The impact of involuntary drug treatment on overdose, subsequent drug use and drug use treatment-seeking among people who inject drugs in Tijuana, Mexico

Background: The treatment of substance use disorders, as any other form of medical care, is a human right and must comply with quality standards of health care, including the right to refuse use of services. Involuntary drug treatment has been reported ineffective in decreasing drug use but its effects on health and subsequent treatment-seeking have not been longitudinally assessed.Aims: (1) To examine the dynamics of involuntary drug treatment from the perspectives of people who inject drugs (PWID); (2) to assess the effect of involuntary drug treatment on non-fatal overdose; and (3) to determine whether past experiences of involuntary drug treatment influence subsequent voluntary treatment-seeking behavior in Tijuana, Baja California, Mexico.Methods: PWID who were at least 18-years old and reported injecting drugs in the prior month were enrolled in a prospective study. Participants completed interviewer-administered surveys at baseline and every six months (2011-2017). For Chapters 2 and 4, a subsample of PWID reporting involuntary drug treatment in the context of a federally-funded policing program was interviewed and thematic analysis was performed. In Chapter 3, generalized estimating equation analyses were conducted on recent (i.e., past 6 months) non-fatal overdose event and its relationship to involuntary drug treatment. In Chapter 4, Cox regression was also conducted to identify factors related to voluntary drug treatment subsequent to involuntary drug treatment experience among those with no prior drug treatment history.Results: In Chapter 2, 25 PWID described punitive characteristics of a local policing program and lack of State oversight and healthcare at drug centers. In Chapter 3, among 670 PWID, 31.5% reported a recent non-fatal overdose, which was independently associated with recent involuntary drug treatment. In Chapter 4, among 359 PWID, a possible pathway through which involuntary drug treatment limits future treatment-seeking was identified through mistreatment, stigmatization and discrimination at drug centers.Conclusions: Findings highlight the use of involuntary treatment as a mechanism of control that may have life-threatening risks as well as a complexity of factors that drive drug treatment-seeking among PWID in Tijuana. Policy implications include the need to protect PWIDs’ right to choose the circumstances of treatment, for adequate professionalization and training of drug treatment staff, and for treatment centers’ oversight