Background
Method
Data collection and sampling
Sampling
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Ángel | M | Black, Speedball | Robbery | A year and a half | Yes | No |
Oleodegario | M | Black | Auto parts theft | Few days | Yes | No |
Luis | M | Black, Speedball | Robbery | 8 years | Yes | No |
Francisco Gabriel | M | Speedball | Robbery | NA | Yes | No |
Juan Pérez | M | Black | Robbery, possession of heroin | NA | Yes | No |
Mario López | M | Black | Robbery, carrying a firearm | 2 years, and 8 months | Yes | No |
Pasgar | M | White | Robbery, injury | 4 years | Yes | No |
Jose Luis | M | black | Robbery | 1 year | Yes | No |
Miguel | M | Black | Robbery | NA | Yes | No |
Lalo Conteras | M | Black, Speedball | Robbery | NA | Yes | No |
Alberto Torres | M | Black | Auto parts theft | 3 days | Yes | No |
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Luis Rojas | M | Black, White, Speedball | Heroin possession | 15–20 days | Yes | No |
Rubén | M | Black | Robbery | 3 years and 3 months | Yes | No |
Héctor | M | Speedball | NA | NA | Yes | No |
Emmanuel | M | Black | Auto parts theft | NA | Yes | No |
Brad Pitt | M | Black, White | Assault, carrying a firearm, drugs | 2 years in penitentiary and 3 years in prison | Yes | No |
John Smith | M | White | Extortion, organized crime | 1 year and 7 months | Yes | No |
Jose Luis 2 | M | Speedball | Assault, carrying a firearm, drugs | 10 years | Yes | No |
Vitor | M | Speedball | Heroin possession, organized crime | 3 years | Yes | No |
Jose Alfredo | M | Black | Assault, Robbery | 4 years and 3 months | Yes | No |
Alex lora | M | Black | Robbery, assault | 3 months | Yes | No |
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Enriqu | M | Black, White | Caught injecting heroin | 3 months | Yes | No |
El Chapo | M | Black, White, brown | Heroin possession | 1 year | No | Yes |
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Víctor (DEAD) | M | Black, White | Marijuana possession | NA | Yes | NA |
Emmanuel | M | Black, Speedball | Assault, carrying a firearm, drugs | NA | Yes | No |
Francisco | M | Black | Robbery | NA | Yes | No |
Héctor Garibaldi | M | Black | Assault, carrying a firearm, drugs | NA | Yes | No |
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Lucas | M | White, Black, blue | Robbery | 8 months | Yes | No |
Michael Douglas (DEAD) | M | Black | Robbery, homicide | 5 years | Yes | No |
Rogelio Manuel | M | Black, Speedball | Assault, Robbery | 9 months | Yes | No |
Jorge Eduardo | M | White, Black, Speedball | Drug possession | 10 years and 6 months | Yes | No |
Gerardo | M | Black, Speedball | NA | NA | Yes | No |
Pseudonym | Sex | Heroin type | Crime | Sentence | Heroin availability inside the prison | Access to methadone treatment in prison |
---|---|---|---|---|---|---|
Ámbar | F | White, Black | Assault, carrying a firearm, drugs, organized crime | NA | Yes | No |
Fátima | F | Black | Sale of drugs, crimes against health | 4 years | Yes | No |
Thematic analysis
Analysis
Results
Pilgrimage for Help
“Nine bastards come for me, they get me up to wash, they tie me up, they wrap me in a blanket, and they take me. You know? So then they tie me up, shave my head, a cold-water bath. Some paddling, some slapping, and they had me standing for eight days in flip-flops…. Some, like those paddles for ice cream, this big, wrapped in duct tape.… Then they wet your butt, bend you over a desk, and “Put your ass in the air, motherfucker.” You know? I mean, it goes on: one, two, three whacks. You know? On the legs, the butt, wherever. It’s like getting hit with a paddle, you know, only bigger of course… And of course I’m all wet.... So, I mean, I can tell you, now, with something like satisfaction, you know? At the time, no, it was very, very hard. Like I was angry at God…. I felt angry with my family, because, well, it was terrible”. (Héctor, Mexico City)
“There were times when it was my parents who sent me because I stole from them. I took money from them, things, and they understood my addiction and they told me, we know you are not like that, we are going to support you, go to a rehab center, and I said ok, let’s go, and they took me. And I would stay there for two or three months, and then I would come out and start all over again”. (Lucas, Michoacán)
“And they come out, since they have lived through hell, they start doing drugs once again. Their family sees that they are using drugs again, and they try to help them again and they send them back. They get out, and even though they know their family is helping them, they don’t care. The family starts telling them, we’ve helped you once, twice, and still you don’t get it, and then they just let you do what you want”. (Hugo, Oaxaca)
