In the centre of the South African city of Pretoria, dozens of people mill around a dusty patch of land beside a main road, openly smoking and injecting drugs. Over the noise of cars whizzing past, one of the users, Benedict, explains that he started using heroin after he left home to get away from his abusive stepfather.
“I didn’t want to fight with him. I just ended up by myself, going to the town, sleeping on the street,” he says, “After some weeks, I started to smoke heroin with my friend.”
At first, the drug offered some relief. “When I was having that [family-related] stress, I was thinking too much during the night, I wasn’t sleeping,” Benedict says. “But when I smoked heroin, I would get sleepy, I forgot about that feeling … you forget about all the past feelings. I didn’t know that after smoking for weeks you’re going to feel alostro [withdrawal symptoms].”
Benedict, who is in his 20s and has been using heroin for five years, is one of an estimated 400,000 people using nyaope or whoonga (as the drug is known locally) across South Africa every day.
The crisis gripping the country’s most disadvantaged communities affects almost 1% of the adult population, making South Africa’s heroin market one of the largest in Africa.
Once limited to a small number of predominantly white neighbourhoods, heroin use has surged across the country.
Andrew Scheibe, a public health researcher at the University of Pretoria and lead author of a recent study, says: “You can buy heroin in any town in South Africa, rural or urban, and there are not many extended families that don’t have someone who is using heroin.”
Between 2011 and 2020, another study found, the rate of opioid-related disorders climbed by 12% a year among members of a large medical insurance scheme. Heroin accounts for most illicit opioid use in South Africa.
Police cases and admissions to rehab centres linked to heroin use also rose sharply over a similar period, and in recently published household surveys a growing number of South Africans admitted to opioid use.
Over the past 15 years, southern Africa has become a more prominent transit hub for smugglers moving heroin, and increasingly methamphetamine, from Afghanistan to Europe. As the drug passed through South Africa’s borders for onward trade, spin-off markets for local consumption formed, boosting supply and reducing prices.
By 2020, the average street price was just $10 (£7.50) a gram – about a fifth of what was in typical European markets.
But there are local roots to the crisis as well. For people like Benedict, the drug is a powerful antidote to the trauma and sleeplessness caused by childhood abuse, which is prevalent across the country. In one study, more than half of children surveyed in two provinces reported experiencing physical abuse, most commonly by caregivers.
Others say the drug simply helps stave off the boredom of unemployment, which has now reached more than 45% among young people.
But while the initial reasons vary, the desired result is the same: “When you smoke nyaope you feel you’re in heaven,” says Nkosana Mahlangu, a former user who lives in Atteridgeville, a township on the outskirts of Pretoria. “[When I used] I would feel like I control everything. I have the power – nobody can tell me what to do.”
Yet Mahlangu says these feelings were soon reversed as his drug use increased and physical dependence formed.
Withdrawal symptoms – which typically include cramps, weakness and fever – can come just a few hours after a user’s last hit, forcing them to work around the clock to stave off the looming threat.
“There’s no resting day, it’s Monday to Monday; if I didn’t get it, I must steal,” says Mahlangu, who used to wash cars to make enough money for six doses a day.
State-funded rehabilitation centres are available, but the success rate is low. In one study, roughly two in every three of the patients at two Johannesburg centres had gone back to using heroin three months after treatment and cases of depression had risen.
By contrast, a programme provided by Pretoria University and the municipal government of Tshwane (which includes Pretoria and its surrounding area) offers a different model – one that helped Mahlangu find a way out of the “heroin hustle”, after years of failed stints in rehab.
Rather than participating in a six-week detox at a rehab centre, and then returning to their communities without any support, the Community Oriented Substance Use Programme (Cosup) runs 16 drop-in centres around Tshwane, where heroin users are helped to meet their own targets.
The centres provide methadone, which blocks withdrawal symptoms, as well as counselling, health screening and job support to people who want to quit or reduce their heroin intake.
Since it was launched in 2016, the Cosup programme has administered methadone to 2,400 people across four of Tshwane’s seven regions, according to programme manager Dr Lorinda Kroukamp. Clients typically take the drug daily for at least six months, as maintenance therapy.
Although national and local authorities outside Tshwane do not fund methadone-maintenance therapy, Cosup is expanding. Kroukamp says that by early next year they plan to reach all seven regions of Tshwane.
According to Cosup’s records, 70% of patients who started treatment at the centres were still collecting their doses six months later.
Solly Kganakga, a former user who got clean with the help of a Cosup centre in Atteridgeville, says that after switching from heroin to methadone, “you [become] more yourself.”
“You don’t get cravings,” he says. “You get to focus more on your life.”
A review of 11 randomised controlled trials by the Cochrane healthcare foundation found that rehab initiatives that offered methadone maintenance treatment were significantly more effective than drug-free programmes.
To be effective, methadone typically has to be dispensed for several months, or even years, to allow users to re-establish their relationships and livelihoods, before the quantity can be reduced as the user gets more stability in their life.
Unlike at Cosup’s sites, where people can get free methadone for as long as they need it, Scheibe says nationally funded centres that offer the drug provide it for two weeks at most; and many do not provide it at all.
Many users are careful to note that Cosup’s success is about more than just the medication. “The support you get from [the social workers], that’s very beneficial for us. The methadone is nothing without people,” says Kganakga.
For Kganakga, it is this combination that has kept him away from heroin for the past eight months, he says, allowing him to get his life back in order. But the most important thing, he says: “I’ve re-established my bond with my mom.”
