Annual report sent to the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) giving an overview of the latest developments on the drug problem in France.
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Driven by a clear public speech on the risks and harm that psychoactive substance use and high-risk use can cause, the 2018-2022 National Action Plan on Addictions, which was introduced by the government in December 2018, focuses on prevention and pays particular attention to the most vulnerable groups based on their age or other qualities that make them more at risk. It improves the quality of responses to the consequences of addiction for individuals and society and demonstrates a strong commitment to combatting trafficking. It suggests new measures for research, observation and developing international cooperation. Finally, it creates the conditions for effective public action in different regions, by improving coordination between different state departments and involving local authorities and civil society. Following on from the previous action plan on drugs and addictive behaviours (2013-2017), the 2018-2022 national action plan on addiction promotes an approach targeting all psychoactive substances (alcohol, tobacco, illegal drugs) and other forms of addictive behaviours (gambling, doping) with emphasis on screens.
It will be implemented over a 5-year period compatible with its objectives notably in terms of prevention. A striking aspect is its commitment to working in harmony with other governmental plans (health, prevention, road safety, child poverty, students, housing, doping, overseas). This plan is accompanied by indicators summarising the main challenges in terms of the envisaged results, and defining the targets to be reached. These targets have variable timelines based on the actual availability of data.
The most recent evaluation concerned the 2013-2017 government action plan on drugs and addictive behaviours. An external team of academics was entrusted with the task of evaluation. Four key measures of the 2013-2017 plan have been selected: the “Student liaison officers on health” scheme implemented in a university setting, a trial among inhabitants in the southern districts of Marseille (mothers, professionals, integrated young people and pre-teens) and local partners (council, police, prevention associations involved, etc.), the new partnership between MILDECA and the National Family Allowance Fund (CNAF), introduced with a view to taking over the main public relations campaign targeting the “general public” and, lastly, two regional intervention programmes aiming for the prevention and early treatment of foetal alcohol syndrome. The final evaluation report was published on 16 January 2018. These guidelines served as inspiration for the directions of the 2018-2022 national action plan on addiction, which is both committed to long-term approach and to cross-sectional local involvement, with a view to creating a real local dynamic in terms of the policy for combating and preventing addiction.
The directions of public policy in the field of drugs and addictions are defined by the "Interministerial Committee for Combatting Drugs and Addictive Behaviours", on the authority of the Prime Minister. This committee is made up of ministers and secretaries of State. Prior to this stage, MILDECA is responsible for drafting the decisions of the interministerial committee, then coordinating French government policy for combatting drugs and preventing addictive behaviours, and for ensuring that the decisions of the interministerial committee are implemented. On the authority of the Prime Minister, its scope of action includes prevention, treatment, harm reduction measures, integration, trafficking, law enforcement and research, monitoring and training of staff involved in activities to reduce supply and demand. A network of approximately one hundred territorial representatives (generally the senior local government officers’ general administrators of the “département”) on a national scale guarantees the consistency of the implemented actions. Eleven of these are responsible for regional coordination.
Approved by the French government in December 2018, the 2018-2022 National Action Plan on addictions, drawn up by the MILDECA, is currently in progress (MILDECA 2018).
With regard to the most recent highlights, 2018 was marked by the controversies surrounding the 2018-2022 draft law of the French Programming Act for Justice, which provides for the creation of a criminal fine procedure in the event that narcotic drugs are used. Furthermore, over the last year, topics specifically related to cannabis have dominated drug debates among French civil society stakeholders and their political representatives. At the end of June 2019, a committee of experts published its draft framework for five pathologies for an experimental phase of therapeutic cannabis, to begin in mid-2020. On 11 July 2019, the National Agency for Medicines and Health Products Safety (ANSM) announced its support for these proposals.
Meanwhile, the Council for Economic Analysis (CAE) published a memorandum on 20 June 2019 entitled "Cannabis: how can we regain control?” The authors recommended legalising the process, establishing a public monopoly on cannabis production and sales. In contrast to this view, the government immediately rejected the working assumptions of the Council for Economic Analysis. This recurring debate on French policy will probably continue with the implementation of a mission to research different cannabis uses announced for September 2019 in the National Assembly.
Apart from the issues that are largely centred around cannabis, crack cocaine remains a major concern in Paris, both in terms of health and public safety. At the end of May 2019, a new plan to combat this phenomenon was drawn up under the aegis of the regional prefecture with the help of the Paris City Hall, the Regional Health Agency (ARS) and the MILDECA.
The social cost of drugs in France was estimated at three points, in 1996, 2003 and 2010. The most recent estimate of the social cost of drugs was published by the OFDT in September 2015: hence, for 2010, this cost amounted to 8.7 billion euros for illegal drugs, far behind the amount estimated for alcohol (118 billion euros) and tobacco (122 billion euros).
In 2017, the total public expenditure on drugs and addictive behaviours was estimated to be €2.45 billion. The contribution from the State and National Health Insurance Fund represents 0.11% of the gross domestic product, with 50% of the total for demand reduction initiatives, 49% for supply reduction activities and almost 1% of the resources allocated to transversal activities (international cooperation and coordination). For the second year in a row, this estimate is up (by 10%), after the figure remained stable between 2014 and 2015 (+1%), following the decrease observed between 2013 and 2014 (by 6%).
