Humiliation and Abuses

in Drug “Treatment”
Centers in Puerto Rico

Copyright © May 2015 by Intercambios Puerto Rico, Inc.
For additional information, please contact
Intercambios Puerto Rico, Inc., Fajardo, PR
C 787.678.9008 T/F 787.860.19.38
www.intercambios.org / www.descriminalizacion.org
Authors
Débora Upegui-Hernández, ph.d.— dupegui@gmail.com
Rafael A. Torruella, ph.d.— r.torruella@housingworks.org
Cover Photo
A resident of a residential drug “treatment” center selling pastries and bakery products elaborated at the “treatment” center as
as part of the so called “Representation and Sales Therapy”. This work is not paid and those who do not want to sell in the
Streets may be punished by having their visitation privileges removed or extending the duration of their treatment.
(Photo: Débora Upegui-Hernández y edited by Javier Fontanez)
Editing and design
Débora Upegui-Hernández
With support from Open Society Foundations—International Harm Reduction Development Program and
amfAR—The Foundation for AIDS Research

Acknowledgments
First of all, we thank the persons who courageously shared with us their stories of mistreatment and abuse so we could make
visible the injustices and human rights violations that are committed in the name of “drug treatment” in Puerto Rico. We thank Dr.
Carmen Albizu García, Mariana Nogales Molinelli, Esq., Rafael Anglada, Esq., Lidia Díaz, Verónica Vélez-Acevedo, Esq. and all of
those who provided their feedback during the process of research, editing and production of this report. We are also grateful to
Dr. Alexander Bennett and Dr. Honoria Guarino for their comments and proofreading of the English translation of this report.
Intercambios Puerto Rico, Inc. is a community-based non-profit organization that promotes the social integration of
marginalized groups, including people who used drugs, people who are homeless and sex workers, from the science-based
perspective of harm reduction and through programs and activities that include direct services, education, advocacy and research.

Suggested citation
Upegui-Hernández, D. & Torruella, R.A. Humiliation and Abuses in Drug “Treatment” Centers in Puerto Rico (Intercambios Puerto
Rico: Puerto Rico, May 2015).

Table of Contents

Foreword by Dr. Carmen Albizu García ………………...…….……………………………………………………. 1
Introduction .…………………………………………………………………………………………………………………….. 3
The Outlook of Treatment for Drug Dependence in Puerto Rico ………………………………..……... 4
Abuses Committed in Residential Drug Dependence “Treatment” Centers
in Puerto Rico as a Violation of Regional and International Human Rights Treaties ………...….. 5
Coerced Committal …………………………..……………………………………………………………………………….. 11
Rompiendo en Frío” – Abrupt and Forced Detoxification Without
Prescribed Medication, Medical Supervision or Adequate Protocols ………………………………... 14
Punishment and Humiliation as “Treatment” —”Confrontational Therapy”
and “Re-education” …..………………………………………………………………………………………………………. 16
Punishment and Abuse .………………………………………………………………………………………………….... 21
Forced Labor as “Treatment”……….. …………...………………………………………………………………….…. 23
Discharge or Desertion —Consequences ..……………………………………………………………………..… 26
Lack of Adequate Supervision by the Puerto Rican Government.…………….……………………..... 29
Conclusion ……………………………………………………………………………………………………………………….. 31
Recommendations …………………………………………………………………………………………………………... 32
Methodology .……………………………………………………………………………………………………………….…. 33
Endnotes ……………..…..………………………………………………………………………………………………….…. 34
About the authors …..…………………………………………………………………………………………………….... 39

Table of contents

FOREWORD by Dr. Carmen Albizu García

This report presents testimonies from participants of drug “treatment” services for psychoactive drug use disorders
in Puerto Rico that document the persistence of approaches based on a false premise that this condition is the
result of pathological personalities and individual moral deficiencies, requiring the use of confrontational and
degrading processes of re-socialization so that affected individuals may learn to conform to social norms that
establish abstinence as the only acceptable outcome. It describes experiences that lacerate the dignity, health and
security as human beings forcing us to ask ourselves: Why are these practices tolerated in a state whose
Constitution proclaims that “the dignity of human beings is inviolable”?, Why are they tolerated in a democracy
that possesses institutions charged with safeguarding the health of its citizens and ensuring that prevention and
curative health services are based on evidence of its benefits and do not cause harm? The authors cite official
statistics that corroborate the predominance of this type of programs among the meager supply of treatment
services for problematic drug use available in the island.
These data adds to the series of reports generated in the country over several decades that denounce the
enormous gap between supply and demand of services based on scientific evidence of effectiveness to treat
problematic drug use in Puerto Rico. This report puts a human face on the tragic situation endured by individuals
who enter through the revolving door of predominantly court mandated services under legal control in which the
criminal justice system and social and health services participate without assuming a critical analysis or position
about their consequences. Under these conditions, the individual affected is placed in a position of inequality and
subject to interventions implemented by personnel that assume legitimized authoritarian approaches that violate a
patient’s autonomy and facilitate abusive and even dangerous practices. After all, we are talking about a person
who suffers from a criminalized condition that is construed as the inevitable consequence of his/her inability to
exert personal control. For that reason, the role of the person in charge of the intervention is reduced to
confronting the individual with his/her deficiencies and to penalize him/her when these are reflected in the
individual’s behavior. These programs result in poor retention rates of these programs and the progressive social
exclusion that turns individuals who need quality health and social services into social outcasts.
In this historic moment when we have evidence that these practices and degrading experiences ill-conceived as
“treatment” are not effective and we have tested interventions that generate better results, it is unacceptable that
the state allows this enormous inequity and continues to support a sector of services that has turned its back on the
development of knowledge about what is effective in the treatment of addictions and persists in degrading its
participants and conceiving them mainly as undeserving of being treated with dignity. We must consolidate our
demands for the state to guarantee a continuum of services options that satisfy the immediate needs of an
individual within his/her hierarchy of possibilities just as we do with other chronic health conditions that are not
stigmatized. Above all, as long as the state does not address the structural conditions that promote the exclusion
and mistreatment of individuals who suffer from a drug use disorder, we are strengthen those sectors that construe
the issue as essentially of a moral or criminal nature, and not as a health problem that can be managed by the social
and health services sector. I exhort readers to feel indignant and to consider the recommendations presented in
this report, which are based on fundamental human rights and evidence of treatment effectiveness agreed upon
and supported by the World Health Organization and other important international and national organizations, and
to demand that these be the ones that Puerto Rico support sand promotes.

Carmen E. Albizu García, MD
Professor
Graduate School of Public Health, Medical Sciences Campus
University of Puerto Rico

Humiliation and Abuses
in Drug “Treatment”
Centers in Puerto Rico

2

Humiliation and Abuses in Drug “Treatment”
Centers in Puerto Rico

Introduction

T

he lack of coherent drug policies in
Puerto Rico has had devastating
consequences for the civilian population,
particularly with respect to violence and
public health. In 2011, Puerto Rico showed an
incarceration rate of 311 per 100,0001
inhabitants, and a June 2012 report issued by
the
Puerto
Rico
Corrections
and
Rehabilitation Department revealed that
87.71% of the inmates in the country had
been sentenced in cases related to
problematic drug use. Almost half of these
inmates were first time offenders, and more
than 75% were considered drug users. During
the last 20 years of the failed war on drugs,
more than 15,000 murders have been
reported in Puerto Rico. In 2010, the Puerto
Rico Police Department estimated that about
60% of the murders were related to drugs (a
figure
considered
by
many
as
underestimated) and in 2011, the UN Office
on Drugs and Crime (UNODC) reported that
the homicide rate in Puerto Rico had reached
26.5 per 100,0002 inhabitants, higher than
Mexico’s – a country that is torn by the war
on drugs (23.7 per 100,000 inhabitants), Brazil
(23.4 per 100,000 inhabitants), the Dominican
Republic (24. 8 per 100,000 inhabitants) and
almost five times higher than the homicide
rate in the 50 U.S. states (U.S.A., 4.8 per
100,000 inhabitants).
Drug policies in Puerto Rico also have
negative consequences for public health.
Puerto Rico has an HIV transmission rate of
alarming proportions (45.0 per 100,000
inhabitants)3. Unparalleled in any of the U.S.
jurisdictions, HIV transmission in Puerto Rico
has mostly resulted from injected drug use. In
2008, at least 45,294 people reported having
used heroin at some point in their lives,
199,405 used cocaine, 48,893 used crack and
105,629 used non-prescription opiates.4 The
same study found that during the previous
year, at least 8,076 people had used heroin,
45,993 had used cocaine, 12,424 had used
crack and 38,212 had consumed nonprescription opiates.5 In terms of gender,

most users of illicit substances during the
previous year were men: cocaine, 82%; crack,
80%; heroin, 84%; and opiates, 67%. These
figures are not exclusive and can reflect
people who used more than one substance.
At least 5,0596 people reported having used
xylazine. Xylazine is usually mixed with heroin
and is linked to the presence of open ulcers
on the skin and a dramatic deterioration of
the health condition and physical appearance
of its users on the island.7
Despite the evident negative impact that drug
abuse and dependence has on wellbeing of
users and public health in Puerto Rico, the
island presents an appalling performance
regarding availability and utilization of
treatment services for problematic8 drug use
based on scientific evidence. The 2008
Household Survey conducted by the Puerto
Rico Mental Health and Addiction Services
Administration (ASSMCA), reported that at
least 52,334 people met the criteria for
substance abuse disorder (not including alcohol) and 59,3229 people met the criteria for
substance
dependence
disorder
(not
including alcohol). 10 This report, however,
concluded that only 8.5% of the people who
met the criteria for abuse disorder, and 24%
of those who met the criteria for dependence
disorder, had access to specialized treatment
services for problematic drug use11, such as
detoxification, hospitalization, and residential
and outpatient programs. The services most
used by drug-dependent individuals who
received some sort of specialized service
were detoxification (34%), residential
programs (31%) and outpatient treatment
(21%). That is, at least 90% of the people who
met the criteria for drug abuse and 75% of
those who met the criteria for drug
dependence in Puerto Rico, did not have
access to treatment.
This lack of available treatment alternatives
on the island has contributed to the
“relocation” or “exporting” of injectable drug
users to the continental U.S. in search of
treatment, that sometimes resemble
situations comparable to human trafficking. 12
Introduction

3

Humiliation and Abuses in Drug “Treatment” Centers

Instead of increasing the provision of
adequate
treatment services for
drug dependence
or striking collaborative agreements
Residential Programs
Total Beds
Percentage
with providers of
evidence-based
Government (ASSMCA)
150
3.4%
services on the
island, mayors and
local government
Government (Corrections, 503
11.3%
officials choose to
Juvenile Institutions and
send drug users
Family Affairs)
who look for treatPrivate (non-profit and/or 1848
41.7%
ment to centers in
the
continental
faith-based)
U.S. that do not
Hogar CREA, Inc
1928
43.5 %
provide evidencebased treatment
(oftentimes under
TOTALS
4429
100%
false
pretenses),
and which many
times
are
not
compliant
with
basic local norms, and even lack state-issued
licenses to operate as treatment centers for
drug dependence.
Table 1. Approximate number of beds in residential
“treatment” centers for drugs and/or alcohol abuse
licensed by ASSMCA’s Licensing Office

The Outlook of Treatment for Drug
Dependence in Puerto Rico
The provision of physical and mental health
services, and of social services (housing,
training and community services) for drug
users who look for help and treatment, has
been left in the hands of organizations that
foster “abstinence” policies and use methods
that are not based on scientific evidence. A
2014 list of organizations (public and private)
licensed to offer services to treat “drug and/
or alcohol” dependence authorized by the
Puerto Rican government,13 reports the
existence of 11 detoxification centers (with
capacity for approx. 156 beds), 11 outpatient/
ambulatory services centers (including the
provision of methadone and buprenorphine
and centers that only provide mental health
services), and at least 132 residential
4

Outlook of Treatment in Puerto Rico

programs (with an approx. capacity of 4,429
beds), see table 1. The Puerto Rican
government is responsible only for the
management of 14.7 % of the spaces
available in residential programs on the island
through the ASSMCA, Department of
Correctional and Juvenile Court Institutions,
and Department of Family Affairs. Over 85%
of the spaces available in residential programs
are operated by non-profit, community-based
and/or faith-based organizations (such as
Hogar CREA14 and non-secular or Christian
centers). Of the 132 residential programs
registered with ASSMCA, at least ten (10) had
expired licenses of operation and five (5) of
them had licensed expired since 2011.
Moreover, in the Directory of Multi-sectorial
Council for the Homeless there were at least
19 centers referenced as centers for drug
and/or alcohol treatment that were not registered in the list of ASSMCA licensed drug
treatment centers for 2014.
Over 90% of the residential programs licensed
by the government through ASSMCA are
managed by private community-based and/or
faith-based, non-profit organizations, many of
which use methods not based on scientific
evidence and follow the “therapeutic
communities”15 model, aimed at “total
abstinence through the reeducation of the
addict,” with out differentiation among
substances consumed nor the level of
consumption – problematic or not (according
to DSM-5), or use, abuse or dependency
(according to DSM-IV) or models based on
Alcoholic/Narcotics Anonymous. Hogar CREA
represents 44.7% of the residential drug
“treatment” programs in the island, and faithbased centers (also know as Christian,
religious or non-secular homes) represent
29.5% (See table 2). This situation is
extremely problematic because “Law 408”,
enacted on 2000, and amended by “Law 183”
on 2008, establishes the “Bill of Rights” for
patients in mental health services, including
the treatment for problematic drug use and
the standards for practices and procedures
for the care and treatment of mental health
patients and problematic use of drugs,
exempts
for-profit
and
non-profit

Humiliation and Abuses Drug “Treatment” Centers

Table 2. Approximate number of residential “treatment“ center for drugs and/
or alcohol abuse licensed by ASSMCA’s Licensing Office
Residential Programs

Total Centers Percentage

Government (ASSMCA)

4

3.0%

Government (Corrections, Juvenile Institutions
and Family Affairs)

5

3.8%

Private (community-based)

25

18.9%

Private (faith-based, non-secular)

39

29.5%

Hogar CREA, Inc

59

44.7%

TOTALS

132

100%

organizations from its compliance. In other
words, 90% of the centers offering residential
“treatment” for drug users are exempt from
compliance with the basic provisions that
protect the rights of patients and to uphold
standards of treatment, because the
legislature in Puerto Rico determined that
these organizations “will continue providing
their community services according to their
historic,
traditional
and
customary
practices,” (Article 13.02 of the Law 408 as
amended on 2008)16 regardless of the
character or contents of such practices. The
inclusion of this grandfather clause was to
great extent the result of heavy lobbying and
political power of some faith-based
organizations and Hogar CREA, despite heavy
opposition from the multi-disciplinary
community of health professionals. In fact,
this clause (due to its ambiguous language)
has allowed these centers to continue
utilizing dubious practices, many already
dismissed by science, such as the
“confrontational
therapy,”
the
“representation and sales therapy,” while
violating the human rights of drug users, such
as the right to confidentiality and privacy, the
right to be free from cruel, inhuman or
degrading treatment, the right to be free

from forced labor without pay and against
their will, and the right to receive adequate
and science-based treatment. In practice, this
means that only 9 out of the 132 residential
programs to “treat” problematic drug use on
the island must adhere to what the law
establishes, or at least that is the common
perception among program managers, service
providers, governmental agencies and the
legal community.

