This week the Global State of Harm Reduction report by Harm Reduction International cited South Africa as having become one of the world’s largest methamphetamine markets. (Photo by Thomas Banneyer/picture alliance via Getty Images)
To get a handle on South Africa’s burgeoning drug problem, policymakers need to adopt a decriminalisation and harm reduction approach — or watch drug use spiral out of control to overwhelm already thin mental health and rehabilitation services.
A doctor, an activist and the national coordinator of South African National Council on Alcoholism and Drug Dependence (Sanca) said methamphetamine and heroin are streaming into the country, finding a large, willing market in deprived areas where people are eager to escape a grim and seemingly hopeless daily reality.
Sanca coordinator Adri Vermeulen said that “rehabilitating and returning people into these toxic social environments is a never-ending vicious cycle”.
This week the Global State of Harm Reduction report by Harm Reduction International cited South Africa as having become one of the world’s largest methamphetamine markets. The report states that there are also “significant” methamphetamine markets in Botswana, eSwatini, Kenya, Lesotho, Malawi, Mozambique, Uganda, Zambia and Zimbabwe.
Doctors working at urban hospital accident and emergency units in South Africa also said that drug-using psychotic patients routinely disrupt weekend shifts.
“They can get crystal meth at any spaza shop,” said Dr Amitabh Mitra, who until May this year was clinical head of the accident and emergency unit at Cecilia Makiwane Hospital in Mdantsane, East London. “Even some of my nurses were addicted. When I asked where they got it from, they said at the gates of the hospital.
“We see up to seven or eight psychotic or near-psychotic sleep-deprived patients most weekends and it’s become worse over the last two years. It’s highly disruptive. They break and throw things and we have to draw blood, take urine samples, and keep them under observation for 48 hours. As soon as they’re well again, they tend to self-discharge, but are back the next day.”
Mitra said a major problem is that there are no specific national or provincial treatment protocols, creating tension between the resident psychiatrist (where one is available) and emergency physicians about who is responsible for these patients.
Dr Andrew Scheibe, a public health researcher and harm reduction activist in the department of family medicine at the University of Pretoria, said the heroin-based opioids nyaope and wonga are narcotics that ease physical and emotional pain, metabolising into morphine in the body, while methamphetamine, as found in crystal meth or tik, is a stimulant.
The report says both drugs are on the increase, with mainly Nigerian distributors bringing in large consignments, replacing widespread local manufacturing methamphetamine plants. Schiebe said there is growing evidence that most meth consignments are now coming in pre-manufactured from South Asia through Nigeria
Shaun Shelly, the founder and a board member of the South African Network for People Who Use Drugs and a policy adviser for TB/HIV care, said methamphetamine was initially produced in Cape Town by Chinese syndicates to part-pay for poached abalone. These sophisticated labs produced large volumes of high-quality methamphetamine.
“Over the last few years, we’ve seen a major expansion of the meth market in SA. It’s really cheap here. You can pay up to £100 for a gram in the UK, whereas here it costs as little as R100 for a gram. The price has been stable and dropping for a while as SA turned from a producer market to a consumer market.”
Vermeulen said the Sanca staff members work with families and try to provide medical services, linking users to resources, “but in the last few years severe problems have spread rapidly across our 31 clinics, overwhelming them”.
“Two years ago, our provincial reports showed that crystal meth and mental health problems were picking up everywhere. I’d say it’s now an epidemic, especially in certain communities like Lavender Hill in Cape Town and other vulnerable areas. It began in Cape Town but it’s now just exploding in other parts of the country. We have to start thinking about where the chemicals are coming from to produce this stuff — obviously, there are major suppliers.”
She said that Sanca admission rates used to be highest for alcohol, followed by cannabis, crystal meth, heroin and other opiates. But this had been “turned on its head”, with cannabis and crystal meth now the number one and two most favoured drugs, followed by alcohol and opiates.
“The co-dependency is also extreme. We’re seeing psychosis like never before.”
