Drug and Alcohol Dependence 79 (2005) 281–293
Historical trends in the production and consumption of illicit drugs in
Mexico: Implications for the prevention of blood borne infections
Jesus Bucardoa, Kimberly C. Brouwerb,∗, Carlos Magis-Rodr´ ıguezc, Rebeca Ramosd,e,
Miguel Fragaf, Saida G. Perezb, Thomas L. Pattersona, Steffanie A. Strathdeeb
aDepartment of Psychiatry, School of Medicine, University of California, San Diego, CA 92093, USA
bDepartment of Family and Preventive Medicine, School of Medicine, University of California, San Diego, 9500 Gilman Drive,
MC 0622, La Jolla, CA 92093-0622, USA
cNational Center for the Prevention and Control of HIV/AIDS (CENSIDA), M´ exico City, CP 11590, M´ exico
dUnited States M´ exico Border Health Association El Paso, TX 79912, USA
ePrograma Compa˜ neros: Compa˜ neros Internacional, Ciudad Ju´ arez, Chihuahua, CP 32330, M´ exico
fUniversidad Aut´ onoma de Baja California, Tijuana School of Medicine, Tijuana 22390, M´ exico
Received 26 March 2004; received in revised form 4 February 2005; accepted 4 February 2005
However, only recently has drug use, particularly injection drug use, been documented as an important problem. Heroin is the most common
drug used by Mexican injection drug users (IDUs). Increased cultivation of opium poppy in some Mexican states, lower prices for black
tar heroin and increased security at U.S.-Mexican border crossings may be contributing factors to heroin use, especially in border cities.
Risky practices among IDUs, including needle sharing and shooting gallery attendance are common, whereas perceived risk for acquiring
blood borne infections is low. Although reported AIDS cases attributed to IDU in Mexico have been low, data from sentinel populations,
such as pregnant women in the Mexican-U.S. border city of Tijuana, suggest an increase in HIV prevalence associated with drug use. Given
widespread risk behaviors and rising numbers of blood borne infections among IDUs in Mexican-U.S. border cities, there is an urgent need
for increased disease surveillance and culturally appropriate interventions to prevent potential epidemics of blood borne infections. We review
available literature on the history of opium production in Mexico, recent trends in drug use and its implications, and the Mexican response,
with special emphasis on the border cities of Ciudad Juarez and Tijuana.
© 2005 Published by Elsevier Ireland Ltd.
Keywords: Injection drug use; Opium; Heroin; Drug treatment; Needle exchange programs; Harm reduction; Interdiction; Mexico
∗Corresponding author. Tel.: +1 858 8226467; fax: +1 858 5344642.
E-mail address: firstname.lastname@example.org (K.C. Brouwer).
Historical context of opium cultivation and drug trafficking in Mexico .....................................................
Recent trends in opium cultivation, heroin production and trafficking ......................................................
Drug use trends in Mexico ............................................................................................
4.1. Drug use in Ciudad Juarez ......................................................................................
4.2.Drug use in Tijuana ............................................................................................
4.3. Impact of changes in border security since September 11, 2001 .....................................................
HIV/AIDS risks associated with injection drug use in Mexico.............................................................
0376-8716/$ – see front matter © 2005 Published by Elsevier Ireland Ltd.
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
6. Response to the drug problem.............................................................................
6.1. Drug laws and enforcement .........................................................................
6.2. Legality of purchasing drugs and syringes ............................................................
6.3. Needle exchange programs..........................................................................
6.4. Drug abuse treatment...............................................................................
With over 100 million people, Mexico is the third most
populous country in the Americas, and one third of its
population is under 15 years of age. Mexico has made
impressive economic gains in the past decade; however,
rapid industrialization and in-migration have led to poor
sanitation and living conditions, especially in the 2000mile
long border region with the United States. A melding of
political, cultural, and identity factors have made this area
particularly vulnerable to substance abuse.
Illicit drug use appears to have increased in Mexico over
the past 10 years. Although the northern border was once
considered primarily a passage way, drugs are increasingly
being distributed and used in the northern region of Mex-
ico (Cravioto et al., 2003; Magis-Rodriguez et al., 2002a;
Medina-Mora et al., 2003). Parameters monitored by the Na-
tional Council on Drug Addiction (Consejo Nacional de las
age at first use, prevalence of current use, injection drug use,
treatment admissions and drug-related deaths have shown a
has been most dramatic in the northwestern region, this phe-
nomenon is also seen in Northeastern Mexico, as has been
documented in the 1988, 1993 and 1998 National Drug Use
Surveys, particularly in large urban centers such as Nuevo
Laredo and Monterrey (CONADIC, 1999).
Of significance is the increase in injection drug use. In-
jection drug use is becoming a major public health problem,
California (Magis-Rodriguez et al., 2002a; SSA, 1998). As
described below, trends in opium cultivation and heroin pro-
duction in some Mexican states may in part explain these
observations; however, other factors such as recent increased
enforcement along the U.S.-Mexico border, low street prices
of black tar heroin, and the poor economy may be contribut-
Although there is some evidence to suggest that health
risks related to injection drug use in Mexico, such as HIV,
have increased over the last decade, a sizeable body of em-
pirical studies is lacking to describe the scope of the problem
and inform the development of culturally appropriate inter-
ventions. Public health authorities have instituted a national
addiction surveillance system [SISVEA, Sistema de Vigi-
lancia de las Adicciones] (SSA, 1990) and have pilot-tested
and methadone clinics, once considered unacceptable in this
The purpose of this paper is to describe the historical con-
text of opium cultivation and heroin production in Mexico
and to document the Mexican response to growing problems
associated with addiction, injection drug use and its associ-
ated harms. This paper focuses primarily on describing the
response of the national government as opposed to that of
local and regional governments and non-governmental agen-
cies (NGOs); thus we do not provide a complete view of the
Mexican situation. Our report also includes special emphasis
on the northern border cities of Tijuana (adjacent to the U.S.
