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The Burden of Disease: Substance Abuse in South Africa

“The basic thing nobody asks is why do people take drugs of any sort? Why do we have these accessories to normal living to live? I mean, is there something wrong with society that's making us so pressurised that we cannot live without guarding ourselves against it?”– John Lennon

Substance use and abuse is becoming a major public health problem, both internationally and in South Africa. Globally, the United Nations Office on Drugs and Crime (UNODC) estimates that between 155 and 250 million people, or 3.5% to 5.7% of the population aged 15-64 years, had used illicit substances at least once in the previous year. The 2010 World Drug Report published by the UNODC states that cannabis (marijuana) users comprise the largest number of illicit drug users (129-190million), with amphetamine-type stimulants (e.g. methamphetamine) being the second most commonly used illicit drugs, followed by opiates and cocaine. South Africa appears to be suffering from a drug pandemic, with drug consumption being twice that of the world norm according to the Department of Social Development’s Central Drug Authority (CDA, 2009). Their statistics indicate that nearly15 percent of South Africa’s population have a drug problem, with substance abuse being a major contributor to poverty, reduced productivity, unemployment, dysfunctional family life, political instability, the escalation of chronic diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB), injury and premature death. These statistics are mirrored in the results from the first nationally-representative study of psychiatric morbidity, the South African Stress and Health Study(SASH), were published.

The SASH study, undertaken by Prof. Dan Stein, Williams and Kessler through the first decade of democracy in South Africa, determined that in South Africa there is high lifetime prevalence (13.3%) and early onset (21 years)of substance use. According to the CDA alcohol, the primary drug of abuse in South Africa, is a factor in nearly half of the motor accidents in South Africa every year, resulting in the loss of some 7 000 lives and a cost to the country of nearly R20 billion. Additionally, the South African Police Service (SAPS) claim that 60 percent of crimes committed nationally were related to substance abuse, with the figure rising to 80 percent in the Western Cape. While it is true that drug-addicted individuals often need more than one treatment episode, there is a large international repository of research with evidence to suggest that drug and psychotherapeutic interventions are effective in the treatment of individuals suffering from substance use disorders. Indeed, even though the chronic nature of the disease of substance abuse often requires a lifetime recovery process to sustain treatment-induced changes, most practitioners believe that providing treatment at an early stage has the potential to prevent enormous disability before substance abuse as an illness becomes more severe and more difficult to treat. South Africa, however, appears to have a number of barriers to effective treatment and rehabilitation for substance abuse. Despite the high prevalence of substance use the SASH Study revealed that only 27.6% of South Africans who met criteria for substance use disorder received treatment in the year preceding the interview.

Compounding this is the research done by Professor Malaka at the University of Limpopo who determined that most drug rehabilitation centres have a success rate of less than 3 percent. Additional international research has criticised the service delivery for the treatment of substance use in low and middle income countries, including South Africa. Findings from this and local research done by Professor Charles Parry of the Medical Research Council of South Africa state that when available, treatment is usually oriented to tertiary treatment of dependence with an emphasis on long-term residential treatment.

So what is the status of South Africa’s substance abuse treatment facilities? The national registry list of substance abuse facilities supplied by the Department of Social Development indicates that of the 65 identified treatment facilities in nationwide in South Africa, only 2 are state owned and operated. Both are In-Patient facilities that offer long-term treatment programmes, with only one providing detoxification services. Why is it that there are so few state-owned treatment facilities in a country that has one of the worlds highest drug usage rates? Mitigating the lack of state-initiative facilities is the fact that of the remaining 63 private treatment facilities located throughout South Africa, 35 receive funding from the Department of Social Development. The exact amount of the funding for each facility is not divulged, but the implication is that the government is attempting to aid those facilities that are not state-owned in order to improve the treatment and rehabilitation turn-over in the country. Of the 63 privately-owned treatment facilities, 36 offer in-patient services and 29 offer out-patient services (of which 17 are run by the South African National Council on Addiction (SANCA)). Only 8 of the out-patient based treatment facilities offer short-term treatment options and only 22 facilities in total offer short-term treatment programmes.

Thus the criticism that was previously levelled against South Africa’s substance abuse treatment service delivery being oriented to tertiary treatment of dependence with an emphasis on long-term residential treatment is proven correct. It is also important to note that, while not all treatment facilities will have been included due to lack of registration with the Department of Social Development of human error in list compilation, 31 of the 65 listed facilities (47.7%) are within Gauteng. South Africa therefore faces logistical obstacles to improving its treatment efficacy in substance abuse. An increase in the number of facilities in other provinces as well as improved access to facilities remains, as always, an issue in service delivery in this country. To maximise the success of any treatment programme, it is imperative that the programme itself must be accessible and the facilitators must have an understanding of the clients they are hoping to treat. The funding provided by the Department of Social Development does illustrate its willingness to improve this situation, but there is still the matter of the level of service provided. South Africa’s current treatment is costly and time-consuming as it relies on the patient being so severely debilitated by the disease that it necessitates longer treatment periods with greater periods of absenteeism from work and family environments. Perhaps government funding could be allocated to investigating the effectiveness of more ‘brief’, initial treatments interventions as have been successful in developed countries, but which are limited in South Africa.

This could be rectified by widening the base of treatment to interventions, such as short-term, out-patient treatment in identified or potential users in the initial phases of substance use. These interventions could have positive outcomes and be more cost-effective. In addition to the high cost and potential lack of availability it is possible that some of the same obstacles that face those who need mental health care apply to those in need of substance abuse treatment. In many instances of substance abuse there is also, as in most diseases that are categorised as mental illnesses by the Diagnostic and Statistical Manual (Fourth Edition-Text Revision), an element of stigma attached. Many people who suffer from addiction and dependence may view themselves as ‘able to control their cravings’ and say that they can ‘give up whenever they choose’, adding to the overall impression that substance users have the ability to take control of their behaviour if they really wanted. This leads people to disregard substance abusers and dependents as pitiable and not worth helping as they believe they are responsible for causing their own illness. James* from Sandton says “When people talk to me and discover that I am a recovering drug addict, I immediately feel that they see themselves as better than me because they could control their lives and I couldn’t. I must be pathetic and weak to not be able to deny myself something like drugs. I am often excluded because they think I might ‘go overboard’ or ‘freak out’.” Even though addiction is categorised as a disease and is seen as a result of significant structural and functional abnormalities which underlie failures to control behaviour despite harmful consequences, many addicts feel that to admit to it is a sign of weakness.

They fear that people will reject them if they admit to having a problem and so prefer to maintain an appearance of control, even when it has been lost. Therefore, reducing the stigma surrounding substance abuse by increasing the awareness that addiction is a defined disease and is successfully managed through therapy and medication may be one way in South African’s can help improve the rehabilitation statistics for the country. This may require not just the education of the general population who are not drug addicts, but the drug addicts themselves. Self-stigma or internalised, when an individual places the stigma of the disease upon themselves, can have serious consequences for individuals and may prevent them from seeking treatment or asking for help when they feel they are not coping in the treatment process itself. Therefore, the lack of short-term immediate service delivery for recreational substance users who could be identified as potential addicts in addition to the stigma and discrimination surrounding drug and alcohol addiction is a major impediment to successful rehabilitation and sobriety in South Africa.

*not his real name.

Originally appeared on

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