“The last time I was in prison, I gave it up for a year, a year and a half. I got into a group in prison; I was in a group called New Dawn… and it worked for me. It was talks, Christian talks most of all, and exercise, talks, distractions, not to keep doing the same in the cells because it’s different, there it was just working and using, working and using, there wasn’t anything else. [In the group] no, there were talks, exercise, and keeping yourself busy. When I was there something that helped me a lot was playing soccer, because there comes a time when they ask you if you want to stay with the group or you want to leave.” (José Alfredo, Oaxaca)
“He was seeing a psychiatrist from social security [health services]. First outside, the first time everything was private, a psychiatrist had treated him about a year, a private psychiatrist.… Then we went to social security. This same psychiatrist referred us there. He told us, if you want, take him to social security. At that time the psychiatrist’s appointments cost us about 350 pesos. He started charging us that, and with the medication, every session amounted to 1000 or 1500 pesos…. I remember the social security medications: olanzapine, clonazepam, and sertraline”. (Wife of Gerardo, Michoacán)
“I haven’t gone [to treatment centers], I have tried to give it up on my own…. But you’re so stupid. I’d say to myself, I’ll try to reduce the dose one day, two days, and yes, I’m going to make it, but then on the third day I relapse and I smoke in one day what I didn’t in three”. (Hugo, Oaxaca)
Methadone use as self-care
Adaptive effects
“In my opinion I think there is a need for more clinics such as this, because in Oaxaca there aren’t any. There used to be one but now it’s closed, and there is no denying it’s the only treatment that helps you feel well. I say this because I’ve taken several things, I have been taken to doctors, and it doesn’t help at all, I feel the same. [Methadone] is the only treatment I feel good with, the one with which I can live a peaceful, normal life. I can work without pain”. (Enrique, Oaxaca)“Yes, it has served me really well, because when I don’t use heroin and I use methadone instead, I feel as if I was another person. I don’t do bad things like stealing from people, selling things I take from home, so many bad things, and the truth is I now regret it because I’ve gone to the extreme of working with people who used to sell”. (Luis, Oaxaca).“For me, [methadone] is a miracle.... At least most people are not going to be on the street, stealing. As a society, no matter what your morality, it’s better not to have people stealing”. (Enrique, Oaxaca)“What methadone does is, it doesn’t drug you, it just gets rid of feeling sick. With it, I can work normally, without worrying. You can eat, go out and work without worrying, without that desperate need to get something to get high”. (Juan Pérez, Oaxaca)
Psychological effects
“The difference is that with methadone, I have, it has made me, it is a heroin substitute that calms anxiety, despair, and the sick feeling you have when you need heroin. I mean, methadone medication really works for me”. (José, Oaxaca)Yes, it does take away the sick feeling. I mean, there’s no problem. Anxiety is the main thing, understand? The shakes—it does away with all that, and I guess to a certain extent it’s a drug, but it can be controlled. Why? Because the effect lasts longer and you can carry on doing things without using and thinking about the next dose, understand? (Luis Rojas, Oaxaca)“I started coming and saw that the medication was working for me, and I started taking two pills a day, then one, and I spread it out like that, then half a pill, and when I’m not doing anything just a fourth of a pill. What I do is a lot of sports: I like boxing, swimming, playing soccer, and running. So, I stay active, and more than anything, I have work, I have a job, because that’s what I’ve seen, that it’s when I don’t do anything that I’m just looking to get into trouble.” (John Smith, Oaxaca)
