HUMAN AND SOCIAL DYNAMICS (HSD) RESEARCH SEMINAR SERIES
Substance Abuse, Harm Prevention and Harm Reduction: Setting a Research Agenda
PARTNERS: Department of Science and Technology (DST), the Human Sciences Research Council (HSRC) and the University of Cape Town
PURPOSE OF THE HUMAN AND SOCIAL DYNAMICS RESEARCH SEMINARS
The Department of Science and Technology (DST) Human and Social Dynamics (HSD) Research Seminar Series aims to:
- Disseminate scientific research findings and transmit a body of new knowledge through an interactive process of critical dialogue and collegial critique to the social sciences and humanities (SSH) research community and other interested actors in the National System of Innovation (NSI);
- Provide an avenue for rated and other researchers, including researchers from rural-based universities to engage in knowledge dialogues across faculties and with other interested actors in the NSI;
- Present and discuss new and ongoing research, identify research gaps, and suggest new research agendas in SSH with a view to forging closer links between the research communities in these fields;
- Reinforce the visibility of SSH research to the higher education and science council sector;
- Enhance wider public understanding of the SSH, including the value and status of both individual and team-based research; and
- Strategically promote, develop, and coordinate collaborative and interdisciplinary research within and between higher education institutions and science councils.
BACKGROUND TO THE SEMINAR
On 12 May 2014, a workshop took place in Pretoria, South Africa, which focused on substance abuse, harm reduction and harm prevention. The workshop – a joint initiative by the DST and the HSRC – brought together various stakeholders across sectors and civil society. Invitations were extended to the Department of Health (DOH); Central Drug Authority (CDA); South African Revenue Services (SARS); Department of Social Development (DSD); Justice, Crime Prevention and Security; the National Youth Development Agency; South African Police Services (SAPS); the Medicines Control Council; representatives from the South African Community Epidemiology Network on Drug use (which included academics and scientists); and the World Health Organization, South Africa (WHO-SA).
The workshop was very well attended and at the right time. A large majority of the stakeholders expressed concern that South Africa has only just begun to address the issue of substance abuse prevention by imposing, for example, sin tax on alcoholic beverages and has to now deliberate on the issue of harm reduction strategies. In addition, the workshop also revealed that we have fairly adequate knowledge of the direct and indirect impacts of alcohol and freely available illicit drugs, such as mandrax and cocaine, but we have inadequate knowledge about the vast array of other licit and illicit drugs, such as indigenous ones like ‘nyaope’ and prescription drugs.
Given the above scenario, DST and the HSRC made a joint decision to maintain the momentum of interest and concern around substance abuse and harm prevention and therefore need to have a follow-up seminar to formulate a research agenda. The purpose of the event would be to conduct a national epidemiological survey every three to four years to establish the prevalence of the various forms of substance use and abuse of licit and illicit drugs at all ages and life stages over time (longitudinally). Reliable, representative data will enable all stake-holders and sectors to tackle the problem, using an evidence-based approach. The proposed seminar is being considered as the platform to launch the research agenda on substance abuse.
THE SEMINAR IN CONTEXT
Substance abuse in South Africa
The scourge of substance abuse
The Prevention of and Treatment for Substance Abuse Act has been passed and the government has approved a National Drug Master Plan for 2013/2017 that is being implemented to reduce the demand for and supply of abused substances, and to reduce the harm caused by substance abuse (National Drug Master Plan, 2012).
The South African government recognise the central role that the abuse of alcohol and drugs play in crime, unemployment, road traffic accidents and other social pathologies (Lightowlers, 2011). The illicit drug trade is linked to international organised crime, terrorism, human trafficking, money laundering and the illicit arms trade (Parry et al., 2006; SAPS, 2013).
Substance abuse has been implicated in disrupting family functioning and social cohesion and is a predictor of a range of traffic and violence related injuries, domestic violence, gang violence, robbery and assault (Affinnih et al, 2005; National Drug Master Plan, 2012; WHO, 2014). Effects are evident amongst vehicle occupants, pedestrian road users, as well as victims and perpetrators of interpersonal violence.
Research on this scourge of substance abuse is fairly conclusive. SAPS data shows a 123% increase in drug-related crimes since 2003/4; and driving under the influence of alcohol increased by 148% (SAPS, 2013). The national injury mortality surveillance system on post-mortem investigations found that 54% of violence-related deaths and 52% of transport-related deaths were alcohol-related. A study at five trauma units in Cape Town, Durban and Port Elizabeth found that one-third of patients were tested positive for cannabis; 15% for metaxalone; and 14% for white pipe (combination of cannabis and metaxalone) (Parry et al, 2004; Parry et al, 2005). Violence is strongly related to use of substances (67% alcohol; 45% illicit drugs; 84% at least one substance; 40% cannabis; 17% white pipe) and a similar trend exists for transport (42% alcohol; 36% illicit drugs; 67% any substance; 31% cannabis; 10% white pipe).
For specific external causes of violent death, alcohol and drugs are frequently associated with instances of the use of sharp objects, blunt objects and firearms. In traffic-related deaths, positive testing for alcohol and/or drugs is also common for pedestrians, drivers and to a lesser extent, passengers. These trends reflect US findings, where 92% of perpetrators of intimate partner violence admitted to using drugs or alcohol prior to the assault; 67% had used a combination of cocaine and alcohol; and 45% of reckless drivers were found to be positive for dagga, and 25% for cocaine (WHO, 2009). More than ten million adolescents and adults have admitted to driving under the influence of illicit drugs. The estimated direct cost of licit and illicit drug use in the US in 2007 was $US193-billion, while the indirect cost in lost productivity, healthcare expenses, law enforcement and criminal justice costs amounted to US$223-billion dollars (Executive Office of the President, 2012).
