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Psychosocial reintegration process in patients who receive maintenance treatment with methadone: A qualitative analysis.

INTRODUCTION

People using opioids such as heroin, a substance that usually involves intravenous injection, not only face serious health risks, but are one of the most deprived, marginalized, and stigmatized group of people who use drugs (United Nations Office on Drugs and Crime [UNODC], 2018).

To treat these patients, the use of opioid replacement therapies has been recommended as the first-line choice (Bruneau et al., 2018; World Health Organization, 2009), of which methadone maintenance treatment (MMT) has been recognized as one of the most cost-effective interventions in managing dependence (Mattick, Breen, Kimber, & Davoli, 2009).

Since its inception, MMT has been evaluated in terms of pharmacological safety and medical benefits (Joseph, Stancliff, & Langrod, 2000). In this respect, it is known that MMT reduces the morbi-mortality attributable to the use of opioids, the costs derived from the associated crime, and the transmission of infectious-contagious diseases such as acquired immunodeficiency syndrome and hepatitis C (Harris et al., 2006), thus contributing to improve the social functioning and quality of life of patients (Khalatbari-mohseni et al., 2019; Fernandez Miranda, 2005).

MMT has been successfully implemented in various clinical settings (Harris et al., 2006) and typically incorporates some form of psychological intervention designed to promote the rehabilitation and social reintegration of patients (Brands, Blake, & Marsh, 2003). It has been emphasized that the incorporation of such elements for social reintegration should be an integral component of addiction treatment (Verster & Solberg, 2003), in order to address the social precariousness that affects people using drugs in general and intravenous heroin in particular (Solal & Schneider, 1996).

Although it has been documented the process of social reintegration is linked to various factors associated with greater therapeutic adherence, such as patients characteristics, individual needs, expectations, and satisfaction with treatment effects (Singh Shrestha, & Bhandari, 2014). The aim of this paper is to contribute to the understanding of the process through an emic analysis of the forms of discursive expression whereby patients with heroin dependency problems who participate in an MMT describe and signify their experience.

METHOD

Study design

Qualitative study of multiple cases, through which we seek to obtain an ideographic understanding of the topic of study based on the experience and meanings given by the participants (Creswell, 2007). We assume a constructionist perspective which presupposes that the way members of a society interpret the reality in which they live contributes decisively to shaping this reality.

This study was conducted in 2012 as part of an evaluation of the Methadone Maintenance and Detoxification Treatment (MMDT) given at a Heroin Treatment Center (HTC) of Centres de Integration Juvenil, in the city of Tijuana.

Participants

Study participants included patients of both sexes who were receiving maintenance treatment with methadone, who were over 18 years old and who agreed to participate in the study.

The sample was integrated by convenience but sufficient to get theoretical saturation.

Sites

The MMDT offered an opioid replacement alternative for people using injected heroin in hospital or outpatient treatment, seeking to reduce the damage associated with use and improve the living conditions of patients. It consisted of three components: 1) detoxification, designed to stop opioid poisoning through safe medication with methadone; 2) maintenance, consisting of stabilization with methadone to prolong abstinence; and 3) rehabilitation, aimed at promoting the reintegration of patients into the family and social environment, for which it incorporated psychotherapeutic interventions focused on preventing relapses and developing social skills, through individual, group and family inter ventions. These activities were voluntary and made available to patients on a regular basis.

Procedure

Interviews were conducted at the HTC treatment facilities, individually, face to face, and audio-recorded. Identification data were recorded, including age, sex, and pseudonyms selected by the respondents. The interview guide was designed to explore the experience of patients in the program, the process of heroin substitution, implications for their health and psychological state, the situation regarding their family and social integration, and the perceived quality of the service. To this end, open questions were formulated: What has your experience of the program been like? What changes have you experienced in the treatment? How have you felt?, and so on. The interviews were conducted by two researchers with field experience, according to general technical guidelines previously agreed upon, with the necessary conditions of silence, privacy, and safety. The interviews lasted between 40 and 60 minutes and were conducted in a single session.

Most were transcribed with a naturalistic approach, with an intermediate level of editing (Farias & Montero. 2005), following the grammatical conventions of Spanish, but with respect for idiosyncratic expressions, phrases, and other characteristics of spoken language. However, one case could only be retrieved through an interview report prepared as a content report. With regards this English version, we could say that even when many idiosyncratic linguistic twists and connotations were lost in translation, it sufficiently reflects the denotative content of the speech.

The "textualization" of the interview segments included in this paper was undertaken with strict adherence to the recovered transcripts, although occasionally, when the content allowed, we took the liberty of incorporating fragments from different moments of the interview or making adjustments to ensure the consistency and congruence of the material or simplify its presentation, eliminating interpolations or excessive repetitions.

Following the review of the transcribed interviews, two cases that failed to offer adequate discursive density were discarded, as a result of which the sample compiled 12 interviews of heroin-dependent patients, 11 men and one woman (Nicte), with the next characteristics (Table 1):

Data analysis

The materials were analyzed in two steps, through narrative and thematic analysis methods. First, we selected--on the basis of the criterion of narrative density--an interview segment as an example that would make it possible to establish a first "diagram" of the discursive contents of interest. According to Agamben (2010), an "example" or "paradigm" is a singular element of a class of objects that it, while being subtracted as example, contributes to constitute. When taken as an example, a specific case allows to define, in its singularity, the intelligibility, structure, and conditions of existence of the whole class (Castro, 2012).

From the analysis of this segment, and according to the logic of real life events depicted in narration (Bal & Van Boheemen, 2009), we identified four clearly differentiated narrative sequences: a) drug abuse and social exclusion before treatment, b) construction of the relationship with the therapeutic system, c) therapeutic process, and d) ongoing social reintegration. We also constructed, through standard coding procedures (Coffey & Atkinson, 2003), a first set of thematic categories, including two dimensions of global semantic articulation, related to how to deal with drugs, and to the expected social reintegration.