In France, the illegal use of any substance or plant classified as a narcotic is an offence punishable by sentences of up to one year in prison and a fine of €3,750 (Article L.3421-1 of the French Public Health Code - CSP). The sentences incurred may be up to five years in prison and a fine of €75,000 when the offence is committed by a public authority, a person responsible for public services or personnel in a company carrying out duties calling into question transport safety. Persons prosecuted for these offences also face additional penalties such as a compulsory awareness course on the dangers of drug and alcohol use, in accordance with the provisions set forth in Article 131-35-1 of the French Penal Code. These penalties are applicable to occasional or habitual use of narcotics, whether used in public or in private.
The law of 23 March 2019 finally provided for the introduction of a fixed fine for drug use. This offence may be punishable by a fixed fine of 200 euros - except in the case of minors - without going to a judge, who may only intervene in the event that the person concerned disputes the offence.
In practice, the penal response to use is graduated, particularly taking into account the nature of the used substance, how much was taken and the individual's criminal record. The public prosecutor may prefer an alternative to prosecution, for example a drug warning, an onward referral to a health, social or professional facility, an awareness course on the dangers of drug and alcohol use or, when circumstances suggest that the alleged offender requires treatment, a drug treatment order (Article L. 3413-1 of the CSP).
The public prosecutor may also implement a simplified procedure (fixed penalty notice, criminal order) to penalise users with a fine and/or a training course.
Illegal transport, possession, proposal, sale, acquisition or use and the fact of facilitating the illegal use of narcotics are punishable by a maximum of ten years in prison and a fine of €7.5 million (Article L.222-37 of the French Penal Code). The illegal proposal or sale of narcotics to a person with a view to personal use is punishable by five years in prison and a fine of €75,000; however, the prison sentence is extended to ten years when narcotics are proposed or sold to minors, in learning or educational establishments or on government premises, and at or very close to the time when students or the public are entering or leaving these establishments premises, in the vicinity of these establishments or premises (Article L.222-39 of the French Penal Code). The maximum penalties incurred for trafficking are life imprisonment and a fine of €7.5 million (Article L.222-34 of the French Penal Code). The law itself does not distinguish between possession for personal use or for trafficking, nor by type of illegal substance.
With regards to cannabis, French regulations stipulate that all activities concerning it (production, possession, use) are prohibited (Art. R.5132-86 I -1° of the Public Health Code). Some forms of hemp without psychoactive properties may, however, be used for manufacturing and commercial purposes, provided that the variety is authorised, the plant contains less than 0.2% THC, and that only the seeds and fibres are used (with the use of the resin, flowers and leaves of the plant being prohibited). Cannabidiol may be advertised if it is addressed through one of the pharmaceutical specialities with a marketing authorisation (art. R.5132-86 III CSP) and if it complies with the relevant drug regulations (CSP, Book 1, Title II, Chapter II, R.5122-1 to 8).
Since December 2018, an expert committee from the National Agency for Medicines and Health Products Safety (ANSM) has been responsible for setting up a two-year trial of therapeutic cannabis in France, targeting patients with neuropathic pain that is resistant to therapy, who have certain severe forms of epilepsy that are resistant to treatment, who are receiving supportive care in oncology, who are in palliative situations, who are experiencing painful spasticity due to multiple sclerosis or who have other central nervous system pathologies. On 26 June 2019, the Committee delivered a favourable opinion for carrying out an experiment. This experiment’s principle was confirmed by the ANSM on 11 July 2019.
There are no specific laws regulating new psychoactive substances (NPS). The rationale for classifying a NPS on the list of narcotics is both individual (each prohibited substance is named on the list) and generic.
Drug use, polydrug use and the main illicit drugs
According to the latest available data (2017), cannabis is still by far the most widely used illicit substance, both among teenagers and the adult population (45% of 18 to 64-year-olds), with overall 18 million people having already tried it. The overall proportion of recent users (in the last month) is 6.4% among adults.
Among last year users aged 18 to 64 years (11%), according to the 2017 Health Barometer Survey of Santé publique France, the proportion of those at high risk of problem cannabis use (according to the Cannabis Abuse Screening Test, CAST – see details in T1.2.3 of workbook 2016) is 25%, i.e. 2.3% of the French population aged 18 to 64 years. Cannabis is also the most frequently reported substance mentioned as the principal reason for entering drug treatment (CSAPA). As far as synthetic cannabinoids are concerned, 1.3% of adults aged 18 to 64 state that they have already used such substances. Their use levels are similar to heroin or amphetamines.
Cannabis use among adults aged 18 to 64 stabilised between 2014 and 2017 (after the substantial rise observed between 2011 and 2014), at a high level, irrespective of age groups and frequency of use: this trend is part of the dynamic context of supply in France, particularly with the local production of herbal cannabis (industrial plantations but also personal cultivation), alongside the innovation and diversification of the resin market (see the Market & Crime workbook).
