South African Community Epidemiology Network on Drug Use (SACENDU)
July - December 1998 (Phase 5)
Charles Parry, PhD
Medical Research Council

SACENDU HIGHLIGHTS
(April 1999)

The focus of this report is on the findings of Phase 5 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 29 specialist treatment centres, psychiatric hospitals, mortuaries, trauma units, the police (SA Narcotics Bureau, Organised Crime Units & Forensic Science Laboratories), 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 abused in each site. However, with the exception of PE the demand for treatment for alcohol problems relative to other substances appears to have stabilized or declined. Other major drugs of use 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 crack cocaine.

Other drugs used to a lesser extent are LSD, Speed (methamphetamine), and heroin. Ecstasy continues to be used by young persons in the club scene. Other substances have entered the market during Phase 5 of the project, e.g. DOB (a variant of MDMA).

The most common mode of ingesting drugs other than alcohol is by smoking. Drug prices fluctuated to a moderate degree over the second half of 1998.

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 64% and 68% of admissions. The proportion of alcohol-related admissions appears to be decreasing over time in most sites relative to other substances. 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 23% of admissions/ discharges). The proportion of alcohol-related psychiatric diagnoses appears to be stable or decreasing in PE and Cape Town.

A strong association between alcohol and non-natural death was reported in Cape Town during 1998 (Salt River Mortuary). Overall, 55% of cases had blood alcohol levels greater than or equal to 0.08gms/100 ml, with 31% having BACs greater than or equal to 0.20gms/100ml. With regard to specific causes of death, 11% of drivers, 35% of pedestrians, and 27% of homicide victims had BACs greater than or equal to 0.20gms/100ml (i.e. were heavily under the influence of alcohol).

With regard to injury, a study of trauma patients at the Groote Schuur Hospital in early 1999 found that 16% had breath alcohol greater than or equal to 0.08gms/100ml (down from 33% in 1997).

Cannabis and Mandrax
These substances are the second and third most common primary substances of abuse among patients seen at specialist treatment facilities in Cape Town, PE and Durban (after alcohol). These substances together account for between 50% (in Gauteng) and 84% (in Durban) of the primary substances of abuse (excluding alcohol) seen by treatment centres. From treatment centre statistics most cannabis users tend to be male and younger than for other substances of abuse (excluding Ecstasy). Across sites patients in treatment whose primary substance of abuse is Mandrax are also more likely to be male. They are also younger than patients whose primary substance of abuse is cocaine/crack or alcohol.

Together 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 78% of arrests (in PE) in the 2nd half of 1998. Nevertheless, arrest indicators for cannabis were down in three of the SACENDU sites. Seizure indicators were down in all sites, and price was stable or up across the four sites. The proportion of arrests for dealing in Mandrax showed an increase across most sites while prices were generally stable. Seizure indicators were mixed. In 1998 in Cape Town, PE and Durban between 49% and 74% of the value of SANAB seizures can be attributed to cannabis. However, for Gauteng the corresponding figure was only 7%. Mandrax comprised between 9% (in Cape Town) and 28% (in PE) of the value of drugs seized by SANAB.

A study of trauma patients at the Groote Schuur Hospital in early 1999 found that 30% of patients had cannabis (THC) in their urine. This was only slightly more than was noted in a previous study conducted in 1997.

Cocaine/crack
The proportion of patients in specialist treatment centres whose primary substance of abuse (other than alcohol) was cocaine/crack ranged from 2% in PE to 21% in Cape Town and 27% in Gauteng. Cocaine powder is primarily snorted, and crack is smoked.

The proportion of SANAB arrests for dealing in cocaine in the 2nd half of 1998 ranged from 14% of all arrests in Gauteng to 81% of arrests in Durban. This proportion was up in three of the four sites. Seizure and price indicators were mixed across sites. The largest amount of cocaine seized in the 2nd half of 1999 took place in Gauteng (433 kgs).