“Having shifted to methadone has been very good for me because it blocks that obsessive side. Other treatments were a kind of suffering for me. To be honest, it was agony for me to go for a day, even a few hours, without using”. (Ámbar, Michoacán)“I feel so much better; I can have a normal, normal, normal day. I can work, I eat well, I stop thinking about how to get money because the effect of the heroin will go away soon and I’ll feel bad, really bad, and so I’ll have to go get more. With methadone you stop thinking about all that: you’re calm. When you use heroin, the only thing you think about is that while you’re trying to get a hundred pesos, you’re going to feel really bad, because the effect of the dose you’ve just taken will soon be gone, and so you have to get another hundred pesos to go buy more when you start feeling really bad once again. It’s a never-ending story.... “(Fátima, Oaxaca)
Physical effects
“I believe that methadone does work, I mean, it’s a matter of someone wanting to move on, and it also eases the suffering heroin causes. For the effects like the shakes, bone pain, diarrhea, sneezing, yawning, all of the effects, it may be that a lot of people say that it isn’t that bad, that’s it’s like a fever, but the fact is that the effects are very strong”. (Rubén, Oaxaca)
Harmful effects
“Methadone is like a [shot], it’s a fix. A fix is a problem. But it’s not a good fix. But they also used different formulas [naloxone] to treat people for heroin addiction; they used it like methadone. They take it every day, they put a pill on your tongue and let it go every day. They don’t give you any to take home, right? People don’t abuse it because if you take one it doesn’t do anything, that’s a fact; one pill a day and you feel strangely normal and that’s why I like it.” (El Chapo, Oaxaca)
“Unfortunately, sometimes you prefer to use heroin, because between heroin and methadone, the effects of [withdrawing from] methadone are worse”. (Héctor. Oaxaca)
Access to methadone treatment
“They didn’t allow [methadone] in jail. They were doing it when there was a female doctor at the clinic. She eased the guys’ suffering by introducing it little by little. But the deal between the prison director and the prisoners’ leaders, there are connections, and that is how [heroin] gets in. They get it in the prison, and they themselves sell it. Every cell has some. (Mario, Oaxaca)
“[Female substance users] do not know how to get to the clinic but they “get lost" with PVC [an inhalant], a drug, a yellow can, which is used to unblock drains. They soak a rag in it and they inhale it through their mouth. They soak the rag in that liquid, and they behave worse than if they were drunk. That’s why they don’t come anymore”. (Fátima, Oaxaca)
Lack of knowledge of health professionals and authorities
“Another doctor used to tell me, [methadone] is [also] a drug, and I would tell him, yeah, but there is no comparing a medication which is controlled, and which they give to you, slowly reducing the dosage, and a drug you can go out and buy right now” (Oleodegario, Oaxaca)“There were times when I had to get a special doctor so that I could buy the ordinary commercial bottle. And I would also ask him to spread the word about the kind of alternative methadone represents, just like they do in the United States, because there are many people who know about it there. Unfortunately, in Mexico, not even the authorities know what methadone is. There are authorities who have arrested us and they don’t even know what it is”. (Héctor, Oaxaca)
Health care in contexts of violence
“I was arrested in November, the doctor was killed in December, and all of us addicts had no clinic anymore, because even though we used methadone, heroin was sold out of the clinic or close by. We would buy methadone and we would go out to buy heroin anyway, and so it was useless. When I was already in jail, we all learned that the doctor had been killed”. (Fátima, Oaxaca)“She [the doctor] was very nice, I liked her, she was a very nice woman. One day I went there and the police were all over the place. They were killing everybody. What a horrible waste! They had just killed everybody…”. (El Chapo, Oaxaca)
Private care for methadone treatment
“When we come for a supply of the medication, whenever I come, I get 10 or 15 doses. Right now, I’m getting only five doses because I have no money. I’m telling you the truth: that’s all the money we have. There are times when my family helps me, and I get more, but right now they have to work and they are in need. So, as I was saying, we have to steal to get more doses. Right now, I have exactly enough for my five doses. These doses last only five or six days, and I’ll come back as soon as I get some more money, because this is an expense, but with this, thank God, we are no longer using”. (Víttor and Brad Pitt, Oaxaca).“In my case I come from Oaxaca, and yes, it’s very expensive. In fact, I paid for my daily dose and it wasn’t hard for me, but the problem is you have to save enough money to come to [Mexico City], pay for methadone, the trip, food, and all that, and so it’s hard. If the clinic was [in Oaxaca], you pay daily, it’s not hard, with a job”. (Juan Pérez, Oaxaca)