Cannabis is also the illicit substance most widely used between the ages of 11 and 16 years, particularly among boys. In terms of lifetime use, in 2018, cannabis use accounted for 6.7% of middle school students (average age 13.5) (ENCLASS 2018 data), a lower percentage compared to in 2014 (9.8%). In 2018, a third of high school students (average age 17.1), had already tried cannabis (33.1%), representing 30.0% of girls and 36.3% of boys. In addition, 17.3% used it in the month preceding the survey. These levels are lower than they were in the previous survey in 2015 (44.0% and 22.6% respectively). This downward trend is also evident in the 2017 ESCAPAD survey among 17-year-olds, where 21% reported to have used cannabis over the past month, compared to 25% in 2014.
In the survey on representations, opinions and perceptions regarding psychoactive drugs (EROPP) conducted at the end of 2018 among people aged 18 to 75, nearly 9 out of 10 respondents (88%) spontaneously reported cannabis as a "drug" they know, even if only by name. Just under half of respondents (48%) considered it to be dangerous to use from the first time.
The spread of cocaine, the second most widely consumed illegal substance, is considerably lower: almost ten times fewer people had already tried it. However, the proportion of 18-64-year-olds with lifetime cocaine use has increased four-fold in two decades (from 1.2% in 1995 to 5.6% in 2017, a stable level compared to 2014). The proportion of last-year users also increased substantially, from 0.3% in 2000 to 1.1% in 2014, then 1.6% in 2017. For the past few years the consumption of this substance once limited to the more well-off, has affected all levels of society, although to varying degrees. The levels of lifetime use for synthetic drugs such as MDMA/ecstasy and amphetamines are 5.0% and 2.2%, respectively among 18-64-year-olds. The proportion of current MDMA/ecstasy users remained stable between 2010 and 2017 (1.0%). Among 18-25-year-olds, the use of this product equals that of cocaine.
Lastly, the prevalence of lifetime use of heroin is 1.3% in the entire 18 to 64-year-old population and current use seems very rare (0.2% of those surveyed).
77% of 18-75-year-olds surveyed in EROPP at the end of 2018 considered cocaine to be dangerous from its first use and 84% thought the same for heroin.
The latest ENa-CAARUD survey, conducted at the end of 2015 in support centres for the reduction of drug-related harms (CAARUD), validated the qualitative findings of the TREND system about the most disadvantaged users turning to less expensive substances, medications and crack cocaine when available.
Overall, substance use in the past 30 days before the survey did not show any major changes in terms of structure. Nevertheless, certain changes can be observed since 2008. As regards opioids, the use of buprenorphine (whether prescribed or misused) has declined steadily (40% vs. 32%), in favour of methadone (24% in 2008 vs. 31% in 2015). The use of heroin stayed stable (30%).
As regards stimulants, the proportion of CAARUD clients having taken freebase cocaine (crack or freebase) continued to increase steadily (22% in 2008, 33% in 2015). No changes were observed for hallucinogens exclusively used by a subgroup of this population (15 %).
The use of illicit drugs with alcohol, tobacco and prescription drugs
In both the French Public Health Agency’s health barometer (adult population) and the OFDT’s ESCAPAD survey (17-year-olds), polydrug use is defined as using at least two of the three following substances over the period of a month: alcohol, tobacco and cannabis. These are not necessarily concurrent uses. In 2014 (latest available data), polydrug use is still uncommon since it only concerns 9.0% of the adult population. It reaches a peak among 18 to 25-year-olds, who are one of the age groups with the highest tobacco and cannabis use (13.2%). Regular polydrug use of three substances is rare since this concerns 1.8% of men and 0.3% of women aged 18 to 64.
In 2017, regular polydrug use of alcohol, tobacco or cannabis concerns 9.3% of 17-year old teenagers. Cumulative regular tobacco and cannabis use is more widespread (4.4%), ahead of cumulative regular tobacco and alcohol use (2.8%). Cumulative regular use of the three substances concerns 1.9% of 17-year-olds.
Between 2014 and 2017, regular polydrug use decreased by more than 3 points, returning to the level observed in 2011.
Regarding the public received in Youth Addiction Outpatient Clinics (CJC), outpatients seeking help for cannabis use were also tobacco users (87% of daily smokers) and subject to frequent or massive alcohol consumption. About 10% of these "cannabis outpatients" are regular drinkers. Almost a quarter (22%) declared at least three heavy episodic drinking (HED) in the last month (Protais et al. 2016).
Alcohol use also appears to be predominant among CAARUD clients (active drug users who are not undergoing active treatment or have withdrawn from the care system, vulnerable from a socioeconomic perspective) : 71% reported last-month alcohol use, and among them nearly half claimed to have drank the equivalent of at least 6 glasses on a single occasion, every day or nearly every day in the past year. As regards medications, in compliance with qualitative findings, the use of buprenorphine (whether prescribed or misused) has declined steadily (40% vs. 32%), in favour of methadone (24% in 2008 vs. 31% in 2015), which is more widely prescribed, and morphine sulphate, which is more frequently misused (15% in 2010, 17% in 2012 and 2015). The use of substances containing codeine has been gradually increasing since 2010, when this was measured for the first time (5% vs. 9%), whereas the use of other opioid medications (for instance, fentanyl), studied for the first time in 2015, reached 7%. Only 4% of users took diverted methylphenidate, although this situation was highly concentrated geographically. However, benzodiazepine use rose sharply between 2012 and 2015 (30.5% vs 36%) (Lermenier-Jeannet et al. 2017).