Subsequently, as the core phase of analysis, we proceeded, through thematic analysis (Aronson, 1995; Braun & Clarke, 2006; Mieles Barrera, Tonon, & Alvarado Saigado, 2012), to identify patterns of meaning that would provide an understanding of the corpus of study, and would allow us to corroborate, expand, and adjust the initial system, of codes and categories. This led us to a last set of semantic-discursive units, i.e., significant elements that share common spheres of meaning and maintain relationships of implication, causality, contradiction, complementarity, and so on. These discursive units distributed distinctly throughout the four narrative sequences, and according to the two transversal axes of discursive and semantic articulation (Figure 1). A sample of these discursive units is presented in the tables.

The joint analysis of materials, the comparison of reviews carried out separately, and a constant discussion of the categories in development enabled us to achieve a reasonable level of "theoretical saturation", with enough iterations and variations of discursive enunciates within our two main thematic axes. The analysis was performed using a text processor.

Ethical considerations

According with the regulatory policies, this study was undertaken in compliance with ethical principles of voluntary participation and confidential data management. Additionally, obtained approbation by the institutional ethical committee.

RESULTS

Paradigm for reading and first categories system

The following is an excerpt from the interview with Matus, a 41-year-old patient who had a criminal record for attempted murder and possession of weapons used by the army, who had lived for years in poverty, and had been in MMDT for two years, participating in individual and group psychotherapy:
"My experience here has been very good; they have helped me. When I
arrived, I was in a really bad state... The first twelve months I spent
here I was in a bad state... because I used methadone, I used pills, I
used crystal, in other words, I used a hotchpotch of things. In my
individual therapies, even Dr. V. once said to me: Why do you come
here? Because I used to fall asleep. She used to tell me: Because
you're just taking up a place...And there are people who really want to
get better. And I think it was the disease itself, I was in a bad
state. But she was patient with me, she guided me, she started giving
me books... to read, very good books, she told me: This can motivate
you. And, for some reason, she hit the nail on the head.

Then there was Dr. T, who gave me the group sessions, and was also very
patient with me. I remember once, I dunno, he said... I got up very
angrily, I was annoyed by something he said, and he calmly replied: No,
look, it's your illness that makes you react like that, and that made
me think: Why...if I'm so rude, do they keep treating me well? And
that's when I started to pay more attention, and I said: There's no way
they can be more worried more about me than I am. They told me things,
you know, because... they said: Look, you're gap toothed..., and that
happened to me because I wasn't clean, I did not bathe, I was always
dirty. I thought they were just saying that to annoy me, but...I began
to understand people 's facial expressions and I saw that they weren 't
saying that because of discrimination, they were telling me that
because they cared.

So, I started to take time, and... I do not know if it was because they
repeated it to me so often... I started to get my teeth fixed and then
I began... And the doctor, who saw I liked to read, said: Why don t
you go to school? I hadn 't finished middle school, I have just
completed it... Now I look cleaner and my family is more respectful to
me...


In this fragment, we can identify elements of a typical narrative structure that links moments or sequences of a process which, beginning with an initial condition, is oriented through a series of episodes and actions as a result of achieving a new state of things. It is a structure of achievement and improvement in which substance abuse is postulated as the initial condition: "When I arrived, I was in a really bad state... The first twelve months I spent here frankly I was in a bad state... because I used methadone, pills, crystal..., " with a negative connotation: "I used a hotchpotch of things." This starting point is altered by two factors of change, resulting from the intervention of the therapeutic system, which refer to elements of a clearly normative nature. First, a call to take responsibility: "... Dr. V. once said to me: 'Why do you come here?'.... She used to tell me: "Because you 're just taking up a place... And there are people who really want to get out of the disease." Second, the fact that the interviewee did not receive the discriminatory treatment and rejection he expected: "But she was patient with me, she guided me, and started giving me books," "Dr. T. was also very patient with me. "

As a result of the "trigger" effect of these two factors, the story takes place through various elements of action:

--Becoming aware: "I was in a bad way."

--Giving oneself time: "Then I started to spend time on myself."

--Assuming responsibility: "I started paying more attention to things... "

--Becoming aware of the acceptance of the therapeutic team: "There's no way they can be more worried about me than I am; I began to understand facial features; I understood that they weren 't saying this to me out of discrimination. "

--Change of self-image: From: "If I'm so rude" or "I did not bathe," "I was always dirty," to: "Now I 'm cleaner."

This set of actions would eventually lead to outcome conditions, related to: a) returning to a school setting: "She said: 'Why do not you go to school? 'I hadn't completed middle school; I have just finished it...;" b) self-care: "I began to get my teeth fixed...;" and a possible change in family relationships: "And my family is more respectful to me..."

This yielded four narrative sequences (background, triggers, narrative action, and outcome) referring to four distinct phases in the treatment and reintegration process:

1. Background conditions of participation in the MMDT that include an initial state with negative connotations (in the case of Matus, an explicit reference to substance abuse), which is therefore expected to change.

2. Story trigger factors, which in this case allude to the first and subsequent meetings with the members of the therapeutic system.

3. Process of adjustment throughout the treatment, comprising a range of actions and measures taken to achieve change.

4. Social reintegration, which includes, as an outcome, a redefinition of self-image and the relationship with drugs, environment, and agencies of conventional normative society.

Thematic analysis

In the course of the interviews, the four sequences identified do not necessarily unfold in a linear and clearly differentiated way, but may be confused, inverted, repeated, and so on. In any case, they offer a logical framework that allows for the analysis of the remaining cases according to a typical articulation of a dominant social discourse.

