Indicators of Substance Abuse Treatment Demand in Cape Town, South Africa

Opsomming Few studies have investigated the demand for substance abuse treatment in South Africa. This article uses data collected from specialist substance abuse treatment cen­ tres to describe substance abuse treatment demand and patterns of service utilisation in Cape Town for the pe­ riod January 1997 to December 2001. Findings suggest that although treatment demand for alcohol-related prob­ lems remains high, treatment demand for substances other than alcohol has increased over time. Patterns of treatment service utilisation suggest that women and black South Africans remain underserved. The need for comprehensive and accessible substance abuse treat­ ment services in Cape Town is highlighted and recom­ mendations are made for improving access to treatment services, and undertaking comprehensive evaluations of existing treatment facilities. Min studies het al die aanvraag vir middelmisbruik behandeling in Suid-Afrika ondersoek. Hierdie studie gebruik data wat van spesialis m iddelm isbruik-b eh an d elin g sen tru m s g ek o llek tee r is om die middelmisbruik behandeling aanvraag en patrone van diensgebruik in Kaapstad vir die periode Januarie 1997 tot Desember 2001 te ondersoek. Bevindings toon dat alhoewel aanvraag vir behandeling van alkohol-verwante probleme hoog bly, aanvraag vir behandeling van middels, behalwe alkohol, oor tyd toegeneem het. Patrone van diensgebruik van behandelingsentrums dui daarop dat dienste vir vrouens en swart Suid-Afrikaners steeds onvoldoende is. Die nodigheid vir omvattende en toeganklike middelmisbruik behandelingsdienste in Kaapstad word uitgelig en aanbevelings vir verbeterings ten opsigte van toegang tot behandelingsdienste en ondememing van omvattende evaluasies van bestaande behandelingsfasiliteite, word gemaak.


Introduction
South Africa, like many developing countries, is experienc ing high levels of alcohol-related problems (Parry, Bhana, Myers, Pluddemann, Flisher, Peden & Morojele, 2002a p.434).A pattern of drinking until intoxication has become common in the country, with the National Demographic and Health Survey of 1998 reporting that almost a third of male and a third of female drinkers consume alcohol at risky levels over weekends1 (Parry, 2001 p.441).Although the use of alcohol has featured prominently in South Africa's socio-political history (see Parry & Bennetts, 1998 pp. 3-23 for a review), the country's physical and economic isola tion, strict monitoring of external borders, and stringent internal controls during the apartheid era restricted access to and availability of most kinds of illicit drugs.However, with the changes in global and local drug markets since the first democratic elections in 1994, South Africans now have access to a broad range of illicit drugs, including cocaine and heroin (Parry, Bhana, Pluddemann, Myers, Siegfried, Morojele, Flisher & Kozel, 2002b pp.974-975).In South Africa, provincial and local governments control the allocation of resources for substance abuse services.Cape Town, a large port city, is one local area that has been identified as having high levels of substance abuse and substance-related problems (Parry et al., 2002a p.434;Parry et al., 2002b p.974).Cape Town is the capital city of the Western Cape Province and the legislative capital of South Africa.It has a population of approximately 2.7 million people, of which about 51 % are Coloured2, 26% are Black, 1 Risky drinking was defined as five or more drinks for males on one occasion, and three or more drinks for females 2 The terms "White, Black, Asian/Indian, and Coloured" refer to demographic markers and do not signify inherent charac teristics.These markers were chosen for their historical significance.The demographic characteristics of substance users are important as accurate user profiles assist in identifying vulnerable sections of the population and in planning effective prevention and intervention programmes.The purpose of this article is to (i) provide descriptive, epidemiological information about trends in AOD treatment demand in Cape Town, for the period January 1997 to De cember 2001; (ii) describe patterns of specialist AOD treat ment service utilisation in Cape Town for the same period; and (iii) to outline the implications of these findings for policies and practices relating to substance abuse inter vention in the region.

Method
Treatment data are collected bi-annually from 23 specialist substance abuse treatment centres in Cape Town.Together these facilities serve over 3000 clients per year.This repre sents at least 95% of the specialist treatment centres in Cape Town.Treatment centres include public and private institutions.In order to be admitted to a specialist AOD treatment centre, patients are required to meet the DSM-IV criteria for substance abuse or substance dependence.For the purpose of surveillance, a standardised one-page form is completed on each person treated by a given centre dur ing a particular 6-month period.The form elicits forcedchoice responses about the source of referral for treatment, biographical information, type of treatment received (inpa tient and/or outpatient), the primary and secondary sub stances of abuse3, the mode(s) of use, and whether the person had received treatment prior to the current episode.Regular training in data collection procedures is given to treatment centre staff.To ensure data quality, completed forms are checked for missing information and possible miscodes.

