Injecting Drug Use and Harm Reduction

I was recently quoted, along with a colleague and some of our out-reach workers in an article on increased levels of injecting drug use in the Western Cape.

The message is important, and unless substitution therapies are introduced it is likely that there will be a significant increase in overdose deaths and a spread in HIV and other infectious diseases.

This article was originally published on Ground Up and then on allAfrica. The article is by Ian Broughton, and the photo is by Andrea Schneider.

Healthcare workers worry injecting heroin on increase

Sunday 31 August was International Overdose Awareness Day. Health workers in Cape Town have warned of a possible increase in drug overdoses and the spread of infectious diseases, including HIV, if the use of needles to inject drugs increases.

This comes as health workers have noticed drug users turning away from smoking towards injecting. In response, the TB/HIV Care Association (THCA) in Observatory are preparing to educate needle using drug users on the safe use of needles.

Heroin abuse is nothing new in the Western Cape, but injecting appears to be gaining popularity. Some drug users are also injecting tik.

“Although injecting drug use has not been very visible, it does exist,” says Catherine Williams, a Professional Nurse Counsellor with THCA. “Professionals in the field, and reports from the drug using community suggest that it is on the rise.”

Injecting heroin used to be taboo among coloured users and black users. This has been a cultural phenomenon for years according to users and the South African Community Epidemiology Network on Drug Use (SACENDU).

‘Only 11% of coloured heroin patients reported injecting the drug compared to 83% of white heroin patients’, according to SACENDU’s Phase 34 report back.

Whereas once hardcore addicts chose to smoke their unga on tinfoil and people who “spiked” the drug were shunned and looked down upon, this is no longer the rule.

“It has become like a fashion. So many people I know are using needles now”

“It has become like a fashion. So many people I know are using needles now. A few years ago most addicts thought it was crazy to inject unga,” says Eugene Beukes, a Woodstock addict who has been injecting drugs for several years.

Another addict said, “I never thought I would be doing this. I used to think people who spiked were out of their minds. It used to be only white people who injected and we always thought they were crazy.”

According to the Medical Research council there are an estimated 67,000 people injecting drugs in South Africa.

Figures based only on users seeking help at treatment centres (and therefore statistics that should be used advisedly), show according SACENDU that the demographic profile of heroin users in the Western Cape is changing with coloured users making up 85% of the user population. In Gauteng, 77% of heroin users were black, a significant increase to the year before, and in Mpumalanga and Limpopo black users made up 86% of users compared to 76% the year before.

Injecting heroin increases the chances of death by overdose and the risk of infection with diseases including HIV and Hepatitis.

One such user, Devon-Lee Zeeman (30) of Summergreens overdosed only a week after coming out of prison after two and a half years. He was left to die next to a railway line, deserted by those who had been with him. His father, Joseph, arrived on the scene after someone came to his house to tell him his son was lying unconscious next to the railway line. This was about three hours after he last saw Devon-Lee. Had someone phoned for help or informed him earlier, his son could have still been alive.

“When I found him I noticed his hands were blue and there was a funny noise coming from his mouth,” says Joseph.

He phoned the paramedics, but it was too late.

He says his son had been struggling with a drug problem since the age of about 15 and that Devon-Lee had been addicted to unga.

A few days earlier, he had come home from a night out with friends. His sister had noticed that his eyes did not look right. When questioned, Joseph says his son told his sister that a friend had bought him a drink.

Joseph says he and his son spent the evening before his death together and the following morning Devon-Lee asked him for R20 for airtime. This is the price for a bag of unga in many parts of Cape Town.

South Africa is lagging far behind other countries in dealing with the problem of needle injecting drug use. THCA works with key populations who are more at risk of HIV infection. Williams explains that people who inject drugs have unique health and HIV prevention needs which have been internationally recognised but have not yet been effectively met in South Africa.

“People who inject drugs face many obstacles including stigma from health care providers as well as profiling by police,” she says. “This exacerbates the risks faced by this already vulnerable population. With co-operation from local and national authorities many of the barriers could be overcome.”

Williams says that it is vital for people to step up and face this growing problem. She adds that worldwide there are harm reduction programmes which have proven to be effective but hardly any such services are available yet in SA.

Harm reduction

Many global health and law enforcement organisations including WHO, UNAIDS and UN Office on Drugs and Crime recommend a package of services to reduce the risks of injecting.

The most essential services include needle and syringe programmes, HIV counselling, testing and treatment with ARVs, and medically assisted treatment of opioid dependence.

Shaun Shelly, Program Manager: Addiction Services Hope House Counselling Centre and currently affiliated with the Addictions Division, Department of Psychiatry and Mental Health, UCT says, “Currently, evidence for an increase in injecting drug use is anecdotal. However, we are seeing an increase on the ground, and injecting drug use is being seen among demographic groups where is wasn’t previously seen.”

“Methadone programs have been running since 1964 and so there has been a lot of research around them. Consistently they have been shown by peer-reviewed research to reduce or eliminate the use of heroin, reduce opioid related mortality and criminality. Importantly, they have also been shown to reduce the spread of HIV/AIDS and other infectious diseases. Overall the evidence is extremely strong that these programs improve the health of both the individual and the community at large.”

“The lack of substitution medications such as methadone and buprenorphine on the essential drugs list is something that urgently needs to be addressed if we hope to reduce the number of injecting drug users in the Western Cape.”

Many harm reduction programs also include overdose awareness and prevention training for users, their families and first responders such as firemen and police officers.

With training in the use of naloxone (an antidote to opioids such as heroin and codeine), witnesses of overdose can buy time until health care professionals can provide emergency care.

The South African National Drug Master Plan devotes only two paragraphs to the subject of harm reduction and states that the term needs to be defined.

Williams says the definition of harm reduction is well established and that evidence-based services have been around for 20 years already.

“We know it works. We would like to see it work in South Africa … There is a shortage of services for the entire drug using community. For those who inject drugs existing services are harder to access, and the recommended HIV prevention package is essentially absent … The mortality rates among this group are particularly high, and the rate of infectious diseases is also high. By focusing on this population we could prevent deaths and the spread of infectious diseases,” says Williams.