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Biology
Medicine offers hope for heroin users in Mitchells Plain
My first article for Groundup…
Medicine offers hope for heroin users in Mitchells Plain
But government unlikely to make it widely available
By Brendon Bosworth
24 March 2016
Shuaib Hoosain is the treatment manager at Sultan Bahu, a rehabilitation facility in Mitchells Plain. Brendon Bosworth.
After 16 years of injecting and later smoking it, Letitia Wyngaard wanted to quit heroin. Her father was ill and she needed to help take care of him. She wanted to be a mother to her two young boys, who she had alienated as she oscillated between the aggression that comes when craving the drug and being “the most lovable person ever” when she had it.
“My son said, ‘if you don’t have that white stuff you’re like a vampire. When you have that white stuff then you’re okay, mommy,’” she recalls. “I didn’t want them to live that life.”
On the advice of a friend who had turned her back on the drug that is notoriously tough to quit, Wyngaard booked into the Sultan Bahu Centre, a rehab in Mitchells Plain named after a Sufi poet. The centre is just a few streets away from where she lives.
Following a detox at Stikland Hospital’s Opioid Detoxification Unit, Wyngaard began treatment at Sultan Bahu. At the centre, a modest two-storey building with yellow walls and a sign that reads “optician” outside — a remnant of its former life as a medical centre — she started taking medication that fends off the harrowing withdrawal symptoms that come when heroin users don’t have the drug in their system.
Withdrawal is “the worst feeling ever,” explains Wyngaard. “You have back pain, you have sweats; your nose is running, your eyes are tearing. You literally can’t walk, especially when the ‘turkey’ really hits you.”
Acting on the same receptors in the brain that heroin works on, a medication called Suboxone curbed the withdrawal symptoms without giving her the heroin high. Suboxone is a combination of the medications buprenorphine and naloxone.
“The Suboxone helps you not to crave,” says Wyngaard. “It’s almost like a crutch. It takes those exit pains away.”
With her treatment keeping the pain and cravings under control, Wyngaard was able to engage with the counselling sessions at Sultan Bahu. She learned about ways to prevent relapse and methods for coping with situations that might drive her to use heroin again, as well as staying clear of people linked to her life as a heroin user. Through one-on-one sessions with the centre’s social worker she learned how to face her own issues.
“I came in with a lot of baggage,” she says. “I used to try and smoke that feeling away and all my feelings [were] coming back, so I had to deal with that.”
After taking Suboxone daily for the first three months of treatment, Wyngaard was gradually weaned off it during a further six months until she was able to stay off heroin without the medication. Almost two years later, she remains free of heroin and still comes into the centre twice a week for “aftercare” sessions, where she can discuss her feelings and any problems she might be having.
Now, expecting her third child, she speaks about her past and present with a calm resolve that underplays what must be a great inner strength.
A way out of addiction
The treatment Wyngaard underwent is called medication assisted treatment (MAT), better known in South Africa as opioid substitution therapy. It involves treating someone addicted to heroin with medications like buprenorphine, naloxone and methadone so that users can feel ‘normal’ while undergoing therapy. It is used in many countries, and when coupled with psychosocial interventions was found to be the most effective treatment option for opioid users, according to the European Monitoring Centre for Drugs and Drug Addiction.
Sultan Bahu’s programme is yielding promising results. Its current “retention rate” — the rate at which clients keep up their treatment — is 93%, says Shuaib Hoosain, the centre’s treatment manager. And 82% of clients were “drug-free” when last tested, according to Hoosain. Such high rates could be due to the Centre carefully selecting the clients for the programme and keeping them motivated, as well as doing things like follow up phone calls and house visits if clients aren’t attending.
Importantly, clients, most of whom are unemployed, are sticking to their treatment, which requires coming to the centre from 8am to 4pm daily. This means they are not on the streets looking for heroin or stealing to support their habits, reducing the harm to themselves and society.
“It costs significantly less to keep somebody on [MAT] than society would pay to have the person in prison, or [for the cost of] the damages the person would cause as a result of acquiring the drugs,” says Hoosain.
Estimates by the World Health Organisation indicate that every dollar invested in opioid dependence treatment programmes may give a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft.