Abuses Committed in Residential
Drug Dependence “Treatment”
Centers in Puerto Rico as a Violation
of Regional and International
Human Rights Treaties

I

n the last few years, at the international
level a consensus has emerged that
international and United Nations human
rights treaties must be applied in the context
of mandatory or “under pressure” detention
for drug treatment. 17, 18 The UN Special
Rapporteur and other experts have offered
the following definitions of what constitutes
Cruel and Inhuman Treatment, and Degrading
Treatment:
Cruel and Degrading Treatment

5

Humiliation and Abuses in Drug “Treatment” Centers

“The pain and
suffering doesn’t
have to be
“severe” in
order to be
considered
degrading.”
[Special Rapporteur for
the United Nations]

“Cruel and inhuman treatment or
punishment occurs when severe pain
or suffering is inflicted, by or at the
instigation of or with the acquiescence
or consent of a public official or any
other person acting in an official
capacity.
The conduct can be
intentional or negligent, with or
without a specific purpose, as opposed
to torture which requires both intent
and an improper purpose.
Degrading treatment or punishment is
specifically the infliction of pain or
suffering, whether physical or mental,
which aims at humiliating the victim.
The pain and suffering does not have
to be “severe” in order to be
considered degrading. The European
and Inter-American Human Rights
Courts have affirmed that degrading
treatment encompasses acts that are
designed “to arouse in their victims
feelings of fear, anguish and of
inferiority capable of humiliating and
debasing them and possibly breaking
their physical or moral resistance.”19
There are multiple reports from international
human rights institutions documenting the
existence of poor practices and abuse in
centers that allegedly provide “treatment for
drug dependence,” and which constitute
cruel, inhuman and degrading treatment,
such as “forced unpaid labor,” psychological
and moral “re-education,” and military drills.
“Detainees are chained or locked up, and are
subjected to abusive and invasive physical
procedures and mental degradation in the
name of treatment.”20 This kind of abuse has
been recently documented in China,
Cambodia, Mexico, and Russia,21 as well as in
Brazil, Guatemala, India, Peru, Serbia, South
Africa and the United States,22 among other
countries, in institutions operated by
faith-based or community-based non-profit
organizations. Unfortunately, many of these
abuses in the name of “treatment or
rehabilitation” for problematic drug use have
been, and continue to be, perpetrated in
Puerto Rico, mainly within residential

6

Cruel and Degrading Treatment

programs like Hogar CREA and in some faithbased or Christian centers. In the past, several
researchers have reported instances of cruel,
inhuman and degrading treatment in Puerto
Rico within “treatment” centers for drug
dependence.23, 24, 25, 26 In 1993, SantiagoNegron
described as follows the practices
conducted in centers under the guise of
“treatment” for drug users:
“…From religious exorcism to physical
and emotional punishments, such as
unconventional haircuts, verbal abuse
(‘hot chair’), denial of access to
correspondence and visits, forcing
them to wear disposable adult diapers
and signs that ridicule the individual,
among other things. None of these
‘treatments’ are based on science;
they all proceed from arbitrary
speculations
by
countless
paraprofessionals,
self-proclaimed
‘experts’ in the field of drug addiction.
Many of these ‘treatments’ become
fads, only to be abandoned as
arbitrarily as they were established
(i.e., some programs painted with
black dye the hands of the people who
were found masturbating).”27
Almost 20 years after that, Perez-Torruella
(2010) documented the use of “shaming
rituals” in the treatment experiences received
by the interviewees in his study while they
were living in Puerto Rico. Perez-Torruella
interviewed Puerto Rican injecting drug users
living in New York about their past
experiences in “treatment” centers for drug
dependency in Puerto Rico. One of the
“therapeutic” practices performed in Hogares
CREA called “Leña” (a reference to the
firewood obtained from fallen trees) was
described as an emotional beating or
“confrontation” which consisted of the
following:
“sitting in a little chair in the middle of
a room, being humiliated and insulted
by your peers who are ‘clean.’ The
abuse escalated to the point where

Humiliation and Abuses in Drug “Treatment” Centers

insults are directed at members of the
family, as a way to get the patient to
recognize his responsibility in his attitudes and behavior.”28
More recently, Rivera-Suazo, et al. (2013) and
Rivera-Suazo (2014), described interviewing a
group of drug users about their treatment
experiences before becoming patients of the
Methadone-Assisted Treatment program on
the island. The participants reported
humiliation and psychological abuse through
arbitrary and unorthodox punishments, and
the use of “confrontation therapy” which is
not based on scientific evidence and fosters
humiliation and denigration of drug users as a
way of “re-educating” them. Following are
some examples of the abuses reported:
“… they also ran some kind of
marathon therapy, as they call it (…)
where you are up all day and night,
and… even if you fall asleep, they
throw a bucket of cold water at you.”
“…if you do something that you should
not do, well, they call you [insulting]
names. You know, that you are a pig,
you are scum, you are a whore, you
are street trash…”

“… one day I forgot my panties in the
bathroom and they had me walk
around all day throughout the
program with my panties over my
head…”
The United Nations, the World Health
Organization (WHO), and the Substance
Abuse and Mental Health Services
Administration (SAMHSA) concur that:
“The right to health applies equally to
drug dependence as it does to any
other
health
condition.
Drug
dependence is considered a multifactorial health disorder that often
follows the course of a chronic disease
which includes relapsing and remitting.
In this respect, ‘nothing less’ must be
provided for the treatment of drug
dependence than for other recognized
illnesses.”
Nevertheless, what passes for “drug treatment” in most centers and residential
programs in Puerto Rico are practices not
based on scientific evidence about what
constitutes effective and adequate treatment
for problematic drug use, but aimed at an
abrupt and total abstinence, regardless of
differences among substances and levels of

“… One day I
forgot my
panties in the
bathroom, and
they made me
walk around the
program all day
wearing my
panties over
my head…”

Figure 1. Truck used for transporting Hogar CREA’s residents
Cruel and Degrading Treatment

7

Humiliation and Abuses in Drug “Treatment” Centers

dependency, and with zero tolerance for
“relapses.” Such “treatments” are based on
myths about drug use and dependence, on
stigma and misperceptions about drug users
as “sinners” or “moral perverts” who use
drugs because they “want to” (making their
own decisions and exerting their free will) or
because they have a “weak or faulty
character” (moral impairment) and therefore
must be “re-educated” or “rescued by God.”
Medical, scientific and human rights
practitioners and advocates at the
international level have reached a consensus
that treatment for problematic use of
psychoactive substances must be of a
psychosocial nature and be supported by
pharmacological treatment in accordance
with the type of substance used and the level
of dependence of each individual. In 2004,
the World Health Organization (WHO)
acknowledged that opioid substitution
therapy, in the form of Methadone,
Buprenorphine or Heroin Assisted Treatment,
has proven to be highly effective in reducing
and
controlling
opiate
and heroin
dependence.30 Likewise, in his report to
Member States of the United Nations during
the 2010 Session of the Commission of
Narcotic Drugs, the UNODC Executive Director
affirmed that:
“…Treatment for drug dependence
(whether voluntary or compulsory)
must be evidence-based, according to
established principles of medicine.
Detention and/or isolation for the
purposes of “forced detoxification” are
unlikely to be effective. Rather,
treatment for drug dependence should
involve comprehensive pharmacological and psychosocial interventions.
Under no circumstances should
anyone subject to compulsory
treatment be given experimental
forms of treatment, or punitive
interventions under the guise of drug
dependence treatment.”31
However, Hogar CREA, the major operator
(44%) of residential programs under the guise
8

Cruel and Degrading Treatment

of providing “drug treatment” in Puerto Rico,
publicly proclaims that “addiction can be
cured, CREA guarantees it,” (see Figure 1),
assumes that the only acceptable result is
“total abstinence” from all psychoactive
substances (legal or illicit), and resorts to
humiliation and psychological abuse under
the name of “group therapy,” prayer and
acceptance of God as “spiritual therapy and
counseling,” as well as forced labor as
“occupational therapy” or “representation
and sales therapy.” This organization does not
provide any kind of psychological support or
pharmacological
treatment
for
drug
dependence, and it provides all of its
residents the same “group, spiritual and
vocational therapy” that extends for 18 to 24
months, regardless of the substance the
individual is using (heroin, cocaine or
cannabis) or the level of dependence to the
substance. In its web page, Hogar CREA
openly states the role that God and religion
play in the institution’s philosophy and
practice:

“Hogar CREA, throughout
its trajectory, has received
the guidance and support
from God. Everyone in
Hogar CREA can bear
witness of the presence of
God in our institution.
Therefore, our organization
has emphasized ecumenical education in order to
enrich the philosophy of
Hogar CREA.”32
It is particularly concerning that this “model”
of “therapeutic community” designed by
Hogar CREA has been expanded and exported
to Latin America, the Caribbean and the
mainland U.S. through the creation of Hogar
CREA International, Inc. and Hogar CREA USA,
Inc., with over 150 Hogar CREA centers in
Colombia, the United States, Panama, Costa

Humiliation and Abuses in Drug “Treatment” Centers

Figure 2. Conceptual Framework of Hogar CREA according to their oficial website.
Rica, Dominican Republic, Venezuela, and El
Salvador, where similar abuses and
ill-treatment are perpetrated to a greater or
lesser degree. The acronym CREA means
Comunidad de Re-Educacián de Adictos
(Community for the Re-Education of Drug
Addicts), directed and operated by “formeraddicts” who have been “re-educated” and
who define addiction as follows:
“the tendency toward a compulsive
consumption of a substance that
affects the state of consciousness of a
drug user due to a personality
disorder, which is manifested in
character flaws. This personality
disorder means that the individual has
not developed certain capacities or
strengths in his/her character through
his/her life experience to face and
overcome difficulties and obstacles
that are a part of life. The Hogar CREA,
Inc. movement maintains that drug
dependence is a symptom; the true
illness lies in the weakness of

character which renders the individual
vulnerable to substance use. The
individual addicted to drugs and/or
alcohol has not developed, or has lost,
if it was ever developed, his/her
behavioral moral compass; the
individual lacks consideration for
himself or herself, as well as for others.
His/her personality reflects strong
impulses
and
temperamental
tendencies such as irritability,
intolerance, impulsivity, aggression,
etc. Therefore, the individual who is
addicted to drugs suffers from atrophy
in the development of his/her
personality.”33
This definition of drug dependence as a
character flaw and a moral deficiency paves
the way for an ill-construed conception of
what a drug user requires to improve their
situation or manage their compulsive use or
dependence on a substance, which is not
based on the latest findings in the fields of
medicine, biology, psychology or social
Cruel and Degrading Treatment

9

Humiliation and Abuses in Drug “Treatment” Centers

sciences, but on the arbitrariness of myths,
stereotypes, discrimination and stigma which
are apparent in the conceptual framework of
the institution. According to the conceptual
framework of Hogar CREA, Inc. (see Figure 2),
the drug user begins his/her ascension
process from “the destruction of the man”
aiming at heaven, with the help of “the hand
of God.”
This vision and philosophy is a far cry from
the position adopted in 2008 by the U.S.
Substance Abuse and Mental Health Services
Administration (SAMHSA), which states that
“addiction has been long recognized as a
chronic condition” and, therefore, drug
dependence must be tackled with a chronic
health care model. A chronic health care
model addresses a “relapse” as the
“recurrence of symptoms,” “recurrence”
being the most adequate term to refer to a
new episode of drug use, instead of a failure
of the treatment. Additionally, the chronic
disease model considers that:
“Positive
addiction
treatment
outcomes should not be be measured
by abstinence alone, but should look
at a broad range of improvements in
areas such as, family life, employment,
and decreased involvement with law
enforcement and the justice system…
Addiction treatment should be held to
the same standards of success used to
judge treatment of other chronic
diseases,
such
as
diabetes,
hypertension, and asthma where
relapse and noncompliance with
therapy
and
medication
are
common.”34
Hogar CREA has not been exempted from
past problems with public scrutiny and
oversight from government officials. In 2001,
the Department of Health in Pennsylvania,
through the Program Licensing Bureau of the
Drugs and Alcohol Division, revoked the
license of Hogar CREA International, Inc. to
operate as a “drug treatment” center in the
state of Pennsylvania, due to a breach of the
1996 regulations of the Health Department of
10

Cruel and Degrading Treatment

Pennsylvania, which required the presence of
professional counselors state-certified on
substance abuse. The organization claimed
that such imposition was contrary to their
philosophy of former addicts helping current
addicts. On that occasion, Hogar CREA
International, Inc. was the only organization
in the state of Pennsylvania which did not
remedy the situation and lost its license to
provide “drug treatment”35,36 in the cities of
Bethlehem, Reading, Freemansburg, Allenton,
and Lancaster, but retained its license to
provide shelter and housing services for
homeless people. However, the reports
indicated that :
“Residents still endure disciplinary
practices that go beyond staying clean.
Men are expected to cut their hair
short. Income from sales and other
jobs go to the organization.
Attendance at group counseling and
Christian
religious
services
is
mandatory. Residents are taught that
such measures are not punishment,
but part of the process of challenging
and undoing their ‘distorted values.”37
In Puerto Rico, Christian residential programs
operated mostly by evangelical churches and
other
community-based
nonsecular
organizations
have
adopted
many
“programmatic” aspects of the Hogar CREA
model, such as their treatment progression
levels and the program length. Many of these
faith-based or religious residential programs
apparently do not demand that their
residents engage in forced labor or resort to
“confrontation therapy” as Hogar CREA does.
However, these residential programs usually
do not provide access to medical
detoxification,
or
to
an
adequate
psychological and pharmacological therapy
for drug dependence, which is especially
necessary for users of heroin, methadone and
xylazine. Prayer, “spiritual” counseling and
willpower are the only forms of “therapy”
available to their residents in these centers. In
some nonsecular residential programs,
attendance of religious services several times
a day is compulsory, while in others it is

Humiliation and Abuses in Drug “Treatment” Centers

voluntary. Typically, these religious or
faith-based residential programs are led by a
pastor and/or members of the church or
religious community. Despite the pressure to
“accept God” and the role of prayer as a form
of “salvation,” the push toward maintaining
“total and immediate abstinence,” and the
lack of access to adequate medical and
psychological care, in general the interviewees
reported a more empathetic and respectful
treatment in these residential programs than
what they received in Hogar CREA. The living
conditions and the treatment vary from one
religious or faith-base residential program to
another, depending on the pastor who leads
it, and there is no adequate protocol based on
scientific evidence.