Policy and organisation
In France, the addictive behaviour prevention policy refer to licit (alcohol, tobacco and psychotropic medicines) and illicit psychoactive substances, but also to other forms of addiction (gambling, gaming). Under the State responsibility, this strategy is coordinated at central level by the Interministerial Mission for Combating Drugs and Addictive Behaviours (MILDECA) and implemented at local levels by deconcentrated services. General goals are not only to delay if not to prevent the onset of use, but also to curb addictive practices and the related abuses and risks. The 2018-2022 National Action Plan on Addictions emphasises the implementation of evidence-based approaches, particularly those focusing on psychosocial skills for children and adolescents, and on the early detection of addictive behaviours so that people in need can be guided more effectively to specialised support services.
In the prefectures, the MILDECA project managers outline, within the framework of regional roadmaps, their objectives to prevent addictive behaviour and share them with the State's territorial departments. They dedicate funding to prevention activities granted by the Finance Act and appropriated to them by the MILDECA as well as funding from the Interministerial Fund for Crime Prevention (FIPD). The intervention funding from the Regional Health Agencies (ARS), particularly the Regional Intervention Fund (FIR), and now the Fund for Combatting Addiction to Psychoactive Substances, constitute other sources of financing prevention.
At local level, school prevention activities are implemented by a range of professionals. Within the area of educative health pathway for pupils, school stakeholders are involved in commissioning, planning and implementing activities. In many cases, external interveners (NGO staff and/or specialised law enforcement officers) are solicited to address pupils. Prevention measures in schools focus on developing students’ individual and social skills, teaching them to resist peer pressure and the temptation to drink and take drugs. Long-term educational projects are encouraged.
School-based universal prevention mostly in secondary schools and indicated prevention through the Youth Addiction Outpatient Clinics (CJC) which deliver ‘early intervention’ towards young users and their families (in 550 consultation points throughout France) are two pillars of the public responses. However, these previous years, preventive responses were enhanced towards priority publics, like youth in deprived urban areas, school drop-out kids and youth in contact with the judicial system. Major efforts have been made to develop collective prevention measures in the workplace as well (private compagnies and public services) beyond the remit of occupational
physicians. Environmental strategies to curb alcohol and tobacco use are well developed and have substantial political support. National media campaigns to prevent alcohol, tobacco or illicit drugs are regularly issued.
Trends & Quality assurance
During the 2010s, professionals and policymakers are showing increasing interest in the quality of prevention services and programmes offered and how to improve them. Prevention stakeholders are encouraged but free to refer to guidelines on drug prevention in school or other settings. The ASPIRE grid (Assessment and selection of prevention programmes arising from "EDPQS" quality standard overview) the French adaptation of the EDPQS, remains relatively unknown and appears to not be used very frequently. Since the end of September 2018, a directory of effective or promising prevention interventions that promote health « Répertoire des interventions efficaces ou prometteuses en prévention et promotion de la santé », managed by the French Public Health Agency (SpF), has been available and is still being expanded.
The 2018-2022 National Action Plan on Addictions involves numerous new objectives in terms of prevention in the coming years.
Two schemes make it possible to provide treatment to illicit drug users: the specialised service for addiction treatment (available either in medical-social establishments - National treatment and prevention centres for addiction - or CSAPA, either in hospitals or towns) and the conventional scheme mainly represented by general practitioners and pharmacists. According to CSAPA activity reports, approximately 138,000 individuals were received in outpatient CSAPA (specialised addiction treatment centres) in 2016 for problems with illegal drugs or diverted psychotropic medications. In 2018, about 57,000 users starting a course of treatment in a CSAPA were actually included in TDI data. However, these figures account for only a proportion of users corresponding to exhaustive data collection.
OST is mainly prescribed in a primary care setting by general practitioners, and is usually dispensed in community pharmacies. In 2017, 162,300 persons received opioid substitution treatment dispensed in community pharmacies and 23,330 patients received treatment dispensed in a CSAPA in 2016.
In terms of outpatient treatment provision, the public authorities developed specific healthcare for young users by creating youth addiction outpatient clinics (CJC) in 2004. Presently, approximately 540 clinics have opened. Although no national "programmes" intended for other target groups exist, some CSAPA have specialised in healthcare adapted to specific populations (women with children, offenders, etc.).
