Not sold here: limited access to legally available syringes at pharmacies in Tijuana, Mexico

Fentanyl, heroin, and methamphetamine-based counterfeit pills sold at tourist-oriented pharmacies in Mexico: An ethnographic and drug checking study

BACKGROUND

Fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists.

AIMS

To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription.

METHODS

We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents.

RESULTS

Of n=40 pharmacies, one or more of the requested controlled substances could be obtained with no prescription (as single pills or in bottles) at 28 (70.0%) and as single pills at 19 (47.5%). Counterfeit pills were obtained at 11 pharmacies (27.5%). Of n=45 samples sold as one-off controlled substances, 18 were counterfeit. 7 of 11 (63.6%) samples sold as "Adderall" contained methamphetamine, 8 of 27 (29.6%) samples sold as "Oxycodone" contained fentanyl, and 3 "Oxycodone" samples contained heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and "painkillers". Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance.

DISCUSSION

The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in tourist-oriented independent pharmacies in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It was not possible to distinguish counterfeit medications based on appearance of pills or geography of pharmacies, because identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Nevertheless, people who consume drugs may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.

Sex differences in the multilevel determinants of injection risk behaviours among people who inject drugs in Tijuana, Mexico

INTRODUCTION AND AIMS

HIV and hepatitis C virus transmission among people who inject drugs (PWID) is fuelled by personal and environmental factors that vary by sex. We studied PWID in Mexico to identify sex differences in multilevel determinants of injection risk.

DESIGN AND METHODS

From 2011 to 2013, 734 PWID (female: 277, male: 457) were enrolled into an observational cohort study in Tijuana. Participants completed interviews on injection and sexual risks. Utilising baseline data, we conducted multiple generalised linear models stratified by sex to identify factors associated with injection risk scores (e.g. frequency of injection risk behaviours).

RESULTS

For both sexes, difficult access to sterile syringes was associated with elevated injection risk (b = 1.24, 95% confidence interval [CI] 1.16-1.33), using syringes from a safe source (e.g. needle exchange programs) was associated with lower injection risk (b = 0.87, 95% CI 0.82-0.94), and for every one-unit increase in safe injection self-efficacy we observed a 20% decrease in injection risk (b = 0.80, 95% CI 0.76-0.84). Females had a higher safe injection self-efficacy score compared to males (median 2.83, interquartile range 2.2-3 vs. median 2.83, interquartile range 2-3; P = 0.01). Among females, incarceration (b = 1.22, 95% CI 1.09-1.36) and police confiscation of syringes in the past 6 months (b = 1.16, 95% CI 1.01-1.33) were associated with elevated injection risk. Among males, sex work (b = 1.16, 95% CI 1.04-1.30) and polysubstance use in the past 6 months (b = 1.22, 95% CI 1.13-1.31) were associated with elevated injection risk.

DISCUSSION AND CONCLUSIONS

Interventions to reduce HIV and hepatitis C virus transmission among PWID in Tijuana should be sex-specific and consider multilevel determinants of injection risk to create safer drug use environments.

Syringe access and health harms: Characterizing "landscapes of antagonism" in California's Central Valley

BACKGROUND

Sterile syringe access reduces injection-related health harms, yet access in the U.S. remains grossly inadequate. In California, syringe services programs (SSPs) are authorized mainly at the local level, and many communities remain underserved. State law also allows, but does not require, non-prescription syringe sales at pharmacies, but participation is low. We draw on the theoretical concept of "landscapes of antagonism" to examine how discordance between state and local decision-making contributes to uneven syringe access and health harms in California's Central Valley, where injection rates are high.

METHODS

Our study took place in Fresno and Kern counties. We draw on participant observation and qualitative interviews with individuals who inject drugs and key informants to examine issues around syringe access.

RESULTS

Overall, 8 key informants represented harm reduction, medical, and faith-based organizations. Among 46 people who inject drugs, mean age was 39 (range: 20-65), 37% were female, and 37% self-identified as Latino. About half of individuals at each site had ever successfully purchased from pharmacies, but limited locations and perceived judgement from pharmacy staff posed common barriers. There was no SSP in Kern County due to political opposition; Fresno's SSP has been run by volunteers for more than 20 years despite opposition, and recently gained authorization. Reflecting this disparity, all but two individuals in Fresno accessed syringes from the SSP, whereas only one person in Kern had ever been to an SSP. To fill gaps in access in both sites, individuals obtained syringes that were often already used from diabetics, friends, and people on the street, sharing and reusing syringes at dangerously high rates.

CONCLUSION

Landscapes of antagonism create syringe access inequities that threaten to exacerbate disease transmission and other health harms. Our study raises questions about accountability for the health of people who use drugs and suggests a need for political action.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Availability, Accessibility, and Price of Rapid HIV Self-Tests, New York City Pharmacies, Summer 2013

We conducted an in-person survey of New York City (NYC) pharmacies to assess the availability, accessibility, and price of the over-the-counter, rapid HIV self-test kit. NYC pharmacies were stratified into high, moderate and low morbidity neighborhoods by the HIV diagnosis rate of the neighborhood in which the pharmacy was located. A random sample of 500 pharmacies was taken [250 from high morbidity neighborhoods (HighMN) and 250 from low morbidity neighborhoods (LowMN)]. Pharmacies were excluded if: closed during survey, non-retail, or >10 min walk from subway. Project staff visited pharmacies to determine kit availability (in pharmacy on day of survey), accessibility (not locked/behind counter), and price (marked on shelf/product). Of 361 pharmacies (161 LowMN; 200 HighMN), kits were available in 27 % and accessible in 10 %; there was no difference by neighborhood. Kits were most often kept behind the pharmacy counter; this was more common in HighMN than in LowMN. Kits were kept solely behind the pharmacy counter in 52 %. Median price was US $42.99 without variability across neighborhoods. The rapid HIV self-test had limited availability and access in retail pharmacies. The high median price measured suggests that cost remained a barrier.

