Table 2: Participants characteristics for the in-depth interviews conducted in eThekwini district, KwaZulu-Natal
Participant
|
Category
|
Gender
|
Race
|
Age
|
Residence
|
1
|
Has been living with HIV since 1999
|
Female
|
Coloured
|
54
|
Durban
|
2
|
Has been living with HIV since 2003
|
Male
|
Coloured
|
59
|
Wentworth
|
3
|
Has been living with HIV since 2003
|
Female
|
Asian
|
42
|
Merebank
|
4
|
Has been an analyst with law enforcement for 4 years
|
Female
|
Black
|
32
|
Pennington
|
5
|
Has been an analyst with law enforcement for 8 years
|
Female
|
Asian
|
32
|
Umhlanga
|
6
|
Has been an analyst with law enforcement for 5 years
|
Female
|
Black
|
29
|
Amanzimtoti
|
7
|
Has been a health care provider since 1988.
|
Female
|
Asian
|
53
|
Asheville
|
8
|
Has been a health care provider since 2014.
|
Male
|
Black
|
36
|
Isipingo beach
|
9
|
Has been a health care provider since 1991.
|
Female
|
Black
|
51
|
Marianhilll
|
10
|
Qualified as a doctor in 1979 and working in the substance abuse treatment facility for 12 years.
|
Male
|
Asian
|
62
|
La Lucia
|
11
|
Qualified as a doctor in 1972 and working in the substance abuse treatment facility for more than 25 years
|
Male
|
Asian
|
74
|
Westville
|
12
|
Qualified as a doctor in 1983 and working in the substance abuse treatment facility since 1992
|
Male
|
Asian
|
57
|
Mount Edgecombe
|
13
|
Has been a pharmacist since 2006.
|
Male
|
Asian
|
33
|
Newlands
|
14
|
Has been a pharmacist for 19 years.
|
Male
|
Asian
|
43
|
Hillcrest
|
15
|
He is a recovering drug user, He used drugs including prescription drugs for 6 years
|
Male
|
Coloured
|
20
|
Permanent residence in Pietermaritzburg, currently visiting Merebank
|
16
|
He is a recovering drug user. He used drugs including prescription drugs for 5 years
|
Male
|
Black
|
19
|
Montclaire
|
17
|
He is a recovering drug user. He used drugs including prescription drugs for 8 years.
|
Male
|
Black
|
34
|
Mayville
|
18
|
She is a recovering drug user. She used drugs including prescription drugs for 13 years.
|
Female
|
Indian
|
34
|
Pinetown
|
Participant’s understanding of drug diversion, misuse and abuse
Majority of participants in the health care profession viewed drug misuse as not taking medication as prescribed, using medication for purposes other than medical diagnosis, wrong dose, wrong duration and taking medication not for the appropriate indication. Most participants associated drug abuse with taking drugs in an addictive potential in order to have some sort of high, using drugs at higher doses, using drugs that are highly addictive with addictive potential or physical dependency. Very few participants were familiar with the term “diversion” however some associated drug diversion with using another patient’s medication, using multiple facilities to collect medication, distributing drugs illegally, drugs taken for another use or by another user not according to policies and essential drug list (EDL). Interestingly, one participant viewed drug diversion as prescribing drugs while not using policies and protocols.