Background conditions

The conditions described before participation in the MMDT point in two directions. First, a topic related to addiction, around which an initial semantic and discursive field is formed defining addiction as being related to submission to a compulsive, irrepressible need (Table 2, segments 2.1.1, 2.1.3). It also refers to an idea of an exceeding, overflowing use, with a combination of various "hard" drugs (2.1.5). At the same time, meanings of insensitivity, anesthesia, or lethargy are attributed to it: "Being in a bubble" (2.1.1, 2.1.2, 2.1.4) and a disturbing effect of "nerves" and "cold turkey" (5.2.3 and 5.2.8). It is also associated with images of "getting hooked", signified as impotence (2.1.4); and of heroin as a "cane" enabling one to walk; of the addict as a "drowsy" subject, "enthralled" by the drug (2.1.3, 2.1.4); and of "reaching rock bottom" as a profound moral and spiritual collapse (2.1.6). Lastly, addiction is linked to relapses, attributed to depression, family and personal problems (2.1.7) and, above all, to the influence of other addicts (5.1.3, 5.1.4). At the same time, it is possible to distinguish, also as an antecedent, social deprivation, including violence and anomie. This involves the prevalence of situations of extreme precariousness and destitution (2.2.1, 2.2.2), discrimination (2.2.3), and violence that goes from the family (2.2.4) to criminal behavior (2.2.5). However, the most frequently observed elements, constituting a central semantic field, refer to invalidation and labeling, with situations such as discredit within the family (2.2.6) and police harassment (2.2.7), whose reiteration affects the internalization of rejection and the production of a profound regulatory gap (2.2.8). Both discursive fields: deprivation and social stigma, share the same sense of exclusion, so they can be assigned to a common thematic axis. Thus, from the same background of treatment, it is possible to infer two axes of thematic articulation which, as will be seen below, are valid in the description of the three remaining phases of the process. The first refers to addiction and dealing with substances; the second, to integration into conventional normative society. Consequently, the analysis of the following phases of the process is carried out considering its link with these two thematic categories, which would therefore operate as transversal axes.

Relationship with the therapeutic system

The second sequence comprises the initial contact with the MMDT and refers to the way the interviewees define the relationship they establish with the therapeutic system.

From the perspective of addiction and substance handling, two opposing discursive fields are formulated. The first involves the question of medication and the pharmacological effects of methadone ("something that touches your brain "), which are given positive connotations and postulate a relationship between taking drugs in regulated doses and obtaining positive results: "being well," "going out looking clean " (Table 3, segments 3.1.1 to 3.1.5); the second raises the problem of being "tied" to the program (3.1.6) and of developing an addiction to methadone (3.1.7), including the expectation of reducing the dose in order to be "independent" (3.1.8).

With regard to the axis of normative integration, one can also see the formation of two semantic-discursive fields, in this case of a complementary nature. In the first place, there is a description of the availability of the service in terms of "open doors" and "feeling attended" (3.2.1), as well as the characterization of the treatment received in terms of adjectives such as "professional," "disinterested," "decent," "humane," "kind," and "respectful" (3.2.2 to 3.2.4). This positive evaluation of the relations established in the therapeutic context intersects with a second domain of "undoing labeling," through notions such as "acceptance, " "support," and "tolerance" that define the attitude adopted by the therapeutic team (3.2.5) and contrast with the previous experience of rejection, thus reversing the fear of being once again subject to stigmatization (3.2.6 and 3.2.7). The effect attributed to undoing labeling is associated with feelings of understanding and trust (3.2.8).

On the other hand, an expectation of guidance was also recorded, expressed explicitly by one of the participants and denoting the establishment of a relationship of dependency on the therapeutic system (3.2.9).

Adjustment process in the treatment environment

Based on the relationship established with the therapeutic system, various issues associated with the actions and measures adopted are displayed, as part of the treatment process, to achieve change.

Regarding the issue of addiction and substance use, the main effects of methadone are cited as being on subjective well-being and adjustment capacity (Table 4, segment 4.1.1), which seem to be attributed, without any mediation, to the effectiveness of the medication alone. However, they are also linked to the need to learn and to develop skills to "be able to walk without a cane" (4.1.2), which could be associated with the expectation of guidance. Other elements include the need to strictly adhere to methadone administration and the benefits of participating in other components of the program: individual psychotherapy and group and family therapy (4.1.3 to 4.1.5). According to the respondents, participating in the program, without restricting themselves to taking the medication, provides the possibility of understanding the meaning of the treatment (4.1.6).

The effort made in the treatment to achieve the purposes of social reintegration encompasses several other thematic fields or spheres of action. A first action that could be considered a point of support for the development of this sequence is "giving oneself time" or "giving the process" time. This triggers a triple process of cognitive change ("realizing"), affective change ("internal work") and normative adjustment (which can be summarized as "learning to control oneself). The field of meanings of "realizing" includes, first of all, becoming aware, the perception of having a problem, and the aim of informing oneself about the process of change (4.2.1) to achieve understanding (4.2.2). and 4.2.3); "understanding" the implications of heroin use, the reasons for beginning to use it, the meaning of treatment, and recognizing the true intentions of the family in encouraging the interviewees to seek treatment, and "things about myself," affects and fears, "grudges and bad thoughts" (4.2.3).

Affective change includes an effort to undertake internal work (4.2.4) which, following the catharsis, "shogging off many things about myself, can lead to an affective change primarily identified as the achievement of peace of mind, motivation to change and enhanced self-esteem (4.2.4 to 4.2.6). Likewise, emotional work or that involving "internal complexes" is associated with the modification of attitudes and the building of new skills (4.2.7).

Third, adjustment in the context of treatment implies the possibility of learning to control oneself and to function, presumably within conventional society (4.2.8). It also means reconsidering and assuming responsibility, in a broad sense that implies reciprocity to others, as well as restoring balance, mainly in the family, by adjusting habits and lifestyles, all of which contributes to the possibility of new identity definitions (4.2.9).

In the same way, it expresses the possibility of thinking about the future, which is projected in the expectation of joining the conventional spheres of work and family (4.2.10), which in some cases, invites them to recover lost values, learned in the family, useful for normative adjustment (4.2.11), or for developing adaptive skills to reverse the effects of exclusion, which show the main role that language and communication skills could have in the process (4.2.12).

Finally, the treatment process also involves the family, both in the sense of bringing it closer to the patient's problem (4.2.13) and in bringing the latter to new forms of rapprochement (4.2.14).

Social reintegration

This phase points to the outcome of the process. The emphasis is on the conditions of the external environment, which, however, reflect the efforts and attempts to change made within the therapeutic process.

Concerning addiction and dealing with drugs, the main issue is the redefinition of the relationship with them, a field in which respondents specifically raise the issue of avoidance. First of all, they mention avoiding drug abuse networks and areas where drugs are available, which is linked to the search for new friendships and the formation of new support networks within normative society, or confinement in the domestic sphere and social isolation (Table 5, segments 5.1.1 to 5.1.3). This is due to the certainty of the risk of relapse (5.1.4), and the reduction of the risk of contagion (5.1.5). Silence around the issue of drugs in the family is also mentioned. (5.1.6 and 5.1.7).

