SACENDU RESEARCH BRIEF VOL 20 (1), 2017 PHASE 41. South African Community Epidemiology Network on Drug Use JULY DECEMBER 2016

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1 SACENDU South African Community Epidemiology Network on Drug Use RESEARCH BRIEF VOL 20 (1), 2017 MONITORING ALCOHOL, TOBACCO AND OTHER DRUG USE TRENDS IN SOUTH AFRICA JULY DECEMBER 2016 Siphokazi Dada, Nadine Harker Burnhams, Jodilee Erasmus, Charles Parry, Arvin Bhana, Furzana Timol, David Fourie PHASE 41 FOREWORD AND SUMMARY The Phase 41 report back meetings of the South African Community Epidemiology Network on Drug Use (SACENDU) took place in Pretoria (11 April), Durban (12 April), Port Elizabeth (13 April) and, Cape Town (20 April). Approximately 200 persons attended these meetings. Established in 1996, SACENDU is a network of researchers, practitioners and policy makers from various sentinel areas in South Africa. Up until June 2006, these sites comprised of Cape Town, Durban, Port Elizabeth (PE), East London (EL), Gauteng Province and Mpumalanga Province (MP). As some sites were beginning to also include data from other towns/cities (e.g. Durban included data from Pietermaritzburg), it was decided to begin to report data by province. From the second half of 2006, data were also collected from treatment centres in the Free State, Northern Cape and North West. For the purposes of this report, these three provinces have been combined into a regional group termed the Central Region. In Limpopo Province, data were also collected from one centre in Polokwane from July December It was decided to combine this data with data from Mpumalanga and we now refer to these two provinces as the Northern Region. Thus, this report now refers to the following six sites: Western Cape, KwaZulu-Natal, Eastern Cape, Gauteng, the Northern Region and the Central Region. The goal to include data from all nine of South Africa s provinces in the SACENDU project has therefore been achieved, though there are still gaps in coverage at some sites. Members of SACENDU meet every six months to provide communitylevel public health surveillance of alcohol and other drug (AOD) use trends and associated consequences through the presentation and discussion of quantitative and qualitative research data. Through this initiative SACENDU provides descriptive information on the nature and pattern of AOD use, emerging trends, risk factors associated with AOD use, characteristics of vulnerable populations, and consequences of AOD use in South Africa. The SACENDU initiative has several specific objectives: a. To identify changes in the nature and extent of AOD abuse and emerging problems. b. To identify changes in alcohol and other drug-related negative consequences. c. To inform policy, planning and advocacy efforts at local and other levels. d. To support networks of local role players in the substance abuse area. e. To stimulate research in new or under-researched areas that is likely to provide useful data to inform policy/planning decisions. f. To facilitate South Africa s full participation in international fora focusing on the epidemiological surveillance of drug abuse. Financial support for Phase 41 was provided by the Mental Health and Substance Abuse Directorate of the National Department of Health. There has been a significant decrease in the number of patients admitted to specialist treatment centres, from to 8787 patients. Alcohol remained the dominant substance of abuse in the EC and the CR. Between 18% (NR) and 47% (CR) of patients in treatment had alcohol as a primary drug of abuse. Across sites between 35% (EC) and 51% (GT) of patients, attending specialist treatment centres had cannabis as their primary or secondary drug of abuse, compared to between 1% (NR) and 20% (WC) for