South African Community Epidemiology Network on Drug Use (SACENDU)
July - December 1999 (Phase 7)
Charles Parry¹, Andreas Pluddemann¹, Arvin Bhana²,
Janet Bayley³, & Hennie Potgieter⁴

¹ South African Medical Research Council
² University of Durban-Westville
³ SANCA (Port Elizabeth)
⁴ Elim Clinic (Johannesburg)

SACENDU HIGHLIGHTS
(April 2000)

Background
The focus of this report is on the findings of Phase 7 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, initiated in 1996, monitors trends in AOD use and associated consequences on a six-monthly basis using multi-source information from 46 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.

Overview
Commonalities across sites:

• Alcohol is still the dominant substance of abuse across sites and has a major impact on individuals and society particularly in the area of violence and traffic-related trauma (60% of violence-related trauma cases in Durban and 90% in PE were alcohol positive. The corresponding percentages for traffic trauma were 41% and 70% respectively. Alcohol still dominates treatment admissions with between 50% (Cape Town) and 65% (Durban) of admissions involving alcohol as the primary substance of abuse. The proportion of alcohol-related treatment admissions, however, continues to show a steady decline in Cape Town and Gauteng relative to other substances. Between 10% (Gauteng) and 33% (Cape Town) of persons arrested for a variety of crimes ("arrestees") reported being under the influence of alcohol at the time of their arrest. Arrestee information was collected at 9 police stations and involved almost 1000 arrestees. Between 6% and 17% of psychiatric patients in selected psychiatric hospitals in Cape Town, Gauteng and Port Elizabeth had alcohol-related psychiatric discharge diagnoses.
• Use of cannabis ("dagga") andMandrax (methaqualone) alone or in combination ("white-pipes") continues to be high. Low grade cannabis (called "majat") is sometimes used with solvents to make the white-pipe burn more readily. Treatment demand for cannabis increased in 3 of the 4 sites, whereas for Mandrax or the white pipe combination treatment demand was stable or declined. Between 50% (Gauteng) and 78% (Port Elizabeth) of patients attending specialist treatment centres had cannabis and/or Mandrax as their primary drug of abuse. The proportion of arrests for dealing in cannabis showed a decline in all sites excluding Gauteng, whereas increases in the proportion of arrests for dealing in Mandrax were noted in two sites (Cape Town and Durban). In Durban 73% of arrests for dealing in drugs involved Mandrax.

  Seizures of cannabis (dealing and possession) increased in Cape Town and Gauteng, but decreased substantially in Durban. Mandrax seizures decreased in all sites. In Durban 460 kgs of Mandrax (over 900 000 tablets) was seized in the 2nd half of 1999. According to the SAPS Forensic Science Laboratory (FSL) 544 571 Mandrax tablets were seized nationally by the SAPS in the 2nd half of 1999, down from 2.6 million in the 1st half of 1999. The price of cannabis has remained stable at R1-R2/stop, while the price of Mandrax has remained stable or has shown a decline (R30-R45/tablet). In PE over 90% of the value of drug seizures by the South African Narcotics Bureau (SANAB) and the Organised Crime Unit can be attributed to cannabis. In Durban over half of the value of drugs seized by SANAB can be attributed to Mandrax).

  Cannabis and Mandrax use is high among persons arrested for a range of crimes across sites, as well as in trauma patients. Across sites between 29% (Gauteng) and 57% (Cape Town) of arrestees tested positive for cannabis, and between 9% (Gauteng) and 42% of arrestees tested positive for Mandrax (Cape Town) using urinalysis. Across sites, two-thirds of persons arrested on charges of housebreaking tested positive for cannabis and over 50% of persons arrested for murder and weapons offenses. Over 50% of persons arrested for housebreaking tested positive for Mandrax, with over a third of persons arrested on weapons charges and almost a quarter of persons arrested for robbery/theft and murder tested positive for Mandrax.
  Over one-third of trauma patients in Durban and PE (34% in Durban and 43% in PE) tested positive for cannabis, and between 11% and 13% tested positive for Mandrax.

• There continues to be 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 Durban (where 26% of patients treated for drug abuse had cocaine or crack as their primary drug of abuse). Treatment demand for cocaine powder/crack in the other sites was stable (ranging from 3% in PE to 28% in Gauteng).

