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That pretense faded seconds later, when she was asked for controlled medications — and got on her hands and knees to pop open a hidden panel under the counter. She rooted around for a minute and emerged with two sealed bottles. In pharmacy after pharmacy in this Mexican resort city, workers offered similar assurances, but time and again the pills proved to be fakes. There were oxycodone pills that tested positive for heroin and over-the-counter cough medicine, and Vicodin tablets that turned out to be fentanyl. Pills sold as Adderall were sometimes methamphetamine or caffeine, and sometimes simply an appetite suppressant. Others denied ever selling medications they had in fact sold just minutes or hours earlier. Last month, reporters visited dozens of drugstores in Mexico to interview pharmacy workers and piece together a fuller picture of the counterfeit medication problem The Times has been investigating for nearly a year. Despite pharmacy raids by Mexican authorities and a warning from the U. State Department, the latest round of testing found that fake medications appear even more plentiful at independent drugstores and regional chains in tourist hot spots and border towns now than earlier this year. Some of the counterfeits are now more sophisticated, and lab testing found a wider array of substances in them than previously documented. And the latest reporting in Puerto Vallarta and Cabo San Lucas found that workers at small chains and individual pharmacies alike often went to great lengths to convince potential customers of the safety and efficacy of their counterfeit wares. The Times is not naming independent pharmacies or workers due to safety concerns, including the threat of violence. After visiting 10 vacation spots and border towns across Mexico this year, reporters used drug-testing strips and later lab testingto show that travelers who shop at pharmacies there risk unwittingly buying pills tainted with powerful drugs, including fentanyl, heroin, meth and MDMA — also known as ecstasy. In February, The Times reported that some drugstores in Tijuana and the Los Cabos area were selling loose pills over the counter, passing off tablets containing fentanyl and meth as expensive brand-name medications, including Percocet and Adderall. A team of UCLA researchers, including Goodman-Meza, reported similar findings in four unnamed cities in northwestern Mexico around the same time. But U. Later, reporters showed that several stores and at least a few regional chains had begun selling tainted medications by the bottle, in elaborate packaging that was sometimes indistinguishable from the real thing. A few medications were consistently legitimate, including the opioid painkiller tramadol and the ADHD pill methylphenidate, best known as Ritalin. But some medications were almost always counterfeit. Testing showed that 9 in 10 pills sold as Adderall, six in 10 pills sold as oxycodone, and 7 in 10 pills sold as hydrocodone were fake. Overall, 26 samples contained methamphetamine and 29 contained fentanyl. In March, authorities in Mexico inspected more than pharmacies in Los Cabos and nearby La Paz, closing nine in Los Cabos for a variety of violations. In June, another series of pharmacy raids in Los Cabos resulted in four arrests and the seizure of cash and nearly 25, pills. But less than 24 hours earlier, the same store had sold three loose pills — purported to be Percocet, Vicodin and Adderall — and one bottle labeled as Adderall. Laboratory testing showed both painkillers were fentanyl, the tablet sold as Adderall was methamphetamine, and the bottle of supposed Adderall contained capsules of an appetite suppressant called clobenzorex. Finally, authorities shut down 31 pharmacies and seized more than 4, boxes of medication during recent raids in Ensenada, where officials said some of the pills probably contained fentanyl. At a Puerto Vallarta pharmacy near bustling Playa de los Muertos last month, a clerk said she had no controlled substances for sale before offering a warning. Others said they stopped offering controlled medications immediately after the sweeps, but soon resumed sales. The Times could not independently verify their claims, and officials did not respond to requests for comment. There were no opioid painkillers in stock, but reporters bought a bottle of supposed Adderall. Aside from the glut of willing sellers and suppliers, another roadblock to reining in the sale of counterfeit pills in Mexico is the constant demand — often from