Nowhere to Turn for Drug Treatment

We wouldn’t accept beatings, humiliation, or prayer as treatment for diabetes or heart disease.

Two recent pieces on This American Life and WBEZ Chicago revealed a hidden world in our midst—a network of unregistered and unregulated drug treatment centers in cities like Chicago and New York. They cater to drug users from Puerto Rico who are shipped to the United States for treatment—often at the expense of the Puerto Rican government.

Once in the centers, they may have their identification cards confiscated. Instead of actual drug treatment, they often endure physical abuse and no medical support—a particularly troubling problem for those who have other serious medical needs. The reporter found that many people escape the centers only to become homeless and unable to afford to return to Puerto Rico. 

Sadly, as a new report from Intercambios Puerto Rico [in Spanish] makes clear, people who use drugs in Puerto Rico may also face abuse when they go in search of treatment on the island. Though there are methadone and buprenorphine programs in Puerto Rico, they are insufficient to meet the communities’ needs, and while these medicines are the gold standard of treatment for opiate dependence, they are not adequate treatment for people who use cocaine or other stimulants.

A chain called Hogar CREA operates most of the so-called drug treatment centers on the island; others are run by evangelical Christian groups. The Intercambios report reveals the unorthodox methods that these centers use to recruit patients and to “treat” them for their drug addiction.

Hogar CREA, for example, sometimes sends vans around towns to “pick up volunteers.” Other times, drug users are committed by their families. Drug courts are also a major source of new recruits—Intercambios reports that representatives of Hogar CREA show up during drug court hearings and get access to files of potential candidates for treatment. They then pressure families and judges to refer users to their centers.

Through coercion or not, once people are inside these centers in Puerto Rico, they often face serious abuse. Centers, many run by former drug users or pastors—most without medical training—are ill-equipped to deal with the urgent health-related complications of drug withdrawal. “Most people who go there were looking for a refuge, which they never received because all they gave us to deal with the pain was ibuprofen, aspirin; they didn’t give us any medication to deal with the habit [heroin dependence], which is what we were missing,” one man disclosed in the report. “The pain, the diarrhea, the vomit. So I suffer from hypertension, and my blood pressure would increase to the point where I felt my heart was jumping from my [chest] … out of desperation.”

Many centers resort to prayer, verbal abuse, or even physical abuse in the absence of evidence-based treatment. “In all the meetings, you must confront somebody,” a man who’d been in a Hogar CREA center reported. “Confronting means that I have to say something bad about you, even if we have no relationship … they would call you ‘pig,’ ‘filthy,’ ‘animal,’ ‘stupid,’ ‘crackhead,’ many things like that … as if you were worthless, so they can build you up again.” So-called “confrontation therapy sessions” sometimes last through the night, and have not been scientifically proven as an effective form of drug treatment.

Humiliation is also used as punishment, often for violations of an internal code that’s unrelated to drug use. “This is typical at CREA,” one man recalled. “If you are caught masturbating, they ask you to go around holding toilet paper or a sign, and you must approach each visitor and tell them why you are holding that.”

In the Hogar CREA centers, work is also a mainstay of treatment. Participants are forced to engage in “representation and sales therapy,” where they go out onto the street, tell passersby that they are drug addicts, and sell goods for the benefit of the center. “I don’t think CREA is [a rehabilitation center] because it leads you to fall into the same things … begging on the streets … selling stuff, because when you are an addict, you steal stuff and then you sell it. Well, and this treatment makes you go out and sell stuff, to ask for money …. I don’t think this is something that helps us move forward.” Some former residents complained that the centers hold you longer when they want to extract additional work (and income) from you.

Though the Intercambios report looks at Puerto Rico, the Open Society Foundations have received reports of similar abuses in other countries throughout Latin America and the Caribbean. Indeed, such abuses—and the scarcity of evidence-based knowledge and interventions that lead to them—appear to be widespread in private drug treatment centers throughout the world.

It’s time for us to demand better from the drug treatment system. We wouldn’t accept beatings, humiliation, or prayer as treatment for diabetes or heart disease. Why should we accept them for people who want help managing drug dependence?

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This is not new and this organization has been doing the same abusive treatment in the U.S. since the 1960s!! It is based on Synanon. See

and and

Unless we recognize that this stuff has a long history in addiction treatment that runs through some of the most famous centers, we are not going to get rid of it. These are not isolated centers in foreign countries— this is an ideology of treatment that started in America.

You're absolutely right; the roots of the abuse as "treatment" movement are in the United States and run many decades. The reason for focusing on the problem regionally and anew is that the Latin America and Caribbean regions are in the midst of reforming their drug policies and are trying to steer towards a "health based" approach. We are trying to highlight that what currently passes for "treatment" is not an improvement over a criminal justice based approach, because it all derives from the same stigma-laden assumptions. A health-based approach requires, as you point out, an acknowledgement that "treatment" (not just drug policy dealing with the criminal justice system) also needs reform. Thanks for all you've done to highlight these abuses, including the links with the insidious spread of Drug Courts.

TDCJ, (TX) does a lot of the same things in their SAFP program. Everything from pressure on courts, (when that doesn't work, the courts then preasure families) to the brutal "confrontation therapy sessions" are just a few of their standard practices. It REALLY deserves looking into.

This is exactly what they're starting to do with prostitutes also in the trafficking movement. The question then becomes "what to do" about it? I've been trying to expose this kind of nonsense in the trafficking movement - and in response of course they lash back with personal attacks against me to get people not to listen to them. But this is why they wrote laws about how someone has to be licensed to give drug treatment. Has anyone checked their licenses?

Unfortunately, that is part of the problem in Puerto Rico. To answer your question, what we found in our investigation is that the centers we reported on, do have licenses issued by the local government through its agency "Administración Servicios de Salud Mental y Contra la Addción" (ASSMCA, translate into Administration of Services for Mental Health and Against Addition) but receive little to no government oversight. The licensing procedure itself is merely a bureaucratic one where they check certificates of compliance with local permits, tax responsibilities and labor laws. Yet, there were at least 5 centers whose licenses were expired for more than 5 years. Still there remained a number of places that did not appear in the list of organizations licensed to provide residential drug treatment. Beyond that, there is a local law governing the provision of drug treatment center “Law 408 for Mental Health of 2000” which was amended in 2008, however this law is virtually useless because of a grandfather clause introduced in 2008 and it is not enforced. Although, the Law 408 for Mental Health 2000, amended 2008 lays out the “bill of rights for patients” and what constitutes appropriate treatment for drug dependence and abuse, the grandfather clause allows private non-profit and for-profit organizations (90% of residential drug treatment centers in Puerto Rico are private) to continue their “historic, traditional and ordinary practices”, in fact allowing them to continue using practices such as “Confrontational Therapy” and “Representation and Sales Therapy”. These practices not only have long been discredited and proven to be prejudicial to psychological well-being, but they also violate human and civil rights and constitute cruel, inhumane and degrading treatment.

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