Many of us know someone who’s battled addiction. We know it takes much more than a strong will and good intentions to overcome this complex, chronic condition. When our loved one’s health is on the line, we want them to have the best chance possible to recover. But what about our neighbours?
It’s in everyone’s interest to have healthy neighbours who can get the care they need. But today in South Africa, of the 13.3% of our population who battle addiction – about eight million people – less than 5% ever access treatment.
This treatment gap does untold damage to families, livelihoods and our shared future. Chronically underfunded services are largely to blame. But so is our approach. Public education is lacking and evidence-based strategies rarely guide policy, especially where addiction and homelessness intersect.
As a social worker who’s helped clients overcome addiction and homelessness, I know silver bullets don’t exist. But with both challenges on the rise, now is the time to confront our shortcomings and change course. We can start by understanding what causes addiction, how it functions and where our response falls short.
Genetics and environment
First, the two major causal factors for addiction are our genetics and environment, with genes accounting for about 50% of our risk.
Adults with any history of adverse childhood experiences (ACEs) – including abuse, community violence or household dysfunction – are 4.3 times more likely to develop addiction. The more ACEs, the higher the risk; adults with five or more ACEs, for example, are seven to 10 times more likely to develop a substance use disorder.
Data like this informs our understanding of addiction, which has evolved over time. Early on, addiction was believed to be a moral failure. But as science and medicine advanced, so did our understanding. Since the 1950s, the disease model has largely shaped our view and treatment of addiction. But in the early 2000s, the trauma-informed care model emerged. Today, this model “is increasingly recognised as a more effective approach than the traditional disease model”.
A substance use disorder is no more a choice or character flaw than diabetes, asthma or anxiety
Trauma is strongly associated with addiction because humans are hardwired to survive. We often develop maladaptive behaviours to cope with stress or trauma. If we don’t heal or learn healthier coping strategies, these behaviours can turn into mental health or substance use disorders. For many, the trauma of homelessness leads to substance use, for example.
Ultimately, addiction (much like homelessness) is rooted in trauma and poverty. Poverty increases a child’s risk of trauma, which increases their risk of addiction, which increases their risk of homelessness. Childhood poverty is the single biggest predictor of homelessness in adulthood.
Next, addiction functions by literally changing the brain. It’s a mental health disorder that alters our brain’s circuitry and chemical systems, interfering with vital functions like decision-making, learning and self-control.
The idea that someone could simply “turn off” their addiction if they really wanted to is mistaken. This false but persistent belief does a lot of harm, seeding stigma and discrimination that further isolate people who need help. The fact is, a substance use disorder is no more a choice or character flaw than diabetes, asthma or anxiety – all are chronic, treatable conditions.
Sometimes, some people will engage in antisocial or even criminal activity to manage the compulsive need their disorder creates, but this isn’t true of the majority. Ultimately, closing the treatment gap is the best way to curb any negative social consequences of addiction.
Treatment gap
Finally, where are we falling short? In the Western Cape, addiction rates are substantially higher (20.6%) than the national average. A recent review of services found that almost a third of patients report poor outcomes, leading researchers to conclude that the province is “unlikely to see a return on its investment in [substance use disorder] treatment without systems-level interventions to improve the quality of existing services”. From training up staff to incorporating mental health services, experts suggest several changes.
Nationally, both public and private healthcare providers (and insurers) narrowly focus on short-term treatment (21 to 42 days) even though it’s well documented that longer-term treatment (90-plus days) delivers better outcomes. This must change. All patients deserve evidence-based care, which is also more cost-effective over time.
Outpatient care is hardly ideal for someone who’s unhoused.
In Cape Town, our shortcomings are most glaring for people seeking treatment while homeless. Without sponsorship from an NPO, recovery is next to impossible for someone living on our streets. An estimated 63% of our 14,300-plus homeless population battle addiction. But we only have two free inpatient rehabilitation centres. Both centres only offer short-term care, and they operate with a massive caveat: if you don’t have a place to live after treatment, you won’t be accepted.
Joining a waitlist for outpatient services, which are typically limited to 21 to 28 days, is the other free option. While these services are suitable for some, outpatient care is hardly ideal for someone who’s unhoused.
Because of underfunding and understaffing, most Cape Town shelters don’t offer daytime programming or in-house addiction services. They also require abstinence and will refuse entry to people who can’t comply because of their disorder. These policies are regularly cited among reasons that most homeless Capetonians don’t use our shelters.
These issues can be divisive. But we should be able to agree that everyone deserves a fair shot at recovery – and right now our homeless neighbours don’t have one. Instead of disparaging people who don’t have viable options, let’s make it easier for them to get healthy.
We can start by following global best practice and local experts’ advice to redirect existing funding away from ineffective punitive measures and towards successful developmental and therapeutic approaches, including harm reduction, trauma counselling and supportive housing.
We’ve seen some movement in this direction, but much more is needed. In the end, failing to solve these problems is far more expensive than succeeding. Let’s decide that we want to succeed. DM