Reportphase2rev1.doc

The Nature and Extent of Heroin Use In Cape Town:
Part 2 - A community survey

Andreas Plüddemann & Charles DH Parry
Alan J. Flisher
Alcohol & Drug Abuse Research Group
Department of Psychiatry & Mental
Medical Research Council
Health and Adolescent Health Research
Institute
Esmé Jordaan
University of Cape Town
Biostatistics Unit
Medical Research Council

October 2004
Funding for this project was provided by the United Nations Office on Drugs & Crime, Contents

1. Background
1.4 Research on heroin use in South Africa 1.5 Estimating the size of the heroin using population 1.6 Pilot study of heroin use in Cape Town 2. Aims and objectives of the present study 4.1.3 Heroin use: age of onset, frequency, and mode of use 4.1.4 Treatment history & treatment issues 4.1.7 Injecting use, needle sharing & blood-borne virus risks 4.1.11 Purchasing heroin and related issues 1. BACKGROUND
1.1 What is heroin?
Heroin is classified as an opiate. Opiates act on opioid receptors on the central nervous system
and include drugs like morphine, codeine, methadone and Wellconal (dipipanone, a derivative
of methadone). Heroin, known chemically as diacetylmorphine, is produced from morphine,
which is extracted from the Asian poppy (Papaver somniferum). Heroin is four to eight times
as potent as morphine. It has the appearance of a white or brownish powder. It was put under
international control at the UN Single Convention in 1961 (International Council on Alcohol
and Addictions, 2000).
1.2 Global trends
The 2002 United Nations Office of Drugs and Crime’s (UNODC) report on Global Illicit
Drug Trends estimates that globally about 13 million people abuse opiates. About 70% of
opiate abuse relates to heroin. Of 63 countries reporting trend data (1999-2000) 71% reported
an increasing trend in heroin abuse. In Asia, Europe and Oceania, which together have 73% of
the world’s total population, between two thirds and three quarters of substance abuse
treatment demand is related to opiate abuse.
1.3 Health consequences of heroin use
Heroin use holds a number of implications for the health and well-being of the individual
user. The depressant action of the drug on the central nervous system (CNS) places the user at
risk for an overdose and pulmonary complications, such as pneumonia and tuberculosis. In
addition, a long-term health outcome of heroin use is psychological and physical dependence
(Darke et al., 1996; Mientjies et al., 1996; Fernandez, 1998).

Research commissioned by the WHO estimated that globally for the year 2000 a median
estimate of 69 152 deaths could be attributed to opioid overdose (Degenhardt et al., in press).
Data from the Australian Bureau of Statistics indicates that in 2000, a total of 737 deaths
attributed to opioid overdose occurred among persons aged 15 to 44 years (National Drug and
Alcohol Research Centre, 2000). A review of all forens ic cases from July 1995-February 1997
in Sydney, Australia, found that 4% of all cases were related to drug overdose and 80% of
these were related to heroin (Garrick, Sheedy, Abernethy, Hodda, & Harper, 2000). A
retrospective analysis of the deaths of over 2700 heroin injecting drug users (1985-1998) in
Italy showed that 37% were due to overdose and a further 33% were due to AIDS (Quaglio et
al., 2001). Non-fatal overdose may also have consequences including paralysis, seizures,
nerve palsy, peripheral neuropathy and cardiac arrhythmia, many of which result in a lifelong
compromise of health and well-being (Strang, 2002).
The use of heroin also holds important implications for public health. Injection drug use
(IDU), through the direct and indirect sharing of injection equipment, is a well-known risk
factor for the transmission of blood-borne viral infections, such as HIV, hepatitis B, hepatitis
C, and hepatitis G. The United States Centers for Disease Control reported that in 1999, 5932
AIDS-related deaths occurred in the United States that were attributed to IDU. Non-injection
users (NIUs) are also at increased risk for contracting HIV and hepatitis due to the high risk
sexual behaviours associated with patterns of drug dependence and the possibility of NIUs
becoming IDUs as heroin dependence develops and users seek a more efficient means of
administering the drug (Diamantis et al., 1997; Neiagus et al., 1998; Koester et al., 1996).
1.4 Research on heroin use in South Africa
Although prevalence rates for heroin consumption are generally low in Africa, UN reports
point to a steady increase in heroin use in a number of African countries, especially countries
located along the primary drug trafficking routes, such as Ghana, Nigeria, and South Africa
According to the UNODC’s report for 2004, South Africa is estimated to have one of the
highest prevalence rates of heroin use in Africa (United Nations Office for Drugs & Crime,
2004).
