Experiences and perceptions of people who use heroin : public health lessons from Hermosillo , Mexico

Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city’s context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system. Heroin Dependence; Social Stigma; Violence; Qualitative Analysis ARTIGO ARTICLE This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. Cuadra-Hernández SM et al. 2 Cad. Saúde Pública 2018; 34(11):e00179417 Introduction Users of injected heroin in Mexico were 0.1% of the population between ages 12 and 65 in 2016 1,2. This is a low prevalence compared with that of the U.S., which was at 0.3% in 2014 3,4. However, the use of heroin must also be analyzed by its consequences within these minority groups and their interaction with the community. The use of injectable illegal drugs, including heroin, is associated with HIV transmission. Between 1983 and 2015, 1,806 injecting drug users were officially registered in Mexico. In this period, an HIV prevalence of 1.42% was recorded for such users, while a prevalence of 2.8% was found in two other Mexican cities at the U.S. border: Tijuana, Baja California, and Ciudad Juarez, Chihuahua 5. Mexico has had strategies and a legal framework to stop the use of illegal substances for more than 12 years. However, the increase in drug injection, especially in the northern states of the country 1, shows that this judicial framework, with all its characteristics, is not running properly, affecting the lives of drug users. Thus, the purpose of this research was to analyze how these regulatory frameworks are experienced, perceived and practiced. This is based on the premise that perceptions and experiences are a phenomenon 6,7 lived in a particular manner, as the actors make different readings of reality and confer meaning to it. In the case of heroin consumption, the phenomenon explored is how a legal context where use is criminalized leads to greater consumption. The study group of users that inject heroin is located in the city of Hermosillo, Sonora, where heroin use has not been explored as in other studies carried out in Tijuana and Ciudad Juarez. Hermosillo is located in north-western Mexico, but, although it is not at the border, it has a long migratory tradition, with a recent spread of heroin use – less than 10 years – and with a 0.79% Human Development Index, which is considered a medium level 8. In addition, the Mexican government has not detected this type of consumption in the state of Sonora or in its capital 9, but empirical observation indicates the contrary. Thus, scientific documentation could be useful for the enrichment of laws, programs and services oriented towards these groups. Material and methods This qualitative research, based on specific techniques such as field observations and semi-structured interviews 10,11,12,13, sought to find out about direct experiences of users that inject heroin: including their perceptions of the introjection, practice and reproduction of the Mexican legal framework in their daily life. This type of phenomenological study, which bases the construction of knowledge on experience and infers what was not experienced 6,7,14,15, provides empirical data with a strong internal validity 16,17, allows an approach of people who are hiding and in persecution contexts, and helps us understand various dimensions of a precarious social world. This is the case of the interviewees who live in semi-clandestine circumstances, in poverty, besides being stigmatized and exposed to abuse by authorities and drug cartels. To insert the qualitative exploration in the local context, the official records of the heroin users were searched in order to learn the magnitude of the population, and then a documentary research was carried out. Subsequently, to contact the informants 18,19, field observations were conducted in places referred by non-governmental organizations (NGOs) and personnel at the HIV health care services. The group of informants consisted of ten people who were located and interviewed on the streets, in parking lots, in “shooting galleries” (called yongos) and rehabilitation center, using the snowball sampling technique 20,21; this was done in June and August 2015. The physician who was in charge of HIV services in the state conducted the interviews. This is part of a small and limited program of public health services that includes the participation of NGOs, which offered to help reduce the risk of HIV infection by providing clean syringes, disinfection materials and condoms. Users that inject heroin know and trust the people in this program, which allowed us to approach them. Still, it was something difficult to do, because of the criminal character of heroin sales; the situation created mistrust in at least two of the interviewees and there was at least one violent reaction against the interviewer. HEROIN USERS AND PUBLIC HEALTH 3 Cad. Saúde Pública 2018; 34(11):e00179417 To find the connection between these experiences and the field of public health policies, we also analyzed the legal framework related to illegal substances. To do so, we looked for the laws that regulate the use of illegal drugs in Mexico and found the General Health Law (Ley General de Salud), the Federal Penal Code (Código Penal Federal) and the Federal Code of Penal Procedures (Código Federal de Procedimientos Penales), which point out punishments for specific cases. We focused on the measures the Mexican State indicate for rehabilitation and incarceration. Some data were also obtained from the local press to reconstruct the context in which the consumption takes place. The testimonies were recorded, transcribed and analyzed using the Atlas.ti (https://atlasti.com/) program for qualitative data, which allows for an analysis of the text based on the selection of paragraphs, their classification into codes and grouping into families of codes to generate thematic areas. The analysis focused on the repercussions on the daily life of heroin users, on the measures proposed in the legal framework of the Mexican State, based on the premise that reality is constructed socially 22,23 and on values that guide practices understood as cultural capital 24. These starting points allowed us to treat the interviewees’ discourse as concrete data, thus avoiding the relativism into which pure phenomenology could fall, and stating that practices, being cultural capitals, can be considered a value and be reproduced, as it happens with economic capitals. We knew theoretically that people in addictive conditions develop their own strategies to get substances. To manage their consumption, they have their versions of harm reduction approach or rehabilitation 25, developing coping mechanisms for dealing with crime 26, stigmatization 27,28, mistreatment, HIV infection and deficient healthcare services; but in this case, we were interested in exploring their specific notions and practices, comparing them with the proposals of the Mexican legal framework and its implementation. In all interviews, informed consent was requested and recorded digitally, as well as the testimonies. The names of all people and their exact location were hidden. An analysis of units of meaning based on the life experiences of the interviewees was carried out following inductive logic, which consists of proposing general conclusions based on particular data 29, from grouping codes until forming four descriptive categories that indicated how the state policy is experienced: childhood and context of drug use, life on the streets, police interaction and the meanings and practices involved in the rehabilitation process (Box 1).


