National annual report on drug issues

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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2018 report


The 2018 report is divided in 10 workbooks: Drug Policy, Legal Framework, Drugs, Prevention, Treatment, Best Practice, Harms and Harm Reduction, Drug Market and Crime, Prison and Research.

Drug policy

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The main strategic lines of the French policy for fighting addiction are shown in the mission statement from the Prime Minister to the Chair of the Interministerial Mission for Combating Drugs and Addictive Behaviours (MILDECA) dated 19 September 2017. The government is reasserting its commitment to a clear and cohesive policy concerning risks, along with schemes able to assist the general public concerned. This objective is based on the implementation of a sustained prevention and support policy among the youngest age groups concerned, taking into account living conditions and the vulnerabilities facing these populations. Another key government priority is the fight against trafficking. 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 (project managers) on a national scale guarantees the consistency of supply and demand reduction actions. Eleven of these are responsible for regional coordination.

A new 2018-2022 national action plan on addiction, drawn up by MILDECA, was adopted in December 2018.
As regards the most recent striking events in terms of the developments in public policies for combating cannabis, 2018 was marked by the publication of an information report on the pertinence of resorting to the criminal fine procedure (already provided for in French law for driving offences).
In terms of public debate, the wide controversy surrounding the emergence of numerous products described as containing cannabidiol (CBD) and shops selling the substance in France has been a major event in the spotlight.
Aside from the issues largely focusing on cannabis, crack trafficking and use in public transport in Paris and its suburbs has increased in visibility. The open crack scene has been widely publicised by the national press and treated by the law-enforcement services as a secondary phenomenon. The resulting debate has led to the creation of an interministerial working group to discuss solutions, and various observation and research projects have been commissioned by the National Health Directorate, MILDECA and Paris city council.

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 2016, total drug-related expenditure was estimated at 2.23 billion euros. State and National Health Insurance Fund contributions account for 0.1% of gross domestic product (GDP), with 52% of the total for demand reduction initiatives, 47% for supply reduction activities and almost 1% of resources allocated to cross-disciplinary activities (coordination and international cooperation). This estimate is on the rise compared to 2015 (+ 9%), after the stabilisation observed between 2014 and 2015 (+ 1%) in contrast with the downward trend observed between 2013 and 2014 (- 6%).

Download Workbook 1.1 : Drug Policy


Legal framework

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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.
Aside from the sentences issued by the courts in compliance with Article L.3421-1 of the CSP, an awareness course may also be proposed by the public prosecutors as an alternative to prosecution or simplified procedure (fixed penalty notice, criminal order). In this context, this measure is particularly intended for occasional narcotics users who do not appear to present health or social integration problems. The course applies to all individuals aged over 13 years. When circumstances show that the respondent requires health care, the legal authorities may require them to undergo court-ordered treatment (Article L.3413-1 of the CSP). Public action is not taken once it has been established that the individual has undergone court-ordered treatment, following the events of which s/he was accused (Article L.3423-1 of the CSP).
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.
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.

Download Workbook 1.2 : Legal framework


Drugs

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Drug 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 (42% 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 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) 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 cannabis use, it was extremely rare among 11 year-olds, it was found in 5.6% of 13 year-olds and 28.3% among 15 year-olds (data from the 2014 HBSC survey). These proportions are stable when compared to 2010. According to the latest ESPAD survey, in 2015, 32% of the students aged 16 have used cannabis at least once during their lifetime (29% of girls and 24% of boys). This represents a decrease compared with the previous 2011 ESPAD survey (39% of the students). This declining trend is confirmed by the 2017 ESCAPAD survey among 17-year-olds: 21% used cannabis in the last month compared to 25% in 2014.

Cocaine, the second most frequently used illicit substance, is well below cannabis: cocaine use concerns nearly one tenth the number of people in terms of lifetime use. 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, highlighting the wider consumption of a substance once limited to the more well-off, and which for the past few years 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. 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).