  Arrests for dealing in cocaine powder (HCL)/crack showed an increase in Cape Town (to 29% of all arrests for dealing in the 2nd half of 1999), but remained stable or declined in the other sites. Seizures of cocaine HCL were up in PE and Gauteng (116 kgs). Seizures of crack rocks increased in all sites excluding PE in the 2nd half of 1999. The price of cocaine HCL/crack has remained stable at between R180 and R400 per gram of cocaine HCL depending on the site. A 0.1 gm rock can be purchased for as little as R50. In Gauteng and Durban 86% and 49% respectively of the value of drug seizures by SANAB can be attributed to cocaine powder/crack. Across sites between 3% (Cape Town) and 5% (Gauteng) of arrestees tested positive for cocaine (including 9% of persons arrested on charges related to housebreaking and murder). 3% of trauma unit attendees in Durban tested positive for cocaine (0% in PE). Use of cocaine at raves (or after raves) continues to be reported. According to the FSL 94.2kgs of cocaine HCL was seized in the 2nd half of 1999, up from 60.5 kgs seized in the previous six months.

• With regard to heroin , treatment demand has remained fairly stable (but in Gauteng is likely to show an increase once additional treatment centres are added). Excluding over-the-counter and prescription drugs, heroin had the highest proportion of females reporting it as their primary drug of abuse (33% of patients in Cape Town whose primary drug of abuse was heroin were female - this has been increasing over time). In both Cape Town and Gauteng the mean age of persons coming for treatment whose primary drug of abuse was heroin was 23 years. In Cape Town and Gauteng (where use of heroin is mostly concentrated) between 7% and 8% of patients in specialist treatment centres have heroin as their primary drug of abuse. Intravenous (IV) use of heroin is still low among heroin users attending treatment, but there are anecdotal reports of increasing IV drug use among younger heroin users in Gauteng.

  Across sites arrests for dealing in heroin are stable or showed a decline. Seizures of heroin declined in both Cape Town and Gauteng in the 2nd half of 1999 and were negligible in the other 2 sites. According to the FSL, 742 gms of heroin was seized nationally in during this period, down from the 3.7 kgs seized in the previous six months. The price of heroin appears stable across sites or is slightly reduced in comparison with the 1st half of 1999, but is very low when compared to most other countries. Most heroin is smoked ("chasing the dragon"). Some concerns have been raised about the quality of heroin being sold in Cape Town and Gauteng (e.g. heroin being mixed with phenobarbital in Cape Town, and dealers deliberately increasing or decreasing the purity of heroin levels with younger clients in Gauteng). 3% of arrestees in Cape Town and Gauteng tested positive for opiates (includes valium, codeine, morphine and heroin) compared to 1% in Durban.

• Club drugs in general appear to be entrenched in the youth culture (and were shown in a SANCA study to now be available in traditionally Black/African residential areas such as SOWETO). Most concerns relate to 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, ephedrine, magic mushrooms, cannabis (afterwards), poppers (amyl nitrate), diet pills (e.g. Thinz, Nobese), ketamine, GHB (gamma-hydroxybutyrate), Rohypnol (Flunitrazepam) and cocaine.
• The proportion of arrests for dealing in Ecstasy was up in Cape Town and PE (particularly) and seizures of Ecstasy were up in all sites excluding Gauteng in the 2nd half of 1999. Across sites the price of Ecstasy varies between the sites and venues (R40 -R150/tablet). In Cape Town the FSL reported that a few cases of Ecstasy contaminated by Strychnine had been discovered. Treatment demand for Ecstasy as the primary drug of abuse is low, but like LSD it often appears as the secondary drug of abuse. Some of the indicators for LSD showed an increase in the 2nd half of 1999 (e.g. arrests for dealing in PE, and LSD seizures in PE and Durban). According to the FSL police nationally seized 1290 units of LSD in the 2nd half of 1999 and 6 867 Ecstasy tablets. LSD seizures have remained stable, but Ecstasy seizures decreased by 57%. The proportion of arrests for dealing in Speed is low across sites. Few seizures of Speed were made (mainly in Gauteng).
• The abuse of over-the-counter and prescription medicines (e.g. slimming tablets, headache and pain medication (Grandpa headache powders, codeine, pethidine), tranquillisers, and benzodiazepines like Rohypnol) continues to be an issue across sites. However, demand for treatment where these substances are the primary drug of abuse was either stable or showed a slight decrease across the sites. 4% of arrestees in Durban tested positive for benzodiazepines. FSL seizures of benzodiazepines showed a dramatic decrease in the 2nd half of 1999.
• An increase in the cultivation and use of Khat (a stimulant) was also reported in Cape Town and Port Elizabeth.
• There appears to be a great deal of poly-substance use, including Ecstasy and heroin, Ecstasy, crack cocaine and cannabis by rave party attendees.