use in Mexico (DEA, 2003a). We initially performed a broad
search of standard medical and social science databases (i.e.,
PubMed) using keywords such as injection drug use, heroin,
drug abuse treatment, narcotics trafficking, needle exchange,
HIV, Tijuana, Juarez, and Mexico. We then expanded our
and policy related websites maintained by the governments
of Mexico and the United States, and abstract books of con-
ferences (i.e., International Conference on AIDS). Officials
from the Mexican Register of AIDS Investigations and In-
terventions were also consulted (CONASIDA). Finally, data
was obtained from personal contacts with members of non-
governmental organizations, treatment centers, and pharma-
cies. Although we attempted a comprehensive review of the
evolution of the current drug epidemic in Mexico by consult-
ing multiple sources, we did not have access to the complete
historical and bibliographic record. Many government and
non-governmental agencies and organizations do not make
their reports public or concentrate them in personal and pri-
vate libraries. Despite these limitations, we attempt to lay the
ground-work for describing the growing problem of opiate
to developing an appropriate response.
2. Historical context of opium cultivation and drug
trafficking in Mexico
Mexico has long been recognized as a major source of
marijuana (Toro, 1995), but its role in poppy cultivation
is less widely known. Poppy cultivation has existed in the
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
northwestern Mexican state of Sinaloa since before the
1900’s. However, it was perceived that opium smoking was
not commonly used among Mexican nationals and was
instead used by “Chinese immigrants, artists and bourgeois
degenerates” (Astorga, 1996).
Historically, the drug situation in Mexico has been
strongly influenced by external pressure and events, espe-
cially from the United States. For example, when the U.S.
Congress passed the Harrison Narcotics Act in 1914, which
tightly monitored and regulated the distribution and sale of
narcotic drugs (Musto, 1998), the Mexican Civil Revolution-
government was preoccupied with maintaining control over
the country and thus curtailing opium trafficking was not a
priority (Astorga, 1999). Prohibition policies drove up drug
prices in the U.S., making opium production and trafficking
more lucrative in Mexico. Entrepreneurial individuals
became involved in small-scale trafficking. With time,
intensive drug enforcement practices drove many of these
entrepreneurial traffickers out of business, benefiting larger,
more organized gangs and cartels that continue to control the
majority of narcotics trafficking in Mexico (Bellis, 2003).
From 1916–1920, most drug trafficking in Mexico was
taking place through the northwest border cities of Mexi-
cali and Tijuana. Cultivation and commerce associated with
poppy was legal in Mexico until 1926. In the 1930’s, opium
smugglers expanded their routes to pass through the more
central border cities of Nogales and Ciudad Juarez, making
use of routes used to transport agricultural products exported
via the U.S. southern Pacific railroad (Astorga, 1999). Drug
policy and prosecution was transferred to the Procuradoria
General de la Rep´ ublica, P.G.R. [Attorney General’s Office]
during the Lazaro Cardenas Administration from 1934 to
1940 (PGR, 2003). The drug trade boomed during the years
post-World War II, during which time the Mexican state of
Sinaloa was reportedly the only opium producing region in
Latin America (Astorga, 1999). Since opium production was
marketed for export (i.e., the United States), and there still
trade appeared to be tolerated.
During World War II, the mobilization of men by the
United States to army bases on the border coincided with the
(Cd.) Juarez, a well-known distribution network that lasted
several generations began in the 1940’s. This network con-
consumers in the Cd. Juarez/El Paso area until the rise of
“regional or national cartels” (Ramos, 1990).
In the 1960’s, Mexico became a major supplier of drugs
extent barbiturates and amphetamines. With the dismantling
early 1970’s, for a time Mexico was the leading supplier of
In 1969, the U.S. government administration under Pres-
ident Nixon had officially singled out Mexico as the primary
supplier of dangerous drugs to the U.S., including heroin,
and implemented “Operation Intercept.” This consisted of
meticulous car inspections for drugs at U.S.-Mexico border
crossings, which caused a major disruption of transit across
border crossings and signaled the beginning of a new era
in U.S.-Mexico drug politics (Doyle, 2003). This intense
interdiction had a significant local impact on the economy
and drug scene in Tijuana and Ciudad Juarez. Historical
reports suggest that the Juarez local consumption market
continued to prosper during this period (Dr. M.E. Ramos,
personal communication). Anecdotal reports suggested
that heroin destined for the U.S. was also diverted to
Tijuana, where a local consumption market was created in
In 1989, a study by the Centros de Integracion Juvenil (a
federally-funded adolescent and young adult drug treatment
of inmates having used the drug (Su´ arez, 1989). This situa-
tion bears some similarities to a report from South East Asia,
where intense interdiction against opium trafficking and use,
during the 1950’s and 1960’s. While opium production con-
tinued in rural mountainous areas, increased price of opium
and prosecution of users in urban areas was associated with
Kong and Thailand (Westermeyer, 1976).
ered in southeastern Mexico in 1972. The Mexican govern-
ment began a military operation against illicit crop produc-
tion and trafficking of opium and marijuana with full co-
operation of the U.S. government. This operation included
the spraying of poppy and marijuana fields with paraquat,
a defoliant herbicide that destroyed the plants (Anderson,
1981). Officials involved in this campaign noticed that fields
would be harvested as soon as they were sprayed. This
complicated matters, as the herbicide-drenched plants and
drugs made their way to the U.S. drug market (Landrigan
et al., 1983). Despite the massive scope of this campaign, it
had limited success. Public and political pressure in the U.S.
arising from reports of the contaminated drugs forced the in-
terruption of this campaign and influenced the resignation
of the top drug advisor to the U.S. government administra-
response to this campaign was that Mexican opium poppy
farmers moved their operations to tropical regions within the
country and changed crop planting strategies, planting on
steep mountainsides and narrow gorges and using the jun-
gle canopy to hide crops (Stevenson, 2003). Opium poppy
flourishes at elevations above 1000m, making fields more
ficials also report that farmers over-plant by as much as 50%
in order to compensate for eradication losses (DEA, 2000).
