Download Substance Use Disorders - ADHD and Substance Abuse

The harsh realities of treating Addictions
and Mental illness within the South African
state sector: the Western Cape perspective
Lize Weich
[email protected]
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Substance use trends
• Alcohol
• Estimated to cost the country an estimated 1% of the Gross
Domestic Product (Parry et al, 2003; Brady M, Rendall-Mkosi K,
2005)
• one of the highest documented rate of fetal alcohol syndrome in
the world (grade 1 learners in Wellington, near Cape Town
increased from 46/1000 in 1997 to 88/1000 in 2001)
• Beer, spirit coolers, ciders and home brewed beer often not
viewed at alcohol
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Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Western Cape BoD study
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HIV, AIDS
TB
Injuries – Violence, RTA
Mental illness
Cardiovascular
• Alcohol in top risk factor contributing to big 5
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Linked to high risk sexual behavior, symptomatic HIV and TB
Contributes 40% to violence
18% to mental health problems resulting from alcohol abuse and
dependence disorders;
12% to road deaths – of which 60% consisted of drunk pedestrians hit
by cars
SAMJ, 87, 8 part2, 2007
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Alcohol ct.
• 1 in 4 high school learners admits to binge drinking in the
previous month
• In just under half of unnatural deaths in 2002, the deceased
had a blood alcohol concentration of >0.05g/100 ml
• similar levels were found in about two-thirds of trauma
patients
• Alcohol use in adolescents and young adults in South Africa
has been linked to high-risk sexual behaviour
• A large infectious disease clinic in Cape Town found in 2003
that 1 in 5 HIV positive patients had an alcohol use disorder
and were more likely to have symptomatic HIV disease.
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Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
SACENDU trends: Alcohol
• 1997- 82% primary substance of abuse of patients
presenting to substance treatment
• 2010 a – 29%
• 2010a – 41% overall use
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Other commonly used substances
• Poly-substance use in 43% of patients presenting for
treatment in 2010a (SACENDU)
• Cannabis
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“dagga”
• Methaqualone
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“Mandax”
• Methamphetamine
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“tik”
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Since about 2003
• Heroin
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“ungah”
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Emerging in certain areas
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Cannabis
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Cannabis
• Extremely cheap (between R1 and R5)
• Use normalized in some communities
• Children starting at ages as young as 8 or 9 not
uncommon
• 1997: primary drug of abuse for 5% of patients in
treatment
• 2010a: 16%
• 2010a: primary drug in 45% of the under 20 year
olds
• 2010a: 34% overall use
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Methaqualone / Mandrax
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Buttons
Henna
Mx
Sproetjie
Pille
Whites
Witpyp
Mandies
Cremora
Volkswagen
Macarena
Cream
Gholfsticks
Doodies
Lizards
Germans
Flowers
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Omo
Departement Psigiatrie  Department Psychiatry
Hits
Use of mandrax: “bottleneck”
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Mandrax as primary drug of abuse
• 1997: 7% of patient is substance treatment
• 2003: 23,6%
• 2005: 2,8%
• 2009: 2,7%
• 2010a: 4%
• 2010a: 18% overall use
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Methamphetamine
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Crystal methamphetamine smoked in
lolly/pop-eye/globe
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Methamphetamine
• 1997: 0% of patients in treatment gave as
primary drug of abuse
• 2003: 2.3%
• 2004: 19%
• 2006: 42%
• 2010a: 34%
• 2010a: 46% overall use
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Heroin
• SACENDU:
• 1997: 1% primary drug
• 2010a: 12%
• 2010a: 14% overall use
• Pockets of endemic use
• Waxing and waning
• Cheap R20-30
• Mainly smoked
• Low intravenous use rates – about 9-12% at
present
• No political buy-in for substitution treatment
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Population of Western Cape
• Census 2001, 4,524,336 people in the Western
Cape, living in 1,173,302 households.
