South African Community Epidemiology Network on Drug Use (SACENDU)
January - June 2000 (Phase 8)
Charles Parry¹, Andreas Pluddemann¹,
Arvin Bhana², Janet Bayley³,
Hennie Potgieter⁴ & Welma Gerber⁵

¹ South African Medical esearch Council
² University of Durban-Westville
³ SANCA (Port Elizabeth)
⁴ Elim Clinic (Johannesburg)
⁵Department of Social Services (Mpumalanga)

SACENDU HIGHLIGHTS
(November 2000)

Background
The focus of this report is on the findings of Phase 8 of the SACENDU Project, an alcohol and other drug (AOD) sentinal surveillance system operational in Cape Town, Durban, Port Elizabeth (PE), Mpumalanga, 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 specialist treatment centres (±55), 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. The information in this report relates to the period January - June 2000 unless otherwise indicated.

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. Alcohol still dominates treatment admissions with between 48% and 71% of admissions involving alcohol as the primary substance of abuse. The proportion of alcohol-related treatment admissions, however, declined in all sites during the first half of 2000. Between 5% and 26% of psychiatric patients in selected psychiatric hospitals in Cape Town, Gauteng and PE had alcohol-related psychiatric discharge diagnoses. Between 40% and 52% of patients seen at trauma units in Cape Town and Durban had positive breath alcohol (BrAC), and between 32% and 60% of subjects tested for alcohol at various mortuaries in Cape Town, Durban, PE and Gauteng during 1999 had a blood-alcohol concentration (BAC) > 0.05. Between 9% and 32% 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 10 police stations and involved over 1000 arrestees in Cape Town, Durban and Gauteng.
• Use of cannabis (’dagga’) and Mandrax (methaqualone and antihistamine) alone or in combination (’white-pipes’) continues to be high. Treatment demand for cannabis (relative to other substances) increased in 2 of the 5 sites, and for Mandrax or the white pipe combination treatment demand increased in 3 of the 5 sites. Across sites between 14% and 36% of patients attending specialist treatment centres had cannabis and/or Mandrax as their primary drug of abuse. Over one-third of trauma patients in Durban and Cape Town tested positive for cannabis, and 7% and 19% tested positive for Mandrax in these sites respectively.

  The proportion of arrests for dealing in cannabis showed an increase in Durban and Gauteng but declined or remained stable in the other sites. Arrests for dealing in Mandrax increased in Cape Town, but decreases or remained stable in the other sites. Seizures of cannabis (dealing and possession) decreased in all sites. Mandrax seizures increased in 3 of the 5 sites. According to the SAPS Forensic Science Laboratory (FSL) 480 044 Mandrax tablets were seized nationally by the SAPS in the 1st half of 2000 -- a slight decline on the previous six-month period. 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-R50/tablet). In PE and Mpumalanga, over 90% of the value of drug seizures by the South African Narcotics Bureau (SANAB) and the Organised Crime Unit (in PE) can be attributed to cannabis.
  Cannabis and Mandrax use is high among persons arrested for a range of crimes across sites (Cape Town, Durban and Gauteng). Across sites, between 32% and 41% of arrestees tested positive for cannabis, and between 4% and 36% of arrestees tested positive for Mandrax. Across sites, almost two-thirds of persons arrested for motor vehicle theft or housebreaking tested positive for cannabis, and over a third of persons arrested for motor vehicle theft or housebreaking tested positive for Mandrax.

• Treatment demand for cocaine powder/crack was stable in all sites (ranging from 1% to 11%), except in Mpumalanga, where a slight increase occurred. 4% of trauma unit attendees in Durban tested positive for cocaine (3% in Cape Town).

