Assessing the revised Clinical Institute Withdrawal for Alcohol Scale use at Stikland Hospital.

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.

Perceptions and experiences of patients attending an opioid substitution clinic in South Africa.

Background: Opioid substitution therapy (OST) is endorsed as the recommended treatment for opioid use disorders. Opioid substitution therapy is not widely used in South Africa, so little is known about its perceived clinical utility in this setting. There is also a paucity of qualitative research that explores the subjective experiences of patients using OST. Aim: To explore patients' perceptions and experiences attending a South African OST outpatient clinic (OST-OC). Setting: The OST-OC at Stikland Psychiatric Hospital, Cape Town, South Africa. Methods: We conducted a qualitative study using semi-structured interviews with eight participants who had been attending the OST-OC for at least 6 months. Transcripts were analysed using Atlas.ti software and thematic content analysis was used to identify themes. Results: Patients stated that OST helped them to regain and maintain a stable lifestyle. Autonomy and agency, the therapeutic relationship and family support were perceived as contributing to successful patient outcomes. The preference for methadone and buprenorphine treatment depended on individual experiences. Patients valued kindness from staff members but reported that improved interactions with some nonclinical staff could better facilitate treatment. Challenges experienced included stigma and cost. Conclusions: This study offers insights about OST that are pertinent to low- and middle-income countries. Reducing the cost of OST, collaborative decision-making between staff and patients, and a non-judgemental attitude by clinical staff were recognised as important factors for optimised service delivery. Contribution: Understanding patients' experiences of OST in a South African setting will allow for future policy development for the treatment of opioid use disorders in similar settings locally and abroad.

Implementing a Substance-Use Screening and Intervention Program for People Living with Rifampicin-Resistant Tuberculosis: Pragmatic Experience from Khayelitsha, South Africa.

Substance use (SU) is associated with poor rifampicin-resistant tuberculosis (RR-TB) treatment outcomes. In 2017, a SBIRT (SU screening-brief intervention-referral to treatment) was integrated into routine RR-TB care in Khayelitsha, South Africa. This was a retrospective study of persons with RR-TB who were screened for SU between 1 July 2018 and 30 September 2020 using the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test). Here we describe outcomes from this program. Persons scoring moderate/high risk received a brief intervention and referral to treatment. Overall, 333 persons were initiated on RR-TB treatment; 38% (n = 128) were screened for SU. Of those, 88% (n = 113/128) reported SU; 65% (n = 83/128) had moderate/high risk SU. Eighty percent (n = 103/128) reported alcohol use, of whom 52% (n = 54/103) reported moderate/high risk alcohol use. Seventy-seven persons were screened for SU within ≤2 months of RR-TB treatment initiation, of whom 69%, 12%, and 12% had outcomes of treatment success, loss to follow-up and death, respectively. Outcomes did not differ between persons with no/low risk and moderate/high risk SU or based on the receipt of naltrexone (p > 0.05). SU was common among persons with RR-TB; there is a need for interventions to address this co-morbidity as part of "person-centered care". Integrated, holistic care is needed at the community level to address unique challenges of persons with RR-TB and SU.

Psychiatric comorbidity among alcohol-dependent individuals seeking treatment at the Alcohol Rehabilitation Unit, Stikland Hospital.

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.

Psychiatric comorbidity among alcohol-dependent individuals seeking treatment at the Alcohol Rehabilitation Unit, Stikland Hospital

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. Keywords: Alcohol use disorder; Alcoholism; Alcohol dependence; Alcohol addiction; Comorbidity; Dual diagnosis; Psychiatric illness

Psychiatric comorbidity and quality of life in South African alcohol use disorder patients.

