South African Community Epidemiology Network on Drug Use (SACENDU)
January - June 1999 (Phase 6)
Charles Parry, Andreas Pluddemann, Arvin Bhana, Janet Bayley, & Hennie Potgieter
Medical Research Council, University of Durban-Westville, SANCA (Port Elizabeth), Elim Clinic

SACENDU HIGHLIGHTS
(November 1999)

Background
The focus of this report is on the findings of Phase 6 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 over 40 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, arrestees, and persons attending rave parties.

The main benefit of such a network is the facilitation of an evidence-based approach to local and national policy formation rather than having policy informed by other factors (eg. whims, one person's opinion, isolated studies, tradition, and using what is done elsewhere).

Overview
Commonalities across sites:

• Alcohol is still the dominant substance of abuse and has a major impact on individuals and society particularly in the area of violence and traffic-related trauma (71% of violence-related trauma cases in Cape Town, Durban and PE were alcohol positive vs 50% for traffic collisions). The proportion of alcohol-related treatment admissions has however showed a decline relative to other substances. High levels of binge drinking were reported in the PE study of Grade 9 and 11 students: 23% in the past year.
• Use of cannabis ("dagga") and Mandrax (methaqualone) alone or in combination ("white-pipes") continues to be high. Indicators for these substances are mixed, though Mandrax indicators are starting to show a decline. According to the SAPS Forensic Science Laboratory (FSL) 2.6 million Mandrax tablets were seized nationally by the SAPS in the first half of 1999 (1.6 million in Durban). Cannabis and Mandrax use is high among persons arrested for a range of crimes across sites, as well as in trauma patients. At least one third of trauma patients in Cape Town, Durban and PE tested positive for cannabis, and between 11% and 22% tested positive for Mandrax.
• There is growing concern about the potential for cocaine (especially crack) and heroin use and associated problems to increase. Mandrax, in particular, seems to be yielding to crack. An increase in the demand for treatment for cocaine/crack was reported in 3 of the 4 sites, and while seizures declined, the price of cocaine/crack has remained stable or declined. Use of cocaine at raves has also been reported. According to the FSL 60.5kgs of cocaine HCL and 4.8kgs of crack rocks were seized nationally in the first half of 1999.
• With regard to heroin , there has been an increase in treatment demand in 3 of the 4 sites (Cape Town, Gauteng and PE), in SANAB seizures in 3 of the 4 sites (Cape Town, Gauteng, and Durban), and in arrests for dealing in Cape Town in the first half of 1999. According to the FSL 3.7kgs of heroin was seized nationally in the first half of 1999. The price of heroin appears stable across sites or is slightly reduced in comparison with the second half of 1998. Most heroin is smoked ("chasing the dragon"). The average age of persons in treatment in Cape Town whose primary drug of abuse is heroin has shown a decline since the second half of 1996. Use of heroin appears much greater in Cape Town and Gauteng than in the other sites.
• Club drugs in general appear to be entrenched in the youth culture. Most concerns relate to problems likely to be experienced by younger/inexperienced users, the quality of the drugs being sold, and the possibility of Ecstasy users using other drugs (especially amphetamines) in combination or moving on to other harder drugs. Other drugs used to varying degrees include LSD, Speed (methamphetamine), magic mushrooms, cannabis (afterwards), poppers, diet pills, ketamine, GHB (gamma-hydroxybutyrate), Rohypnol (Flunitrazepam) and cocaine.
• Except for Durban we note a decline in the proportion of arrests for dealing in Ecstasy and seizures of Ecstasy in the first half of 1999. Treatment demand for Ecstasy as the primary drug of abuse is low, but like LSD it often appears as the secondary drug of abuse. There were increasing reports of use of LSD by young persons and of police arrests and seizures. In general LSD indicators are up. According to the FSL police nationally seized 1197 units of LSD in the first half of 1999 and 16 034 Ecstasy tablets.
• In general there appears to be a decline in the age of drug users (from treatment centre statistics and some school surveys).
• In terms of drug markets the big issue appears to be the emergence of "real" organised crime (often involving Nigerians and cocaine/heroin) rather than local traffickers in dagga. There is evidence of movement of drug markets from high density drug trafficking areas to the suburbs.
• There are reports of increasing drug use among sex workers (e.g. larger doses and harder drugs) and of their direct or indirect link to the drugs trade.
• The abuse of over-the-counter and prescription medicines (e.g. slimming tablets, headache powders, and benzodiazepines like Rohypnol) continues to be an issue across sites. This has been linked to various negative outcomes, e.g. paracetamol-related poisonings and suicides in Cape Town. The FSL in Gauteng reported seizures of 58207 units of benzodiazepines in the first half of 1999. Most of the cases involved Rohypnol.
• There appears to be a great deal of poly-substance use, e.g. Ecstasy and heroin, alcohol and cannabis, alcohol and Mandrax, cocaine and Rohypnol, crack and heroin, alcohol and analgesics, Ecstasy and amphetamines, and Ecstasy and Rohypnol.
• There appears to be large variability in drug prices within sites.

