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Official websites use. Share sensitive information only on official, secure websites. 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 In —, 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. To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription. We employed an iterative, exploratory, mixed methods design. 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. Counterfeit pills were obtained at 11 pharmacies Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance. 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, drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Counterfeit pharmaceutical drugs—especially those containing illicitly manufactured fentanyls IMF —are playing an increasing important role in the United States US overdose crisis 1 — 3. IMF and other synthetic opioids have transformed the risk environment for people who use drugs PWUD given their much higher potency and shorter half-life compared to other opioids. Although reports of counterfeit prescription opioids containing IMF surfaced as early as the early s, 4 in recent years they have become commonplace across the US 5 , 6. IMF-based pills e. They have also been driving a large relative increase in the overdose death rate of adolescents 3 , who are more likely to experiment with drugs they perceive as prescription pharmaceuticals relative to powders sold as heroin, or other drugs that are more stigmatized For the general population, there is a profound added risk of counterfeit prescription medications relative to other fentanyl-based illicit drug formulations. Pills purporting to be pharmaceuticals may be perceived as a lower-risk category of recreational drugs 2 , despite currently representing one of the most potentially lethal options for illicit drug use, especially because they may be more likely to be used by individuals with no tolerance to opioids. Counterfeit versions of psychoactive drugs have been identified in numerous contexts, often using point-of-care techniques like Fourier transform infrared spectroscopy and fentanyl and benzodiazepine testing strips, or more time and cost-intensive techniques like gas chromatography with mass spectroscopy 5 , 6 , 9 , 11 — Importantly, the existence of counterfeit versions of non-psychoactive medications that are expensive or difficult to obtain is a longstanding and well-described problem in many low- and middle-income countries 15 — Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 19 — In —, study participants—especially those who were US citizens that frequently visited in or stayed in Mexico to consume illicit drugs—began describing new, unusually potent medications, sold ostensibly as controlled substances, from pharmacies that cater to English-speaking tourists. This raised suspicion for the proliferation of counterfeit prescription drugs in brick-and-mortar pharmacies 1. Although counterfeit prescriptions have been described in the US illicit drug market—and it is well-known that a large portion of the IMF and methamphetamine that are pressed into counterfeit prescription drugs sold in the US originate in Mexico 23 , 24 —the prevalence of their consumption among PWUD in Mexico is not well-described in academic literature. Previous drug checking and ethnographic studies have characterized the arrival of IMF to Tijuana and elsewhere in Mexico, especially in the form of China White ostensibly powder heroin, often found containing fentanyl , which has increased in prevalence in recent years 21 , However, previous ethnographic literature describing illicit drug supply chains in Mexico indicate that a complicated and varying set of cartel politics and on-the-ground dynamics limit which products are sold in Mexico versus those exclusively earmarked for export to the US 21 , It should therefore not be assumed that illicit drug products produced in Mexico for export to the US—including counterfeit pills—are consumed by PWUD in Mexico. Given the potential public health risks associated with IMF-based counterfeit prescriptions sold from pharmacies, we sought to characterize the availability and composition of pills sold as ostensibly controlled substances in pharmacies across Northern Mexico. Ethnographic data were collected as part of a wider study investigating shifting risk environments of PWUD in Mexico. Sampling dynamics and methodology have been described extensively elsewhere 19 — Briefly, we targeted initial fieldwork towards the immediate surroundings of drug- and sex-tourism micro-neighborhoods. The largest fraction of participants in the initial ethnographic work were deported individuals who had spent significant time in the US but could not return at-will. However, a sizeable minority of key ethnographic informants consisted of US citizens and residents intentionally visiting or residing in Mexico for the purpose of purchasing and consuming illicit drugs at far cheaper prices than those seen in proximate parts of the US. Ethnographers accompanied and informally interviewed participants as they engaged in routine daily activities, including the acquisition, preparation, and consumption of illicit drugs, and the generation of funds. With IRB approvals, we employed a conversational interview format, frequently using audio recording with participant permission. Over time, most key informants were formally and informally interviewed on dozens of occasions during the research process. All ethnographers were bilingual, and textual data were translated to English for presentation. Study protocols were approved by the institutional review board at the University of California, Los Angeles, in the United States, and the institutional review board at Prevencasa, a non-governmental organization, in