the cannabis/mandrax (Methaqualone) combination aka white-pipe. In all sites, cannabis was reported as the predominant primary substance of abuse by patients younger than 20 years. Cannabis use by patients younger than 20 years was followed by alcohol across all sites, except in the CR. Treatment admissions for cocaine have shown a continued decrease over the past few reporting periods and remain low across sites. Cocaine is often reported as a secondary substance of abuse. Between 3%, (WC) and 10% (KZN) of patients in treatment have cocaine as a primary or secondary drug of abuse. Compared to the previous period, treatment admissions for heroin as a primary drug of use remained stable in most sites, except in the NR region where it increased significantly from 26% to 36%. A slight decrease in KZN (from 15% to 10%) and a slight increase in the WC (from 11% to 13%) in patients reporting heroin as a primary substance of abuse was also noticed during this period. Mostly, heroin is smoked, but between 2% (NR) and 52% (GT) of patients reported injecting the drug. Injection use of heroin has remained stable in the WC, slightly decreased in the NR compared to the previous period, but significantly increased in GT (from 38% to 52%). Nyaope/whoonga (low-grade heroin and other ingredients smoked with dagga), continued to pose a problem, with 9% of patients in GT (and KZN), and 3% of patients in the NR admitted for nyaope/ whoonga use. Treatment admissions for MA as a primary drug of abuse was low except in the WC (29%) and the EC (16%). MA (aka tik ) remains the most common primary drug reported by patients in the WC, although the proportion decreased slightly (from 37% in 2015b). Among patients under 20 years the proportion reporting MA as a primary or secondary substance of abuse was 9%, a significant decrease compared to 17% in 2016a. Across sites between 22% (EC) and 42% (WC) of patients, attending specialist treatment centres had MA as their primary or secondary drug of abuse. Treatment admissions for ecstasy and LSD also remained low. Across sites, only 1% of patients had ecstasy as a primary or secondary drug of abuse. Methcathinone (CAT) is an amphetamine-type stimulant and has effects similar to that of MA. CAT was noted in most sites, especially in GT and the CR where 17% and 13%, respectively, had CAT as a primary or secondary substance of abuse. Poly-substance abuse remained high, with between 19% (NR) and 48% (WC) of patients indicating more than one substance of abuse. The abuse of over-the-counter and prescription (OTC/PRE) medicines such as slimming tablets, analgesics and benzodiazepines (e.g. diazepam and flunitrazipam) continued to be an issue across sites. Treatment admissions for OTC/PRE medicines as a primary or secondary drug of abuse were between 2% (NR) and 9% (EC). During this reporting period, 212 (2.4%) patients across all sites reported the non-medical use of codeine, with the majority of patients coming from GT (N= 81). Inhalant/solvent use among young persons continued to be an issue across sites, although the number of patients reporting inhalants as their primary drug was low. During this period, the proportions ranged between <1% (EC) and 2% (CR). TREATMENT CENTRES: SITE SUMMARY In the Western Cape (WC) the most common primary substances of abuse reported by the 33 specialist treatment centres/programmes participating in the project between July December 2016 were MA (aka tik ), cannabis, alcohol and heroin (together comprising 91% of all admissions). The proportion of patients presenting with MA as their primary substance of abuse decreased slightly to 29% in this period. SACENDU is funded by the SAMRC and the National Department of Health 1 South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

