Reforming medication-assisted treatment to achieve harm reduction goals and address injection initiation assistance in Tijuana, Mexico.

Maria Luisa Mittal, Claudia Rafful, Sonia Jain, Shelly Sun, Andy Guise, Paty Gonzalez-Zuñiga, Steffanie A. Strathdee, Dan Werb

Background: Persons who inject drugs (PWID) play a key role in initiating others into injection drug use (IDU). In the U.S. and Canada, enrollment in medication-assisted treatment (MAT) has been associated with a significant reduction in injection initiation assistance among PWID. We aimed to explore such association in Tijuana, Mexico, a resource-limited setting.

Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. This mixed methods analysis drew from the Tijuana participating cohort survey and linked qualitative interviews. Participants were ≥18 years old, reported past month IDU prior to enrollment, and were asked about recent (i.e. past 6-months) injection initiation assistance starting in 2014 (i.e. PRIMER baseline). Descriptive and content analyses examined drug treatment experiences and injection initiation assistance.

Results: In the PRIMER baseline, out of 748 participants, 607 (81.1%) reported recent daily IDU, 41 (5.5%) reported recent injection initiation assistance, and 21 (2.8%) were enrolled in MAT (i.e. methadone). There were no significant associations between MAT and recent injection initiation assistance. Qualitative analysis (n=21; male=13, female=8) revealed a general disregard for MAT, citing MAT clinic closures, costs equitable to daily drug supply doses, concurrent MAT and substance use, and that “people get more addicted to methadone and suffer more than with heroin.” Those enrolled in MAT recognized that MAT changed drug-seeking behaviors, social networks, and consequently, they were less likely to assist others into IDU.

Conclusion: In this setting, MAT must first be operationalized to reduce harms associated with IDU in order to explore potential for secondary benefits of reducing initiation assistance. MAT interventions should also consider widespread MAT stigma reduction efforts and low-threshold MAT models, including medication options to support treatment access and address experiences of MAT as controlling and coercive among vulnerable populations.