Methadone use for acute opioid withdrawal in Tshwane shelters during the COVID-19 lockdown

BACKGROUND

 Temporary shelters were established for street-based people during the national level 5 coronavirus disease 2019 (COVID-19) lockdown. However, street-based substance users' need to access substances was not addressed, resulting in large numbers of people experiencing withdrawal. The Community Oriented Substance Use Programme (COSUP) in Tshwane provided methadone to manage opioid withdrawal.

METHODS

 A cross-sectional, descriptive study was conducted using the daily methadone dosing records from shelters in Tshwane between March 2020 and September 2020.

RESULTS

 The final analysis included 495 participants, of which 64 (12.9%) were initiated on 20 mg - 30 mg of methadone, 397 (80.2%) on 40 mg - 50 mg, and 34 (6.9%) on 60 mg - 70 mg. A total of 194 (39.2%) participants continued their initiation dose for 1-2 months, after which 126 (64.9%) had their doses increased, and 68 (35.1%) had their doses decreased. Approximately 12 (2.4%) participants were weaned off methadone after 1-3 months and 46 (9.3%) after 4-6 months. In all, 100 (20.2%) participants left the shelter prematurely and did not continue with methadone. A total of 126 (25.5%) participants continued to stay in the shelters and received methadone for 6 months, with 125 (25.3%) participants leaving the shelter with continued follow-up at a COSUP site.

CONCLUSION

 This study demonstrates variability in methadone dosing regimens among shelter residents. As the lockdown measures eased, many chose to leave the shelters, while others remained to receive methadone and other services. The COSUP appears to be effective during periods of increased vulnerability, since a large number of participants were successfully followed up.Contribution: Opioid dependence is a persistent, lifelong disease. It is multifaceted with complex environmental and individual determinants. This study highlighted the use of opioid substitution therapy during a period of increased vulnerability.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study

BACKGROUND

Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community.

METHODS

Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes.

RESULTS

Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release.

CONCLUSIONS

OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

Mental health symptoms among homeless shelter residents during COVID-19 lockdown in Tshwane, South Africa

BACKGROUND

In order to contain the spread of COVID-19 in South Africa during the national state of emergency, the Gauteng Department of Social Development established temporary shelters and activated existing facilities to provide basic needs to street-homeless people in Tshwane, which facilitated primary health care service-delivery to this community.

AIM

This study aimed to determine and analyse the prevalence of mental health symptoms and demographic characteristics among street-homeless people living in Tshwane's shelters during lockdown.

SETTING

Homeless shelters set up in Tshwane during level 5 of the COVID-19 lockdown in South Africa.

METHODS

A cross-sectional, analytical study was conducted using a Diagnostic and Statistical Manual of Mental Disorders (DSM-5)-based questionnaire that looked at 13 mental health symptom domains.

RESULTS

Presence of moderate-to-severe symptoms were reported among the 295 participants as follows: substance use 202 (68%), anxiety 156 (53%), personality functioning 132 (44%), depression 85 (29%), sleep problems 77 (26%), somatic symptoms 69 (23%), anger 62 (21%), repetitive thoughts and behaviours 60 (20%), dissociation 55 (19%), mania 54 (18%), suicidal ideation 36 (12%), memory 33 (11%) and psychosis 23 (8%).

CONCLUSION

A high burden of mental health symptoms was identified. Community-oriented and person-centred health services with clear care-coordination pathways are required to understand and overcome the barriers street-homeless people face in accessing health and social services.Contribution: This study determined the prevalence of mental health symptoms within the street-based population in Tshwane, which has not previously been studied.

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting

Background

The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane’s Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response.

Aim

To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.

Setting

Three community-based COSUP sites in Mamelodi (Tshwane, South Africa).

Methods

A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data.

Results

Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants’ median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol.

Conclusion

Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.

Contribution

This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Harm reduction in practice - The Community Oriented Substance Use Programme in Tshwane

BACKGROUND

The Community Oriented Substance Use Programme (COSUP) is the first publicly funded, community-based programmatic response to the use of illegal substances in South Africa. It is founded on a systems thinking, public health and clinical care harm reduction approach.

AIM

To describe the critical components, key issues and accomplishments in the initiation and delivery of evidence-based, community-oriented, substance-use health and care services.

SETTING

The Community Oriented Substance Use Programme is implemented by the University of Pretoria in four of seven Tshwane Metropolitan Municipality regions.

METHODS

Quantitative and qualitative data were extracted and triangulated from plans, reports, minutes and other documents.

RESULTS

Between 2016 and 2019, COSUP engaged in national and local policy and guidelines development. In Tshwane, it created practical working relations with 169 organisations and institutions and set up 17 service sites. These provide counselling, linkage to care and opioid substitution therapy services to 1513 adults (median age of 30 years), most of whom are male (90%), with similar proportions of clients who smoke (51%) or inject (49%) heroin. It also offers needle and syringe services (approximately 17 000 needles distributed/month) and has built human resource capacity in harm reduction among staff, clients and personnel in partner organisations.

CONCLUSION

The Community Oriented Substance Use Programme offers an evidence-based, public-health informed, feasible alternative to an abstinence-based approach to substance use. However, to translate the programme's achievements into sustainable outcomes at scale requires health system integration; generalist, patient-centred care; affordable medication in a comprehensive package of harm reduction services; multisectoral partnerships; systematic, continuous capacity development; financial investment; and sustained political commitment.