Regional differences:
In comparing Cape Town, Durban, PE, and Gauteng the following were among regional differences that appeared:

• The level of drug use generally appears higher in Cape Town and Gauteng than in Durban and PE (e.g. from school surveys, SANAB statistics, treatment demand, trauma statistics and studies of arrestees)
• There are indications of a higher levels of alcohol use and alcohol-related negative consequences (trauma admissions, treatment demand) in PE than in Cape Town and Durban.
• Heroin appears to be mostly prevalent in Cape Town and Gauteng.
• Drug prices are often lower in Cape Town and Gauteng than in PE and Durban. Cannabis prices are lower in Durban. Sites also differ in terms of whether the market for certain drugs is controlled by a single syndicate or is more diffuse.

Policy implications
During the Phase 6 (January - June 1999) regional report back meetings of SACENDU 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 there is a need for greater debate around strategies such as 'zero tolerance' and 'harm minimization'.

In terms of demand reduction:

• Youth have become desensitised to the harmful effects of drug use. The Internet might be a useful vehicle in addressing this (see RaveSafe which has 30 000 ‘hits’ per month).
• Multi-faceted interventions are required: Teachers need to be empowered to discipline more effectively and parents need to be educated about drug abuse. Drug education is required within the mainstream curriculum. Young persons need to be given skills to make autonomous decisions. Peer education approaches must also be explored.
• "Healthy" recreational opportunities for young persons need to be created.
• There is an urgent need to address possible "gateway drugs": alcohol, cigarette smoking, and cannabis use among adolescents.
• There is an urgent need to address the lack of treatment services available to persons residing in traditionally African residential areas (either through providing new services or increasing access to services in general).
• Treatment approaches must not ignore lower educated and non-urban populations
• While the need for increased outpatient facilities is recognised, many patients will still require some inpatient treatment.
• We need to address substance abuse treatment needs of psychiatric patients.
• We need greater awareness of the abuse of over-the-counter and prescription medicines (e.g. Stilpayne, Grandpa headache powders, products containing paracetamol). Work with pharmacists to reduce abuse of scripts.
• Trauma unit personnel should be trained to recognise indications of concomitant substance abuse and be able to make appropriate referrals to substance abuse treatment services.

In terms of supply reduction:

• Reduce the supply of drugs in and around selected residential hotels (e.g. in Hillbrow and Point area of Durban) and in/around schools. With regard to the former, the Drug & Drugs Trafficking Act 1992 (Article 26 (1) (b)) allows for confiscation of property used in drug dealing.
• Given recent political changes in Nigeria, South Africa should rethink whether there are legitimate reasons for considering Nigerians suitable for refugee status given the high level of involvement of Nigerians in the trade in cocaine and heroin. There should be rapid processing of Section 41 hearings (Immigration Act) involving Nigerian nationals.
• Reduce the length of time before scheduling certain chemical compounds (e.g. GHB).

Issues to monitor
Phase 6 of the SACENDU Project highlighted several conditions/factors that need to be carefully monitored over time:

• Demand for treatment where heroin is the primary substance of abuse.
• The decreasing age of drug users (especially heroin users).
• The use of drug combinations by young persons.
• The impact of changes in the Labour Relations Act and Medical Schemes Act in terms of the number and demographic profiles of people coming to specialist substance abuse treatment centres.
• The quality of rave drugs (especially following successful police seizures of drugs or closing clandestine laboratories) and changes in the chemical composition and effects of amphetamine type stimulants (e.g. MDMA-type drugs).
• Possible links between the granting of casino licenses and use of methamphetamine (by workers in casinos).
• Movement by drug users from one drug to another (e.g. Mandrax users to crack, or Wellconal users to heroin).
• A possible increase in street crime (burglary, pickpocketing and other property crimes) that might be associated with an increase in harder dug use.
• Expansion of drug markets to other locations within sentinel sites (e.g. Hillbrow to Sandton).
• Poly-substance use, especially the use of one substance to "come down" from the effect of another (e.g. use of heroin by sex workers to come down from crack).
• Changes in the mode of drug use (e.g. intravenous use of heroin).
• A possible increase in court referrals following the implementation of the South African Arrestee Drug Abuse Monitoring (SA-ADAM) Project.
• Drug prices (especially the price of Ecstasy being sold to young persons).

Research questions
At the SACENDU meeting in October 1999 various topics for research were identified. These included:

• Treatment needs of women and barriers to treatment experienced by women and other groups.
• Methods for harm minimisation among rave party/club attenders (especially those younger and less experienced).
• The reasons young persons (and others) use drugs.
• The physical addiction potential of Ecstasy and the long term negative consequences.
• The links between use of Ecstasy and other drugs (either at the same time or at a later stage).
• Reasons why particular drugs come into fashion.
• What distinguishes between drug users who function well versus those who do not?
• Link between cannabis/Mandrax use and schizophrenia.
• The nature and extent of substance abuse among out-of-school youth.

Future directions
The SACENDU Project is likely to be strengthened by several new initiatives during 1999/2000 including:

• A study of HIV risk behavior and substance use among adolescents in community samples in Cape Town and Durban.
• Expansion of the study of drug markets to Cape Town.
• Further analysis of the data from the school studies conducted in Cape Town, PE and Durban, and the possible initiation of a school study in Gauteng.
• Continuation of the Three Metros arrestee study (part of the SA-ADAM initiative)
• Further studies of AOD use among trauma unit attendees.
• Possible expansion of SACENDU to selected SADC countries and to other sites in South Africa.