Treatment demand for heroin-related problems
The South African Community Epidemiology Network on Drug Use (SACENDU), a project
monitoring drug abuse trends in the cities of Cape Town, Durban, Port Elizabeth, and
Gauteng and Mpumalanga province has shown an increasing demand in recent years for
treatment of heroin abuse in the urban areas of Cape Town and Gauteng, but not in the other
sites (Plüddemann et al., 2003a). In Cape Town only 2% of all patients (N = 2301) in
substance abuse treatment during the first half of 1998 has heroin as a primary substance of
abuse. However, in the second half of 2003, 7% of all patients (N = 1659) were in treatment
for heroin abuse. The trend in Gauteng has followed the same pattern, with 8% of 2617
patients treated for heroin during the 1st half of 2003, although decreasing to 6% in the 2nd
half of that year. In both these sites a further 2% of all patients reported heroin as a secondary
substance of abuse in the 2nd half of 2003. Most patients are white and relatively young. Since
January 1997, the mean age at which patients present for heroin abuse treatment has
decreased from 29 to 24 years in Gauteng and 27 to 24 years in Cape Town. From 1997 to
2003, between 22% and 34% of persons seeking treatment for heroin abuse in Cape Town and
between 24% and 43% in Gauteng, were female. This contrasts with drugs like cannabis and
Mandrax, where over 90% of patients are male. An increase in injection heroin use has also
been noted, with the proportion of patients reporting injection drug use increasing from 29%
in the second half of 1999 to 51% in the second half of 2001 in Cape Town, however
decreasing again to 44% in the second half of 2003. In Gauteng the proportion of heroin
patients reporting injection has increased steadily from 36% in the second half of 2001 to 49%
in the second half of 2003. Heroin was also the third most common primary drug of abuse
amongst patients who are younger than 20 years in Cape Town and in the second half of
2003. Anecdotal information from professionals working in substance abuse treatment and
prevention also suggests a possible increase in heroin use in certain township areas, such as
Hammanskraal in Pretoria and Langa in Cape Town (Plüddemann et al., 2004a; Plüddemann
et al., 2004b).
Quantitative community/school surveys
Household, school and community surveys on drug abuse have been conducted from time to
time in South Africa, however all reported very low levels of heroin use.
A household survey of youth aged 10-21 years conducted during 2000 and 2001 by WHO and
UNDCP (WHO & UNDCP, 2003) in greater Pretoria and in Bela-Bela (a rural town) found
that 1% of the 193 respondents reported lifetime use of heroin, while non of the rural
respondents had used it.
A national household survey of persons 15 years and older in 2002 by Shisana et al. (2003)
found that 0.01% of the respondents reported having used heroin in the past 30 days. This
would translate to a national past 30 days prevalence of 4500 users, probably an
underestimate given the nature of household surveys.
A national survey conducted amongst 10-21 year olds in black communities in 1994 by the Human Sciences Research Council found that 0.9% of the 1378 respondents reported life-time, past 12- month and neighbours use of heroin respectively (Rocha-Silva, 1996). A survey conducted in the uThukela health district in KwaZulu-Natal during 2002 amongst youth aged 13-23 (both in-school and out-of-school) found that 4% of in-school males reported life-time use of heroin and 1% of the in-school females, while 3% of the out-of-school males reported life-time use of heroin and <1% of these females. Furthermore, 3% of the in-school males reported current use of heroin (1% of females) and 1% of out-of-school males reported current use (<1% of females). A total of 1692 in-school youth and 562 out-of-school youth participated in the survey (Adejumo, 2003). A non representative survey conducted in five high schools in the Helderberg region of the Cape Metropole during 2000 by a substance abuse prevention NGO (Bridges) found that 1.9% of the 3474 respondents had tried heroin at least once (Fisher, 2000). Another survey by Bridges conducted in 2002 in both primary and high schools in the Helderberg region found that only one primary school pupil (N = 991) and one high school pupil (N = 387) reported having tried heroin at least once (Fisher, 2003). High-school surveys conducted among large, representative samples in Cape Town in 1997 (Flisher et al., in press), Durban in 1998 (Bhana et al., 1998) and Port Elizabeth in 1999 (Terblanche, 1999) did not report any use of heroin. Even a survey of 3082 adult arrestees, conducted in Cape Town, Durban and Johannesburg at total of ten police stations over an 18- month period from 1999 to 2000, found that very few participants reported heroin use. Interviews were conducted in August/September 1999, February/March 2000 and August/September 2000 to establish changes over time. Results showed that across the three sites and for each of the three phases of the survey between 0.2% and 2.5% of the arrestees reported having used heroin at least once. Johannesburg and Cape Town had slightly higher levels than Durban (Plüddemann et al., 2002). A national survey of 1143 arrestees conducted by the HSRC during 2000 did not report any use of heroin. Quantitative surveys with non-representative samples Surveys conducted amongst young people in ‘special settings’ also did not find particularly high levels of heroin use, or the sample sizes were very small. For example, a survey conducted by a volunteer organisation known as Ravesafe at three raves in Johannesburg between December 2000 and February 2001 found that 8% of the 80 participants had tried heroin, but only one used it daily (Gillespie, 2001) . A second survey conducted at two raves in Johannesburg in 2001 found that 4.8% of the 126 respondents had used heroin at least once, however only one person reported weekly use of the drug (Gillespie, 2002). A second survey by the same organisation at a rave in Boksburg in 2002 found that 7% of the 54 respondents had used heroin at least once, although only one person reported daily use (Gillespie, 2003). Both surveys conducted by Ravesafe relied on volunteer participation, although the latter survey did offer an incentive for participation in the form of a draw for two music concert tickets. A number of small surveys conducted at rave parties in Gauteng found some use of heroin. A study of 56 ‘ravers’ in Johannesburg in 1999 found that 12% reported having used heroin at least once (Willmers, 1999). Qualitative studies
A study commissioned by the UNODC of drug markets in Johannesburg, using mainly key
informant interviews reported that use of heroin is used by some sex workers in Hillbrow and
surrounding areas (Leggett, 2000). However, research conducted by the same author amongst
over 50 sex workers in Durban did not report any use of heroin (Leggett, 2001).
