Maverick Life

Maverick Life

Addiction & Recovery: When the carrot beats the stick

South Africa saw its share of drug-related crime in 2016. Media personality Hope Zinde was reportedly the casualty of a drug-related murder, while murder accused Henri van Breda was more recently busted for drugs. According to the 2015/2016 crime statistics, an average of more than 700 drug-related crimes were recorded each day. Approaches to the problem vary, but most agree on two things: one, a punitive approach doesn’t work; and two, it’s time to go back to the drawing board. MARELISE VAN DER MERWE talked to two men working in the trenches, whom you can catch at this year’s South African Recovery Film Festival.

1. Shaun

Shaun Shelly is an addiction specialist. He’s not what you’d expect, although talking to him, you’ll find yourself wondering why his approach is so unusual.

Our starting point is that we treat drug users like human beings,” he says.

You’d think he was stating the obvious, but unfortunately for many, he isn’t. Human rights abuses remain rife against those most likely to use substances.

If Shelly’s name sounds familiar, you may be recalling an earlier interview with John Maytham, in which Shelly argued against the redesign of Cape Town park benches in a way that would disadvantage the city’s homeless. He himself had spent a period on the streets, which he attributed to addictions and mental health difficulties; he agreed to speak to Maytham after writing a strongly worded letter to the radio station which sceptical listeners thought was fake. Shelly went on air, confirmed he existed, and the doubting Thomases were duly chastised.

I’m a drug guy, for lack of a better term,” he says today, although the unofficial job title belies a relentless work ethic. In addition to postgraduate study, much of Shelly’s work, affiliated to the Addictions Division in the Department of Psychiatry and Mental Health at the University of Cape Town, involves advocating for human rights. This covers a fight for changing drug policy at local and national level, homeless rights, and advocacy within the TB/HIV Care Association StepUp Project. The latter includes delivering HIV prevention and harm reduction services to people who inject drugs.

Shelly has extensively researched the perceptions and experiences of heroin users accessing medical treatment, and the picture isn’t pretty. As one might expect, drug users experience prejudice, insufficient access to medical care, and difficulty managing disease.

In his spare time – and there isn’t much – he takes on private clients, helping them find appropriate levels of intervention. Perhaps the most unusual aspect of his approach is that it isn’t rooted in abstinence. Abstinence, he believes, is not always essential to harm reduction, and drug use should not be uniformly maligned. It depends on the client.

I am developing a cumulative continuum-based model for addiction treatment that embraces both harm reduction and abstinence approaches within the same framework, so as to provide appropriate levels of intervention according to the patient needs, stage of change and desired goals,” he says. “I use a non-abstinence based harm reduction approach to help the individual achieve the changes they desire.”

In other words, you decide where you lie on the spectrum. And based on that, you decide whether you want to abstain, reduce use, or neither.

Shelly is working in a special project advocacy role on three harm reduction projects: two of which are under way in Cape Town and Durban respectively, and one of which is about to kick off in Nelson Mandela Bay. The aim is to deliver the recommended set of health services to injecting drug users. This is extremely important to containing the spread and impact of HIV/Aids, since its incidence is nearly 30 times higher among people who inject drugs in South Africa. Despite their risk, however, this group remains among those with the least access to life-saving treatments, healthcare and preventive measures.

We are also looking at human rights abuses among drug users in general, and have taken on the role of looking at drug policy in this context,” says Shelly.

It’s a revolutionary approach, and one which, if it is embraced widely, has major potential to impact on both drug policy and healthcare. Already this year, says Shelly – who has worked extensively with the International Drug Policy Consortium – the South African Drug Policy Week received strong support from policy-makers and the international healthcare community. Its first event was held in February 2016; it will be followed up in August 2017.

Meanwhile, Shelly and colleagues are continuing with a non-punitive approach on the ground. They try, as far as possible, to provide drug users with access to medical care. They record human rights abuses. They provide clean needles and syringes.

They [injecting drug users] are highly stigmatised,” says Shelly. “We talk to them. We treat them like human beings.”

Support comes from surprising quarters, says Shelly. Some of the most productive partnerships have been with street police officers, who have offered valuable insights into how drug use can be managed more productively. Overwhelmingly, police officers call for a safety rather than a securitised approach. It’s possible that they, too, feel overwhelmed.

I advocate a lot for decriminalisation of drug use in South Africa,” says Shelly. This isn’t only supported by anecdotal evidence; in South Africa, we spend R60-million per year on incarcerating low-level cannabis users (5,671 people arrested per year; it would be R300-million in Gauteng alone if the conviction rate were higher). If only 50% of those people made it onto the court roll, that’s over 2,000 court days – a major burden on the legal system and the economy.

