Healing the Dragon: Intervention for Heroin Use Disorders and HIV/AIDS
1. Healing the Dragon
Heroin use disorders and HIV/AIDS
- intervention
Dr Monika dos Santos
PhD (psych)
FOUNDATION FOR PROFESSIONAL DEVELOPMENT
2. 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)
3. 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)
4. 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)
5. 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)
6. 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).
7. 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).
8. 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).
9. 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.
10. 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?
11. 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.
12. * 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.
13. 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
14. 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).
15. The remaining nine participants fulfilled
the DSM-IV-TR criteria for Opioid
Dependence Early Partial Remission
(American Psychiatric Association, 2000).
16. Purpose sampling / interviews were
conducted with 10 specialist
participants in the field of heroin use
disorder intervention(Babbie & Mouton, 2002).
17. * 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 department
and 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).
18. * 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.
19. * 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.
20. * 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.
21. * 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.
22. 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).
23. Data was obtained from the SACENDU
project (MRC) for comparison purposes
with the socio-demographic data of the
study(Parry et al., 2005).
26. 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?’
29. 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.
30. Content analysis was utilized to
analyse the case-study and specialist
interview information.
31. 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
----------------------------------------------------------------------------------------------------------------
32. 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
---------------------------------------------------------------------------------------------------------------------
33. 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
34. 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
35. Characteristic % n
---------------------------------------------------------------------------------------------------------------------
Ever incarcerated
Yes 15 6
No 85 34
Frequency of heroin abuse
Daily 95 38
Weekly 5 2
Primary mode of heroin ingestion
Smoked 37.5 15
Intravenous 55 22
Snorted 7.5 3
36. * 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)
37. * 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).
38. 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
--------------------------------------------------------------------------------------------------------------------------------------------------------------
39. 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.
40. The following heroin use disorder
intervention principles emerged from the
study in terms of HIV/Aids:
41. * 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 ?
42. It is no longer acceptable to simply
do what feels right.
43. 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.
45. 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.
46. 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).
47. 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.
48. This sort of reductionism fails to
recognise that one size does not fit all.
The appropriate strategy depends on
current local circumstances.
49. 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.
50. 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.
51. 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).
52. The question of any given society must
be: is this strategy workable in the
present circumstances (Leggett, 2001)?
53. 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).
54. 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.
56. We are only in the beginning stages of
determining how to produce optimal
patient outcomes with an effective
outlay of health care monies.
57. 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.
59. 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.
60. 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
61. 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)