A qualitative investigation into the use of heroin in Cape Town by Gossman (2003) indicated
that heroin use appeared to be increasing and that heroin was available in many suburbs in
Cape Town.
Police data
Currently purity testing of heroin samples seized by police is not routinely conducted,
however statistics on heroin seizures and arrests made by police are available. On a national
average an increase in heroin seizures has been reported by the South African Narcotics
Bureau (SANAB) over the past few years. SANAB reports that in 1996 only 800g of heroin
were seized nationally. This increased steadily to 13.5kg by 2000, with a slight decline from
this figure being recorded in 2001 (9.5kg) and 2002 (9.5kg). The number of arrests made
nationally for either the possession of or dealing in heroin has also increased steadily from 12
in 1996 to 284 in 2002. Seizures of heroin reported by the Forensic Science Laboratories in
Cape Town and Pretoria also increased drastically in the 2nd half of 2002, with over 73kg
reported by the Pretoria lab in the 2nd half of 2002, compared to no more than about 6kg in
previous periods (Plüddemann et al., 2004a). According to the UNODC’s Country Profile on
Drugs and Crime (UNODC, 2002) heroin is sourced from markets in Southeast and
Southwest Asia, couriered principally via Johannesburg International Airport. Other sources
include seaport entry via Mombasa and Dar es Salaam. The drugs are then transported down
East Africa’s main arterial road networks toward South Africa. Most of the heroin available in
South Africa is known as “Thai White”.
1.5 Estimating the size of the heroin using population
Although research shows an increase in demand for heroin abuse treatment, the size of the
heroin using population is still unknown. As mentioned above, data sources are currently
limited to information from treatment centres, reflecting only those seeking treatment, and a
few school and community surveys where the potential for under-reporting is high.
Mortuaries and trauma units do not currently routinely report heroin overdose
deaths/incidents.
Given the health consequences of heroin use mentioned above, estimating the size of the
heroin using population, in a defined area, is important for policy development and health
resource planning, especially at a local level. Estimates are also required by the UN,
specifically for their Annual Reporting Questionnaire on Drug Abuse (ARQ). A number of
methods to estimate the actual size of a population using available data exist.
One such technique is the ‘multiplier method’. Multiplier techniques work by making
informed assumptions about the proportion of cases in the study population who experience a
particular event in a particular time period, such as an estimate of the proportion of drug users
in treatment at some point during a give n year – the so-called multiplier – and a benchmark
number representing the total number of the drug- using population known to have been in
treatment during the year in question. Benchmark data are normally gleaned from various
existing data sources, such as records of drug treatment centres, whereas the multiplier is
usually extracted from an emerging survey. For example, if primary data collection as part of
a survey revealed that 20% of heroin abusers had been in treatment the previous year, the total
number of likely heroin users can be estimated by multiplying the total number of recorded
treatment cases (e.g. 5000) by the multiplier (5) (= 25000) (UNODCCP, 1999).
A second technique is the ‘capture-recapture method’. This method was first used to estimate
animal populations in parks or nature reserves. Researchers identified a herd, for example,
tagged a random sample of animals, released them and then drew a second random sample of
the same number and determined how many of the tagged animals were in the second sample.
This number is then multiplied with the original sample to determine the population. A
similar methodology can also be applied to estimating numbers of drug users.
Internationally a number of countries have used these techniques to estimate the size of the
heroin- using population, including the UK, Australia and Pakistan (Hall, Ross, Lynskey, Law,
& Degenhardt, 2000; Frischer et al., 1993).
In South Africa benchmark data on the number persons in treatment for heroin was available
from data collected by the South African Community Epidemiology Network on Drug Use
(SACENDU) (Parry et al., 2002), however no good multiplier information is available. This
study aimed to obtain a treatment multiplier to estimate the number of heroin users in Cape
Town. The ideal is to obtain a range of multipliers (estimates) from different data sources or
through different methods (e.g. capture-recapture). Based on intensive discussions held at a
UNODC sponsored meeting in Pretoria in November 2002 it was clear that there was no other
readily available bench mark data (such as arrest data or fatal overdose data) from which to
obtain additional estimates. Due to the high cost and practical issues the capture-recapture
method was not a feasible option for this study.
