South African Community Epidemiology Network on Drug Use (SACENDU)
January - June 1998 (Phase 4)
Charles Parry, PhD
Medical Research Council

SACENDU HIGHLIGHTS
(November 1998)

The focus of this Brief is on the findings of Phase 4 of the SACENDU Project, an alcohol and other drug (AOD) sentinal surveillance system operational in Cape Town, Durban, Port Elizabeth (PE) and Gauteng (Johannesburg/Pretoria). The system monitors trends in AOD use and associated consequences on a six-monthly basis using multi-source information from 27 specialist treatment centres, psychiatric hospitals, mortuaries, trauma units, the police, and from research conducted in schools and with sex workers, street children, persons attending primary health care clinics, and persons attending rave parties. The project is at different stages of development in each of the sites.

Overview
Alcohol is still by far the major substance used/abused in each site. Other major drugs of use/abuse continue to be cannabis alone, or in combination with Mandrax (Methaqualone), over-the-counter (OCM) and prescription medicines (such as slimming tablets, headache powders and benzodiazepines), and cocaine powder/crack. Other drugs used/abused to a lesser extent are LSD, Speed (methamphetamine), Ecstasy (MDMA), and heroin. Other substances have entered the market, e.g. crystal methamphetamine and MBDB (a variant of MDMA). The most common mode of ingesting drugs other than alcohol is by smoking. Arrest, seizure and treatment demand indicators for crack cocaine show an increase in Cape Town. In Gauteng arrest and seizure indicators for heroin are up, while in Durban LSD arrest and seizure indicators all showed an increase in the first half of 1998. Increased trafficking and use of both cocaine and heroin is expected. The value of drugs seized by the Narcotics Bureau (SANAB), the major unit within the SA Police Service tasked with drug crimes, in the four SACENDU sites in the first half of 1998 was over R90 million ($15.7).

Statistics collected as part of Phases 3 and 4 of the SACENDU Project have highlighted the burden of harm associated with AOD use in several areas, including premature death, visits to trauma services, use of psychiatric services, arrests for dealing and possession of illicit drugs, and demand for specialist substance abuse treatment services. More detailed information on the health and social consequences of AOD use is expected in 1999 as a result of the expansion of the Project and related initiatives. While it is clear that various opportunities are being taken to prevent drug use/abuse (e.g. via school-based interventions) and to minimise the harm associated with drug use (e.g. by RaveSafe), opportunities to treat substance abuse are being missed, particularly by the health sector at psychiatric hospitals and primary health care (PHC) clinics.

Phase 4 of the SACENDU project has highlighted several conditions that need to be carefully monitored:

• Changing patterns in the use of crack cocaine, Ecstasy, LSD, Speed, and heroin, and associated problems, as well as the use of multi-drug combinations
• Gaps in services available to women and Black-African populations
• AOD use among adolescents
• The length of time between first regular use of a drug and the demand for treatment
• The production and use of synthetic drugs (especially amphetamine type stimulants (ATS) and heroin derivatives)
• The association between AOD use and crime, premature death, and injury
• Changes in the quality of drugs (e.g. Mandrax, Ecstasy, heroin and Speed) and especially increases in the doses used (of drugs such as Ecstasy)
• Changes in the street prices of drugs
• Changes in mode of drug use, especially IV drug use among heroin users and by users of the crack/heroin ‘speedball’ combination.

Review by substance of abuse
Alcohol
Alcohol is still the most common primary substance of abuse among patients seen at specialist treatment centres across all four sites, accounting for between 61% of admissions (in Durban) and 74% of admissions (in Cape Town). The proportion of alcohol-related admissions appears to be decreasing over time in Cape Town, stable in Durban, but increasing relative to other substances in PE. Such patients tend to be older and are more likely to be male. Alcohol-related diagnoses are common among psychiatric inpatients seen in Cape Town and PE (ranging from 5% to 17% of admissions/discharges). Alcohol is also used in combination with many other drugs.

