Findings from SACENDU indicate that over time cocaine use has placed an increased burden on AOD treatment services in several provinces in South Africa, though some inter-site variation is occurring. This increase has not been constant and at times cocaine related treatment admissions have even shown a decline. The drop off in cocaine related treatment admissions in Cape Town and Gauteng in the second half of 1999 and the subsequent increase might be linked to changes in global cocaine production over that time period [14]. In all sites reported on in this paper, treatment admissions related to cocaine use have increased over time, but the current rate of increase appears to be much higher in the Eastern Cape than in Gauteng and Cape Town. There have been no systematic changes in the provision of treatment services or admissions policies that could explain these findings. Discussions with community sources and the police indicate that the increase in cocaine related admissions in the Eastern Cape is mainly due to the recent emergence of the cocaine trade in Port Elizabeth and East London and the very aggressive marketing practices accompanying it. If only national data had been reported on, local variations such as those recently experienced in the Eastern Cape and in Cape Town would have disappeared.

The overall increase in cocaine related treatment admissions over time has been accompanied by a reduction in treatment admissions for other drugs of abuse with depressant qualities, specifically alcohol and methaqualone [15]. It has also been accompanied by an increase in admissions for a broad range of other stimulants including methamphetamine (in Cape Town) and methcathinone (in Gauteng) [15]. A similar rise in treatment admissions related to cocaine use was indicated in the 2007 Annual Report of the EMDCCA on trend data for 1999 through 2005, increasing from 11% to 24% of new drug clients during this period [18]. In contrast, in the USA there appears to have been a steady fall off in cocaine related treatment admissions since the mid 1990s, accompanied by a rise in problems related to other stimulants and opiates [16]. The recent decline in cocaine related treatment admissions in Cape Town is in all likelihood also due to the increase in treatment admissions related to another stimulant, methamphetamine [17]. In both South Africa and the European Union, the majority of patients coming to treatment with cocaine as a primary drug of abuse are new admissions. In the absence of other systemic changes, this may reflect an increasing incidence of cocaine related problems.

In order to form effective prevention and treatment programmes the demographic profile of cocaine users needs to be identified. Persons in treatment for cocaine for the first time across the three South African sites are aged between 27 and 32 years and are generally older than individuals with problems related to other drugs [9]. They generally started using cocaine three to five years prior to treatment. Similar findings were reported by the EMCDDA, where in 2004 the mean age for new patients entering outpatient treatment for cocaine was 31 years for males and 28 years for females. They were also reported as being typically older than other drug consumers, apart from users of hypnotics and sedatives, who are the oldest even if figures are low [18]. In the USA the average age of primary cocaine admissions was 38 years for smoked cocaine and 34 years for non-smoked cocaine [16]. The older age of cocaine patients may have implications for issues that will need to be addressed during treatment, such as a greater focus on the effect of their drug use on partners, children and work than perhaps would be needed for patients in their late teens and early twenties.

Substantially more males than females accessed treatment for cocaine problems. The male to female ratio for patients entering outpatient treatment for cocaine as a primary drug of abuse in 15 European countries in 2004 was 5.7:1 [18] which is fairly similar to what was found in this study.

Rather than reflecting lower levels of cocaine use among women, this may partly reflect gender differences in access to treatment [19]. There seems to be a greater stigma associated with drug dependence in females, and the abuse of illicit drugs tends to remain hidden. In addition, women in South Africa often do not have an independent income to pay for treatment. Nevertheless, about 10%–30% of persons treated for cocaine abuse are female.

Furthermore, the data suggest an increase in cocaine related treatment admissions by Coloureds in all three sites and by black Africans in Gauteng. In the 1990s drug markets in South Africa were clearly segmented along racial lines, with drugs like cocaine being marketed to whites who tended to be more affluent [20]. Since 2000, these markets have become less segmented, as reflected in the aforementioned demographic shifts. The changes over time cannot be explained in terms of systematic changes in service delivery that might have increased access by particular population groups. The likely reason that black Africans are not showing up in greater numbers at drug treatment centres in the Eastern Cape is probably due to the substantially higher levels of poverty [3] which has meant that black Africans in this province tend to abuse alcohol and cannabis rather than more expensive substances, as well as the limited number of treatment slots in the affordable, non-profit treatment sector. Lower utilisation of drug treatment services for cocaine and other drug problems by black Africans in Cape Town and Gauteng could also be due to the fact that the majority of black Africans still reside in suburbs far from drug treatment and other services [21].