The effects of illicit drugs on injury depend on drug type, dosage and demographics. Amphetamines and cocaine are associated with violence; opiates with illegal opiate procurement and sex work; cannabis affects concentration and reaction times. Withdrawal symptoms occur in the case of alcohol, meth and meth amphetamines, benzodiazepine and cocaine. A range of system influences exist at a family level (parental use of drugs, exposure to violence) or at other social levels (drug availability and dealing, nightlife environment, exposure, the culture of using drugs and neighbourhood depravation) or at the individual level (age, psychiatric factors, history of victimisation, social functionality) (Dunlap et al, 2010; WHO, 2012).
Substance abuse and risk of disease onset
Alcohol, tobacco, a poor diet and lack of physical exercise are key modifiable and preventable risk behaviours associated with non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, diabetes, mental illness and chronic respiratory diseases (Marrero et al, 2012; Saxenian, 2013). A relationship exists, for example, between volume of alcohol consumed per day and relative risk of hypertension. Similar patterns exist for tobacco use where there is evidence to show that smoking is a key risk factor for a range of cardiovascular, respiratory and other diseases, and cessation of tobacco use is associated with significant improvements in health (Stephen et al, 2013).
Alcohol drinkers have a 77% higher risk of HIV infection than their non-drinker counterparts and a three-fold higher risk of TB infection exists for people who drink more than 40g of alcohol per day or who have an alcohol use disorder (Baliunas, 2010; Schneider, et al, 2014). Additionally, a greater chance of non-adherence to medication exists amongst individuals who use or are dependent on alcohol and a worse prognosis and more rapid disease progression is likelier (Rehm et al, 2010; Naidoo et al, 2013). People with TB who drink heavily have higher relapse rates than people with TB who do not drink alcohol at all (Rehm et al, 2009; Peltzer et al, 2012). Cardiovascular diseases, mental illness and chronic respiratory conditions are associated with the use of cocaine and a range of other substances and the injecting of illicit drugs and sharing of needles is commonly associated with infection with HIV and TB.
Implications of what we know about substance abuse
In South Africa we have a fairly good knowledge about the negative effects of substance abuse and have consequently been able to intervene at various levels to reduce these effects for the more commonly known licit and illicit drugs that are consumed. Interventions have taken many forms, including economic reforms such as imposing “sin” tax on alcohol; community-level monitoring and policing; work-place interventions; and individual level rehabilitation programmes.
We know, for example, that alcohol is a significant predictor of poor health outcomes and reduced quality of life. Recognizing the disastrous direct and indirect effects of alcohol on individual health, the health of others, and the public health care system, the minister of the National Department of Health in SA is not only keen to restrict the sale of alcohol to selected hours, he is also motivating for a ban on alcohol advertising.
While many substance abuse reduction interventions work well, we do not have sufficient evidence that these interventions are both effective and efficient. Developing a research agenda for the purpose of not only proving that interventions are effective, but that interventions can be scaled up for population level effect, proving efficiency, becomes critical.
Do we know enough about the extent of substance use and abuse in South Africa? Setting a research agenda
Generally, we know “enough” about substances that are freely advertised (such as alcohol and tobacco), and readily available even though they are illicit (such as methamphetamine). We have insufficient knowledge, however, about the extent of other substances such as caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedative hypnotics, and other prescription and over-the-counter medical drugs.
Given the gaps in our knowledge, we need regular, national surveys to be conducted at least once every three to four years to establish the epidemiological pattern of substance use and abuse across South Africa to provide the evidence-base for policy development and implementation. A longitudinal national survey is a reliable design to enable researchers to ascertain the prevalence and incidence of substance abuse of the wide spectrum of existing and new licit and illicit drugs. Using data from nationally representative data bases the country will then be equipped to work towards incremental progressive realisation of a 100% substance-free South Africa.
Sustainable funding should be secured for surveys of households, schools, other educational institutions and of service providers. Issues to be surveyed should include the experience and nature of cultural practices, peer pressure, traditions, costs, substance types (legal, illegal, homebrews, mampoer, tot-tot, glue), quantities, risk factors, access to treatment, substance suppliers, skills levels of service providers, gender, impact (psychological, social, economic), bio-indicators (blood, hair, nail samples), age of onset, household income, educational level, employment status, and health status. Self-reported survey data should be compared with third party reporting using triangulated methodologies and where possible biological markers should be used to verify the self-report data. GIS mapping should be utilised to determine distribution of trends in relation to location of local shebeens and pubs. Institutions should share and harmonise research efforts.
Clearly, a synergistic, co-ordinated effort is required across sectors to implement strategies for substance abuse prevention. The results of surveys and other data gathering efforts will be used to inform these strategies.
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Chair: Prof. Neo Morejele, South African Medical Research Council, MRC
Rapporteur: Professor John Seager, freelancer
09:00 – 09:10 Introduction and Setting the Stage for the Seminar
Prof Neo Morejele, South African Medical Research Council, MRC
09:10-09:15 Welcome: Background and purpose of the Substance Abuse Seminar
Dr Temba Masilela, Deputy CEO, Human Sciences Research Council, South Africa and Prof. Priscilla Reddy, HSRC
09:15-09:45: Setting a substance abuse research agenda for South Africa: Lessons from the United States and globally.
Dr Paul Seale, Mercer University School of Medicine, Georgia, United States of America
09:45-10:15 Q & A