“There are times when you don’t have any money; there are times when there is no medication, and so what can you do?”. (Víttor and Brad Pitt, Oaxaca)
Strategies for coping with methadone unavailability
“In fact, I was on the verge of quitting methadone; I was taking only twenty grams every other day. But then there were problems and it was cut off. And then, until I was able to go online and find out about the clinic in Mexico City, then we came back. But, as I was saying, there are times when they suspend it for months and you relapse. Well, at least you have the option to look somewhere else, you look elsewhere. [On the black market] the problem is that the strength is different. I don’t know if they cut it a lot; I wonder if it is methadone at all”. (Héctor, Oaxaca)“And in those two weeks when I didn’t have any methadone, I used heroin and I believe I used more in those 15 days than I did in a month before”. (Oleodegario, Oaxaca)“There’s a way to get methadone, but you need a prescription from a physician and it has to have a psychotropic medication stamp. You need this to get a bottle with a hundred 10 mg pills. I bought one once, but I wasn’t able to get another prescription”. (Alex Lora, Oaxaca)
“I had a few [methadone] pills, for a week… but I went for a month without using any [heroin], and then there came the moment finally when I didn’t have enough to alleviate the symptoms and go on living. I couldn’t find it in Oaxaca. And then, finally, after a lot of research, I looked on the internet and I contacted a clinic in Mexicali, or Tijuana, I don’t remember which, and they sent me a list of all the clinics in Mexico.So, I started coming here [Mexico City]. There was a problem with the paperwork and there was no medication; weeks and months went by. And at each one of those times, you have to do something. Even though I lowered my dose, I haven’t lowered it as much as I could.... So, you start all over again, using as much methadone as before, and it takes a few weeks, but you’re actually stable again…. I even looked for a place to get myself admitted for two weeks or something like that…. I didn’t have enough money, on the one hand, and really, where would they take care of me? I need to know I’m going to have [methadone] and that I’m going to have good medical treatment”. (Enrique, Oaxaca)
Discussion
“Thank you for at least being interested in learning a little about my life, among thousands. You’re the only person who has asked me, except when I’ve been arrested. Because unfortunately, the rest don’t care about what we live, what we feel, what we experience, until we are no longer...until we’re a target, unfortunately. And what you are doing is very valuable, because at least it tells a little about the reality we live. And not theoretically speaking, but from real-life experience”. (Héctor, Oaxaca)
“I did not have a direct encounter with the substance users: I was only a witness, the most empathetic one I could be, based on what I read, what you told me, and the way in which you told me. I live in another part of the country, up to now I have not used heroin and I have not been in a process of rehabilitation. I suppose I am in a position of greater privilege in terms of education and maybe of socioeconomic level and ethnicity. Although I have a clinical view, in looking at their interviews, I was interested in de-pathologizing their experience and focusing on it as a form of social suffering, as Das and Kleinman propose. As a user of health services, and a witness of their limitations, I was especially sensitive to identifying the barriers that appeared in their interactions with them. My prior experience with persons with HIV has sensitized me to the implications of stigma in health care and the way in which these services require a person to become an autonomous, independent patient, although there are structural conditions that limit their staying in treatment. And finally, having lived in places where organized crime influences urban dynamics, and I see every day now how people use drugs in the street, I sought to focus on the way in which the state has abandoned substance users, in complicity with drug trafficking. I suppose that from my previous journeys, my education, and my current everyday experience, ideas emerge that I seek to identify in the stories I read and listen to”.