1.6 Pilot study of heroin use in Cape Town
Findings from a qualitative study on heroin use in Cape Town indicated that heroin use
appears to be increasing in Cape Town. Through interviews with key informants in contact
with heroin users in Cape Town and through focus group discussions with heroin users in
treatment, it was established that a number of issues are cause for concern relating to the
apparent increase in heroin use in Cape Town, including the lack of affordable treatment
services for heroin users, problems with methadone prescription, an increase in heroin use
amongst previously disadvantaged communities, and the lack of affordable detoxification
services. The study also suggests that changes are taking place in the profile of users, with
increasing use among females, Afrikaans speakers and lower SES populations on the Cape
Flats. The time between taking other drugs and experimenting with heroin may be declining.
2. AIMS AND OBJECTIVES OF THE PRESENT STUDY

2.1 Aims
The study had the following aims:
1. To obtain an estimate of the number of heroin users in Cape Town. 2. To identify heroin users in Cape Town in terms of demographic and other factors.
2.2 Objectives
Further to the above aims the study had the following objectives:
1. To identify the nature of heroin use, namely frequency of use, supply source, mode of use, the using environment/setting, and other drugs used. 2. To begin to assess the health and broad social burden of harm incurred by heroin users to themselves, friends, family and society in general. 3. To inform intervention efforts to reduce harm associated with heroin use in Cape
3. METHODS

3.1 Study design and sampling strategy
In order to obtain the multiplier, a snowballing or chain referral sampling technique was used
to interview 250 heroin users us ing a structured questionnaire. This type of sampling is most
frequently used where there is no access to an adequate sampling frame and when there is
little information available about the specific group under study. The technique involves
identifying a few respondents who thereafter refer others from their particular social network,
in this case heroin using acquaintances, for possible involvement in the study.
The survey was initiated in different settings and geographical areas where clusters of heroin
users were known to reside, and an attempt was made to recruit respondents from as ma ny
locations as possible to improve the validity of the sample. Originally eight areas were
identified as suggested starting points for sampling, spread across the six s-called
“substructures” of the Cape Metro. In the eventual sample all six substructures were
represented, including a wide range of suburbs in terms of socio-economic status and
demographic profile. Table 1 shows the number and proportion of participants residing in
each substructure.
Table 1: Study participants by substructure of residence
Suburb
Frequency
In order to obtain the multiplier for estimating the number of users subjects were asked if they
have been in treatment between July 2003 to June 2004 and to name the centre (in order to
identify those who had been to the centres forming part of the SACENDU data collection
system).
3.2 Procedures
Eligibility criteria
Heroin users between 18 and 49 years of age, residing in the Cape Town metropolitan area
were targeted.
Inducement
No monetary inducement was provided to participants. Petty cash to cover the cost of tea,
coffee or cooldrink for the participants was provided to interviewers.
Interviewers
Interviewers were trained in a group training session by the principal investigator in a five
hour training session. This training included:
1. The goals and objectives of the study. 2. Discussion of recruitment issues. 3. Discussion of eligibility criteria. 4. Training in drug terminology and effects, including overdose. 5. Comprehensive guidance in the administering of the questionnaire. 6. Ethics. 7. The avoidance of potential bias. 8. Briefing on the services available to drug users in the study site.
Ultimately four interviewers were utilized for the study. Interviews were completed
over a five week period.
Questionnaire
The questionnaire consisted of 13 sections: 1) demographic information, 2) heroin use history,
3) drug use history, 4) treatment history, 5) treatment issues, 6) arrest history, 7) overdose
issues, 8) injecting, 9) blood-borne virus risks, 10) sexual risk, 11) dependence severity scale,
12) blood-borne virus testing, 13) heroin market questions. It was informed by questions used
in studies conducted in other countries as well as the pilot study conducted in 2003/2004.
3.3 Ethics

Informed consent, confidentiality and anonymity
Ethical approval for the study was granted by the University of Cape Town’s Research Ethics
Committee in May 2004. All participants in the study provided informed consent. Subjects
received an information sheet on the study and were asked to sign a consent form. Subjects
were assured of confidentiality and anonymity.
4. RESULTS
4.1 Frequency analyses
4.1.1 Demographic profile of the sample
The demographic profile of the heroin users is given in Table 2. Almost 80% of the sample
was male and 55% were White, 37% Coloured and 6% Black.1 The mean age of the
participants was 23.4 years (SD = 3.92). Most had never been married (78%). Over 60% of
the sample had completed grade 12 and 33% reported some tertiary education. The majority
of the sample reported living in a house or flat (84%) and a further 14% reported renting a
single room. The average number of people living in each ‘household’ was 4.5 (SD = 1.59).
Most of the participants were South African citizens or permanent residents (97%). Of those
who were not SA citizens two were Angolans and one was Canadian.
