According to the South African Community Epidemiology Network on Drug Use (SACENDU), up to 26% of patients in specialist treatment centres reported heroin as their primary drug of abuse. But there may soon be a safer alternative available for Opioid addicts in Pretoria. Working with the University of Pretoria, the City of Tshwane is providing Opioid Substitution Therapy (OST) at seven clinics in Pretoria and surrounding townships.
In May, Executive Mayor of Tshwane, Solly Msimanga said, “The agreement between the City of Tshwane and the University of Pretoria was finalised in June 2016 and funds were made available in August 2016.” In a 16 March article published in The Citizen titled ‘Tshwane, Tuks join forces to tackle drug abuse’, Msimanga said that “measures to address drug abuse have resulted in the city engaging with the university as a partner in the fight against substance abuse.” Msimanga went on to say “the approach to dealing with substance abuse has shifted from sending users either to jail or to rehabilitation centres where withdrawal and total abstinence are the sole aim. It has now moved to a human rights, harm reduction and health care approach where early detection, hard reduction and care in the community through relationship building, support and re-integration into the society are the main focus. The [community-oriented primary care] COPC, brief interventions, opioid substance therapy (OST) and a needle exchange programme are central to this approach. The Department of Health and Social Development are engaged in the development and monitoring of the project. A medical doctor, registered nurse, clinical associates and social workers have been trained and they have already started the screening of substance users at homes and have initiated treatment at several sites.” Gauteng already has 14 specialist treatment centres, where according to SACENDU 3 989 patients were treated between January and June in 2016.
Jannie Hugo, University of Pretoria’s head of Family Medicine department, told Bhekisisa that the Gauteng programme is already seeing results in its initial two months. He says it strengthens the argument that OST should be increasingly available in the public sector – a call supported by the country’s latest HIV plan. Hugo explains: “Our experience is that it makes a significant difference. The person is able to build a normal life as the cravings are controlled. We are of opinion that OST should be made available widely for use in primary health care as part of a comprehensive care programme to deal with substance use.”
Opioids include prescription painkillers and heroin, which according to the South African Addiction Medicine Society (SAAMS) is the most frequently used illicit opioid in South Africa, and the fourth most common substance of abuse overall with a prevalence of 7.9%. In South Africa there are several common versions of heroin such as “sugars”, a mixture of cheap heroin, cocaine, and often other dangerous substances such as rat poison; “nyaope”, common in Gauteng, is heroin mixed with cannabis; and “woonga”, which is common in Durban and contains heroin mixed with a variety of substances, sometime including crystal methamphetamine.
According to SAAMS, the prevalence of heroin in South Africa is due to increased opium production in Afghanistan and South Africa’s location along one of Africa’s main drug trafficking routes.
Opiates produce painful withdrawal symptoms. When in the system, opiates bind to opioid receptors on the brain (creating the pain relieving effects drugs such as Morphine are known for) and produce a secondary effect, causing the release of dopamine – the body’s ‘reward’ neurotransmitter. The dopamine in turn suppresses the release of norepinephrine, causing the user to feel calm and sleepy. Over time, physical dependence and tolerance occur. DrugAbuse.com explains physical dependence as “the brain transition to functioning normally when the substance is present and abnormally when the drug is unavailable” and tolerance as “the brain will begin to register less of a dopamine response when the opiate is used like it did initially. The person will need to consume higher doses of the substance more often to produce the same level of wanted effects.”
DrugAbuse.com also explains that the extreme withdrawal symptoms “with tolerance driving increasing patterns of use and physical dependence in place, someone who suddenly attempts to end use will experience a combination of very low dopamine levels and very high noradrenaline levels. This out-of-balance neurotransmitter combination helps to explain some of the unpleasant opiate withdrawal symptoms that begin to arise.” These withdrawal symptoms, including nausea, vomiting, and muscle pains, can “begin between 12 and 30 hours after last use and will last between 4 and 10 days in most situations, although someone withdrawing from a longer-acting opioid drug like methadone will require up to 21 days to end this acute withdrawal phase”, says DrugAbuse.com. The only way to prevent withdrawal symptoms is to continue to take opioids. This is where the opioid replacement therapy comes in. According to a 2011 article titled ‘Opioid substitution therapy in resource-poor settings’ in the Bulletin of the World Health Organization, “Opioid substitution therapy supplies illicit drug users with a replacement drug, a prescribed medicine such as methadone or buprenorphine, which is usually administered orally in a supervised clinical setting.” These drugs allow users to avoid withdrawal symptoms, but do not give them a “high”.
Another risk for illegal opioid users is contracting HIV. In an article Bhekisisa published on 30 May titled ‘New Gauteng programme allows drug users to swap illegal highs for safer alternatives’, “People who inject drugs are at a high risk of HIV and Hepatitis C infection, in part because users may share needles. A five city study conducted in South Africa found that the HIV prevalence rate among injecting drug users was about 40% higher than that of the general population, according to 2016 research published in the International Journal of Drug Policy.” OST also provides patients with counselling, job skills training, and tests for HIV and Hepatitis C.
Image: Michelle Hartzenberg