• 53.91% coloured
• 26.68% black
• 18.41% white
• 1.00% Asian
• In the province 55.3% of residents speak Afrikaans
at home, 23.7% speak Xhosa, 19.3% speak English,
and less than 2% speak another language
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
POPULATION PROFILE
Race
1%
Asian
12.4%
(Africans)
16.6%
(White)
70.2%
Coloured
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Socio-economics: 2001 census
• Telephone: 2.7% of households have access that is not
nearby or no access.
• 13.5% of households have no flush or chemical toilet.
• 12.2% do not have refuse removed by the municipality at
least once a week and 1.4% have no rubbish disposal.
• 32.5% do not have running water inside their dwelling,
14.8% do not have running water on their property, and
1.7% have no access to running water.
• 78.8% of households use electricity for cooking, 73.4% for
heating, and 88.0% for lighting. 79.1% of households have a
radio, 74.1% have a television, 18.2% own a computer,
73.5% have a refrigerator, and 41.4% have a cell-phone.
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Organization of substance treatment
substance services
• 3 tier system
• If you have lots of money or insurance – high
quality private care
• If you have some money – NGO subsidized
programs
• If you don’t have money- state programs/
NGO subsidized programs
• Mostly no MDT, only social workers
• Sponsorship only for 6-8 weeks of treatment
• Long waiting lists for inpatient programs
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Treatment of addictions- challenges
• Lead department for managing substance
disorders is social welfare
• Addiction not managed as a chronic medical illness
• Highly reliant on an under-funded NGO sector for treatment
• Rarely employ MDT’s
• High rates of unemployment, poverty, broken
homes, domestic violence, gangsterism
• Uneducated public
“moral weakness”
• Users should be “sent away” and will come back “cured”
• Big problem with unregistered treatment providers who think
“cheer leading” or punishment is treatment
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
• Dep of Health only mandated to do “detox” and
treat co-morbidity
• Resistance from top management to advocate for an increased
mandate, unwillingness from DSD to give up this responsibility
• No pharmacology other than detox (and occasionally a bit of
disulfiram)
• “substitution treatment is not politically palatable”
• Uneducated health service who stigmatize in patients
• Central drug authority, who should advice
Parliament and is responsible for NDM,
underwrites a social treatment model
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Some recent changes…
• Priority for Premier
• Central substance coordinator within Premier’s office
• Development of PGDip in Addiction Care from 2011/12
• Move towards outpatient programs
• Move towards evidence based interventions
• Move towards quality care, rather than numbers
• Motivations with HPCSA to register Addiction
Psychiatry as a subspecialty
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
What about mental health?
• Private vs State sector
• State sector is again 3 tiered
• 1- nurse led service, supported by medical officers and Specialist Family
Practitioners
• Community psychiatric nurses at clinics (not all rural areas)
• District hospitals
• Community psychiatrists
• 2/3- each of 3 rural districts have a community psychiatrist and psychiatric
ward in 2 level hospital; metro has three big hospitals; 3 level services at GSH
and TBH
• Resistance towards patients with substance use disorders
• Stigmatized, ostracized
• Overburdened services
• Lack of knowledge and skills
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Mental health challenges
• Severe bed shortages
• Bed closures without a properly developed community
services
• Poorly develop services in some of the other Provinces
• HIV epidemic
• Methamphetamine epidemic
• Poorly developed community services
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Developing services for mental health patients with
comorbid substance use disorders
Substance severity
Substance services
with MH support
Specialized dual
disorder services
Primary health and
MH servicesneeds to be skilled
to deal with both
problems
General MH services needs to be skilled to
deal with comorbid
substance problems
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Severity of mental illness
ADHD and substance use disorders
• Harsh reality of under resourced and understaffed facilities
• Not even capacity to properly treat severe and enduringly
mentally ill
• Adult ADHD not commonly recognized by many local
psychiatrists
• Fear among gen. public that Methylphenidate (only Rx
registered in state for this indication) would be “abused” –
reality is that this happens very uncommonly
• Patients with ADHD are not diagnosed and treated
• Probably diagnosed as personality disorders, or simply
viewed as “unmotivated” in treatment
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry
Fakulteit Gesondheidswetenskappe  Faculty of Health Sciences
Departement Psigiatrie  Department Psychiatry