  Arrests for dealing in cocaine powder (HCL)/crack increased sharply in PE and Durban. Seizures of cocaine HCL also increased in 3 of the 5 sites. The price of cocaine HCL/crack has remained stable at between R180 and R300 per gram of cocaine HCL depending on the site. A 0.1 gm rock can be purchased for as little as R50. In Durban 37% of the value of drug seizures by SANAB can be attributed to cocaine powder/crack. Across sites between 2% and 4% of arrestees tested positive for cocaine (including 5% of persons arrested on charges related to shoplifting and robbery). According to the FSL, 32kgs of cocaine HCL was seized nationally in the 1st half of 2000, down from 94 kgs seized in the previous six months

• With regard to heroin , treatment demand has increased slightly in 3 of the 5 sites. A slight decrease in the mean age of persons treated for heroin abuse in Cape Town was noted. Heroin had some of the highest proportions of females reporting it as their primary drug of abuse (33% of patients in Gauteng and 75% in Durban whose primary drug of abuse was heroin were female). In Cape Town and Gauteng (where use of heroin is mostly concentrated), 4% 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 in most sites, although almost half of heroin patients in Cape Town reported injecting this drug. Most heroin is smoked ('chasing the dragon'). In Cape Town and Durban 11% and 7% of trauma patients respectively tested positive for opiates (includes valium, codeine, morphine and heroin).

  Across sites the proportion of arrests for dealing in heroin is very low and was either stable or showed a decline. Seizures of heroin declined in both Cape Town and Gauteng in the 1st half of 2000, but increased slightly in Durban and Mpumalanga. According to the FSL, 1.2kgs of heroin was seized nationally during this period, up from the 742 gms seized in the previous six months. The price of heroin appears stable across sites, but is very low when compared to most other countries. Three percent of arrestees in Durban and Gauteng tested positive for opiates compared to 2% in Cape Town.

• Club drugs in general appear to be entrenched in the youth culture. 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 by ravers include LSD, (pseudo)ephedrine, magic mushrooms, cannabis, diet pills (e.g. Thinz, Nobese), ketamine, GHB (gamma-hydroxybutyrate), Rohypnol (Flunitrazepam) and cocaine.
• The proportion of arrests for dealing in Ecstasy was fairly stable across sites, however a decrease was noted in Mpumalanga and PE. Seizures of Ecstasy were up in Cape Town, PE and Gauteng in the 1st half of 2000. Across sites the price of Ecstasy varies between the sites and venues (R60 -R170/tablet). Treatment demand for Ecstasy as the primary drug of abuse is low, but like LSD it often appears as the secondary drug of abuse. A slight increase in treatment demand for Ecstasy was noted in 4 of the 5 sites. Some of the indicators for LSD showed an increase in the 1st half of 2000 (e.g. arrests for dealing in Cape Town and PE, and LSD seizures in Cape Town and Gauteng). According to the FSL, police nationally seized 177 991 Ecstasy tablets (MDMA) and 2 159 units of LSD during the 1st half of 2000, both of which increased compared to the previous 6 month period. Seizures of other amphetamines also increased as did the proportion of arrestees testing positive for amphetamines.
• The abuse of over-the-counter and prescription medicines (e.g. slimming tablets, headache and pain medication (Grandpa headache powders, codeine, pethidene), tranquillisers, and benzodiazepines like Rohypnol) continues to be an issue across sites. Demand for treatment where these substances are the primary drug of abuse was either stable or showed a slight increase across the sites. Two percent of arrestees in Cape Town tested positive for benzodiazepines. FSL seizures of benzodiazepines showed an increase in the 1st half of 2000 to 1 119 tablets (compared to 342 between July and December 1999). In Cape Town and PE it was noted that anti-epileptic drugs are sometimes smoked with cannabis and/or Mandrax.

Regional differences
In comparing the 5 sites the following were among regional differences that were noted:

• The level of drug use as well as the range of drug used is higher in Cape Town and Gauteng as compared to PE, Durban and Mpumalanga.
• Heroin use, in particular, continues to be lower in Durban, Mpumalanga and (especially) PE as compared to the other 2 sites.
• Cocaine now seems to be firmly rooted in Durban and may be increasing in Mpumalanga and PE. It is the third most common illicit substance of abuse in Gauteng (superceding Mandrax).
• The use of Mandrax is more common in Cape Town and PE than in the other three sites. However, the largest seizures of this drug were reported in Gauteng and Mpumalanga.
• Various indicators highlight the high levels of abuse of alcohol, over-the-counter and prescription medicines in Port Elizabeth.

