Healing the Dragon

Heroin use disorders and HIV/AIDS- intervention

Dr Monika dos SantosPhD (psych)

FOUNDATION FOR PROFESSIONAL DEVELOPMENT

HIV/AIDS - Background

PEPFAR (US President's Emergency Plan for AIDS Relief) recently warned that despite

low rates of HIV caused by sharing drug use paraphernalia on the African continent,

countries such as Kenya, Tanzania, Nigeria and South Africa, were now beginning to

report HIV infections among people

injecting drugs (Suleman, McCoy & Gray. 2009)

The Medical Research Council (MRC) and the US Center for Disease Control and

Prevention (CDC) found that injecting drug users did not know how to clean needles

and dispose of them properly.

People still share and use the same needle up to15 times. (Shisana et al., 2009)

Drug abusers are also more likely to have sex without condoms, do not

know how to access HIV/AIDS services such as antiretroviral treatment, and have poor knowledge of HIV/AIDS

transmission. (Suleman, McCoy & Gray, 2009)

In a 2003 study conducted in the Pretoria/Centurion area,

* 53% reported use of some dirty needs,

* 29.4% did not consider it necessary to use clean needles,

* while 47% stated that their reason for not using clean needles was due to a

lack of accessibility to clean needles

(Alavi, Naicker, Cassim Peer, 2003)

The growing number of intravenous drug use (IDU) in Africa also has the

potential to provide a significant contribution to the spread of HIV/AIDS on the continent, arising within the

context of an established and growing HIV/AIDS epidemic - causing havoc across a continent plagued by other

tragedies (Ball, 1999).

HIV transmission per injection is six times higher than for heterosexual acts.

IDU-driven epidemics tend to spread much more rapidly than those driven by sexual transmission (United Nations Office on Drugs and

Crime, 2005).

The prevalence of HIV/AIDS among IDUs can reach more than 50% of a given population, sometimes up to 90%

within very short periods of time. Such rapid transmission have been

observed in both industrialised and developing countries (Des Jarlais, 1999).

STUDY OBJECTIVES

* 10 heroin use disorder specialists

* Synthesised the findings with the results of a previous study undertaken by the author relating to 40 long-term voluntarily abstinent heroin dependents.

The first study - 40 long-term voluntarily abstinent heroin dependents.

The following research questions were posed:

* What are the reflections of long-term voluntarily abstinent heroin dependents on the recovery process they underwent?

* What are the biographic and socio-demographic backgrounds of the

long-term voluntarily abstinent heroin dependent participants?

Objectives of the second study

* To compare and integrate the views of long-term voluntarily abstinent heroin dependents with those of heroin use disorder specialists.

* To obtain expert opinion from heroin use disorder specialists with regard to intervention strategies that best facilitate heroin dependence recovery.

* To furnish a description of the effective and ineffective aspects of heroin use disorder intervention from the perspective of heroin use disorder specialists.

* The formulation of tentative suggestions for the advancement of heroin use disorder intervention programmes.

Method

* A mixed design

* qualitative analyses of both the in-depth case-study and specialist interviews

* quantitative analyses of data from the cross sectional survey regarding the sample profiles of the long-term

voluntarily abstinent heroin dependents

Participants and setting

Information was collected from 40 participants, 31 of whom had remained voluntarily abstinent from heroin for over a year, meeting the DSM-IV-TR criteria for Opioid Dependence Sustained Full Remission (American Psychiatric Association, 2000).

The remaining nine participants fulfilled the DSM-IV-TR criteria for Opioid Dependence Early Partial Remission (American Psychiatric Association, 2000).

Purpose sampling / interviews were conducted with 10 specialist participants in the field of heroin use disorder intervention(Babbie & Mouton, 2002).

* Specialist 1 is a director and founder of an established rehabilitation centre, and is also registered as a National

Association of Alcoholism and Drug Abuse Councillors

(NAADAC) counsellor.

* Specialist 2 is head of a university psychiatry departmentand was formerly within the Central Drug Authority forefront. The specialist possesses extensive international experience within the substance-related disorder field, having worked in Singapore, Hong Kong, Canada, Australia, the SADC region, Western and Central Africa, Thailand, the United Kingdom and the United States. The specialist is also a board member of the South African Medical Research Council and of the International Council

on Alcohol and Addictions (ICAA).

* Specialist 3 is an executive director of an organisation that specialises in substance use disorder research, advocacy and policy formulation for state departments. The specialist holds a diploma in drug and alcohol policy and intervention from the University of London, and has over seventeen years of experience within this specialised field.

* Specialist 4 is a social worker from the National Department of Social Development who has worked for over fifteen years within the substance use disorder field, specifically with heroin dependent committals for rehabilitation. The specialist is also an honorary member of Narcotics Anonymous and renders a facilitator role within Nar-Anon.

* Specialist 5 is a social worker who formerly worked for a state hospital. The specialist managed an outpatient programme for heroin dependents for five years and also worked in the United Kingdom with heroin dependents.

* Specialist 6 is a board member of ToughLove South Africa.

