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With its superhighways, gleaming skyscrapers, fancy art museums and leafy plazas, Monterrey has always been safe — so safe, in fact, that drug lords chose to park their families here. Life in Monterrey represented another Mexico, cozily above the national fray of violence and disintegration. Now, however, as drug-trafficking syndicates expand their reach across Mexico, they have brought even Monterrey to its knees. Monterrey is perhaps paying the price for tolerating the presence of traffickers for so many years, allowing them to fester and grow amid the shared wealth. It is easier to get guns than a scholarship. In the space of a few weeks in recent months, drug gangs repeatedly blocked off city streets, snarling traffic and preventing police and soldiers from patrolling. Regular gun battles in and around Monterrey had claimed lives this year as of May 7, almost the same number as in the two previous years combined. The dead included two popular engineering students caught, apparently, in crossfire at the gates of their prestigious university. On April 21, 50 gunmen overran the downtown Holiday Inn, a high-end hotel popular with business travelers, forced the receptionist to ID guests and yanked four men and a woman from their fifth-floor rooms. A clerk from another hotel across the street, thought to be an informant, was also seized. They have not been seen since. Authorities later arrested seven police officers accused of helping the gunmen, who are believed to be members of a notorious drug gang known as the Zetas. On May 2, a single gunshot at a fairgrounds during an annual cattle festival triggered a panicked stampede of people in attendance. Five people were killed and dozens injured. For all its wealth, Monterrey is also home to circles of poor and out-of-work people whom traffickers have effectively exploited. As The Times reported last year, the Zetas began moving into the rough, neglected barrio of Independencia that slopes haphazardly up from the Santa Catarina riverbed. There they recruited young men as dealers, mules, spies and disciples. Today, the Zetas have launched a bloody battle to challenge the longtime dominance of their former patron, the Gulf cartel. It is being waged most ferociously in the northeastern state of Tamaulipas that borders Texas, in towns such as Reynosa and Nuevo Laredo, and has spilled miles southward to engulf Monterrey. Larrazabal said he inherited a police department rife with corruption and deeply infiltrated by drug cartels. But experts say it would take years to clean up the statewide police force. He acknowledged that the mayhem has hurt the local economy and stalled business recovery. Larrazabal spoke at City Hall, where hundreds of people were signing up for welfare benefits and unemployed demonstrators waved signs demanding work. Guns for everybody so we can defend ourselves? And so, as in so many other parts of Mexico, the citizens of Monterrey are changing the way they live. The frequent shopping trips to McAllen, Texas, have been curtailed; they drive the now-dangerous highway only at certain high-noon hours. They look over their shoulders, viewing one another with suspicion. 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. Reporting from Monterrey, Mexico — With its superhighways, gleaming skyscrapers, fancy art museums and leafy plazas, Monterrey has always been safe — so safe, in fact, that drug lords chose to park their families here. And as authorities lose control, the business elite is worried, ordinary residents panicked. But they came away with nothing but platitudes, one participant recalled. Tracy Wilkinson. More From the Los Angeles Times. California Navy identifies two aviators killed in crash near Mt. Rainier as California natives. Defense chief promises Ukraine what it needs to fight Russia but goes no further.

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Official websites use. Share sensitive information only on official, secure websites. Goodman-Meza and D. Werb conceptualized the idea for the article. Goodman-Meza conducted the literature review and evidence collection and wrote the initial draft. Medina-Mora and C. Werb, R. Landovitz, and S. Shoptaw critically revised the article. All authors contributed to the editing and final approval of the article. In North America, opioid use and its harms have increased in the United States and Canada over the past 2 decades. However, Mexico has yet to document patterns suggesting a higher level of opioid use or attendant harms. Historically, Mexico has been a country with low-level use of opioids, although heroin use has been documented. Low-level opioid use is likely attributable to structural, cultural, and individual factors. However, a range of dynamic factors may be converging to increase the use of opioids: legislative changes to opioid prescribing, national health insurance coverage of opioids, pressure from the pharmaceutical industry, changing demographics and disease burden, forced migration and its trauma, and an increase in the production and trafficking of heroin. In addition, harm-reduction services are scarce. Mexico may transition from a country of low opioid use to high opioid use but has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a widespread opioid use epidemic. Furthermore, continental drug trafficking patterns and similar approaches to opioid prescribing suggest that the current opioid use epidemic has likely been similar in the United States and Canada because of cultural and prescribing similarities. Curiously, Mexico has yet to document patterns suggestive of a national trend toward higher levels of opioid use Table 1. This has been largely related to its role as a transit and production country from which illicit drugs are trafficked to the United States, the ensuing violence associated with domestic efforts to disrupt this traffic, 11 and a high prevalence of injection drug use at its northern border and along drug trafficking routes leading into the United States. For the purpose of this essay, we define the opioid use epidemic as a rapid increase in the use of prescription and nonprescription opioids leading to intentional and unintentional harms i. We propose this definition to assess the risk that Mexico will experience its own opioid use epidemic and investigate strategies to mitigate these risks. Historically, Mexico has been a country with a low prevalence of substance use, with alcohol by far the substance most commonly used. The highest prevalence of heroin use occurred in men aged between 18 and 34 years, reaching 0. Heroin use in this region has been associated with economic disadvantage, sex work, internal displacement, and the presence of drug-trafficking routes. However, heroin use was also detected in states in the interior and south of the country, namely Morelos, Puebla, Guerrero, and Oaxaca. Misuse of prescription opioids in Mexico has been low. In , morphine was first regulated in Mexico. Since the s, several efforts by the World Health Organization WHO and national palliative care advocacy groups had failed to increase coverage of opioid analgesics in the Mexican market. Before , limits on the prescribed use of opioids in Mexico were largely attributable to legislative restrictions, which were extensive in comparison with those in the other North American countries. Another structural barrier had been the cost of opioids. For example, in , it was reported that a monthly supply of opioid therapy could cost more than twice the mean monthly salary in Mexico. However, a survey on risk perceptions of analgesics undertaken among more than medical students and residents reported morphine as being perceived as the riskiest, with its potential for addiction of highest concern. Nonetheless, a systematic review from the United States suggested that Hispanic American patients noted concerns about using strong pain medications, like opioids, and were more likely to use stoicism, religious coping, and catastrophizing, while also preferring nonpharmacologic treatments for pain though this review was not specific to Mexican Americans. These changes and their potential impacts in promoting an opioid use epidemic are summarized in the next sections. In , the structural barriers reported previously were highlighted in a report by Human Rights Watch, which stated that the lack of training for medical providers, their difficulties in prescribing opioids, and patient barriers to accessing palliative care services left many terminally ill patients needlessly in pain. In the United States, as the harms of opioid use have become increasingly widespread, the Food and Drug Administration requested that the highly addictive oral opioid oxymorphone hydrochloride Opana ER, Endo Pharmaceuticals be removed from the formulary, 38 while various states have initiated legal action against Purdue Pharma the maker of OxyContin and others for their role in contributing to the ensuing opioid overdose epidemic. As the population ages in Mexico, diseases linked to aging are more common. In , the 5 leading causes of disease burden in the country were chronic diseases: diabetes, ischemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders. Given the aging population in Mexico, it might be argued that traditional cultural beliefs that have limited opioid use may persist; nonetheless, the increased need for pain medication caused by chronic diseases may precipitate a change in beliefs, and lobbying by the pharmaceutical industry and increasing ease of prescribing may change beliefs at the provider level. Changes in attitudes toward opioids tied with structural factors opening up opioid prescribing may tilt the balance toward an epidemic. Deportation has been identified as a key risk factor for heroin injecting along the US—Mexico border. In a review of the effect of forced migration on substance use, Horyniak et al. The increase in Mexican production and trafficking of heroin has been accompanied by expanded use within the country. Given these factors, we note the real possibility of a widespread opioid use epidemic in Mexico in the coming years, particularly as the population ages. Mexico has the chance to mitigate the risks of widespread opioid use and their related complications see the box on page Because of the previous inaccessibility of opioids and low prescribing, Mexican providers e. Evidence-based prescribing methods are being adopted and tested in the United States 75—77 and could be tailored for Mexican providers. Furthermore, future generations of clinicians should receive this training during medical school education. Of concern, Mexico largely remains without access to key interventions that could limit potential opioid-related morbidity and mortality, such as adequate medication-assisted treatment MAT; e. Mexico could also implement or expand a variety of harm-reduction strategies that have been shown to reduce potential opioid-related harm or risk behavior. These include syringe distribution services, improving the interface of law enforcement and people who use drugs, provision of naloxone, and medically supervised injection facilities. Syringe distribution services have been implemented and found to be cost-effective in Mexico, 89 although these are limited to major cities, 85,90 and considerable stigma exists in Mexico regarding the purchase of syringes from commercial pharmacies. Finally, supervised injection facilities where PWID can use heroin or other drugs with sterile equipment under medical supervision have demonstrated health and cost savings in analyses undertaken in cities including Vancouver, Canada, 97 and Sydney, Australia. Mexico faces unique vulnerabilities given its geographic location, changing population demographics, and population disease burden, all of which place it at great risk of a widespread opioid use epidemic similar to that of the United States and Canada. The intersection of a fragile emerging social structure as a result of nationals returning through deportation from the United States; structural challenges in the treatment of pain; lobbying from pharmaceutical companies; increasing local production, distribution, and availability of heroin; and a lack of infrastructure to support evidence-based treatment of opioid use disorder are likely to increase the risk of a generalized Mexican opioid use epidemic. Nevertheless, previous examples of increased usage in settings with increased domestic availability of opioids as a result of international drug trafficking suggest that a grave risk exists that the combination of expanded access to prescribed opioids and local heroin production may lead Mexico past the threshold for an opioid use epidemic. Mexico has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a fate similar to that of its neighbors. Externally, Mexico is likely to face political pressure from the United States if it moves to enact formal regulation of currently illegal drugs and will also face concerns regarding reconciling this policy decision with its role as a signatory to the United Nations conventions on drugs as have other countries such as Canada in the wake of cannabis legalization. When one considers the high levels of human mobility among Mexico, the United States, and Canada, there is a shared continental responsibility to champion efforts to reduce the ongoing burden of preventable opioid-related morbidity and mortality. As US drug policy will likely continue to earmark aid toward supply reduction and military counternarcotics campaigns south of the US—Mexico border, Mexico should negotiate support for harm reduction and substance use treatment within its borders to accompany any such aid. Other collaborations could entail capacity building for providers in the areas of the prevention and management of chronic pain-causing conditions and provision of MAT. Finally, if and when new, safer medical drugs for treatment of pain or substance use come to market, preferential drug prices for Mexico should be negotiated and made available. Shoptaw and R. We are also grateful to the anonymous reviewers who provided suggestions to further strengthen the article. No human participants were part of this research. Institutional review board approval was not necessary. As a library, NLM provides access to scientific literature. Am J Public Health. Raphael J. Find articles by David Goodman-Meza. Find articles by Maria Elena Medina-Mora. Find articles by Raphael J Landovitz. Find articles by Steve Shoptaw. Find articles by Dan Werb. Accepted Sep 9; Issue date Jan. Open in a new tab. See also Palinkas, p. 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. Prescribing based on evidence-based conditions and only when nonpharmacologic therapies and other analgesics have been tried. Evidence-based early detection and treatment programs e.

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