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South African Journal of Science

versão On-line ISSN 1996-7489
versão impressa ISSN 0038-2353

S. Afr. j. sci. vol.116 no.5-6 Pretoria Mai./Jun. 2020 



'Meet people where they are': An approach to opioids and harm reduction in South Africa



Danielle A. MillarI; Caradee Y WrightI, II

IEnvironment and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
IIDepartment of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa





Book Title: Opioids in South Africa: Towards a policy of harm reduction
Editor: Thembisa Waetjen
ISBN: 9780796925756 (softcover, 184 pp)
Publisher: HSRC Press, Pretoria; ZAR250
Published: 2019



Use of psychoactive and opioid substances is under-researched in South Africa. Traditionally, the approach towards treatment of opioid misuse was established in prejudice: stereotyping, stigmatisation, and connotations of its criminalisation. Opioids in South Africa: Towards a Policy of Harm Reduction presents a shift in mindset that will undoubtably bend the mind of its readers. The text challenges normative thinking pertaining to opioid substance use with case studies and reflections. It opens with an historical account of opioids in South Africa using graphics from archives. It introduces dilemmas of reducing harm among people who use drugs and shows that regulation and criminalisation of opioids and their use serves to exacerbate social division. Addressing these issues calls for a practical and compassionate social response.

Focus is given to paradigms of scheduling and use of drugs and medicines. A key example is methadone: a drug needed for opioid substitution therapy (OST), which is expensive and is not readily available. The OST Demonstration in Durban suggests success of OST and that it be applied as an evidence-based intervention to inform policy change. Also, the landmark cases which led to an amendment in the Constitution for the personal and private growth and use of cannabis, and its consequent rulings, are discussed and questioned for what these may mean for opioid use.

In Tshwane, a collaboration has given rise to the Community Oriented Substance Use Programme (COSUP) - a service which is a low-threshold response to drug use that seeks to reduce harm and is integrated into primary health care, including the provision, collection and safe disposal of sterile needles and syringes. The interplay between health and disease is analogous to a soccer game, where the playing field extends beyond the hospital, to clinics and 'the streets'. The motto 'Sport is your gang' culminates with a soccer tournament between the South African Police Service and the community, including community members who use drugs.

'Drugs are the biggest problem we have' was a preconception in Cape Town based on the stereotypes surrounding tuberculosis (TB) patients who use drugs. Some TB strains are drug-resistant, leading to an intensive daily drug regime to which it may be difficult to adhere. Non-conforming patients are considered those who take other substances that interfere with TB treatment. Attitudes of health-care workers towards these patients has created an environment of fear for patients who then give false information about substance use habits for fear of being denied TB treatment. Harm reduction was introduced to these clinics and has promoted honesty, trust and medication adherence.

Generally, South Africa's punitive approach creates an overall negative experience and outcome of rehabilitation programmes. They are limited, expensive and inaccessible. A case of a person using nyaope (a mix of heroin, cannabis and bulking agents such as rat poison, washing detergent and antiretroviral drugs) in Gauteng tells of the challenges with rehabilitation. Stories from the Sowetan 'Bombtsubi' illustrate the personal dilemma of nyaope use: there is a dependence, not necessarily on the high it brings, but on avoiding the awful 'down'. Nyaope is considered a social ill and its users a threat to society, making them easy scapegoats for any crime. There is the story of whoonga, another term for nyaope, in Durban, where users are typically among economically disadvantaged communities, who work in the informal sector, or commit petty crimes and get blamed for all crime. Work done in Durban on a low-threshold OST programme has made a tremendous impact on its participants who are progressively able to reintegrate into society.

Several organisations exist to uplift drug users and provide them with skills and tools to conduct research about drugs and drug use - an excellent approach to research which bypasses participants' scepticism as they are talking to someone who understands their unique position, as opposed to an 'outsider'. Participation in a Cape Town research team was voluntary and based on the perception of creating something that would benefit others, and maybe themselves, and that their input was invaluable to this process. The project discussed how people who use drugs make, expend and sustain income, challenging the 'lazy layabouts' misconception. Being a research team member improved the members' sense of confidence and self-worth as they went from feeling that they 'had nothing to offer', to feeling 'proud and gave us a sense that, despite our drug use, we are able to achieve something in life'.

Substances can be hailed as life-changing or vilified depending on social and cultural understanding. Moreover, these perceptions can change over time, as they did for tobacco and cocaine, for example. The manufacture, use and cultivation of drugs, and the consequent drug treatment and drug laws, also change over time due to the fluid definition of 'drugs'. Drug use has been seen as a 'natural force... the fourth drive for people to seek intoxication'1. Historically, use of drugs is ever-present, and the approach to eradication has been ineffective. Harm reduction can resolve issues of habituated and dependent drug use. Prohibitionist approaches dominate policies about drug use and significantly increase direct harms of drugs. Harm reduction is adaptable; it is based on a central aim as opposed to a strict frame, i.e. it 'meets the person where they are rather than where others expect them to be'.

Harm reduction is more than treatment; it is a complex, patient-led treatment model. Continued social stigma contributes to limited access to resources, health inequities and ultimately to harms associated with drug use. The concept of harm reduction is founded on the radical assertion of drug users' humanity. A contemporary harm reduction view includes long-term OST and decriminalisation of substances. This approach will help to integrate and accept drug users into society and eliminate the stigmatisation surrounding them. Throughout this book, voices of different groups of people are heard, from those who use opioids to their family members, health-care professionals, and the police. Thembisa Waetjen and the authors are to be congratulated for 11 fascinating chapters. The book encourages the reader to re-think opioids and their users, and the ways in which to reduce harm that people using opioids face in South Africa.



1. Siegel RK. Intoxication: The universal drive for mind-altering substances. 2nd ed. Rochester: Park Street Press; 2005.         [ Links ]



Caradee Wright

Published: 27 May 2020

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