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Substance Use and Abuse in South Africa
Insights from Brain and Behavioural Sciences
By George F.R. Ellis, Dan J. Stein, Kevin G.F. Thomas, Ernesta M. Meintjes
Juta and Company LtdCopyright © 2012 UCT Press
All rights reserved.
Epidemiology of substance use and abuse in South Africa
Shandir Ramlagan and Karl Peltzer
At the end of the apartheid era, research relating to the nature and extent of use of drugs other than alcohol and tobacco among the general adult population in South Africa was virtually nonexistent (Rocha-Silva, 1992). In his opening address to the South African Parliament in 1994, President Nelson Mandela signalled alcohol and drug abuse as a problem among the social pathologies that needed to be combated. By February 1999, the country's Drug Advisory Board noted an unacceptable increase in substance abuse (the age of first experimentation had also dropped) and its associated problems. In 1997, the inappropriate use of narcotic drugs was estimated to cost countries between 0.5% and 1.3% of their GDP annually. In South Africa, this amounted to between R2.4 and R6.3 billion (UNODC, 2003). This problem has been identified by the National Drug Master Plan as fuelling crime, poverty, reduced productivity, unemployment, dysfunctional family life, political instability, the escalation of chronic diseases such as AIDS and TB, injury and premature death (Drug Advisory Board, 1999). Its sphere of influence reaches across social, racial, cultural, language, religious and gender barriers and, directly or indirectly, affects all South Africans.
Results and discussion
In the 1960s and 1970s, the widespread abuse of psychotropic substances emerged in South Africa. Globalisation has since facilitated the introduction of potent addictive drugs, such as heroin, cocaine and ecstasy. Leggett (2004) noted that prior to 1994, cocaine and heroin were not readily available in South Africa. After South Africa's re-integration into the world community in the 1990s, its well-developed transport and communication systems and advanced banking structure meant that the country came to be used for the purpose of illicit trafficking of many commodities, including drugs (UNOCD, 2002).
The end of apartheid has increased South Africa's vulnerability to illicit drug trafficking between source countries in Asia and South America and the major consumer markets in Western Europe and North America. While not the most direct route between these areas, South Africa may be used for trans-shipments of illegal drugs. The quality of air and sea travel connections via South Africa to many parts of the world offers drug traffickers opportunities that did not exist earlier. The country's geography, porous borders and expanding international trade links with Asia, Western Europe and North America have made it an attractive drug transit country. Drug trafficking and abuse have accordingly escalated. The point of escalation is traceable to the fall of apartheid and the liberalisation of most aspects of society in the years following the country's first democratic elections in 1994.
Cocaine from Latin America and heroin from the Far East transits through South Africa to Europe, and the United States (US Department of State, 1996). South Africa, along with Namibia, Kenya, Swaziland, Angola, Tanzania and Uganda are now on the major cocaine trafficking routes. Colombian cocaine drug lords are reported to be moving their operations into South Africa, which allows them easier access to Europe. More recently, the cartels have established contacts with Asian and Far Eastern producers to use South Africa as a conduit for smuggling hashish, heroin and opium to Europe and the United States (Hawthorne, 1996).
Long, porous borders and weak border control, including understaffed ports and numerous secondary airports, give traffickers nearly unlimited access to South Africa. The growing presence of illicit drugs in South Africa is indirectly a result of the dramatic increase in the number of international flights to the country, relaxed visa requirements for South Africans to travel overseas, the movement of large numbers of legal and illegal people across the borders, poor border monitoring and ill-equipped customs officials. All of these create a highly attractive market for the influx of drugs (SAPA, 1995), and a growing reputation as a 'paradise' emerging market and transit point for illicit drugs (Steyn, 1996; Ryan, 1997). Although there is little available evidence to substantiate it, the growth of organised crime, and the lack of adequate resources to deal with it contributes, among other factors, to an increase in the accessibility and availability of illicit drugs in South Africa. A corresponding increase in consumption is probable.
Tobacco use and abuse
According to the World Health Organization (Saloojee, 2006), 4 million deaths worldwide are attributed to tobacco each year. In South Africa, according to Groenewald (2007), 34 108 deaths in males (12.4% of all male deaths) and 10 306 deaths in females (4.2% of all female deaths) in 2000 were attributed to tobacco. The tobacco-related studies in Table 1.2 show that from 1999 (Global Youth Tobacco Survey, or GYTS) to 2002 (GYTS) the percentage of children below 10 years of age who had started using tobacco among those with a history of having smoked seemed to have decreased from 18% to 16%. In Table 1.2, from 1999 to 2002, we also see that there seems to be a decline among adolescents in lifetime tobacco use from 46.7% to 37.6% (GYTS, 2002) to 30.5% (Youth Risk Behaviour Survey, or YRBS, 2002). Current tobacco use among adolescents also seems to be declining, yet at a smaller rate, from 23% (GYTS, 1999) to 18.5% (GYTS, 2002), with YRBS in 2002 reporting 21.1%. Although there is a relatively high proportion of smokeless tobacco use among adolescents, (18% to 21%), there seems to be a decline in its use from 18% (GYTS, 1999) to 15% (GYTS, 2002), with YRBS (2002) reporting 11%. The 1998 Demographic Health Survey (DHS) and the GYTS (1999) showed daily smoking among adolescents at 10.6% and 10.1%, respectively. The GYTS (2002) and YRBS (2002) figures indicate a decline to 5.8% and 6.5%, respectively.
