A qualitative study of methamphetamine initiation in Cape Town, South Africa

Highlights

• Meth's popularity, accessibility, and perceived normality contribute to initiation.

• A lack of socio-economic opportunities contributes to meth initiation.

• Peers, more so than family, are influential in introducing others to meth.

• Meth initiation may occur as a means of coping with stress and trauma.

• Many reported transitioning to meth from other substances, like alcohol.

Abstract

Background

Despite a significant rise in methamphetamine use in low- and middle-income countries, there has been little empirical examination of the factors that contribute to individuals’ initiation of methamphetamine use in these settings. The goal of this study was to qualitatively examine factors associated with methamphetamine initiation in South Africa.

Methods

In-depth interviews were conducted with 30 active methamphetamine users (13 women and 17 men) in Cape Town, South Africa. Interviews included narrative descriptions of the circumstances surrounding methamphetamine initiation. Interviews were audio recorded, transcribed, and translated. Transcripts were analyzed with document memos, data display matrices, and a constant comparison technique to identify themes.

Results

On average, participants began regularly using methamphetamine around age 21 and had used for seven years. Four major themes emerged related to the initiation of methamphetamine use. The prevalence of methamphetamine users and distributors made the drug convenient and highly accessible to first time users. Methamphetamine has increased in popularity and is considered “trendy”, which contributes to social pressure from friends, and less often, family members to initiate use. Initiation is further fueled by a lack of opportunities for recreation and employment, which leads to boredom and curiosity about the rumored positive effects of the drug. Young people also turn to methamphetamine use and distribution through gang membership as an attempt to generate income in impoverished communities with limited economic opportunities. Finally, participants described initiating methamphetamine as a means of coping with the cumulative stress and psychological burden provoked by the high rates of violence and crime in areas of Cape Town.

Conclusion

The findings highlight the complex nature of methamphetamine initiation in low- and middle-income countries like South Africa. There is a need for community-level interventions to address the availability and perceived normality of methamphetamine use, and to provide young people opportunities for recreation. On an individual level, addressing mental health and misconceptions about the dangers and benefits of methamphetamine could ameliorate willingness for initiation. Potential points of intervention include mass media campaigns and school-based interventions to raise awareness of the physical and social impacts of methamphetamine, and structural interventions to create safer neighborhoods, provide opportunities for employment and recreation, and expand mental health services to improve emotional health and coping skills.

Introduction

The global production and trafficking of methamphetamine, a highly addictive psychostimulant, has reached unprecedented levels (United Nations Office on Drugs and Crime, 2014). According to the World Drug Report, global methamphetamine seizures quadrupled from 2008 to 2012 (United Nations Office on Drugs and Crime, 2014). Although it is difficult to capture accurate substance use prevalence estimates in countries like South Africa, where the use of illicit substances like methamphetamine is stigmatized, the United Nations estimated that there were 610,000 amphetamine users (a category that includes methamphetamine) in South Africa in 2014 (United Nations Office on Drugs and Crime, 2014). Localized areas, like Cape Town, have been crippled by the sudden rise in methamphetamine. In Cape Town, admissions to substance abuse treatment centers primarily for methamphetamine rose from 0.3% in 2002 to 33% in 2013 (Johnson et al., 2014). The use of methamphetamine, colloquially referred to as “tik”, is particularly common among young men of Coloured race (“Coloured” refers to people of mixed race ancestry who form a unique cultural grouping in South Africa). However, several studies have also documented high rates of methamphetamine use among women and in densely populated Black African communities (Myers et al., 2013, Wechsberg et al., 2010).

In Cape Town, methamphetamine use contributes to poor mental and physical health, disrupted relationships, and increased rates of crime, violence, and unemployment in the community (Watt et al., 2014). When compared with non-methamphetamine users, methamphetamine users reported more polysubstance use; higher rates of interpersonal violence, including childhood physical and sexual abuse, and intimate partner violence; and risky sexual behavior such as sex trade, sex with multiple partners, and unprotected sex (Meade et al., 2012, Plüddemann et al., 2010, Plüddemann et al., 2013, Simbayi et al., 2006, Wechsberg et al., 2012). Given the high prevalence of methamphetamine use in this context and the well-documented detrimental effects of this drug, evidence-based strategies to prevent the initiation of methamphetamine use are urgently needed in this region. In order to develop these strategies, an in-depth understanding of the contextual and psychosocial factors that drive the initiation of methamphetamine use is required.

Despite this need, few studies have explored factors associated with the initiation of methamphetamine use, where initiation may occur either through transition to methamphetamine from the use of other substances, such as alcohol, tobacco, and cannabis, or by using methamphetamine as the first introduction to any substance. The few studies that have investigated this topic have been conducted in high-income countries and have mainly focused on injection of methamphetamine. For example, in a Canadian study, factors such as being male, sexual abuse history, young age, neighborhood, prior illicit drug use, and homelessness were all associated with increased risk of initiating methamphetamine injection (Marshall et al., 2011). In a qualitative multi-site U.S. study, methamphetamine injectors identified several reasons for their first use, including curiosity, peer influence, popularity and availability of methamphetamine, the rush of injecting over smoking, and using methamphetamine to cope with poor mental and physical health (Lankenau et al., 2010). While these findings contribute to our understanding of the range of individual, interpersonal and environmental factors associated with the initiation of methamphetamine injection, the extent to which these findings extend to low-and-middle income countries (LMIC) is unknown. Factors leading to the initiation of methamphetamine use in LMIC may be different than those found in North America, especially given the high rates of drug-related crime and violence in regions like post-apartheid South Africa (Johnson et al., 2014, Norman et al., 2007). In addition, our current knowledge on this topic only characterizes the initiation of injection methamphetamine use and provides little insight into the initiation of smoked methamphetamine, which is related to similarly negative consequences for users (Schifano, Corkery, & Cuffolo, 2007). Further research on factors associated with the initiation of methamphetamine smoking is needed, particularly as smoking is a common route of methamphetamine administration in emerging methamphetamine “hot spots”, such as Cape Town, South Africa (Meade et al., 2015).

The current study used qualitative methods to gain an in-depth understanding of the circumstances surrounding the first use of methamphetamine among active users in Cape Town, South Africa. The primary aim was to understand the contextual, social, and individual factors that drive people to initiate methamphetamine use. Identifying the factors that contribute to methamphetamine initiation may lead to the development of additional strategies for the prevention of methamphetamine initiation in this region.