The government is preparing to trial a medically-assisted treatment programme to help heroin users who want to quit the drug – this after long resisting the approach in favour of drug-free rehab programmes that have yielded low success rates, writes Jesse Copelyn for GroundUp.
In July, the National Department of Health (NDoH) requested bids to run a pilot programme to provide opioid agonist therapy (OAT) to heroin users. OAT is a form of treatment in which people who are quitting the drug (or reducing their intake) are provided with opioid agonists.
The OAT blocks the painful withdrawal symptoms.
The department has until February 2025 to appoint a service provider to manage the pilot, which will run for 20 months. It’s supposed to operate at two primary healthcare facilities – one in Emalahleni in Mpumalanga and another in Madibeng in the North West, both chosen as they reportedly include a “high number of people” who use heroin.
The opioid agonist drug to be used in the pilot scheme is methadone, a syrup taken once a day. OAT programmes usually offer it alongside other forms of assistance, like counselling or therapy. The medicine is typically administered for a minimum of six months.
Clinical trials show heroin users are more successful at kicking the habit when they’re provided with methadone than when they’re sent to drug-free rehabilitation centres. For the treatment to work, however, people need to take it for several months or even years.
This allows them to establish a more stable social environment (for example, getting off the street, finding work, and re-establishing family relationships) before slowly tapering off the medicine.
Many countries, like the US and UK, provide OAT free of charge. But South Africa has historically taken a more conservative approach.
People who are suffering from heroin withdrawal at public hospitals can be provided with methadone, but only for up to 10 days, as a detox therapy, which research shows isn’t as effective as longer-term OAT programmes.
Similarly, at government-funded rehab centres, users are either expected to quit cold turkey, or are provided with one to two weeks’ worth of methadone.
There isn’t any national-level data on the success rates of these rehab programmes but the available evidence isn’t promising.
One study looking at 300 heroin users who went to state-funded rehabs in Johannesburg found that three months after the programme had ended, two-thirds of them had gone back to using heroin, and many of those that had stopped were simply on other substances.
For instance, the number of people using crystal meth (commonly known as tik) had increased. The researchers partially attributed these disappointing results to the lack of OAT.
The government has slowly been changing tack. In 2018, civil society groups and academics made a submission to the National Essential Medicines List Committee requesting methadone for long-term OAT at public clinics.
This led to a long period of consultation.
In 2021, the committee published a review stating that OAT is more effective at reducing heroin use than drug-free or detox-based programmes. But it expressed “concerns that the current service delivery platform (South Africa’s system of primary health facilities) is not adequate to deliver (OAT) safely, considering the risk of respiratory depression in toxicity and the risk of diversion to illicit drug markets”.
The committee thus recommended that OAT be conducted from pilot sites first, to see whether government clinics have the capacity to manage these safely. The health department believes this “will help to inform the roll-out (of) OAT in a safe, cost-effective and efficient way”.
Effects of methadone
For people dependent on heroin, withdrawal can come just a few hours after their last hit, symptoms including fever, body aches and intense fatigue.
Users in Cape Town’s Joe Slovo township told GroundUp they needed at least six quarter gram shots a day (though usually more), which cost R25 a pop. To support this, they engage in a range of odd jobs that provide immediate cash, a hustle which becomes all-consuming.
It’s for this reason that OAT can be so powerful for those who are looking for a way out. By blocking withdrawal, people can exit the constant street hustle, and instead begin to make long-term planning decisions.
Risks shouldn’t be overstated
OAT is not without its criticisms. According to a 2023 study, the hesitancy to roll out OAT at South African clinics has partially been motivated by the fear that patients may overdose on methadone. This is in part because in the US, thousands have died of methadone overdose.
The US Centres for Disease Control notes that these deaths have primarily been linked to the use of methadone for pain relief however, rather than as an OAT drug. The rate at which people have overdosed on the drug has dropped in the that country since the regulator curbed the use of methadone for pain relief.
This is despite the distribution of methadone for OAT programmes rising significantly over the same period.
Dr Andrew Scheibe, a medical doctor and harm reduction researcher at the University of Pretoria, said most overdoses on methadone are linked to pain medication, and “not so much around its use for opioid agonist therapy”.
Scheibe notes that there are risks linked to methadone use in OAT but these can be managed. “The highest risk of overdose is in the beginning. So in the first couple of weeks or even months, people are on direct observed therapy.” In other words, they take their medication at the clinic under the watch of clinicians.
Doing this from primary healthcare facilities in South Africa will require additional resources. According to Andy Gray, who sits on the Essential Medicines List committee, “there has been a fair bit of back and forth with the NDoH on questions of capacity at primary healthcare clinics”.
Scheibe added that while observed daily treatment is needed in the beginning of OAT, “it is also important that people can transition to take-home methadone when they’re stable, because that t allows them to resume other parts of their lives”.
“The pandemic pushed many countries to allow take-home methadone … and there was no change in overdose deaths as a result”.
In the US, after lockdown regulations, OAT clinics began providing users with weeks’ worth of methadone at a time, after previously requiring daily observed treatment.
A paper in The Lancet Public Health reviewed six studies which analysed the impact of this and found “no evidence of increased methadone overdose risk as a result of the (more flexible) guidance”. (Though one study has since come to the opposite conclusion).
Prices coming down
A final concern about OAT has previously been the high price tag of methadone, which has historically been provided by a single supplier in South Africa – Equity Pharmaceuticals. But in recent years, prices have dropped as new products have entered the market. These include a product by Adcock Ingram called Adco and another by Umsebe Healthcare called Misyo.
Both were registered by the South African Health Products Regulatory Authority (SAHPRA), in 2021. But Misyo only came to market in 2023, while Adco was launched in February 2024.
Equity is still the government’s supplier of methadone, as the most recent tender was awarded in 2023 before the new players were able to bid. A new tender will be issued in 2026, however.
Currently, Adco costs R368 (including VAT) for a 100ml bottle.
Users on OAT start on a low initiation dose, and steadily increase their daily intake until they reach a stabilisation dose. This level varies across individuals, though the global recommendation is 60mg-120mg a day.
At a stabilisation dose of 90mg, the Adco product cost about R33 a day – a lot less than the R150 people pay for heroin in Joe Slovo. These prices would inevitably come down even further once they are negotiated on tender.
See more from MedicalBrief archives:
SA's free methadone project to help whip heroin habit
‘Profound’ growth in South Africa’s heroin market fuels drug crisis
Time for humane, radical rethink on drug policy in South Africa