Table 2: General demographic information
Marital status
Highest level of schooling completed
1 * The terms “white", "black", and "Coloured”, originate from the apartheid era. They refer to demographic markers and do not signify inherent characteristics. They refer to people of European, African and mixed (African, European and/or Asian) ancestry, respectively. These markers were chosen for their historical significance. Their continued use in South Africa is important for monitoring improvements in health and socio -economic disparities, identifying vulnerable sections of the population, and planning effective prevention and intervention programmes 4.1.2 Self-reported drug use
Table 3 shows the lifetime, past 12 months, past 30 days and past 3 days use of various
substances as reported by the participants in the survey. The Table shows that regular tobacco
use was very common among heroin users interviewed, with 98% having smoked cigarettes in
the past 3 days. Alcohol use was also common, although this survey did not assess the
quantities of alcohol consumed. Notably the next most common drug of use was
methamphetamine (a drug that has shown a rapid increase in use in 2004), with 75% of
participants reporting that they had used methamphetamine in the past 3 days. Cannabis was
the next most common substance reported, with 37% reporting use in the past 3 days. Use of
Mandrax (the sedative, methaqualone) was also fairly common. While a relatively high
proportion had tried Ecstasy at least once (18%) very few had used it in the past 3 days. Use
of other drugs in the past 3 days was uncommon.
Table 3: Self-reported drug use (%)
- Over-the-counter medicines used to achieve effects other than what they are medically used/prescribed for - Substances that relieve severe pain, e.g. Welconal, morphine - Substances that help people to relax, e.g. Valium, Librium, Ativan 5 - Substances that help people to sleep, e.g. Amytal, Nembutal, Rohypnol
4.1.3 Heroin use: age of onset, frequency, mode of use
The average of onset of heroin use was 20.5 years (SD = 2.59), ranging from 12 years to 32
years. Over 80% of the participants were introduced to heroin by a fr iend. For over a third
(35%) of the participants heroin was the first drug they ever tried. Most of those who reported
trying other drugs first had tried cannabis or cannabis/Mandrax first. Three quarters of the
sample reported smoking/inhaling or snorting as their mode of heroin use, while 25% reported
injecting as their mode of use. Of those who had injected in the past 12 months, 67% reported
that they had shared a needle. Most of those who reported injecting in the past 12 months had
also injected in the past 30 days (93%). In the 30 days preceding the interview the majority of
participants had used heroin every day (67%) and 93% had used heroin in the past 3 days.
Coloured participants had used heroin for a significantly longer period on average than the
White participants (t = 2.117, 227 df, p < 0.05), however White participants were significantly
more likely to have injected heroin in the past 3 days (?2 =10.733, p < 0.01).
4.1.4 Treatment history & treatment issues
Twenty-one percent of all the participants stated that they had “been in treatment” for
substance abuse in their lifetime (Table 4). Of these 33% had been in treatment in the past 12
months, with 82% reporting heroin as the primary substance for which they received treatment.
Of these participants who could recall the location, 90% (n=9) had been to a private specialist
substance abuse treatment centre and one had been to a general practitioner. Eight participants
had been in treatment for substances other than heroin (lifetime). Eight percent of all the
participants reported that they had been to a general practitioner, general hospital or psychiatric
hospital for heroin treatment in their lifetime.
Only 29% of the participants felt they “might need treatment for heroin”. Interestingly, 61%
thought there were enough treatment centres in Cape Town where heroin users could seek help
and 55% thought treatment was affordable for most heroin users. In response to the question
which type of facility may be most needed (i.e. inpatient, outpatient or aftercare), however,
almost 75% said “all of the above”. Overall, 27% of the participants had used methadone at
least once. Very few reported having used other substitutes like buprenorphine or Naltrexone
(3%).
4.1.5 Arrest history of participants
Thirteen percent of all the respondents had been arrested at least once. Of those who had been
arrested, 31% had been arrested in the past 12 months (n = 10). Seven of these had been
arrested for drug possession. Only two participants were charged and none were found guilty
of the alleged offence. Ten participants reported other offences they had committed in their
lifetime, most of which were related to stealing or selling/possessing drugs. Participants who
had been using heroin for a longer period were significantly more likely to have been arrested
at least once (t = 2.603, 238 df, p < 0.05).
4.1.6 Overdose and suicide
Of all the participants 33% answered “yes” to the question “have you ever had a heroin
overdose?” Over three quarters (26%) of those who reported an overdose, had an overdose in
the past 12 months of who almost half had one or two overdose experiences in the past 12
months. Four participants reported eight overdose experiences in the past 12 months and one
participant reported 12 overdoses. O verdose was significantly related to the duration of heroin
use, with those having used heroin for a longer period being significantly more likely to have
experienced an overdose (t = 5.982, 204 df, p < 0.01).