High cost. Low access
Despite the successes of MAT at Sultan Bahu and its widespread use elsewhere, South Africa has not embraced this treatment option. Sultan Bahu is billed as the only rehab in the country where clients can get government-funded MAT medication free. The Western Cape’s Department of Social Development has funded the programme since its inception in 2014, the year Wyngaard booked herself in.
People dependent on heroin are a vulnerable group. They die at a rate that is between six and 20 times higher than expected for people of the same age and gender in the general population. Those who inject the drug, instead of smoking it, face the added risk of contracting HIV and other diseases from infected needles.
Hoosain says he is seeing more people who inject heroin coming into the centre. Many former tik (methamphetamine) smokers have also graduated to heroin, sometimes using both drugs together. “The guys I saw, previously, using methamphetamine back in 2007, all of them are using heroin,” he says. “And I’m not exaggerating.”
In the Western Cape, 14% of people admitted to rehabs reported using heroin as their primary drug of abuse in the first half of 2015, according to figures from the South African Community Epidemiology Network on Drug Use.
Sultan Bahu treated 84 patients in the MAT programme’s first year and 94 in the second year. But the demand for treatment far outstrips the centre’s ability to provide it, says Hoosain.
At this point, however, government is not set to beef up its funding.
The Western Cape Department of Social Development earmarked just under R2 million for the programme for the 2015/2016 financial year and is funding it for a third year, according to Sihle Ngobese, spokesperson for Albert Fritz, the province’s Minister of Social Development
But due to the costly nature of treatment the programme’s sustainability will depend on partnerships with the Department of Health and pharmaceutical companies, he says. The Department won’t be extending the programme to other rehabs either due to budget constraints.
Outside Sultan Bahu and private rehabs, heroin users can get MAT therapy at Stikland Hospital and Groote Schuur Hospital, but need to pay for the medication themselves, sourcing it from private pharmacies. With the high cost of Suboxone, treatment can be out of reach especially for those who are unemployed.
It costs about R125 for a seven-pack of 2mg Suboxone tablets. For a pack of stronger 8mg tablets it’s about R500. With treatment running for between three and six months, and in many cases longer, costs quickly rack up.
The steep price tag means the MAT clinic at Stikland often has to prescribe lower doses of medication. But skimping on medication means an increased chance that people in treatment will use heroin while undergoing MAT instead of staying clean.
“The worry [with] under medicating patients using too low doses is that they still have breakthrough slips on heroin. The higher the dose the better they can stay clean but the more expensive it becomes,” says psychiatrist Lize Weich, coordinator of addiction services at Stikland Hospital.
“We often end up under-prescribing because that’s all that people can afford. But under-prescribing is already better than no prescribing when we think about retaining patients,” she says.
“What’s worse?” says Weich. “Using 12 bags of heroin a day, or using one twice a week and coming back and seeing the doctor and working on what were the triggers, high risk situations, and how can I manage my life differently so that I don’t use that once or twice?”
Stikland and Groote Schuur are the only two facilities nationally to offer MAT treatment like this, and the Department of Health can’t expand the service due to the current financial state of the country, says Bianca Carls, spokesperson for the Western Cape Department of Health.
“These medications are exceptionally expensive and when compared to medicines required for ailments such as HIV/AIDS and chronic [health conditions], it is the duty of the Department to prioritise which medications are essential for our patients,” she says. Importantly, though, methadone and buprenorphine are listed as essential medicines by the World Health Organisation.
For those who get into Sultan Bahu’s MAT programme the cost of medication is not a problem. And for people like Wyngaard the programme has proved to be a life-changer. Whether or not more heroin users have a chance to follow the same path remains in the hands of government.
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‘Normal’ screens at SA Recovery Fest
The short film Simon Taylor and I produced, ‘Normal’ screened at the SA Recovery Festival in September. The film is a 16-minute documentary that gives a window into the work of psychiatrist John Parker, who I wrote about for the ‘City Desired‘ exhibition. It includes Mykyle, one of Parker’s patients who is in recovery.
The film shows how John and Mykyle are both outsiders. One is a doctor who works in a
community very different to his own. The other is unfairly placed outside of what society considers ‘normal’ due to the stigma around mental illness. It shows the value each of them brings to the
world and takes an honest look at the subject of mental illness, something that afflicts as many as one in three adult South Africans in their lifetimes.