BACKGROUND: Understanding the psychopathology accompanying alcohol use disorder (AUD) is important as it impacts negatively on quality of life (QoL) with subsequent implications for treatment and recovery. We evaluated the association of psychiatric comorbidity with QoL among treatment-seeking South African AUD patients. METHODS: Cross-sectional assessment of 101 (Male, n = 65; 64.5%) patients with AUD was done using the World Health Organisation Quality of Life (WHOQoL)-Bref, the World Health Organisation Disability Assessment Scale (WHODAS) and Mini-International Neuropsychiatric Interview (MINI) to collect QoL, disability and psychopathology data, respectively. RESULTS: Psychiatric comorbidity was noted in 63 (62.3%) of the patients with most (55.6%) having more than one disorder. Mood (39; 61.9%) and anxiety (33; 52.4%) were the most common co-occurring disorders. Disability scores were not significantly different between comorbidity and gender groups However, QoL scores were significantly lower for participants with comorbidity in three of the four WHOQOL domains and declined with increasing number of psychiatric disorders. Focussing on the two main psychopathologies, participants with anxiety alone consistently had the lowest QoL scores compared to those with neither or both disorders (p < 0.05). CONCLUSION: The results confirm the well-known high rate of psychiatric comorbidity in patients with AUD and the negative impact it has on QoL. The results should alert clinicians managing AUD patients to screen for comorbid psychopathology and include findings into their treatment plan as this may impact on the patient's QoL.

Report on the first government-funded opioid substitution programme for heroin users in the Western Cape Province, South Africa.

BACKGROUND: Although pharmacological opioid substitution treatment (OST) is a well-established treatment modality for heroin addiction, it is a relatively recent introduction in low- and middle-income countries. OBJECTIVE: To report on a pilot OST programme initiated in 2013 that was the only public-funded programme in South Africa (SA) at the time. Participants were offered standard care only (n=68) or, for the OST group (n=67), standard care plus Suboxone (Reckitt Benckiser), a synthetic partial opioid agonist, in a 12-week clinician-monitored programme. METHODS: Clinical records of 135 participants in the rehabilitation programme at Sultan Bahu Rehabilitation Centre in Mitchell's Plain, Cape Town, SA, from 1 January to 31 December 2014 were reviewed. Data collected included demographics and duration in treatment (retention) as well as number of urine samples provided, positive tests or self-reported use events and dates of first positive/negative tests. RESULTS: Significantly more participants in the OST group (65.7%) than controls (44.1%) completed the treatment (p=0.019). Among the non-completers, retention was higher in the OST group than in the standard care group (48.2 v. 30.1 days; p=0.001). The groups did not differ in respect of number of missed appointments and time to first positive test. However, the proportion of participants testing positive was higher in the OST group (80.6%) than in the standard care group (61.8%), although the former were tested nearly three times (18.3 v. 6.6 times) more. Consequently, the positive rate (proportion of positive tests) was substantially lower in the OST group (16.8%) than in the standard care group (23.3%). CONCLUSIONS: The results demonstrate modest success of this pilot OST programme in terms of completion and retention and should argue for a move to increase availability of and accessibility to OSTs for the management of opioid use disorder.

Methamphetamine-induced psychosis: Clinical features, treatment modalities and outcomes.

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.

The effectiveness of a hospital-based intervention for patients with substance-use problems in the Western Cape.

District hospitals regularly experience a high incidence of substance use disorders, but rarely provide interventions. We describe the effectiveness of an intervention developed and implemented by a Western Cape hospital. Patients with probable substance use were referred to an on-site social worker for an alcohol, smoking and substance involvement screening test (ASSIST), a brief motivational intervention and referral to specialist care. At the 3-month follow-up, the ASSIST was re-administered telephonically. An intervention was received by 127 patients. A significant reduction in substance use was reported in 92 patients who completed a 3-month follow-up evaluation (p<0.001). Of the 60 patients referred to further care, half entered treatment. We conclude that, with minimal resourcing, it is feasible to administer a brief substance use intervention for patients attending district hospitals.

Medical management of opioid dependence in South Africa.

Medical practitioners in South Africa are increasingly confronted with requests to treat patients with opioid use disorders. Many do not possess the required knowledge and skills to deal with these patients effectively. This overview of the medical treatment of opioid dependence was compiled by an elected working group of doctors working in the field of substance dependence. Recommendations are based on current best practice derived from scientific evidence and consensus of the working group, but should never replace individual clinical judgement.