* Specialist 7 is a medical sister, specialising in psychiatry, who was employed within the SANCA network for seventeen years.

* Specialist 8 is also a medical sister who has been employed within the SANCA network for twelve years. The specialist has been involved in the assessment and medical intervention of heroin dependents since 1995.

* Specialist 9 is a general medical practitioner who has for the last five years, in a private practice capacity as well as at a private psychiatric hospital, practised within the field of heroin use disorder intervention. The specialist has also undergone international training with regard to buprenorphine maintenance intervention regimes.

* Specialist 10 is a clinical psychologist, also qualified and experienced as an anthropologist, who has worked in private practice for twenty-three years.

Instrument

For the purposes of the cross-sectional survey, a questionnaire was used to obtain the biographic/socio-demographic particulars of the sample, substance abuse/dependence history and interventions undertaken (psychosocial and pharmacological).

Data was obtained from the SACENDU project (MRC) for comparison purposes with the socio-demographic data of the study(Parry et al., 2005).

Semi-structured interviews

Semi-structured case-study interviews were conducted. The following initiating question was asked;

‘Describe to the fullest your process in coming “clean” from heroin.’

Semi-structured individual interviews were also conducted with the heroin use disorder specialists

The specialist participants were asked the following initiating question:

‘What interventions, both psychosocial and pharmacological /

medical, are in your opinion the most effective in treating

heroin use disorders?’

Procedure

Interviews were conducted from April 2004 -June 2005. No incentive was offered to the participants during recruitment.

The specialist interviews were conducted from March 2006 to August 2008.

Data analysis

Non-parametric statistical analyses, by use of SPSS for Windows, were performed on the cross-sectional survey data, this data related to the participants biographic, socio-demographic and drug use history.

Content analysis was utilized to analyse the case-study and specialist interview information.

DISCUSSION & FINDINGS OF 1ST STUDY

Characteristic Mean Standard Deviation

N = 40

----------------------------------------------------------------------------------------------------------------

Age (years) (16-49) 23.98 7.721

Duration of heroin dependence (years)(1-12) 2.65 2.568

Years heroin abstinent (<1-27) 2.88 4.404

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Characteristic % n

---------------------------------------------------------------------------------------------------------------------

Gender

Male 80 32 Female 20 8

Ethnicity

White 92.5 37

Black/African 7.5 3

Marital status

Married 15 6

Divorced 2.5 1

Single 82.5 33

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Characteristic % n

---------------------------------------------------------------------------------------------------------------------

Place of residence

Pretoria 77.5 31

Johannesburg 7.5 3

Cape Town 5 2 Northern Province 5 2

Mpumalanga 2.5 1

United Kingdom 2.5 1

Living arrangement

With others 87.5 35

Alone 2.5 5

Characteristic % n

---------------------------------------------------------------------------------------------------------------------

Educational status

Tertiary 35 14

Matriculation 30 12

Grade 7-11 35 14

Employment status

Full-time 50 20

Part-time 12.5 5

Unemployed 22.5 9

Scholar 15 6

Reason for unemployment

Could not find work 10 4

Heroin dependence 5 2

Family responsibilities (children) 7.5 3

Other reasons 10 4

Characteristic % n

---------------------------------------------------------------------------------------------------------------------

Ever incarceratedYes 15 6No 85 34

Frequency of heroin abuseDaily 95 38Weekly 5 2

Primary mode of heroin ingestionSmoked 37.5 15Intravenous 55 22Snorted 7.5 3

* The older the participants, the longer they had remained abstinent from heroin (χ² = 16.841; ρ = 0.001; df = 3)(supporting the maturing out hypothesis)

* Participants who had lived without family and / or friends over the last year subsequent to them being interviewed, as opposed to those who lived with others, tended to have been dependent on heroin for longer (Mann-Whitney U = 38.5; ρ = 0.041; α = < 0.05).

* Participants with a schooling of 12 or more years had ceased using heroin significantly longer than those with schooling ranging from 7-11 years (Mann-Whitney U = 120.00;

ρ = 0.055; α < 0.05).

Substitution history______________________________________________________________________________________________________________________________________________________________

Substance longer than a year heroin abstinent N = 31 less than a year heroin abstinent N = 22

% n % n

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Alcohol 45 18 40 16

Cannabis 27.5 11 32.5 13

Cocaine powder 7.5 3 15 6

Crack cocaine 7.5 3 3 12

Hallucinogens 7.5 3 15 6

Methcathinone 7.5 3 2.5 1

Inhalants 5 2 - -

Mandrax 5 2 5 2

Methamphetamine 2.5 1 15 6

Benzodiazepines 2.5 1 10 16

Methadone/Opiates 2.5 1 12.5 5

Amphetamines - - 5 2

Barbiturates - - 2 2

Sedatives - - 12.5 5

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DISCUSSION & FINDINGS OF 2ND

STUDY

HEROIN USE DISORDER & HIV/AIDS INTERVENTION WITHIN THE SOUTH AFRICAN CONTEXT

* strategic plan

* combination of social, health and law-enforcement solutions.