Surveys of South African adult smoking trends (see Table 1.3) show that daily smoking declined from 26.2% in 1998 (DHS) to 19.8% in 2003 (DHS), with the World Health Survey (WHS, 2003) reporting 14.6%. Among a national sample of educators (HSRC, 2004), daily smoking was reported by 8.5% of educators. Daily tobacco use was found in four national surveys to be higher among urban than rural residents, higher in the Western Cape and Northern Cape than in other provinces, higher among coloureds, whites and Indians than Africans, and higher among those with a lower education level.
Alcohol use and abuse
Globally, the net effect of alcohol consumption on health is detrimental, with an estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years (DALYs) attributable to alcohol (Rehm et al, 2009). In South Africa, the estimated burden of disease attributable to alcohol use in 2000 was estimated at 7.1% (95%, uncertainty interval 6.6–7.5%) of all deaths and 7.0% (95%, uncertainty interval 6.6–7.4%) of total DALYs. As a cause of alcohol-attributable disability, alcohol use disorders ranked first (44.6%), interpersonal violence second (23.2%), and fetal alcohol syndrome (FAS) third (18.1%) (Schneider et al, 2007).
How alcohol is consumed in a country or within a group (ie, pattern of drinking) is an important determinant of types and levels of problems associated with drinking. Alcohol consumption should be understood in the context of how it is drunk, that is, the patterns of drinking. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g. physical or psychological harm) (Reid et al, 1999).
In 2005, the second South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey (SABSSM II) showed a decline in lifetime and current alcohol use among adolescents, whereas the 2008 survey (SABSSM III) survey showed a slight increase (see Table 1.4). Lifetime and current alcohol use among adults seemed to have remained stable for the adult population (Peltzer & Ramlagan, 2009). Current (past month) alcohol use has been about 30% (40% among men and 16% among women), which is lower than the levels reported for other developing countries, e.g. Namibia (men 61%, women 47%), Mexico (men 77%, women 44%) and Thailand (men 77%, women 46%) (Room et al, 2002).
The 2008 SABSSM III rates show a slight increase compared with SABSSM II, 2005, with 24.5% overall, and 39.2% for men and 15.7% for women. However, these levels were about the same in the DHS of 1998, with 28% overall; 44.6% and 16.9% current drinkers among men and women, respectively.
Binge drinking among youth (15–24 years) increased slightly, from 29% of current drinkers in 1998 (DHS) to 31% of current drinkers in 2005 (SABSSM II). Among adults, binge drinking was relatively high: 32.4% for women in 1998 (DHS), compared to 20.6% among female current drinkers in the 2005 survey. The SABSSM III study found that overall 9.6% of South Africans (17.1% among men and 3.8% among women) engaged in past-month binge drinking (Peltzer et al, submitted). These rates also show a slight increase compared with SABSSM II, with 7.4% overall, and 14.3% in men and 3.2% in women (Peltzer & Ramlagan, 2009).
Among youth (15–24 years), problem drinking with the CAGE (Cut down, Annoyed, Guilty, Eye-opener) assessment measure (see Chapter 2 for more details) was 17% among men and 6% among women in 1998 (DHS). Hazardous or harmful drinking assessed with the AUDIT (Alcohol Use Disorder Identification Test) measure (see Chapter 3 for more details) was 10% among men and 2% among women in the same age group in 2005 (SABSSM II). Among adults, 17% were problem drinkers (assessed with the CAGE) in 1998, 6% (assessed with the AUDIT) in 2005 and 5% (assessed with the AUDIT) among a large representative sample of educators in 2004. Further, the 2008 SABSSM III study found that hazardous or harmful alcohol use was 9.0% (in men 17% and women 2.9%), which is a considerable increase from SABSSM II 2005, with an overall rate of 6.2%; in men 12.7% and women 2.2% (Peltzer & Ramlagan, 2009). This is, however, still lower than in other developing countries: for example, in Tibet the overall figure is 16.2% (female 9.6%, male 31.6%) (Guo et al, 2008); in rural Vietnam it is 25.5% among men and 0.7% among women (Giang et al, 2008); among 16–25-year-olds in Thailand, the figure for hazardous and harmful drinking is 24.3% (Jirapramukpitak et al, 2008). This is lower than in European Union countries, where the comparable figure is 15% (Anderson et al, 2006), and similar to Sweden, where 18% of men and 5% of women reported hazardous or harmful alcohol use (Bergman et al, 2002).