2 Overall, 2808 patients were treated across all 33 treatment centres in the second half of In KwaZulu-Natal (KZN) the main primary substance of abuse in this period was alcohol (37%), followed by cannabis (34%). admissions significantly decreased from 15% in the previous period to 10%. Four percent of patients reported crack/cocaine as their primary substance patients were treated across the eleven treatment centres who submitted data in the second half of 2016, a slight decrease compared to the previous period. In the Eastern Cape (EC) the main primary substances of abuse reported by the treatment centres from July December 2016 were alcohol, cannabis, MA and cannabis/mandrax (Table 3). The proportion of patients reporting MA as their primary substance of abuse significantly decreased during this period. Admissions for OTC/ PRE medication as a primary substance of abuse remained stable at 6%. Five hundred and thirty-seven patients were treated at the seven centres that collected data in the EC province, a significant decrease compared to the previous period (N=638). There was no data received from SANCA Port Elizabeth during this reporting period. In Gauteng (GT), which includes the metropolitan areas of Johannesburg and Pretoria, 2948 admissions to 14 treatment centres were recorded in the second half of For 36% of patients, the most common primary substance of abuse was cannabis. Apart from cannabis, the most common primary substances of abuse were alcohol (22%), heroin (13%), CAT (11%), methamphetamine (6%), and nyaope/ whoonga (5%). The proportion of admissions reporting heroin use remained fairly the same when compared to the 1st half of The proportion of patients who reported CAT as a primary drug of abuse remained higher than in other provinces, but remained stable at 11% of the total treatment population compared to the 1st half of In the Northern Region (NR), which now includes data from four centres in Mpumalanga and one in Limpopo (SANCA Far North in Polokwane), the main primary substance of abuse reported by the treatment centres was heroin (36%), followed by cannabis (34%) and alcohol (18%) (together comprising 88% of treatment admissions). The proportion of patients admitted for heroin use significantly increased to 36% when compared to the previous period (26%), and remains high when compared to other sites. In the Central Region (CR) (comprising of the Free Sate, Northern Cape and North West) alcohol was the most common primary substance of abuse, accounting for 47% of all admissions. Among the 388 patients treated at four centres during this period, cannabis was the second most common primary substance of abuse (27%), followed by CAT (10%) and cannabis/mandrax (4%). The proportion of patients reporting CAT use increased slightly when compared to the previous period and the proportion of admissions for cannabis remained stable in this period. TREATMENT ISSUES First time admissions: The proportion of first time admissions to treatment centres ranged between 75% (WC) and 96% (NR) across sites. First-time admissions now appear on average to make up about three quarters of admissions, and this indicates an increasing demand for services by persons who have not been in treatment before. Across sites, heroin, OTC/PRE, MA and cocaine were the substances that had the highest proportions of readmission. For example, in the WC 56% and 62% in the NR of patients treated for heroin dependence in the second half of 2016 had been in treatment previously. Referrals: Across most sites, the most common source of referral to specialist treatment centres was self/family/friends. This was followed by health professionals in the EC and schools in the NR, WC, and GT. The second common source of referral to specialist treatment centres in the CR and KZN was work/employer. A significant increase in referrals by work/employer in the CR was noticed during this reporting period (Table 1). During this period, the proportion of referrals by schools in KZN significantly decreased. Table 1: Referral sources (July - December 2016) (Column % add up to 100) SOURCE WC KZN EC CR GT NR Self/family/friends 46% 43% 46% 38% 56% 59% Work/employer 5% 14% 7% 29% 7% 8% Social services/welfare 13% 14% 7% 13% 10% 5% Doctor/psychiatrist/nurse (aka health professionals) 5% 4% 32% 6% 2% 6% Hospital/clinic 3% 4% 2% 1% 2% 2% Court/correctional services 6% 5% 3% 4% 8% 4% Schools 18% 12% 3% 8% 11% 14% Church/religious body 1% 1% <1% 1% 1% 2% e.g. radio 4% 3% - -% 2% - Gender: Across all sites between 73% (in the WC) and 89% (KZN) of patients were male, and gender differences were noted for various primary substances of abuse (see under specific drugs below). This trend remained fairly stable across all sites, although the WC and the EC have experienced a gradual increase in the proportion of female patients. This may be linked to the fact that a relatively higher proportion of MA, cocaine, and alcohol patients were female compared to many other substances. Race: (Table 4). In this period, proportions of Black African patients decreased slightly in the CR and the NR. Furthermore, and notwithstanding the demographics of these three provinces, in KZN 83%, GT 68%, NR 89% and in the CR 73% of patients younger than 20 years were Black African, indicating that in these sites there is better access to and utilisation of treatment facilities by young Black African people compared to adults. Employment status and education: Between 17% (WC) and 38% (CR) of patients were employed full-time across sites. The proportion of patients who were pupils/learners ranged from 12% in the EC to 24% in the WC. Over 70% of patients in the CR, GT and the NR have some secondary school education. The majority of patients younger than 20 years were students/learners. Mode of use: Smoking remained the most common mode of use for substances other than alcohol. Injection drug use was still low across sites but in the WC 5% of patients with heroin as their primary substance of abuse reported injecting as a mode of use versus 52% in GT, 3% in KZN and 2% in the NR. Age of patients: Across sites the mean age of persons seen by treatment centres was years and has remained fairly stable (Table 2). However, major age differences were noted for different substances. Persons, whose primary substance of abuse is alcohol, crack/cocaine, heroin or OTC/PRE, were substantially older than persons having other primary substances of abuse. Conversely, patients whose primary substances of abuse are inhalants and cannabis, tend to be younger than persons who have cannabis/mandrax as their primary drug of abuse. The proportion of patients younger than 20 years also remained fairly stable in most sites; with between 21% (EC) and 28% (WC) falling in this age group across all sites (Figure 1). 2 South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