Simon and I were pleased to see how many people came to watch the film. After the screening, we had an engaging question-and-answer session that highlighted the importance of understanding mental illness and how it impacts our society. We came away motivated to work on our next project, a longer film we are developing.
Jozi
Growing up in Cape Town I seldom heard a good word about Joburg. The city was commonly denigrated for not having a coastline and for being a hotbed for hijacking, murder and robbery.
But lately I’ve also heard good things. Particularly, how welcoming people are, unlike the insular Cape Town set.
At times I’ve flitted with moving to Joburg and trying to seek my fortune among the rest of the people hustling in the city space. Through work and travel I’ve become increasingly attracted to world cities and the urge to know Joburg has grown ever stronger.
Today was the fourth of a five-day trip to the city of gold. A break from Cape Town, a chance to watch Bruce Springsteen rocking the FNB stadium, and a chance to explore the city spaces. Newtown, Braamfontein and the rest. It was also an opportunity to get robbed.
I pulled up to a red light in Newtown at about noon, window rolled halfway down, driving alone, on my way back from Museum Africa. Out the corner of my eye I saw two guys at the window. “I don’t want to hurt you,” said one. “But give it.”
The second guy was standing right behind him. I’m still not sure if they were holding weapons. Could have been since the guy in front seemed to be holding something under his shirt. Automatically, I reached for my wallet and handed it to them. That wasn’t enough. They also wanted my phone, which I handed over, meek as a lamb.
After parting with my valuables I pulled off, and immediately began beating myself up for not checking to see if they had weapons, and for not just dropping the car into first and pulling away before they could rob me. I could have been a lot tougher about the whole thing. Not an easy victim.
The rest of the day was consumed by an unmemorable wash of admin: cancelling bankcards, getting my sim card blocked, changing passwords for email and twitter.
Jozi screwed me today. Part of me wants to write the city off and not give it another chance. But that would be shortsighted. I have the feeling I’ll be back, hopefully a little more streetwise. And since I met someone minutes after he’d been stabbed during a mugging on the path up to the car park from Sandy Bay in Cape Town last Wednesday, I can’t say I feel much safer in the mother city either.
False Bay
View from above Muizenberg, Cape Town.
From Toilet to Tap for Water Scarce City
(My third and final article on the Umgeni River for Inter Press Service).
KWAZULU-NATAL, South Africa, Oct 1 2013 (IPS) – In a few years, residents of the eThekwini municipality in the port city of Durban in South Africa could be drinking water that was once flushed down their toilets, as authorities are planning to recycle some of the municipality’s sewage and purify it to drinking quality standards.
“We’re going through a crucial water shortage, which is increased by the water demand of eThekwini,” Speedy Moodliar, the municipality’s senior manager of planning for water and sanitation, told IPS.
The municipality relies on the Umgeni river system for water. But demand on the system, which supplies drinking water to about five million people and fuels industry in the economic hubs of Durban and Pietermaritzburg, a town 66 kilometres from the coast, has outstripped supply for the past seven years.
To boost supply in future, the South African government has proposed building a dam with a capacity of 250 million cubic metres on the uMkhomazi river, the third-largest river in KwaZulu-Natal, and transferring water to the Umgeni system.
But this scheme will only be operational by 2024 at the earliest, said Moodliar. “Between now and when the uMkhomazi [project] comes online, [wastewater] re-use will be our mitigation measure.”
In dry countries like Israel, Egypt, and Australia treated wastewater is used for industry, landscaping and agriculture. But worldwide few countries put it directly into their drinking water supplies.
Singapore uses purified wastewater to meet 30 percent of its water needs, although just a small percentage goes to drinking water and the majority is used by industry. Citizens of Windhoek, the capital of South Africa’s arid northwestern neighbour Namibia, have been drinking recycled wastewater for over 40 years.
In 2011 the Beaufort West municipality, which serves close to 50,000 people, began treating its sewage for use as drinking water after a vicious drought, making it the first in South Africa to do so. According to a 2012 World Bank report “The future of water in African cities: why waste water?” few cities in Africa have functioning wastewater treatment plants and “only a small proportion of wastewater is collected, and an even smaller fraction is treated.”
eThekwini municipality plans to upgrade two of its existing, and underperforming, wastewater treatment plants – the KwaMashu and Northern treatment works, Moodliar explained.