Nonprescription syringe sales: a missed opportunity for HIV prevention in California

OBJECTIVE

To assess implementation of California Senate Bill SB41 in two inland California counties where prevalence of injection drug use is among the highest in the nation.

DESIGN

Syringe purchase trial.

SETTING

Fresno and Kern counties, California.

PARTICIPANTS

All 248 community pharmacies in the counties.

MAIN OUTCOME MEASURE

Successful or unsuccessful syringe purchase attempt.

RESULTS

Only 52 (21.0%) syringe purchase attempts were successful. The proportion of successful attempts did not vary by county or by data collector ethnicity. The most common reasons for unsuccessful syringe purchase attempts were prescription requirements (45.7%), the requested syringe size was not available (10.7%), and the pharmacy did not sell syringes (9.7%). In addition, some syringe purchase attempts (4.1%) were unsuccessful because the data collector was asked to purchase more syringes than allowed by law. Although 80% and 78% of Fresno and Kern residents, respectively, live within a 5-minute drive of a community pharmacy, less than one-half live within a 5-minute drive of a community pharmacy that sold syringes.

CONCLUSION

SB41 has not resulted in broad pharmacy-based syringe access in California's inland counties, where a disproportionate number of cases of human immunodeficiency virus (HIV) infections are associated with injection drug use. Additional steps by legislative bodies, regulatory agencies, and professional organizations are needed to actively engage pharmacies in expanding nonprescription syringe sales to reduce HIV transmission among injection drug users.

Sex Work, Heroin Injection, and HIV Risk in Tijuana: A Love Story

The relationships between female sex workers and their non-commercial male partners are typically viewed as sites of HIV risk rather than meaningful unions. This ethnographic case study presents a nuanced portrayal of the relationship between Cindy and Beto, a female sex worker who injects drugs and her intimate, non-commercial partner who live in Tijuana, Mexico. Based on ethnographic research in Tijuana and our long term involvement in a public health study, we suggest that emotions play a central role in sex workers' relationships and contribute in complex ways to each partner's health. We conceptualize Cindy and Beto's relationship as a "dangerous safe haven" in which HIV risk behaviors such as unprotected sex and syringe sharing convey notions of love and trust and help sustain emotional unity amidst broader uncertainties, but nevertheless carry very real health risks. Further attention to how emotions shape vulnerable couples' health remains a task for anthropology.

Pharmacies as providers of expanded health services for people who inject drugs: a review of laws, policies, and barriers in six countries

Background

People who inject drugs (PWID) are underserved by health providers but pharmacies may be their most accessible care settings.

Methods

Studies in the U.S., Russia, Vietnam, China, Canada and Mexico employed a three-level (macro-, meso-, and micro-) model to assess feasibility of expanded pharmacy services for PWID. Studies employed qualitative and quantitative interviews, review of legal and policy documents, and information on the knowledge, attitudes, and practices of key stakeholders.

Results

Studies produced a mixed assessment of feasibility. Provision of information and referrals by pharmacies is permissible in all study sites and sale and safe disposal of needles/syringes by pharmacies is legal in almost all sites, although needle/syringe sales face challenges related to attitudes and practices of pharmacists, police, and other actors. Pharmacy provision of HIV testing, hepatitis vaccination, opioid substitution treatment, provision of naloxone for drug overdose, and abscess treatment, face more serious legal and policy barriers.

Discussion

Challenges to expanded services for drug users in pharmacies exist at all three levels, especially the macro-level characterized by legal barriers and persistent stigmatization of PWID. Where deficiencies in laws, policies, and community attitudes block implementation, stakeholders should advocate for needed legal and policy changes and work to address community stigma and resistance. Laws and policies are only as good as their implementation, so attention is also needed to meso- and micro- levels. Policies, attitudes, and practices of police departments and pharmacy chains as well as knowledge, attitudes, and practices of individual PWID, individual pharmacies, and police officers should support rather than undermine positive laws and expanded services. Despite the challenges, pharmacies remain potentially important venues for delivering health services to PWID.

The emerging HIV epidemic on the Mexico-U.S. border: an international case study characterizing the role of epidemiology in surveillance and response

PURPOSE

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome surveillance data are critical for monitoring epidemic trends, but they can mask dynamic subepidemics, especially in vulnerable populations that underuse HIV testing. In this case study, we describe community-based epidemiologic data among injection drug users (IDUs) and female sex workers (FSWs) in two northern Mexico-U.S. border states that identified an emerging HIV epidemic and generated a policy response.

METHODS

We draw from quantitative and qualitative cross-sectional and prospective epidemiologic studies and behavioral intervention studies among IDUs and FSWs in Tijuana, Baja California, and Ciudad Juarez, Chihuahua.

RESULTS

The recognition that the HIV epidemic on Mexico's northern border was already well established in subgroups in whom it had been presumed to be insignificant was met with calls for action and enhanced prevention efforts from researchers, nongovernmental organizations, and policy makers.

CONCLUSIONS

Successful policies and program outcomes included expansion of needle-exchange programs, a nationwide mobile HIV prevention program targeting marginalized populations, a successful funding bid from the Global Fund for HIV, TB, and Malaria to scale up targeted HIV-prevention programs, and the establishment of bi-national training programs on prevention of HIV and substance use. We discuss how epidemiologic data informed HIV prevention policies and suggest how other countries may learn from Mexico's experience.