Regional differences
In comparing the 4 sites the following were among regional differences that appeared:

• The level of drug use as well as the range of drug used is higher in Cape Town and Gauteng as compared to PE and Durban.
• Heroin use, in particular, continues to be lower in Durban and (especially) PE as compared to the other 2 sites. Particular concern was expressed with regard to the use of heroin by young persons in Gauteng.
• Cocaine now seems to be firmly rooted in Durban. Durban continues to be a major port of entry for Mandrax into the country.
• Various indicators highlight the high levels of abuse of over-the-counter and prescription medicines in Port Elizabeth.

Implications for policy/practice
During the Phase 7 (July-December 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.

• Increase outpatient and other treatment options for addressing AOD abuse (including primary health care)
• Increase capacity to deal with substance abuse in general hospitals
• Increase treatment options for women, people from disadvantaged areas, youth and the unemployed
• Establish protocols for handling arrestees under influence of AODs
• Ensure HIV prevention efforts include a focus on IV drug use (include needle sharing)
• Strategies to reduce drug use and drug-related crime must be area specific, and also focus on youth
• Address possible gateway drugs (alcohol, tobacco, and cannabis)
• Increase health education aimed at community (including use of data from Forensic Science Laboratories on drug purities)
• Address weaknesses in judicial system (easy bail for drug traffickers, and dealers)
• A specific strategy (supply and demand reduction) may be needed to decrease use of heroin among persons under 20
• Increase capacity of Forensic Science Laboratories to get information on drug sources
• Raise awareness of health sector to negative impact of AOD abuse
• Lobby medical aids to provide increased cover for AOD abuse
• Priority needs to be given to addressing alcohol abuse in Eastern Cape and to reducing the supply of Mandrax through Durban
• Focus greater efforts on drunk pedestrians.

Issues to monitor
Phase 7 of the SACENDU Project highlighted several conditions/factors that need to be carefully monitored over time:

• Changes in proportion of females, younger patients and persons from previously disadvantaged communities coming to treatment (especially with regard to certain drugs, e.g. cocaine, heroin and Ecstasy)
• Link between drug trade and gambling
• Increasing use of LSD and Ecstasy in PE and possible negative consequences
• AOD-related traffic infringements
• Changes in drug supply chains and how these affect drug use patterns
• Heroin use among ravers
• Cultivation of Khat in the Eastern Cape and its distribution chain and user groups.
• Poly-substance use
• Use of less common drugs, e.g. GHB
• Changes in the mode of drug use especially IVDU among young heroin addicts (and changing of purity by dealers)
• Links between taxi industry, shebeens, and street vendors in drugs trade.

Research questions
At the SACENDU meeting in March 2000 various topics for research were identified. These included:

• Why are a greater proportion of people from some suburbs going into treatment?
• How much AOD use is there among primary school children?
• Link between repeat visits to PHC clinics and trauma units and substance use
• Where do people go who need detoxification & rehabilitation?
• The link between substance use and HIV (not just focusing on IVDU)
• What health education approaches might be effective in reaching rave party attenders?
• Prospective study to understand link between substance use and crime (including a focus on the psychoactive properties of drugs)
• What is the nature and extent of abuse of over-the-counter and prescription medicines?

Future directions
The SACENDU Project is likely to be strengthened by several new initiatives during 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.
• A study of drugs and HIV among sex workers in Cape Town, Johannesburg and Durban.
• Further market research among school going youth in Cape Town, Durban, Gauteng and Bloemfontein and the Eastern Cape.
• Research into foetal alcohol syndrome in the Eastern Cape as well as a demonstration project to address AOD use among PHC clinic attendees.
• Continuation of the Medical Research Council/Institute for Security Studies 3-Metros Arrestee Study.
• Further studies of AOD use among trauma unit attendees.
• The expansion of SACENDU to selected SADC countries and to other sites in South Africa (possibly Mpumalanga).