Of those who reported an overdose, 12% experienced it in the last 3 months or less, 30% 3-6
months ago, 34% 6-12 months ago, and 25% more than 12 months ago. Most had the overdose
at a friend’s home (77%) or in their own home (15%). Only 44% sought medical treatment the
last time they had an overdose, mostly at an emergency room (83%). In response to the
question “Have you heard of other users in Cape Town having fatal overdoses in the last 12
months”, 47% answered “yes”. The number of overdoses participants claimed to have heard
about ranged from one to thirty in the past year, while the average number of overdoses
participants had heard about was 6.4 and the mode was 2.2
2 Note that where participants gave ranges (e.g. 10-20 overdoses) the midpoint of the range was used to calculate the mean. Of all the participants, 9% reported that they had tried to commit suicide in the past 12 months. Table 4: Summary of key indicators Question
answering answering
“yes”
“yes”
Have you ever been in treatment for substance abuse? Do you feel you might need treatment for heroin (again)? Have you tried to deliberately overdose or kill yourself in the past 12 4.1.7 Injecting use, needle sharing & blood-borne virus risks
Overall 23% of all the participants had injected heroin in the past 12 months. Furthermore,
18% of all the participants reported that they had injected heroin in the past 3 days and 80%
of those who had, reported injecting daily. Of those who injected, the youngest starting age
was 17 years and oldest 32 years, with an average of 22.2 years (SD = 2.93). Most were
taught to inject by a friend (56%) or partner (32%), while some were also taught by a parent
(9%). Over three quarters reported injecting in either their own home, and/or their friend’s
home, and/or their dealer’s home. Two participants reported injecting in a public toilet, while
none reported injecting in a “shooting room”. Most said they had last injected at a friend’s
home (90%).
Although only one person reported injecting with a needle they had already used more than
five times in the past 30 days, 69% said they had done so 2-5 times. Five respondents had
shared a needle more than five times in the past 30 days, while 29% had shared 3-5 times and
27% had shared twice. Most reported using the needle after a close friend (45%) or their
regular sex partner (37%). Most of those who reported injecting reported having been injected
by someone else in the past month (91%), ranging between once and more than 5 times. Two
thirds had been injected by someone else 2-5 times in the past 30 days, mostly by a close
friend or regular sex partner (75%). Most reported that they were in a friend’s home the last
time they used a needle after someone else (88%). All but six of the injectors had also used
injecting equipment after someone else, including a spoon, water, filter, tourniquet and the
drug solution/mix.
In the past month most of the injectors got their needles from a pharmacy (43%) or a heroin
dealer (28%). An equal proportion also got needles from another user (13%) or from a
hospital (13%). Over ha lf of the injectors (57%) had been denied needles at least once, and
48% had been denied needles in the past 30 days. Most of these “denials” had occurred at a
pharmacy or hospital (81%). Asked whether needles were easy to obtain, a third said “very
easy”, another third said “easy”, and a third said “difficult” or “very difficult”.
Those participants who reported injecting in the past 3 days were significantly more likely to
have been in treatment for substance abuse (?2 = 16.238, P<0.01), to feel they might need
treatment for heroin (again) (?2 = 16.482, p<0.01), to ever have had a heroin overdose (?2 =
39.421, p<0.01), and to have tried to commit suicide in the past 12 months (?2 = 7.594,
p<0.05).
4.1.8 Sexual risk behaviour
A third of the participants had one sexual partner in the past 12 months, 30% had two sexual
partners, 28% had three to five sexual partners, and 7% had more than five sexual partners in
the past 12 months. Over the past 30 days, 57% had one sexua l partner and 38% had two
sexual partners. Six percent of the respondents had been paid for sex at least once in their life
(nine males and five females), and nine participants were currently working in sex work (five
males and four females). The number of clients they had in the past month ranged from one to
twelve. Overall, 28% of participants had always used a condom with their regular partner,
66% “sometimes” used a condom, and 5% never used a condom with their regular partner.
Proportions for condom use with “non-regular or casual” partners were fairly similar, with
35% always using a condom, 60% sometimes using a condom, and 1% never using a condom.
4.1.9 Severity of dependence
The Severity of Dependence Scale (SDS) is a measure of dependence developed by Gossop et
al. (1995), estimating the severity of a drug users dependence. The scale was developed for
users of cocaine, heroin and amphetamines, but has also been used for other drugs. The scale
consists of five items, namely:
1) Did you think your use of heroin was out of control?
2) Did the prospect of missing a fix or not chasing make you anxious or worried?
3) Did you worry about your use of heroin?
4) Did you wish you could stop?
5) How difficult would you find it to stop or go without heroin?
Items 1-4 are scored on a four-point scale (0=never/almost never; 1=sometimes; 2=often;
3=always or nearly always), while item 5 is scored as 0=not difficult; 1=quite difficult;
2=very difficult; 3=impossible. Scores are totalled and higher scores indicate a higher degree
of dependence.
In this sample, 85% of the participants had a score of 4 or more which is indicative of
dependence. Scores ranged from 1-12 and the mean score was 5.4 (SD=1.81).
4.1.10 Blood-borne virus testing
A number of participants declined to answer questions on HIV testing/status (13%). However,
68% of those who responded had been tested for HIV. Eight of these participants stated that
HIV test had been positive, yielding an overall prevalence of 3.2% of all participants and
5.4% of those who were tested.