Coerced Committal

C

urrently, many of the drug users who
arrive at these “residential drug
treatment programs” are sent by Puerto
Rico’s judicial system through several legal
mechanisms:

Compulsory Detention Due to a Mental
Health Crisis – The Law 67 of the Puerto
Rico Mental Health and Addiction
Services Administration (ASSMCA), can
commit involuntarily a drug or alcohol
user to treatment at the request of the
family, if this individual poses a danger to
himself/herself or others.

Drug Courts – they can divert to drug
treatment programs people who meet
the criteria of drug abuse or dependence,
and who have been charged of a crime
that is directly or indirectly related to
drug abuse.

TASC Program (Treatment Alternatives to
Street Crime) – which decides on the
eligibility of offenders for Supervised
Parole under the Law 247.1 (Penal
Procedures) and the Law 404 (B), applicable to controlled substances.

Oftentimes, relatives of drug users, including
cannabis users, resort to ASSMCA to request
the detention and compulsory committal to
drug treatment of a family member who uses
drugs under Law 67. Drug users are then
arrested against their will and must appear in
court. The court diverts the individual to the
drug treatment program (which typically is a

“...when you don’t want to
go to a center on your
own... it is called Law 67.
They arrest you and take
you to one of these homes.
That’s right, you have not
committed any crime… you
have not committed robbery… and they force you
to… they don’t force you,
they arrest you and they
take you to prison,… as if
you were a criminal…”

live-in arrangement) and, if the individual
refuses to comply with the referral, the
alternative is to go to prison. Tito, one of the
people we interviewed to learn about his
opinion and experiences in residential
treatment centers in Puerto Rico, was committed at least three times by his family, invoking Law 67:
“I went to the Christian centers on voluntarily, and… well, it wasn’t so much
my decision because… I was forced by
my family because in Puerto Rico there
is a law called Law 67… when you don’t
want to go to a
residential program
on your own... well, the court sends you
Coerced Committal

11

Humiliation and Abuses in Drug “Treatment”

to a center by the will of the Puerto
Rico, using the law… it is called Law
67. They seek you out and they arrest
you and take you to one of these centers. That’s right, you have not committed any crime… you have not committed robbery… and they look you
up…they force you to… they don’t force
you, they arrest you and they take you
to prison, there is no break here… as if
you were a criminal… I have ended up
there three times... They cannot keep
you in prison more than 6 months if
you haven’t
committed any crime
because your family wants is that you
end up in one of these residential programs. Now, if you leave one of these
centers, they can throw you in jail for
years, can you believe that?… You have
not committed any crime but if you
escape from one of these centers it is
used to attribute you [a charge of]
evasion, and in Puerto Rico they can
send you [to jail] for 1 or 2 years. […] If
you hold out in jail, because I have
done this, if you stick it out in jail they
have to let you go because you have
not
committed any crime... I did
not crack, I stuck it out in jail, I managed to endure two times,… and they
had to let me go because I really had
not committed any crime… [… if they
send you to a center]… you have to
stay for 18 months,… 24 months, or 3
years, just like that.” ( Tito)
Often the families of drug users are not aware
of the kind of mistreatment and practices
that are perpetrated inside these “centers,”
and they honestly expect that their relatives
will receive adequate attention to treat their
condition. This is an example of how the fact
that [individuals] use illicit substances is often
used as an excuse to diminish their autonomy
and coerce them into entered “treatment.”
People who are detained under Law 67 and
who refuse the court order to commit
themselves to treatment are declared “in
contempt to court”
(considered
a
misdemeanor) which usually involves 30 days
in jail, and a criminal record, which is erased
12

Coerced Committal

six months after serving the sentence. Some
judges realize they have leeway to issue jail
sentences of up to 6 months, even though a
federal case determined that the sentences
cannot be stretched up to 6 months.
Unfortunately, many people are unaware of
the legal minutia and end up accepting
treatment to avoid a prolonged stay in jail.
The law stipulates that the identification of a
given program (outpatient or residential)
must be done after conducting a specialized
clinical evaluation to determine the need for
the treatment and the appropriate threshold
required. However, in practice such
assessment is seldomly done and usually
inadequate. According to a former clinical
coordinator who worked at a regional
outpatient treatment center managed by
ASSMCA, too often the evaluation does not
make use of scientific or clinical tools, but is
rather the result of arbitrary decisions made
by court officials (such as parole officers who
are commonly referred in Puerto Rico as
“socio-penales,” or social-criminal officers),
without clinical experience on drug
dependence. Despite the fact that the best
practice standards to treat drug dependence
stipulate that the type of treatment to be
implemented should depend on the
substance abused and be individualized, all
drug users at Hogar CREA facilities and the
faith-based residential programs receive the
same “treatment.” Heroin dependent
individuals receive the same “treatment” as
someone who is dependent on cocaine or
cannabis. All the people we interviewed had
been or still are users with dependence on
injected heroine or cocaine. Most of them
reported that during their stays in the centers, they witnessed that people who were
dependent to different drugs would receive
the same mistreatment and “therapy.”
Some drug users reported that occasionally
Hogar CREA visits the towns with their vans,
looking for recruits or trying to “pick up
volunteers.” Pablo told us that:
“… every now and then they do the
‘round-ups’… ‘Who wants to go to

Humiliation and Abuses in Drug “Treatment” Centers

CREA?,’ they shout… they pay these
visits around Christmas, to clean up
the towns. They sign a contract with
the municipal police, when the town is
having a major holiday or something
like that. And the authorities tell them,
‘Look, pick them all up,’ and they [keep
them in] for a week, and after that
they kick you out because they don’t
want to have too many people either.
What they want is to have a certain
number of people to get by. So they
choose: ‘This one gets in, this one has
to go’… They pick you up... and then,
well... if you want to go, you can go.
They run these campaigns once or
twice a year “ (Pablo)
Hogar CREA generally sends their staff to the
Drug Courts, looking for potential new
recruits. We have received reports that
members of Hogar CREA show up during the
hearings and obtain direct or indirect access
to the files of individuals indicted of a crime
who are viable candidates for “diversion” to
drug treatment. Hogar CREA’s members then
convince the drug users and their families to
request a diversion to Hogar CREA, and
also convince judges to assign the cases to
Hogar CREA to conduct the drug “treatment”.
Under these circumstances, the families and
the drug users themselves who are in very
vulnerable emotional states and, unaware of
the questionable practices perpetrated in
these centers, accept the offer in the hopes
that this will be a better alternative than jail.
Juan described how his family was approached at the court by Hogar CREA‘s staff
members:
“They took me to jail... They brought
me to court to subdue me, without a
cause… two days after that, their
brought me to the court for a hearing.
And it was that my family had
requested a bail hearing and CREA was
there. They were [there] when my
mom was requesting my bail hearing.
And they told her, ‘Look, talk to these
guys, they can help you out,’ and...
when they walked into the court, my

mom told me, ‘Accept their proposal so
they can bail you out.’ And I accepted
it, thinking that they were going to
help me... Right now, I would rather be
in jail than there… they took me to the
court house on the second day, and I
was throwing up… The second day is
the worst, when you are kicking the
‘vice’ [heroin], and that’s how they
took me to the court house. I had
diarrhea and was vomiting… [at the
court house]… well, that’s when my
mom and my wife felt bad for me and
said, ‘Please, go to the center so they
can negotiate your bail.’ I opened my
eyes and thought to myself, ‘Damn it,
what am I going to do?’ When I got
there, they said, ‘Sure, we’ll help you
out,” and they let him [a member of
Hogar CREA] interview me. ‘Sure, we’ll
provide services to you... you will see
how you’ll be able to kick the vice”…
and within five days they were
exploiting me. In five days they were
exploiting me.” (Juan)
Accepting to join a treatment program under
pressure from the court cannot be considered
as “voluntary consent,” when the only
alternative is to serve time in jail. Over and
over, public defenders and private attorneys
persuade their clients that treatment in a
live-in program with Hogar CREA or a faithbased center is better than the alternative of
serving time in prison. However, many legal
defenders and attorneys are unaware of the
mistreatment and abuses that take place
inside these institutions. On the other hand,
judges and probation officers (socio-penales)
are invested in a system that considers any
consumption and dependence on drugs as
criminal behavior that must be punished. A
former clinical coordinator at a regional
outpatient treatment center run by ASSMCA,
and who worked with the Drug Courts in
Puerto Rico, affirm that probation officers
consider that outpatient treatment is like an
“award,” while a more restrictive residential
treatment acts like a “punishment” because it
sets restrictions to mobility and an oversight
that is closer to the prison system.

“I accepted it,
thinking that
they were going
to help me…,
Right now, I
would rather be
in jail than
there… they
took me to the
court house on
the second day,
and I was
throwing up…”

Coerced Committal

13

Humiliation and abuses in Drug “Treatment” Centers

Sometimes, this type of misinformation and
stigma in relation to drug users are the criteria which guide their decisions when assigning
treatment to drug users who have been
“diverted” for drug treatment.

“Rompiendo en Frío” – Abrupt and
Forced Detoxification Without
Prescription, Medical Supervision or
Adequate Protocols

F

ormer residents of Hogar CREA and some
faith-based residential programs have
reported being forced to quit drugs “cold
turkey” by not having access to a medicated,
gradual detoxification process under medical
supervision and with adequate protocols for
drug dependence withdrawal syndrome.
Detoxification from opiate use without medication causes severe pain and suffering. In
2010, the Commission on Narcotic Drugs
(CND) of the UN Office on Drugs and Crime
(UNODC) stated:
“The role of opioid substitutes is to
assist with detoxification by alleviating
symptoms of opioid withdrawal.
Forced, abrupt opioid withdrawal
(both from legally prescribed therapy
such as methadone, as well as from
illicit opioids) can cause profound
mental and physical pain. According to
WHO and UNODC, ‘the main goal of
detoxification programs is to achieve
withdrawal in as safe and as
comfortable a manner as possible.”39
Thus, forcing an opiate user to quit “cold
turkey” or denying him/her access to
medication-assisted detoxification under
medical supervision (intentionally or by
dereliction) constitutes cruel, inhuman and
degrading treatment, and goes against the
right to health and to access the highest
attainable standard of health.40 Detoxification
without the assistance of medications should
not be considered or used under any
circumstance as a test of character, or as a
moral or existential commitment to
14

“Rompiendo en Frio”

participate in a drug dependence treatment
program.
Juan, one of the drug users we interviewed,
was taken to court while he was experiencing
severe withdrawal symptoms including
vomiting and excruciating pain, without any
medication to alleviate the symptoms.
Despite the pain and severe symptoms he
was experiencing, in prison he only received
over-the-counter painkillers that could be
bought without prescription, such as
ibuprofen and acetaminophen, which are not
strong enough to mitigate the pain caused by
an abrupt and forced detoxification. Cruel and
inhuman treatment continued once he was
admitted to the Hogar CREA he was assigned
to. Despite the fact that Hogar CREA operates
al least two detoxification centers in the
island, many individuals who are dependent
on heroin and methadone, and who are
committed like Juan to Hogar CREA, are
forced to an abrupt detoxification without
sedatives or substitution opiates, and with
limited access to adequate painkillers or other
prescription
medication
to
alleviate
withdrawal symptoms such as vomit, fever,
muscular pain and diarrhea.
“In prison, what they give you is
Panadol [acetaminophen], Motrin
[ibuprofen]. That is what they give you
in prison. In prison they only give you
that. I did get checked by a doctor in
prison. At first, when you get to jail…
when you get in, a doctor has to check
you out to see the conditions you suffer
from, and all that. And, like I said, that
time I was vomiting for two days… they
took me there [to Hogar CREA] on the
third day… I still could not even get out
of bed… because in the courthouse I
was covered in vomit and everything.
And when I got to CREA, I was still
vomiting and all that. And I asked for
help… ‘No, what you have to do here…
is to take a cold shower… a long cold
shower,’ they said… I told them, ‘Dear
God, man, but you have no idea the
habit I am trying to kick here [heroin
dependence], help me out here…’ But

Humiliation and abuses in Drug “Treatment” Centers

they don’t help nobody, they don’t help
nobody, nobody at all… They put me in
the same [room] with everybody else…
There were four of us who were there
trying to kick the habit. They gave us
Tylenol [acetaminophen]… Motrin
[ibuprofen]. No doctor came to see me,
nobody. No doctor came, a nurse came
to see me because of a toothache,
when I had been there for eight days
already… They took me outside… that’s
when they took me to the emergency
room… that’s how a came to see a
nurse.” (Juan)
Luis, a heroin user, told us:
“Most people who entered there were
looking for a refuge, looking for help,
which they never received because all
they gave us to deal with pain was
Panadol [ibuprofen], Bayer [aspirin],
but they did not give us any
medication to deal with the habit
[dependence to heroin], which was
really what we needed. The pain, the
diarrhea, the vomit. So, I suffer from
hypertension, and my blood pressure
would increase to the point where I felt
that my heart was jumping from my…
out of desperation.
[Q = So, while you were kicking the
habit, did a doctor come to check on
you at CREA?]
No. Not that I can remember. All they
would tell you [was], ‘Resist, resist.
Resist, take this pill for the pain… You
can take 4 or 6, 8, 10 pills [of ibuprofen
or aspirin] and it will not have any
effect whatsoever, it does not get rid of
the pain. If you have a headache it
does not go away.” (Luis)
A woman who used heroin and xylazine and
who checked-in voluntarily in one of the
live-in drug dependence centers run by the
government reported that she was denied
access for over a week to medication for the
sizable opened ulcers in her legs caused by
the xylazine use.