In a pilot study of substance use among patients attending six primary health care clinics in PE, over 90% of patients indicated that alcohol use is affecting their functioning. However, few patients reported receiving any treatment for substance abuse problems. In comparison with data collected in 1990, a substantial increase in binge drinking among a representative sample of 2 779 male and female Grade 8 and 11 students in Cape Town was noted in 1997. While the studies were not entirely comparable, rates of binge drinking, that is drinking 5 or more drinks on at least one occasion in the past two weeks, increased by between 3% and 7% depending on the grade. Rates were as high as 39% in white males in Grade 11. It was estimated that Grade 11 students in Cape Town alone spend roughly R14 million per year on alcohol (and R5.7 million on cigarettes).

Cannabis and Mandrax
These substances are the second and third most common primary substances of abuse among patients seen at specialist treatment facilities, together accounting for between 15% of admissions (in Cape Town) and 27% of admissions (in Durban). This was similar to the previous six month period. From treatment centre statistics most cannabis users tend to be male and younger than for other substances of abuse. Mandrax users are also more likely to be male than for most other substances. An increase in the proportion of psychiatric inpatients whose primary substance of abuse was cannabis was noted in Cape Town and PE, and a substantial increase in the proportion of psychiatric inpatients whose primary substance of abuse was Mandrax was noted in Cape Town.

These were the most common drugs for which persons were arrested by SANAB for dealing in three of the four sites, accounting for between 57% of arrests (in Cape Town) and 98% of arrests (in PE) in the first half of 1998. Arrest and seizure indicators for both cannabis and Mandrax were mixed across the four sites. Seizures for these two substances were substantially higher in both Durban and Gauteng as compared to the second half of 1997. No common trend was noted across sites in terms of whether prices for these two substances were increasing or decreasing.

According to a UCT/MRC study, lifetime use of cannabis appears to have almost doubled in both male and female students in Grades 8 and 11 attending schools in Cape Town in 1997 as compared to a fairly similar study conducted in 1990. Lifetime and past month use of cannabis among Grade 11 males was 32% and 16% respectively. Lifetime use of the cannabis/Mandrax (‘white-pipe’) combination among this group was 6%. It was estimated that Grade 11 students in Cape Town alone spend R2.3 million per year on these two drugs. While cannabis is used at rave parties, it appears that use of Mandrax at such events is much less common.

Cocaine/Crack
The proportion of patients in specialist treatment centres whose primary substance of abuse was cocaine/crack ranged from 0% in PE to 9% in Durban. The biggest change was noted in Durban where the proportion of patients whose primary substance of abuse was cocaine/crack increased from 1% in the first half of 1997 to 3% in the second half of 1997 to 9% in the first half of 1998. Cocaine/crack accounted for over 8% of admissions to specialist treatment centres in Gauteng. Cocaine powder is primarily snorted, and crack is smoked.

The proportion of SANAB arrests for dealing in cocaine ranges from 2% of all arrests (in PE) to 22% of arrests (in Cape Town). This shows a dramatic increase in Cape Town from 7% of all arrest for dealing in the second half of 1997. The proportion of arrest for dealing in/possession of cocaine in Durban showed a dramatic decrease from the 22% reported in the second half of 1997 (to 2%). In Gauteng the proportion of arrests for dealing in cocaine has remained fairly stable at 14% - 17% over the past 3 reporting periods.

Lifetime use of crack was reported as 3% for males in Grade 11 in the Cape Town school study. The average price of cocaine powder and crack has remained fairly stable across the sites as compared to the second half of 1997. One study showed purity to be about 70%. Cocaine powder is rarely used at rave parties and use of crack at such events is non-existent.

Over-the counter and prescription medicines
From treatment demand information, from the PHC clinic study in PE, and from police seizure information it is clear that there is also considerable abuse of over-the-counter and prescription medicines. Products such as slimming tablets (Thinz and Nobese) and headache powders/tablets are sometimes abused. Headache powder is sometimes used with Coca-Cola as a form of stimulant/analgesic. Painkillers, cough mixtures and benzodiazepines (e.g. Ativan, Rohypnol and Valium) are also frequently abused. Sometimes barbiturates are mixed with heroin to create a ‘brown sugar’ cocktail which is smoked. Ephedrine is used in the manufacture of Ecstasy.

Ecstasy/LSD/Speed (methamphetamine)
The proportion of persons using specialist treatment services whose primary drug of abuse was Ecstasy, LSD, or Speed is still low across all sites (less than 5% combined) but may be increasing (especially in Durban). In Durban for instance, the proportion of patients in treatment whose primary substance of abuse was Ecstasy increased from 1% in the second half of 1997 to 3% in the first half of 1998. Some patients have these substances as secondary drugs of abuse.

