Friedman Joseph, Godvin Morgan, Molina Caitlin, Romero Ruby, Borquez Annick, Avra Tucker, Goodman-Meza David, Strathdee Steffanie, Bourgois Philippe, Shover Chelsea L
Center for Social Medicine and Humanities, University of California, Los Angeles.
The Action Lab, Center for Health Policy and Law, Northeastern University.
medRxiv. 2023 May 31:2023.01.27.23285123. doi: 10.1101/2023.01.27.23285123.
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 2018. In 2021-2022, 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. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. 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.
Of n=40 pharmacies, one or more of the requested controlled substance could be obtained with no prescription (as single pills or in bottles) at 28 (70.0%) and as single pills at 19 (47.5%). Counterfeit pills were obtained at 11 pharmacies (27.5%). Of n=45 samples sold as one-off controlled substances, 18 were counterfeit. 7 of 11 (63.6%) samples sold as "Adderall" contained methamphetamine, 8 of 27 (29.6%) samples sold as "Oxycodone" contained fentanyl, and 3 "Oxycodone" samples contained heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and "painkillers". 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. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.
基于芬太尼和甲基苯丙胺的假冒处方药在美国导致过量用药死亡率不断攀升，然而其在墨西哥的情况尚未得到评估。自2018年以来，我们的人种志研究团队一直在墨西哥北部针对非法毒品市场开展纵向研究。在2021年至2022年期间，研究参与者描述了一种新型、药力异常强劲的药片的出现，这些药片被当作表面上的管制药物出售，无需处方，直接来自面向美国游客的药店。
描述墨西哥北部药店向无处方的讲英语游客提供假冒和正宗管制药物的情况。
我们采用了迭代式、探索性混合方法设计。纵向人种志数据用于描述以游客为导向的微型社区，并指导在墨西哥北部4个城市的40家药店的选择。在每家药店，以英语交流时索要“羟考酮”“阿普唑仑”和“安非他明”的单粒药片样本，之后记录详细的人种志描述。我们使用基于免疫分析的检测试纸检查每粒药片中是否含有芬太尼、苯二氮卓类药物、苯丙胺类药物和甲基苯丙胺类药物。我们使用傅里叶变换红外光谱进一步表征药物成分。
在40家药店中，28家（70.0%）无需处方（以单粒药片或瓶装形式）就能获得一种或多种索要的管制药物，19家（47.5%）能获得单粒药片。在11家药店（27.5%）买到了假药。在作为一次性管制药物出售的45个样本中，18个是假冒的。作为“安非他明”出售的11个样本中有7个（63.6%）含有甲基苯丙胺，作为“羟考酮”出售的27个样本中有8个（29.6%）含有芬太尼，3个“羟考酮”样本含有海洛因。提供假药的药店都位于面向游客的微型社区，通常有治疗勃起功能障碍药物和“止痛药”的英语广告。药店员工偶尔会表达对过量用药风险的担忧，并提供减少伤害的指导。
在墨西哥北部面向游客的独立药店中，基于芬太尼、海洛因和甲基苯丙胺的假冒药物的存在构成了公共卫生风险，且发生在以下背景下：1）医疗旅游常态化，以应对美国医疗保健费用不断上涨导致人们难以承受的情况；2）美国阿片类药物处方率骤降，这既影响了慢性疼痛患者，也影响了不受监管市场上合法药品的供应；3）基于芬太尼的假冒阿片类药物的兴起，成为阿片类药物危机第四波也是迄今为止最致命一波浪潮的关键驱动因素。无法根据药片外观或药店地理位置来区分假药，因为外观相同的正品和假冒药品往往在地理位置上很接近。然而，药品消费者可能会更信任直接从药店购买的管制药物。由于墨西哥阿片类药物过量用药监测基础设施有限，目前这些物质导致的死亡率尚不清楚。