After increasing between 2014 and 2016, the number of people receiving care for the first time as part of the specialised service for addiction treatment, declined in 2017. It remained stable between 2017 and 2018. The increase in these treatment demands between 2014 and 2016 mainly came from cannabis users, who represented an overwhelming majority (74% in 2018). The number of treatment demands related to opiates has been declining since 2016. The number of demands related to cocaine, which were very low in 2014, more than doubled between 2014 and 2018 and may soon exceed the number of demands related to opioids. Over the 2007-2018 period, the number of cannabis related demands increased between 2007 and 2014 and then stabilised. The proportion of opioid related demands decreased between 2007 and 2014 at the same rate. Since then, the figure has continued to decline but at a fairly slow rate. The proportion of opioid related demands slightly increased between 2016 and 2018.
Developments in the number of treatment entrants are similar to those for first treatment demands, even though there are less when it comes to cannabis (lower increase and decrease rate). The distribution according to substances seems fairly stable up to 2010, with a slight downward trend in the percentage of cannabis users. The percentage of these users then increases significantly, peaking at 62% in 2016 to then decrease in 2017 for the first time since 2010 and stabilising in 2018 at around 60%. The evolution of the share of opiate users is roughly symmetrical to that of cannabis users. As for first-time treatment demands, the most significant trend is the continued increase in the number and share of treatment demands related to cocaine.
Furthermore, since 2013, the number of persons receiving opioid substitution treatment (OST) has remained stable, after increasing constantly since this type of treatment was first introduced. The number of persons treated with buprenorphine decreased slightly over this period, in favour of patients treated with methadone, in keeping with sales data for these opioid substitution medications.
As in 2017, 2018 was marked by the number and percentage of treatment demands related to cocaine continuously progressing. The number and percentage of treatment demands related to cannabis seem to stabilise after the sharp increase from 2010-2016.
In 2017, 162,300 people received opioid substitution treatment dispensed in community pharmacies: 99,900 were prescribed buprenorphine (Subutex® or generics), 61,700 methadone and 7,600 buprenorphine in combination with naloxone (Suboxone®).
Furthermore, 23,330 patients were dispensed opioid substitution medications in CSAPA (19,800 methadone and 3,530 buprenorphine) in 2016.
The new national action plan on addiction for the 2018-2022 period reaffirms the government’s willingness to reinforce quality in public responses on the basis of observation, research, evaluation and a reinforced training strategy, with a special impetus on prevention. Under the prevention, care and research strategical pillars, it defines quality assurance objectives with regards to the promotion and the implementation of evidence-based knowledge, evaluation and skill raising through training and scientific mediation. The Interministerial Commission for the Prevention of Addictive Behaviours (CIPCA), that ceased its activities in 2018, reflects the political will of developing evidence-based prevention knowledge.
In France, quality assurance in Drug Demand Reduction (prevention, risk reduction, treatment and rehabilitation) builds on specific advocacy, guidelines or trainings from public health institutions or professional societies. It is in the remits of the French Public Health Agency (Santé publique France - SpF) and the French National Authority for Health (Haute autorité de santé - HAS). SpF disseminates evidence in drug prevention research and supports the local experimental transfer of international evidenced-base programmes like Unplugged (Lecrique 2019), GBG, SFP, etc. The HAS diffuses professional guidelines/recommendations on risk reduction and treatment addressing: (i) Opioid Substitution Treatment, (ii) Early intervention and risk/harm reduction for crack or free base users, (iii) Clinics for young drug users, (iv) Treatment of cocaine users, (v) Harm and risk reduction in low threshold services (CAARUD) and (vi) Prevention and risk reduction delivered by drug treatment centres (CSAPA) (released in Autumn 2018). The two later documents (v and vi) serve as a baseline for compulsory evaluations of drug services but the fulfilment of the other guidelines is not a formal prerequisite for support or subsidies. Tools exist to help decision makers to select quality prevention programmes (EDPQS materials and the ASPIRE toolkit adapted from them) but the extent to which they are used is unknown.
Professional federations are also engaged in developing quality and professional supports: the new portal on addictions for primary care professionals (GPs, school nurses, dentists, pharmacists, midwives, emergency doctors) is an example: https://intervenir-addictions.fr/. This portal was created by the Fédération Addiction with support from the public authorities, the French Public Health Agency (Santé publique France), the OFDT and various other partners in the field of addiction.
The addiction treatment services (so-called CSAPA) are marginally impacted by the existing accreditation and certification systems applied to health establishments and processed by the HAS (French National Authority for Health). However, the CSAPA, most of which were authorised as medico-social establishments at the beginning of the 2010s for a period of 15 years, are required to provide two external evaluations during this period. These evaluations must be carried out by a body approved by the HAS and follow a set of specifications outlined by decree.
In the 2010’s, although many resource services in prevention engineering have collapsed at local level, there is a noticeable willing at national level to enhance quality in the programmes and services delivered, especially in prevention.
The National training Institute of the National Police (INFPN) provides specialised law enforcement agents with four-week training on drug issues and prevention intervention towards adults and adolescents. In the recent years, several initiatives were undertaken to:
- develop knowledge and competence on addictions in medical studies. Endeavours will be extended to other health studies (nursing, pharmacy);
- integrate a module on early detection of addictive behaviours and early intervention in the curricula of future school agents (educational advisers, education professionals and teachers).
The first national prevention plan calls for a charter of ethics for school health promotion interventions from September 2018 onwards.