Results
Since January 1997, a number of changes in substance abuse treatment demand have been observed in Cape Town.Although alcohol remains the most common primary sub stance of abuse, the proportion of patients citing alcohol as their primary substance of abuse, relative to other drugs, decreased significantly from 1997a (January to June 1997) to 2001b (July to December 2001), from 82% to 46% (Z= -35.52; p < 0.001; N = 17529) (Table 1).Cannabis or cannabis smoked with Mandrax (termed a "white pipe") is the most common primary drug of abuse in Cape Town.From January 1997 to December 2001, treat ment demand for cannabis abuse increased from 5% to 12% of the total demand for AOD treatment (Z = 12.83 \p < 0.0001; N = 17525) (Table 1).For the same period, treatment de mand for white-pipe abuse, as a proportion of the total demand for AOD treatment, increased significantly from 7% to 25% (Z = 14.78; p < 0.0001; N = 17525) (Table 1).Treatment demand for cocaine-related problems, as a pro portion of the total demand for substance abuse treatment, also increased significantly, from 4% to 6 % (Z = 6.26; p < 0.0001; N = 17525) from January 1997 to December 2001 (Table 1).In addition, the proportion of patients treated for heroin-related problems, relative to other substances, in creased significantly, from 1 % to 6% (Z= 14.15 ;p< 0.0001; N = 17525).Similarly, treatment demand for Ecstasy-related problems increased significantly, albeit from a low base, from 0.5% to 1 % of the total demand for AOD treatment (Z = 2.74; p = 0.006; N = 17529) (Table 1).Over time, a large proportion of patients in specialist AOD treatment facilities report abusing more than one substance.For example, 42% and 40% of the total proportion of pa-3 Responses to these two items are not forced-choice From January 1997 to December 2001, the proportion of patients who were less than 20 years old increased significantly from 6 % to 24% of the total proportion of patients receiving spe cialist substance abuse treatment services (Table 3).Of concern is the in crease in treatm ent de mand among adolescents in Cape Town for heroinrelated problems, from 2% (1997a) to 8% (200 lb) of the total ad o lescen t su b stance abuse treatment demand.Since the start of surveil lance in 1997, over 80% of patients receiving specialist sub stance abuse treatment services have been male (Table 3).Over time, the proportion of Black patients receiving treat ment for substance abuse has ranged between 4% and 13% of the total proportion of patients receiving specialist sub stance abuse services (Table 3).

