South African Community Epidemiology Network on Drug Use (SACENDU)
July - December 2000 (Phase 9)
Charles Parry, Andreas Pluddemann, Arvin Bhana
Sanchia Matthysen, Hennie Potgieter, & Welma Gerber

SACENDU HIGHLIGHTS
(May 2001)

Background
The focus of this report is on the findings of Phase 9 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 (50+), psychiatric hospitals, mortuaries, trauma units, the police (SA Narcotics Bureau (SANAB), Organised Crime Units & Forensic Science Laboratories (FSL)), and from research conducted in schools and with sex workers, street children, service providers, 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 July - December 2000 unless otherwise indicated.

Overview by drugs of abuse
Alcohol
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 morbidity and mortality. Alcohol still dominates treatment admissions, with between 51% (Cape Town) and 79% (Mpumalanga) of admissions across the five sites involving alcohol as the primary substance of abuse. The proportion of alcohol-related treatment admissions increased in Port Elizabeth (PE) and Mpumalanga but remained stable in the other sites during the 2nd half of 2000. Between 4% and 25% of psychiatric patients in selected psychiatric hospitals in Cape Town, Gauteng and PE had alcohol-related psychiatric discharge diagnoses. In PE 92% of trauma patients had positive breath-alcohol (up from 79% in 1999). In Cape Town 56% of mortuary cases in 2000 had blood-alcohol concentrations >0.05 g/100ml. Between 6% (Gauteng) and 23% (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 8 police stations and involved over 1000 arrestees in Cape Town, Durban and Gauteng in August/September 2000. About one in four Grade 7, 10 and 11 learners in a Pretoria school survey undertaken by the University of South Africa (UNISA) reported getting drunk occasionally during the course of a typical month.

Cannabis and Mandrax
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) remained fairly stable (or decreased in Durban). Treatment demand decreased for Mandrax or the white pipe combination in all sites. Across sites between 13% (Mpumalanga) and 32% (Cape Town) of patients attending specialist treatment centers had cannabis and/or Mandrax as their primary drug of abuse. About 20% of trauma patients in PE tested positive for cannabis (down from 43% in 1999), and 11% tested positive for Mandrax.

The proportion of arrests for dealing in cannabis showed an increase in PE and Gauteng but decreased in Durban and Mpumalanga. Arrests for dealing in Mandrax increased in Durban, PE and Mpumalanga, but decreased in Cape Town and Gauteng. Seizures of cannabis (dealing and possession) increased in Durban, Gauteng and PE. In Durban 11.5 tons of hashish was seized. Mandrax seizures increased in three of the five sites, and over 2 million tablets were seized nationally in the 2nd half of 2000. The price of cannabis has remained stable at R1-R2/stop (1 US$ = 8 ZAR), while the price of Mandrax has increased slightly in Durban and PE. In Durban and Mpumalanga, over 90% of the value of drug seizures by SANAB and the Organized 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 24% (Gauteng) and 50% (Cape Town) of arrestees tested positive for cannabis, and between 5% (Gauteng) and 32% (Cape Town) of arrestees tested positive for Mandrax. Across sites, over 60% of persons arrested on drug/alcohol charges or for housebreaking tested positive for cannabis, and over a third of persons arrested for housebreaking tested positive for Mandrax.

In the UNISA school survey referred to earlier, about one-third of respondents admitted having smoked cannabis (23% of them being under the age of 12). A RaveSafe survey in Johannesburg found that three-quarters of respondents had tried cannabis and 13% had tried Mandrax at least once.

Cocaine
Treatment demand for cocaine powder/crack was down or stable in four sites. The exception was Durban where 12% of patients had cocaine powder/crack as their primary substance of abuse - an increase from the 8% reported in the 1st half of 2000. The majority of the patients in Durban whose primary drug of abuse was cocaine were women. Between 7% and 8% of patients in Cape Town and Gauteng had cocaine as their primary drug of abuse. The corresponding percentages were much lower for PE and Mpumalanga (1% - 3%). Fourteen percent of trauma unit attendees in PE tested positive for cocaine (up from 0% in 1999).

