San José, Costa Rica, since 1956

Public Health System Grapples with Drug Users

Drug users and addicts can be a nightmare for health care and social service workers. They are noncompliant and uncooperative, they often relapse, have multiple urgent needs, and usually come with histories of crime, violence and abuse.

But the lock-’em up and put-’em away approach isn’t working. Drug users cycle repeatedly through the criminal justice system, which strains public resources. Stiffer penalties and longer sentences have not been shown to reduce recidivism, violent behavior or drug use. And holding drug users leads to overcrowded jails, overtaxed judicial systems and police without the resources to tackle more serious crimes.

A 2009 exhaustive, multi-country analysis of drug policies by Dutch political scientist Martin Jelsma found that, “After decades of mass incarceration and ever-increasing sentencing levels, evidence indicates that law enforcement measures are not an effective means of reducing the extent of the illicit drugs market.”

Moreover, the report said, “The removal of criminal sanctions does not lead to significant increases in drug use or drug-related harm. Criminalizing users pushes them away from health services out of fear of arrest … and locks them up in prisons, which serve as schools for crime.”

The report was published by the Latin American Commission on Drugs and Democracy, an initiative of three former presidents – César Gaviria of Colombia, Mexico’s Ernesto Zedillo, and Fernando Henrique Cardoso of Brazil – to evaluate the effectiveness and impact of current drug policies in order to contribute towards more efficient, safe and humane policies.

But at the same time, traditional health services often aren’t prepared to deal with the complex array of mental and physical health problems found in drug users and addicts, either. Despite the challenges, Costa Rica has taken some big strides recently toward incorporating this population into its public health and social service system. And while the country lags in availability of services and programs, the good news is that it appears to be on par, if not ahead of the game, in terms of its philosophy toward the issue.

For example, President Laura Chinchilla appointed Mauricio Vargas, a solid public health figure for whom the drug abuse problem is a top priority, as vice minister of health. He started by reshaping the board, of which he is now president, of the country’s Alcoholism and Drug Abuse Institute (IAFA) and is leading the agency through an ambitious planning process to create a scientifically grounded, feasible, and multi-institutional public health drug policy to take effect in January 2011.

“Drug addiction is a mental health problem,” Vargas said in a telephone interview. “It doesn’t arise out of a vacuum. There are social, cultural, economic, biological, and environmental factors that, in the end, determine the development of the problem. This is something we are very clear about. We must focus on these determinants in the area of drug addiction.”

And, while the debate rages in many countries as to whether to lock people up for drug possession, Costa Rica’s police force has already eased into a more sensible approach. According to Tatiana Vargas, spokeswoman for the Public Security Ministry, “It is a matter of judgment. When there is a drug bust, the police take testimonies on the spot to find out who was dealing drugs. Those (dealers) are arrested; the others are not.”

She continued, “Personal use is not a crime. There is not an exact quantity allowed for each drug, rather, the police use their judgment to decide whether the person is using it for their consumption. They have a right to treatment and are informed of existing services at the IAFA and the Caja (Costa’s Rica’s social security and health care system).”

In addition to IAFA’s 10 regional centers for adult drug treatment, eight of which have a Caja-run Integral Drug Attention Center (CAIDS), police can refer users who are under 18 to a special center for minors inaugurated by IAFA last year. A long-awaited outcome of a May 2006 Supreme Court ruling, the center provided residential drug treatment to 89 minors last year, 71 of whom were boys. The CAIDS saw 2,941 people in 2009.

Keeping people from even forming drug habits is the other part of the challenge. Education is certainly key. But a strictly individual focus neglects the many family, community and societal factors that contribute to people’s likelihood of using drugs. The public health system’s great challenge is how to work at a number of levels simultaneously in order to have the greatest possible positive outcome for drug users, their families and communities.

The most effective educational and prevention strategies have a nuanced focus that starts in elementary school and reaches into early adulthood.

The U.S. National Institute on Drug Abuse’s Research-Based Guide for Parents, Educators and Community Leaders emphasizes, “Early intervention with risk factors (e.g. aggressive behavior and poor self-control) often has greater impact than later intervention by changing a child’s life path away from problems and towards positive behaviors.”

Bolstering the view that drug abuse is primarily a public health issue, a 2008 World Health Organization study, based on interviews with 85,000 adults in 18 countries, concluded that “Drug use … does not appear to be simply related to drug policy, since countries with more stringent policies towards illegal drug use did not have lower levels of such drug use than countries with more liberal policies.”

The Costa Rican Drug Institute, set up under the previous administration to coordinate the country’s diverse policies, programs and strategies to control both the supply and the demand of illegal drugs, lists an impressive series of achievements during its first four years (Informe de Fin de Gestión, 2006-2010,

Though the report lacks baseline statistics and evaluation results to support its accomplishments, it clearly points to the development and implementation of multifaceted programs needed to effectively address the complex problem of drug use and addiction. These include a school-based healthy lifestyles and drug prevention curriculum, training on drug addiction for professionals in a number of fields, systems for inter-institutional coordination on the issue, outreach to families, community studies, establishment of regional treatment facilities, strengthening the Justice Ministry’s Alternatives to Incarceration program, in addition to other prevention programs and a whole range of efforts to capture and interdict drugs.

 With continued concerted government, community and individual efforts, Costa Rica might just be able to get ahead of its drug use and addiction problem, despite the northward flow of drugs through its land and waters.

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