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 on the changes in this problem drug user population: the most disadvantaged users turning to less expensive substances, medications and crack 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 the Santé publique France Health Barometer (adult population),  like in the OFDT ESCAPAD survey (17-year-olds), polydrug use is discussed through regular use (at least 10 uses in the month, and daily tobacco) of at least two of three substances, alcohol, tobacco and cannabis, without being able to determine whether this involves concomitant use. In 2014 (latest available data), this type of practice 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 in2011.

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.

Alcohol use also appears to be predominant among CAARUD clients: 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, 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%).

Download Workbook 2 : Drugs


Prevention

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Policy and organisation: In France, drug prevention falls under the addictive behaviour prevention policy referring not only to illicit or licit (alcohol, tobacco and psychotropic medicines) psychoactive substances, but also other forms of addiction (gambling, gaming, doping). This strategy is a State responsibility, 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 Addiction emphasises the implementation of evidence-based approaches, particularly those focusing on psychosocial skills, and on the early detection of addictive behaviours among adolescents so that they can be guided more effectively to support services.
The MILDECA territorial representatives (“chefs de projet”) coordinate the implementation of the national prevention priorities at the local level (regions, counties, cities). They allocate credits for prevention activities, raised by a fund fed by confiscated proceeds of drug trafficking. Funding for prevention arises from the independent Regional Health Authorities (ARS), a specific fund of the French national health insurance system and, especially for a couple of years, from the Interministerial Fund for Crime Prevention (FIPD).
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. School-based prevention mainly aims to develop pupils’ individual and social skills to resist drug use.

Prevention interventions: 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. Hence over the 2010’s preventive responses were enhanced towards priority publics, like female users, youth in deprived urban areas, youth in contact with the judicial system. Major efforts have been made to develop collective prevention measures in the workplace as well (primarily in 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: Over the 2010’s, there has been a growing concern among practitioners and decision makers to enhance quality in the delivered prevention programmes and services. The creation of the Interministerial Commission for the Prevention of Addictive Behaviours (CIPCA), in 2014, is a sign of this willingness. Still, prevention stakeholders are encouraged but free to refer to guidelines on drug prevention in school or other settings. The ASPIRE (Assessment and selection of prevention programmes arising from "EDPQS" quality standard overview) chart has been sent out to MILDECA project managers with a view to the nationwide roll-out of the national guidelines for 2018. Information on the scope, cover and quality of prevention activities is still incomplete, owing to the absence of a national observation system.

New development: The adoption of the new National Action Plan on Addiction in 2018, over a 5-year period, involves numerous new objectives in terms of prevention in the coming years.

Download Workbook 3.1 : Prevention


Treatment

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There are two schemes available for dispensing treatments to people using illicit drugs: the specialised addiction treatment system (in socio-medical establishments) and the general healthcare system (hospitals and general practitioners). 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 2017, slightly more than 58,000 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.).

Among those managed for the first time in the specialised addiction treatment structure, the proportion of cannabis users has stabilised after increasing between 2007 and 2014. The proportion of opiate users, which showed a downward trend, has also stabilised in a symmetrical manner. In 2017, this population, with an average age of 27,3 (median age of 24) comprises nearly 74% cannabis users, 14% opioid users and 8% cocaine users.
As regards all treatment entrants, the distribution according to substances seems fairly stable up to 2010, with a slight downward trend in the percentage of cannabis users. However, the share of these users increases then sharply and amounts to 62% in 2016 and decreases for the first time since 2010 in 2017. The evolution of the share of opiate users is roughly symmetrical to that of cannabis users.
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.

The proportion of new patients treated for a cannabis problem is high (59%), but decreased between 2016 and 2017. The proportion of opiate users followed a symmetrical progression to that of cannabis users. The proportion of cocaine users markedly increased between 2016 and 2017. The developments in 2017 contrast with the trends emerging in 2010-2011.
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.

Download Workbook 3.2 : Treatment


Best practice

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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) 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, 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.

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).
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.