Baja California, Mexico. During the process of accompanying key informants, visits to pharmacies were commonplace, especially among US citizens and residents participating in cross-border drug use visiting for short periods or living in Mexico for the purpose of drug use , who would occasionally purchase one-off benzodiazepine pills, bottles of tramadol for use in heroin cessation, or boxes of syringes at pharmacies proximate to drug and sex tourism microneighborhoods. Given the existing information available, pharmacies were chosen strategically to be geographically broad—both within and between cities—maximizing the probability of discovering counterfeit prescriptions in at least one area, should they exist. This was accomplished by sampling various pharmacies in distinct types of micro-neighborhoods within several cities e. Therefore the study sought to be hypothesis generating and exploratory, not assessing prevalence in a representative fashion. Based on initial ethnographic insights, all pharmacies appeared to be independent entities, not part of one of the many popular national pharmacy chains. These pharmacies were deemed the most likely to provide counterfeit medications and other controlled substances without a prescription. All pharmacies were located in areas frequented or transited by US-based tourists. Generic names e. Each category of pills was requested as single tablets, and when multiple formulations were offered of the same medication, one sample of each formulation was acquired. Immediately after each encounter, metadata was recorded, indicating if controlled substances were available in any form including full bottles , and if single pills could be obtained which were universally requested when full bottles were offered. Only single pill samples were obtained and analyzed because initial ethnographic insights led researchers to believe that they were widely available, and would represent the highest potential for representing counterfeit products. Labeled bottles of pills were deemed less likely to contain counterfeit substances, and also would have involved considerably increased costs. After each encounter, detailed ethnographic accounts were recorded, transcribed, added to the existing corpus of data, and coded. Data from prior to — were drawn from the pre-existing corpus of ethnographic information, whereas novel ethnographic data were collected in for this study. All qualitative data were entered into NVivo and analyzed for emergent themes. Of particular relevance for this analysis, all encounters occurring in pharmacies were analyzed separately to track the evolving use of pharmacies by PWUD over time to Narratives from pharmacy staff were also specifically assessed when spontaneously offered during the course of the study, although they were not actively solicited. They were combined with narratives from key ethnographic informants from the wider study with detailed relevant knowledge regarding medication quality, safety, contents, and origin. After analysis, key thematic elements from the ethnographic results were presented in a narrative style, consistent with our previous work on these topics 19 — 21 , 28 — In sum, the final set of ethnographic data analyzed consisted of 1 the subset of the previously existing and continuously evolving corpus of ethnographic data recorded interviews and field notes from the wider study that pertained to pharmacy-based practices and encounters 2 ethnographic data recorded immediately after the pharmacy-based encounters specifically conducted for this study. All samples were processed in a standardized fashion see supplement for step-by-step details. Briefly, the entire pill was pulverized using a glass instrument in a single-use plastic receptacle, and pill contents were mixed thoroughly to minimize heterogeneity. A small sub-sample was then selected—the smallest quantity that completely covered the crystal window of the Fourier-Transform Infrared FTIR Spectroscopy window. Subsequently, the same sample was added to 1. We then employed 4 immunoassay-based testing strips from BTNX laboratories for each sample, to check each pill for the presence of 1 fentanyls, 2 benzodiazepines, 3 amphetamines, and 4 methamphetamines. Each strip was inserted into the dissolved solution for ten seconds, and the result was read after 5 minutes by two trained investigators. In the rare case of disagreement between investigators, or an inconclusive or invalid result, a second strip was employed, providing a definitive result in all cases. For samples sold as Adderall, we further diluted the solution using mL of water for fentanyl testing, to avoid the known issue of false positives at high concentrations of certain stimulants See the supplement for more details of the drug checking analysis, including the logic employed to reach each final read. Pharmacy-level statistics are shown, depicting the availability of controlled substances, as well as counterfeit status as determined with immunoassay and FTIR spectroscopy. None of the pills sold as Xanax were found to be counterfeit. A wide variety of presumptively authentic controlled substances based on fentanyl and methamphetamine negative status with immunoassay strips, and FTIR confirmation were available see Figure 3. A variety of phenotypes of counterfeit medications were also observed Figure 3. See the supplemental materials for more details regarding how final drug checking designations were determined. Pill-level data are shown, with one row per sample analyzed. The labs on the far left show the prompt used to obtain each pill, i. FTIR results are shown in free text, with up to 3 results separated by semi-colons. Photos front and back are shown of example pills, by what the sample was sold