Americans looking for medications that may be cheaper or easier to get than in the U. He had recently been prescribed Adderall in the U. Shopping for narcotic medications in pharmacies in Mexico often means listening to workers explain that bottles stashed in hidden compartments and loose pills kept in unlabeled plastic bags contain legitimate medications. But the painkillers purchased from that pharmacy tested positive for fentanyl, and the supposed ADHD medications were made of methamphetamine. At a Puerto Vallarta outpost of a drugstore chain that sold reporters fake medications, Ed Sheeran was crooning through tinny speakers about having faith in what he sees. The clerk claimed the pharmacy did not stock counterfeit pills. On two separate trips to Puerto Vallarta, reporters visited several stores in that same regional chain, and repeatedly purchased pills sold as Adderall that tested positive for methamphetamine. Another was a bottle that a young worker pulled from a locked hiding spot. In addition to concealing illicit wares and offering empty assurances about safety, pharmacy workers seemed choosy about their customers. Several residents said the stores would sell narcotic medications over the counter only to foreign tourists. At one drugstore, when a reporter started speaking Spanish, the clerk grew suspicious. At a Puerto Vallarta location of the prominent national chain Farmacias Similares, a worker said only customers with prescriptions could buy controlled medications. Other pharmacies, she said, would sell them without a prescription — depending on who you are. Only to foreigners. Organized crime experts say that Mexican drug cartels are almost certainly involved in making the sophisticated counterfeit medications. But it is unclear exactly how the pills end up on pharmacy shelves or in hidden compartments behind the counter. Workers at other stores suggested their pills came from California, but also could not name a supplier. Most did not respond to repeated messages inquiring about the counterfeit goods or the suppliers who provided them. One worker who did respond said he knew the Cabo pharmacy where he worked did not sell opioid painkillers because he was one of only two people who worked there. When a reporter explained that the store had sold fentanyl-tainted pills weeks earlier, his tone shifted. Instead of denial, some responded with fear. Watch L. Times Today at 7 p. Before joining the Los Angeles Times in , she spent nearly seven years in Texas, first covering criminal justice for the Houston Chronicle and then covering prisons for the Marshall Project. Previously, she wrote narrative pieces with a strong emphasis on the Latino community and others that make up the diversity of L. She joined The Times in Connor Sheets is an investigative and enterprise reporter at the Los Angeles Times. De Los. Times Everywhere. For Subscribers. All Sections. About Us. B2B Publishing. Hot Property. Times Events. Times Store. Special Supplements. Share via Close extra sharing options. Many pharmacies in Puerto Vallarta and other tourist-friendly parts of Mexico continue to sell fake medications to unsuspecting foreigners. Reporters visited 10 vacation spots and border towns across Mexico this year and bought controlled prescription medications from pharmacies. Tests showed many pills were tainted with powerful drugs including fentanyl, heroin, meth and MDMA. Many pills purchased by reporters in Mexico this year were lab-tested to confirm the initial findings from testing strips. A pharmacy in Cabo San Lucas advertises its wares to English-speaking visitors. Many also sell controlled medications — or counterfeit versions of them — upon request. In Puerto Vallarta, several pharmacies were raided by Mexican authorities in recent months, drugstore employees say. Officials would not elaborate on or confirm their accounts. A Mexican pharmacy offers a wide array of powerful medications over the counter. Earlier in , drugstores in Mexico tended to sell counterfeits of controlled medications as loose pills — but the fakes are increasingly sold by the bottle in convincing packaging. VIDEO More to Read. Chinese chemical manufacturer is targeted by federal prosecutors trying to stop flow of fentanyl. Old newspaper boxes are being used to distribute the overdose reversal drug naxolone. An industrial chemical is showing up in fentanyl in the U. Keri Blakinger. Brittny Mejia. Connor Sheets. More From the Los Angeles Times. Defense chief promises Ukraine what it needs to fight Russia but goes no further.