“On the third day that I was in the
hospital, they gave me Demerol
[analgesic opioid], only there. So,
because [the outreach social worker]
told the doctor that I was an addict,
they gave me Demerol. [When I got to
the residential program] I was in
withdrawal. I was there for a week and
they gave me nothing. After one week,
when
the
psychologist…
the
psychiatrist came to see me, they gave
me medication… They prescribed
anxiety medication and sleeping pills.
They said that until the psychologist or
psychiatrist could come to prescribe
medication, they could not give me
anything. Not even pills for the pain
caused by the ulcers. What I wanted to
do was to turn around and go back to
the streets but I did not do that, I rode
it out.” (Maria)
Tito, who has injected heroin and cocaine for
at least 25 years, described his experience
with abrupt and forced detoxification at
Hogar CREA as follows:
“We were placed in very small beds,
other people were in bunk beds too. In
the bunks bed, as you can imagine,
when you take all those pills, you turn
around and you go crazy and then with
a sudden thud, people would just fall
off the bed. I was sleeping in a lower
bunk bed and I fell and made a bump
here [pointing at his face]. Well, that’s
a madhouse. I call CREA the madhouse
of kicking the habit… Everybody is
moaning, throwing up, the people on
top throw up on the guys on the
bottom… If you ask me, I would say
this is a shithouse. They came to clean
when it was time to clean, because
they don’t do it as soon as people
vomit, and you are not supposed to
clean [oh, no!]… an outrage, an
outrage… it’s all I am saying, it’s an
abuse.” (Tito)

“They do not
have medicines
to kick the
habit. When I
was in the
Christian
centers there
was nothing…
not even for
headaches…
nothing… all of
a sudden you
start kicking
the habit cold
turkey…”

In the Christian homes, heroin or methadone
dependent users are also forced to an abrupt

“Rompiendo en Frio”

15

Humiliation and Abuses in Drug “Treatment”

“Although
involved in
treatment as an
alternative to
criminal justice
sanctions…
Treatment should
not become a
form of
extrajudicial
punishment.”
[United Nations Office on
Drugs and Crime]

detoxification without substitute opioids or
prescribed pain medication. Angel, who
checked-in voluntarily in residential drug
“treatment” run by Hogar CREA and other
Christian centers, shared his experience (and
the experience of other people like him) in
the Christian centers:
“They do not have medicines to kick
the habit. When I was in the Christian
centers there was nothing… not even
for headaches… nothing… all of a
sudden you start kicking the habit cold
turkey… [and that] is not good because
a lot of people have heart attacks and
a whole lot of problems because they
can’t handle this pressure.
[Q = And, were there many people
kicking the habit cold turkey?]
Yes… in the Christian centers where I
have been, yes.” (Angel)
It is routine that these institutions promise
the people they are recruiting that they will
have access to a quality, adequate treatment,
including detoxification assisted with
medicines. Once they arrive at the centers,
however, drug users find a very different
reality and no alternatives. Another resident
reported that he had been promised they
would help him to endure a controlled and
comfortable detoxification; however, when
he got to the center, not only he did not find
medical assistance; he was asked to start
working without having finished his
detoxification process:
“They never dealt with me the way
they promised they would. They
wanted me to kick the habit – because
I was hooked [dependent]… hooked on
“droga”[heroin]… they wanted me to
kick the habit [overcome the
withdrawal syndrome] with Tylenol
[acetaminophen], Motrin [ibuprofen],
they give you Benadryl [antihistamine],
things that have nothing to do with
kicking the habit… They call it a
treatment but it is a scam to take you
in. Once you get there, find yourself in
a bed, that’s another 20 pesos,

16

Punishment and Humiliation as “Treatment”

because you can be up to four days
without a shower, depending on the
“habit” you have. Remember that this
is when the sickness, the vomiting and
the diarrhea occur... they destroy you…
the fever. It breaks you. You can’t
walk… you feel an atrocious weakness.
‘Hey! Just try it, Just try!’ They should
not say, ‘Try it.’… They should help you,
right? They did not do that, did not
help the poor people laying there. They
did not do that. They didn’t… If you ask
me, none of these centers are worth
it… And when they learned that I was a
mechanic, within a week of checking in
and before I had finished kicking the
habit or anything, they put me to
work.” (Juan)

Punishment and Humiliation as
“Treatment” – “Confrontational
Therapy” and “Re-education”

P

unishment and humiliation are the main
tools for “treatment” at Hogar CREA and
in some Christian centers. Hogar CREA
maintains they provide “group therapy,”
“spiritual therapy” and “vocational therapy.”
However, the actual contents of these
interventions are unknown to most of the
population in Puerto Rico. The UN Office on
Drugs and Crime has stated:
“Punishment is not the appropriate
response to persons who are
dependent on drugs... Although
involved in treatment as an alternative
to criminal justice sanctions, treatment
programs should conform to their role
as therapeutic providers by adopting a
compassionate
and
supportive
approach, and avoiding becoming
agents of punishment. Treatment
should not become a form of
extrajudicial punishment.”41
Also, the World Health Organization stresses
that “for a treatment to yield favorable
results, it needs to go hand in hand with a

Humiliation and Abuses in Drug “Treatment”

positive therapeutic relationship, as well as
with effective counseling or therapy.” 42
Compassion and support are a far cry from
the reality experienced at Hogar CREA by
current and former drug users whom we
interviewed. Conversely, punishment and
humiliation were part of their daily lives
inside Hogar CREA. Tito’s account reflects the
perceptions that many of the current and
former users we interviewed had about
Hogar CREA:
“Life is tough in these CREA centers,
and in the Christian centers, life is
tough. Too many humiliations, too
many humiliations… because they
humiliate your manhood, your
essence… your life, in front of your
family… you become a thing, a puppet,
a thing… a fan, you become something
but you are no longer a man because
you are following a regime that… that
wasn’t…. That is not supposed to force
you to do things that do not
correspond to the dictates of your
heart… and you are man. Come on,
you are a man… how can they do
things that humiliate you like that in
front of your family.” ( Tito)
The main component of the “treatment” used
at Hogar CREA is called “confrontational
therapy,” commonly referred to by the
residents as “the therapy.” Confrontation
therapy was one of the examples of cruel,
inhuman and degrading treatment that was
denounced the most. Pablo describes “the
therapy” in the following terms:
“At the meetings you have to tell… you
must confront… in all meetings you
must confront somebody. Confronting
means that I have to say something
bad about you, even if we have no
relationship, not even a pana [friend]
and don’t’ hang together, I just have to
say something like, ‘Yes, I saw this one
smoking indoors the other day’… You
have to make accusations… that’s the
worst thing for a person who comes
from the streets, you can’t inform on

others… making accusations is as if you
were a cop or a guard… They read the
accusations, and then you have to
confront that person. ‘Look, this is
Pablo who smoked indoors on
Wednesday,’ and the rest of the group
must start [insulting me]. ‘So you are a
sleaze bag, smoking under a roof even
when you know it is not allowed,’ and
stuff like that, right? They claim that
that is the therapy… Yes, that is what
‘re-educating’ is about… Once you
have been re-educated, you have
completed the program. And it takes
from 18 [months] to 2 years, 18
months to 2 years… the re-education
process takes 2 years. It’s not just filing
one report, you have to do [it] every
week. Almost every day they opened
the box and looked for accusations to
start. They called it ‘therapy,’ rang the
bell and had everyone come to the
‘therapy.’
‘Therapy’
time
is
confrontation time. Every day they did
that, “confrontation’… And they would
tell you anything. They would call you
‘pig,’ ‘filthy,’ ‘dirty,’’damn’, ‘stupid,’
anything, ‘tecato,43’ many things like
that, ‘worm’… as if you were
worthless, so then they can build you
up. That is part of the ‘re-education’
and it takes about two years.” (Pablo)

“They are like

children who have
not developed
emotionally…
instead of
maturing, they
become
emotionally
stunted in the
childhood phase…
that is why they
must be treated as
children until they
grow up …“
[Consejero en adicciones
de Hogar CREA]

Another drug user shares his observations:
“They would use rather strong words,
and some people let out some words,
like’ you are this, or you are that’… like
calling someone a ‘coward’? To me,
that is quite disparaging. I don’t like
one bit to be called a coward. I also do
not appreciate being called a bastard…
Those words hurt, for sure. They are
offensive… I have seen men crying.
Grown men, crying… Because of the
names they were called… because of
the way they were treated, because [if]
they insult me, I’d rather take a blow in
the face than take their insults and
humiliations in front of older people...
or younger people, whatever… it
Punishment and Humiliation as “Treatment”

17

Humiliation and Abuses in Drug “Treatment”

hurts… No, that is not useful at all because what it does is to create hatred
among people. If they speak ill [to]
you, if someone does that, if they insult
you, you would not hold this person in
high esteem… I would hate their guts.
And I don’t know what I would do in
the future if some day I suddenly run
into any of these people who have
offended me. Because in the street
things are completely different and I
would seek revenge.” (Luis)

other thing is not like that.’ Which I
find very, very offensive. And then
there were the punishments they used.
That was worse. It would extend your
stay. You would work longer cleaning
up and wearing a sign around your
neck… it was worse
because even
your family would see that… even your
family would see.” (Jimmy)

Residents are forced to participate in these
confrontation and humiliation groups against
their peers to avoid being punished. The goal
is to “break” any kind moral or psychological
resistance, to undermine their
individual self-esteem and to make
them feel worthless. Only then the is
individual considered capable of
accepting the root of their addiction
and of learning to live under the rules
of the organization. If a resident talks
back, becomes defensive about
accusations or refuses to participate,
he or she can receive countless
arbitrary, humiliating and degrading
punishments, such as losing the right
to receive visitors, or being forced to
wear a sign that describes their fault
around the neck. Jimmy, a former
resident of Hogar CREA, reported:
“Yes. Well, they would do the
confrontation. They would insult
you… They humiliated you, called
you
many
names…
‘bacatran’ (thug)… ‘bacatran,’
‘dog,’ words like that… and
offensive, very offensive words…
They treated you as if you were a
‘trafala,’44 a ‘dog.’ They would not
give you the respect you deserved
as a person… that everyone
deserves. And that doesn’t fly with
me. They start talking to you and
all of a sudden they would say,
‘But, look, bacatran, this situation
is like this and that, and that
18

Punishment and Humiliation as “Treatment”

This kind of “therapy” is also utilized at the
CREA sites for adolescents, despite evidence
showing that the use of “confrontational
therapy” has negative consequences for drug
users and individuals with low self-esteem
and poor self-image.45 Furthermore, “four
decades of research have failed to yield a

Figure 3 – Dress Code for Levels 1-4 Residents at
Hogar CREA, Inc. They must wear short pants
to symbolize that they are children.

Humiliation and Abuses in Drug “Treatment”

single clinical trial showing efficacy of
confrontational counseling, whereas a
number have documented harmful effects,
particularly
for
more
vulnerable
populations.”46 Sometimes these therapies
take the form of “confrontation marathons”
at night, where residents are insulted and
emotionally abused for about 8-12
continuous hours, as Pablo refers:
“Yes, 12 straight hours. Once [a week],
12 hours... but everyday, 2 or 3 times a
day
there
were
confrontation
‘therapies.’ But the other was the
extended one. Yes, for everybody…
They don’t give you food there. It
happens at night. Yes, after dinner.
They run it at night, and it goes on
through the night… until dawn, that’s
right. Sometimes [until] 8 am or
breakfast time. Everyone is there. If
you fall asleep… no, no. They don’t
allow that, they yell at you. You are not
supposed to fall asleep, you can’t. If
you do, they kick you out. No, no, no,
that is not allowed. […] And then, the
next day, it’s the same all over
again.” (Pablo)
Sometimes these confrontations give way to
fist fights and serious personal security
problems for residents, inside and out of the
centers. Several interviewees reported
witnessing physical altercations related to the
quarrels
and
insults
during
the
“confrontational” therapies.
“… sure… if they are in the same room,
they end up in the hospital for sure…
picture this: ‘you told me that… we
both did this… ok, we got caught. If we
both keep quiet no one else would
know… but no, you had to rat me
out’… if you live in my room, I am
going to get you back for that one. You
know that there is going to be a major
‘revolu’ [commotion/problem]… and
sometimes they even call the
ambulance… Yes, ambulances to take
people because there was a revolu and

somebody wants to defend someone
else, and there is a major revolu in the
‘nave’ (ship)… the ‘nave’ means in the
room…” (Tito)
The people who run the centers and who are
in charge of the therapies, and in other roles
within these private live-in facilities, do not
have the professional training about drug
treatment and dependence based on
scientific evidence that should be present in
quality drug treatment centers, more so when
the judicial system and the government
entrusts them with the provision of these
services for people under the purview of the
penal system. During a guided group visit, a
“drug counselor” from Hogar CREA told us:
“Drug use has destroyed their brain
cells and that is why they relapse. They
are like children who have not
developed emotionally and are in a
chronic state of emotional atrophy…
instead of maturing, they become
emotionally stunted in the childhood
phase… that is why they must be
treated as children until they grow up…
they use short pants to show that they
are immature children… as they
progress through the [program] levels
and mature emotionally, they can
begin to dress like men again [at level
4-5]”47
This philosophy of Hogar CREA means not
only that the residents do not deserve to be
treated and respected as “adult men,” but
also that as children they must obey orders,
have no control over their lives and must
abide by the authority without questions. For
grown men, used to surviving in the streets or
in jail where a “macho” culture predominates, questioning and depriving them
(physically and symbolically) of their manhood (see Figure 3) constitutes an
intrinsically humiliating, cruel, inhuman and degrading act.
The situation worsens when those in charge
of enforcing the rules and running the
Punishment and Humiliation as “Treatment”

19

Humiliation and Abuses in Drug “Treatment”

Figure 4 – Sticker about Suicide “Prevention” at an Hogar CREA site

confrontations are former drug users who do
not always possess the moral integrity to fit
their roles. The people who operate the
centers are residents who have spent a few
months in the institution and who have
earned the favor of the leaders for abiding by
the center’s philosophy without questioning
it, not necessarily because they are
professionally trained or prepared staff to
carry those roles. About such enforcers, one
person who had been “diverted” to Hogar
CREA reported that they are:
“…people who are in a much worse
situation than oneself. Because when
you look at the echelons [former drug
users in charge of the residents] they
are “arrebatados” [showing the effects
of being under the influence of
substances].
The
director
is
arrebatado. That is where you get riled
up… because if you see someone who
is arrebatado, you say, ‘Damn it, what
has this one been shooting up?’ You
see them unsteady… These people
exploit others, to get something for
themselves and something else for the
owner of the center. Because that is
what this is about, they are trying to
benefit economically from their
positions.” (Juan)

20

Punishment and Humiliation as “Treatment”

Another user who checked in voluntarily into
Hogar CREA on two occasions reported:
“And they… that is another thing
because the higher-ups… the ‘levels’ as
they call themselves, are still using
substances. This is more common there
in Hogar CREA than in the Christian
centers. They, the ‘upper echelons,’
because they have access to the street
they can do anything or use
substances… But we can tell who is still
using, particularly when you are doing
something that changes your physical
appearance or demeanor… and they
claim that you questioning their moral
character, that you are disrespecting
them, when it is them who are doing it
all wrong. They are there, they are
‘upper echelons’ [former users in
charge of the other residents], they
don’t do it all the time but they are
using substances. So when you see
something like this you say, ‘If they are
using substances here, what am I
doing here? They are not helping me.
They are going to bring me to the
same spot I was in,’ and it happens a
lot. When you see that, you say, ‘No,
why go to CREA?’… Because the effect
is quick, for people who don’t use
everyday, their skin turns redder, their
eyes get swollen, their voices change.