Introduction
Users of injected heroin in Mexico were 0.1% of the population between ages 12 and 65 in 2016 1,2 .This is a low prevalence compared with that of the U.S., which was at 0.3% in 2014 3,4 .However, the use of heroin must also be analyzed by its consequences within these minority groups and their interaction with the community.The use of injectable illegal drugs, including heroin, is associated with HIV transmission.Between 1983 and 2015, 1,806 injecting drug users were officially registered in Mexico.In this period, an HIV prevalence of 1.42% was recorded for such users, while a prevalence of 2.8% was found in two other Mexican cities at the U.S. border: Tijuana, Baja California, and Ciudad Juarez, Chihuahua 5 .
Mexico has had strategies and a legal framework to stop the use of illegal substances for more than 12 years.However, the increase in drug injection, especially in the northern states of the country 1 , shows that this judicial framework, with all its characteristics, is not running properly, affecting the lives of drug users.Thus, the purpose of this research was to analyze how these regulatory frameworks are experienced, perceived and practiced.This is based on the premise that perceptions and experiences are a phenomenon 6,7 lived in a particular manner, as the actors make different readings of reality and confer meaning to it.In the case of heroin consumption, the phenomenon explored is how a legal context where use is criminalized leads to greater consumption.
The study group of users that inject heroin is located in the city of Hermosillo, Sonora, where heroin use has not been explored as in other studies carried out in Tijuana and Ciudad Juarez.Hermosillo is located in north-western Mexico, but, although it is not at the border, it has a long migratory tradition, with a recent spread of heroin use -less than 10 years -and with a 0.79% Human Development Index, which is considered a medium level 8 .In addition, the Mexican government has not detected this type of consumption in the state of Sonora or in its capital 9 , but empirical observation indicates the contrary.Thus, scientific documentation could be useful for the enrichment of laws, programs and services oriented towards these groups.