A practical struggle in the non-punitive approach, however, lies with opioid substitution. In South Africa, where heroin and its cousins (nyaope/whoonga) are so popular, it’s a crucial problem that the pharmaceutical substitutes are not on the central drug list. Even if they were, stock-outs are common. Only one public health treatment centre in South Africa stocks substitutes at all.

The lack of substitutes also impacts on standard healthcare. “People go into hospital for TB treatment, for example, but it’s difficult to retain them [if they’re in withdrawal],” explains Shelly.

For Shelly, the only way forward is a community-oriented primary care approach. Decriminalise, provide adequate healthcare, and manage addiction based on the needs of the individual.

Addiction, he says, is the only area where it’s still acceptable to practise “apartheid-style policing”.

It doesn’t help that we criminalise a coping behaviour,” he says. “It’s just another way of oppressing marginalised people.”

2. Ashley

Ashley Potts is chalk to Shelly’s cheese. Director of the Cape Town Drug Counselling Centre in Observatory, he advocates abstinence. He also deals, frequently, with addicts for whom drug use and crime have become part of the same lifestyle. But Potts and Shelly do have one thing in common: they believe in absolute respect and zero judgement.

We provide a service to the public,” says Potts. “We have outpatient sessions, and clients can come in on a daily basis. All our services are rendered by qualified registered therapists and supervised by a clinical officer.”

The centre’s approach is based on the disease model; that is, it regards addiction as an illness to be treated. The counselling style is motivational interviewing, which works on resolving ambivalence. This, says Potts, helps to bring a client that may still be unsure of whether they want to stop using their substance of choice to a point where they realise they do need to change.

It’s a non-confrontational, non-judgemental way of helping them realise they are heading for disaster,” says Potts. “It helps the client understand their status.”

The entire evidence-based treatment process takes six weeks, plus an optional extra three weeks of after-care.

Firm-but-kind myth busting is an important part of Potts’ job, not only to help clients understand their situation, but also to help counsellors and families understand what they are facing.

Daily Maverick asks Potts about some of the misconceptions around addiction; it turns out there is no shortage.

Uncomfortable truth 1

The success rate of the programme is high, but not as high as one might hope. A large sample study by UCT revealed a 60% success rate. Counsellors are advised by the centre to “let go”; that is, to understand that not everybody will stop using, and not everybody will be okay using.

Uncomfortable truth 2

Everything is not okay in the end. Potts and his staff reconcile themselves to the fact that there will be a reasonably high relapse rate; it goes with the territory. Even where there is not, some of the client letters are heartbreaking.

A 32-year-old recovering tik user writes: “Before I came to the centre I had years of drugging behind me. I wasn’t aware of the resources I had open to me. Coming here was the best thing I could have done for myself. I am no longer so scared.”

A 25-year-old tik user adds: “I never in my life had received so much support.”

It’s difficult to imagine that someone may not be aware that they can approach a drug counselling centre or that the support they receive from strangers may be the most they ever get in their lives, but this is the reality for many at the centre. And it’s spreading among younger people. Schools are increasingly referring pupils to the centre, and the staff are communicating with police to bring young people in.

We always say, if you have to bring them in by the scruff of the neck, bring them – our people know how to talk to them to calm them down,” Potts says. “Just bring them in.”

Uncomfortable truth 3

It’s not what the drug is, it’s your relationship with it. One can have a much worse addiction to a so-called “milder” drug. Just because it’s alcohol or cannabis or gambling or even food, Potts says, doesn’t mean it’s “better” than, say, tik or nyaope. It can still ruin your life when you’re not looking. “We get that [misconception] a lot,” he says.

Uncomfortable truth 4

There hasn’t been a spike in adolescents coming to the centre, exactly, but those that are coming are getting younger.

If they come to us at 12, that means they are starting at nine or 10,” Potts explains. “It only presents when they are caught out. As communities, we need to be a lot more responsive, a lot more alert.” A supportive network, too, is crucial.

The trouble with this is that a large portion of Potts’ clients are gang members, for whom gangs can be substitute families, communities, or their actual families. Sometimes family members happily use with their children. Then it’s a little more complicated.

As you say, you don’t just walk out of a gang,” Potts says wryly. “It would take a very rare person to maintain sobriety under those circumstances.”

Uncomfortable truth 5

The glass isn’t half full. It’s a myth that any treatment is better than none. Inadequate treatment does more harm than good; go to a professional and stay there.

Recovery does not end on completion of the programme,” says Potts. “It’s lifelong.” DM

Catch Shaun Shelly and Ashley Potts at the 2016 South African Recovery Film Festival, opening at the Labia in Cape Town and the Bioscope in Johannesburg on 22 September. A portion of the proceeds from tickets sold will support the Cape Town Drug Counselling Centre.

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