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
In the 1980’s, the torture and murder of Enrique Ca-
marena, a U.S. DEA agent stationed in Guadalajara, Mexico,
signaled the start of the current chapter in the story of the
drug trade in northern Mexico. This event underscored
the fact that the political and social elite was no longer
“untouchables” in Mexico (Astorga, 1999). Drug traffickers
became richer, more powerful, and bolder. Their application
of technological advances, finance, communications, and
transportation in the pursuit of their illegal trade created
an entrepreneurial style of drug trade intermingled with
extreme levels of violence (DEA, 2002).
In recent years, Mexico has had an important role in
(DEA, 2003a). Additionally, Mexico is the largest sup-
plier of marijuana to the U.S. and an estimated 70% of all
South American derived cocaine passes through the Cen-
tral America-Mexico corridor (DEA, 2003a). Furthermore,
as described in more detail below, Mexico remains a major
producer of opium and a major supplier of heroin to the U.S
and its own consumer markets.
3. Recent trends in opium cultivation, heroin
production and trafficking
With the fall of coffee and corn prices and limited govern-
ment assistance to farmers, poppy farming has surged in the
southwestern Mexican state of Guerrero in the past decade.
Opium gum sells for $700 to $1200 U.S. dollars per pound
in contrast to coffee, which yields 15 cents a pound (Lloyd,
government estimates that Guerrero state accounts for 51%
of opium poppy grown in Mexico (Lloyd, 2003). Addition-
of Durango and Sinaloa can be over 5feet tall with large
bulbs that measure up to 2inches in diameter (DEA, 2000).
Mexico has an annual net cultivation of opium poppy aver-
aging between 3600 and 5000 hectares (DEA, 2003a). The
growing association between Mexico’s economy and opium
cultivation now overshadows revenues from the oil business
Since opium is bulky and more inconvenient to conceal, it
last year for which national estimates are available, Mexico
down from its average yearly output of 7.2 metric tons over
the preceding 5 years (DEA, 2003a). According to the DEA,
Mexican heroin accounted for 30% of the heroin sold in the
U.S. in 2001 and approximately 98% of the heroin avail-
able west of the approximately midcontinental Mississippi
River (DEA, 2003a), which is striking considering that the
world leaders in heroin production are Burma, Afghanistan
and Laos (UNODC, 2003). Most recently, there was a 78%
increase in opium poppy cultivation, from 2700 hectares in
2002 to 4800 in 2003 (Green, 2004).
ally produce is “black tar”, which is a poorly refined product
that is typically injected. However, when Mexico became a
transit point for purer white-powder Colombian heroin in the
1990s—a product that is more potent and can be snorted,
some Mexican gangs began to apply similar techniques to
refine the drug (DEA, 2003b). Since 1998, the price of Mex-
ican black tar heroin in U.S. markets has almost halved, and
there are reports that the powder form of Mexican heroin is
on the rise (DEA, 2003b).
potentially affect drug users’ behaviors and the subsequent
risks of blood borne infection and overdose in Mexico and
the United States. Black tar heroin has typically been the
most common form of the drug in Mexico and in the western
United States, whereas heroin powder has accounted for the
vast majority of heroin used East of the Mississippi River
in the U.S. (DEA, 2003a; Stevenson, 2003). Since black tar
drug in a cooker, which depending on temperature achieved,
can inactivate HIV and other blood borne viruses (Ciccarone
heroin powder for injection does not require a heating step,
transmit blood borne viruses more readily.
Differences in the preparation of heroin have been pro-
posed as a possible explanation for the observed higher HIV
ern versus Western United States (Ciccarone and Bourgois,
2003). Although speculative, an increasing trend towards the
could be accompanied by increases in the number of heroin-
dependent persons, higher overdose morbidity and mortality,
and potentially increased incidence of HIV and other blood
borne infections in both Mexico and the U.S. These trends
should be monitored closely so that timely interventions can
be implemented in both countries.
4. Drug use trends in Mexico
ican government implemented a national drug addiction epi-
demiologic surveillance system called Sistema de Vigilancia
in 1991 with only eight sites in six states primarily located
on the U.S./Mexican border, it now covers 53 cities in all
31 Mexican states and the Federal District, which consti-
tutes Mexico City, the capital of Mexico (SSA, 2002). By
compiling data from drug treatment centers, medical foren-
provides wide-ranging, periodic information on the problem
of drug use in Mexico. It attempts to identify changes in pat-
terns of consumption, risk groups, new drugs, and factors
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
associated with the use and abuse of tobacco, alcohol, and
illegal and prescription drugs. In addition, since 1988 the
riodic National Survey on Addictions [Encuesta Nacional de
the growing drug use problem in Mexico (SSA, 1998).