Overall, 50% of the participants had been tested for hepatitis C, and 8% of those tested were
positive (n=10). Of those tested for hepatitis B (47%), three reported a “current infection”,
three reported that they “have hepatitis B”, three had a “past infection”, and two were a
“carrier”.
4.1.11 Heroin purchasing and related issues
Participants were asked a series of questions relating to their heroin purchasing
activity/behaviour. Asked how they contacted the person they got their he roin from the last
time, 51% “visited a house”, 39% “called them on a telephone”, 4% “approached them in
public”, and 4% “paged them on a beeper”. Most of the participants got their heroin at a
“house or apartment” the last time they got it (71%), 18% got it at a “public building”, and
6% got it in a “street or alley”. It was more common for the participants to purchase the
heroin “outside their neighbourhood” (72%) than in their own neighbourhood. Over a third of
the participants (36%) stated that someone else had obtained the heroin for them the last time
they got heroin. For 55% of the heroin users, the person they got their heroin from the last time was a “regular source”, while it was an “occasional source” for 40%, and a “new source” for 5%. Over half of the participants reported that they had purchased heroin every day over the past 30 days (56%), and a further 7% got it on 20-29 of the past 30 days. Most got their heroin from one or two different people over the past 30 days (54%) and a further 40% got it from three to five different people in the past 30 days. Most participants paid between R50-R60 per quarter gram of heroin. Most purchased one or two sections only. Asked whether there was a time over the past 30 days when they tried to purchase heroin, had the cash, but did not buy, 38% answered “yes”. This related mostly to “police activity” (51%) or lack of availability from dealers (26%). A number also stated that the dealer did not have the quality they were seeking (18%). On average the participants had spent ZAR342 on heroin in the past 7 days, with one participant spending ZAR840 in the past 7 days. Overall participants spent an average of ZAR548 on drugs in the past 7 days (including alcohol and cigarettes) and overall the 250 participants spent almost ZAR 135 000 on drugs in the past 7 days. This would translate to over seven million Rand in one year for these drug users alone. Also noteworthy was that overall 27% of the participants had, at some point in their life, sold heroin. 4.2 Estimating prevalence in Cape Town
As described in the “Aims & objectives” section of this report, this study aimed to obtain an
estimate of the number of heroin users in Cape Town, using the multiplier technique.
Benchmark data was available from the SACENDU project, and it was decided to use the
period from 1 June 2003 until 31 July 2004 as the benchmark input.
Of all the participants interviewed in this survey, only five could be positively identified as
having been in one of the treatment centres monitored by SACENDU during July 2003 to
June 2004. During this period 294 adult patients (aged 18-49 years) had been in treatment at
all the centres monitored by SACENDU with heroin as their primary substance of abuse.
Thus an estimate was calculated as follows:
Benchmark (B) = 294 [the number of heroin patients in treatment during a 1 year period]
Multiplier (M) = 5 in 250, i.e. 1 in 50, therefore M = 50
Thus estimate: B x M

In 2001 the city of Cape Town’s population was estimated at 2.9 million people. Using the
prevalence of 14 700, this yields a ratio of 5.1 per 1000.
If adolescents (i.e. those younger than 18) who were in treatment centres monitored by
SACENDU during the above period are included in the calculation, the estimate increases by
about 1000 users.

Robustness of the estimate
The standard survey methods of calculating confidence intervals that are available depend
upon the validity of the assumptions of the method. It is not important to show how the
estimate is influenced by the sampling variation (confidence interval), but to show how it is
influenced by departures from these assumptions, since failure to meet these assumptions
produces biased estimates.
Multiplier methods seldom use statistical theory to derive confidenc e intervals. Instead, an
upper and lower estimate is generated by varying the multiplier or the benchmark, based on
information on their uncertainty obtained during the study or from an outside source.
Example:
Estimate is
Varying multiplier by 1: Lower estimate: It is clear that the estimate is much more influenced by changes in the multiplier than in the benchmark. 5. DISCUSSION & CONCLUSION

Multiple drug use was clearly common in this sample of heroin users, with 75% reporting
methamphetamine use, 37% reporting cannabis use, and 22% reporting Mandrax use in the 3
days prior to the interview. Alcohol and tobacco use was also very common. On average the
participants in this survey started using heroin when they were 20 years old and on average
had been using heroin for about 3 years. According to the SDS, 85% of the participants were
classified as “heroin dependent”. Although about a fifth of the participants had been “in
treatment” at some point in their life for substance abuse, only 7% had been “in treatment” in
the past year.
Only 10 of the participants (4%) reported that they had been arrested in the past year and
offences were generally related to theft or drug possession. It would thus appear that heroin
users are not engaging in overt criminal activity on a regular basis that result in their being
arrested. A key informant interviewed in Phase 1 of this study described the typical “criminal
behaviour” of a heroin user as “wheeling, dealing and stealing”. This was, to some extent,
confirmed by this survey, although the findings in this survey could reflect policing rather
than actual levels of criminal behaviour.
