Over the past few years there has been a steady increase in harmful drug use in the city of Tshwane. Doctors, clinical associates and social workers from the University of Pretoria (UP) realised that there is a major shortage of services in the city to help people who use drugs. This led UP’s Department of Family Medicine and the City of Tshwane to come together to create a safer healthier city. Research shows that existing drug related programmes, such as rehabilitation and going “cold turkey” have little positive effect. In fact, they often create more damage by further isolating people who use drugs and accentuate the social stigma. Research also shows that while there is a lot of harmful drug use in the city, substance use is often a coping strategy for underlying problems in the home and community.

The Community Orientated Substance Use Programme, or COSUP is an initiative between University of Pretoria's Department of Family Medicine, the City of Tshwane (who funds the programme), and the Gauteng Government (the Department of Health and the Department of Social Development). It aims to provide meaningful and effective community based support for the people who use, support or are affected by harmful substance use. It focuses on evidenced based approaches to restoring functionality, improving health and reducing the social destruction of harmful substance use.

In COSUP, harmful substance use is regarded as a medical condition rather than as a criminal activity. Rather than forcing people to stop using drugs, it works closely with users to find out what their goals are and what they need to do to achieve them. Where users do not want to stop taking substances, COSUP helps them to access health services and support from their clinics. COSUP pays particular attention to both informing and responding to users’ high risk of contracting HIV, TB and Hepatitis C. Sister Linda Makala, based at the COSUP sites in Mamelodi, says harm reduction and safer use of drugs is a fundamental teaching and practice of COSUP. Makala even teaches users how to tie their injection site is in a way that is less damaging to the veins. The Needle Syringe Programme (NSP) offers new clean needles in exchange for dirty ones. “The evidence that a NSP is effective is there and COSUP is showing that it can be implemented in a South African context,” says the Head of Department of Family Medicine, Prof Jannie Hugo. Opioid substance therapy (OST) is prescribed by the COSUP medical team to people who want to get off heroine. Results from both NSP and OST are proving effective.

Taking a harm reduction approach to substance use may seem controversial, but in fact, it is consistent with centuries’ old health care practice that in present day South Africa has led to the successes in HIV/AIDS management.

COSUP is part of a larger Community Orientated Primary Care approach to integrated district health. Through the combination of public health and clinical care, COPC is designed to provide generalist primary care that extends from a community based tier of service rendered by clinically supervised community health workers to people in their homes and facility services to health care facilities and services. Social workers and Clinical Associates play a pivotal role in the COSUP team of experts. They work through each person’s unique background and help them deal with the issues that are often the cause of their drug problem. The peer support component of the programme is also critical in keeping the individual in the programme. Peers are people who come from similar backgrounds whose lives have improved (as a result of the programme). Peers provide support and assistance and make sure individuals are on track to achieve their goals. Peers are a fundamental asset to the programme as the individual sees them as relatable and trustworthy. Peers stand as a beacon of hope for the person wanting a better life. The skills development component equips people with skills to be able to find a job and this has shown that often people will stop using drugs when their lives improve.

COSUP is a first-of-its-kind programme in the world and it is making incredible strides to ensure a safer and healthier city for all. This programme works because it is relevant and non-judgemental. It sees people who use drugs as human beings and helps them feel worthy again.

Dr Lorinda Kroukamp, Public Health Specialist in the Department of Family Medicine and Project Manager of COSUP, says that for sustainability of the initiative beyond the project’s period, the community based approach to harmful substance abuse needs to be integrated into the existing primary health care model. In order for a sustainable project to flourish that provides real support to people in need, collaboration between all sectors of primary health care needs to ensue.

A way out of the dark world of drugs

When you are unsure if you will survive the week, finding relief in heroin is worth the risks of overdose and arrest. Described by one user as “lying in the arms of your mother and lover at the same time,” heroin is often used as a result of exclusion and psychosocial dislocation. The user finds great comfort and even identity in using drugs, even finding a sense of belonging among their fellow drug users.

Heroin is one of the most addictive substances on earth. It is an analgesic, meaning it reduces both physical and psychological pain. Even if temporarily, the effects of heroin become very attractive to people living in difficult or painful circumstances, giving them a sense of well-being.

Heroin is an opiate drug that suppresses some of the functions of the central nervous system, such as heart rate, blood pressure, respiration and temperature regulation. It also binds to opioid receptors, increasing chemicals in the brain that are responsible for feelings of pleasure. When heroin is abused, a rush of pleasure occurs, and when it is removed, the opposite effect happens.