A study of trauma patients at the Groote Schuur Hospital in early 1999 found that 5% of patients had cocaine in their urine, up from 2% in 1997. Extensive use and marketing of crack by sex workers was reported in Durban. In this population crack cocaine appears to be often used in combination with Mandrax (to come down from a crack high). Across sites prices range from R180-R300/gm of cocaine HCL.

In 1998 the proportion of all drugs seized by SANAB which could be attributed to cocaine ranged from 3% in PE and Durban to 31% in Cape Town and 79% in Gauteng. Dealing in cocaine and cocaine-related problems appear to have become firmly established in PE during 1998.

Over-the counter and prescription medicines
Continued reports of abuse of OCM and prescription drugs were received (e.g. tranquillizers, analgesics, barbiturates, benzodiazepines). Excluding alcohol, between 3% (in Durban) and 20% (in PE) of patients attending specialist treatment centres in the four sites had OCM and prescription drugs listed as their primary drug of abuse. While treatment demand decreased slightly in three of the sites, a substantial increase in the demand for treatment for problems related to the abuse of over-the-counter and prescription medicines was noted in PE. SANAB (PE) also reported that flunitrazipam (Rohypnol) had been stolen from a pharmaceutical company in the area in the second half of 1998. A few emergency room visits associated with the use of gamma hydroxy-butyrate (GHB, aka "Liquid Ecstasy") were also reported in the second half of 1998.

Solvents
Abuse of solvents (petrol, thinners, glue, and household cleaners) by young persons continues. While this is widespread among street children, these substances are also abused by children living in better circumstances.

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. However, some patients have these substances as secondary drugs of abuse.

The proportion of SANAB arrests for dealing in Ecstasy ranged from 2% in Durban, to 11% in Cape Town and 18% in Gauteng. Arrest and seizure indicators are mixed across sites. In 1998 Ecstasy comprised between 1% and 2% of the estimated value of drugs seized by SANAB in Durban, PE and Gauteng compared to 10% in Cape Town. The price of Ecstasy appears stable or decreasing. Ecstasy continues to be used in the club scene, especially by young persons. The DOB variant was reported as being used in Durban and Gauteng. Use of Ecstasy in combination with other amphetamines was reported. Serotonin inhibitors are also being purchased from health food stores by some users to enhance the effect of Ecstasy and to reduce the effect of coming down from the drug ("preloading").

Use of LSD and Speed was also reported, particularly within the club scene. The highest proportion of arrests for LSD and Speed was in Gauteng (4%, down from 11% in the first half of 1998).

The proportion of arrests for dealing in LSD/Speed showed a decrease across sites. Seizures for LSD by SANAB showed an increase only in Gauteng, whereas seizures of Speed increased only in Cape Town. The price of Speed appears to be decreasing in most sites whereas for LSD the opposite may be occurring. Across sites these two drugs in 1998 comprised less than 1% of the estimated value of drugs seized by SANAB.

Heroin
Heroin treatment demand showed an increase in Gauteng, and the average age of heroin users in treatment appears to be declining in both Cape Town and Gauteng. In these two cities 5% - 6% of persons attending specialist substance abuse treatment centres for abuse of substances other than alcohol had heroin as the primary substance of abuse. The proportion of females using heroin is greater than for many other drugs. In Cape Town and Gauteng, for example, the proportion of persons in treatment whose primary substance of abuse was heroin was 32% and 21% respectively, and the average age of persons in treatment was 23-24 years old. Heroin is mostly smoked. Some intravenous drug use was reported among heroin users (e.g. 11 out of 31 patients in specialist treatment centres in Cape Town in the second half of 1998).

Arrest and seizure indicators for heroin are mixed across sites. No arrests (for dealing) or seizures relating to heroin where made by SANAB in PE or Durban during Phase 5. In Gauteng SANAB seized 1229 grams in the second half of 1998. The purity is reportedly high and the drug is apparently being cut in South Africa before being exported to other countries. Across sites in 1998 less than 1% of the total value of drug seizures could be attributed to heroin. The price of heroin is low in comparison to other countries (R120-R350/gm).