Three quarters of those who reported an overdose (33%), had experienced it in the past 12
months. Given the estimated number of users in Cape Town, this phenomenon has significant
implications for the health services in Cape Town, particularly the emergency rooms. It
should be ensured that emergency room staff are adequately trained to recognise and treat
heroin overdose cases. Although no data exists in South Africa on heroin overdose deaths, the
fact that almost half of the participants in this survey claimed to have heard of a heroin
overdose death in the past year give some indication that this is occurring relatively
frequently.
Injecting heroin use was fairly uncommon in this sample, with 18% reporting injecting use in
the past 3 days and 23% in the past 12 months. [This is comparable to the 28% of heroin
patients reporting injecting in Cape Town in the first half of 2004 (as noted by the SACENDU
project)]. Over two thirds of the injectors reported needle sharing in the past month, indicating
that this issue is cause for concern and does occur commonly among injectors. Although only
eight participants reported that they were HIV positive, HIV transmission through needle
sharing may still become a serious issue as heroin use (and injecting) increases in the city.
Incidentally, two of the eight participants who were HIV positive reported having shared a
needle in the past month. While many participants reported obtaining their needles from
pharmacies, almost half had been denied needles in the past month. This would seem to
indicate that there may be a need for needle exchange programmes or that local government
should perhaps consider taking a position on the issue of needle purchasing from
pharmacies/ho spitals.
Information on heroin purchasing behaviour obtained in this survey confirmed comments
made by key informants and focus group participants in Phase 1 of this study. Heroin dealing
activity is still relatively “hidden”, with most users visiting a house or apartment for their
purchase or calling the dealer on the telephone. Very few “approached the dealer in public”.
There was an indication that police presence is sometimes a hindrance in the heroin buying
process, indicating that an increase in visible policing in the city ma y indeed have a curbing
effect on heroin dealing activity.
The amount of money spent on heroin (and other drugs) by the participants gives some indication as to the sheer size of the illegal drugs market. If the estimate of ZAR 7 million (which however also includes alcohol and cigarettes) referred to earlier as the total spent by 250 heroin users in one year is used to calculate the spending of the estimated 15 000 heroin users in the city, a sum of almost ZAR 420 million is arrived at. This projection provides some idea of the “muscle” behind the drug marketing industry, and depicts what intervention efforts are up against in their effort to curb both use and marketing. The estimate obtained in this study was substantially higher than any of the key informant estimates (which ranged between 3000-5000). It would seem clear that Cape Town has a large number of heroin users who have not had recent contact with a specialist treatment centre. It would also seem that the city’s capacity for treating heroin dependence is woefully inadequate, given the assertion that most heroin users would seek treatment at some point in their “using career”, and (according to the key informants interviewed in Phase 1 of this study) this is likely to occur relatively soon after heroin use commences. It should nevertheless be kept in mind that ideally a prevalence estimation study would have multiple estimates to compare from different sources (e.g. arrests or overdose deaths) and thus the estimate arrived at in this study should be used with caution, as no alternative estimation technique is currently readily available. In conclusion, it is clear that heroin use has become a major concern in Cape Town and may still be increasing. The drug is being used in many suburbs of the city and is no longer confined to White youth but is increasingly used by Coloureds and, though still less commonly, Blacks. The lack of state funded rehabilitation services must be addressed urgently and post treatment support networks and follow-up systems also need to be encouraged and supported. Limitations of the study The prevalence estimation obtained in this study should be treated with caution, as only one benchmark and one multiplier were used. Ideally multiple benchmark data sources (and hence a variety of multipliers) should be used in a prevalence estimation exercise. Unfortunately alternative baseline/benchmark data is currently not available in South Africa. For example, non-natural deaths are currently not routinely subjected to toxicology screens, only upon request from the authorities (usually when there is a suspicion of drug involvement). Thus no accurate data on drug related deaths in the country/Cape Town is available. Data on arrests has also become difficult to obtain due partly to restructuring in the police force. Future research Future research could investigate to what extent heroin users are engaged in criminal activity for which they are not arrested, focus on particular geographic areas, and possibly emp loy alternative methods for prevalence estimation (such as capture-recapture). Ongoing surveillance of heroin users may also be required as the problem is unlikely to remain static, perhaps in the way the problem is monitored in Australia via the Illicit Drug Reporting System (IDRS) (Shand et al., 2003).
ACKNOWLEDGEMENTS
The authors would like to acknowledge the contributions to this study of the following
persons:
• Celeste Naidoo and her team of fieldworkers (Fazlin Jappie, Juliet Windvogel, Carla Adams, and Moeniba Jappie) for the recruiting and interviewing of the participants; • The United Nations Office on Drugs & Crime for their funding of this project and their support in initiating this project (especially Gary Lewis & Matthew Warner-Smith) • All the survey participants who gave up their time and some of their privacy to REFERENCES

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