Regarding the issue of incorporation into the normative environment, a couple of expressions are proposed as guiding ideas: leading a life like that of "normal" people and taking responsibility, with a clear imperative connotation (5.2.1). However, one of the issues that is consistently identified is coming out of anesthesia, "reconnecting" and "feeling again." It is not only a question of recovering the ability to enjoy and experience affects (5.2.2) but also of recovering the sensitivity of the body and opening up to the world and others. This experience refers to a new state of well-being (5.2.3) and tranquility (5.2.4). Concomitantly, there is a perception of improvement (5.2.5) that refers to both the ability to reinsert oneself into an institutional setting, and to establish significant interpersonal relationships. All these can be linked to the adoption of positive attitudes (5.2.6) and normative expectations.

Among the factors pointing to change, the respondents cited health care and its effects: "Cleaning up the body," "Waking up without feeling nervous" (5.2.7, 5.2.8), changing their physical appearance and body image (5.2.9, 5.2.10), as well as changing their habits and lifestyles (5.2.11). At the same time, there is a recognition of a change in attitudes among people around (5.2.12, 5.2.13) which in some way, lends continuity, in the external environment, to the undoing of labels. The perception of this change ("being seen differently") reinforces feelings of acceptance, validation, and support. Finally, there is a development or recovery of social and communication skills, which permits rapprochement with representatives of the dominant society. It also involves the basic interaction skills required to chat up a girl (5.2.14), take part in a job interview, or engage in conversation with people regarded as being from a higher class. With regards the social spaces in which the reintegration process takes place, the first thing is the importance given to the family, with which a re-encounter takes place, allowing the re-establishment of acceptance, trust, and mutual care (5.2.15 to 5.2.17). The work sphere also plays an important role in the process of the "normalization" and development of regulatory mechanisms (5.2.18 to 5.2.20), as does going back to school and joining religious groups.

DISCUSSION AND CONCLUSION

The analysis undertaken reveals the predominance of narratives with a typical structure that coincide with those identified some time ago by structural analysis (Barthes et al., 1972) and sociology (Labov, 1972). This narrative structure makes it possible to give a pattern, shape, and meaning to the experience of normative adjustment, tracing an upward trajectory characteristic of a progressive narrative of achievement and improvement (Gergen, 2007), with a strong psychosocial content.

Accordingly, this paper allows an approach to "emic" elements of experience (Albertin Carbo, 2000) that yields thematic spheres referring to a process of social and normative adjustment. Without being exhaustive, we can highlight the following:

--The problem of drug use and the relationship with substances. Despite being in a process of reconfiguration, this issue is not necessarily resolved, leading to avoidance and concealment strategies with a high psychosocial cost. These aspects have been highlighted by Lopez Torrecillas, Peralta, Munoz Rivas, and Godoy (2003) and Rodriguez Kuri, Cordova Alcaraz, and Fernandez Caceres (2015).

--The social rejection, outcasting, and precariousness, which place the heroin addict in a particular condition of vulnerability. Regardless of whether social exclusion is considered an antecedent or a consequence of drug consumption, it involves a complex combination of interrelated problems such as unemployment, low economic income, loss of skills, the erosion of support networks, exposure to violence, and the breaking of balance in family and other institutions (March, Oviedo-Joekes, & Romero, 2006; Epele, 2010). In Mexico, Fleiz and collaborators have documented factors of this nature associated with exclusion (Fleiz et al., 2019). Disaffiliation and social exclusion combine the effects of psychosocial deprivation, invalidation and rupture of primary integration networks, which lead to the loss of a socially recognized place (Castel, 1997).

--The experience of undoing labeling and gaining acceptance and recognition, to which, according to the testimonials of the respondents, we must grant a central place at the beginning of the treatment and process of change. It implies putting the incidence of relational and interpersonal factors in first place, in accordance with Rubio Arribas (2001) and Pascual Molla and Pascual Pastor, (2017).

--The importance given to the experience of "reconnecting" and "feeling again" which, from a subjective perspective, allows to attribute meaning to the reestablishment of a place in the world, enabling the subject to aspire to recognize himself as a human being with full rights, with the capacity for self-observation, becoming closer to others, and having agency over reality (Krause et al., 2006).

--Self-care and the development of "lifestyles" and skills for interaction as a twofold strategy of normative adjustment within the dominant framework of normality, including, in particular, linguistic and communication skills for interaction with representatives of the conventional society. That is to say, work with and on oneself, which has been considered the foundation of the ethical subject (Foucault, 1984).

--The naturalization of a stereotyped representation of the family and of the means of adjustment (incorporation into educational, work, or religious institutions), which reflects the dominance of relatively rigid conventional adaptation imperatives (Rodriguez-Kuri & Fernandez Caceres, 2014; Osuna Diaz, 2013).

Based on these findings, we can emphasize the advisability of making the treatment approach more flexible, in order to accompany and reinforce the reintegration process without providing scope for the reproduction, from the therapeutic system, of new forms of dependence or abuse (Albertin Carbo, 2000). Our study shows the importance of incorporating psychotherapeutic components that offer integral adjustment alternatives and encourage the broad participation of patients.

Within the therapeutic context, it is worth mentioning the suitability of alternative approaches aimed at the person and not exclusively focused on the addictive process (Brands, Blake, & Marsh, 2003), adapted to the particular needs of each patient, strengthening the socially validated effect of acceptance and recognition that seems to be a central aspect of the patients' experience.

It is also advisable to develop care strategies that permit closer links between the therapeutic system and the environment, in order to more effectively remove the mechanisms of exclusion and stigma that usually continue operating, as well as to reverse the "deviant" affiliation of those affected (Singh et al., 2014; Verster et al., 2003).

It is also possible to recommend the development of follow-up or accompaniment strategies that will enable the process of change in the external environment to continue, in order to address the relationship between exclusion and relapse conditions. In this respect, it should be noted that the lack of knowledge of both the relational dimensions of reintegration and the suffering associated with exclusion can play a decisive role in the persistence of substance use (Harris et al., 2006; March et al., 2006; Verster et al., 2003).

