Our findings suggest that general social services are an important point of entry into the substance abuse treatment system for people from socio-economically disadvantaged backgrounds. Within our sample, unmet service needs were high and only 13% of substance-using clients receiving social welfare services had received prior treatment for a substance use disorder. This is not surprising given the limited availability of substance abuse treatment in South Africa and the documented difficulties that people from disadvantaged communities have in accessing substance abuse treatment [3, 6]. For treatment naïve individuals from disadvantaged communities, district social services appear to act as a bridge into substance abuse treatment, with more than a third of the substance-using clients in the SASS data system being referred to specialist substance abuse treatment services.
Apart from being an important entry point into substance abuse services for people from disadvantaged communities, our findings suggest that district social service offices are an important point of intervention for people with substance use disorders; with more than two-thirds of substance-using clients receiving some form of intervention for their substance-related problem. While the types of substance abuse intervention services provided by district social service offices are often low-threshold (comprising mainly of brief interventions or once-off counseling sessions), these services are helpful as they expand the range of substance-related services available in the province. Historically, the main type of intervention provided to people with substance use disorders has been inpatient (residential) or intensive outpatient treatment services provided by specialist substance abuse treatment agencies. These high-threshold services are costly to provide, time-intensive and difficult to access because of the limited availability of treatment slots [3, 6]. Our finding that social workers within district social service offices not only refer clients to these high-threshold services but also provide lower threshold interventions is a promising development. If the policy environment continues to support investment in the provision of low threshold services, this may strengthen the existing substance abuse treatment system through reducing waiting lists for high threshold services and increasing the availability of substance abuse interventions in the province.
In addition, our findings hold value for service planning as they provide further insight into the typical profile of persons using alcohol and drugs in the Western Cape. Despite some similarities in the typical profile of person seeking substance abuse services (being male, Coloured, single and unemployed), several significant differences were found between clients within the SACENDU and SASS data systems. First, while men form the bulk of substance-using clients in both specialist substance abuse treatment and social welfare services, women were significantly more likely to seek substance abuse services from social welfare offices than specialist substance abuse treatment facilities. Specifically, women comprised more than a third of all substance-using clients at social service offices whereas women comprised only 20%–25% of admissions at specialist substance abuse treatment facilities . One explanation for this difference may lie in findings from previous research which noted that women experience greater difficulties and more barriers in accessing specialist substance abuse treatment services compared to men . It is quite possible that women seek assistance from district social service offices for their substance use as there are fewer barriers to accessing these services compared to specialist treatment facilities.
Another partial explanation for the large proportion of women in our study may lie in the fact that this sample was selected by screening all prospective users of general social services who did not necessarily report substance abuse as their presenting problem. For example, a third of the sample presented for help with a family problem and more than a quarter cited financial problems as their reason for seeking social welfare assistance. For many South African women, substance use remains hidden and they may be reluctant to seek substance abuse-related services due to the stigma associated with women who use substances . This stigma partially arises from the perceived inability of substance-using women to fulfill traditional gender roles, such as taking care of dependent children . As people from poor communities seek social welfare assistance for all kinds of reasons, there is probably little stigma associated with using general social services. As a result, women who are concerned about being stigmatised may find general social services more appealing than specialist substance abuse services. This claim is supported by evidence which shows that women are more likely to seek care for mental health or physical health problems (often related to their substance use) and to avoid seeking help for substance abuse . These findings suggest that the routine screening of users of general social services for substance use provides social workers with an opportunity to intervene with individuals who may otherwise not have sought care for their substance use. This may allow for the early identification of people with substance-related problems and for interventions to occur at an earlier stage of problem severity before problems become entrenched and require intensive intervention services.
A further difference between the profile of substance-using clients attending general social welfare services and those attending specialist substance abuse treatment services is that clients from social welfare services appear to be more vulnerable. Specifically, general social welfare services served a significantly greater proportion of Black African and Coloured persons, younger, and poorly educated persons who were less likely to be employed than specialist substance abuse treatment facilities in the province. As district social service offices provide free intervention services to people who are economically disadvantaged and because these services are located within poor communities, these general social services may help bridge the affordability and accessibility barriers that hamper substance abuse treatment entry for people from disadvantaged communities in the Western Cape . This may be especially true for people from the more rural parts of the province where the availability of specialist substance abuse treatment services is limited . This explanation is supported, in part, by our finding that close to two-thirds of the substance-using clients attending social welfare services resided in rural districts.
Third, we found significant differences in patterns of substance use between clients attending social welfare services and clients attending specialist treatment services. Specifically, a significantly greater proportion of clients attending social welfare services compared to clients at specialist treatment centres reported alcohol as their primary substance of abuse. The prevalence of alcohol-related problems among clients attending social welfare services is not altogether surprising given the consistently high levels of alcohol-related problems reported in the Western Cape [1, 2]. This is especially true for rural communities  which were well-represented in the SASS system. In contrast, alcohol is probably not well-represented within the specialist substance abuse treatment sector due to the primacy of methamphetamine-related problems in this sector. Methamphetamine-related problems are often associated with more acute mental health and health consequences than alcohol and as such people with methamphetamine problems enter substance abuse treatment more quickly than those with alcohol-related problems . Some support for this explanation is provided by the finding that a significantly greater proportion of clients attending specialist treatment facilities cited methamphetamine as their drug of choice relative to clients in the social welfare system. Regardless of the reason for the focus on treating methamphetamine (and other illicit drugs) within the substance abuse treatment system, our findings clearly show that alcohol use remains problematic within the Western Cape and service planners and policy makers should be aware of the need for more interventions to address alcohol use in this region.
Although a significantly smaller proportion of clients reported methamphetamine use than clients within substance abuse treatment facilities, this does not mean that methamphetamine use should be neglected within general social services. Our findings point to a considerable number of participants who reported problems related to the use of methamphetamine. This highlights the importance of screening all social welfare clients for the use of methamphetamine, particularly as people using this drug were significantly more likely to report severe health, family and financial problems compared to people who used other substances. This finding has implications for the delivery of social services, because if left untreated, it is quite likely that clients using these substances will place a considerable burden on an already taxed social welfare system in the province. Social workers in district social service offices therefore need to be trained to respond and intervene effectively with people who use methamphetamine.
While our findings provide insight into how social welfare services are a point of entry into treatment and a point of intervention for people with substance use disorders, findings should be interpreted in the light of some limitations. First, the study did not utilise standard clinical screening tools such as the Alcohol Use Disorders Identification Test (AUDIT)  or the The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)  that provide cut-off scores for hazardous or harmful substance use or need for treatment. While we used frequency of substance use as a proxy measure for severity, this is a crude indicator of substance abuse severity. As such, it is difficult to assess whether the interventions provided to people were appropriate for their level of problem severity or to assess treatment need. Future research should consider using validated screening tools that assess for degree of substance use involvement and problem severity. Secondly, this study was not able to unpack and describe the causal relationships between specific substances of abuse and associated consequences or problems. Future research should include longitudinal prospective studies that track participants over time. These studies will allow researchers to determine the direction of this relationship.