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Background: The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane’s Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response.Aim: To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.Setting: Three community-based COSUP sites in Mamelodi (Tshwane, South Africa).Methods: A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data.Results: Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants’ median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol.Conclusion: Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.Contribution: This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Background In South Africa, increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), like methadone, provided it is prescribed at the recommended dose and duration. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with Opiod Use Disorder across Tshwane, South Africa on need-based criteria. Methods A retrospective cohort using secondary data of patients treated with methadone at eight COSUP sites. The factors associated with the retention of 575 participants for the period December 2016 to September 2018 were analysed. Results Participants on lower methadone doses had decreased odds of being retained (0 to 20mg: adjusted odds ratio (aOR) 0.25, p-value (p)=0.002, 95% Confidence Interval (CI) 0.10 - 0.61; 20 to 40mg: aOR 0.20, p < 0.001, 95% CI 0.08 - 0.49). Participants receiving free methadone had 3.75 the odds to be retained (p < 0.001, 95% CI 2.47 - 5.70). Inner-city participants had 5.19 the odds to be retained (p < 0.001, 95% CI 2.99 - 9.03). White participants had 3.39 the odds of being retained (p = 0.001, 95% CI 1.64 - 7.00). Injecting heroin users had 0.63 the odds of being retained (p = 0.032; 95% CI 0.41 - 0.96). Conclusions Methadone doses above 50mg, access to free methadone, accessing care within the inner-city and the white population group were positively associated with retention. Injecting drug use was negatively associated. Key messages Provision of free methadone at adequate doses can aid in retaining patients within an outpatient OST programme.