as, as well as presumed authentic or counterfeit status. Despite intensive fieldwork employed in concert with drug checking technologies, the ethnographic team determined that at the independent pharmacies assessed here, it was not possible to distinguish counterfeit medications from their authentic counterparts based on appearance, as identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Geographic context was at times helpful—with substances sold in specific microneighborhoods found to be more likely to be counterfeit—but provided no guarantee of authenticity. Only the use of several concurrent drug checking technologies provide a reasonable measure of confidence in medication composition. Of note, heroin-based counterfeits were not initially detected by immunoassay strip testing and were only identified by FTIR spectroscopy—a level of drug checking sophistication currently unavailable in many settings where illicit drugs are purchased and consumed. In her early 30s, she has been dependent on injection opioids for nearly a decade. She is excited to show me a dizzying array of drug consumption spaces in the city. One of the stops is a somewhat formal looking brick-and-mortar pharmacy. And then you can even take it in the back and use it back there. We go into this pharmacy, which I had never taken a second look at, despite passing by it frequently. She greets the pharmacist, who is wearing a white coat, and is visibly covered in tattoos on all exposed parts of his hands, arms, and neck. He barely notices me, which I imagine is because Linda is a charismatic force of nature, who frequently can be seen pulling male clients around in her orbit as she traverses the urban landscape. She hands over 50 pesos and asks for a Valium. He gives her a single pill and 20 pesos in change, and we go into the back room so she can snort it. After she crushes up the pill with a plastic card, and snorts the white powder, she tells me that with the remaining twenty pesos she can show me a shooting gallery right across the street; if we can find five more pesos we can get a 25 peso bag of meth. We leave the pharmacy, cross the street, and duck into an alleyway…. The ethnographic passage above—from the pre-existing ethnographic corpus—details a pharmacy-based drug acquisition encounter occurring in Single tablets of controlled substances—especially benzodiazepines—could be routinely obtained at affordable prices from specific pharmacies known to PWUD. Most were proximate to drug- and sex-tourism microneighborhoods catering to English-speaking tourists and heroin- and methamphetamine-dependent Mexican nationals. On rare occasions, the ethnographic team also observed methamphetamine and heroin purchased directly from white coat-clad pharmacy employees. More central to the lives of most PWUD was the acquisition of individual sterile syringes a legal practice ; PWUD often shared details with one another from a complicated taxonomy of which pharmacies would sell syringes to tourists, which ones were open to individuals who appear to have a homeless habitus, and if a cover story was required e. Oxycodone was not routinely pursued at pharmacies by most ethnographic study participants, and most opioid users used peso 2. In —, ethnographic participants began describing new, unusually potent controlled substance tablets sold from pharmacies that cater to English-speaking tourists mostly from the United States :. So I started doing a bunch of em, like 7 a day if I had the money. But they felt different, the oxys felt like heroin to me, but these new ones, are like fentanyl or some shit. It used to be more than a dollar per milligram, like 35 dollars for an M30, but all the sudden they were 20 dollars. And then all the pharmacies in this area were selling them. In these instances, a broad variety of taxonomies were used to describe the various options available. The full one might be too dangerous. He goes under the counter and pulls out a cardboard box full of syringes. He reaches underneath the needles, and pulls up this false bottom on the box, and the bottom is full of these little blue pills, just loose in the box. He takes one out of the pile and puts it in a little plastic bag for us. As he hands it to me. Then we ask about Mexican Adderall. He shows us the bottle and it says methylphenidate Ritalin. On rare instances, pharmacy employees were more forthcoming about what they suspected were the contents of their medications. I asked for Oxy, and one of them pulled out this plastic case from beneath the counter, with lots of little boxes, like for fishing tackle. It was transparent, so we could see all these different looking pills in little bags. They had two different colors of pills that looked like oxy M30s, one blue and one green. They also had a bunch of white and yellow pills of various sizes and shapes, that looked like Percocet, Norco, etc. One spoke better English and relayed the question to the other in Spanish. These pharmacies tended to be larger, with more employees working at a given time, and located in areas catering to more formal kinds of tourism i. However, it was not possible for investigators to reliably predict with certainty which pharmacies would sell controlled substances or counterfeit products. On numerous occasions, two pharmacies directly adjacent to one another would provide highly discordant products. Further complicating these dynamics, some pharmacies sold a mixture of counterfeit and authentic oxycodone products. One-off counterfeit and authentic controlled substance tablets in pharmacies were observed to be stored and accessed in a variety of fashions. However, the degree of discretion employed by pharmacy staff did not appear to be predictive of product authenticity. Tablets were