English: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 prescriber‟s 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 patient‟s 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.
Afrikaans: Agtergrond: Histories gekenmerk deur „n hoë voorkoms van alkoholverslawing en afhanklikheid, het Suid-Afrika oor die afgelope aantal jare „n ongekende toename in onwettigemiddelgebruik beleef, gekoppel aan georganiseerdemisdaadaktiwiteite. Terwyl die rol van farmakoterapie in die multidissiplinêre behandeling van verslawing/afhanklikheid internasionaal toeneem weens die groeiende bewyslas van die biologiese aard van die toestand, is daar major transformasie van Gesondheidsorg- en Maatskaplikediensleweringsisteme plaaslik. Doel: Die studie het „n kritiese analise van huidige behandelingspraktyke aangaande farmakoterapie vir alkohol- en dwelmverslawing en afhanklikheid in die Vrystaat ten doel. Die analise geskied teen die agtergrond van die biologiese prosesse betrokke by die toestand van verslawing sowel as die aspekte van gesondheidsorg dienslewering wat die gebruik van farmakoterapie beïnvloed. Die analise vorm die basis vir die ontwikkeling van „n raamwerk vir die behandeling van substans verslawing en afhanklikheid betreffende farmakoterapie, met die inagneming van die bevindinge uit die literatuur en lokale konteks. Materiaal en Metodes: Beide kwantitatiewe en kwalitatiewe metodes is gebruik. „n Vraelys is voltooi en „n gestruktureerde onderhoud is gevoer met 121 professionele gesondheidsorgwerkers wat redelikerwys verwag kan word om gekonfronteer te word met verslawing en afhanklikheid. Die populasie bestaan uit „n lukraak geselekteerde monster van algemene praktisyns uit streeks-, distriks- en basiese omgewings in die Vrystaat; doelmatig geselekteerde verteenwoordigers van staatshospitale en private behandelingsentra, en private psigiaters en terapeute in ooreenstemmende dorpe. Resultate: Hulpsoeking vir verslawing kom voor in „n waarneembare patroon oor die onderskeie professionele groepe. Private algemene mediese praktisyns vorm „n belangrike toegangspunt vir behandeling vir alkohol verslawing en afhanklikheid. Afhangend van die lokale organisasie van dienste, is hulle ook aktief betrokke by die mediese behandeling van verslawing/afhanklikheids gevalle. Private psigiaters is slegs betrokke by dubbele diagnose gevalle, maar het kontak met „n wyer reeks van verslawings en afhanklikheids gevalle. Staatshospitaaldienste wissel van uitgebreide tot geen dienste. Persepsies rakende toegang tot staatshospitale en die kwaliteit van dienste is swak, terwyl private dienste oor die algemeen as duur, maar effektief gesien word. Siekefonds beleid speel „n belangrike rol in die bepaling van toegang tot fasiliteite en dienste en dikteer die individuele voorskrywer se benadering tot farmakoterapie. Respondente beskou die rol van farmakoterapie as essensiëel in onttrekking en neuropsigiatriese ondersteuning, maar minder belangrik in terugvalvoorkoming. Onttrekkingsregimens is meesal konvensioineel, met „n paar streeks-afhanklike uitsonderings. Die herkenning van die neurotoksiese aard van die onttrekkingsstaat word nie deurgaans gereflekteer deur die keuse van farmakoterapie in onttrekkingregimens nie. Slegs disulfiram word algemeen gebruik vir terugvalvoorkoming, maar die gebruik daarvan word beperk deur die hoë koste. Benewens die finansiële oorwegings, word die besluit om disulfiram voor te skryf gebaseer op die pasiënt se motivering of wilskrag. Gevolgtrekking: „n Basiese gebrek aan erkenning van die biologiese oorsprong van verslawing is herkenbaar in die huidige wetgewing, die organisasie van dienste en in die behandeling van verslawing. Mediese ingryping in verslawing en afhanklikheid vind tipies laat plaas en volg „n intermitterende verloop met korttermyn doelwitte. Aanbevelings: „n Geïntegreerde raamwerk is ontwikkel en behoort oorweeg te word vir implementering op beide organisatoriese en behandelingsvlakke in die streek met die primêre oogmerk om behandelingsuitkomste te verbeter. „n Voorvereiste vir rasionele voorskrywing van farmakoterapie is „n uitbreding van medikasie opsies en verbeterde siftingsmetodes om geïndividualiseerde behandeling, „n biologiese noodsaak vir suksesvolle behandeling, moontlik te maak. Terselfdertyd moet getuienis-gebaseerde beste praktyke gestandardiseer en geïmplimenteer word. Die rol van private algemene praktisyns as primêre toegang tot the gesondheidsorgsisteem behoort herstel en uitgebrei te word ten einde „n platform vir toeganklike mediese behandeling van verslawing en afhanklikheid te skep.
Doctoral Degrees (Pharmacology)