Arrests for dealing in cocaine powder/crack were stable in Cape Town and Gauteng, decreased in Durban and PE, and increased in Mpumalanga. Sixty-five kilograms of cocaine powder was reported as being seized in Gauteng in the 2nd half of 2000, up from 48 kgs seized in the 1st half of the year. There have been reports of increasing sales of crack cocaine in traditionally African townships and informal settlements (e.g. Cato Manor in Durban). Across sites between 3% (Cape Town) and 6% (Durban) of arrestees tested positive for cocaine (including 9% of persons arrested for alcohol/drug offenses, 6% of persons arrested on weapons charges, and 5% of persons arrested on charges of either robbery, housebreaking or immigration/document offenses). Both Gauteng and Durban (in particular) showed an increase in the proportion of arrestees testing positive for cocaine. Cocaine positive arrestees were most likely to be found in police stations like Sea Point, Hillbrow and CR Swart that serve high density residential areas, and for the first time among younger arrestees (<20 years).

Heroin
With regard to heroin, treatment demand has increased slightly in Cape Town, but has remained stable in the other sites. Overall, 5% of patients in Cape Town and 4% in Gauteng report abusing heroin as either a primary or secondary drug. Levels are 1% or lower in the other sites. The proportion of heroin abusing patients appears to have increased in younger and female patients in Cape Town. Most heroin is sniffed (‘chasing the dragon’), but 36% of patients in Gauteng and 47% of patients in Cape Town having heroin as their primary drug of abuse report some injection use. In PE 13% of trauma patients tested positive for opiates (includes Valium, codeine, morphine and heroin). This is up from 0% in 1999.

Across sites the proportion of arrests for dealing in heroin is very low, ranging from 0% of all arrests for dealing (in PE and Mpumalanga) to 6% in Gauteng. Increases were noted Cape Town, Durban and Gauteng. Seizures of heroin were very low or non-existent in Durban, PE and Mpumalanga, but showed a substantial increase in Gauteng (from less than 1 kg to over 12 kgs between the 1st and the 2nd half of 2000). There have been reports of increased availability of Thai White heroin. The proportion of arrestees testing positive for opiates was 3% in both Gauteng and Cape Town and 2% in Durban, reflecting a slight increase in Cape Town and a slight decrease in Durban in comparison to the previous six-month period.

Club drugs
Club drugs in generalappear 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, cannabis, poppers, cocaine, diet pills, (pseudo)ephedrine, magic mushrooms, Speed, GHB (gamma hydroxy butyrate), and Mandrax. Persons attending rave parties appear to be aware of the negative consequences associated with use of club drugs (e.g. memory loss and personality changes) but use them anyway. Twenty percent of ravers studied in Gauteng report weekly use of Ecstasy.

The proportion of arrests for dealing inEcstasydecreased in PE (from 11% to 3% of arrests) and in Gauteng (from 16% to 11% of arrests). The proportion of arrests for dealing inEcstasyincreased in Durban from 4% in the 1st half of 2000 to 7% of all arrests for dealing. The corresponding increase in Cape Town was from 7% to 14%. Across sites, except for PE, seizures of Ecstasy were down. Treatment demand for Ecstasy as the primary drug of abuse is low and fairly stable (under 2%), but like LSD it often appears as the secondary drug of abuse. One change of note is the decrease in the mean age of persons in treatment whose primary drug of abuse is Ecstasy in Cape Town from 23 years to 19 years and in Durban from 24 to 21 years in the 2nd half of 2000. 11% of the rave party attendees studied in Gauteng reported weekly use of LSD.

Some of the indicators for LSD showed an increase in the 2nd half of 2000 (e.g. arrests for dealing in Cape Town, Durban and Gauteng, and LSD seizures in Durban, Cape Town and Gauteng). Seizures of Speed showed an increase in Cape Town, Durban and Gauteng as did the proportion of arrestees testing positive for amphetamines in Cape Town, Gauteng and Durban.

Over-the-counter (OTC) and prescription medicines
The abuse of OTC and prescription medicines, such as slimming tablets (e.g. Nobese), headache medications and analgesics (Stopayne, codeine products), and benzodiazepines (e.g. Valium, Ritalin) continues to be an issue across sites. Demand for treatment where these substances are the primary drug of abuse decreased in three sites (Cape Town, PE and Mpumalanga), but increased in Durban and Gauteng. In general the proportion of persons having OTC or prescription medicines as their primary drug of abuse across sites ranged from 0% to 4% of treatment admissions. Of persons arrested for a range of crimes, across sites, 4% tested positive for benzodazepines (up from 1% in the 1st half of 2000). The biggest increase was noted in Cape Town where 13% of arrestees tested positive for benzodiazepines compared to 2% in the 1st half of 2000.