It is also possible to implement harm reduction programs that imply a different perception of the patient and their needs, such as safe injection rooms, the provision of naltrexone or naloxone to cope with an overdose crisis, and the distribution of methadone for external administration (Priest et al., 2019; Brands et al., 2003; Gutwinski et al., 2013).

Moreover, the implementation of programs must be based on the development of public policies that not only consider the problem of poverty and social and economic precariousness (Verster et al., 2003), including aspects such as access to employment, housing, and dignified salary, but also aspects such as the response of structures in normative society to addicts' attempts at reintegration.

From a methodological point of view, all of the above results point to the advisability of using indicators sensitive to the various components of the reintegration process in the evaluation of programs, beyond a purely functionalist vision focused on aspects such as obtaining employment or a reduction of antisocial behavior (March et al., 2006).

To conclude, we point out some limitations of this paper. As any exercise of elucidation of the meaning of experience, the one carried out in this work does not constitute but a set of conjectural hypotheses of a material that, from other angles and at other moments, could undoubtedly offer other reading perspectives. Limitations also include those of a qualitative design, which limits the generalization of findings or refers to the specific characteristics of the population segment from which the sample was drawn. One aspect that warrants further exploration, for instance, is the conditions of acute disaffiliation and exclusion that are likely to affect social groups such as women addicts, HIV patients, migrants, and ex-convicts (Joseph et al., 2000; UNODC, 2018).

Funding

None.

Conflict of interest

The authors declare they have no conflicts of interest.

Acknowledgements

We would like to thank Raul R. Palacios for his support in carrying out this work and Sara E. Garcia Gutierrez de Velasco for sharing some significant clues for the analysis of cases.

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David B. Diaz-Negrete, (1) Marina Velazquez-Altamirano, (2) Jose L. Benitez-Villa, (1) Carmen Fernandez-Caceres (3)

(1) Direccion de Investigacion y Ensenanza, Centros de ntegracion Juvenil, A.C., Ciudad de Mexico, Mexico.

(2) Departamento de Investigacion Clinica y Epidemiologica, Centros de Integracion Juvenil, A.C., Ciudad de Mexico, Mexico.

(3) Direccion General, Centros de Integracion Juvenil, A.C., Ciudad de Mexico, Mexico.

Correspondence: David B. Diaz Negrete

Direccion de Investigacion y Ensenanza, Centros de Integracion Juvenil. Avenida San Jeronimo 372, Col. Jardines del Pedregal, Alcaldia Alvaro Obregon, C.P. 01900, Ciudad de Mexico, Mexico.

Phone: +52 [55] 5999 - 4949, ext. 1911

Email: dir.invens@cij.gob.mx

Received: 11 April 2019

Accepted: 3 June 2019

DOI:10.17711/SM.0185-3325.2019.023
Table 1
Patients characteristics

                           Age of drug  Age of heroin
                  Age      use onset    use onset

Case (pseudonym)  (years)  (years)      (years)

Ozzy              22        (*)          (*)
Nicte             28        12           16
Aguila            31        11           20
Angel             33        (*)          (*)
Smiley            33        12           18
Juan              36        10           22
Johny             39        17           26
Matus             41        12           16
Junior            42        10           23
Memo              45        10           19
Meno              45        12           22
Rogelio           45        15           26

                                    Methadone
                  Substances used   initial dose

Case (pseudonym)  in last 30 days   (mg)

Ozzy              TB, MJ, MTH, HR,   (*)
Nicte             TB, HR             40
Aguila             (**)              80
Angel             TB                 (*)
Smiley             (**)             110
Juan               (**)              80
Johny             TB, MJ, HR         50
Matus             TB                 60
Junior            MJ, MTH, BZ, HR   130
Memo              MJ, HR             40
Meno              HR                100
Rogelio           TB                 80

                  Methadone      Lapse in metha-
                  stabilization  done maintenance

Case (pseudonym)  dose (mg)      treatment

Ozzy               (*)           1 week
Nicte              40            2 years
Aguila            120            6 months
Angel              (*)           6 months
Smiley            110            7 weeks
Juan               80            2 years
Johny              50            2 months
Matus             100            2 years, 10 months
Junior            100            2 years
Memo               40            1 year, 6 months
Meno              100            6 months
Rogelio            90            2 years

Notes: (*)(no information avialable), (**)(no consumption reported).
TB: tobacco; MJ: marijuana; MTH: metanphetamines; HR: heroin; BZ:
benzodiazepines.

All participants reported injecting heroin.

Table 2
Segments related to conditions prior to treatment

Axis: Addiction and
dealing with substances    Axis: Social and normative integration

2.1.1. I used to
get up to use drugs
and then I had
to chase money,            2.2.1. At least I'm not on the street
money, money,              [Nicte, 28 years old].
and I didn't have
time for my
hygiene, for bathing,      2.2.2. I lived in the street, going hungry,
because that was a         eating garbage, asking for money, putting
waste of time ...          out my hand, I did all that, many things,
Everything I earned        I prostituted myself with homosexuals
I spent on                 and so on... [Junior, 42 years old].
drugs, however much,
or kept it for
another dose...
I was numb,
anesthetized...
[Eagle, 31 years old].     2.2.3. Three times they deported me and
2.1.2. With heroin,        I went back... And they separated me
I was like in my           from my child, he was about six years
bubble... In my            old... Not because I had
addiction I only           committed a crime, just because
thought about how          I was Mexican [Rog- elio, 45 years old].
I'd get my fix,
what time I was
going to go to get
it, I didn't enjoy
being with my family
... [Ozzy, 22 years
old].
2.1.3. The life I          2.2.4. Once my father beat me about
led involved getting       a hundred and twenty times, when I was
the substance,             ten... I experienced all that and it
using it and go-           made me very nervous... At home there
ing home, that is,         was never moral help, just scorn:
it was a triangle:         "Get out of here, you bloody
Drugs, shoot up,           drug addict"... [Meno, 45 years old].
home; drugs,
shoot up and home          2.2.5. When I was in a really bad
or drugs, shoot up,        state, I remember that once they
and shooting gallery...    took me to the penitentiary because
Impotence is wanting and   of a fight I had and I was committing
not being able, you        a crime with a person and I cut
want to stop using a       him with a knife and they took
substance but you          me away... and in there they were also
cannot, because            killing me, in there...
it is a                    [Juan,  36 years old].
physical dependence,
not only mental,
and you cannot...
Addicts are like
the undead, we
just walk around
like zombies, we
just think about
drugs, we drug
ourselves to
live... [Angel,
33 years old].