Material and methods
This qualitative research, based on specific techniques such as field observations and semi-structured interviews 10,11,12,13 , sought to find out about direct experiences of users that inject heroin: including their perceptions of the introjection, practice and reproduction of the Mexican legal framework in their daily life.This type of phenomenological study, which bases the construction of knowledge on experience and infers what was not experienced 6,7,14,15 , provides empirical data with a strong internal validity 16,17 , allows an approach of people who are hiding and in persecution contexts, and helps us understand various dimensions of a precarious social world.This is the case of the interviewees who live in semi-clandestine circumstances, in poverty, besides being stigmatized and exposed to abuse by authorities and drug cartels.
To insert the qualitative exploration in the local context, the official records of the heroin users were searched in order to learn the magnitude of the population, and then a documentary research was carried out.Subsequently, to contact the informants 18,19 , field observations were conducted in places referred by non-governmental organizations (NGOs) and personnel at the HIV health care services.The group of informants consisted of ten people who were located and interviewed on the streets, in parking lots, in "shooting galleries" (called yongos) and rehabilitation center, using the snowball sampling technique 20,21 ; this was done in June and August 2015.The physician who was in charge of HIV services in the state conducted the interviews.This is part of a small and limited program of public health services that includes the participation of NGOs, which offered to help reduce the risk of HIV infection by providing clean syringes, disinfection materials and condoms.Users that inject heroin know and trust the people in this program, which allowed us to approach them.Still, it was something difficult to do, because of the criminal character of heroin sales; the situation created mistrust in at least two of the interviewees and there was at least one violent reaction against the interviewer.
Cad. Saúde Pública 2018; 34 (11):e00179417 To find the connection between these experiences and the field of public health policies, we also analyzed the legal framework related to illegal substances.To do so, we looked for the laws that regulate the use of illegal drugs in Mexico and found the General Health Law (Ley General de Salud), the Federal Penal Code (Código Penal Federal) and the Federal Code of Penal Procedures (Código Federal de Procedimientos Penales), which point out punishments for specific cases.We focused on the measures the Mexican State indicate for rehabilitation and incarceration.Some data were also obtained from the local press to reconstruct the context in which the consumption takes place.
The testimonies were recorded, transcribed and analyzed using the Atlas.ti(https://atlasti.com/)program for qualitative data, which allows for an analysis of the text based on the selection of paragraphs, their classification into codes and grouping into families of codes to generate thematic areas.The analysis focused on the repercussions on the daily life of heroin users, on the measures proposed in the legal framework of the Mexican State, based on the premise that reality is constructed socially 22,23 and on values that guide practices understood as cultural capital 24 .These starting points allowed us to treat the interviewees' discourse as concrete data, thus avoiding the relativism into which pure phenomenology could fall, and stating that practices, being cultural capitals, can be considered a value and be reproduced, as it happens with economic capitals.
We knew theoretically that people in addictive conditions develop their own strategies to get substances.To manage their consumption, they have their versions of harm reduction approach or rehabilitation 25 , developing coping mechanisms for dealing with crime 26 , stigmatization 27,28 , mistreatment, HIV infection and deficient healthcare services; but in this case, we were interested in exploring their specific notions and practices, comparing them with the proposals of the Mexican legal framework and its implementation.
In all interviews, informed consent was requested and recorded digitally, as well as the testimonies.The names of all people and their exact location were hidden.An analysis of units of meaning based on the life experiences of the interviewees was carried out following inductive logic, which consists of proposing general conclusions based on particular data 29 , from grouping codes until forming four descriptive categories that indicated how the state policy is experienced: childhood and context of drug use, life on the streets, police interaction and the meanings and practices involved in the rehabilitation process (Box 1).

Results
The official records of users that inject heroin from Hermosillo, were only found at the HIV health services for injecting drug users.Until the 4th trimester of 2015, 747 users that inject heroin were registered at state health services from Hermosillo, all of them were living with HIV and most of them had already developed AIDS (Table 1).This was the only official state registration in the city.This information is part of the 4,011 existing cases officially registered by the National Center for the Prevention and Control of HIV/AIDS of México for the state of Sonora 30 .
The participants in the qualitative study were eight men and one woman, who were not registered in the official records of the HIV health services (Table 2).All participants reported experiences of migration to the U.S. Time of heroin use ranged from 4 to 30 years.All of them were living in family groups.The interviewees had shared syringes and heroin at least once in their lives.
The main arguments for sharing syringes and heroin were eagerness to consume the drug and solidarity with peers.Five of them said they had not used a condom during their last sexual encounter, and seven reported having had multiple partners.Seven people had been at least once in a rehabilitation center -institutions managed by psychiatrists and at other times by personnel who only had empirical knowledge -, whose objective is to help people with addictions to detoxify and overcome their obsession with substance consumption; some of these centers are public and some are private.Three of the participants had been in jail.All the participants in the study said they had had contact with legal or illegal addictive substances at a very early age in their domestic group or community.The context of drug use, proposed as a category (Box 1), is clearly described in these testimonies: "In my family, my mom is the only woman who did [illegal drugs], and we can say that my addiction began because of her.She (...) since I can remember she has always done it" (Female 9)."I met a group of friends from the neighborhood (...).It was filled with cholos [Mexican Americans] (...).They were already doing drugs, smoking, they pisteaban [drank alcoholic beverages], smoked marijuana.I was about 13 or 14 years old" (Male 5).
In Mexico, the legal framework to prevent illegal substance abuse includes several laws.The General Health Law 31 , in Chapter V, classifies narcotics and psychotropic substances.Heroin belongs to the first group.This law also prohibits cultivation, possession, sale and distribution of illegal drugs, although it allows the use of minimum doses (Box 2).This Chapter is linked to the Federal Penal Code 32 and to the Federal Code of Penal Procedures 33 , where punishments are established for infringing the General Health Law.From the perspective of the Mexican legal system, consumption of illegal substances will not be punished for moderate use, since the system emphasizes rehabilitation.The only actions considered crimes are cultivation, trafficking (which is proven when more doses than the amount allowed are carried), and/or sales.Currently, punishments for carrying larger amounts than those allowed imply sentences from 10 months to 6 years in prison.
Cad. Saúde Pública 2018; 34(11):e00179417  Although Hermosillo is not the point where opium gum passes directly into the U.S., according to the local press, the city is part of the circuit of heroin return, being transported on land, with a stopover in San Luis Río Colorado, Sonora 34 .To cover that long route, it is necessary to involve federal, state and local authorities.In this context of economic interests based on corruption, violence and financial precariousness, users that inject heroin are concerned about their health by trying to control and/or reduce consumption.
The categories "life experiences and practices for surviving in the public space" and "meanings and practices of their own rehabilitation and harm reduction" proposed in the encoding plan (Box 1) interact with each other.Thus, participants reported taking methadone to reduce heroin consumption instead of taking buprenorphine or attending a detoxification program with behavioral therapies.In Mexico, methadone is distributed by private clinics, with high out-of-pocket costs for users that inject heroin; also, the users stated that methadone substitution is not effective to feel clean, which is a very important notion for users thar inject heroin: Cad. Saúde Pública 2018; 34(11):e00179417