The number of overdose deaths in 2016 amounted to 309 among 15-49-year-olds (463 in total) according to the latest available data of the general death register. In 2017, 537 deaths were registered in the specific registers (432 in DRAMES added to the 105 deaths of DTA). According to the specific overdose death register (DRAMES scheme), 432 overdose deaths were registered in 2017 with opiates implicated in 78% of cases. Opioid substitution medications were implicated in 45% of cases and heroin in 25% of cases. Cocaine was involved in 26% of deaths. Otherwise, the mortality cohort study included 1,134 individuals, and for 955 (or 84%) of these subjects, the vital status was checked in December 2015. For men, the standardised mortality ratio was 5.6. For women, it was much higher (18.5).
The number of overdose deaths in the general death register has sharply risen (+31%) among 15-49-year-olds in 2016 compared to 2015. Between 2010 and 2016, opioid substitution medications were the main substances implicated in overdose deaths, ahead of heroin. Cocaine involvement is on the rise in deaths related to drug use since 2014.
Nearly 13,000 hospital emergency presentations related to drug use were reported in France in 2015 (Oscour® network). More than a quarter of presentations were related to cannabis use and less than a quarter to opioid use, whereas cocaine was implicated in 7% of cases, other stimulants in 3% of cases, hallucinogens in 4% of cases and, lastly, multiple or unspecified substances were responsible in 36% of cases.
In 2017, people infected through intravenous drug use represented 2% of new cases of HIV infection. The number of HIV seropositive diagnoses associated with drug use has been declining since 2010. The number of new AIDS cases related to drug use is also steadily declining since 2010.
Furthermore, between 2012 and 2017, the reported prevalence of HIV and HCV remained stable, both in the harm reduction facilities (CAARUD) and specialised drug treatment centres (CSAPA) context. This stability highlights the end of the declining prevalence of HCV among injecting drug users (IDU) observed since the beginning of the 2000s. The most recent data on biological prevalence are from 2011. The biological prevalence of HIV among drug users having injected at least once in their life was 13.3%, while the biological prevalence of HCV in this population reached 63.8%. The seroprevalence of AgHB (which indicates chronic hepatitis B virus infection) was 1.4% among drug users surveyed in the Coquelicot survey from 2011 to 2013.
National profile and trends harm reduction
Harm reduction (HR) measures are intended for vulnerable populations whose substance use patterns expose them to major risks. These are notably based on the distribution of sterile single-use equipment (syringes, crack pipes, snorting equipment, injection and inhalation kits, etc.) and the diffusion of opioid substitution treatment. Preventing infectious diseases also relies on encouragement to undergo screening for HIV, HBV and HCV, as well as HBV vaccination and HCV treatment. Another major objective of HR measures is to promote drug user access to treatment and social benefits (accommodation, training, employment, etc.), particularly for the most destitute and socially isolated individuals.
Approximately 12 million syringes were distributed or sold to drug users in France in 2016. It was estimated that 9.8 million syringes were distributed in 2011 (last year available before the discontinuation in collated data). This development represents an 18% increase (i.e. an increase of 2.2 million syringes between 2011 and 2016). Pharmacy syringe sales in the form of injection kits, which represent a third of syringes distributed to drug users in 2016, fell by a third in 5 years (a 33% reduction between 2011 and 2016, i.e. 1 million fewer syringes), offset by the increase in distribution in specialised drug treatment centres (CAARUDs) (+37% in 5 year), harm reduction facilities (CSAPAs) (+20% in 5 years), automatic distribution machines (+47 in 5 years) and postal Needle and Syringe exchange Programme (+95% in 5 years).
Updated guidelines on the management of HCV-infected individuals, and on the HIV screening strategy urge the continuation and consolidation of action already taken along these lines, particularly among injecting drug users. 59,000 patients suffering from chronic hepatitis C were treated and cured by direct-acting antivirals (DAA) between 2014 and 2017, including at least 11,000 former or current drug users. During 2017, reimbursement of DAA (100% reimbursed by the National Health Insurance Fund) was extended to all adults with chronic hepatitis C irrespective of fibrosis stage. The most prescribed DAAs have been available in pharmacists since March 2018 and certain DAAs have been available on prescription from all physicians since May 2019, making it easier to treat hepatitis C.
As regards the implementation of a naloxone distribution programme (antidote to opioid overdose) in France, a proprietary medicinal product containing naloxone for nasal use (Nalscue®) obtained a marketing authorisation for use in July 2017. It has been on the market since January 2018 and is only available in CAARUDs, CSAPAs and specialised services. Intramuscular naloxone kits (Prenoxad®) have been available in pharmacists and specialised facilities since June 2019.
Drug consumption rooms, which were previously reserved for users injecting psychoactive substances, have also been available to inhaling or smoking users since July 2019.
Domestic drug market
Herbal cannabis is the only illegal substance for which production is seen in France. While growing herbal cannabis in metropolitan France was mainly the work of small, self-sufficient growers, the situation began to change at the start of the 2010s with the emergence of cannabis factories run by organised crime groups and with individuals investing in its commercial production.
