Risk of Violence in Drug Rehabilitation Centers: Perceptions of People Who Inject Drugs in Tijuana, Mexico

BACKGROUND:

In 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at "Peer Support" (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico.

METHODS:

Secondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement "going to rehabilitation puts me at risk of violence". Logistic regression was used to examine factors associated with perceived risk of violence.

RESULTS:

Of 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level.

CONCLUSION:

The perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs' concerns about violence.

Demographic characteristics (n=733)

Variable name	Total	Feared violence	Didn't fear violence	p-valuea
	(n=733)	(n=253, 34.5%)	(n=480, 65.5%)
Ageb	37 (31, 44)	36 (30, 42)	37 (31, 45)	0.08
Female (n, %)	279 (38.1%)	102 (40.3%)	177 (36.9%)	0.38
Married (n, %)	332 (45.3%)	113 (44.7%)	219 (45.6%)	0.82
Education
Years of education completedb	8 (6,10)	8 (6,11)	8 (6,10)	0.15
Main source of income
No income (n, %)	25 (3.4%)	8 (3.2%)	17 (3.5%)	0.82
Formal source of income (n, %)	502 (68.5%)	177 (70.0%)	325 (67.7%)
Informal source of income (n, %)	203 (27.7%)	67 (26.5%)	136 (28.3%)
Homeless (where slept most often last 6 mos)
Homeless (n, %)	146 (19.9%)	60 (23.7%)	86 (17.9%)	0.06
Mobility
Lived in Tijuana whole life (n, %)	278 (37.9%)	107 (42.3%)	171 (35.6%)	0.08
Years lived in Tijuana (n= 454) b	21 (10, 34)	20 (10, 34)	21 (10, 33)	0.54
Drug Use History
Age of first time use of illegal drugb	14 (12,16)	14 (12,16)	14 (12,16)	0.30
Age of first injected drugsb	19 (17,24)	20 (17,25)	19 (17,24)	0.58
Ever used heroin	730 (99.6%)	252 (99.6%)	478 (99.6%)	0.99
Ever used cocaine	559 (76.3%)	171 (67.6%)	388 (80.8%)	<0.01
Ever used crystal/methamphetamine	647 (88.3%)	206 (81.4%)	441 (91.9%)	<0.01
Interactions with Law Enforcement
Ever stopped by law enforcement	661 (90.2%)	220 (87.0%)	441 (91.9%)	0.04
Ever been told by law enforcement that you would be required to go to drug treatment	17 (2.3%)	10 (4.0%)	7 (1.5%)	0.04
Drug Rehabilitation History
Great or urgent need to get help for drug use (n, %)	375 (51.2%)	144 (56.9%)	231 (48.1%)	0.02
Ever received professional help for drug usec	417 (56.9%)	124 (49.0%)	293 (61.0%)	0.01
Lifetime # of times received professional help for drug use (n=417) b	1 (0, 3)	0 (0, 3)	1 (0, 4)	0.01
Ever enrolled in drug rehabilitation center (n, %)	375 (51.2%)	109 (43.1%)	266 (55.4%)	0.37
# of times enrolled in drug rehabilitation center(n=375) b	1 (0, 3)	0 (0, 2)	1 (0, 3)	0.01

acomparisons of means made using Student t-test, comparisons of proportions made using chi-squared test, all p-values are two-sided

bMedian, interquartile range

cEver received professional help refers to outpatient counseling services and might include drug rehabilitation services

Full article at:  http://goo.gl/vLPhjh

By:  Harvey-Vera AY1,2, González-Zúñiga P3, Vargas-Ojeda AC4, Medina-Mora ME5, Magis-Rodríguez CL6, Wagner K7, Strathdee SA8, Werb D9.

• 1Division of Global Public Health, University of California, San Diego, School of Medicine, San Diego, California, USA. alvera@ucsd.edu.
• 2Universidad Autónoma de Baja California, Facultad de Medicina y Psicología, Tijuana, Baja California, Mexico. alvera@ucsd.edu.
• 3Division of Global Public Health, University of California, San Diego, School of Medicine, San Diego, California, USA. pgonzalez@ucsd.edu.
• 4Universidad Autónoma de Baja California, Facultad de Medicina y Psicología, Tijuana, Baja California, Mexico. caro_vargas@uabc.edu.mx.
• 5Instituto Nacional de Psiquiatría de México, Ciudad de Mexico, Distrito Federal, Mexico. mmedina@hsph.harvard.edu.
• 6Centro Nacional para la Prevención y Control del VIH/SIDA, Ciudad de Mexico, Distrito Federal, Mexico. carlos.magis@gmail.com.
• 7Division of Global Public Health, University of California, San Diego, School of Medicine, San Diego, California, USA. kdwagner@ucsd.edu.
• 8Division of Global Public Health, University of California, San Diego, School of Medicine, San Diego, California, USA. sstrathdee@ucsd.edu.
• 9Division of Global Public Health, University of California, San Diego, School of Medicine, San Diego, California, USA. dwerb@ucsd.edu. 

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