“Abuse would be that if a patient umm! probably is not taking their medication as prescribed or using other or another patient’s medication umm! or just maybe using multiple facilities to take medication, to collect medication from and that term of abusing in that way abusing the health systems as such and misuse probably is not when they are not taking their medication as prescribed, giving medication to people that umm! were they haven’t been seen at the health facility. They are actually prescribing medications to those patients issuing medications without a proper prescription. Diversion I’m not too sure really. It’s a term that’s new to me.” (Participant 7, Health care provider)
“Diversion it could be a person addicted or the person dealing with it. It’s a person distributing it illegally now my concern is mostly with those who would become addicted to it that means they use it not in the way that it was intended to be used.” (Participant 10, Doctor for substance abuse treatment)
“Misuse would be, the wrong dose, for the wrong duration, for not the appropriate indication and things like that. Abuse for me would be when they are taking it in an addictive potential so, where they are taking it in order to feel high. Using it at higher doses and also you see the type of drug would come in there. So, things that are highly addictive. Your amphetamines, your opioids things like that they have a central nervous system addictive potential or a physical ability. A physical dependency. Prescription drug diversion, to be honest. I have not come across that term.” (Participant 13, Pharmacist)
“You prescribe a drug not using policies and protocols and for the wrong reasons the drug is taken for another use not according to policies and EDL.” (Participant 9, Health care provider)
Participants not in the health care profession viewed drug misuse as not taking medication as prescribed, not fully following instructions, using drugs for wrong purposes, inconsistent use, overuse, wrongful intake, overdosing and taking drugs to relax. Meanwhile drug abuse was associated with addiction, dependency, use for recreational purposes and use for wrong reasons and illegal. Interestingly, some participants associated drug abuse with using drugs to sleep, feeling good, getting high and taking things like sugars. Few participants were familiar with the term “diversion” however drug diversion was viewed as drugs manufactured in clandestine laboratories, drugs bought on the street, passing drugs to another person not suited to and asking for medications from others.
“drug diversion… drugs that are manufactured in clandestine laboratories… something that have been bought on the street… Drug misuse, let’s take if you were prescribed medication and then they say you have to take it this way and you didn’t take it that way so you are misusing the drug. You are not fully following instructions.” (Participant 4, Law enforcement)
“Basically, I would say is the wrongful intake of medication. That its prescribed to you and other people think like they either want to abuse it or they run out of their own medication, but they are asking for your medications to supplement their own.” (Participant 1, Person living with HIV)
Recovering drug users were able to relate to their experiences and viewed inappropriate drug use as taking drugs to feel nice, unable to cope with normal life without the drug and using drugs to get high. For example, taking ritalin drug while not being diagnosed with attention deficit hyperactivity disorder (ADHD) to get high. Others viewed inappropriate drug use as mixing cough mixtures with cold drinks to get high.
“I think how it makes you feel, cos I know umm! if you are diagnosed with ADHD you put on ritalin and has certain effect on that is helpful but if you not ADHD then you take ritalin then you gonna get high.” (Participant 18, Recovering drug user)
“I think it’s something like, this thing that is happening nowadays where people mix cough mixtures like bronclear, benylin, different milligrams with cold drinks.” (Participant 15, Recovering drug user)
Thematic Framework
Five themes emerged during the interviews:
- Manifestation of drug diversion
- Extent of prescription drug diversion, misuse and abuse
- Accidental addiction
- Consumer’s attitude and behaviour
- Availability of medicines
- Gaps in the health care system
- Challenges and barriers to drug abuse treatment
1. Manifestation of drug diversion
Participants presented different manifestation of drug diversion, these include the following: surplus prescribed medications; incorrectly prescribed medications; and mixing codeine containing cough mixtures with anti-depressants to boost the effect or taking sleeping tablets to replace heroin effect. A pharmacist described the legal channels of obtaining prescription medication and another participant described how he got involved in diversion.
“It can occur in formal channels as well, where patients are getting doctors to write up prescriptions they don’t actually, they are not the end user of that medication.” (Participant 13, Pharmacist)
“These people could not access, they used to ask me. Why are you asking me to get the beta pain tablets? The pharmacy does not want to give us. The mother and daughter used a pack per day”. (Participant 2, Person living with HIV)
“So your doctor refuse to write you another script so you go looking on the street and, on the streets, they not going to sell you morphine tablets they are gonna give you heroin and that’s often how clients and other people start using heroin is to compensate for morphine.” (Participant 18, Recovering drug user)
a. Extent of prescription drug diversion, misuse and abuse
Most participants viewed drug diversion, misuse and abuse as a serious growing problem occurring everywhere to anyone. Drug diversion, misuse and abuse was mostly observed in private facilities. Despite, measures put in place in facilities, people have strategies to prescription drug diversion, misuse and abuse. Two participants specifically mentioned pain medication as the commonly misused drug class.