In the 10-year period between the first National Survey of
Addictions in 1988 and the most recently published in 1998,
the percentage of Mexicans reporting ever using an illegal
drug in their lifetime increased from 3.3 to 5.3% among the
Nationwide, the most popular drugs used were marijuana,
which had been used by 4.7% of the population, cocaine by
1.5%, and inhalants by nearly 1% (SSA, 1998). Among the
Mexicans surveyed who reported injecting drugs, heroin was
the drug of choice for 73%, and 19% of IDUs disclosed that
they had injected with a used needle (SSA, 2001).
poppy is cultivated are lacking; however, it has generally
been assumed that there is little local consumption (Magis-
identity and more capacity for integrating change (Wagner et
al., 2002). However, distribution of heroin within Mexico
predominantly occurs through overland routes, in contrast
to Colombia where illicit drugs tend to be trafficked via air
(DEA, 2003a). Since the process of refining heroin is time
consuming, “spill-over” of the drug often occurs in com-
munities along heroin trafficking routes. This phenomenon
has been documented in Brazil along major highways used
for drug trafficking (Bastos et al., 1999), in overland heroin
routes in Southeast (Beyrer et al., 2000) and Central Asia
(Parfitt, 2003), and in parts of Nigeria which have become
transit points for heroin trafficked by air (Adelekan and
of drug use trends is therefore recommended in such regions
4.1. Drug use in Ciudad Juarez
is at the approximate mid-point of the 2000mile long border
between Mexico and the United States. The Metroplex has
a combined population of over 2 million people, with Ciu-
Juarez had the second highest drug use rate in the country at
9.2%, second only to Tijuana (SSA, 1998). Among adoles-
cent drug users enrolled in drug treatment in Cd. Juarez, one
years (Dr. J. Ferreira-Pinto, personal communication, 1998).
In a community-based survey in 2001, it was estimated
that there were approximately 6000 IDUs in Cd. Juarez
(Dr. C. Magis-Rodr´ ıguez, personal communication). A
capture-recapture study by Cravioto in 2002 (Cravioto,
2003) estimated that there were 3000–3500 “heavy” heroin
users (defined as having used heroin 2–3 times a day in the
previous 6 months) and as many as 186 shooting galleries
[picaderos] in Cd. Juarez.
Since 1989, with the support of the United States Mexico
Border Health Association, studies began to systematically
document injection drug use and associated sexual risks in
Cd. Juarez. In a formative research study conducted from
1989 to 1991 among 312 female sex workers and 435 female
sex partners of male IDUs, the prevalence of injection drug
use was 3 and 2%, respectively. Nevertheless, both groups of
women were at very high risk for HIV and STDs based on a
of male IDUs in Cd. Juarez, the prevalence of unprotected
sex decreased from 92 to 78%, although this change was
not statistically significant (Women Helping Empower and
method from the 1992 Hammet study, found the percentage
of sex workers having injected drugs to be over 10% (Valdez
et al., 2002). More recently, a large, ongoing study of female
communication, January 2005).
4.2. Drug use in Tijuana
Tijuana is the northwestern-most city in Mexico and
has over 1.2 million inhabitants. Tijuana and San Diego
together form the world’s largest binational metropolis,
and the San Ysidro border station between these cities is
the busiest point of entry along the U.S.-Mexico border
(INEGI, 2000; U.S. Customs Service, 2004). In a survey
of homosexuals/bisexuals, prostitutes, and prisoners in
Tijuana, only 22, 5, and 21%, respectively, originated in
the Baja California region (G¨ uere˜ na-Burgue˜ no et al., 1992).
Yet migration operates in both directions. Of IDUs in the
Tijuana prison, 14% reported having injected drugs in
the U.S. at some point (Magis-Rodriguez et al., 2000b).
These north–south interaction reflect a drug scene that
is particularly unique (U.S. Customs Service, 2004), and
provides a kaleidoscope view of Mexico’s drug problem and
Whereas Tijuana has been a point of transit in the smug-
gling of cocaine and heroin from South America towards the
drug market (Medina-Mora et al., 2003; SSA, 1998) and is
thought to have one of the fastest growing IDU populations
in Mexico (Magis-Rodriguez et al., 2002a; SSA, 1998). The
1998 National Survey of Addictions data for Tijuana showed
that the percentage of the general population 12–65 years of
age reporting having ever used an illegal drug was almost
three times (14.7%) that of the national average (5.3%); in
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
drugs in the country, with the next highest being Cd. Juarez
at 9.2% (SSA, 1998).
to use an illicit drug in their lifetime than women, in Tijuana
this ratio was lower at 6:1, suggesting that women are over-
represented among the general population of drug users in
Tijuana compared to other Mexican cities (SSA, 1998). In
the late 1990’s, heroin had been used by approximately 0.5%
of the Tijuana population in the past 12 months (SSA, 1998).
Five percent of new drug users reported injecting heroin as
their first illicit drug.
According to the 2002 addiction surveillance system re-
port for Tijuana, drug users are initiating at a young age.
Over 45% of drug users reported that their onset of illicit
drug use was between the ages of 10 and 14 years, whereas
reported initiating drug use between the ages of 15 and 19
years (SSA, 2002).
By 2002, heroin was the primary reason for seeking treat-
ment for almost a third of drug users at treatment facilities in
Tijuana (ISESALUD, 2002; SSA, 2002). The regional drug
treatment network RUTA [Red de Unidad de Tratamiento de
Adicciones] reported that there were at least 21,000 active
drug users in Tijuana, although the mode of administration
and type of drugs used were not specified (Trillo, 2002). A
CENSIDA survey in December of 2003 conducted among
juana estimated that there were more than 6000 active IDUs
attending such establishments (Morales et al., 2004), but the
total number of IDUs in the city is likely to be much larger.
Of concern are reports that risky behaviors such as shoot-
ing gallery attendance are common in Tijuana. The number
of picaderos is unknown, but in a recent address by Mexican
1400 picaderos in Tijuana in the first half of 2002 (Oficina de
la presidencia de la republica, 2002). A cross-sectional study
of 402 IDUs in Tijuana conducted in 2003 found that 53%
had ever used a shooting gallery (Dr. C. Magis-Rodr´ ıguez,
Anecdotal reports also suggest that heroin use is on the
rise in Tijuana and other Mexican communities bordering
the United States, where a heroin fix can cost as low as $2
U.S. (DEA, 2000). In the past, increases in the consumption
of cocaine and marijuana in the U.S. have been followed by
parallel increases in such consumption in Mexico, generally
with a 5- to 7-year lag. Given the current heroin epidemic in
the U.S., low prices, ready availability, and increasing purity
in Mexico, Mexican officials project that local consumption
of heroin will continue to increase, especially in border re-
gions (DEA, 2000).
