Andrew Scheibe, a public health specialist at TB HIV Care, said the organisation estimates there are about 400,000 heroin users in South Africa.
Methadone is available only at district hospitals for those experiencing withdrawal symptoms (because they’ve stopped using altogether) and then only for up to 10 days. This means obtaining the drug to wean a person off gradually is not realistic if they rely on public healthcare.
The plan's aim is to provide methadone free at state clinics to all opioid users who want it.
But for a countrywide rollout to work, the government has to do five things over the next five years, says Scheibe, who helped to write guidelines on establishing OST programmes for the UN Office on Drugs and Crime.
“A programme like this wouldn't start everywhere at once; it would have to be a stepwise process.”
Five things over the next five years
1. Get a plan in place
A good start is to have policies that identify people who use drugs as a focus for the public health sector. This has been done by including substance users in the new HIV plan and National Drug Master Plan.
With this in place, medication can be added to the government’s list of essential treatments, which names all medicines available at public health facilities, and treatment guidelines can be written up.
Earlier this year the government started making plans for how a methadone programme could be rolled out by getting input from experts, says Kgalabi Ngako, deputy director for the mental health and substance abuse directorate at the health department.
2. Find the money
Methadone treatment is costly. To help someone stop using opioids, they should ideally be on OST for at least 12 months, starting with a dose of between 10mg and 30mg a day. This is gradually upped to a level where they don’t experience withdrawal symptoms (the maintenance level). At a starting dose of, say, 20mg a day, a single pop could cost about R12.25 (if we take the lowest price at which methadone sells). A month’s supply would therefore work out to almost R400 per user.
For a maintenance level, a dose of at least 60mg a day is advised. A daily fix would then cost just more than R36 at the lowest price. For a month, it would work out to about R1,080.
For comparison, it costs the health department about R60 for a month's supply of the oral HIV-prevention pill for one patient (this increases to about R90 when administration costs are included). In the private sector, it costs about R700 for a month’s supply, which works out to R58 a day.
3. Get enough hands on deck
Methadone is a schedule 6 medication, which means only a doctor can prescribe it. But for a full OST programme, a team of health workers is needed, including nurses, social workers, pharmacists, counsellors and peer educators. And, says Scheibe, health workers would need training and support on how to prescribe methadone correctly and help people stay with the programme.
4. Set up systems to manage supply
In an OST programme, it’s possible people who receive an opioid substitute such as methadone free might sell it to others. Hospitals and clinics would therefore have to keep good records of who is receiving treatment and their progress.
“We already have systems in place [for monitoring how much of a schedule 6 medicine such as methadone has been given out]. We just have to strengthen them to make sure they account for the stock,” Scheibe says. “The risk of diversion exists for every schedule 6 medication; it’s not different because it's methadone.”
5. Have a network of other services too
For OST programmes to work at community health centres, people would need to be able to dispose of needles and syringes safely. Such services are already available for patients who use injectable medicines, for example insulin, says Scheibe.
Offering HIV and hepatitis testing, handing out ARVs and making counselling part of the treatment package can also help to cut HIV infections among people who inject drugs, a study from Canada has shown.
The World Health Organisation (WHO) also recommends having help on hand for people who have overdosed or are dealing with withdrawal symptoms. Such services are available at district hospitals.
Why swap rather than stop?
Evidence shows weaning people off opioids gradually by using substitutes (called maintenance) works better in helping them beat the addiction than using these medicines simply to treat withdrawal symptoms after they’ve suddenly stopped using (which is called detoxification).
For example, in a 2017 study, 199 opioid users agreed to be admitted to an abstinence programme at a Cape Town health centre that does not offer substitution therapy. The users were referred for detoxification before entering the programme if they couldn’t manage their withdrawal symptoms. Only 23 participants completed the two-month treatment.
In contrast, a pilot study in the Western Cape in 2014 showed two out of three people who received an opioid substitute called buprenorphine (which is similar to methadone) completed a 12-week treatment programme to curb their use of heroin, while just less than half stuck with the programme when they received only normal treatment — counselling, group therapy and urine tests — to prevent relapse.
Done right, a national rollout can work
Mauritius is a good example of a country where OST programmes funded mainly by the government work well.
In 2007, the island nation had about 24,000 opioid users — among the highest in Africa. Data shows that two years before, nine out of 10 Mauritians who were HIV-positive injected drugs.
After rolling out the substitution programme to 40 government sites (including healthcare facilities and prisons) in 2014 after a small pilot project, new HIV cases among this group dropped to two in 10 by 2020.
“There’s no doubt about the effectiveness of methadone [to treat substance use]. It’s just a question of whether our primary healthcare system can feasibly and safely deliver it,” says Scheibe.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
Will South Africa's plan to supply methadone to curb heroin addiction be successful?
Image: 123RF/Maxim Evdokimov
By 2028, South Africa wants to have medicines such as methadone available at state clinics. This to help those addicted to opioids such as heroin get off the drugs. It is part of a plan, released in March, for services to cut HIV infections over five years.
In 2021 South Africa recorded about 210,000 new HIV infections.
Opioids give a feeling of extreme pleasure because they prompt the brain to release feel-good chemicals, but they are addictive. Other than illegal heroin, painkillers morphine and codeine are also part of this group of drugs.
People who are addicted to opioids such as heroin often get their fix by injecting them.
Though it’s difficult to obtain exact numbers (because using drugs such as these recreationally is illegal in South Africa), a study of 926 users published in 2019 showed one in five people who inject drugs have HIV. Why? When drug users share or use discarded needles, there’s a high risk of them contracting the virus or spreading it.
