I am a recovering heroin addict. Where can I access Subutex replacement therapy to treat my addiction?

The long answer

Heroin addiction is an enormous problem in South Africa, and only a small percentage of addicts are receiving opioid substitution therapy (OST) according to a 2023 article by Harm Reduction International. But it has been shown that OST works better by weaning people off opioids rather than just treating withdrawal symptoms after they’ve suddenly stopped using.  

For example, Bhekisisa in a 2023 article pointed out that, in a 2017 study, only 23 out of 199 opioid users completed a two-month programme at a Cape Town health centre that does not offer substitution therapy, after they had gone through a detox. In contrast, a 2014 study in the Western Cape showed that two out of three people who got an opioid substitute called buprenorphine completed a 12-week programme to stop their heroin use. But only half of those who didn’t get the buprenorphine completed the programme. So, clearly OST works.

Let’s look at what these OST medications are:

In South Africa, some of the medications used for OST are methadone, buprenorphine (Subutex) and buprenorphine-naloxone combination (Suboxone).

Methadone is called “a full agonist”, meaning that it is addictive like other opioids, and must be taken under medical supervision. Methadone overdoses are associated with severe respiratory depression, decreases in heart rate and blood pressure, coma, and death.

Subutex and Suboxone are both “partial agonists”, meaning that the brain acts as it would on opioids, preventing the patient from craving opioids. But Suboxone contains a small amount of naloxone, which is an “antagonist” rather than an “agonist” – which means that if it is injected, it would cause immediate severe withdrawal symptoms. Often people taking Subutex have misused it and injected or snorted it, but as snorting or injecting Suboxone would cause sudden intense withdrawal symptoms, Suboxone is generally preferred to Subutex as an OST. Also, if a person used heroin immediately after taking Suboxone, they would suffer severe withdrawal symptoms.

But both Subutex and Suboxone are forms of Medication-Assisted Treatment (MAT) that use buprenorphine to manage opioid addiction.  

So how available is this OST?

The Department of Health said in 2024 that, although the evidence suggests that buprenorphine is not associated with increased mortality during the first four weeks of treatment (as opposed to methadone), buprenorphine and buprenorphine-naloxone are not currently included in the Adult Hospital Level Standard Treatment Guidelines and Essential Medicine List for the management of opioid use disorders. But because they are effective, they may be considered as alternatives to methadone in opioid substitution therapy (OST). 

The Department of Health also said that because daily supervised dosing may not be practical in low-resourced areas, buprenorphine may allow for more frequent take-home doses, and with Suboxone, the added naloxone would help to prevent intravenous injection of the tablets. Subutex, on the other hand, is often given through a supervised dosing programme. 

In 2023, Bhekisisa said that methadone as OST was currently available only at district hospitals for people who were experiencing withdrawal symptoms (because they had stopped using altogether) – and then only for only up to ten days.

Andrew Scheibe, a public health specialist, told Bhekisisa that there are around 400,000 heroin users in South Africa. This means that getting methadone to help wean people off heroin gradually is not a realistic option if they rely on public healthcare. 

But there is a new five-year plan, which aims to give all opioid drug users free methadone at state clinics. However, he said methadone treatment is expensive. To help someone stop using opioids completely, they should ideally be on OST for at least 12 months, starting with a dose of between 10 and 30mg per day. This is then gradually upped to a level where they don’t experience withdrawal symptoms (which is called the maintenance level). At a starting dose of, say, 20mg per day, a single pop could cost about R12.25 (in 2023). A month’s supply would therefore work out to almost R400 per user. 

For a maintenance level, a dose of at least 60mg per day is advised. A daily dose would then cost just over R36 at the lowest price, and for a month it would work out to about R1,080. 

Scheibe said the question was whether or not our primary healthcare system could feasibly and safely deliver it.

South African Family Practice said in 2023 that this outpatient opioid substitution is definitely the way to go, and such projects do exist in South Africa, but many provinces have not yet adopted them because they lack the necessary infrastructure to supervise daily consumption of substitution opioids, plus regular follow-up and monitoring because of the risk of accidental overdoses.

OST is available as part of NGO-funded programmes in Tshwane, Cape Town, Durban, and Johannesburg. But because not all services are state-subsidised, the cost of medication remains one of the main barriers to accessing treatment.

So where can you go? It depends where you are living, but these are some of the options:

• There is an Opioid Substitution Therapy (OST) outpatient clinic at Stikland Hospital in Bellville, Cape Town, on a Monday morning from 8am. Only clients who have been referred by a social worker and general practitioner are able to make use of the services available at the clinic. 

• If you are in Tshwane, the Community-Oriented Substance Use Programme (COSUP) provides “evidence-based substance use services, focusing on harm reduction and Community Oriented Primary Care (COPC)”. The services provided include screening and assessment for substance use, physical wellbeing and mental health, brief interventions and referrals, harm reduction counselling, OST, and needle and syringe services (NSP), as well as social services, skills development, food services and shelter. By mid-2019, there were 17 functional and viable COSUP sites available to residents of the City of Tshwane. COSUP is funded by the City of Tshwane and is administered by the University of Pretoria. 

COSUP can be contacted through Mr Lesego Sehume:

Tel: 012 356 3301

Email: [email protected] 

Or via the Tshwane Municipality:

Tel: 012 358 0000

Toll-free number: 0800 11 44 44 

• A GroundUp article on 24 March 2016 said that Sultan Bahu is the only rehab in the country where clients can get government-funded MAT (OSP) medication free. The Western Cape’s Department of Social Development has funded the programme since it started in 2014. 

GroundUp wrote that outside of Sultan Bahu and private rehabs, heroin users can get OST therapy at Stikland Hospital and Groote Schuur Hospital, but need to pay for the medication themselves, sourcing it from private pharmacies. With the high cost of Suboxone, treatment can be out of reach, especially for those who are unemployed.

Sultan Bahu rehab stated that the centre offers a full-day intervention programme for enrolled clients, starting at 8am and ending at 5pm. A client will have access to group psychotherapy, psycho-education, one-to-one counselling sessions, family sessions and numerous other initiatives aimed towards substance abuse prevention, relapse prevention and maintaining sobriety.  

It has a very high success rate. You can email them on [email protected]. These are the addresses and phone numbers for different clinics:

Sultan Bahu Johannesburg:

Address: 96 3rd Avenue, Mayfair, Johannesburg

Tel: 011 839 2025

Sultan Bahu Mitchells Plain:

Address: 92 Shephards Way, Westridge, Mitchells Plain

Tel: 021 372 2945

Sultan Bahu Hanover Park:

Address: Cnr of Lansur & Lonedown Road, Hanover Park 

Tel: 021 691 0632

Sultan Bahu Bellville:

Address: 14 Middel Street, Kempenville

Tel: 021 694 9874

Sultan Bahu Durban:

Address: 326 Randles Road, Cnr of Laverly Crescent, Overport

Tel: 031 207 3462

Wishing you the best,
Athalie