"[I] used methadone, but I didn't feel clean with methadone. Yes, I felt better, that's true, but the day I stopped using methadone was the worst! For 35 days I was like almost dead, I couldn't even stand up. I was worse than with the heroin withdrawal symptoms and that was what made me come back to heroin (...)." (Male 7).
According to users that inject heroin, cleansing of the body and vein fattening are the most effective ways to reduce consumption and survive in a context where there are no effective harm reduction programs.The first stage of these practices consists of mixing heroin with other legal or illegal drugs to reduce heroin consumption, avoiding withdrawal: "Right now I shoot up heroin and the medicine [Clonazepam] that controls me, so I don't continue shooting more heroin, and it works.Sometimes I smoke a joint (...).I don't drink alcohol" (Male 7).
Consumption must be safe, controlled and held in an environment protected from the desert climate, as the temperatures in Hermosillo, reach more than 122 degrees Fahrenheit during the summer.The heat is deadly if one is out on the street.To hide from the heat some users get themselves admitted to rehabilitation institutions, whose goal is to encourage their own perception of safe and clean consumption or at least avoid overdoses.Getting locked up in a rehabilitation center may be a personal option or a State order.This happens when the user has been arrested and a judge decides he/she is a drug addict and orders his/her confinement in an institution.As a result, users that inject heroin need a safe place for controlled consumption, and the State sends them to rehabilitation center or to jail, where there is trafficking of illegal substances, so safe use is guaranteed when committing a crime.Cleaning the vein can also be done in jail.There is food there, drinks, and in case of withdrawal symptoms, there are palliative drugs, such as crack, clonazepam and heroin: "When I felt flat out terrible, I knew that I needed a break, that I needed to go inside to fatten up the vein, so yes, I would go [to jail]" (Male 1).
The legal system indicates rehabilitation for the sake of the public health, but in people's real experience, almost the same conditions that exist in jail occurs at rehabilitation centers: human rights violations, corruption, torture and extortion: "

I've been in rehabilitation centres about 5 times. The first time I made the decision to go in, but I got pulled out ahead of time because I was getting beaten by the other guys" (Male 2). "They [the police] come and pick you up. If you have money, it's good, you get away. If not, they fuck you over. Last time they caught me with half a gram (...). They really fucked me over and said: 'put it here!', 'with whom do you work?', 'I don't work with anyone, can't you see that I'm getting it to get myself high?' Even policemen have told me 'OK, te damos línea (we'll give you instructions that you have to obey) and we can sell it to you'" (Male 4).
In this context, users go to prison almost periodically to keep themselves alive and able to consume.Going through this situation is normal.Prison as a space for reintegration is a myth: drug users do not believe in this, nor do the jailers.Jail is not designed for that: "The first time I was at the Cereso [jail], yes, I did consume.There is another type of heroin, I think it has a better quality (...).At the beginning, at the Cereso, it was difficult to inject yourself (...), but then it became something normal" (Male 6).