4.3. Impact of changes in border security since
September 11, 2001
Efforts to crack down on drug trafficking across the
on September 11, 2001 led to reported increases in heroin
availability in Mexican border towns (Medina-Mora and
Rojas Guiot, 2003). Border crossings between Mexico and
the U.S. were interrupted for approximately 3 weeks after
the terrorist attacks. As a consequence, the price of heroin
dropped to around $25 U.S. a gram in Ciudad Juarez and $40
in Tijuana, but remained as high as $60–$80 a gram in San
Fluctuations in drug prices on the street in these settings
may be temporary in nature, but should not be dismissed in
terms of their potential importance. Changes in drug traffick-
ing routes, in this case arising from more stringent border
market for heroin and cocaine in new locations in Mexico,
as has been documented elsewhere in Latin America and
Asia (Bastos et al., 1999; Beyrer et al., 2000; Parfitt, 2003;
Strathdee et al., 2003). The challenge is to identify these
new drug trafficking patterns and the conditions that create
them in an effort to predict potential drug use trends and to
In a historical context, these recent conditions resemble
der region experienced an increase in drug use in a previous
era of intensified enforcement during “Operation Intercept”
(Doyle, 2003; Cravioto et al., 2003). Current security condi-
tions and an increase in the number and percentage of people
treatment suggests that vigilance is needed to avoid a repeat
of this experience (SSA, 2002).
5. HIV/AIDS risks associated with injection drug use
almost doubled between 1995 and 2001, from 25,746 to
51,914 (CONASIDA, 2002). Currently, Mexico places fifth
in the number of reported AIDS cases in the Americas, after
the U.S., Brazil, Haiti, and Colombia (UNAIDS, 2004).
However, Mexico is near the bottom of the list in regards
to the rate of HIV prevalence in persons 15 to 49-year-old,
with only Nicaragua, Bolivia, and Cuba having lower rates
in the Americas (UNAIDS, 2004). The vast majority of new
AIDS cases reported to the national AIDS registry in 2002
were attributed to heterosexual or homosexual activity (57.5
and 42.4%, respectively) (CONASIDA, 2002), with only 1%
efforts to safeguard the blood supply through mandatory
HIV antibody screening are thought to have curtailed a more
widespread epidemic (del Rio and Sepulveda, 2002).
HIV prevalence among IDUs and other high-risk groups
in Mexico has thus far remained low (Bastos et al., 1999;
G¨ uere˜ na-Burgue˜ no et al., 1991; Magis-Rodriguez et al.,
et al., 2002b; Noriega-Minichiello et al., 2002; UNAIDS,
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
2004). In comparison, injection drug use accounts for 39%
of reported AIDS cases in Argentina and 25% of reported
AIDS cases in Brazil but accounts for very low proportions
of AIDS cases in other Latin American countries such as Bo-
5%, but is much higher in North Eastern U.S. states (e.g.,
20–30%) (Garfein et al., 2004). These observations suggest
that factors such as IDUs’ social networks or environments
may be influential in determining the risk of HIV infection
in Mexico and elsewhere. Stigma surrounding injection drug
use may have led to some degree of under-reporting injec-
tion drug use as a risk factor for HIV/AIDS in Mexico but
the extent to which this has occurred is unknown.
There is growing concern that there are “pockets” of HIV
statistics may not account for heterogeneity in dynamic HIV
sub-epidemics. Injection drug use, particularly along the
U.S.-Mexico border, is thought to contribute directly or indi-
transmission with non-IDU partners (Ort´ ız-Mondrag´ on et
al., 1998). For example, in 2003 a rapid HIV testing program
among 947 pregnant women attending the Tijuana General
Hospital showed HIV prevalence to be 1.26% at delivery,
a disturbingly high prevalence for this population (Viani et
al., 2004). Earlier reports found HIV prevalence in pregnant
women to be 0.09% (Magis-Rodriguez et al., 2000a) and
0.3% in the general adult population (Magis-Rodriguez et
al., 2000a; UNAIDS, 2004). It is noteworthy that all of these
HIV cases were directly or indirectly linked to drug use
among these women or their sexual partners (Viani et al.,
2004). While caution should be exercised in generalizing
these recent findings to all women of child-bearing age in
Tijuana, these results may serve as a warning sign of a larger
HIV epidemic among drug users in the city.
There is a dearth of reliable, published estimates of HIV
prevalence among IDUs in Tijuana, Cd. Juarez or other
Mexican border cities, where injection drug use and asso-
ciated risk behaviors are increasingly reported. In a recent
HIV prevalence was 5% (Dr. C. Magis-Rodr´ ıguez, personal
communication); similar data are lacking for Cd. Juarez
and elsewhere. Qualitative data from in-depth interviews
among IDUs in Tijuana and Cd. Juarez recently conducted
by our group suggest that IDUs in Tijuana are less aware of
HIV risks and are less likely to report syringe disinfection
practices compared to IDUs in Cd. Juarez (Strathdee et
al., submitted). However, sharing of contaminated injection
paraphernalia remains an ongoing problem in both cities
(Strathdee et al., submitted; Valdez et al., 2002).
conceptions about the viability of the virus (e.g., belief that
HIV is killed by air) (Strathdee et al., submitted), which is
likely to exacerbate the risk of acquiring blood borne infec-
IDUs in Puerto Rico (Dr. H. Colon, Center for Addiction
Studies, Universidad Central del Caribe, Bayamon, Puerto
Rico, personal communication).