Humiliation and Abuses in Drug “Treatment”

You don’t see a quick change with the
people who do it every day, but when
someone is clean and starts using, you
can spot it right away. And they deny
it. And start saying, ‘You are
disrespecting me.’ And the problems,
bickering
and
challenging
begin.” (Angel)
At an Hogar CREA site we visited, we found a
sticker which was supposed to provide
information on how to prevent suicide. The
sticker read, “TU VIDA PERTENECE A DIOS. NO
PERMITAS QUE SATANAS TE LA QUITE. ¡NO AL
SUICIDIO!” [Your life belongs to God. Don’t let
Satan take it away. Say “No” to suicide!] (see
Figure 4). Instead of providing useful
information or referring to the Specialized
Psychological Hotline ran by ASSMCA, the
sticker referred to the phone number and
name of a church. The sticker on the door of
the director’s office at the center gives a
negative, guilt-ridden message which states
that suicide is a sin. Instead of offering help,
this could increase the feelings of alienation,
shame and guilt that an individual toying with
suicide could experience, right when the need
of specialized psychological support is more
pressing.

Punishment and Abuse

P

ractices used as punishment for breaking
the rules at Hogar CREA and some faithbased residential programs are designed to
humiliate and degrade residents in order to
break their physical, moral and psychological
resistance. Many of these punishments
resemble old forms of punishment for
“unruly” or “spoiled” children that many
would now consider child abuse. Treating
adult men as children in public and within a
“macho” all-male context is highly humiliating
and
degrading.
Additionally,
other
punishments such as sleep deprivation during
an 8- or 12-hour long “confrontation
marathon,” placing a person inside a litter
bin, throwing pig feed to people, humiliating
residents before their families and strangers

during their family visits, and increasing the
time they must stay detained under arbitrary
“treatment” as a punishment (particularly for
those who have been diverted to the center
under legal “pressure”), amounts to
psychological abuse and constitutes cruel,
inhuman and degrading treatment, bordering
on what could be considered torture. Pablo
gave us some examples of the infractions that
merited these types of punishment:
“Anything is considered an infraction
there… smoking indoors… smoking in
the balcony, if you smoke there or if
you forgot and lit a cigarette, right
there you get caught... they give a
mouth full…they bring you to the
center of the circle and everyone has to
say something bad about you… and
then, ‘coco pelado’ [they shave your
head]. You know, that’s so stupid.
That’s why... I stayed for a week and
then I left… I’d rather serve time in
prison… And they tease you. They keep
an eye on you and are alert about
anything... if you ran to your room for
a minute... if you walked around in
underwear in your room... even though
there are no women there..., or came
out of the bathroom covered with just
a towel, while picking up the clothes on
your bed, that’s an accusation. I mean,
it’s all very, very stupid.” (Pablo)

“Degrading
treatment
encompasses acts
that are designed
to arouse in their
victims feelings of
fear, anguish and
feelings of
inferiority capable
of humiliating and
debasing them
and possibly
breaking their
physical or moral
resistance ”
[United Nations Special
Rapporteur]

One of the most humiliating and
psychologically hurtful punishments for
residents inside Hogar CREA is to be
embarrassed before family members and
strangers on visiting day. It also constitutes a
grave violation of the right to privacy and
confidentiality
regarding
health
and
treatment, which is covered by the U.S.
Health Information Privacy Protection Act
(HIPPA). A 44 year old man who has been
using heroin and cocaine for at least 23 years
and was committed by his family to Hogar
CREA’s residential programs on at least three
occasions under Law 67, says:

Punishment and Abuse

21

Humiliation and Abuses in Drug “Treatment”

“Neither
detention nor
forced labor
have been
recognized by
science as
treatment for
drug use
disorders”
(World Health Organization
and United Nations Office
of Drugs and Crime)

“That is typical at CREA, if you are
caught masturbating, they have you to
go around holding toilet paper or a
small backpack, and you must
approach each visitor and tell them
why you are holding that. ‘I am so and
so…
I
am
here
for
this
reason’...approach all the families,
whether you know them or not. That is
a terrible humiliation. And you have to
explain, ‘I am walking around holding
this because of this reason’… it makes
you feel like a piece of shit, because
you are subjected to whatever they say
and to those norms... that is a shitty
life, and I don’t believe in any treatment, trust me. […] Outrage, what you
feel is outrage... this situation breeds
outrage… hatred toward life. You are
nothing, less than an insignificant
thing. Yes, you feel like shit when you
are there. Right now I am trying to
come out of all the blows that I felt in
my heart, and that’s it. It’s hard. I am
trying to cope with it.” (Tito)
Another former resident at Hogar CREA who
was committed through judicial “diversion”
because of a false robbery charge, and who
had a family and a steady job before his
arrest, described some of the punishments he
received inside Hogar CREA:
“Yes, they cut my hair. It was
humiliating. To me it was humiliating
because one looks like a clown and
they give you a sign that you must
wear… [with] the infractions that you
have committed. So you can flaunt it,
and so you can look like a clown
showing the infraction you committed
in the program as if you were a dog
carrying a cowbell. You know, that I
did not like at all, because I have
always been a proud man.” (Jimmy)
The denial, or the threat to lose the privilege
of visits or communication with families, is
another punishment frequently used in these
institutions. We also heard stories that go
beyond humiliation and psychological abuse,

22

Punishment and Abuse

and border on physical abuse. Tito told us
about the punishment one of his mates
received while he was living at Hogar CREA
when he refused to make an accusation and
rat someone out:
“Physical abuse… You saw another
resident doing something and you did
not report it to the director. Let’s see if
you find this is physical abuse. The
stuff they feed the pigs… they ask you,
‘Did so and so do this? Did so and so do
that?’ Well, if you don’t answer and
they know that you know… they throw
the pigs feed at you. How do you top
that kind of abuse?… The stuff they use
to feed the pigs, they throw that on
you… that is the ultimate abuse… in
front of everybody… pig’s feed, worms
and all, falling on you... and you can’t
say anything… If you do, they send you
to jail. That’s tough, that’s tough...
They shave your head, and send you
off to receive the visit of your family.
Imagine doing that with your head
shaven like that.” (Tito)
On another occasion, Juan refuse to fix the
vehicle of one of the directors at Hogar CREA
where he had been “diverted” by the judicial
system and, as punishment, he was kept for 4
hours submerged in a pit filled with filthy
water. He described the incident as follows:
“I have seen people… people who were
stuffed into a pit [filled] half-way with
water. Half-way with water… yes. I
experienced that, at least half-way…
get it?, not waste… but dirty water,
stinking water… they did not finish
building those water tanks and they
use them to punish people. I lived
through that. I did. Because the
director himself told me, ‘Look, man,
my car is giving me trouble,’ and I said,
‘So, take it to the shop.’ ‘What
happened? You are a mechanic and
you are right here.’ ‘Yes, I am here but
I am not a slave’… You know, I did not
like the guy. ‘So, what is the problem,
why don’t you want to fix my car?’ I

Humiliation and Abuses in Drug “Treatment”

Figure 5. Hogar CREA residents must sell products and request donations in the streets
said, ‘Well, because you have to pay
for a mechanic. Take it to the shop,
that’s it. They told me I had to fix all
the trucks and buses from CREA. They
did not tell me that I had to fix the
director’s car.’ ‘I call the shots here. I
will show you who the boss is’, he
replied. The next day I spent four hours
in the water. [At that moment, what I
wanted to do was] get the guy and kill
him.’ (Juan)

Forced Labor as “Treatment”

I

n Puerto Rico, one of the better known
features of the Hogar CREA program is that
its residents sell pastries or small household
items such as plastic bags, which are
produced by other residents in small factories
operated by Hogar CREA. What most the
public often ignores, however, is that these
residents are being forced to work without
pay or benefits, under duress or threats of
punishment if they refuse.

“Like I said, your treatment might be
going well, you might be progressing
from one level to the next and all that,
and then for any silly excuse like, for
example…, if you don’t want to go out
in the street to sell plastic bags… right
then, they take that as an infraction.
So they move you back to square one
in the sequence of your treatment…
And you say, ‘Wow, but I was at this
level and because I did not want to go
out and do what they told me, so they
can [decrease your level]… so people
abandon the treatment quite fast.
Even if you were sent here to serve
time, or if you came here on your
own.” (Angel)
According to Hogar CREA, selling stuff in the
streets is part of the program’s “vocational
therapy,” also knows as “representation and
sales therapy” (see figure 5). In prison,
inmates usually receive payment (albeit
minuscule) and a reduction of their sentences
as compensation for the work they carry out
while incarcerated. At Hogar CREA, the
residents
receive
no
compensation
Forced Labor as “Treatment”

23

Humiliation and Abuses in Drug “Treatment”

conditions (including visible skin ulcers)
begging for money in the streets and corners
while living under bridges. Forcing residents
to sell small products and ask for money in
the street reinforces this stigma and
constitutes forced labor.

Figure 6. A resident of a faith-based treatment
program asking for donations in the street
whatsoever for their work, and refusal to
work is met with punishments and retaliation.
“Selling in the streets” is not a marketable
skill that can improve the residents’ chances
of obtaining decent employment when they
are reinstated in their communities, and does
not represent job training by any means. To
the contrary, the World Health Organization
and the United Nations Office of Drugs and
Crime (UNODC) affirmed that “neither
detention nor forced labor have been
recognized by science as treatment for drug
user disorders;”48 moreover, some human
rights defense groups compared these practices to slavery and human trafficking.
This practice reinforces the stiereotype that
the only thing drug users and homeless
people know how to do is to beg and
panhandle, and it increases the perception
that they are a public nuisance. In Puerto
Rico, when people think about drug users, the
image that comes to mind is that of a
homeless person living in the worst physical
24

Forced Labor as “Treatment”

“At CREA, even though it is supposed
to be a rehabilitation center… CREA, I
really don’t think … that it is a
rehabilitation center because it leads
you to the same things… I mean…,
begging in the streets… selling stuff,
because when you are an addict, you
steal stuff and then you sell it. Well,
and this treatment makes you to go
out and sell stuff, to ask for money,
which is something that you want to
avoid, right?… But in CREA… CREA asks
you to go out and sell stuff. I don’t
think this is something that will help us
to move forward… In fact, I don’t think
it is very satisfactory to force you to do
things that you don’t want to do
because you got out of them… Because
if you already moved away from asking
and selling stuff [in the street], because
you stole something and sold it… It is
the same… that Hogar CREA runs a
bakery and makes cake… they make
hundreds of cakes every day and you
take them to the street and sell cakes
for them. That is for their benefit, that
is not for you, get it? That is for their
benefit. And to me all that, I consider it
a business… which indeed to my
understanding is not favorable for the
rehabilitation of drug users.” ( Tito)
Not only does forced, unpaid labor violate an
individual’s human rights, forcing someone to
sell products in the street is degrading and
humiliating because it exposes them to scorn,
constant rejection and contempt by drivers
who are tired of seeing panhandlers in the
streets. For those residents who used to have
a profession and higher education before
joining the center, it is more humiliating
because they are familiar with the stigma
associated with asking for money and selling
in street corners. Besides constituting forced

Humiliation and Abuses in Drug “Treatment”

labor and the being coerced to comply to
avoid retaliation and punishment, the
working conditions themselves are abysmal.
Selling in the street means being exposed to
extreme sun and heat (approx. 78°-95°
Farenheit, or higher), to the elements, carbon
monoxide emissions from vehicles, and possible traffic accidents for 6 to 8 hours a day, up
to six days a week.
“I disagreed with it. I did it because I
was already there and I did not want
to leave or I was afraid to go back to
jail… I did not want to go to jail again
but I was already there for so long and
I did not want to lose the time I had
been there. But in the end, when I saw
they were, that they made you do it,
like it or not… I lived through so many
things that I said, ‘No, the buck stops
here.’ And I moved out [into another
center]” (Jimmy)
Some faith-based centers send their residents
to ask for donations in street corners on
behalf of their institutions (see figure 6).
Some former drug users reported that selling
products in the streets increased their
chances of a “relapse” because it exposed
them too soon to an environment that was
too close to the past conditions in which they
regularly used drugs. Very often they share
the street corners with current users and
homeless people who are also asking for
money. Work in construction, improvement
of infrastructure, auto repairs and other
activities are also carried out without pay by
the residents and under the threat of
punishments and retaliation if they refuse.
People who have been institutionalized by
legal “diversion” are most affected, because
they are threatened with
receiving a negative report for the courts, which would result
in longer sentences. Those who entered the
program on their own enjoy more freedom
because they can decide to stop the treatment and leave.
“Ever since they learned that I was a
mechanic, on my first week there,
without having ‘kicked the habit’ or

anything, they put me to work. ‘Look,’
they said, ‘here you have to lay a
hand..., you can’t just hang around.’
From there, I was transferred to the
Hogar [CREA] in Tejas, Humacao. I
worked as a mechanic there because
they brought in the buses, the trucks. I
made them a flatbed trailer… I fixed
the trucks and the buses. You know, I
think that they exploited me. I felt
used..., I felt bad..., they took the food
stamps… they asked the government
for subsidies. When I realized that, I
told them, ‘But, come on, they say this
is free.’ I left, I went home after that. I
would rather go to prison. So I put an
end to that sentence […] It should not
be like that, because if you go to
treatment I believe it is because you
need treatment, not to be exploited…
without any pay.” (Juan)
Juan also reported that on many occasions he
was assigned work as a mechanic for people
who were not related to the institution who
apparently were sponsors or donors of the
institution. Another resident reported that it
is fairly common for the program’s leaders to
try to persuade the residents who possess a
technical skill, such as electricians, mechanics,
construction workers, etc., to remain living
in the centers after they had concluded the
program, so they would have access to these
skills for free. Juan said that sometimes the
directors would make up infractions to lower
someone’s progress in the program and keep
that person at the center for longer, to have
access to their professional talents.