Enter methadone, a substitute for heroin. Taken daily, it helps curb withdrawal symptoms from the drug.
Taking the battle, not the war, to the streets
To your brain, methadone looks like heroin, yet it doesn’t cause as much of a high. So if you don’t get another dose soon after the high wears off, your body doesn’t experience withdrawal symptoms (for example, vomiting, breathing very fast, stomach cramps and feeling anxious) that are as bad. This is why methadone is used to help people break heroin dependence. It is called opioid substitution therapy (OST).
Because people swallow their fix rather than inject it, there’s a smaller chance of opioid users sharing needles or using an old one.
Moreover, OST programmes don’t just hand out methadone, they also offer other harm-reduction services, such as giving clean needles and syringes to drug users who may still be injecting.
Studies show OST can halve the risk of contracting HIV and hepatitis C (which leads to a blood infection and damages the liver), and help HIV-positive users to stay on antiretroviral (ARV) treatment because people can often get HIV medicine and methadone at the same place.
Andrew Scheibe, a public health specialist at TB HIV Care, said the organisation estimates there are about 400,000 heroin users in South Africa.
Methadone is available only at district hospitals for those experiencing withdrawal symptoms (because they’ve stopped using altogether) and then only for up to 10 days. This means obtaining the drug to wean a person off gradually is not realistic if they rely on public healthcare.
The plan's aim is to provide methadone free at state clinics to all opioid users who want it.
But for a countrywide rollout to work, the government has to do five things over the next five years, says Scheibe, who helped to write guidelines on establishing OST programmes for the UN Office on Drugs and Crime.
“A programme like this wouldn't start everywhere at once; it would have to be a stepwise process.”
Five things over the next five years
1. Get a plan in place
A good start is to have policies that identify people who use drugs as a focus for the public health sector. This has been done by including substance users in the new HIV plan and National Drug Master Plan.
With this in place, medication can be added to the government’s list of essential treatments, which names all medicines available at public health facilities, and treatment guidelines can be written up.
Earlier this year the government started making plans for how a methadone programme could be rolled out by getting input from experts, says Kgalabi Ngako, deputy director for the mental health and substance abuse directorate at the health department.
2. Find the money
Methadone treatment is costly. To help someone stop using opioids, they should ideally be on OST for at least 12 months, starting with a dose of between 10mg and 30mg a day. This is gradually upped to a level where they don’t experience withdrawal symptoms (the maintenance level). At a starting dose of, say, 20mg a day, a single pop could cost about R12.25 (if we take the lowest price at which methadone sells). A month’s supply would therefore work out to almost R400 per user.
For a maintenance level, a dose of at least 60mg a day is advised. A daily fix would then cost just more than R36 at the lowest price. For a month, it would work out to about R1,080.
For comparison, it costs the health department about R60 for a month's supply of the oral HIV-prevention pill for one patient (this increases to about R90 when administration costs are included). In the private sector, it costs about R700 for a month’s supply, which works out to R58 a day.
3. Get enough hands on deck
Methadone is a schedule 6 medication, which means only a doctor can prescribe it. But for a full OST programme, a team of health workers is needed, including nurses, social workers, pharmacists, counsellors and peer educators. And, says Scheibe, health workers would need training and support on how to prescribe methadone correctly and help people stay with the programme.
4. Set up systems to manage supply
In an OST programme, it’s possible people who receive an opioid substitute such as methadone free might sell it to others. Hospitals and clinics would therefore have to keep good records of who is receiving treatment and their progress.
“We already have systems in place [for monitoring how much of a schedule 6 medicine such as methadone has been given out]. We just have to strengthen them to make sure they account for the stock,” Scheibe says. “The risk of diversion exists for every schedule 6 medication; it’s not different because it's methadone.”
5. Have a network of other services too
For OST programmes to work at community health centres, people would need to be able to dispose of needles and syringes safely. Such services are already available for patients who use injectable medicines, for example insulin, says Scheibe.
Offering HIV and hepatitis testing, handing out ARVs and making counselling part of the treatment package can also help to cut HIV infections among people who inject drugs, a study from Canada has shown.
The World Health Organisation (WHO) also recommends having help on hand for people who have overdosed or are dealing with withdrawal symptoms. Such services are available at district hospitals.
Why swap rather than stop?
Evidence shows weaning people off opioids gradually by using substitutes (called maintenance) works better in helping them beat the addiction than using these medicines simply to treat withdrawal symptoms after they’ve suddenly stopped using (which is called detoxification).
For example, in a 2017 study, 199 opioid users agreed to be admitted to an abstinence programme at a Cape Town health centre that does not offer substitution therapy. The users were referred for detoxification before entering the programme if they couldn’t manage their withdrawal symptoms. Only 23 participants completed the two-month treatment.
In contrast, a pilot study in the Western Cape in 2014 showed two out of three people who received an opioid substitute called buprenorphine (which is similar to methadone) completed a 12-week treatment programme to curb their use of heroin, while just less than half stuck with the programme when they received only normal treatment — counselling, group therapy and urine tests — to prevent relapse.
Done right, a national rollout can work
Mauritius is a good example of a country where OST programmes funded mainly by the government work well.
In 2007, the island nation had about 24,000 opioid users — among the highest in Africa. Data shows that two years before, nine out of 10 Mauritians who were HIV-positive injected drugs.
After rolling out the substitution programme to 40 government sites (including healthcare facilities and prisons) in 2014 after a small pilot project, new HIV cases among this group dropped to two in 10 by 2020.
“There’s no doubt about the effectiveness of methadone [to treat substance use]. It’s just a question of whether our primary healthcare system can feasibly and safely deliver it,” says Scheibe.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
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