2.1.4. When I was          2.2.6. My mother didn't believe me
using heroin, all          anymore, she didn't want to bring
my time was spent          me here anymore. On the contrary,
getting money,             she gave me money: "Here,
money to be able           take it so that you can go and screw
to use and I               yourself up, as you wish, rather
didn't work...             than lying to me..." [Johnny,
what I was paid was        39 years old].
not enough for me
to use, apart
from having to
ask for permission
to get a fix and
they got angry and I
ran from work...
Before, all the
time when I was
drugged, I used
to get money to
be able to drug
myself, and when
I was not drugged,
I was angry, I
had withdrawal             2.2.7. Before they used to stop me
syndromes and I was        there, near 20 Street, because
in a bad mood...           I was much skinnier, and my
Well, I was asleep         appearance was more... Before there
all the                    were more arguments, disagreements,
time, anesthetized         you know? They got angry because I was
... [Memo, 45 years old].  using, you know? and one way or
                           another they tried to get my attention
                           or tell me to stop now, and then
2.1.5. I also felt         I couldn't... I couldn'y get
bad out there, you         inside, like that, in other
know, because I            institutions and I went out and
was also combining         used again and... I could n't
heroin and getting         communicate properly with
pills or crystal           them...[Memo, 45 years old].
and... Uhm, a
series of things that
ended very badly at
the end, I had
convulsions... [Junior,
42 years old].
2.1.6. For me that
is hitting rock
bottom... spiritually
and morally you
are down, and you
can't get any
further down.
The moment you hit
rock bottom, you
start thinking...
or you ask yourself,
a question                 2.2.8. I had inferiority complexes,
that is very painful       I had fears deep inside me, insecurities,
... "When will all         something that would not let me
this gonna end?"           move... Uhm, I went to a job...
[Angel, 33                 Uhm, I asked for a job and I felt
years old].                inferior to the person and
                           especially if the person was
2.1.7. The times           trained, or had a degree,
I have left a              uhm, I didn't feel I was up
rehabilitation             to their level... [Junior,
center I have used again,  42 years old].
for the same reason,
due to depression,
family problems,
personal problems,
I have relapsed
[Eagle, 31 years old].

Table 3
Segments associated with the relationship with the therapeutic system

Axis: Addiction                    Axis: Social and
and dealing with                   Normative
substances                         integration
3.1.1. When I arrived,             3.2.1. Here I have always
I started taking                   been treated well, with the
methadone and                      doors open... I come
looked at the effects it has       every day for my dose, early,
and how it affects you and how     see the doctor, the doctor
many times you have to             checks me, asks how
take the medication... and it has  I feel... They treat me well,
helped me stop. [Eagle, 31         there are psychologists, I
years old].                        have group therapy... I
                                   like the things here, they look
                                   after you, it's chill...
                                   [Ozzy, 22 years old].
3.1.2. We are seeing what          3.2.2. I am very grateful to
dose they are going to give        all the people who have
me, they gave me 70, but it        helped me here, mainly
was a bit high for me and          because they have been
made me dozy... right now          selfless... You know, I
they are reducing it, to see if    don't pay anything, I'm not
they can bring it down to 50       required to pay... And I'm
to see how I feel, I think it's    very grateful to them because
going be fine... [Ozzy,            they have had a lot of
22 years old].                     patience and they have helped
                                   me a lot [Junior, 42, years].
                                   3.2.3. The doctors are very kind,
                                   the psychologists, the
                                   psychiatrist... They
3.1.3. And the doctor told         know their work, they are very
me, more or less, how to stop      well trained... They have been
taking the diazepam...             very attentive
to get clean [Rogelio,             and have behaved very
45 years old]                      well [Johnny, 39
                                   years old].
3.1.4. Wth methadone               3.2.4. We need people like
I do not feel very doped           them and they also become
or any-                            like your... your friend,
thing, I feel very good,           someone who understands
I do not feel like                 you or when you need help
using heroin or                    with a problem or advice,
anything like that                 they give it to you without
[Smiley, 33 years old].            asking for anything in
                                   return, and then you see they
3.1.5. Methadone has               take the time to talk to you,
helped me in that                  they explore your life, I tell
I haven't used                     you, and then you see that
again, I feel good, I              there is understanding and
feel I don't need a dose           they are giving you a hand...
to be able to                      [Eagler, 31 years old].
work, with methadone I             3.2.5.1 have felt very
can do it, I can be                supported and I feel that
active all day                     somebody cares for me and I see
without having to use              that they pay a lot of
a dose and it makes                attention here and, the
me feel good                       truth, uhm, they worry
... [Eagle, 31 years old].         ... They ask
                                   how I am, my therapist
                                   always has time for me, always
                                   ... [Smiley, 33 years].
3.1.6. I feel tied, like           3.2.6. Here they treat us
I have to come every               like people, like human
day, but that's                    beings, they treat you like
okay... [Ozzy, 22 years old].      they don't treat you
                                   anywhere else, you know?
                                   Sometimes as an addict you
3.1.7. Nicte [28 years] has        can feel humiliated... Then
spent nearly 10 years in meth-     you come here and they
adone replacement                  give you care you didn't
therapy and is concerned           expect, and then, you don't
about the                          know what to do, in the
                                   beginning you don't know
addiction she now has to           what to do [Angel, 33
this substance, because the        years old].
withdrawal symptoms are            3.2.7. They treat you well,
worse than those for heroin. It    as a person, and in other
is more difficult to give          places they do not treat
up using methadone,                you like that because you
especially                         are an addict, you know?
when you have been                 They discriminate against
using it for a long time.          you... [Memo, 45 years old].