Discussion
In Hermosillo, the only official sources of information on users that inject heroin were records of HIV care centres; however, they lack sociodemographic or consumer data, which does not allow us to know in depth the patterns of this group.
Analysing the Mexican legal framework, we could say that the approach to individual drug use is a public health problem, since it is regulated by the General Health Law: a limit is established between individual consumption and delinquency, and treatment is proposed to help users move away completely from addiction.However, consumption is not distinguished from trafficking; both are pursued and punished.This criminalization is supported by stigmatization.To pursue and punish is convenient for many other groups that profit from a captive market such as that of people who have already developed an addiction.
In this context, users that inject heroin develop their own notion of safe consumption in jail, which is the same as what they get at rehabilitation centers.The State's perspective does not consider ways to Cad.Saúde Pública 2018; 34 (11):e00179417 reduce or change heroin to another substance that is less harmful, providing real and effective harm reduction for the strong addiction to heroin.The Mexican legal framework only proposes the absolute abstinence achieved through a rehabilitation program that includes punishment, torture and/or extortion by the police.Prison and internment in rehabilitation centers have the same characteristics: mistreatment, violence and corruption.
The web of meanings supporting heroin consumption has at its center the notion that the substance helps people live, and, following certain strategies in a disciplined way, it becomes a pillar for health.Pauses in consumption have been documented in other investigations and places 35,36 with strategies that are different from those used by the participants in this research.Heroin rationing strategies, built around the idea of cleaning or fattening the vein, are dangerous, not only because of the havoc caused by the substance 37 , but also because to be effective they must be carried out in criminal circuits, putting aside other public health problems such as HIV transmission.As described in other studies 38 , these are empirical ways of injecting heroin and taking care of the body, but structurally they drive people towards crime circuits.The relationship between users and the State only exist in criminal institutions; thus, the approach to crime circuits becomes a routine event that is normal and generates profits.

Conclusions
The case of Hermosillo shows that legal framework does not respond to the real rehabilitation for the users of inject heroin, and the State does not have social scientific informations to improve programs and laws.This qualitative research can be useful to evaluate the existing policies and redesign legal programs and frameworks if the social situation permits 39 .
The Mexican legal framework proposes full rehabilitation without infrastructure or effective harm reduction strategies for heroin users, who need to control and reduce consumption in safe conditions.The lack of effective strategies for harm reduction is dangerous, reproducing harmful practices that increase the risk of overdose and crimes, creating scenarios of violence for users and for the rest of the community.Besides, the users interviewed were living in poverty, their criminalization and stigmatization makes heroin consumption a spiral that limits access to all services until they become unreachable, and it is only worse in contexts of HIV 40,41 .Lack of access to services is a strong inequity in health 42,43,44 , which turns into a "structuring structure", as established by Bourdieu 45 , reproducing harmful practices that are more and more inequitable and creating scenarios of more vulnerability for users.The exploration of these minority groups also implies taking an ethical position, which we hope will help decrease stigmatization and discrimination for consumers; this is a matter of urgency, especially because of the present escalation of violence, murders and disappearances in Mexico.
Cad. Saúde Pública 2018; 34(11):e00179417 Contributors S. M. Cuadra-Hernández contributed in the manuscript preparation, background, documentary research, supervision of theoretical an empirical work, analysis of the interviews, results and discussions.S. Salazar-Arriola contributed in the research project, contact with NGO and key populations, field work, semi-structured interviews, analysis of the interviews.A. Arredondo-López contributed in the development of the method, analysis of the interviews.M. B. Duarte-Gómez contributed in the documentary research and discussions for the article.V. Cuadra-Hernández contributed in the analysis of information, documentary law research, design of strategies of information diffusion.C. Rueda-Neria contributed in the technical review and discussions for the article All the authors revised and approved the final version of the article.Cad.Saúde Pública 2018; 34(11):e00179417 Analysis of interviews: coding, families of codes and categories.

Table 1
Injecting drug users living with HIV/AIDS registered in health services in Sonora,Mexico, 1986-2015.

drug users living with aids Injecting drug users living with HIV diagnosis
Source: Health Services of the state of Sonora.Nominal cases of HIV and AIDS register, State program's response to HIV/AIDS/STI, Sonora, Mexico: 4th quarter of 2015.
Table of maximum doses of illegal substances permitted under the Mexican law, 2016.