“if you go to
treatment
I believe it is
because you
need treatment,
not to be
exploited…
without any
pay .”

In Puerto Rico, the public recognizes the
bright green shirts from Hogar CREA and
knows that the people who wear them are
drug users in “rehab” or “treatment” for drug
dependence. In fact, the monologue that the
Hogar CREA residents must recite to the
people they are trying to sell the products
made by Hogar CREA, Inc., as part of so-called
“representation and sales therapy,” requires
that they disclose to strangers their condition
as drug dependence treatment patients. This
represents a grave violation of the right to
Forced Labor as “Treatment”

25

Humiliation and Abuses in Drug “Treatment”

privacy and confidentiality related to their
health and treatment, which is protected by
the U.S. Health Insurance Portability and
Accountability Act (HIPPA), as well as by
regional and international human rights and
medical ethics treaties.

Discharge or Desertion –
Consequences
“They ‘make us fail’ exactly for that
reason, to bring you back in the
progression of the treatment” (Angel)

T

26

to treatment for the first time, the more
appropriate option should be outpatient
treatment. However, most inmates who are
sent to treatment by “diversion” are assigned
to residential centers run by Hogar CREA or
religious/faith-based centers, even if it is the
first time they receive treatment, and
regardless of the type of substance they use.
According to the World Health Organization
and United Nations, the most effective
treatment for heroine dependence treatment
is outpatient buprenorphine or methadoneassisted treatment, not residential treatment
based on abstinence, prayer and humiliation.

echnically, the people who are sent to
these residential centers under judicial
“pressure” continue to be under the oversight
of the Department of Justice and of the
Courts, on probation or with suspended
sentences, so their activities are constantly
being monitored and watched. Even when the
residents (voluntary or “diverted”) go out to
sell
products in the streets to fundraise for
the center, they are monitored by other
residents who have lived at the center for
longer and who play the role of drivers and
guards, making rounds every 15 minutes to
make sure the residents don’t abandon their
posts, escape or get involved in other
activities. If a “diverted” resident does not
report him/herself or come back to the
center, the institution notifies the police and
the courts to activate an arrest warrant. This
context stresses the fact that the residents
have no control over their lives and are at the
mercy of other people’s decisions, which are
usually arbitrary. It also reinforces the
narrative and the perception that drug users
must be treated as criminals subject to
suspicion and mistrust, instead of being
treated as patients who deserve care and
empathy.

Even though Law 408, as amended by Law
183 of 2008, establishes that a person sent to
treatment under judicial “pressure” must be
continually re-evaluated and receive followup by the court and the ASSMCA, in practice
this does not happen. If a person is
re-evaluated and it is determined that a less
restrictive treatment is in order, the person
must be re-assigned to an outpatient
treatment. In practice, however, if a person
is assigned to residential treatment at Hogar
CREA or a nonsecular center, the chances of
undergoing re-evaluation before completing a
minimum stay of 18–24 months as
established by the Hogar CREA program are
almost non-existent. If the 4 levels of
treatment are not completed, the person
cannot graduate from Hogar CREA and has
not fulfilled its treatment. Generally, when a
court re-evaluates a case is because the
family or the resident requested it through a
lawyer.

Law 408, of 2000, as amended by Law 183 of
2008,49 requires residential treatment to be
reserved for people for whom a less
restrictive treatment (outpatient and/or
substance assisted treatment) has not worked
in the past. This means that if a person is sent

“Well, I came to CREA, I checked
myself in but I don’t like the system
there because, truth be told, you start
fine and then you begin to progress but
they want to keep you there… I mean,
when it is clear that you are already

Discharge or Desertion

The feeling shared by many of the users and
former users whom we interviewed is that
the intent is to keep them locked up for the
longest possible time for the financial benefit
of the organization. As Angel puts it:

Humiliation Abuses in Drug “treatment”

fine, they always want to keep you in…
particularly when you have been
committed… how do they say that?…
under ‘pressure’… And then, to the
people who are there [under
‘pressure’]… when your time is up,
when your sentence is due, they don’t
tell you that you are done. They keep
you there working, going to the
streets… they are happy seeing the
money coming in that is sent [by the
government] to each inmate. Same
when the resident comes on his own.
Those who check in themselves, we
need to get the Food Stamps and stuff
like that. So, in addition to the money
that you are leaving there with the
Food Stamps, they also receive money
from the government, and when you
want to leave or when you are done
with the treatment, they don’t tell you.
They keep you quandary and you must
ask all the time how much longer you
need to stay in.” (Angel)
It is customary that complaints voiced by the
residents of the centers go unattended or are
not adequately addressed, since residents are
regarded as untrustworthy. We have often
heard people questioning why we take drug
users at their word, “because they will say
anything to get what they want,” associated
to the stereotype that drugs users are
“manipulative” and would do anything in
order to procure drugs. Jimmy explained that
being locked up for so long also affected his
family negatively since he could not provide
for them. If he had access to an outpatient
treatment, he could have maintained a job
and therefore provide for his family.
“They (Hogar CREA) would go to court
and, instead of helping you out, they
pushed to get you stay for longer at
the center rather than helping you to
get out and back to your family.
Because if you are in the center, what
can you do for your family, how can
you help?… nothing. When you are
out, you can help cover the household

expenses… There are utilities’ bills
(water, electricity), you have to buy
food. I had three kids. I have three
children to support. But they didn’t
care about that there, what they want
is money and to keep you in. And they
wanted to have everyone under their
thumb.” (Jimmy)
There is no scientific evidence to justify
keeping an individual at the most restrictive
(residential) level of treatment, without
recourse, for 2-3 years, even more so when
such a treatment does not include any form
of medication or psychological and social
therapy. Furthermore, the residential
programs operated by the ASSMCA have a
maximum duration of one year, and private
health insurance companies are only
obligated to cover the first 3 months (90 days)
of residential treatment. In 2009, a study
conducted on the specialized Drug Courts in
Puerto Rico50 indicated that of the 67 people
interviewed who had been “diverted” and
made a court appearance during the study
period, 45 percent had been in the
“diversion” program for two years or longer,
and 34 percent were between one and two
years. It is obvious that, for the justice
system, Hogar CREA and religious/faith-based
centers serve the function of maintaining a
punitive approach of lock-up, control and
restriction of freedom of the users/inmates,
while at the same time reducing
overcrowding in local prisons in the guise of a
“therapeutic justice” approach.

“...so you can
look like a
clown showing
the infraction
you committed
in the program
as if you were a
dog carrying a
cowbell.”

The reality is that a large number of people
who are “diverted” to these centers abandon
the “treatment” when they decide that they
cannot tolerate the cruel, inhuman and
degrading treatment. In so doing, they
become subject to re-arrest for failing to
comply with their sentences, without the
benefit of using their time in treatment as
time served. They also have to endure the
psychological blow of having failed in their
attempt to seek treatment for their health
condition.

Discharge or Desertion

27

Humiliation and Abuses in Drug “Treatment”

“The last time [in Fajardo] I was there
for like 1 or 2, 3 months…, something
like that. And I left, I left… I was
arrested, went back to the program
and I left. [Since I scrammed], they lock
you up and you start over your time [in
jail] without having committed any
crime, since I screwed up the
programming [did not finish the
program], I had to follow the jail
programming... Like 18 months, yes…
and they release you in 14. You get out
in 14 months… or they give you a break
to [go to] another place…, because,
you know, you have not committed any
crime, they send you to another
program… and sometimes I finished it,
and other times I did not. I never did
[finish the full program in CREA]. That
one is tough for me. They arrested me
the last time [when I took off].” (Tito)
Despite the threat of being rearrested
hanging over those who are in residential
drug treatment centers via legal “diversion”,
many escape because they prefer to go to jail
than putting up with the abuse:
“The day that I left CREA, you know
how many people left that day? Eleven
people… We left the place almost
empty… They told me, ‘Juan, you are
the mechanic; you are the one who can
leave the garage door open when you
take the car for a test run.’ And I said,
‘Fine, let’s do it, but I want to leave
too.’ And 11 of us left that day. Eleven
people, all at once.” (Juan)
A drug-user who has been in several Hogar
CREA and faith-based centers, told us that it is
not always feasible to leave the centers and
that it can occasionally lead to repercussions
that threaten the physical safety of those who
escape:
“I used to escape. Yes, I would escape
and if they caught you, they would give
you a beating and take you to jail. I
never had that experience myself but I
did escape, and I managed to leave
28

Discharge or Desertion

many times. Yes, they throw stones at
you until you stop running… and if they
hit you, they would take you to the
hospital to get sewn and then, back to
jail. [They chase you and] throw stones
at you, and if they hit you and you fall,
you were done. I never had that done
to me but I have seen it done to others.
I saw it, they were bringing someone
back, all bloody… the eyes swollen, a
mess. Because you have to realize, you
will catch me and I am going to fight
with you and you will fight back… I will
also be tired and you will come chasing
me in a van so if you catch me… you
will hit me with your fists. I never
experienced that… but a fistfight, the
eyes swollen, a busted head and all
that… I saw that… a busted head and
everything.” (Tito)
There is no justifiable reason for the staff at a
drug treatment center to act as law
enforcement agents when capturing a person
who does not want to remain at a
“treatment” center. At any rate, if the person
has broken the law by leaving the center, it is
the role of the police to capture him/her, and
the staff at the center should limit themselves
to reporting the escape to the relevant
authorities, instead of taking the law into
their own hands. Besides, it is problematic
and dangerous to promote the psychological
perception that a human being or employee
can have unlimited power over another
human being.

Humiliation and Abuses in Drug “Treatment”

Lack of Adequate Supervision
by the Puerto Rican Government

I

n 2010, the Executive Director of the UN
Office on Drugs and Crime categorically said
that any “treatment offered as alternative to
criminal justice sanctions has to be evidencebased and in line with [existing] ethical
standards.” The standards established by
international institutions such as UNODC and
WHO stress that, whenever alternative
treatment policies are adopted in lieu of
incarceration:
“evidence-informed treatment within
the community as an alternative to
criminal justice sanctions should
include clinical and social interventions
(both
psychosocial
and
pharmacological) that are provided by
a multi-professional team of health
professionals under the auspices of
the health care system.”52
These same institutions state that the
treatment options offered to vulnerable
populations under the auspices and oversight
of the courts should be subject to public scrutiny and higher standards than any voluntary
treatment available in the wider community.
Under no circumstance it is acceptable to
send inmates to punitive “treatment” programs for drug dependence where they are
exposed to human rights violations or cruel,
inhuman and degrading treatment. The burden and responsibility for safeguarding the
wellbeing and human rights of participants in
“diversion” programs falls directly on the
Puerto Rican government, the Department of
Justice, the Courts and the Administration of
Mental Health and Addiction Services
(ASSMCA).
ASSMCA is the public agency in charge of
issuing the permits and accreditation of care
providers and services related to mental
health and problematic drug use in Puerto
Rico. Such oversight is mostly limited to
bureaucratic procedures involving verification
that fiscal and legal paperwork of the

organizations is up to date. Even though the
authorities are supposed to make mandatory
visits to the service providers in order to
issue, accredit and renew the licenses, most
of the time these visits do not take place or
are limited to a superficial visual inspection.
In 2013-14, it was reported that there were
only two staff members at the office in charge
of supervising the licenses and accreditation
for 531 programs. According to a former
director of this institution:
“These employees are supposed to
review all the applications and visit all
the centers before renewing a license
but they simply don’t have the
capacity to it. There is a system to file
complaints and grievances but the
people in the rural areas or remote
towns [where many of these centers
are located] are the ones with the
least chances to submit complaints. By
default, the centers located outside of
the metropolitan area are less
supervised… They [the licensing office
at ASSMCA] usually does not open an
investigation about a complaint unless
it is related to an outrageous abuse
that has received political or media
attention.”53

“There is
nothing worse
than facing
humiliation in
front of other
people… that
they make you
feel less than
everybody else.
… Because it is
a much stronger
pain, ..., and
psychologically
it stays with
you.”

