Lize Weich lizew@sun.ac.za

1. The harsh realities of treating Addictions and Mental illness within the South African state sector: the Western Cape perspective Lize Weich lizew@sun.ac.za

2. Substance use trends Alcohol Estimated to cost the country an estimated 1% of the Gross Domestic Product (Parry et al, 2003; Brady M, Rendall-Mkosi K, 2005) one of the highest documented rate of fetal alcohol syndrome in the world (grade 1 learners in Wellington, near Cape Town increased from 46/1000 in 1997 to 88/1000 in 2001) Beer, spirit coolers, ciders and home brewed beer often not viewed at alcohol 2

3. Western Cape BoD study • HIV, AIDS • TB • Injuries – Violence, RTA • Mental illness • Cardiovascular • Alcohol in top risk factor contributing to big 5 • Linked to high risk sexual behavior, symptomatic HIV and TB • Contributes 40% to violence • 18% to mental health problems resulting from alcohol abuse and dependence disorders; • 12% to road deaths – of which 60% consisted of drunk pedestrians hit by cars SAMJ, 87, 8 part2, 2007

4. Alcohol ct. • 1 in 4 high school learners admits to binge drinking in the previous month • In just under half of unnatural deaths in 2002, the deceased had a blood alcohol concentration of >0.05g/100 ml • similar levels were found in about two-thirds of trauma patients • Alcohol use in adolescents and young adults in South Africa has been linked to high-risk sexual behaviour • A large infectious disease clinic in Cape Town found in 2003 that 1 in 5 HIV positive patients had an alcohol use disorder and were more likely to have symptomatic HIV disease. 4

5. SACENDU trends: Alcohol • 1997- 82% primary substance of abuse of patients presenting to substance treatment • 2010 a – 29% • 2010a – 41% overall use

6. Other commonly used substances • Poly-substance use in 43% of patients presenting for treatment in 2010a (SACENDU) • Cannabis • “dagga” • Methaqualone • “Mandax” • Methamphetamine • “tik” • Since about 2003 • Heroin • “ungah” • Emerging in certain areas

7. Cannabis

8. Cannabis • Extremely cheap (between R1 and R5) • Use normalized in some communities • Children starting at ages as young as 8 or 9 not uncommon • 1997: primary drug of abuse for 5% of patients in treatment • 2010a: 16% • 2010a: primary drug in 45% of the under 20 year olds • 2010a: 34% overall use

9. Methaqualone / Mandrax Buttons Henna Mx Sproetjie Pille Whites Witpyp Mandies Cremora Volkswagen Macarena Cream Gholfsticks Doodies Lizards Germans Flowers Omo Hits

10. Use of mandrax: “bottleneck”

11. Mandrax as primary drug of abuse • 1997: 7% of patient is substance treatment • 2003: 23,6% • 2005: 2,8% • 2009: 2,7% • 2010a: 4% • 2010a: 18% overall use

12. Methamphetamine

13. Crystal methamphetamine smoked in lolly/pop-eye/globe

14. Methamphetamine • 1997: 0% of patients in treatment gave as primary drug of abuse • 2003: 2.3% • 2004: 19% • 2006: 42% • 2010a: 34% • 2010a: 46% overall use

15. Heroin • SACENDU: • 1997: 1% primary drug • 2010a: 12% • 2010a: 14% overall use • Pockets of endemic use • Waxing and waning • Cheap R20-30 • Mainly smoked • Low intravenous use rates – about 9-12% at present • No political buy-in for substitution treatment

16. Population of Western Cape • Census 2001, 4,524,336 people in the Western Cape, living in 1,173,302 households. • 53.91% coloured • 26.68% black • 18.41% white • 1.00% Asian • In the province 55.3% of residents speak Afrikaans at home, 23.7% speak Xhosa, 19.3% speak English, and less than 2% speak another language

17. POPULATION PROFILE Race

18. Socio-economics: 2001 census • Telephone: 2.7% of households have access that is not nearby or no access. • 13.5% of households have no flush or chemical toilet. • 12.2% do not have refuse removed by the municipality at least once a week and 1.4% have no rubbish disposal. • 32.5% do not have running water inside their dwelling, 14.8% do not have running water on their property, and 1.7% have no access to running water. • 78.8% of households use electricity for cooking, 73.4% for heating, and 88.0% for lighting. 79.1% of households have a radio, 74.1% have a television, 18.2% own a computer, 73.5% have a refrigerator, and 41.4% have a cell-phone.

19. Organization of substance treatment substance services • 3 tier system • If you have lots of money or insurance – high quality private care • If you have some money – NGO subsidized programs • If you don’t have money- state programs/ NGO subsidized programs • Mostly no MDT, only social workers • Sponsorship only for 6-8 weeks of treatment • Long waiting lists for inpatient programs

20. Treatment of addictions- challenges • Lead department for managing substance disorders is social welfare • Addiction not managed as a chronic medical illness • Highly reliant on an under-funded NGO sector for treatment • Rarely employ MDT’s • High rates of unemployment, poverty, broken homes, domestic violence, gangsterism • Uneducated public “moral weakness” • Users should be “sent away” and will come back “cured” • Big problem with unregistered treatment providers who think “cheer leading” or punishment is treatment

21. Dep of Health only mandated to do “detox” and treat co-morbidity • Resistance from top management to advocate for an increased mandate, unwillingness from DSD to give up this responsibility • No pharmacology other than detox (and occasionally a bit of disulfiram) • “substitution treatment is not politically palatable” • Uneducated health service who stigmatize in patients • Central drug authority, who should advice Parliament and is responsible for NDM, underwrites a social treatment model

22. Some recent changes… • Priority for Premier • Central substance coordinator within Premier’s office • Development of PGDip in Addiction Care from 2011/12 • Move towards outpatient programs • Move towards evidence based interventions • Move towards quality care, rather than numbers • Motivations with HPCSA to register Addiction Psychiatry as a subspecialty

23. What about mental health? • Private vs State sector • State sector is again 3 tiered • 1- nurse led service, supported by medical officers and Specialist Family Practitioners • Community psychiatric nurses at clinics (not all rural areas) • District hospitals • Community psychiatrists • 2/3- each of 3 rural districts have a community psychiatrist and psychiatric ward in 2 level hospital; metro has three big hospitals; 3 level services at GSH and TBH • Resistance towards patients with substance use disorders • Stigmatized, ostracized • Overburdened services • Lack of knowledge and skills

24. Mental health challenges • Severe bed shortages • Bed closures without a properly developed community services • Poorly develop services in some of the other Provinces • HIV epidemic • Methamphetamine epidemic • Poorly developed community services

25. Pilot project for integrated dual diagnosis treatment Workshops PG Dip Training Advocacy for MDT’s PG Dip Outreach clinics Developing services for mental health patients with comorbid substance use disorders Substance severity Substance services with MH support Specialized dual disorder services Work shops PG Dip Primary health and MH services- needs to be skilled to deal with both problems General MH services - needs to be skilled to deal with comorbid substance problems Severity of mental illness

26. ADHD and substance use disorders • Harsh reality of under resourced and understaffed facilities • Not even capacity to properly treat severe and enduringly mentally ill • Adult ADHD not commonly recognized by many local psychiatrists • Fear among gen. public that Methylphenidate (only Rx registered in state for this indication) would be “abused” – reality is that this happens very uncommonly • Patients with ADHD are not diagnosed and treated • Probably diagnosed as personality disorders, or simply viewed as “unmotivated” in treatment