Implications for policy/practice
During the Phase 8 (January - June 2000) 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.

• Give priority to development of age appropriate prevention programmes aimed at children and youth (aimed at preventing or delaying onset of AOD use). Priority specifically needs to be given to reducing heroin use by young persons in Cape Town and Gauteng. The focus needs to be on young persons, teachers, parents and the broader community.
• Increase treatment options (and awareness of existing options) for women, people from disadvantaged areas, youth and the unemployed. The need for treatment services for youth was highlighted in several provinces.
• Introduce strategies to reduce level of treatment recidivism by cocaine users.
• Establish protocols for handling arrestees under influence of AODs.
• Strategies to reduce drug use and drug-related crime must be area specific, and also focus on youth.
• Lobby medical aids to provide increased cover for AOD abuse.
• Intervene to reduce alcohol-related injury and death (specifically among young males). Target cyclists, pedestrians, shack dwellers – both individual and environmental strategies. Particular attention needs to be given to enforcement of drunk driving regulations (random breath testing).
• Intervene to reduce cannabis-related violence and traffic injuries
• Provide tools to general practitioners to monitor, recognise, manage, and refer substance abusing patients.
• Increase efforts to reduce the abuse of prescription drugs by pharmacies (including a real-time national register) and theft of prescription drugs by health workers. Also counter abuse of psychiatric medications.
• Motivate social workers, employers and others to refer persons abusing substances to treatment.
• Educate mothers (e.g. at baby clinics) of the harm associated with giving alcohol to babies/toddlers.

Issues to monitor
Phase 8 of the SACENDU Project highlighted several conditions/factors that need to be carefully monitored over time:

• Changes in patterns of referral to treatment (especially decline in referrals from courts, schools, clinics/hospitals and employers in certain sites).
• Proportion of females, younger patients and persons from previously disadvantaged communities coming to treatment (especially with regard to certain drugs, e.g. heroin).
• Link between the drug trade and gambling (as well as the development of a deep seaport at Coega (PE)).
• Changes in the mode of drug use especially IVDU among young heroin addicts (and changing of purity by dealers).
• Link between amphetamine use and violence-related trauma and crime in certain sites.
• Use of amphetamines and LSD.
• Abuse of psychiatric medications.
• The different levels of potency (and price) of dagga and the impact on drug use behaviour.

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

• Barriers to treatment by black persons, young persons, women, and unemployed persons.
• Prospective study to understand link between substance use and crime (including a focus on the psychoactive properties of drugs and the link between use of cannabis, Mandrax and cocaine and property crime).
• Extent to which general practitioners, psychiatrists and psychologists are treating patients abusing substances.
• The psychological consequences of drug use.
• The abuse of OTC and prescription medications. Who are abusing which substances (e.g. codeine)? What quantities are being used. How are prescription drugs sourced? What are the health and social consequences of abusing OTC and prescription medicines? What are the treatment outcomes for persons abusing such substances?
• Why are treatment settings in certain sites seeing an increase in repeat admissions?
• The impact of the increased restrictions on drinking and driving and AOD practices by young persons. Could this lead to an increase in cannabis use?

Future directions
The SACENDU Project is likely to be strengthened by several new initiatives during 2001 including:

• A study of HIV risk behavior and substance use among adolescents in community samples in Cape Town and Durban.
• Further analysis of the data from the school studies conducted in Cape Town and Durban.
• Research into foetal alcohol syndrome in the Eastern Cape as well as a demonstration project to address AOD use among PHC clinic attendees.
• The expansion of the SACENDU Project to selected SADC countries: Lesotho, Mauritius, Seychelles, Zambia, and Zimbabwe (in 2001).