Staff at TB HIV Care provide methadone at a drop-in centre in central Cape Town. Archive photo: David Harrison
Research shows that people are more successful at quitting heroin when they enrol in opioid agonist therapy (OAT) programs, which provide prescribed medicines to block withdrawal symptoms.
Government has largely failed to fund OAT. Instead, it has invested in abstinence or detox-based rehab programs that are usually unsuccessful.
The government appears to be changing tack. In July it advertised a pilot OAT program to begin next year at two government clinics – one in Mpumalanga and another in the North West.
Concerns have previously been raised that state-sponsored OAT could lead to an uptick in methadone overdoses, but some researchers say these risks can be managed by ensuring that users take their medication at clinics under the watchful eye of clinicians in the first weeks or months of their treatment.
The government is preparing to trial a medically-assisted treatment program to help heroin users who want to quit the drug. This is after long resisting this approach, in favour of drug-free rehab programs that have yielded low success rates.
In July the national health department requested bids to run a pilot program to provide opioid agonist therapy (OAT) to heroin users. OAT is a form of treatment in which people who are quitting heroin (or reducing their intake) are provided with medicines, called opioid agonists. These drugs block the painful withdrawal symptoms that occur after a person quits heroin.
The health department has until February 2025 to appoint a service provider to run 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. These locations were 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 that is taken once a day. OAT programs usually offer it alongside other forms of assistance, such as counselling or therapy. The medicine is typically administered for a minimum of six months.
Clinical trials show that heroin users are more successful at kicking the habit when they’re provided with methadone than when they’re sent to drug-free rehabs. 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, such as 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 ten days. This short-term option is called detox therapy, and research shows that it isn’t as effective as longer-term OAT programs.
Similarly, at government-funded rehabs, 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 programs but the available evidence isn’t promising.
One study looked at 300 heroin users who went to state-funded rehabs in Johannesburg. It found that three months after the program 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.
After getting new needles and syringes from a mobile program at a site in Wynberg, Cape Town, a man prepares a small dose of heroin nearby. Photo: David Harrison
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. The committee is an advisory body that helps select which drugs the government should buy for public sector patients.
This led to a period of consultation. In 2021, the committee published a review which stated that OAT is more effective at reducing heroin use than drug-free or detox-based programs. 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, in order to see whether government clinics have the capacity to run these programs safely. The health department states that this “will help to inform the rollout [of] OAT in the country in a safe, cost-effective and efficient way”.
Effects of methadone
For people who are dependent on heroin, withdrawal can come just a few hours after their last hit. The symptoms can include fever, body aches and intense fatigue. The American author, William Burroughs, who used heroin for years wrote that it “is a feeling as if the life energy has been shut off so that all the cells in the body are suffocating”.
Heroin users who live on the street are constantly hustling to buy enough heroin to stave off these looming withdrawal symptoms.
Users in Cape Town’s Joe Slovo township told GroundUp that they needed at least six quarter gram shots a day (though usually more), which cost R25 a pop. This comes to R150 a day. To support this they engage in a range of odd jobs that provide immediate cash, such as carting scrap metal to recyclers or assisting small informal businesses with cleaning up.
The hustle 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 – applying for jobs, finding a steady shelter, and building relationships.
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 Centers 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 US since the country’s regulator curbed the use of methadone for pain relief. This is despite the distribution of methadone for OAT programs going up significantly over the same period.
Meanwhile, evidence from Norway shows that when that country rolled out a national OAT program, total overdose deaths from opioids came down, as the program helped people to get off illicit drugs like heroin.
According to Dr Andrew Scheibe, a medical doctor and harm reduction researcher at the University of Pretoria, “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 on opioid agonist therapy is in the first couple of weeks of use. 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 national health department on questions of capacity [at primary healthcare clinics]”. Gray noted that this is also given the “need to provide comprehensive services to users, not only OAT”.
According to Scheibe, 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 then allows them to resume other parts of their lives”. Scheibe says that “the COVID epidemic pushed many countries to allow take-home methadone … and there was no change in overdose deaths due to methadone as a result”.
In the US, following lockdown regulations, OAT clinics began providing users with weeks’ worth of methadone at a time, after previously requiring daily observed treatment. A paper in 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 come down as new products have entered the market. These include a product by Adcock Ingram called Adco and another by Umsebe Healthcare called Misyo.
Both of these products were registered by the country’s medicines regulator, SAPHRA, 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.
At present, Adco sells at R368 (including VAT) for a 100 ml bottle, and there are 10 milligrams of methadone per ml.
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 60-120mg 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 were negotiated on tender.