The proportion of SANAB arrests for dealing in Ecstasy was up by 8% in Gauteng (to over 10% of all arrests). In Durban the proportion of arrests for dealing in/possession of Ecstasy increased from 3% to 21%. In Gauteng 14037 Ecstasy tablets were seized by SANAB in the first half of 1998. Typically Ecstasy tablets contain a mixture of substances, large part MDMA, and Ephedrine or caffeine (sometimes with MDEA). A variant, MBDB is also being used instead of MDMA in some instances.

Lifetime use of Ecstasy was found to be 10% for white Grade 11 females and 4% for white Grade 11 males in Cape Town schools in 1997. A higher proportion of males and females in Grades 8 and 11 reported lifetime use of Ecstasy than crack cocaine. Concerns about the quality of Ecstasy have been expressed. LSD also appears to be gaining in popularity, though from a low base. The highest proportion of seizures for LSD and Speed were in Gauteng (11% of all arrests for dealing) and in Durban (7% of all arrests for dealing and possession). LSD seizures showed an increase in Cape Town and Durban. Seizures of Speed were low across all sites. Both Speed and LSD are reported to be popular drugs within the rave scene.

Heroin
The proportion of persons using specialist treatment services whose primary drug of abuse was heroin is still low across all sites (less than 2%). The proportion of females using heroin is greater than for many other drugs. Some intravenous drug use was reported among heroin users (e.g. 20 out of 44 patients in specialist treatment centres in Cape Town in the first half of 1998). The proportion of arrests for dealing in heroin was up in Cape Town (from 0% to 8% of all arrests) and Gauteng (0% to 3%). In Gauteng both arrest and seizure indicators for heroin showed an increase. This reflects a growing concern that has been expressed that South Africa may experience an increase in heroin trafficking, use and associated problems in future. Heroin is sometimes mixed with crack (‘speedball’) or as part of a five drug cocktail (phenobarbital, mephobarbital, diazepam, heroin and caffeine) and smoked. Heroin prices have generally not shown a decrease during the last reporting period.

Inter-site comparisons
Policy implications
The findings of Phase 4 of the SACENDU Project raise several implications for policy:

• Alcohol must not be ignored in national, provincial or local efforts to address substance abuse.
• The opportunity for addressing substance abuse by the primary health care sector and by psychiatric institutions must not be missed.
• Lifeskills programmes in schools must give special emphasis to alcohol, cannabis, Mandrax, cocaine, Ecstasy, Speed and LSD.
• Some thought needs to be given to the role of harm reduction strategies within the broader strategy for addressing substance abuse.
• Particular attention should be given to controlling the supply of drugs such as cocaine and heroin, and reducing the demand for such drugs.
• A new initiative is needed to address the abuse of over-the-counter and prescription medicines.
• A taskforce should be set up to investigate the manufacture, marketing, and use of amphetamine type stimulants (ATS). Particular attention needs to be given to reducing the length of time before scheduling certain chemical compounds or banning their trade.
• A more secure funding base must be found for monitoring patterns of AOD use, and especially the harm associated with AOD use. Economic (cost) issues should not be ignored in assessing the consequences of drug use.
• Further attention should be given to addressing the economic issues in the drug trade. The failure to pass the Money Laundering Control Bill of 1997 is a matter of concern.

Future initiatives
The SACENDU Project is likely to be strengthened by several new initiatives during 1999, including a study of drug use (and HIV status) among arrestees in Cape Town, Johannesburg and several other areas, the establishment of an injury surveillance system in +/-18 mortuaries around the country, a further study of drug use among trauma patients in two facilities in Cape Town, the analysis of information collected on substance use among a representative sample of Grade 8 and 11 students in Durban, further analysis of data collected on high school youth in Cape Town, and research on high school students and persons attending rave parties in PE. In addition, a more thorough study of substance use among primary health care patients in PE is planned for early in 1999. The expansion of SACENDU to selected SADC countries in late 1999 is also envisaged.

Table 1: SACENDU Project -- Intersite comparisons
(January-June 1998)

* - January - June 1998