A study by the Department of Family Medicine at the University of Pretoria (UP) has found that a significant proportion of hospital inpatients in Tshwane use regulated and unregulated substances including tobacco, alcohol, cannabis and heroin (known locally as nyaope).

The study aimed to determine the prevalence and nature of substance use and treatment as well as willingness to enter harm-reduction programmes among 401 inpatients in various departments at four hospitals: Steve Biko Academic Hospital, Kalafong Hospital, Tshwane District Hospital and Mamelodi Hospital.

According to the findings, which were published in the South African Medical Journal, a third of study participants showed moderate- to high-risk substance use practices for at least one substance. About a quarter exhibited moderate- to high-risk use of tobacco and one in 10 moderate- to high-risk alcohol use; 28 showed moderate- to high-risk use of cannabis; and nine moderate- to high-risk use of opioids. 

“The hospitals predominantly serve the majority of the middle to low socio-economic segments of the population,” explained Dr Andrew Scheibe, who was part of the research team, which included Dr Tasha Gloeck, Shaun Shelley, Professor Tessa Marcus and Professor Jannie Hugo. Dr Scheibe said that people tend to have substance use disorders due to factors such as trauma, lack of basic services and socio-economic issues.

The team of researchers highlighted the need for clinicians to screen for substance use among people in hospital settings, and proposed that those with high-risk or dependent use receive evidence-based treatment while in hospital and upon being discharged.

“On leaving hospital, patients with high-risk substance use should also be offered the best available primary healthcare, including harm-reduction services like opioid substitution therapy, which is available in the City of Tshwane via the Community Oriented Substance Use Programme (COSUP), which UP leads,” said Dr Scheibe. COSUP is a partnership between UP’s Department of Family Medicine, the City of Tshwane and the respective provincial departments of social development and health. It assists substance users with counselling, safer using practices, opioid substitution therapy, and needle and syringe exchange services.

“Opioid dependence needs to be identified so people in hospital can receive treatment and support to manage withdrawal symptoms and cravings, and complete their treatment,” says Dr Scheibe. “Without access to opioid substitution therapy, those with opioid dependence are at high risk of leaving hospital before completing their treatment.”

Upon discharge, opioid substitution therapy “reduces risks of morbidity and mortality, including from overdose”, said Dr Scheibe. He added that unregulated substances, usually bought off the street, hold additional dangers. “Contamination with other substances and unknown concentration increase the risk of poisoning and overdose. Substances can be consumed through various routes, not limited to ingestion, smoking and injecting.” The relative risk of overdose and the transmission of blood-borne infections are higher through injecting than other routes. Furthermore, sufficient and accessible sterile injecting equipment is needed to prevent needle and syringe reuse and sharing of needles to reduce the risk of HIV infection and hepatitis C, he said.

While the study found higher levels of substance use among men, women who use drugs face additional challenges as they are often less visible. “Some barriers include less access to resources (including transport), limited family support, absence of childcare services, and fear that contact with the criminal justice system and social welfare services may jeopardise their custody of their children,” explained Dr Scheibe.

Among respondents with moderate- to high-risk substance use, two-fifths (43%, 55/129) thought they needed professional assistance. Three in five (60%, 78/129) expressed interest in learning about a programme to help them reduce the health risks of their substance use without abstinence as a precondition. Most participants (84%, 108/129) said they would potentially be willing to participate in a community-based substance use programme that used a harm-reduction approach.

The team of scientists said hospital staff should be adequately trained around substances, substance use screening and on the provision of brief interventions, opioid substitution therapy and referral to effective services. An assessment of hospital staff knowledge, attitudes and practices around substance use would be an important first step towards developing health worker training. “As per the Batho Pele principles [constitutionally based principles that outline how public services should be provided], all people should receive non-judgmental service,” said Dr Scheibe.