To remove contaminants and clean the water to drinking quality standard, a three-stage system that treats effluent through ultra-filtration and reverse osmosis, as well as disinfection by ultraviolet light and chlorine would be used. The treated water would also be stored and tested before being released.
The purified water will be mixed with conventional drinking water at a ratio of 30 percent re-used water to 70 percent conventional, said Moodliar. It will feed the municipality’s northern regions, including Umhlanga, Durban North, Reservoir Hills, and KwaMashu.
Re-using wastewater in this way will add 116 megalitres of tap water to the municipality’s supply daily. This is enough to fill just more than 46 Olympic-size swimming pools. It is roughly 13 percent of the municipality’s current daily consumption, and will provide an estimated seven years of water security.
Read the full article at Inter Press Service.
Swale of a time at Platbos Forest
I learned a new word recently. Swale: a ditch on a contour which catches run-off. As an assistant team leader at Greenpop’s Reforest Festival over the weekend one of my job’s included inspecting swales to make sure they were up to scratch. I might also have been responsible for some very poor jokes (“swale of a time,” “swale watching,” “who supports swaling?”) but I’m kind of a geek when it comes to new words.
The festivalgoers planted 3,000 trees at Platbos Forest, which is the southernmost indigenous forest on the continent, on Saturday. We dug holes, shaped swales, and got our hands dirty. The new trees will help stave off the threat of encroaching alien vegetation and keep the forest growing strong.
I was glad to be part of it.
Would a legal trade in rhino horn curb poaching?
In the face of rampant rhino poaching in South Africa, some conservationists and private rhino farmers are lobbying for removal of the international ban on rhino horn trading and the creation of a legal market to quell poaching.
My latest article for Inter Press Service News delves into the arguments for and against creating a legal trade.
Here’s an excerpt:
The trade ban is creating a situation where rhinos are being killed unnecessarily,” Duan Biggs, research fellow at the Centre of Excellence for Environmental Decisions at Australia’s University of Queensland, told IPS. “It’s taking resources away from other conservation efforts, and is leading to the situation where there’s a pseudo war taking place in the Kruger National Park.”
The South African government is exploring this option and could make a proposal at the 2016 Convention on Trade in Endangered Species of Wild Fauna and Flora (CITES) to allow it to open up rhino horn sales. That would require support from a two-thirds majority of the 178 member states.
Proposals to lift the ban, which has been in place since 1977, have sparked debate about whether a legal market would actually curb poaching. Opponents worry that it would stimulate the black market trade that exists in parts of Asia, where rhino horn sells for 65,000 dollars a kilogramme – more than gold or cocaine – and is touted as a cure for hangovers and an aphrodisiac in countries like Vietnam.
But advocates say it would be the solution to the poaching crisis.
Full article at IPS News and also republished at The Guardian.
Buzz of the undead
Check out my new post at High Country News about how the phorid fly “zombifies” and kills honeybees.
Here’s an excerpt:
“If you were a honeybee, you might scare your children into obedience with tales of the phorid fly, a creature whose depravity sinks to deep depths. Picture this: you’re going about your business, pollinating flowers and the like, when one of these devils swoops in, clamps down on your abdomen and, using a spiked injector called an ovipositor, injects its eggs inside you. Within a few days, maggots hatch from the eggs and start eating your guts, disemboweling you from the inside. Obviously, this is enough to drive anyone demented. As the torture reaches its pinnacle you flee the hive, crazed and confused, and never return. You die a desperate death, vainly spinning in ridiculous circles, under the cold beam of a light that you are inexplicably attracted to. With little respect for your corpse, about a week later as many as 13 phorid fly larvae wiggle their way out of your decaying body, ready to begin the cycle anew by infecting some of your friends.”
Image: A female phorid fly (Apocephalus borealis) courtesy Brian V. Brown.
California Dreaming
An evening sky on fire along Highway 1, somewhere north of San Francisco, where the Colorado cold is just a distant memory. (Photo/Faith Bosworth).
Today we ran a collection of photos at The Boulder Stand under the header “What is Winter?” This shot, from my sister Faith, was taken on a road trip last November through California. We were heading south to San Francisco along Highway 1 and the liquid sky just could not be ignored.
To see the full collection check out “Photo Round-up: What is Winter?” at The Boulder Stand.
Brendon Bosworth 
