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BACKGROUND: Alcohol use disorder (AUD) is a major public health concern in South Africa (SA). Abrupt cessation or reduction of alcohol intake in chronic users can result in withdrawal symptoms. Benzodiazepines are the treatment of choice but need to be used cautiously in patients with a lifetime history of substance abuse given their highly addictive potential. Symptom-triggered prescription of benzodiazepines during alcohol withdrawal using the Revised Clinical Institute Withdrawal for Alcohol Scale (CIWA-Ar) has been associated with improved safety and reduced benzodiazepines use. AIM: To investigate if implementation of the CIWA-Ar during alcohol detoxification impacted the dose of benzodiazepines used and withdrawal-related outcomes. SETTING: Alcohol rehabilitation unit (ARU) at Stikland Psychiatric Hospital. METHODS: A retrospective cohort study of 135 admissions over a six-month period comparing two groups: before (2015) and after (2017) the implementation of the CIWA-Ar. RESULTS: The study noted no differences in sociodemographic and alcohol-associated variables between the two groups, and there were no recorded complications in either group. The 2017 group had a lower percentage of patients that required benzodiazepines (33.8% vs. 51.4%, p = 0.04) and a lower median total amount of benzodiazepines used during alcohol withdrawal (0 mg vs. 5 mg, p = 0.01). CONCLUSIONS: The CIWA-Ar rating scale was an effective alternative to prescribing benzodiazepines pro re nata and decreased the total dose of benzodiazepines used during alcohol withdrawal. CONTRIBUTION: The use of a symptom triggered regime, like the CIWA-Ar rating scale, during withdrawal can be implemented safely in a SA treatment setting for patients with low-risk AUD.

Background: International studies have found high rates of psychiatric comorbidity among patients with alcohol use disorders (AUDs) and highlighted the clinical and prognostic implications of this finding. There is a paucity of information with regard to the extent of this problem within the South African context. Aim: The aim of this study was to investigate the prevalence of psychiatric comorbidity (DSM IV-TR) in treatment-seeking, alcohol-dependent South Africans. Setting: This study was conducted at the Alcohol Rehabilitation Unit (ARU), Stikland Hospital, Western Cape. Methods: This cross-sectional study was conducted over a 6-month period. The Mini-International Neuropsychiatric Interview (MINI, version 5) was used to assess psychiatric comorbidity in 101 (male, n = 65; 64.5%) alcohol-dependent patients. Interviews were conducted after the first week of admission to ward 13. Results: Most participants ( n = 63, 62.4%) had a co-occurring psychiatric disorder, the most common being major depressive ( n = 30, 29.7%) and anxiety disorders ( n = 43, 42.6%). Of the anxiety disorders, agoraphobia without a history of panic disorder ( n = 10, 9.9%) and social phobia ( n = 10, 9.9%) occurred most frequently, followed by generalised anxiety disorder ( n = 9, 8.9%) and post-traumatic stress disorder ( n = 9, 8.9%). Thirteen patients (13%) had a comorbid substance use disorder other than AUD. Conclusion: The prevalence of psychiatric comorbidity at this unit is high, especially among female patients. The findings emphasise a need to thoroughly assess patients and provide treatment and personnel who can manage the complex needs of a dual diagnosis patient population.

Objective: To investigate the clinical features, prescribing patterns and outcomes of psychiatric inpatients admitted with methamphetamine-induced psychosis.Method: A cross-sectional, descriptive pilot study was conducted between March 2014 and August 2014 at three South African Mental Health Care Act designated hospitals prior to admission to a psychiatric hospital. Patients with methamphetamine-related psychotic symptoms according to the DSM-5 criteria were eligible. Structured face-to-face interviews were conducted and the Brief Psychiatric Rating Scale was employed as a measure of current psychopathology.Results: Fifty-six participants were included. Positive psychotic symptoms (e.g. hallucinations) were more prominent than negative symptoms (e.g. affective blunting). Almost half the participants (43%) had previous episodes of methamphetamine-induced psychosis. Within this group, all had defaulted on the prescribed treatment prior to admission. Only 29% of the participants had received prior formal substance-use rehabilitation as treatment for their disorder. High rates of comorbid cannabis and alcohol use (51%) were recorded. Most of the participants required transfer to specialist psychiatric hospitals. The amounts of methamphetamine used were not a predictor of the persistence of psychosis; however, the pattern of use was.Conclusion: Clinical features correspond with other international findings. The currently employed model of sequential, non-integrated psychiatric and substance use treatment in this setting appears ineffective.

Background. There is a lack of studies addressing the frequency and correlates of comorbidities among heroin users admitted for treatment in South Africa (SA). Objective. To assess the frequency and correlates of psychiatric comorbidity among patients with heroin use disorder admitted to the Opioid Detoxification Unit at Stikland Hospital in the Western Cape, SA.Method. Participants (N=141) were assessed for psychiatric illness (Mini International Neuropsychiatric Interview), comorbid substance use disorders (World Health Organization’s Alcohol Smoking Substance Involvement Screening Tool), and legal and social problems (Maudsley Addiction Profile). Demographic, personal, psychiatric and substance-use history, in addition to mental state examination on admission, were collected from the case notes.Results. The largest group of patients (n=56, 40%) had not been abstinent from heroin use since drug debut, and most had been arrested for drug-related activities (n=117, 83%) and had family conflicts related to use (n=135, 96%). Nicotine was the most common comorbid substance of dependence (n=137, 97%) and methamphetamine was the most common comorbid substance abused (n=73, 52%). The most common comorbid psychiatric illness was previous substance-induced psychosis (n=42, 30%) and current major depressive disorder (n=37, 26%). Current major depressive disorder was significantly associated with females (p=0.03), intravenous drug use (p=0.03), alcohol use (p=0.02), and a higher number of previous rehabilitation attempts (p=0.008).Conclusion. Patients with heroin use disorders present with high rates of psychiatric comorbidities, which underscores the need for substance treatment services with the capacity to diagnose and manage these comorbidities.

Background. There are no studies in South Africa (SA) on the outcomes following detoxification and psychosocial rehabilitation of heroin-dependent patients.Objective. To compare the demographic, clinical, forensic and treatment data of active heroin users v. users who were abstinent at the time of interview 4 years after attending the Opioid Detoxification Unit at Stikland Hospital in the Western Cape Province, SA. Method. Participants included patients above the age of 16 years who had been admitted to the Opioid Detoxification Unit at Stikland Hospital for heroin detoxification between July 2006 and June 2007. Participants were individually interviewed (either in person or tele­phonically) using a structured self-report questionnaire to collect demographic, clinical, forensic and treatment data 4 years following heroin detoxification treatment at this unit. Results. Of the participants, 60% were abstinent and a large portion (34%) attributed this to social support. Furthermore, there was a significant (p=0.04) difference in the longest period of abstinence between the past user group and active users, with more participants in the past user group being abstinent for 18 months or longer (n=24, 57%) than in the active users group (n=8, 29%). Active users (n=18, 64%) had significantly (p=0.03) more legal problems than abstinent users (n=14, 33%). Most participants (n=38, 54%) relapsed within 3 months after index detoxification and rehabilitation. Conclusion. Active users had more legal problems than abstinent users, with social support structures playing a pivotal role in abstinence. Future research should assess the impact of interventions such as post-discharge social support programmes on criminality and heroin use in those that relapse following treatment.

A worrying increase in heroin use disorders has been noted in South Africa over recent years. Despite this, very limited treatment options exist in the state sector. This article provides a brief overview of the local extent of the problem and its implications, and discusses treatment options. It briefly investigates international treatment implementation strategies and makes suggestions for local policy.

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