Other substances
In terms of other substances, solvents continue to be abused by young people (e.g. one quarter of grade 7, 10 and 11 learners in Pretoria reported having inhaled solvents at least once). Other substances reported as being abused include khat (catinone), nitrous oxide, magic mushrooms, Nexus (4-bromo-2.5-dimethoxyphenethylamine), poppers (amyl-nitrate). In general poly-substance abuse is very common, e.g. crack use and heroin (among sex workers), Ecstasy and LSD, and cannabis and Mandrax. Alcohol is often used in combination with various substances.

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 drugs used is higher in Cape Town and Gauteng as compared to PE, Durban and Mpumalanga.
• The proportion of persons in treatment under the age of 20 was greatest in Cape Town and least in Mpumalanga (which had the highest proportion of persons whose primary substance of abuse was alcohol). Compared to Durban and Gauteng, Cape Town had the highest proportion of arrestees who reported being under the influence of alcohol at the time of the offence for which they were arrested.
• Heroin use, in particular, continues to be lower in Durban, Mpumalanga and (especially) PE as compared to Cape Town and Gauteng.
• The use of Mandrax is more common in Cape Town and PE than in the other three sites.
• Durban experienced a major increase in patients coming to treatment for problems associated with cocaine use. Cocaine now appears to be firmly rooted in Durban.

Implications for policy/practice
During the Phase 9 (July - December 2000) regional report back meetings of SACENDU a number of recommendations were made with regard to specific interventions needed to address substance abuse and substance abuse policy in general. Many were aimed at addressing substance abuse by young persons:

• Increase the range of treatment and prevention programmes focusing on children and youth (aimed at preventing or delaying onset of AOD use).
• Equip teachers to identify AOD use and make appropriate referrals. Address abuse of alcohol by teachers.
• Improve access to quality, school-based prevention programmes.
• Equip parents (other adults) to reduce risk behaviour by adolescents (e.g. monitoring behaviour, setting limits, dealing with hostility, and safeguarding medicines).
• Implement measures designed to combat the increasing use of heroin by young persons (especially females) in Cape Town and Gauteng.
• Increase the availability of programmes aimed at addressing substance abuse among young offenders (via court diversion to treatment, prison-based programmes, and post-incarceration options).

It was recommended that employers be encouraged to implement policies and practices to address AOD at the workplace. Psychiatric facilities should also be encouraged to become more actively involved in addressing the abuse of alcohol, cannabis and Mandrax among their patients.

Others recommendations were more general:

• Implement a multi-pronged intervention programme aimed at addressing weekend binge drinking.
• Implement programmes aimed at addressing the high incidence of abuse of certain drugs in particular geographic areas.
• Take tougher action to combat drug dealing by illegal immigrants.
• Lobby government and civil society to see the importance of intervention in the area of AODs as part of overall crime prevention.

Issues to monitor
Phase 9 of the SACENDU Project highlighted several conditions/factors that need to be carefully monitored over time:

• Changes in patterns of referral to treatment (e.g. by schools and courts), and the impact of the Labour Relations Act on employer referrals.
• Changes in the demographic characteristics of users of particular drugs and drugs in general (e.g. age, race, gender, area of residence, employment status).
• The impact of matinee discos on drug use among young persons.
• Adulterants in drugs such as heroin and Ecstasy and associated negative health effects.
• Increases in the rates of IV drug use (especially among heroin users).

Topics requiring further research
At the SACENDU meetings in April 2001 various topics for research were identified. These included:

• Reasons for the decreasing age of persons coming to treatment.
• The drugs/crime link focusing on juveniles.
• Comparison of crimes committed under the influence of cannabis versus the cannabis and Mandrax combination.
• The effectiveness of prison-based treatment services.
• Factors influencing where people seek treatment for AOD abuse problems.
• Reasons why females are not reflected in treatment demand statistics.
• Reasons for the big increase in cocaine found in trauma patients in PE.

The relationship between drug use and psychiatric problems.

• 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/violent crimes).
• The nature and extent of the abuse of OTC and prescription medications and precipitating factors.
• The extent of treatment of persons with AOD problems by general practitioners.
• The relationship between drug use and HIV.
• The extent of child-headed households and the relationship with substance abuse.

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

• A study of HIV risk behaviour 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.
• The expansion of the SACENDU Project to selected SADC countries: Botswana, Lesotho, Mauritius, Namibia, and Seychelles.
• The Sensible Drinking Project in health centers in Cape Town.
• A study of drug markets focusing on West African nationals.