Given France’s geographic position at the heart of Western Europe, it is a transit area for the main illegal substances (cannabis, cocaine, heroin and synthetic drugs) produced worldwide. This is also the case due to its overseas departments on the American continent (Guadeloupe, Martinique and Guiana) close to the major cocaine production and transit zones (Colombia, Venezuela).
Cannabis resin used in France comes from Morocco and usually transits through Spain while herbal cannabis is imported mainly from Spain, the Netherlands and Belgium.
The cocaine used in France is produced mainly in Colombia. It mainly passes via sea routes through the south via Spain (Algesiras) and the north via the Netherlands (Rotterdam), Belgium (Antwerp) and to a lesser extent Germany (Hamburg). Over the past few years, cocaine, transiting through Venezuela then via the French West Indies, has been entering the European continent through the port of Le Havre. There has also been a major increase in air trafficking by “mules” between Guiana and mainland France.
The heroin used in France mainly comes from Afghanistan (brown heroin) and passes via the Balkans (Turkey, Greece, Albania). the Netherlands, ahead of Belgium, is the main platform which supplies French dealers.
Synthetic drugs (MDMA/ecstasy, amphetamines) used in France also mainly come from the Netherlands.
National drug law offences
In 2018, the total number of persons accused of narcotic use in France is 161,300 against about 164,000 in 2017. 8 out of 10 people accused of a drug-related offence corresponded to simple use. The number of people implicated in trafficking offences (15 400) increased by 6% compared to 2017, and user-dealers (18 200), increased by 3%. In 2010, 90% of the arrests concerned the simple use of cannabis, 5% simple heroin use, and 3% simple cocaine use (since 2010 national statistics no longer provide details of arrests for each substance).
Key drug supply reduction activities
The national action plan on addictions (2018-2022) emphasises the importance of implementing a genuine national strategy based on better coordination between the various services involved (police, customs, Gendarmerie, justice). Money laundering, a key issue in a dynamic French drug market, is a major priority. The challenge of international cooperation, in particular, has also been placed at the forefront, notably the important role of French overseas departments (Guiana, Martinique and Guadeloupe, together with the French overseas territory Saint-Martin) in supplying the mainland market with cocaine. Lastly, emphasis is placed on prevention to stop young people, especially minors becoming involved in local trafficking, firmly established in large cities.
As of 1st January 2018, France had 185 prison establishments with a total operational capacity of 59,765. With 68,974 inmates, there are 120 inmates for every 100 beds in France. The only recent surveys on the subject merely provide preliminary or partial data. However, studies conducted about a dozen years ago demonstrated that one third of new inmates stated prolonged, regular use of illegal drugs in the year prior to entering prison. Nearly 11% of inmates stating that they used illegal drugs on a regular basis used multiple substances prior to their imprisonment. 10% of inmates were addicted, but the total number of problem drug users (PDU) in prison settings is not quantified in France. No studies provide data on NPS use in prisons. Inmates have greater rates of infectious disease than the general population: although declining, HIV infection prevalences vary, depending on the source, from 0.6% to 2.0% (three to four times the prevalence in the general population), while prevalences of HCV are from 4.2% to 6.9% (four to five times higher).
The Ministry of Health has been responsible for healthcare in prison since 1994. Health care in prison is made up of health units in prison settings (USMP) which offer somatic and psychiatric care. Psychiatric care units (regional medico-psychological hospital services - SMPR) coordinate and support USMP. They have hospital places for during the day. To treat people presenting with addictive behaviour and the resulting somatic and/or psychiatric symptoms, these units can benefit from working with a CSAPA in a prison environment, located in eleven of the largest institutions in France (representing around a quarter of the imprisoned population) or other addiction care specialists, depending on the local organisations. A reference CSAPA is designated to each prison. Its aims are to help prepare prisoners for getting out and to promote the necessary monitoring of the inmates on their release. In 2016, 202 CSAPA reported that they had worked in a prison, with 11 CSAPA exclusively working in prisons (previously Antennes-Toxicomanies, created at the end of the 1980s) and 126 being reference CSAPA. These centres worked in 162 different prisons.
To guarantee the application of harm reduction measures, two main ways of preventing the spread of infectious diseases have been implemented in prison settings since 1996. Firstly, inmates have to be able to not only continue their opioid substitution treatment (OST) that was prescribed to them before they were imprisoned but to also start such a treatment if they so desire. In addition to substitution, prison establishments offer prevention and decontamination tools for fighting against HIV and hepatitis’s.
Since 2009, different laws have proposed to step up harm reduction measures in prison. The main lines of improvement concern the increased scope and role of the reference CSAPA, routine implementation of screening tests, and widespread access to all existing harm reduction measures, including needle and syringe exchange programmes. These objectives are reasserted in the 2016 health reform law.
Around 13,700 inmates received opioid substitution treatment in 2017, representing 8% of those who stayed in a prison setting, a figure that has remained stable since 2013.