Vermeulen said Sanca, although abstinence based, was open to a mixed approach of abstinence and opioid substitution drug treatment tailored for each user.
“If I could wave a magic wand, I’d point it at changing societal views and the stigma on addiction. I’d teach every household that addiction is a mental health condition. People see it as the person being bad, weak-willed, or unmotivated. They don’t understand that it affects the functioning of the brain.
“We need to look at why we use drugs. It’s because we’re not well ourselves. What are we treating by using a drug? It’s a symptom of something far larger — and unless we address the roots of the problem, we’ll never win.”
Vermeulen said Sanca took people out of toxic, dysfunctional environments, treated them and then returned them to those environments. “But it’s like a sick fish; if you don’t treat the water that the fish lives in, you have a problem.”
Scheibe and Shelly said South Africa’s policies, laws and criminal justice system was “way out of touch” with the benefits of a harm reduction approach, preferring a punitive, stigmatising “war on drugs” market-fuelling approach that, if maintained, would aggravate the situation.
“Harm reduction is critically important because it keeps people alive — world-wide it reduces all-cause mortality and injecting frequency, and by doing so decreases the risk of HIV and viral hepatitis C,” said Scheibe.
The two said viewing drugs as the problem is counterproductive.
Scheibe added: “The reality is our world is a difficult and complex place to navigate. In SA there’s lots of hopelessness, a lack of opportunity, poverty and a loss of confidence in the state. A substance addresses peoples’ need for a range of things — enjoyment, escapism, to manage trauma or help people work.
“The substance is not inherently the problem. These drugs can do good for a lot of people and most use them without harm to family or society. The harms come from the criminalisation of drugs and those who use them. In terms of potential harm, methamphetamine has a lower potential risk for society than alcohol and tobacco.
He said many of the harms were related to South Africa’s failure to have an evidence-based response and could be reduced through accurate information and the managed purity of substances.
“Instead, we believe the myth that drugs are evil and criminalise them and their users. We must move towards the legal regulation of drugs. It’s a significant mind-shift.”
He said usage and the market for drugs were growing because it has been criminalised, “which suits people engaged in large scale organised crime”.
Shelly said: “A major issue is the emphasis on abstinence — people who use drugs are never taught how to use drugs — psychosis in meth users is highly dependent on dose and drug combinations.
“SA has a huge system of incarceration and recidivism, cycling people in and out of jail, which is a school for gangsters. It creates a massive market, which transnational criminal organisations exploit. Subsistence dealers are not transnational criminals; the guys who bring drugs into the townships are sitting in Sandton and gated estates all over the country and remain unaffected.”
Scheibe said that heroin (whoonga, unga and nyaope) is injected by a minority of drug users but, like methamphetamine, it is increasing.
The World Health Organisation’s recommended treatment for opioid dependence is opioid substitution maintenance therapy, using methadone or buprenorphine. But because it is expensive, such opioid substitution therapy is not available in the public sector.
“We urgently need to get this in at primary healthcare care level,” he said.
Scheibe added that for the estimated 82 500 people who inject drugs in South Africa, clean needle and syringe services are provided in only nine of the country’s 56 health districts situated in all the main centres, except for Bloemfontein and East London.
“Overall, we’re not at the level we need to be to control the public health impact this has on HIV and hepatitis C,” he said.
Harm reduction services needed to at least double, while opioid substitution maintenance therapy coverage had to increase “by at least ten-fold” to meet the Joint United Nations Programme on HIV/AIDS’ (UNAIDS) 2025 target of providing opioid substitution services to at least half of the people with opioid dependency.
“By 2030 every person who injects drugs needs to get 300 clean injecting sets a year, according to UNAIDS,” Scheibe quoted.
The Global State of Harm Reduction Report, 2022, was released on Tuesday. It tracks the availability of services, including drug consumption rooms (also known as overdose prevention centres or supervised injection facilities), needle and syringe programmes, and opioid substitution therapy such as methadone and buprenorphine — all of which have increased world-wide since 2020.
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