3.1.8. What I sometimes say        3.2.8. The doctors are
is that they don't lower the       interested in you, often
dose, every so often, I think      your family isn't interested in
they should lower the dose,        you but they are... and that is
you know?... Uhm, you              why it's good, because I can
have to come to the therapies      tell when someone
here, but there are times when     is interested in me... They are
you can't... And when it's         people you can trust...
the month when they are            [Meho, 45 years old].
supposed to reduce your dose,
they don't reduce it... I think    3.2.9. We need like a map
it should be like that, they       or a plan, a guide... How
should reduce the dose             should we continue the
every month, so that               treatment... what to do
you can finish the program faster  tomorrow or after you leave
[Memo, 45 years old].              here. You take your first
                                   steps, like that, you learn to
                                   be a baby, you know? And
                                   if they just let you loose,
                                   you will trip. And once you
                                   have the information, you
                                   know where to go, what
                                   steps to take... [Eagler,
                                   31 years old].

Table 4
Adjustment process in the treatment environment

Axis: Addiction and dealing   Axis: Social and normative
with substances               integration

AAA. Methadone                4.2.1. You find out how
removes all the discomforts   you should deal with your
and lets me do more things,   feelings, what things are
like working... [Johnny,      going to happen, like when
39 years old]                 you were anesthetized...
                              it's different, you know?
                              [Eagle, 31 years old]
                              4.2.2. You start to realize
                              many things... [Juan,
                              36 years old]
4.1.2. It's as if you had     4.2.3. I'm already
grabbed hold of a cane and    understanding more things
used it for twenty years,     that I didn't understand
and the doctor says:          ... They explained why
"The time has come for        [drugs are used], as a way
you to let go of the cane",   of escaping from reality...
and you are so used to        I've been hearing stories
it that you do not know       of people who are in the
how to walk without           same situation as me and
it. So, here they are         I see myself reflected in
preparing me so that I        them, everything I drugg,
can walk without it...        all my grudges and bad
[Angel, 33 years old]         thoughts... [Johnny, 39
4.1.3. I almost never         years old]
miss a meeting, I try         4.2.4. That's where you
to go to all the therapies    have to do the work, and
and to medicate               one of the most difficult
too, almost every day         things is the work
I come, it's rare when        you do on yourself... The
I don't come for my           point is to work with
medication. Yes, I try        your emotions... I
to come every day and         open my eyes and
to take the program           see the positive things
as it is, to stick to the     in life, not the negative
program [Meno, 45             ones like I used to...
years old]                    That's my goal, first,
                              to be well, second, to
                              have the motivation to
                              be well, third, to have
                              the motivation to get
                              up, bathe and
                              do what you have to
                              do [Angel, 33 years old]
                              4.2.5. I've examined a
                              lot of the things I have
                              inside me and I'm
                              beginning to find out
                              why I started taking
                              drugs... I'm beginning to
                              find out many things I
                              didn't know about
                              myself... I used to
                              get angry... And I'm
                              already starting to find
                              the peace I wanted
                              [Johnny, 39 years old]
                              4.2.6. I can handle my
                              emotions differently
4.1.4. Since I've             because I know I'm not
been here, I haven't          under the influence of a
missed the meetings           drug and that I'm now
... If you don't come or      starting in a clean, drug-free
if you don't stop             way... When you come out
using, they don't adjust the  of the group meeting, you
dose... That has              come out with your batteries
worked for me,                recharged and your self-esteem
I was at 80                   rises and it is not as low as
                              when you have no-one to
and right now I'm at          listen to or your pals...
30... I come to all the       [Eagler, 31 years old]
                              4.2.7. Before I couldn't
                              interact the way we are
meetings and all this         doing right now, I used
also counts here, in-         to get tongue-tied,
cluding how they see          and right now I feel like
you and whether you           I'm more self-confident,
                              and that I have less
                              complexes than I used
make an effort. Coming        to [Junior, 42 years old].
to the meetings and
                              4.2.8. I've been thinking
                              things over and what I
all that, all that counts     did wasn't good...
also because a lot of         What I'm planning to do
people just come to           now is think about the future,
medicate and leave...         live well, and look for a job,
[Juan, 36 years old]          I want to see my family
                              and behave
                              properly.. [Juan, 36 years old]
                              4.2.9. They make you be
                              responsible, and have a
4.1.5. I decided to be        routine... Right now I'm
admitted to finish the        doing things very differently,
                              really, I try and do what I
                              didn't do before, which are
program because I             good things. Because
couldn't come to the          before, I just used to do
                              damage, I was harming
therapies, that's why         my family... the people
they didn't lower my          I had around me, like
dose and now that I've        a source of infection...
been admitted I go            That's what I am changing
to my therapies and           now [Junior, 42 years old]
everything... [Johnny         4.2.10. In the program they
                              teach you more than anything
39 years old]                 else to develop and to know
4.1.6. Everything has a       how to control yourself...
reason, a meaning:            in the way you control
so we reconnect with          your impulses [Smiley,
our families [Junior, 42      33 years old]
years old]                    4.2.11. When I got here, I
                              started to open my eyes,
                              I started to use what
                              my family had
                              taught me, I started using
                              manners, caution and honesty
                              ... I started doing other things,
                              and doing exercise, I began
                              walking in the park, I started
                              to appreciate life in a different
                              way...
                              The information that I was
                              given here... [about] what I
                              should do... [Angel, 33 years
                              old]
                              4.2.12. Right now I don't feel
                              bad anymore when I talk to
                              other people, sometimes you
                              can't... You get used to using
                              swear words, you come out
                              with swear words. And
                              so I started
                              to get used to talking to other
                              people and so on when I go
                              to work or whatever, I know how
                              to communicate well with other
                              people so that they have a good
                              opinion of you... [Juan, 36]
                              4.2.13. It also means that the
                              family has to get involved in
                              the program, so that they know
                              how everything works and
                              particularly how to treat an
                              addict... [Smiley, 33 years old]
                              4.2.14. When I came to family
                              therapy with my mom, they
                              really helped me communicate
                              with her, and with my dad too
                              and so on... [Ozzy, 22 years old]