blood borne infections in association with needle sharing. A
2000 survey found that the prevalence of injection drug use
was 37 and 24% among prisoners in Tijuana and Cd. Juarez,
respectively; with 92% injecting heroin and 46% injecting
cocaine simultaneously with heroin in the form of speedball
(Magis-Rodriguez et al., 2000b). In this same study, in Ti-
HIV-infected; while in Cd. Juarez 40% of the heroin injec-
tors shared syringes and 1.3% were HIV infected (Magis-
Rodriguez et al., 2000b). Recent surveys of these same two
prison populations in Tijuana and Cd. Juarez found 100%
hepatitis C prevalence among IDUs (Magis-Rodriguez et al.,
The extent of drug use among sex workers in Mexico is
also understudied. In Mexican border cities, prostitution is
common and is legally tolerated. Cities such as Tijuana and
a 1992 study, 9% of female sex workers had a history of hav-
ing a sexual partner who injected drugs (G¨ uere˜ na-Burgue˜ no
et al., 1992). In 1997, a small ethnographic study of Mexican
female prostitutes in El Paso, Texas, reported that one third
had injected heroin or cocaine (Deren et al., 1997). A later
study conducted in Ciudad Juarez in 2002 with 75 female
sex workers found that 59% currently used drugs and 36% of
these had initiated illicit drug use prior to entry into sex work
(Valdez et al., 2002). The most common drugs injected were
cocaine (31%), heroin (31%) and speedball (38%) (Valdez et
6. Response to the drug problem
6.1. Drug laws and enforcement
Like other countries in Latin America, there is low
tolerance for illicit drug use in Mexico, and the response to
the drug problem has emphasized legal sanctions (Magis-
Rodriguez et al., 2002a). Since Mexican President Vicente
Fox was elected in 2000, a national crusade against narcotics
trafficking has been launched whereby police have stepped
up drug enforcement (Oficina de la presidencia de la repub-
lica, 2002). Yet Mexican anti-drug trafficking policies could
inadvertently lead to an increased risk of acquiring HIV and
other blood borne infections among IDUs. For instance, a
recent law-enforcement campaign taking place in Tijuana
called “Ponle Dedo al Picadero” [“Target the Shooting
Galleries”] has led to closure of 1400 “picaderos” (Fudacion
Azteca, 2002). In various contexts, fear of police detainment
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
needles in shooting galleries (Harvey et al., 1998; Koester,
1994; Rhodes et al., 2003; Strathdee et al., 2003). This
increase the risk of blood borne infections. A series of 20 in-
depth interviews from a qualitative study conducted recently
among IDUs in Tijuana indicated almost all participants reg-
syringes and police oppression (Strathdee et al., submitted).
On the other hand, in Cd. Juarez there is a long history
of collaboration between non-governmental organizations
(primarily Programa Compa˜ neros) and the criminal justice
system. One key long-term collaboration has been the
continued presence of Programa Compa˜ neros in delivering
education and harm reduction services within the prisons.
Their experience has been that prison guards for the most
part have a “laissez faire” attitude to the discreet distribution
of prevention supplies.
Similar cooperation had prevailed with the police, with
Compa˜ neros offering HIV prevention education within the
Police Academy. However, during the past administration
(2002–2004) the relationship with police became tense,
with some outreach workers being harassed. In the past the
identification cards; when a policeman encountered a well-
identified outreach worker in possession of bleach, condoms
and other prevention supplies, they did nothing to hinder the
tinued efforts to educate police at every level to ensure that
detailed studies are needed to determine the extent of the di-
rect and indirect effects of police pressure and other social
and environmental influences on needle sharing behaviors.
6.2. Legality of purchasing drugs and syringes
Possession of narcotics is illegal in Mexico and enforced
actively by the police. In limited circumstances (e.g., the late
stages of certain terminal diseases), the use of heroin, mor-
phine, or marijuana is permitted by order of a judge under
skillful interpretation of public health law and the federal pe-
nal code (Carlos Reyna, Lawyer, Universidad Aut´ onoma de
Baja California (UABC), personal communication).
Sale of needles and syringes is legal in Mexico and
does not require a prescription (C. Reyna, Lawyer, UABC,
personal communication). In fact, injection of antibiotics,
pain killers, and vitamins is a relatively common occur-
rence in Mexican culture (Deren et al., 1997; McVea, 1997;
Simonsen et al., 1999). Medicines are rarely self-injected but
rather are administered by nurses aides, medical paraprofes-
sionals, or non-professionals such as pharmacy attendants,
neighborhood women who have taken first aid courses, and
family members (McVea, 1997).
However, in areas of high drug activity some pharmacists
limit sales of needles and syringes to those who appear to
be drug users, by either saying that they have “run out” of
the type of needles popular with drug users or by artificially
raising prices. In Ciudad Juarez, two attempts have been
made to set up a training program for pharmacists, one in
the early 1990’s and one within the past 2 years. In the
first instance pharmacist assistants who actually operate the
pharmacies in Juarez were trained on HIV, risk factors of
HIV associated with drug use, and the importance of access
to clean syringes and works in HIV prevention. Similar
training was provided to prison guards to permit access to
clean syringes within the jail. After 12 months, follow-up
showed that few pharmacies were being manned by the staff
that had received prior training.
To combat the trend among pharmacists to impede access
to sterile syringes, Tijuana officials held a meeting in 2003 to
needle sharing and increased transmission of HIV (Ignacio
Romo, President Asociaci´ on de Farmacias y Boticas, per-
sonal communication). The extent to which this has changed
in-depth interviews conducted with 20IDUs in Tijuana in
2004 suggested that few pharmacies in Tijuana sold syringes
to persons they suspected to be IDUs, and those who did
so often sold them syringes at a higher price (Strathdee
et al., submitted). Clearly, long-term efforts are needed to
educate pharmacists and clerks about the need to make
sterile syringes available to IDUs as part of a comprehensive
policy to reduce the spread of blood borne pathogens.