The following heroin use disorder intervention principles emerged from the study in terms of HIV/Aids:

* HIV testing - Are HIV testing and treatment services made available in places accessed by vulnerable people? Fear of stigma and discrimination often keep injecting heroin/drug users away from public health facilities.

* Harm reduction – Are pragmatic and evidence-based public health policies designed to reduce the harmful consequences associated with heroin/drug use and HIV/AIDS implemented ?

It is no longer acceptable to simply do what feels right.

It is the ethical responsibility of the clinical practitioner in the heroin use disorder intervention field, as in other fields (such as cancer and heart disease), to stay informed with regards to new and more effective clinical procedures.

PROHIBITION VERSUS DECRIMINALISATION / LEGALISATION

& HARM REDUCTION

Efforts at social control do not always lead to predictable consequences.

The efforts of police, doctors, pharmaceutical association and others to restrict access to needles and syringes in Edinburgh during the early 1980s, led to addicts stealing from hospital dustbins and buying injecting equipment from other users.

This restricted access was one of the reasons for needle sharing that led to such explosive growth in HIV infection and hepatitis among Scottish injectors. Surveys found that up to 65% of some samples of drug injectors were HIV positive. These HIV rates were as high as anywhere else in the world and Edinburgh became known as the AIDS capital of Europe(Gossop, 2000; Robertson, 1987).

The frightening complexity of these issues has led many to seek a solution to the problem, either by increasing aggressive enforcement and punishment or by simply legalising the whole affair.

This sort of reductionism fails to recognise that one size does not fit all. The appropriate strategy depends on current local circumstances.

When heroin use can be prevented, every effort should be made to stop the problem before it starts.

The problem is that heroin dependence is a kind of mental illness that often does not manifest itself until it is too late.

When social coherence is high, a large percentage of the population agrees with the ban and the state is powerful enough to enact effective enforcement, even highly addictive drugs can be stamped out; for example, China was able to eliminate opium and heroin use under communist rule, after hundreds of years of widespread misuse.

In more diverse and conflictual societies, however, prohibition tends to be a big joke. Despite spending $30 billion a year on fighting drugs, every major drug of abuse is readily available in most major cities in the United States. South Africa is clearly closer to the United States situation than the Chinese (Leggett, 2001; Plant,1999).

The question of any given society must be: is this strategy workable in the present circumstances (Leggett, 2001)?

People in favour of more ‘regulated’ drug markets advocate a variety of harm-reduction techniques, such as allowing dependents to obtain their heroin or methadone from a government clinic or sponsoring needle-exchange programmes (Alavi et al., 2003; Gossop, 2003).

Programmes have been piloted in Europe and have lead to mixed results even there

(Laurence, 2007).

While it is unlikely that the South African government will be offering any free drugs in the near future, as the specialist participants suggested, condom distribution represents a very real concession to the view that endorsing ‘abstinence’ is not always enough.

PRACTICE, POLICY AND FUTURE RESEARCH IMPLICATIONS

We are only in the beginning stages of determining how to produce optimal patient outcomes with an effective outlay of health care monies.

The results of the study indicate that facilities may be best served by implementing feasible treatment plans which raise the likelihood of treatment completion and which retain clients for longer periods.

Making accreditation mandatory might also result in significant benefits for clients in treatment, especially those in residential care.

The results of this study highlight the importance of collecting data / information on the individual and programme levels, as well as of employing multilevel methods to examine the effects of heroin use disorder and HIV/AIDS intervention.

He is no hero who never met the dragon,

or who, if he once saw it, declared afterwards that he saw

nothing.

Equally, only once one who has risked the fight with the

dragon

and is not overcome by it wins the hoard, the ‘treasure hard to

attain’. He alone has a genuine claim to self-confidence,

for he has faced the dark ground of his self and thereby has

gained… an inner certainty which makes him capable of

self-reliance.

Carl Gustav Jung

Study Publications• Dos Santos, M. & Van Staden, F (2008). Heroin dependence recovery. Journal of Psychology in Africa, 18(2),

327-338.

• Dos Santos, M.M.L., Rataemane, S.T., Plüddemann, A., Matthews, R.E., Sinizi, V & Benn, G.M. Heroin use disorder intervention within the South African context. New Voices in Psychology,5(1). (in press)

• Dos Santos, M. (2009). Healing the dragon: Heroin use disorder recovery and intervention. Saarbrücken: VDM Verlag Dr. Müller Aktiengesellschaft & Co. KG

• Dos Santos, M. (2009). Defeating the dragon: Heroin dependence recovery. Saarbrücken: VDM Verlag Dr. Müller Aktiengesellschaft & Co. KG

• Rataemane, S.T. & Dos Santos, M.M.L. (2009). An approach to the management of illicit substance use disorders. African Journal of Psychiatry. (In Press)

• Dos Santos, M.M.L. (2009). Heroin use disorders and HIV/AIDS – an approach to management within the South African context: A content analysis study. Substance Abuse Treatment, Prevention, and Policy. (working paper)