Table 5
Segments related to the process of social reintegration

Axis: Addiction and           Axis: Social and
dealing with substances       normative integration
5.1.1. We shouldn't go        5.2.1. I feel that I can work
to places where               so that I can lead a responsible
there are people... where     life and contribute to the house-
there is a lot                hold expenses... pay the bills,
of drugs and prostitution     utilities, water, electricity...
... Before, all my            [Rogelio, 45 years old]
friends were people           5.2.2. Right now I am not
who used drugs and            anesthetized, I can see what
... it is easier for them     is happening around me and inside
to drug me to use             me... When I was anesthetized,
drugs than for me to          I had lost many things, even
bring them onto my            emotions. And now my emotions
side... Now, uhm, I look      are really strong, now I really
for a different kind          feel things the way they are
of friends... I prefer         ...A feeling towards something
to stay home [Junior,          that is real while not being
42 years old]                  anesthetized... [Eagler,
                               31 years old]
                               5.2.3. I can interact more, I
                               am more receptive, and I
                               pay more attention to
                               everything and I
                               feel less pressured and
                               have no cold turkey...
                               [Smiley, 33 years old]
5.1.2. I began to stop        5.2.4. Now I talk more to
going to the places I         my family and cousins. I
used to go to, I started      hadn't spent time with
to get new friends,           them for a long time
to change going to            and now it's better... I
places that did not lead      feel calm, without the
to anything... [Angel,        anxiety of what I'm going
33 years old]                 to use or that I'm going
                              to feel bad or afraid...
                              I'm doing well, I'm calm
                              ... [Ozzy, 22 years old ]
                              5.2.5. Several parts have
                              improved: family, friends,
                              work...You do things
5.1.3. I see people           you didn't do before
doin' it on purpose,          [Rogelio, 45 years old]
because when they
look at you like that,        5.2.6. Changes in my
they don't invite you,        judgments and attitudes
not a peso, nothing.          ... I see things differently,
But if they see you are       I have a better criterion,
clean, they want to           especially one that is not
see you defeated, and         as negative as it was
I say it's the devil          before, when everything
at work... They want to       looked bad
offer you drugs,              [Eagle, 31 years old]
they want to see you
beaten... [Rogelio,           5.2.7. Now I brush my
45 years old]                 teeth, and change my
                              clothes... I'm gradually
                              cleaning up my body
                              [Junior, 42 years old]
                              5.2.8. I began to sleep
                              for five minutes, half an
                              hour and then all night...
                              And now I begin to
                              wake up well, without
                              nerves, or anything...
5.1.4.1 kept seeing the       [Meno, 45 years old]
same people, I kept           5.2.9. My physical
the same kind of              appearance has improved
company, I went every-        and my hygiene too...
where with my buddies         Now I can bathe, I clean
... I went on flirting        myself up better and I
with drugs, I kept            like all that...
meeting with the same         [Eagler, 31 years old]
people and that was
what affected me              5.2.10. Right now I'm a
[Ozzy, 22 years]              bit fatter, before I was
                              very thin and scrawny
                              [Rogelio, 45 years old]
                              5.2.11. On a normal day,
                              I am at home and... I
                              talk a lot to the clerk in
                              the store, I watch television
                              ... very different
                              from how I lived when I
5.1.5. Now that I'm           used heroin... [Rogelio,
awake ...and that I can       45 years old]
look around, I can work       5.2.12. And when they
without drugs,                see you look well, and
without infection from        see the change, and that
a contaminated syringe,       you're freshly bathed
all that ... Now              and a bit chubbier, a bit
with this medication,         fatter, and they see the
I don't have to use           changes, they treat you
contaminated needles          differently [Meno, 45
or ones that have             years old]
been used by someone          5.2.13. Now I have
else who may have             realized that they see me
AIDS or some other            differently, they support
disease... [Eagle, 31         me, many people open
years old]                    their doors to me, and
                              offer me a taco or
                              something... Unlike
                              before... because they didn't
5.1.6. People don't talk      trust me [Juan, 36 years old]
about it much but
                              5.2.14.1 started talking to
                              girls and... I went out with
                              a girl, my girlfriend. I
                              started doing things
they do know I have           that I wanted to before,
an illness... I don't         many things became possible
                              [Angel, 33 years old]
                              5.2.15. I've got closer to my
know, they ignore the         family, I get along better
subject, just as if it        with them, I spend
                              more time with
                              them... I have two
had not happened, as if       grandchildren and now I
it were already a             enjoy them, I play with
                              them... Because I never
new chapter, as if I          enjoyed my children because
were just a new person        I have been using heroin for
and... [ Ozzy, 22 years old]  many years, and now I do enjoy
5.1.7. I don't know how       them... [Memo, 45 years old]
to handle this with           5.2.16. My family is
my daughters. The             supporting me and so on
youngest one is the           ... I talk more with them,
one who asks questions.       I spend more time
I don't give them             around my family. I don't
explanations... but one       have to hide any more
day they will find            [Ozzy, 22 years old]
out, won't they? I            5.2.17. The relationship with
would prefer it if they       my family has improved
never found out...            in terms of their being
[Nicte, 28 years old]         more trusting,
                              more accepting of me, my
                              behavior, my way of doing
                              things... [Eagle, 31 years old]
                              5.2.18. I began doing an
                              honest job... [Angel, 33
                              years old]
                              5.2.19. Now I just come
                              and ake my medication in
                              the morning and I can work
                              all day, you
                              know, I can work...
                              [Memo, 45 years old]
                              5.2.20. Like people who
                              are being reincorporated into
                              society, because it's good
                              to be busy
                              at work a certain number of
                              hours a day, and then to
                              go home and rest and do
                              the things you
                              have to do. Well, like
                              everything, you know?
                              It's important to have a
                              job [Eagle, 31 years old]
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Title Annotation:ORIGINAL ARTICLE
Author:Diaz-Negrete, David B.; Velazquez-Altamirano, Marina; Benitez-Villa, Jose L.; Fernandez-Caceres, Car
Publication:Salud Mental
Geographic Code:4EUSP
Date:Jul 1, 2019
Words:10642
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