If the user does not get this daily stimulation, their body will go into withdrawal, which includes extreme physical and mental symptoms. These withdrawal effects are so severe, one user described them as being worse than death. Some of these symptoms include restlessness, excruciating aches and pains in the bones, muscular spasms, diarrhoea, vomiting and severe discomfort, as well as depression and nervousness. Long term use of heroin also affects the endocrine system. As the use of heroin increases, so does the withdrawal effects, requiring the amount of heroine to increase to keep these effects at bay. Invariably, people who are addicted stop using heroin to get high, but rather just to prevent these horrible effects.

Opioid substitution therapy (OST) is a practical way of helping people normalise their lives. Extensive research shows OST is an exceptionally effective way of reducing the risks and impacts of the illicit use of heroin, significantly improving quality of life. Shaun Shelly, researcher in COSUP, says mortality is reduced by up to 75%, and new HIV infections are reduced by up to 55%. OSTs are a heroin alternative that has similar effects, attaching to receptors in the brain. Methadone, a type of OST, is commonly used to substitute heroin and is a prescribed medicine that alleviates the withdrawal effects and cravings, without giving the person a “high” like heroin. Bodily functions are able to return to normal.

OSTs usually only need to be administered once a day by a medical professional. Patients can be on this treatment for as long as they need to be. OST is made available in the city of Tshwane through COSUP, however, the programme firmly believes OST should be made available at a primary health care level as part of a comprehensive care programme. Further, if South Africa is truly committed to effectively managing HIV, TB and Hepatitis C, the reduction of harmful substance use through practical effective ways like OST is critical.

Drug intervention that works and makes you feel human again

Intervention is practical and measurable. The process is individualised, mindful that each person that enters the programme has a different story. COSUP ensures that a clear path is set for the patient to follow, with attainable goals that won’t overwhelm the patient. Fundamental to the intervention process is to empower and inform each person that uses harmful substances.

Assessment comprises several sessions conducted by a trained staff member of COSUP. Sister Linda Makala is integral in Mamelodi’s COSUP sites, knowing that every person’s story is unique and it is imperative that the purpose of the assessment is to better understand the type and extent of the substance use. By understanding the psycho-social issues and family dynamics (or lack thereof) that are specific to the individual, COSUP staff is able to determine an action path to take. Assessment also looks at the possibilities of illnesses that have gone undiagnosed. Dependent on the results from the assessment, COSUP staff is able to bring the individual to a point where they can identify their goals, whether it be to change their current using patterns completely, or to just use drugs in a healthier safer way. All medical assessments are conducted by qualified doctors or clinical associates. Treatments such as Opioid Substitution Therapy (OSTs) are also administered by the medical staff of the COSUP team. Makala says it is imperative not to judge these people: “Our job is to heal these people and uplift the broken.”

In addition to the medical assessments, individual counselling, group work, and skills development are just some of the other components in this successful programme. Prof Jannie Hugo stresses the crucial role of the social worker in an individual’s journey, “Medical personnel can give someone the medicines they need for their drug addiction and HIV, but the social issues need to be addressed if you really want to help the person get out of their situations.”

Based on the assessments, the type and extent of each service will be determined. Specialists involved in the necessary counselling could include a trauma specialist, a pastoral counsellor, a psychologist, a social worker or specialist lay-counsellor.

Group sessions where individuals become aware of their levels and reasons for substance use have also proven to add benefit to the individual. These sessions help people start making conscious choices around their substance use, rather than just doing something out of habit. Group sessions empower individuals to become more aware of their own health and the decisions they need to make to achieve the goals they have set for themselves.

Skills development groups comprise 24 sessions per individual and are designed to give the individual the resources and skills necessary to attain their goals. Other groups available also deal with identity, life skills and purpose. It helps the individual create a structure that facilitates the attainment of their goals. Important topics such as managing life and money, stress management, emotional triggers and recreational activities are addressed. Relational needs, personal strengths, mental health and responsibilities are also covered.

People like Sister Makala that work in COSUP have gained the trust of users and their families who realise the value and life changing experience COSUP can bring to their lives. COSUP helps individuals slowly move away from a harmful life by getting off of drugs, while working on a plan for their lives after drugs. The programme equips each individual with the tools needed to make peace with their past, re-build relationships that are healthy and find their purpose in life.

The successes of COSUP

There is a strong sense of achievement and positivity as you walk through the corridors of Sediba Hope Community Clinic in Bosman street, Tshwane. Interacting with people involved in COSUP makes one realise that most of these young people have not had many opportunities in life and many have grown up in very difficult circumstances. Yet, these people, many of whom were on death’s door not so long ago, are hopeful and triumphant, and on track to a new life.