3 Figure 1: Treatment admissions trends - % of patients <20 years Figure 2: Proportion (%) of persons in treatment with crack/cocaine as their primary drug of abuse Figure 3: Proportion (%) of persons in treatment with heroin as their primary drug of abuse Figure 4: Treatment demand trends: (%) as primary drug and secondary substance of abuse (WC) 3 South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

4 Table 2: Mean age of patients in treatment centres by selected primary drugs of abuse (July December 2016) SUBSTANCE WC KZN EC CR GT NR Alcohol CAT Cocaine/crack Cannabis Inhalants Nyaope/Whoonga OTC/PRE All substances Over-the-counter or prescription medicines Where n < 5, the mean is not reported Sources of payment The most common source of payment for treatment was state in the WC (67%) and GT (56%), family in the NR (42%) and KZN (38%), and medical aid in the EC (49%) and the CR (35%). Family was the second most common source in the WC and the EC, while medical aid was the second most common source in GT. Payment is of course linked to the availability of state funded centres and the proportion of inpatient centres for which medical aids are more likely to provide cover. HIV testing Across sites between 39% (EC) and 63% (WC) of patients had been tested for HIV in the past 12 months, showing an increase over time but still lower than desirable. FINDINGS BY DRUG OF USE/ABUSE ALCOHOL Alcohol was still the most common primary substance of abuse among patients seen at specialist treatment centres in the EC (39%) and the CR (47%). Alcohol accounted for 21% of admissions in the WC, 22% in GT, and 18% in the NR (Table 3). The proportion of alcohol-related admissions slightly increased in KZN. The mean age of patients seen at treatment centres who had alcohol as the primary substance of abuse ranged from 31 years to 38 years across sites. This was substantially older than the mean age for other drugs (see Table 2). Such patients were also more likely to be male. The proportion of patients who were female with alcohol as their primary substance of abuse ranged from 12% in the CR to 37% in the WC. A breakdown of patients in treatment for alcohol as a primary substance of abuse by race is provided in Table 5. CANNABIS (DAGGA) AND MANDRAX Cannabis was the most common primary substance of abuse among patients seen at specialist treatment facilities in the WC and GT regions accounting for 29% and 36%, respectively. It was the second most common primary substance of abuse in the CR (27%), NR (34%), EC (24%) and KZN (34%) regions. The proportion of patients with cannabis/mandrax as their primary substance of abuse remained very low in all sites (Table 3). mandrax was still relatively common as a secondary substance of abuse in the WC with 20% of all patients reporting it as a primary or secondary substance in the 2nd half of Persons seen in specialist treatment centres who reported cannabis/ mandrax as their primary substance of abuse tend to be older than those who had cannabis alone as their primary substance of abuse (Table 2). In this reporting period the most common primary substance of abuse for patients younger than 20 years in all sites (except in the CR) was cannabis (Table 6). MA has been the most common primary substance of abuse for patients younger than 20 years in the WC since However, during this period it was reported as the secondary substance of abuse among persons younger than 20 years. Data from specialist treatment centres suggests that the use of these substances are still mainly a male phenomenon. Across sites between <1% and 29% of patients whose primary substance of abuse was cannabis/mandrax were female. Between 7%, (NR) and 18% (WC) of patients whose primary substance was cannabis were female. Table 5 shows primary substances of abuse by race. Black African patients continue to dominate admissions for cannabis/mandrax across all sites, except in the WC and GT. The proportion of Black African patients who report cannabis/mandrax as a primary substance of abuse appeared to be increasing in the EC (and KZN), and this proportion slightly increased from 60% to 65% in this period. In the WC (87%) and GT (57%) the majority of patients that were admitted for cannabis/mandrax abuse were Coloured. CRACK/ COCAINE The proportion of patients at specialist treatment centres whose primary substance of abuse was crack/cocaine remained stable across all sites (Table 3). The proportions ranged from 1% in the WC to 5% in the CR (Figure 2). Cocaine powder is primarily snorted, and crack is smoked. Between 3%, (WC) and 10% (KZN) of all patients had used crack/cocaine either as their primary or secondary substance of abuse (Table 7). This indicates that crack/cocaine was also commonly a secondary substance of abuse. In all sites the mean age of persons in treatment, whose primary drug of abuse was crack/cocaine, ranged from 29 years to 34 years (Table 2). The proportion of female patients reporting cocaine/crack as their primary substance of abuse ranged from 11% in the CR to 32% in the WC. The majority of patients with cocaine/crack as their primary substance of abuse were Black African (except in the EC, KZN and the WC), followed by White patients in the CR, GT and NR. The majority of patients with crack/cocaine as their primary substance of abuse in the WC were White patients, followed by Coloured patients; and in the CR over 60% of the patients who reported crack/cocaine as their primary substance of abuse were Black African patients (Table 5). Generally, few adolescent patients reported crack/cocaine as their primary substance of abuse, the highest proportion being 2% in the EC. Between 8%, (NR) and 54% (WC) of cocaine patients had been in treatment before. HEROIN Between 2% (EC) and 36% (NR) of patients in specialist treatment centres reported heroin as their primary drug of abuse (Table 3). A slight 4 South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

