly, the Heroin Study by the INPRFM was approved by their Institutional Review Board in 2017.

Results

The Escudo sample included 707 officers that were mostly men (85.2%) and married (79.4%), with a mean age of 38.2 years. Women had a mean age of 35 years. Nearly 20% of the officers had less than the minimum level of high school education. The sample of 200 PWID was mostly single (55.1%) and men (89.17%), with a mean age of 32.9 years women’s mean age was 40.2. More than 70% did not have a high school degree (Table 1).

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Both groups had high personal support for SCS (~82%) with the level of perceived success above 80%. As for SCS peer support, officers and PLE reported 58.9% and 79%, respectively. Around 76% of both groups agreed that a SCS would help to improve their health. Finally, 86.2% of the officers would refer people to a SCS while 62.5% of PLE would use the service (Table 2).

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Discussion and conclusion

Several studies have documented the positive effects of SCS around the world, including decreased HIV incidence, increased treatment uptake, and reduced overdose fatalities (Kerr et al., 2009; MSIC Evaluation Committee, 2003). In our study we found strong and positive attitudes from police and PWID to works SCS. These preliminary results point out the possibility to implement SCS in Tijuana successfully. Likewise, these results could explained because the actors directly involved into the drug we on street, open the opportunity of new ways to prevent harm and improve community health. Interestingly, police officers indicated that their peers would be around 23% less supportive of a SCS, while PWID believed that peers would show the same level of support.

Besides positivelying modifying the urban environment, SCS could potentiate a positive effect on community health (Salmon et al., 2009). In the safe environment provided by a SCS, PWID would have access to clean injection materials and disposal resources, reducing syringe litter in their neighborhood. Moreover, police officers stated they would refer PWID to these sites, minimizing their own risk of accidental needle-stick injuries. Improving community health must inform the narrative surrounding SCS to gather broad community support.

A SCS without support from police officers could be detrimental as officers play a role in referring clients to the site or could discourage attendance through active policing and harassment. Although most officers indicate that they would refer people to the SCS, however, approximately half of PLE report they would use the SCS. These differences between groups might reflect the lack of trust in government institutions and actors. Thus, it would be necessary to generate a targeted information campaign directed towards PWID of the benefits of SCS in the city.

The report is subject to some limitations: first, since the selection of the participants was not random, it’s difficult to generalize the findings from both police officers and PLE into other places in the country. Additionally, more detailed statistical analysis is required to understand specific associations between exposure to harm reduction training and changes in attitudes among police officers (Arredondo et al., 2019). Lastly, it was impossible to know if officers and PLE had previous knowledge of SCS and their benefits, influencing their attitudes before the data collection periods.

The implementation of a SCS presents an innovative way to protect PWID from police harassment and victimization, reduce HIV and HCV risk, and connect PWID to essential health and social services. This intervention could help guide PWID into path changing decisions while ending the cycle of substance use, imprisonment and homelessness. The current Mexican law does not prohibit or regulate the topic of SCS in the country. The positive attitudes registered among police officers and PWID in the city of Tijuana open the door for the implementation of a SCS in a middle-income setting that could become a leading example to other locations throughout Mexico and Latin America.