typically stored inside of small plastic bags, kept inside metal breath mint containers in fanny packs, in small cardboard boxes previously containing electronics, in plastic organizer boxes with numerous compartments, or occasionally loose in drawers. At times these boxes were transparent and were left out on pharmacy counters for extended periods of time, as pharmacy staff attended to other patrons seeking medications that were not controlled substances. On other instances, pharmacy staff appeared distinctly concerned about security and employed maneuvers to minimize risk:. When I asked about Xanax, he was only going to sell by the bottle, minimum 30 pills. He did the math and took the money for everything I had asked for. But after he took the money, he just kind of stood behind the counter, counted the money and just like leaned on the wall, like nothing was going to happen. In hindsight, that was probably because there were quite a few police cars right outside in that area. It was at least two full minutes of just standing around, and then someone from the outside finally came in, and the guy moved around me to the back of the store in this really awkward way and pulled the little baggie with two pills out of his pocket and handed it to me and I left. It felt like way more precautions were taken than other encounters, which I attributed to it being in a part of town with more formal tourism in the area, so they took more precautions than pharmacies in the part of town where people go for sex tourism, where things were a bit more out in the open. Additionally, on several occasions, pharmacy employees selling exclusively authentic oxycodone products would counsel caution purchasing products elsewhere, implying risk of overdose or adverse drug reactions:. And look, we want you to have a good time, but if you take one of those, you are not coming back. But I have the real thing. Always ask to see the package, OK? I only have 20 milligrams. But you guys are gonna be happy. In this encounter, the 20mg oxycodone pills were determined to be presumed authentic. Key informants also confirmed that consumption of counterfeit IMF-based tablets, often pressed to look like blue Oxycodone M30s, was subjectively associated with an increased risk of overdose:. But one of my homies did almost, yeah, he was smoking the blues and he nodded real hard, actually right over here, and the girl from the pharmacy had to keep pushing on his chest like this motions doing chest compressions. A distinct phenotype of tourist-oriented pharmacies—focused on selling controlled substances exclusively in bottles and blister packs of quantities ranging from 10 to tablets—was noted in several locations. Pharmacy employees offered various strategies for successful importation of the medications to the US on return flights, and some offered to facilitate international shipping for an additional fee. At a subset of these pharmacies, single pills could be obtained, but only after considerable insistence that a large quantity was not of interest. Leveraging recent improvements in point-of-use drug checking technologies, we provide the first characterization—to our knowledge—of the contents of medications sold at pharmacies in tourist-serving areas of Northern Mexico, in single pill form, to English-speaking tourists without a prescription. We find a high rate of counterfeit products, with widespread fentanyl and methamphetamine prevalence in numerous sites. The availability of fentanyl, methamphetamine, and heroin-based counterfeit medications in Northern Mexican pharmacies that are oriented towards serving tourists represents a distinct public health threat. These medications have been implicated in large increases in overdose risk in the United States, especially among subpopulations of individuals that are willing to experiment with prescription pills but not more stigmatized formulations like powder heroin 2 — 6. Although IMF-based pills represent a very high-risk category of illicit drug product, drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Critically, it is not possible to distinguish counterfeit medications based on appearance of pills or geography oh pharmacies, as identically-appearing authentic and counterfeit versions are often sold in close geographic proximity. Harm reduction logic would dictate that a person consuming purported controlled substances purchased at pharmacies in these micro-neighborhoods should test each pill on each occasion that drugs are consumed, to ensure IMF and methamphetamine contamination has not occurred. The presence of controlled substances in pharmacies of northern Mexican occurs in the context of a long history of drug and medical tourism to Mexico by US residents and citizens 32 — This demand in large part reflects the extremely expensive, unaffordable, confusing, and exploitative nature of the US healthcare system, where many individuals fear that even simple healthcare encounters may result in financially catastrophic outcomes Additionally, it is well-described in the literature that many prescription drugs are dozens to hundreds of times more expensive in the US than in other countries, including Mexico Legally, this does not apply to controlled substances—such as opioids, benzodiazepines, or stimulants—which Mexican law dictates do require a special kind of prescription from a licensed physician authorized to prescribe psychoactive drugs 39 — However, in specific locations we observed a widespread practice wherein certain kinds of controlled substances, especially alprazolam, were readily available with no prescription, at pharmacies that visibly cater to English-speaking tourists. Indeed, it was never the case in any of the tourist-oriented pharmacies where controlled