5 decrease from 15% to 10% was noticed in KZN during this period. In the CR, heroin admissions saw a slight increase, but remained stable in other sites when compared to the last period. In the NR, the proportion of patients reporting heroin as a primary or secondary drug increased significantly from 27% to 37% during this period (Table 7). The mean age of persons who had heroin as their primary substance of abuse ranged from 25 years to 38 years across all sites (Table 2). appeared to be more of a male phenomenon like other drugs such as cannabis and cannabis/mandrax. However, the WC had the highest proportion of female patients who reported heroin as their primary drug of abuse (15%). In KZN and the WC, between 7% and 15% respectively, of patients with heroin as the primary substance of abuse were female. In the NR, 83% of heroin patients were Black African, decreasing slightly compared to the previous period. In GT, 76% were Black African, remaining stable compared to the previous period (Table 5). In the NR, 62% of heroin patients reported that they have received treatment before, and this has increased significantly compared to previous periods. In GT, 20%, KZN 12%, WC 56% and the EC 9% of heroin patients had been in treatment previously. Injection use by patients with heroin as their primary drug of abuse remained high in GT, with 197 users (out of 382 heroin users) reporting heroin injection. Amongst patients who reported injecting heroin, 79% were Black African and 19% were White patients. In the CR two patients, KZN four and in the NR only seven patients reported injecting heroin. In the WC 13%, in GT 16% and the NR 37% of all patients reported the use of heroin, as either primary or secondary drug (Table 7), indicating a slight increase in these regions. It is very likely that a large proportion of patients who report heroin as a secondary substance would soon experience it as their primary drug problem. For patients younger than 20 years, the proportion reporting heroin as their primary drug of abuse ranged from <1% (CR) to 11% (NR) (Table 6). In GT the number of patients reporting nyaope/whoonga (low grade heroin and other ingredients smoked with dagga) as their primary substance of abuse was high (n=174) relative to other sites. In NR sixtythree patients reported nyaope/whoonga as their primary substance of abuse. A total of 4% in KZN reported nyaope/whoonga as either their primary or as a secondary drug of abuse. OVER-THE-COUNTER AND PRESCRIPTION MEDICINES Between <1% (CR) and 6% the (EC) of patients seen at specialist treatment centres from July December 2016 had OTC/PRE medicines listed as their primary substance of abuse (Table 3). This proportion remained stable in the EC compared to the previous six-month reporting period (7%). The majority of patients who had OTC/PRE medicines as their primary substance of abuse across all sites, except in the WC, were male. The average age of these patients ranged between 28 years to 38 years (Table 2). OTC/PRE medicines are more common as secondary drugs of abuse with between 2% and 9% of patients across sites reporting these substances either as a primary or secondary substance of abuse (Table 7). Medicines abused included benzodiazepines, analgesics, codeine products and sleeping pills. During this reporting period, 212 (2%) patients across all sites reported the non-medical use of codeine, with the majority of patients coming from the GT region (N=81), followed by those coming from the WC (N=51). AMPHETAMINE-TYPE STIMULANTS (ECSTASY, METHAMPHETAMINE (TIK), METHCATHINONE (CAT)) AND LSD The proportion of persons using specialist treatment services, whose primary drug of abuse was ecstasy, remained very low across all sites. No more than 1% of patients reported ecstasy as their primary substance of abuse across all sites. was however reported as a secondary substance of abuse by several persons attending specialist substance abuse treatment facilities across all sites with between 0% and 2% reporting ecstasy as a primary or secondary substance of abuse (Table 7). In the WC, the proportion of patients reporting MA ( tik ) as their primary substance of abuse decreased to 29%. The mean age of patients presenting with MA as their primary drug of abuse in the WC was 30 years. Compared with a mean age of 19 in 2004, this may suggest a reduction in the number of adolescents using the drug as the proportion of new (first) admissions remains fairly stable. Most of the patients were Coloured (83%) and were male (67%). Most of the patients reported smoking the drug (98%) and only 3 patients reported snorted/sniffed it. Of the MA patients, 56% reported daily use of the drug and a further 21% reported using it 2-6 days per week. Overall 42% of all patients reporting for treatment in the WC in the second half of 2016 reported MA either as a primary or secondary substance of abuse, remaining stable compared to the previous period (Figure 4). For patients younger than 20 years, 9% reported MA as either a primary or secondary substance of abuse, a significant decrease from 17% in the previous period. In the EC, 22% of patients reported MA as a primary or secondary drug of abuse. Since the 2nd half of 2009, Port Elizabeth specifically has seen an increase in local patients admitted for MA, and the proportions significantly increased when compared to the previous period. In other sites, there were few patients who reported MA as their primary or secondary drug of abuse, ranging between 1% (KZN) to 9% in GT. In GT the number of patients reporting CAT as their primary substance of abuse remained high (n=325) relative to other sites. A total of 17% in GT and 13% in CR reported CAT as either their primary or as a secondary drug of abuse. Few patients in the other sites reported using this drug. OTHER SUBSTANCES/POLY-SUBSTANCE ABUSE substances abused by patients receiving substance abuse treatment included inhalants. Between <1% (WC) and 2% (CR) of patients seen at specialist treatment centres from January - June 2016 had reported inhalants as their primary substance of abuse. Poly-substance abuse also remained high, with between 24% (NR) and 50% (EC) of patients in specialist treatment centres reporting more than one substance of abuse. COMORBIDITY Overall, and across all regions 17% of patients presented with a dual diagnosis at treatment admission. The majority of patients reported mental health problems at the time of admission (24%), followed by respiratory diseases (21%) and diabetes (18%). A higher proportion of patients suffering from mental health problems were found in the WC, accounting for 30% of admissions. On the contrary, patients in the CR were more likely to suffer from diabetes, accounting for 79% of admissions. Table 3: Mean age of patients in treatment centres by selected primary drugs of abuse (July December 2016) Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N WC b < < a < b < a b < a b a b a South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