Some pharmacies in Mexico passing off fentanyl, meth as legitimate pharmaceuticals

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Official websites use. Share sensitive information only on official, secure websites. Corresponding author: Steffanie Strathdee, PhD, sstrathdee ucsd. Although most people who inject drugs PWID in Tijuana, Mexico, primarily inject heroin, injection and non-injection use of methamphetamine and cocaine is common. We examined patterns of polydrug use among heroin injectors to inform prevention and treatment of drug use and its health and social consequences. Latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past 6 month polydrug and polyroute use: cocaine injecting, cocaine smoking or snorting, methamphetamine injecting, methamphetamine smoking or snorting. Latent class membership was regressed onto covariates in a multinomial logistic regression. Latent class analyses testing 1, 2, 3, and 4 classes were fit, with the 3-class solution fitting best. Class 1 was defined by predominantly heroin use Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher risk sexual practices and lower heroin injecting frequency, and a group of methamphetamine users who were younger and more likely to be female. Discrete subtypes of heroin PWID were identified based on methamphetamine and cocaine use patterns. These findings have identified subtypes of heroin injectors who require more tailored interventions to reduce the health and social harms of injecting drug use. Keywords: polydrug use, latent class analysis, HIV risk, Tijuana, people who inject drugs. Use of multiple illicit substances, either over a short period or at the same time, has been associated with greater drug dependence, increased risk for overdose, and behaviors that are associated with increased risk for HIV and related infections. Motivations for polydrug use include preference for specific pharmacological effects, experimentation, availability of different drugs at different times, replacing use of one drug with another, and seeking stronger effects from drugs as tolerance increases Brecht et al. Tijuana, Mexico, is located on a major drug trafficking route and is unique as a city where heroin, and to a lesser extent, cocaine and methamphetamine are commonly injected. Heroin in this region is usually in the form of black tar, which is typically injected. Methamphetamine has become a major drug of abuse in Tijuana Brouwer et al. Among people who inject drugs PWID , it has also been associated with higher risk of needle and syringe sharing Rusch et al. Cocaine is also associated with high risk sexual behavior Brouwer et al. Heroin is often injected in combination with methamphetamine or cocaine i. Latent class analysis assigns individuals to classes on a probabilistic basis based on responses to a set of indicator variables, allowing comparison of covariates across classes. This method has been used to model patterns of substance use in general population samples Agrawal et al. Although specific drugs and route of administration varied by population and region, all studies found multiple classes of polydrug use, defined by single drug use, pairs of drug use, route of administration, and level of use. For example, in a sample of inner city heroin and cocaine users in Baltimore, Maryland, Kuramoto et al. In another sample of heroin and cocaine users in Baltimore, Harrell et al. Additionally, in a sample of opioid users in five Canadian cities, Monga et al. Due to different drug availability and contextual factors, drug use profiles of PWIDs in Tijuana are likely to be quite different than those of heroin and opioid users in other parts of North America. The objective of this analysis was to identify classes of polydrug use among heroin users in Tijuana Mexico, and to in turn compare these classes with respect to the HIV risk behaviors associated with each. In this analysis, we applied latent class analysis to describe subgroups or classes of cocaine and methamphetamine injecting and non-injecting polydrug use in a sample of heroin PWID. It was hypothesized that individuals in classes with more polydrug use would report more HIV risk behaviors. Participants were PWID enrolled from to in a prospective study examining contextual and behavioral risk factors for HIV, syphilis, and tuberculosis infection as previously described Strathdee et al. At baseline, eligibility criteria included having injected in the past 30 days, being aged 18 years or older, speaking Spanish or English, and residing in Tijuana with no plans to move over the next 18 months. Participants were recruited by respondent driven sampling to access a more representative sample of this hard-to-reach population Heckathorn, Eligible peers who enrolled in the study were then given the same number of coupons to recruit additional peers who injected drugs. From the initial group, 24 seeds recruited eligible peers. Additional information on recruitment procedures, tolerance, sample convergence, recruitment chains, and sample characteristics has previously been reported Brouwer et al. Of note, all 24 seeds were included in the analyses presented here. Participants provided informed consent and were given pre- and post-test HIV counseling; those testing HIV-positive were referred to local public health providers for free care. The survey included questions about demographics, substances used, frequency of