These practices and abuses have caused a
great deal of harm in the lives of the people
we interviewed, and they affect the physical
and psychological wellbeing of the individuals
who spend time in these centers. Moreover,
among the people we interviewed, these
experiences created distrust toward drug
dependence treatment in general, as well as
painful memories they wish they could leave
behind.
“There is nothing worse than facing
humiliation in front of other people.
For me, that’s the worst possible thing
in one’s whole life… that they make
you feel less than everybody else. That
is the absolute worst. I prefer a beating
to that. Because it is a much stronger
pain, it will haunt you for much longer,
and psychologically it stays with you.
Inadequate Supervision

29

Humiliation and in Drug “Treatment”

“By denying
effective drug
treatment, State
drug policies
intentionally
subject a large
group of people
to severe physical pain, suffering
and humiliation.”
[UN Special Rapporteur]

You can recover from a blow in the
head. But dealing with that memory in
your mind…” (Juan)
Many of the people we interviewed were
adamant in reiterating that they “would
rather go to jail than ever go back to an Hogar
CREA center.” Despite the fact that their
experiences in faith-based residential facilities
were not positive and violated their right to
adequate pharmacological and psychological
treatment, they did not report the
humiliation and scorn they suffered in Hogar
CREA.
Drug users are being “locked-up” under the
guise of receiving “treatment” for 18 to 24
months, under unnecessarily restrictive
conditions that replicate an incarceration
environment in the name of “drug
dependence treatment.” These residential
treatment facilities do not provide evidencebased treatment for drug dependence, nor
follow best practices and basic standards of
care recognized by the medical and mental
health community, which define drug
dependence as a chronic disease and a public
health issue, not a criminal justice matter.
Furthermore, the principle of the right to
informed consent involves the right to
withdraw from a treatment without negative
or punitive repercussions, a right that cannot
be exercised by drug users who are sent to
treatment under judicial “pressure.” A drug
user sent to treatment as a judicial
“diversion” cannot withdraw from treatment
because of mistreatment and abuse without
suffering
negative
and
punitive
consequences, because he/she will be
rearrested and sent back to jail, without the
benefit of counting the period he/she did stay
in treatment as time served.
The World Health Organization (WHO)
emphasizes that compulsory treatment for
drug dependence “is only legally and ethically
justifiable if the rights of the individual are
protected by procedural guarantees… and if
the treatment provided is effective and
humane.” Moreover, the WHO concludes that
if an inmate, as a member of a vulnerable

30

Inadequate Supervision

population who deserves additional ethical
protections, is offered an alternative
treatment in lieu of judicial
sanctions, this
person should have the right to make two
“limited” decisions to guarantee that the
ethical standards of respect and dignity are
maintained: “The first ‘limited’ decision is
about whether this person wants to
participate or not in a treatment for drug
dependence… The second ‘limited’ decision
this person should be able to make is, for
those who accept to be part of a treatment,
they should be given the option to decide
what kind of treatment they will receive.”54
Currently in Puerto Rico, the decision on the
type of treatment assigned to people under
“diversion” is completely beyond their control
and because of lack of evidence-based
treatment, the only treatment available in
most of the cases is not “treatment” but
rather punitive lock-up and abuse in private
residential facilities that are exempt from
oversight by public agencies.

Drug treatment
under coercion “is
only legally and
ethically justifiable
if the rights of the
individual are
protected by
procedural
guarantees… and if
the treatment
provided is
effective and
humane.”
[World Health Organization]

Humiliation and Abuse in Drug “Treatment”

Conclusion

I

n 2013, the UN Special Rapporteur on
Torture and Other Cruel, Inhuman and
Degrading Treatments said:
“By denying effective drug treatment,
State drug policies intentionally
subject a large group of people to
severe physical pain, suffering and
humiliation, effectively punishing them
for using drugs and coercing them into
abstinence, in complete disregard of
the chronic nature of drug dependency
and of the scientific evidence pointing
to the ineffectiveness of punitive
measures.”
Rather than receiving help from public and
private institutions that are supposed to
protect their rights and wellbeing, drug users
in Puerto Rico are treated as a commodity,
without basic consideration for the dignity
and respect they deserve as human beings.
The experiences and stories documented in
this report show that the human rights and
integrity of drug users in Puerto Rico
continue to be violated, under the guise of
providing “treatment” in residential facilities
mostly operated by non-profit, faith-based
organizations such as Hogares CREA, Inc. and
religious centers. These so-called “drug
dependence treatment centers” represent
over 90 percent of the residential drug
treatment programs licensed by the
government.
Inside
these
so-called
“treatment” facilities, abuses are perpetrated
every day which constitute cruel, inhuman
and degrading treatment toward drug users.
Humiliation and threats of arbitrary and
degrading punishments are a daily
occurrence.

through the judicial system, which renders
them more vulnerable to abuses inside these
institutions. In most of these centers, drug
users are exposed to:



Severe physical and mental pain, as they
lack access to a gradual, medicationassisted detoxification process under
medical supervision and following
adequate protocols.
Excessive and long lock-up periods,
which last 18, 24 and even 36 months,
under the guise of receiving “treatment”.
Continual
humiliation,
degrading
treatment and psychological abuse, as a
result of the “confrontational therapy.”
Treatment that borders on physical and
psychological torture, presented as
“confrontation marathons” and physical
punishment.
Forced labor without pay, under the
guise of “representation and sales
therapy,” like selling products in the
streets,
working
in
mechanics,
construction and baking, subjected to
threats of punishment, humiliation and
extension of the length of stay in the
program.
Violation of the right to confidentiality
and privacy about their treatment and
health condition which are disclosed
publicly as part of “representation and
sales therapy” and punishment during
family members visits.
Violation of the right to free
communication when visitation and
communication privileges are revoke as
retaliation or punishment.

The residents in these centers not only lack
access to adequate, pharmacological and
psycho-social treatment based on scientific
evidence and ethical principles, but also many
of them are recruited under false pretenses
to receive “voluntary” or “coerced” treatment
Conclusion

31

RECOMMENDATIONS

I

n light of this reality, the government and other public institutions must take measures to
remedy this situation and prevent these abuses from continuing to be committed, especially
under auspice of public funds.

32

Recommendations

1.

We demand that drug “treatment” institutions discussed herein cease violating
individuals’ human rights and the bill of rights of mental health patients as established by
Law No. 408 of 2000, as amended on 2008.

2.

We demand that the licenses to provide “treatment for drug dependence” be revoked
from institutions that do not comply with the standards of evidence-based treatment provided by a multidisciplinary team of health professionals until they are able to demonstrate
their compliance with the standards of treatment established by the World Health Organization (WHO) and the Substance Abuse and Mental Health Services Administration
(SAMHSA) that were incorporated in Law No. 408 of 2000, as amended on 2008.

3.

The Legislature of Puerto Rico must eliminate article 13.02 of Law No. 408 of 2008 of Mental Health of Puerto Rico, as amended on 2008, which allows community-based and faithbased organizations to continue providing their services according to their “historical,
traditional and ordinary practices”, given that those practices constitute human rights
violations and violate the rights established by the Bill of Rights of Mental Health Patients.

4.

The government of Puerto Rico must supervise and carry out adequate, regular evaluation
of the processes that occur inside these institutions including regular compulsory visits that
check for compliance with Law No. 408 of 2000, as amended on 2008, ensuring that the
rights of patients are respected and that minimum standards of evidence-based treatment
and best practices accepted by the mental health professional community are adhered to.

5.

The government of Puerto Rico must actively work to provide more treatment
alternatives that are evidence-based and must not “divert” prisoners to private institutions that do not provide treatment based on scientific evidence and treat their residents
in a cruel, inhumane and degrading manner violating their integrity and dignity as human
beings.

6.

The government of Puerto Rico must investigate violations of patients’ civil and human
rights and must take legal action against those persons and/or institutions that
committed these violations by action, omission and/or negligence.

7.

ASSMCA, as the regulating entity charged with ensuring compliance of Law No. 408 of
2000, as amended on 2008, must keep records and follow up all drug treatment patients
that participate in legal “diversion” programs in public and/or private centers to ensure
quality of services and compliance with the standards of the law.

8.

We must decriminalize drug users in Puerto Rico. Only when we stop viewing drugs users
as “criminals” and “persons outside the law” will it be possible to eliminate stigma and
discrimination against them. By labeling drug users as “criminals” and “persons who are
breaking the law”, we allow for their dehumanization and create the conditions whereby
violations of their human rights no longer cause public outrage; at the same time,
criminalizing drug use prevents us from approaching this issue from a public health
perspective.

METHODOLOGY

This report is based on a review of available
literature
and
semi-structured
qualitative
interviews conducted between June and October,
2014. Ten in-depth interviews were conducted
with former and current drug users, the majority of
whom lived in eastern Puerto Rico. Due to limited
time and resources, most interviewees were
mostly recruited through the Syringe Exchange
Program (SEP) at Intercambios Puerto Rico, Inc.
The Eastern area of Puerto Rico is characterized by
having a extremely limited availability of drug
treatment services. To date, there are no Methadone treatment services in the area, access to
Buprenorphine treatment is extremely limited and
the majority of residential drug treatment centers
available are Hogar CREA or religious/faith-based
programs. One of the interviews was conducted in
the Ponce area. The photos were all taken by the
principal researcher (Upegui-Hernández) in the
course of data collection.
The participant selection criteria included: having
participated in residential drug “treatment” in
Puerto Rico on more than one occasion and having
had negative experiences in at least one of them.
Among the interviewees, there were seven men
and three woman, with an age range of 26-63
years old, and an average age of 52 years old. At
least eight interviewees had been residents at a
Hogar CREA center.
Four interviewees had
entered residential drug treatment through legal
“diversion” and six were voluntary admissions.
The majority of the interviewees had also
participated in religious/faith-based residential
centers. In order to avoid potential negative
repercussions for participants currently in a
program, especially for those under legal
“diversion”, we opted to recruit only among
individuals who were not currently enrolled in a
treatment center.
The interviews lasted on average one and a half
hour to two hours. The interview protocol was
standardized with a research team at Centro de
Orientacion e Investigacion Integral (COIN) of the
Dominican Republic in order to allow a country
comparison afterwards. The interviews were
recorded in digital audio and a confidentiality
protocol was followed. Interviewees’ names were
replaced by pseudonyms in the process of writing
this report. Experts were also informally interviewed about their experiences with these processes and institutions of interest. For the purposes of this report, the term “religious” or “faithbased” residential treatment center or program
was used to refer to residential centers whose

name clearly denotes a religious or faith-based
connotation or affiliation.
For the purpose of this report, institutional data
was requested about admissions and number of
participants assigned to specific residential drug
treatment programs by fiscal year, region/
municipality, age, service provider, average time in
the program, and program costs per individual
from the Puerto Rico Mental Health and Addiction
Services Administration (ASSMCA) and the Office
of Courts Administration (OAT). We received some
data from ASSMCA that were incorporated in this
report; however, they explained that available data
does not allow for tracking by individual-level
variables. Their data is limited to providing total
numbers of persons served in a given year. We
were also informed that ASSMMCA does not keep
records and do not follow up “diversion”
participants that are assigned to privately run
residential drug “treatment” centers such as Hogar
CREA. On the other hand, the Office of Courts
Administration (OAT) could only produce data for
the total numbers of person admitted into the
“diversion” program, referred to an institution and
number of cases in which diversion was revoked
without the possibility of segmenting by any other
variable. The OAT database did not even have
information about which center an individual was
assigned to or how long he/she remained there.
These data did not allow for segmentation by
participants’ characteristics or assigned service
provider. As of the date of this publication, we
have not received the data we requested from the
Office of Courts Administration. They also were
not able to provide data segmented by region, nor
any information about treatment costs.
The work of documenting and preparing the
original report in Spanish was made possible by a
grant from the International Harm Reduction
Development Program of Open Society
Foundations. The English translation of this
publication was in part supported by a grant from
amfAR– The Foundation for AIDS Research. This
report is part of a larger initiative to document
experiences of abuse in drug treatment centers in
Latin America and the Caribbean.

Methodology

33

ENDNOTES
1.

Roy Walmsley, World Prison Population List, 10th ed. (London: International Centre for Prison Studies,
2013), available at: http://www.prisonstudies.org/sites/prisonstudies.org/files/resources/downloads/
wppl_10.pdf.

2.

United Nations Office on Drugs and Crime (UNODC), Global Study on Homicide (Vienna: UNODC,
2011), available at: http://www.unodc.org/unodc/en/data-and-analysis/homicide.html.

3.

Centers for Disease Control and Prevention, Incidence and Diagnoses of HIV Infection --- Puerto Rico,
2006, Morbidity and Mortality Weekly Report 58, no. 21:589–591 (2009), available: at http://
www.cdc.gov/mmwr/preview/mmwrhtml/mm5821a3.htm.

4. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias
y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico] (Puerto
Rico: ASSMCA, 2009). Table 12. Available at: http://www2.pr.gov/agencias/assmca/Documents/
EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%20USO%20DE%
20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%20%E2%80%93%
202008.pdf
5.

Ibid. Table 19.

6.

Ibid. Pp. 37.

7.

The effect of xylazine among injectable drug users in Puerto Rico has been documented by Torruella,
R.A. Xylazine (veterinary sedative) use in Puerto Rico. Substance Abuse Treatment, Prevention, and
Policy, 6, (2011). Available at: http://www.substanceabusepolicy.com/content/6/1/7

8.

The term “problematic drug use” was introduced by the current DSM-5 (APA 2013) and is the most
appropriate term for referring to the health condition associated with severe substance use that has
negative consequences for an individual’s functionality. This classification distinguishes between
“problematic use” and “non-problematic use” (which goes along a continuum from mild, moderate or
severe according to the level of dysfunction). Before this newest edition of the manual, DSM-IV
utilized the categories of “use, abuse and dependence”. The categories of abuse and dependence are
contained within the term “problematic use”. For the purpose of this report, we use the DMS-IV and
DSM-5 terminology interchangeably. We decided to not eliminate the language of “dependence”
because we understand that this term is more known by the public and it is used in much of the
literature on drug use. The term “problematic use” is still rather unknown in many circles.

9. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias
y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico] (Puerto
Rico: ASSMCA, 2009). Table 28. Available at: http://www2.pr.gov/agencias/assmca/Documents/
EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%20USO%20DE%
20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%20%E2%80%93%
202008.pdf
10. ASSMCA’s Households Survey 2008 utilized the DSM-IV’s classification for substance use disorders
with the categories of “use, abuse and dependence”. The DSM-5 was introduced in 2013.
11. Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Trastornos de Substancias y Uso de Servicios en Puerto Rico [Substance Use Disorders and Use of Services in Puerto Rico]
(Puerto Rico: ASSMCA, 2009). Table 39. Available at: http://www2.pr.gov/agencias/assmca/
Documents/EstudiosyEstadisticas/AF%202008-2009/TRASTORNOS%20DE%20SUBSTANCIAS%20Y%
20USO%20DE%20SERVICIOS%20EN%20PUERTO%20RICO%20-%20ENCUESTA%20DE%20HOGARES%
20%E2%80%93%202008.pdf
12. Rafael A. Torruella, “¿Allá en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of
Drug Users from Puerto Rico to the United States.” Doctoral Dissertation, City University of New York

34

Endnotes

(2010), available at: https://www.academia.edu/306628/
_Alla_En_Nueva_York_Todo_Es_Mejor_A_Qualitative_Study_on_the_Relocation_of_Drug_Users_Fro
m_Puerto_Rico_to_the_United_States. Also reported on public media by Sanjurjo, Libni “No todo es
como lo pintan” [Not everything is as it ‘s painted], PrimeraHora.com (January 1, 2014) available at:
http://www.primerahora.com/noticias/puerto-rico/nota/notodoescomolopintan-983978/ and more
recently by Cardona-Maguigad, A., “Puerto Rico exporta personas con adicciones,” [Puerto Rico
exports person with addictions] Centro de Periodismo Investigativo (April 14, 2015) available at:
http://www.periodismoinvestigativo.com/2015/04/perto-rico-exporta-personas-con-adicciones-aChicago/ discussing the exporting of drugs user to Chicago to obtain “treatment” for problematic drug
use.
13. Source: Puerto Rico Mental Health and Addiction Services Administration (ASSMCA), Certification,
Licenses and Safety Division, October 2014.
14. However, it would be wrong to consider Hogares CREA, Inc. as a community-based organization
because of the significant religious component of its philosophy. It would be more appropriate to
consider them as a faith-based non-profit organization. In its webpage, Hogares CREA, Inc. states that
it is “a movement guided by God to alleviate the problem of drug addiction and its consequences.”
Available at: http://hogarcreainc.org/creapr/index.php?
option=com_content&view=frontpage&Itemid=1 .
15. In this report, therapeutic communities are considered as support services for the rehabilitation of
drug users and, as such, can play a role in the spectrum of services which drug users have access to.
However, they do not constitute per se a “treatment for drug dependence” because they do not
provide adequate pharmacological or psychological therapy delivered by health care professionals,
and their practices are not based on scientific evidence. The U.S. National Institute of Drug Abuse
(NIDA) says that an effective treatment for problematic drug use must include psycho-social therapies
in combination with medication (available at: http://www.drugabuse.gov/publications/principlesdrug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/what-drugaddiction-treatment). The treatment for problematic drug use, based on a model of a chronic disease,
assumes that recurrence of symptoms and problematic use can resurface at different moments in the
life of the drug user, and is part of the course of the disease, while therapeutic communities pursue
total abstinence at all costs.
16. Law of Mental Health in Puerto Rico, Law No. 408, October 2, 2000, as amended by Law No. 183,
August 6, 2008. Secretariado de la Conferencia Judicial y Notarial del Tribunal Supremo. It includes
amendments made until November 2010. Page 119.
17. Elliot, R. & Symington, A. Treatment or Torture? Applying International Human Rights Standards to
Drug Detention Centers, Campaign to Stop Torture in Health Care Services (2011) available at: http://
www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf.
18. Schleifer, R. & Elliott, R. ¿”Tratamiento” torturador? Evaluando las Responsabilidades de Gobiernos y
Agencias Donantes en Abusos Cometidos en Centros de Detención por Drogas desde una Perspectiva
de Derechos Humanos. Open Society Foundations. Torture in Healthcare settings: Reflections on the
Special Rapporteur on Torture’s 2013 Thematic Report. Center for Human Rights & Humanitarian
Law: Anti-Torture Iniciative, American University – Washington College of Law (Washington, DC,
2014), Pp.105-122.
19. Elliot, R. & Symington, A. Treatment or Torture? Applying International Human Rights Standards to
Drug Detention Centers, Campaign to Stop Torture in Health Care Services (2011), page. 15, available
at: http://www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf.
20. Ibid. page 4.

Endnotes

35

ENDNOTES

21. Campaign to Stop Torture in Health Care. Treated with Cruelty: Abuses in the Name of Drug Treatment Rehabilitation, Open Society Foundations, edited by Roxanne Saucier, et.al. (2011). Available at:
http://opensocietyfoundations.org/sites/default/files/treatedwithcruelty.pdf.
22. Saucier, R. & Wolfe, D. Privatizando la Crueldad – Tortura, Trato Inhumano y Degradante en Centros
de Rehabilitación por Consumo de Drogas a cargo de Organizaciones No Gubernamentales. Torture in
Healthcare settings: Reflections on the Special Rapporteur on Torture’s 2013 Thematic Report .
Center for Human Rights & Humanitarian Law: Anti-torture Initiative, American University – Washington College of Law (Washington, DC – 2014), Pp.123-132.
23. Santiago-Negrón, S. Alternativas al modelo prohibicionista en el tratamiento de la adicción a drogas
[Alternatives to the prohibitionist model for treating drug addiction]. Revista Ciencias de la Conducta,
Vol.7, Numbers 1 y 2, pp. 7-38 (1993).
24. Perez-Torruella, R.¿Allá en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of Drug
Users from Puerto Rico to the United States. Doctoral Dissertation, City University of New York
(2010), available at : https://www.academia.edu/306628/
_Alla_En_Nueva_York_Todo_Es_Mejor_A_Qualitative_Study_on_the_Relocation_of_Drug_Users_From_
Puerto_Rico_to_the_United_States.
25. Rivera-Suazo, S. Stigmatizing Practices in Addiction Treatment Settings: Participants’ Perspectives.
Paper presented at panel “Stigma Manifestations towards Drug Users in the SUD Treatment Sector
and Its Implications for Public Health Policies”, at the 60th Puerto Rican Psychology Association
Convention, Ponce, PR. (November, 2013)
26. Rivera-Suazo, S. Albizu, C.E., Salvador, S. & Perez, C. Stigmatizing Experiences while in Drug Treatment: A Qualitative Exploration of Client’s Perceptions. Poster presented at the College on Problems
of Drug Dependence Annual Conference. (June, 2014)
27. Santiago-Negrón, S. Alternativas al modelo prohibicionista en el tratamiento de la adicción a drogas
[Alternatives to the prohibitionist model for treating drug addiction]. Revista Ciencias de la Conducta,
Vol.7, Númbers 1 y 2, pp. 7-38. (1993) Page 16.
28. Perez-Torruella, R. ¿Allá en Nueva York Todo es Mejor?: A Qualitative Study on the Relocation of Drug
Users from Puerto Rico to the United States. Doctoral Dissertation, City University of New York
(2010), available at: https://www.academia.edu/306628/
_Alla_En_Nueva_York_Todo_Es_Mejor_A_Qualitative_Study_on_the_Relocation_of_Drug_Users_From_
Puerto_Rico_to_the_United_States.
29. Costa, A. Drug Control, Crime Prevention and Criminal Justice: A Human Rights Perspective – Note by
the Executive Director. Commission on Narcotic Drugs, 53ava session, UN Doc. E/CN/.7/2010/CRP.6-E/
CN.15/2010/CRP.1 (March 3, 2010) paragraph 46 available at: http://www.unodc.org/documents/
commissions/CCPCJ/CCPCJ_Sessions/CCPCJ_19/E-CN15-2010-CRP1_E-CN7-2010-CRP6/E-CN15-2010CRP1_E-CN7-2010-CRP6.pdf.
30. World Health Organization. Neuroscience of Psychoactive Substance Use and Dependence. (WHO:
Geneva, 2004).
31. Costa, A. Drug Control, Crime Prevention and Criminal Justice: A Human Rights Perspective – Note by
the Executive Director. Commission on Narcotic Drugs, 53ava session, UN Doc. E/CN/.7/2010/CRP.6-E/
CN.15/2010/CRP.1 (March 3, 2010) paragraph 40 available at: http://www.unodc.org/documents/
commissions/CCPCJ/CCPCJ_Sessions/CCPCJ_19/E-CN15-2010-CRP1_E-CN7-2010-CRP6/E-CN15-2010CRP1_E-CN7-2010-CRP6.pdf.

36

Endnotes

32. Official web page of Hogar CREA, available at: http://hogarcreainc.org/creapr/incex.php?
option=com_content&view=article&id=4&Itemid=2.
33. Ibid.
34. Thomas McLellan, paraphrased by Kipnis, S & Killar, R. Managing Addiction as a Chronic Disease. New
York State Office of Alcoholism & Substance Abuse Services: Addiction Services for Prevention,
Treatment, Recovery, (2007). Available at: https://www.oasas.ny.gov/AdMed/documents/
mngngadctn.pdf
35. Department of Health, State of Pennsylvania. Available at www.portal.state.pa.us (2007).
36. Darragh, T. & Assad, M. Hogar CREA attempt makeover in wake of money, licensing woes. The
Allentown Morning Call (November 2, 2003) available at:
http://www.puertorico-herald.org/issues/2004/vol8n01/HogarCrea.html.
37. Ibid.
38. Personal communication with former clinical coordinator of ASSMCA’s regional outpatient treatment
center in Arecibo, August 11, 2014.
39. Elliot, R. & Symington, A. Treatment or Torture? Applying International Human Rights Standards to
Drug Detention Centers, Campaign to Stop Torture in Health Care Services (2011), page 28, available
at: http://www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf .
40. Ibid.
41. United Nations Office on Drugs and Crime. From Coercion to Cohesion: Treating Drug Dependence
through Healthcare, not Punishment . Discussion Paper (UNODC: New York, 2010) page 7.
42. World Health Organization. Neuroscience of Psychoactive Substance Use and Dependence. (WHO:
Geneva, 2004), page 84.
43. “Tecato” is a derogatory term used to refer to injectable drug users in Puerto Rico. However, some
drugs users have appropriated as a term they used among themselves.
44. ““Trafala” is a term used in Puerto Rico to refer to a cheat, a dishonest liar who cannot be trusted. It is
also used to refer to a person who has a criminal record. (see Español Puertorriqueño in Wikipedia.org
and Diccionario Urbano in wikia.com).
45. Miller, WR; Benefield, RG; Tonigan, JS. (1993) Enhancing Motivation for Change in Problem Drinking:
A controlled Comparison of Two Therapist Styles . Journal of Consulting and Clinical Psychology, 61
(3), pp. 455-61.
46. White, W. & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and
time for change, Counselor, 8(4), pp. 12-30. Available at: http://www.williamwhitepapers.com/
pr/2007ConfrontationinAddictionTreatment.pdf.
47. Personal communication with a drug abuse counselor at Hogares CREA, Inc. during a guided visit to an
Hogar CREA center in Puerto Rico, July 29, 2014.
48. Elliot, R. & Symington, A. Treatment or Torture? Applying International Human Rights Standards to
Drug Detention Centers, Campaign to Stop Torture in Health Care Services (2011), page 42, available
at: http://www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf.

Endnotes

37

ENDNOTES

49. Law of Mental Health in Puerto Rico, Law No. 408, October 2, 2000, as amended by Law No. 183,
August 6, 2008. Secretariado de la Conferencia Judicial y Notarial del Tribunal Supremo. It includes
amendments made until November 2010.
50. Meléndez Nieves, V.M. Melendez Nieves, V.M. Salas Especializadas y la Justicia Terapéutica
[Specialized Drug Courts and Therapeutic Justice] . Escuela Graduada de Administración Publica
“Roberto Sanchez Vilella”, Recinto de Rio Piedras, Universidad de Puerto Rico. Master in Arts Thesis
(2009).
51. United Nations Office on Drugs and Crime. From Coercion to Cohesion: Treating Drug Dependence
through Healthcare, not Punishment. Discussion Paper (UNODC: New York, 2010) Prologue.
52. Ibid. page. 6.
53. Personal communication with the former director of the Puerto Rico Mental Health and Addiction
Services Administration [ASSMCA] (2013-2014), Dr. Salvador Santiago-Negron, August 5, 2014.
54. World Health Organization. Neuroscience of Psychoactive Substance Use and Dependence. (WHO:
Geneva, 2004), page 234.
55. Mendez, Juan. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading
treatment or punishment, Center for Human Rights & Humanitarian Law: Anti-torture Initiative,
American University – Washington College of Law (Washington, DC, 2014), AR/HRC/22/53, page 316,
paragraph #74 (299-321).

38

Endnotes

ABOUT THE AUTHORS

Débora Upegui-Hernández is a social psychologist, researcher and author of the book “Growing Up
Transnational: Colombian and Dominican Children of Immigrants in New York City” (2014). She has taught
at the University of Puerto Rico, Rio Piedras Campus and Carolina Campus, St. Peter’s College in New
Jersey and Baruch College in New York and was a Research Associate at National Latina Institute for
Reproductive Health in New York. Dr. Upegui-Hernandez has work on several research projects about
immigration, education, social justice and the experiences of Latinas/os. Upegui-Hernandez has authored
several reports for the Latino Data Research Project at CUNY’s Center for Latin American Caribbean and
Latino Studies, journal articles in Encyclopedia of Critical Psychology, Feminism and Psychology, Journal of
Pacific Rim Psychology and chapters in “Navigating Multiple Identities” and “Diversity in Mind and Action:
Volume I—Multiple Faces of Identity.” She holds a doctorate in social and personality psychology from the
CUNY Graduate Center and received several awards from CUNY’s Center for Latin American, Caribbean
and Latino Studies, the Humbolt University Summer Research Program, the Spencer Social Justice and
Social Development Fellowship and the Center on Philanthropy and Civil Society's Interdisciplinary Seminar
on Civil Society, Government, and Governance of the CUNY Graduate Center.
Rafael A. Torruella is executive director of Intercambios Puerto Rico, Inc, a non-profit community based
organization that provides harm reduction services in the northeast of Puerto Rico. He is also the director
of Descriminalizacion.org, a drug policy change campaign and board member of New York Harm
Reduction Educators (NYHRE), a New York harm reduction community based organization. His research
and advocacy work has focused on understanding processes and issues related to drug use in Puerto Rico
and New York, advocating for evidence-based services and treatment for drug users, and developing drug
policy that is respectful of drug users’ human rights and improves their quality of life and wider
community. His doctoral tesis “Allá en Nueva York Todo es Mejor?:” A Qualitative Study on the Relocation
of Drug Users from Puerto Rico to the United States explores the relocation of drug users from Puerto Rico
to the United States with the goal of receiving drug treatment.. Dr. Torruella holds a doctorate in social
and personality psychology from the CUNY Graduate Center and was awarded pre and post-doctoral
fellowships by the National Institute on Drug Abuse (NIDA) to conduct behavioral research with drug users
at the National Development Research Institute (NDRI). He also received a fellowship from the
Interdisciplinary Research Training Institute (IRTI) on Hispanic Drug Abuse. He has authored journal
articles in the Journal of Social Issues, Substance Use & Abuse, Substance Abuse Treatment Prevention &
Policy, and el Centro Journal and was recently recognized by Drug Policy Alliance as a “Latino Drug Policy
Reformer” during 2015 Hispanic Heritage Month.

About the Authors

39

Intercambios Puerto Rico, Inc
www.intercambiospr.org
www.descriminalizacion.org