6 Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N WC b a b a b a b a b a b a b a b a b a b a b a b a b a b KZN a b a < b <1 9 < a b <1 12 < a < b <1 1 <1 0.0 < a < < b < < a b a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

7 Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N KZN a b a b a b a b a b a b a b a b a b a b EC a <1 <1 < b <1 <1 < a < < b a b a < b < a < b < a < b a b a b a b a a b a b a b a South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

8 Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N EC b a b a b a b a b a b a b GT 1998a <1 < b < a < b < a < b a < b < a < b a b a b a b a b a b a b a b a b a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

9 Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N GT 2014a b a a a b NR a <1 < b <1 < a b a b a < b a b a b a b a b a b a b a b a b a b a b a b a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

10 Site Period Alcohol Cannabis Crack/ Cocaine OTC/ PRE N CR a b a b a b a b a b a b a b a b a b a b Cape Town, Atlantis, Worcester; 2 Durban, South Coast, Pietermaritzburg; 3 Port Elizabeth and East London; 4 Mpumalanga & Limpopo; 5 Free State, North West, Northern Cape Table 4: Comparison of proportion of patients in treatment (July December 2016) with census data by site 1 BLACK AFRICAN INDIAN COLOURED WHITE WESTERN CAPE KWAZULU-NATAL EASTERN CAPE CENTRAL REGION GAUTENG NORTHERN REGION Population 1 33% 1% 49% 16% In treatment 17% <1% 72% 11% Population 1 89% 7% 1% 4% In treatment 71% 12% 7% 10% Population 1 86% <1% 8% 5% In treatment 49% 1% 25% 25% Population 1 83% 1% 8% 8% In treatment 60% 2% 14% 24% Population 1 77% 3% 4% 16% In treatment 59% 2% 17% 21% Population 1 94% <1% 1% 5% In treatment 79% 1% 3% 17% Table 5: Primary substance by race (columns per site add up to 100%): July December 2016 ALCOHOL CANNABIS CANNABIS/ MANDRAX CRACK/ COCAINE OTC/PRE HEROIN METHAM- PHETAMINE Western Cape Black African 28% 22% 8% 19% 8%* 3% 10% Coloured 46% 73% 87% 19% 21% 89% 83% Indian <1% <1% 1% 0% 4%* 1%* 0% White 26% 4% 4% 62% 67% 7% 7% 10 South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

11 KwaZulu-Natal Black African 71% 78% 73% 31% 23%* 74% 50%* Coloured 4% 7% 0% 14% 23%* 5%* 13%* Indian 12% 9% 20%* 45% 23%* 12% 0%* White 13% 5% 7%* 10% 31% 9% 37%* Eastern Cape Black African 46% 59% 65% 21%* 30% 73% 47% Coloured 26% 23% 19% 43% 43% 9%* 19% Indian 1% 0% 0% 0% 0% 0% 0% White 27% 19% 16%* 37% 27% 18%* 34% Gauteng Black African 56% 68% 40% 57% 31% 76% 36% Coloured 6% 21% 54% 11% 3%* 7% 28% Indian 2% 3% 2%* 1%* 0% 1% 3% White 36% 8% 4%* 31% 66%* 16% 32% Northern Region Black African 71% 85% 87% 71% 50%* 83% 33%* Coloured 4% 2% 0% 5%* 0% 3% 0% Indian 1% 1% 0% 0% 0% 1%* 0% White 25% 12% 13%* 24%* 50%* 13% 67%* Central Region Black African 56% 64% 63% 78% 0% 37%* 56% Coloured 14% 12% 19%* 11%* 100%* 13%* 38% Indian 1%* 2%* 6%* 0% 0% 0% 0% White 29% 22% 12%* 11%* 0% 50%* 6*% * = N<5 Table 6: Primary substances of abuse for patients younger than 20 years (%): July December 2016 Site Alcohol Cannabis Cocaine/ Crack Total (N) WC¹ 03b a b a b a b a b a b a b a b a South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

12 Site Alcohol Cannabis Cocaine/ Crack Total (N) WC¹ 11b a b a b a b a b a b KZN² 03a b a b a b a b a b a b a b a b a b a b a b a b a b a b EC 3 03a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

13 Site Alcohol Cannabis Cocaine/ Crack Total (N) EC 3 06a b a b a b a b a b a b a b a b a b a b a b GT 03a b a b a b a b a b a b a b a b a b a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

14 Site Alcohol Cannabis Cocaine/ Crack Total (N) GT 15a b a b NR 4 03a b a b a b a b a b* a b a b a b a b a b a b a b a b a b CR 5 06b a b a b a b a b a b a b a South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

15 Site Alcohol Cannabis Cocaine/ Crack Total (N) CR 5 13b a b a b a b Cape Town, Atlantis, Worcester; 2 Durban, South Coast, Pietermaritzburg; 3 Port Elizabeth and East London; 4 Mpumalanga & Limpopo; 5 Free State, North West, Northern Cape * Excludes data from Limpopo for 2007b Table 7: Overall substances of abuse* (%): July December 2016 Site Alcohol Cannabis Crack/ Cocaine OTC/ PRE Total (N) WC 1 04a b a b a b a b a b a b a b a b a b a b a b a b a b KZN 2 03a b a b a b a b South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41

16 Site Alcohol Cannabis Crack/ Cocaine OTC/ PRE Total (N) KZN 2 07a b a b a b a b a b a b a b a b a b a b EC 3 03b a b a b / a b a b a b a b a b a b a b a b a a a b a South African Medical Research Council SACENDU South African Community Epidemiology Network on Drug Use PHASE 41