6.3. Needle exchange programs
The concept of harm reduction is a relatively new concept
in Mexico. Like most countries in Latin America, few non-
governmental organizations in Mexico appear to be involved
et al., 2002a). Harm reduction programs; especially needle
versy within the Mexican government. Some politicians and
public servants and clinic staff look disparagingly on IDUs
and reject harm reduction practices based on moral grounds.
and Control of HIV/AIDS (CENSIDA) recently developed a
position paper to educate and sensitize policy makers and
those who work with IDUs to the benefits of harm reduction
To our knowledge, there currently is only one docu-
Compa˜ neros (Ramos, 2000). Through their community-
based approach to HIV/AIDS prevention, Compa˜ neros has
succeeded in establishing the trust of drug users, community
members and local and state politicians. Most activities are
directed towards providing IDUs with education on health
risks and the importance of adequately cleaning needles and
syringes, while NEP activities are currently on a very small-
scale due to fiscal restraints. While not officially sanctioned,
the state government in Chihuahua tolerates the NEP.
In rare situations within some Mexican prisons, inmates
have been provided with Hepatitis B Virus vaccinations,
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
access to bleach for syringe disinfection and, in a few
instances, syringe exchange, albeit on a quasi-official basis
(Magis-Rodr´ ıguez, 2000; Magis-Rodriguez et al., 2002a;
Dr. R. Ramos, personal communication, May 2004).
On the whole, harm reduction activities in Mexico ap-
America, NEP was introduced in Brazil as early as 1994, and
33 programs were operating by 2000 (Bastos and Strathdee,
2000). In Argentina, IDUs had no free access to sterile nee-
dles until the end of the 1990s, but since this time, a syringe
and other methods of expanding access to sterile syringes
among IDUs in Mexican border cities.
6.4. Drug abuse treatment
Little data exists which describes the extent of drug abuse
treatment in Mexico overall. According to the United Na-
tions Office on Drugs and Crime, 48,500 people were treated
for substance abuse in Mexico in 1999 (UNODC, 2001), but
a breakdown of the drugs of abuse was not provided. A re-
port from SISVEA indicated that among NGOs providing
substance abuse treatment, the main substances of abuse for
treatment admissions in 2002 were heroin (26.3%), alcohol
(16.3%), methamphetamine (16.1%) and cocaine (15.3%)
(SSA, 2002). In contrast, among government-operated treat-
ment programs during the same year, the main substances of
abuse were cocaine (28.5%), marijuana (18.2%) and alcohol
(14.7%). NGOs reported treating 31,819 persons throughout
the country, with the exception of no reports from the state of
in admissions are likely due in part to under-reporting, self-
and the fact that NGOs may try to cater to specific clients.
Both agencies reported that the vast majority of their clients
were male, although the age and education level of those
treated at NGOs were somewhat higher than at government-
run centers (SSA, 2002).
In Tijuana, only one drug treatment program existed in
to adequately serve the needs of the city. In support of this
found that only 13 of 371 patients with history of injection
drug use were Tijuana residents (G¨ uere˜ na-Burgue˜ no, 1990).
The remaining individuals resided in different cities in the
U.S. and had traveled to Tijuana in search of inexpensive,
anonymous drug abuse treatment.
Today in Tijuana, there are close to 20 residential drug
treatment programs that form the Unity Network for Treat-
ment of Addictions [RUTA] with a capacity to treat 3500
persons per year (Trillo, 2002). While this represents a con-
siderable increase in drug treatment services, taking into ac-
count estimates of the number of drug users in the city, the
coverage of these programs is believed to be less than 20%.
Until recently, these programs were not officially sanctioned
by the Health Ministry, which has now enacted laws to regu-
late drug treatment programs and has created the Municipal
Office for Control and Treatment of Addictions. Still, most
residential and governmental programs are abstinence-based
(Magis-Rodr´ ıguez, 2000) and few offer methadone mainte-
In fact, only two private clinics in Tijuana provide
methadone maintenance and treat up to 1800 patients in a
in existence in Baja California for over 10 years with about
400 clients receiving services per week. At about $7 U.S. per
visit, the fee for services is comparable to the price of many
(Dr. J.J. Curiel, Medical Director of Profesionales Contra la
include more comprehensive private clinics, where detoxifi-
Alba, Director, Clinica Ser, private Tijuana drug rehabilita-
tion clinic, personal communication, January 2004).
The official Mexican government’s drug addiction treat-
ment institution, Centros de Integracion Juvenil, began to pi-
lot a comprehensive intervention and rehabilitation program
for injection drug users in Ciudad Juarez in 2001. As part
of this program, the first government run clinic to provide
methadone treatment in Mexico opened in October 2001 in
Ciudad Juarez (Guisa Cruz, 2002). To our knowledge, this
is still the only government-operated clinic providing such
services. This program combines psychological and social
services with methadone treatment for those who have been
heroin dependent for more than 2 years, suffer severe with-
drawal symptoms, use heroin while pregnant, or are IDUs.
Within the first 5 months of opening the program provided
methadone to approximately 100 patients a day, yet demand
continues to outpace delivery (Guisa Cruz, 2002). Patients
have remained abstinent from drugs and returned to work in
places such as local maquiladora factories. Among govern-
ment health officials there exists the intention to open more
(Dr. C. Magis-Rodr´ ıguez, personal communication).
Also in Ciudad Juarez, since the early 1990’s Programa
Compa˜ neros piloted several interventions targeting IDUs,
such as narcotics anonymous groups, family and peer led
support groups, and a detoxification and maintenance pro-
gram provided to 75 drug users consisting of acupuncture
rations. The latter intervention showed promising reductions
Pinto, personal communication, 1998).