The Circé survey, conducted by the OFDT between 2016 and 2018, updated the existing data on the organisation of drug trafficking in custody and the responses to this. It shows that currently the two main means used by convicts to introduce prohibited substances are in the visiting rooms and throwing them in the exercise yard. It reveals that there are specific people that bring drugs into custody, including prison officers. The report also examines this market’s organisation and the main people involved. It shows that the social organisations where trafficking takes place are varied and that this phenomenon is at the origin of specific prison pathways. Finally, the study examines the variability of the prison authorities' responses, ranging from punitive to “laissez-faire” attitudes that aim to negotiate with inmates to keep the peace. Health units also vary their policies, going between implementing prescriptive practices and more compassionate solutions.
Since June 2017, France has been experimenting with the first therapeutic community in a prison environment (Drug user rehabilitation unit: URUD) at the Neuvic detention centre. An operating assessment has been requested from OFDT to evaluate its implementation. It shows promising results: the scheme makes it possible to ease relations between inmates and prison officers, while proving to have a positive impact on beneficiaries. However, this assessment raises some questions, mainly concerning the selective element of the programme and the issue of the confidentiality of the personal information provided. Medical and economic data is also expected to decide whether the scheme should be implemented elsewhere.
In June 2019, the Ministry of Solidarity and Health and the Ministry of Justice adopted a roadmap targeting 28 priority actions for the period 2019-2021, based on the "health/prison" strategic actions plan on health policy for inmates adopted in 2017.
In France, the Ministry of National Education, Higher Education and Research (MENESR) designs, coordinates and implements national policy on research and innovation. Two primary academic organisations, the National Centre for Scientific Research (CNRS) and the National Institute for Health and Medical Research (INSERM), cover a wide range of research areas, from neurosciences, through public health and clinical research to social sciences.
The French National Focal Point (OFDT) is the main body involved in drug-related data collection, studies and network development. It collaborates extensively with national and European drug-related research teams. Dissemination of data and research results are also part of its mandate, together with publishing in national and international scientific journals, and promoting the use of research results in practice and policymaking.
The Interministerial Mission for Combating Drugs and Addictive Behaviours (MILDECA) is the central structure responsible to the Prime Minister for coordinating governmental action in the drugs field. Part of its role is to promote and fund drug-related research.
In line with previous government plans, developing research and observation in the field of addiction in order to provide information on the implementation of public policies is one of the 6 major challenges included in the 2018-2022 National Action plan on Addiction (MILDECA 2018). The measures to be implemented focus on two main priorities:
1) Bringing science, political policy-making and citizens closer together;
2) Broadening knowledge in all areas of public action.
In order to improve links between the scientific community, policymakers and citizens, the plan aims to increase places and times for meetings about spreading knowledge on addiction, both nationally and regionally. The importance of the focal point (OFDT) being in a prime position to spread knowledge faster and for this knowledge to be adopted by stakeholders and the general public is underlined. A series of measures also aim to help those working in the field of addiction improve control and investment in this area, particularly with regard to alcohol-related issues.
Linked to the priority to “bring science, policy-making and citizens closer together”, the MILDECA also wants to create an interministerial “science-policymakers” forum categorised by major policy area (science and prevention, science and treatment, science and judicial response and science and counter-trafficking). This “science-policymakers” forum will focus on planning regular interministerial meetings to provide more information on addiction. This will involve sharing existing documentation with public stakeholders and working with them to determine the gaps in existing research and the necessary studies they will need to undertake to determine appropriate intervention measures. Interministerial requests for expertise or impact assessments can therefore be prepared together to meet their requirements. Finally, the MILDECA will strive to share the results of this work with the relevant policymakers in order to help them give the public the answers they need.
The plan highlights several key areas where new knowledge is required: prevalence of use among vulnerable groups (people with disabilities, people living in poverty, people subject to a court order, migrants), influence of environmental factors and preventative and health care supplies on the path to using, individual vulnerability factors, gender specific factors, etc.
In order to prevent more people from using, emphasis is placed on carrying out intervention research in schools and workplaces. The plan also promotes developing knowledge on marketing strategies that influence how the risks of using are perceived among young people in order to deconstruct the discourse conveyed by industrialists and to put in place appropriate responses.
To better reduce risks and improve care and access to care, the plan confirms support for clinical and therapeutic research by encouraging a transversal and collaborative approach. Evaluating medico-social and harm reduction interventions is also valued.
Moreover, in terms of questioning the effectiveness of criminal solutions, the authorities stress the need to develop evaluative research in this field in order to encourage solutions to develop to create the most promising judicial measures. As regards research relating to drug supply, the plan notably encourages improved monitoring of new psychoactive substances and studies on the changes in supply.
All reports :
Drugs in Europe
What do the latest data tell us about the European drug market? What are the new trends in drug use among European adults and school students? What are the harms associated with drug use and what is being done to counter them? These and other questions are explored in the 2019 EMCDDA European Drug Report.
Country drug reports 2019
Developed by the EMCDDA, in cooperation with the Reitox national focal points, these graphic-rich reports cover: drug use and public health problems; drug policy and responses and drug supply.
The European Union and the drug phenomenon
The European Union & the drug phenomenon : Frequently asked questions, joint publication between the EMCDDA and the European Commission, october 2010, 12 p.