“In South Africa and in most developed countries it is prescription drugs. It’s a growing epidemic. Sometimes, I feel that maybe a bigger epidemic than the illicit drugs… in eThekwini there is a lot of pain tablets abuse especially the poly drugs.” (Participant 12, Doctor for substance abuse treatment)
“That’s a big problem in my private practice. Beside those drugs what we see mainly is codeine. Mainly codeine, codeine dependent you know the cough mixtures and the pain tablets.” (Participant 11, Doctor for substance abuse treatment)
b. Accidental addiction
Most participants described accidental addiction as one of the leading problems that puts vulnerability to consumers. Pre-existing conditions such as pain, predisposes consumers to continuously use painkillers and subsequently develop into an addiction problem.
“Well, they start, they probably take it you know like codeine and the pethidines and all. They probably take it for a genuine headache when they start getting headaches and because they can get over the counter. They think it’s just a minor medication. Whenever they get headache now and again. Instead of taking paracetamol or panado they take umm! codeine with it and eventually get addicted or sometimes they can’t sleep they take a sleeping tablet the doctor gives them. I give them four tablets but ones they find that they get a nice sleep with these drugs they want it all the time. That’s how the addiction starts.” (Participant 11, Doctor for substance abuse treatment)
“I was put on morphine tablets for my hip pain just before I had my hip replacement so the doctor write a script and he says am only going to give you this for 3 months, but then after 3 months you have been taking this morphine three times a day for 3 months do they honestly don’t think that you gonna be addicted to this someway.” (Participant 18, Recovering drug user)
“Circumstances will be a pre-existing condition like pain they have been prescribed is strong painkiller by the doctor for example. They might have been in an accident. Maybe traumatic accident at that point, maybe they might have needed pethidine shot at the hospital to keep under control. There after it becomes an addictive substance.” (Participant 14, Pharmacist)
2. Consumer’s attitude and behaviour
Participants raised concerns about the consumers’ attitude and behaviour towards health care providers when they require more prescription drugs to treat or cure their conditions. It was reported that consumers become aggressive, demanding, asking for specific drugs. It was also noted that most consumers who are addicted to prescription or over the counter drugs are in denial of their addiction problem.
“Doctors cannot afford the time per patient to see… because patients are very demanding as well, they become very aggressive. And so doctors feel like to avoid the conflict they would prescribe and if they prescribe it…a lot of the time where these treatments get used, they are prescribed not on an assessment of the doctor but because the patient is asking for it.” (Participant 13, Pharmacist)
Health care providers and pharmacists felt that their profession is been put in difficult situation and disrespected most of the time by consumers who are addicted to prescription drugs.
“You get one to two patients who you can see they come regularly, and they bully you to give them the tablet if you don’t give it to them, they go to the next doctor until they find somebody.” (Participant 11, Doctor for substance abuse treatment)
“You have issues were the patients says, “but the doctor prescribed it and I need it.” so it puts you at a difficult position.” (Participant 13, Pharmacist)
“I got to the point where panado or gen-payne, all those types of things were not helping me, so I decided not to disclose to the doctor that I had a history of addiction”. (Participant 18, Recovering drug user)
3. Availability of medicines
All participants believed that medicines are readily available and accessed everywhere either via legal or illegal channels through facilities or dealers and emphasised that there is no need of a physical location. Most drug misusers prefer using the cheapest and easily accessible drugs, which can be obtained over-the-counter. It was also reported that illegal drug venders are also sell drugs during social grant collection targeting elderly people and introducing inappropriately packaged and unlabelled medicines.
“You get from dealers that get from pharmacies or whoever, that we can get from very easily and over the counter in pharmacies.” (Participant 15, Recovering drug user)
“When it is pension time…when you just passing by you see pills, they look like stilpane some are capsules in transparent plastics.” (Participant 4, Law enforcement analyst)
Participants perceive that medicinal drugs were cheaper compared with illegal drugs.