use, route of administration, sexual behaviors, and drug use history and behaviors. Regarding substances used, participants were first asked if they have ever used a substance, and in the case of affirmative responses, they were asked to indicate the frequency of use of that substance in the past six months by route of administration injecting, smoking, or snorting. Frequency of substance use was dichotomized into yes or no for past six month use of cocaine or methamphetamine. Due to smaller prevalence and different risks from injecting, use via snorting and smoking was combined into non-injection use, resulting in four indicators of past six month polydrug use: methamphetamine injecting, methamphetamine non-injecting, cocaine injecting, and cocaine non-injecting. Demographic factors included age, gender, education, income, homelessness, deportation history, and being born in Tijuana. Education level was dichotomized as incompletion or completion of secondary school. Income level was dichotomized from an eight level categorical scale to greater than or equal to vs. Sexual behaviors in the past six months included reporting sex in exchange for something e. Drug use behaviors included frequency of heroin injection in the past 6 months, years since first injection, overdose in the past year, receptive needle sharing, and distributive needle sharing. Frequency of heroin injection was dichotomized into more than once a day versus once a day or less. A latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past six month polydrug use: 1 cocaine injecting, 2 cocaine smoking or snorting, 3 methamphetamine injecting, and 4 methamphetamine smoking or snorting. The latent class analysis was conducted in Mplus version 7. Next, several multinomial logistic regression models were fit with the polydrug use latent classes as the outcome variable. To better understand the unique and shared impact of demographics, sex behaviors, and drug use behaviors, three separate models were run with each set of covariates regressed onto the latent class outcome. Peer recruitment through respondent driven sampling may introduce dependence between observations, as participants may tend to recruit others who are similar on given traits of interest. Additionally, to account for the increased similarity among individuals in the same recruitment chain compared with those in different chains, Model 2 used a generalized estimation equation approach like the approach used by Rudolph et al. Finally, a sub-analysis was run examining simultaneous co-injection of substances. Prevalence of co-injection use was assessed for each class and chi-squared tests of association were run between co-injection and drug and sex risk behaviors. Among the participants, Less than half Baseline prevalence of HIV was 4. In the past 6 months, 9. Latent class analyses testing 1, 2, 3, and 4 classes were fit to the data. Latent class probabilities for each class were Class 1 was characterized by low probabilities of all four polydrug use indicators Class 2 had high probabilities of methamphetamine injection and non-injection 1. Class 3 had high probabilities. Despite their increased duration of injecting and more frequent injection of heroin, those using predominantly heroin class 1 shared syringes less class 1: Compared to those using predominately heroin, those in the heroin and methamphetamine use class class 2 were significantly more likely to be female, to use drugs before sex, and to inject with syringes that had previously been used by others. They were also significantly younger and had lower monthly incomes. Compared with predominately heroin users, those using methamphetamine, cocaine and heroin class 3 were significantly more likely in the past six months to have multiple casual sex partners, to participate in sex exchange, to report a prior overdose, to inject with syringes that had previously been used by others and they were less likely to report daily heroin injection. Interestingly, this group had higher levels of education and fewer individuals reporting injection of heroin more than once per day class 3: We assessed recruitment homophily, or the propensity for people to recruit others with similar characteristics, on the outcome of interest polydrug use class using RDSAT 5. Volz et al. Positive values indicate preferential recruitment of peers who are similar on a characteristic, negative values indicate an increased likelihood of recruiting peers who are dissimilar on a characteristic, and zero indicates that peers recruitment is random with respect to a characteristic. Together, the homophily indices and the p-value from the chi-squared test suggest that latent class membership among respondents was not completely independent of the latent class membership of their peer recruiters. As seen in Table 3 , the parameter estimates for Models 1 and 2 were nearly identical, though the confidence intervals were tighter around the parameter estimates in the GEE model. Although these classes were defined by use of methamphetamine or cocaine use by itself, many participants injected combinations of these drugs and heroin, so even in the non-polydrug use class there were individuals who had injected methamphetamine along with heroin, though not methamphetamine by itself. The majority of individuals in the methamphetamine, cocaine, and heroin use class In a sub-analysis, we assessed whether simultaneous use of pairs of drugs was associated with variation in sex and drug use behaviors. Chi-square tests of association between each pair of simultaneous drug injection and sex and drug use behaviors showed that injection of heroin and cocaine together i. In these bivariate analyses, simultaneous injection of heroin and cocaine or methamphetamine was associated with syringe sharing, and simultaneous injection of methamphetamine with heroin or cocaine was associated with increased sex risk behaviors. In this analysis of polydrug use among heroin injectors in Tijuana, we identified discrete subtypes of heroin injectors based on patterns of concurrent methamphetamine and cocaine use. Substance use type informed the formation of latent classes, but the route of administration did not. Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher risk sexual practices and decreased heroin injecting frequency and a group of methamphetamine users who were younger, more likely to be female, and with lower incomes. In general, the classes defined by use of more substances were associated with higher risk for overdose and with higher levels of HIV drug use and sexual risk behaviors. Receptive syringe sharing was more common in both of the polydrug use classes compared with the predominantly heroin using class. Though prevalence of HIV and syphilis were similar across the classes, higher prevalence of receptive syringe sharing and higher risk sex behaviors in the polydrug use classes especially the cocaine and methamphetamine use class poses a greater likelihood of transmission of blood-borne and sexually transmitted infections. The methamphetamine and cocaine class class 1 had a higher proportion of females, greater involvement in sex exchange, more casual sex partners, and more drug use before sex, suggesting that cocaine use may be driving these sexual risk behaviors. Interestingly, this group had higher levels of education and lower levels of daily heroin injection, likely supplemented by use of methamphetamine and cocaine. This class was also more likely to have reported an overdose in the past, which may be partly explained by the higher rates of simultaneous injecting drug use. Overall, polydrug use of methamphetamine, cocaine, and heroin compared with predominantly heroin use appears to be associated with more overdoses, more syringe sharing, and higher risk sex behaviors. We also observed higher prevalence of overdose for the two polydrug use classes: 9. Although this relationship only retained significance for the methamphetamine and cocaine class in multivariate analyses, polydrug use was in general more common among those with more polydrug use. Previous research on latent class analysis of polydrug use in users of illicit drugs has been conducted among illicit opioid users in Canada Monga et al. Though these studies had different indicators of polydrug use and were conducted in samples of injection and non-injection drug users in locations with less methamphetamine use, there were several notable consistencies between the present analysis and previous research. Among illicit opioid users in a multisite study in Canada, Monga et al. In the same sample Patra et al. In a sample of heroin and cocaine users in Baltimore, Kuramoto et al. And in another sample of heroin and cocaine users in Baltimore, Harrell et al. There were several limitations to this analysis. Generalizability of these findings to other drug using populations may be limited as these drug use patterns and contextual risk factors may be unique to Tijuana e. Additionally, to describe basic patterns of use, variability in frequency of use was reduced to any use in the past 6 months. Though there may have been some misclassification into classes, the average probability for most likely class membership was fairly high at Finally, with this cross sectional assessment we are only able to determine association, not causation. Through this analysis, we identified subtypes of heroin injectors who may require more tailored interventions to reduce the health and social harms of injecting drug use in Tijuana. In this and other resource limited settings, this work may be of value where there is greater need to tailor targeted interventions based on types of concurrent drug use. For example, PWID who use both heroin and cocaine may benefit from interventions that address both injection and sexual risk behaviors. Expanded access to sterile syringes through syringe exchange programs or pharmacies and overdose prevention efforts should be targeted to both groups of polydrug users, who reported higher levels of syringe sharing and overdose history. Future research is needed to explore variability in frequency of use and simultaneous drug use to determine if these patterns predict longitudinal patterns and changes in polydrug use. As a library, NLM provides access to scientific literature. Subst Use Misuse. Published in final edited form as: Subst Use Misuse. Find articles by MC Meacham. Find articles by AE Rudolph. Find articles by SA Strathdee. Find articles by ML Rusch. Find articles by KC Brouwer. Find articles by TL Patterson. Find articles by A Vera. Find articles by G Rangel. Find articles by SC Roesch. Issue date PMC Copyright notice. The publisher's version of this article is available at Subst Use Misuse. 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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