Inter-site comparisons
See table below

Policy/planning implications
During the Phase 4 (January - June 1998) and 5 (July - December 1998) regional report back meetings of the SACENDU Project a number of recommendations were made with regard to specific interventions needed to address substance abuse and with regard to substance abuse policy in general:

• Alcohol must not be ignored in national, provincial or local efforts to address substance abuse.
• Greater thought needs to be given to the place 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 to reducing the demand for such drugs.
• A new initiative is needed to address the abuse of OCM and prescription medicines (including medicine theft).
• Attention needs to be given to reducing the length of time before scheduling certain chemical compounds or banning their trade (e.g. GHB).
• Further attention should be given to addressing economic issues in the drug trade (e.g. alternative income generation strategies and to reducing the economic incentives for involvement in the drug trade).
• Improved inter- and intra-sectoral collaboration is required.
• Special attention needs to be given to improving the treatment of substance dependent persons:
  • Improve referrals and early identification.
  • Encourage drug users to seek treatment early.
  • Ensure adequate treatment by psychiatric institutions and primary health care (PHC) services.
  • Develop protocols for the treatment of heroin addicts.
  • Implement continuing-medical-education programmes for medical practitioners.
  • Increase access to anti-craving drugs.
  • Develop effective short duration treatment approaches.
  • Establish mechanisms for funding the treatment of unemployed persons.
• Calls were made for standardization of policies around diversion of offenders from the criminal justice system into treatment (e.g. who, when).
• Improve interventions to decrease drug use among sex workers and to minimise associated harm.
• Improve supply reduction in high risk areas (e.g. in and around selected residential hotels).
• Addressing alcohol abuse should be an important component of crime prevention strategies.
• Improved access to information on ATS from SAPS Forensic Science Laboratory’s drug units was requested.
• There is a need to improve police capacity to quantify drugs seized (i.e. the actual quantity of illicit substances).

Issues to monitor
Phases 4 and 5 of the SACENDU Project highlighted several conditions/factors that need to be carefully monitored over time:

• Changing patterns in the use of crack cocaine (relative to Mandrax), Ecstasy, and heroin, as well as the use of multi-drug combinations.
• Demographic changes in treatment demand.
• AOD use among adolescents and by African sex-workers.
• The length of time between first regular use of a drug and the demand for treatment.
• The production and use of synthetic drugs and associated problems.
• Changes in the quality of drugs (e.g. Mandrax, Ecstasy, heroin and Speed) and especially increases in the doses used (e.g. Ecstasy).
• Changes in mode of drug use (esp. intravenous drug use among heroin users).

Research questions
At the SACENDU meetings in October 1998 and March 1999, various topics for research were identified. These included:

• The need to assess which different drugs are taken in combination and the effects of taking particular drug combinations.
• The abuse of OCM and prescription medicines by high school youth (and others).
• The extent to which substance abuse problems are treated by general practitioners and others, often under the guise of depression.
• Unmet treatment needs among women and African populations, and ways to improve access to treatment by these groups.
• Emergency room visits associated with drug use.
• The link between substance use and HIV infection (esp. among sex workers).
• Psychological reasons for drug use.
• The availability of drugs in a broad spectrum of venues frequented by young persons.
• The impact of the increased availability of generic drugs on the abuse of prescription medicines.
• The association between AOD use and crime, premature death, and injury.
• The impact of interventions aimed at 1st time smokers on later drug use.
• The costs/benefits of treatment versus incarceration for certain groups of offenders.

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/Pretoria and Durban.
• The establishment of an injury surveillance system in 18 mortuaries.
• A study of drug use among trauma patients in two facilities in Cape Town. And in Durban.
• School surveys in PE and Gauteng and the (further) analysis of school survey data collected in Durban and Cape Town in 1997 and 1998.
• Studies of persons attending rave parties in each of the 4 sites.
• Research among PHC patients in PE.
• Possible expansion of SACENDU to selected SADC countries in 1999/2000.

Table 1: SACENDU Project -- Intersite comparisons
(July - December 1998)

* - July - December 1998