In contrast to Europe where more than 80% of new outpatients with cocaine problems report using cocaine hydrochloride [18], in South Africa the most prominent mode of cocaine consumption reported by persons coming to drug treatment is crack cocaine (65% to 84% in the three sites currently). Treatment data from the USA also indicates high levels of crack cocaine usage (72% in 2005). There are indications that the use of cocaine in this form increases sexual risk behaviour and is related to levels of violence [22,23]; although these associations could also be partially explained by contextual factors such as crowding. The growing use of crack cocaine is of great concern to a country like South Africa where sexual risk behaviour and interpersonal violence together contribute 40% of the total burden of death and disability in the country [24]. With high levels of patients reporting daily use of cocaine (e.g. 65% of patients in Cape Town) this is an added concern. With regard to mode of use, roughly 70% of patients in treatment reported smoking their cocaine with the remainder mostly snorting/sniffing. Smoking is an extremely potent and direct form of administration. In contrast, EMCDDA treatment data for 2005 reported that 53% of patients in treatment reported snorting or sniffing the substance, 34% smoking it and 5% injecting [18]. Fortunately less than one percent of patients in the South African study reported injecting cocaine, thus decreasing their risk of contracting injection-related HIV or Hepatitis B/C.

In responding to the threat of cocaine use in South Africa it is important to remember that poly-drug use is high. In roughly two-thirds of cases where cocaine was the primary drug of abuse other drugs were reported as secondary, typically alcohol and cannabis. Similar secondary drugs were reported by the EMCDDA with the addition of heroin [18]. Conversely, in Gauteng and the Eastern Cape a high proportion of patients having heroin as a primary drug of abuse had cocaine as a secondary drug. Treatment planning needs to take into account such poly-drug use. According to the most recent European data a diversification of cocaine users in treatment can be identified. Three main groups are seen, (i) users of cocaine powder often combined with alcohol and/or cannabis, (ii) users of crack cocaine with other drugs and/or heroin, and (iii) polydrug users, consuming cocaine and heroin [18].

While political attention in South Africa has been given increasingly to problems related to methamphetamine and heroin use, very little attention has been directed to cocaine abuse despite the fact that roughly one in five patients coming to drug treatment currently has cocaine as a primary or secondary drug of abuse. One of the policy implications of this research is that substance abuse practitioners need to be trained in and provided with specific treatment protocols for addressing cocaine and other stimulant related problems. Such protocols and training are lacking in South Africa. The increasing levels of cocaine related treatment admissions in Gauteng and the Eastern Cape also highlight the importance of addressing gaps in supply reduction and ensuring that universal and selected prevention programmes take cognisance of particular issues related to cocaine use. Prevention efforts need to focus on persons who have not used any drugs as well as persons in their early twenties who might be using other drugs. Given the ongoing rise in use of cocaine among Coloured and black African populations, prevention efforts need to be sensitive to pressures to use cocaine among these population groups and in communities where they tend to reside.

The main limitation of this study is that treatment data are affected by the lack of available treatment options for drug abuse in South Africa, particularly for the most disadvantaged sectors of society [21]. This limitation highlights the need for further community-based studies such as school surveys, key informant and user interviews to assess the use of the drug in populations that might not have access to specialist substance abuse treatment or who might be accessing other services such as private mental health professionals and other kinds of support services. While we controlled for double counting of patents within a treatment centre we were not able to control for double counting across centres. This may have slightly inflated the number of patients receiving treatment and may have biased the data towards those patients who seek treatment across more than one institution. Another limitation of the study is that not all the patients would necessarily have met the criteria for cocaine dependence. Further research is therefore required that would investigate the severity of the problems experienced by patients seeking treatment for cocaine problems. A further limitation of this study comes from the fact that data were only reported on three sites. It is possible that other patterns of cocaine use exist in other areas. With the expansion of SACENDU to all provinces in 2007/8, this shortcoming will be addressed.