Interestingly, a federal program in Mexico offers drug
users small doses of heroin as a form of substitution ther-
apy. Beginning at the end of the 1970’s, this program still
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
exists and was treating approximately 20 people at the end
of 2003 (Uriarte, 1988; Dr. C. Magis-Rodr´ ıguez, personal
communication, December 2003). Since heroin maintenance
therapy is being evaluated as a form of drug treatment in sev-
eral countries with promising results (e.g., Switzerland, Ger-
option worth consideration elsewhere in Mexico.
Beyond price and availability, lack of treatment seeking
remains a problem among drug users in Mexico. In a recent
of addiction sought treatment (SSA, 2001). Several reports
suggest that drug users in Mexico often avoid seeking medi-
cal attention for addiction and chronic or infectious diseases
until health problems become severe and, consequently, less
amenable to treatment (Cravioto et al., 2003; Ortiz et al.,
1997). A study of heavy heroin users in the Ciudad Juarez
and not having experienced a chronic illness were predictors
of failing to seek treatment (Cravioto et al., 2003). Despite
venously, few had worries in regards to risks to their health
(Cravioto et al., 2003).
Faith-based residential centers, particularly in Ciudad
Juarez have offered drug treatment services to injectors since
the 1990’s. Most of the treatment had focused on faith heal-
ing. However more recently, with the onset of training from
non-governmental groups like Programa Compa˜ neros, faith-
based centers have begun to use intervention models derived
from behavioral science and have also participated as active
or the methadone-based program operated by Centros de In-
Beliefs as well as cultural factors may affect utilization
of drug abuse treatment. Significant differences in rates of
icans and Latinos compared to Whites in the United States
minorities in Los Angeles, Latino drug users were less likely
than Anglo or African Americans to have sought drug treat-
ment and were more likely than these groups to report a low
perceived need for drug abuse treatment (Longshore et al.,
1992). The extent to which cultural factors represent barriers
to drug treatment does not appear to have been systemati-
cally studied in Mexico; however, stigmatization and alien-
ation have been major barriers to seeking treatment (Ortiz et
Migration presents another challenge to drug prevention
to best target education and services to those of diverse back-
grounds. Mexican migrants who have tried unsuccessfully to
cross the border into the U.S. often feel of a lack of iden-
tity or attachment; many harbor a distrust of local officials,
thus discouraging treatment seeking (Montiel-Hernandez et
al., 1996). Some drug users report traveling to the U.S. to
seek drug treatment that is considered unavailable in Mexico
(Ferreira-Pinto and Ramos, 1997; Ramos, 1990). Maintain-
ing drug treatment regimens in a highly mobile population
may present at clinics in both Mexico and the U.S. also pose
challenges to officials on both sides of the border and under-
score the need to develop coordinated prevention and treat-
Mexico’s role in the production and/or distribution of
illicit drugs has long been recognized, but only relatively
Efforts to monitor trends in drug use through the national
on addictions will help to inform program planning and
policy, but efforts at the state and local levels are also needed
since national data likely mask heterogeneity in drug use
injection drug use has remained low in Mexico, ‘pockets’ of
HIV infection may nevertheless occur and there is growing
tive studies are needed both to monitor trends in drug use
and the incidence of blood borne infections, but also to
evaluate the impact of existing and future interventions.
a multifaceted approach is needed. Although methadone
not widely accessible. Efforts to expand methadone mainte-
nance should be scaled up immediately, since this proven
treatment is generally considered socially, politically, and
Since it is legal for IDUs to purchase syringes without a
prescription in Mexico, efforts to identify IDUs’ barriers to
the purchase of sterile syringes should be undertaken among
IDUs, pharmacists and pharmacy clerks to ensure that IDUs
need not resort to needle sharing.
The acceptability and feasibility of harm reduction
programs that may be considered controversial in Mexico
should be further explored, which could include physician
prescription of sterile syringes to IDUs, expansion of NEPs,
and implementation of syringe vending machines and safe
injection facilities. In past experiences in Mexico, interven-
tions such as mass-media social marketing of condom use
received strong opposition from conservative and religious
groups in both the public and legal arenas (Rico et al.,
1995). However, by working with conservative and religious
groups, local human rights organizations, non-governmental
agencies, and influential citizens, the development and
implementation of successful prevention strategies can
occur. Indeed, despite low coverage, the range of innovative
J. Bucardo et al. / Drug and Alcohol Dependence 79 (2005) 281–293
is encouraging. Since 60% of the Latino population in the
U.S. includes Mexicans and Mexican-Americans; many of
whom cross the 2000mile porous Mexican-U.S. border on
a regular basis, there is a growing need for both countries to
claim ownership over Mexico’s growing drug problem and
intervene with culturally-appropriate interventions.
J.B. is supported by a National Institutes of Health (NIH)
grant (1 R01 MH065849-01A2). K. B. holds a Ruth L.
Kirschstein National Research Service Award sponsored
by the NIH (5 T32 AI07384). We gratefully acknowledge
donor support for the Harold Simon Chair in International
Health and Cross-Cultural Medicine. This research was
funded in part by a 2004 developmental grant from the
UC San Diego Center for AIDS Research, an NIH funded
program #P30 AI36214-06 NIH grant 5 R01MH62554-03
and 3R01 DA009225-10S1. Funding for research by Pro-
grama Compa˜ neros was provided by the National Institutes
the Carnegie Foundation through the Mexican Health Foun-
dation and the Levi Strauss Foundation. In compiling the
grey literature for this review, we appreciate assistance from
Ms. Maria Elena Ramos Rodriguez (Programa Compa˜ neros
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