Discussion
Although findings from specialist substance abuse treat ment services suggest that treatment demand for alcohol as a primary substance of abuse has decreased over time, when the overall proportion of substance use (reported by patients in these facilities) is considered, alcohol accounts for more than 60% of the treatment demand (Ta ble 2).Trauma, mortality and psychiatric indica tors cited in other stud ies also point to the high need for alcohol-related treatment services in the general p o p u latio n (Peden, Van der Spuy, Smith, & Bautz, 2000 p.254; Parry et al" 2002a p.434).Findings from specialist substance abuse treat ment facilities also point to the increase in treat ment demand for sub stances other than alco hol.More specifically, since the start of surveil lance in 1997, the propor tion of patients reporting cannabis, white pipes, cocaine and heroin as their primary substances of abuse has increased significantly.Although these increases in de mand for drug-related treatment may be due to factors other than an in- crease in the need for treatment (such as improved public awareness of the availability of substance abuse treatment services), indicators from other studies seem to confirm that the need for drug-related treatment is increasing in Cape Town, with this region having a high rate of psychiat ric patients with drug-related disorders, a high rate of drugpositive trauma patients (Peden et al., 2000 p.254;Parry et al., 2002b p.973), a high proportion of drug-positive mortal ity cases (Lourens, 2001 pp.60-61) and a high proportion of arrestees who test positive for at least one drug (Parry et al., 2002b p.973).Despite this finding, many of the region's AOD treatment centres provide services primarily aimed at alcohol-related problems and the abuse of so called "softer" drugs, such as cannabis.The significant increase in de mand for the treatment of cannabis, white pipe, cocaine, and heroin-related problems from 1997 to 2001 however, points to the (urgent) need for AOD treatment centres to expand their treatment programmes from a primary focus on alcohol to include services aimed at cocaine, heroin, and poly-substance abuse.
Although evidence points to the great need for substance abuse intervention services in Cape Town, the local De partment of Social Services has significantly cut its fund ing to non-government organisations and state-subsided treatment facilities.In recent years, the Western Cape De partment of Health has closed a number of specialist sub stance abuse treatment centers.At present only two state specialist substance abuse treatment facilities are available to the population of the Western Cape.The number of beds in general state hospitals for patients with substance abuse problems has also been decreased.Given the high levels of substance abuse in this province, and the limited number of state facilities, responsibility for the treatment of sub stance abusers rests heavily on non-government organiza tions and the private sector (Western Cape Department of Health, 2002 p.5).Yet, the lack of minimum standards of care guiding the provision of substance abuse treatment services and gaps in current policy and legislation have allowed the substance abuse treatment industry to remain unregulated.Importantly, few treatment facilities, whether licensed or unlicensed, have conducted systematic, com prehensive evaluations of their treatment services.As a result, claims about the effectiveness and efficacy of exist ing treatment facilities in Cape Town remain unsubstanti ated.
To ensure that substance abuse services are accessible to clients from all sectors of the population, treatment serv ices planning should be informed by patterns of AOD treat ment service utilisation.Data from specialist treatment fa cilities show that since the start of surveillance, the race profile of patients has not reflected the demographics of the general population in Cape Town (Statistics South Af rica, 1998 pp.3-4).In general, there has been an under representation of Black and an over-representation of White South Africans.Instead of reflecting lower levels of sub stance abuse by Black South Africans, this pattern of treat ment service utilization probably reflects the limited avail ability of treatment services in historically disadvantaged areas; the limited accessibility of treatment facilities for his torically disadvantaged race groups due to difficulties in paying for transport to facilities located in urban centres and the inability to pay for services; linguistic difficulties in participating in English-or Afrikaans-medium pro grammes, where few programmes employ African-language speaking counsellors or translators; and the questionable cultural appropriateness of programmes developed in West ern settings for Black South Africans.Over time, significantly more male than female patients have utilised substance abuse treatment facilities in the Western Cape.Given that equal proportions of male and female cur rent drinkers reported drinking at risky levels in the South African demographic health survey of 1998 (Parry, 2001 p.441), the high prevalence of foetal alcohol syndrome in the Western Cape, and the high proportion of women who report drinking at risky levels during pregnancy (London, 2000 pp.202-203;May, Brooke, Gossage, Croxford, Adnams, Jones, Robinson & Viljoen, 2000pp. 1909-1910), it is likely that women's utilization of treatment services is reflective of gender differences in accessibility to treatment rather than gender differences in AOD abuse.Women's utiliza tion of treatment services may be hampered by the greater stigma associated with AOD-help seeking behaviour among women (Mphi, 1994 p.945), the limited accessibility of serv ices due to a lack of an independent income to pay for treatment, limited resources to arrange for independent childcare, and the lack of women-sensitive treatment pro grammes with services that focus on the special needs of women such as domestic violence and sexual assault (Booth & McLaughlin, 2000p. 1272).The steady increase in the proportion of adolescents utilis ing AOD treatment services in Cape Town since 1997 points to the need for substance abuse treatment services in Cape Town to ensure that they are able to provide age-appropri ate treatment services that cater for the special develop mental needs of young substance abusers.These are im portant points to consider in the planning of treatment pro grammes as they can impact on the treatment outcomes of adolescents (Weinberg, Rahdert, Colliver & Glantz, 1998 p. 258).Based on the above findings, a number of health and other policy recommendations can be made to help improve sub stance abuse treatment service delivery and utilisation, and ultimately address the high level of treatment demand for AOD-related problems in Cape Town.Firstly, an increase in affordable, accessible and effective substance abuse treatment services in the Western Cape is needed.Sec ondly, policy and legislation to regulate treatment facilities and the training and qualification of treatment service pro viders needs to be developed as a matter of urgency.A comprehensive audit of available services, service deliv ery, and competencies of staff delivering these services would also help identify the gaps in current treatment serv ices.It is also essential that existing treatment services are comprehensively evaluated so that the extent to which they effectively meet AOD treatment needs in the region can be established, to improve the outcomes of existing treatment facilities, and to develop models of best practice for AOD treatment in the South African context.Finally, access to treatment services by underserved groups such as women, Black patients and young people needs to be improved through targeted interventions that address the barriers that prevent clients from these groups from accessing treat-30 Curationis May 2004 ment.

Conclusion
Over time, indicators of substance abuse treatment demand for Cape Town have pointed to the need for comprehen sive and accessible substance abuse treatment services in the region.Findings from specialist treatment facilities re flect the need for treatment services to cater not only for alcohol-related problems, but also for problems related to the use of a broad range of substances.Analysis of pat terns of treatment service utilisation point to the increased use of treatment services by adolescents, while women and black South Africans remain under-represented in treat ment facilities.Future treatment service planning needs to develop age-, gender-and cuiturally-sensitive interventions that ensure that clients from these special population groups do not slip through the gaps of existing services.

Table 2 . Proportion (%) of patients in treatment in Cape Town by primary and secondary substance of abuse (1997-2001)
substance abuse, such as the abuse of alco hol and cocaine, or alcohol, cannabis and Mandrax.When the overall proportion of patients reporting a specific sub stance as a primary or secondary substance of abuse is considered, alcohol is the most common substance of abuse.The most common illicit drugs of abuse, in order of impor tance are white pipes, cannabis, cocaine, Ecstasy, and heroin (Table2).Treatment centre data also reflects the high re lapse rate among patients.Since the start of surveillance in 1997, between 30% and 33% of patients have reported re ceiving AOD treatment prior to the current treatment epi sode.