In South Africa, higher binge drinking levels were found in urban than in rural areas among men (17% and 11%, respectively) and women (4% and 2%, respectively) in SABSSM II (2005) and in the WHS (12% and 9%, respectively). However, among current drinkers higher levels of binge drinking were found among rural than urban women in both DHS (1998) (39% and 29%, respectively) and SABSSM II (26% and 19%, respectively).
According to province, SABSSM II showed that the highest rates of binge drinkers among men were in the Western Cape (24%), followed by North West (20%), Gauteng (16%) and Free State (15%). According to racial group, SABSSM II showed that binge drinking among men was highest among coloureds (23%), followed by whites (16%), blacks (13%) and Indians or Asians (7%). However, among male current drinkers the highest levels of binge drinking were found among coloureds (41%) and blacks (41%), as opposed to whites (25%) and Indians or Asians (18%). Both the DHS 1998 and SABSSM II showed that lower levels of education were associated with higher levels of binge drinking among current drinkers. These findings are similar to that of the SABSSM III survey (Peltzer at al, submitted).
Cannabis use and abuse
South Africa is a major producer of cannabis (the world's third largest), most of which is consumed in the southern African region, but at least some of which finds its way to Europe (UNODC, 2006). Cannabis is cultivated in South Africa, but is also imported from neighbouring countries (Swaziland, Lesotho, Mozambique, Zimbabwe), exported to some of the neighbouring countries (eg, Namibia) and Europe (mainly the Netherlands and the UK) and, of course, consumed in South Africa (Peltzer & Ramlagan, 2007). According to Parry and Bennets (1998), cannabis comes second to alcohol as the most extensively used drug in South Africa.
The school-based Youth Risk and Behaviour Survey (YRBS) conducted in 2002 in South Africa (Reddy et al, 2003) found that current (past month) use of cannabis was 9% among students (see Table 1.5. Table 1.5 also shows that between 2005 and 2008, according to the SABSSM II and SABSSM III surveys, cannabis usage almost doubled in all categories.
Higher current cannabis use rates were found in urban (2.3%) than in rural (1.0%) areas in both SABSSM II and SABSSM III surveys. According to Peltzer et al (in press), among school students current cannabis use was highest in the provinces of Gauteng, Western Cape, Mpumalanga, Free State and Limpopo. The highest rates among adults were in Western Cape, Gauteng and North West. Among adolescents, current cannabis use was highest among Indians or Asians and coloureds, while among adults it was highest among coloureds and whites. Current cannabis use was especially low (about 0.2% or less) among women from black African and Indian/Asian backgrounds. Current cannabis use rates seem not to be related to any educational level.
The range of current use of cannabis among adolescents is from 2% to 9% in three national samples (YRBS, SABSSM II and SABSSM III).
Treatment demand for cannabis abuse alone increased from 14% in 1999 to 17% in 2005 of all treatment demand, while treatment for cannabis mixed with Mandrax has remained stable: 7% in 1999 and 7% in 2005 of treatment demand of all drugs (Peltzer & Ramlagan, 2007). From 1999 to 2005, cannabis treatment demand has been consistently the highest in treatment centres in KwaZulu-Natal (see Figure 1.1) and cannabis and Mandrax treatment demand has been consistently the highest in treatment centres in the Eastern Cape. In South Africa, as in other countries, there has been an increase in the share of primary cannabis users in treatment populations since 2002: Denmark (27%), Greece (7%), Netherlands (17%) and UK (10%) (Peltzer & Ramlagan, 2007).
Other illicit drugs
Based on four national surveys among adolescents (see Table 1.6), lifetime illicit drug use was highest for over-the-counter or prescription drugs (16%), followed by inhalants (0.2–11.1%), cocaine (crack) (0.1–6.4%), Mandrax/sedatives (0.1–6.4%), club drugs (0.2–5.8%) and opiates (11.5%). (The latter figure, from the 2002 YRBS, seems unreasonably high.) Past-three-month use appears to be well under 1% for most of these drugs in general population samples. Less than 0.3% of adult females reported past-three-month use of each non-cannabis drug. There were gender differences: more male than female adolescents took inhalants, Mandrax/sedatives, club drugs and cocaine (crack) (see Table 1.6).
Excerpted from Substance Use and Abuse in South Africa by George F.R. Ellis, Dan J. Stein, Kevin G.F. Thomas, Ernesta M. Meintjes. Copyright © 2012 UCT Press. Excerpted by permission of Juta and Company Ltd.
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