substances were obtained that a prescription was required; specific medications were either available or unavailable, regardless of prescription status. In some of these pharmacies, employees routinely offered advice to English-speaking tourists on how they can smuggle controlled substances back into the United States and avoid detection. In this context, it could be especially difficult to recognize the threat of possibly counterfeit controlled substances—because a mix of counterfeit and authentic controlled substances are illegally sold either by the lack of a legally-required prescription, or by being illicit drugs from the same locales. For an English-speaking tourist with a poor level of knowledge of the Mexican legal landscape, it may not be immediately apparent that the sale of any controlled substance without a special prescription constitutes an illegal act. The sale of individual pills from larger bottles or boxes is also not legally permissible. These decreases have been shown to have affected many patients with known painful chronic conditions, including terminal cancer, and other palliative care patients Many patients have been rapidly tapered off opioid regimens, which has been associated with increased rates of suicide and drug overdose 44 , We would argue that a large unmet demand for diverted and legitimate prescription opioids has likely led to widespread consumption of counterfeit opioids in the US by witting and unwitting consumers. Similarly, recent shortages of Adderall have led to substantial unmet demand for amphetamine among US patients and diverted medication consumers, which some drug policy experts have hypothesized may lead to increased use of counterfeit methamphetamine-based Adderall tablets The rise of counterfeit pills in the US, as well as the shifts we note here, seem to have intensified during the COVID pandemic, which may have driven these trends in unknown ways. Disruptions to the illicit drug supply during the pandemic may be involved, and this represents an important area for further study. There is a lack of drug mortality surveillance data in Mexico, largely stemming from limitations on epidemiological and drug checking data sources. A number of qualitative and drug checking studies have indicated that fentanyl has arrived to Tijuana and other northern Mexican border cities 21 , 22 , Yet the quantitative epidemiological impact of these shifts, and any further implications from the availability of counterfeit medications, has not been adequately characterized. This study is exploratory in nature, and the results should be considered hypothesis-generating and limited, requiring validation. Importantly, we did not seek to characterize or represent the prevalence of counterfeit medications across all pharmacies in the four cities of interest. Instead, we used ethnographic data to guide a purposive sampling approach that we believed was most likely to document the presence of counterfeit medications if they were present in any one of an array of intentionally selected micro-neighborhoods. This study also leverages several drug checking methodologies that are relatively new, and which require validation. Although we took extensive efforts to reduce false positives and negatives see supplement , we cannot rule them out, and all results should be interpreted in light of the inherent uncertainties of modern drug checking methodologies. We also were not able to employ gas chromatography, mass spectrometry confirmatory testing for the samples analyzed here, although that has been done in some similar analyses. We also did not seek to characterize the full population of individuals that may be purchasing these drugs, relying on a convenience sample of known informants. Data came from a single region of Mexico, and from independent, not corporate pharmacies, and therefore do not represent the full market of pharmacies. The availability of fentanyl-, heroin- and methamphetamine-based counterfeit medications in tourist-oriented independent pharmacies in Northern Mexico represents a public health risk to Mexican residents and tourists, 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 legitimate pain patients and the availability of legitimate pharmaceuticals on the black 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. Among the samples obtained from the tourist-oriented independent pharmacies we studied here, it was not possible to distinguish counterfeit medications based on appearance of pills, because authentic and counterfeit versions are often sold in close geographic proximity and are visually and otherwise indistinguishable from one another. Nevertheless, English-speaking tourists may be more trusting of controlled substances purchased directly from pharmacies. We gratefully acknowledge the contributions of Dr. Pamina Gorbach and Dr. Steven Shoptaw to earlier drafts of this manuscript, as well as those of several collaborators at Mexican institutions who chose to remain anonymous. Pendleton Charitable Trust. CLS was supported by the U. AB was supported by the U. DGM was supported by the U. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. This is a preprint. It has not yet been peer reviewed by a journal. Other versions. Find articles by Joseph Friedman. Find articles by Morgan Godvin. Find articles by Caitlin Molina. Find articles by Ruby Romero. Find articles by Annick Borquez. Find articles by Tucker Avra. Find articles by David Goodman-Meza. Find articles by Steffanie Strathdee. Find articles by Philippe Bourgois. Find articles by Chelsea L Shover. PMC Copyright notice. The complete version history of this preprint is available at medRxiv. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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