“For some people that I know they go for the cheapest drugs and its easier accessible you can just get it over the counter.” (Participant 15, Recovering drug user)
“That drug is much expensive drug, this is cheaper, so price comes in.” (Participant 12, Doctor for substance abuse treatment)
4. Gaps in the health care system facilitating drug diversion, misuse and abuse
Majority of participants had perceptions of gaps in the health care system at various dimensions. In the public sector, there were issues of consultation time, negligence and no proper guidelines contributing to diversion. Meanwhile the private sector was money driven therefore influencing diversion.
“If its public it is usually time and negligence. If I think of all my interaction with pharmacist or pharmacist assistant they are talking with the person next to them or behind or looking at their phones and they are really not looking at the file and the prescription, not really not engaging much with the patient and so the patient become a problem rather than the reason for their job.” (Participant 1, Person living with HIV)
“The medical profession is over regulated to a point where doctors and pharmacists will be looking at other avenues of obtaining money.” (Participant 14, Pharmacist)
“It’s the doctor’s role going into the backgrounds. Lots of patients complain about the doctor’s interaction.” (Participant 12, Doctor for substance abuse treatment)
Within the health system, health care providers viewed their prescribing patterns as inappropriate.
“Very bad. We shouldn’t even be prescribing but I stopped in fact I refuse to prescribe in my rooms. I refused to.” (Participant 11, Doctor for substance abuse treatment)
“I think within the facility environment, us as prescribers so you find that we prescribe antibiotics where else the patient doesn’t need that antibiotic it does happen.” (Participant 8, Health care provider)
Majority of participants believed that medicines were easily accessed in pharmacies since pharmacies do not question consumers during purchase.
“Whenever I feel like going to the pharmacy to get medication, no question asked I will be given the medication.” (Participant 8, Health care provider)
“You get from dealers that get from pharmacies or whoever, that we can get from very easily and over the counter pharmacies, some pharmacies don’t ask you for it they just give it to you over the counter.” (Participant 15, Recovering drug user)
5. Challenges and barriers to drug abuse treatment
Drug abuse is difficult to treat when patients don’t take ownership of the underlined problem. Barriers such as inadequate knowledge of how treatment works, health systems barriers with pharmacies were by even after confrontation some pharmacies continued issuing the addictive products was the main concerned mentioned by drug users.
“Is very difficult to treat because they are in denial. They won’t accept the fact that they are addicted to any because it’s an over the counter. Lots of these things you buy from the chemist, so they don’t believe it’s addictive you know.” (Participant 11, Doctor for substance abuse treatment)
“If you taking methadone, and taking heroin it is like doing nothing. You are flushing methadone into the toilet, because how is it going to work while you are smoking. That’s what happened last time, that’s why I didn’t manage to use methadone by myself.” (Participant 17, Recovering drug user)
“My mom had to actually go to most of the pharmacies and showed them a picture of me and said they should to stop selling me drugs and stuff. But they still sold it to me.” (Participant 15, Recovering drug user)
Participants recommended methadone or opioid substitution therapy as treatment including harm reduction interventions. Some drug users receiving treatment favoured the out-patient treatment which allowed them to face the reality of the outside environment, barriers to treatment and the ability to address them daily.
“I feel very strong toward it, it helped me. I went to six or seven rehabs, they were all excellent based. That didn’t do anything for me, when I came back few weeks later, I was back on drugs. Methadone is the only thing that really helped me, obviously with my deep wish to stop. You need to be able to want to stop then the medication work for you., if you want to but if you don’t want to stop you will find a million reasons.” (Participant 18, Recovering drug user)
“Here, we come daily and go home later. For the first three to four months on treatment yes, I did cheat. I was smoking. Until I understood the concept of harm reduction. Smoking is not the problem. The problem is when you can no longer control your life.” (Participant 16, Recovering drug user)