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Background: Historically characterized by a high prevalence of alcohol addiction and dependency, South Africa has in recent years experienced an unprecedented increase in illicit drug use, linked to organized criminal activities. While internationally, the role of pharmacotherapy in the multi-disciplinary treatment of addiction/dependency becomes more important based on an increasing body of evidence revealing the biological nature of the condition, major transformation in the Health and Social delivery systems are taking place locally. Aim: The study aims to provide a critical analysis of current treatment practices regarding pharmacotherapy for drug addiction/dependency in the Free State against the background of the biological processes involved in the addiction/dependency state as well as aspects of health service delivery that may influence the use of pharmacotherapy. The analysis forms the basis for the development of a framework for the treatment of substance addiction and dependence regarding pharmacotherapy, taking into account the findings of the literature study and local context. Material and Methods: Both quantitative and qualitative methods were used. A questionnaire and structured interview were conducted with 121 health care professionals that could reasonably be expected to be confronted by patients with addiction and dependency. The population included a randomized sample of general practitioners selected from regional, district and basic environments in the Free State; purposely selected representatives of state hospitals and private treatment centres, as well as private psychiatrists and therapists in the corresponding towns. Results: Help-seeking for addiction occurs in a distinguishable pattern across the various professional groups. Private general medical practitioners are an important conduit into treatment for alcohol addiction and dependency. Depending on the local organization of services, they are also actively involved in the medical treatment of addiction and dependency cases. Private psychiatrists exclusively deal with dual diagnosis patients and are exposed to a wider range of addiction/dependency cases. State hospital service delivery varies from comprehensive services to no services. Perceptions regarding access to state hospitals and the quality of services in state hospitals are poor, while private services are generally regarded as costly, yet effective. Medical Scheme policies play an important role in determining access to facilities and services and dictate the individual prescriberâs approach to pharmacotherapy. Respondents regarded the role of pharmacotherapy as essential in withdrawal and neuropsychological support, yet less important in relapse prevention. Convention mainly determines the withdrawal regimens used by respondents, with a number of area-dependent exceptions. Recognition of the neurotoxic nature of the withdrawal state is not universally reflected in the selection of pharmacotherapeutic agents in withdrawal regimens. Only disulfiram is commonly used for relapse prevention and its use is limited by high cost. Besides financial status, the decision to prescribe these drugs is based on the patientâs motivation or willpower. Conclusion: A basic lack of recognition of the biological basis of addiction and dependency exists in the current legislation, in the organization of services and in the management of addiction/dependency. Medical intervention in addiction/dependency typically occurs late and follows an intermittent course with short-term goals. Recommendations: An integrated framework was developed and needs to be considered for implementation at both organizational and treatment practice levels in the region with the primary objective to improve treatment outcomes. Rational prescribing of pharmacotherapy requires an expansion of medication options and improved screening methods to allow individualized treatment, a biological imperative for successful treatment. At the same time standardization of evidence-based best treatment practices should be implemented. The role of private general practitioners as primary gatekeepers of the health system should be restored to provide a platform for accessible medical treatment of addiction and dependency. |