Download Workbook 3.3 : Best practice


Harms and Harm Reduction

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The number of overdose deaths in 2015 amounted to 236 among 15-49-year-olds (373 in total) according to the general death register (for which the data availability period is 2 years). According to the specific overdose death register (DRAMES scheme), 406 overdose deaths were registered in 2016 with opiates implicated in 83% of cases. Opioid substitution medications were implicated in 46% of cases, heroin in 26% of cases and cocaine in 18% of cases. 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 remained stable among 15-49-year-olds in 2015 compared to 2013 and 2014. 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 since2014.
Nearly 12,000 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 2016, people infected through intravenous drug use represented 1% of new cases of HIV infection. The number of HIV seropositive diagnoses associated with drug use remained stable since 2008, following a steady decline between 2003 (date on which monitoring of this indicator began) and 2008. The number of new AIDS cases related to drug use is steadily declining since 2003.
Furthermore, between 2012 and 2016, the reported prevalence of HIV and HCV remained stable, both in the CAARUD and 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.

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 11.9 million syringes were distributed or sold to drug users in France in 2015. Pharmacy syringe sales in the form of injection kits, which represent a third of syringes distributed to drug users in 2015, fell by a quarter in 5 years, offset by the increase in distribution in CAARUDs, CSAPAs, automatic distribution machines and postal Needle and Syringe exchange Programme.
In France, the level of coverage in the syringe distribution is below the threshold defined by the EMCDDA: coverage is considered "good" from 200 syringes per injector per year. According to the latest estimates about 110 syringes were distributed by injecting drug users in 2015 in France.

Trialling of drug consumption rooms (DCR), which falls within the scope of the health system reform law, began in Paris and Strasbourg in 2016. The 2018-2022 national action plan on addiction makes provision for the creation of other facilities to cater for unmet needs, including in Paris.
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. 60,000 patients suffering from chronic hepatitis C were treated and cured by direct-acting antivirals (DAA) between 2014 and March 2018. 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.
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 available since January 2018. Priority users are newly released inmates together with users after opioid withdrawal. From August 2016 to December 2017, during the temporary cohort authorisation (which ended in January 2018), just over 1,000 naloxone kits were distributed to drug users.
A new death certificate, as well as an additional medical section, came into force in January 2018. The additional medical section is used for stating the causes of death when known several days after death, for instance in cases of overdose death resulting in forensic investigations.
As regards viral hepatitis, the priorities of the prevention policy include significant measures aiming to eliminate hepatitis C by 2025 in France; furthermore, infant immunisation against hepatitis B has been compulsory since January 2018. In order to achieve this objective, 3 key measures are being implemented: greater access to treatment for hepatitis C via new prescribers by encouraging city-hospital networks; increasing local screening via rapid diagnostic tests (RDT) as part of a combined approach for HIV, HCV and HBV, and improving prevention via innovative outreach actions aimed at priority populations far removed from the health system. As regards HIV-AIDS, the national sexual health strategy aims to eradicate the AIDS epidemic by 2030.

Download Workbook 3.4 : Harms and Harm Reduction


Drug market and crime

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Domestic drug market (domestic production/cultivation; trafficking routes for imported drugs)

Herbal cannabis is the only illegal substance for which production is seen in France. It is mainly cultivated by individuals at home and on a very small scale, but, starting in 2011, “cannabis factories” overseen by organised crime has begun to appear.

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 French Guiana) close to the major cocaine production and transit zones (Colombia, Venezuela).

Cannabis resin smoked in France comes from Morocco and usually transits through Spain while herbal cannabis comes mainly from Spain, Belgium and Netherland. New trafficking routes emerges, through Lybia for cannabis resin and from Albania for herbal cannabis.

The cocaine used in France mainly comes from Colombia. It mainly passes through the south via Spain and the north via the Netherlands (Rotterdam) and Belgium (Antwerp). 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 (main drugs linked to offences; distinguishing between possession/use, trafficking, cultivation/production)

In 2017, the total number of persons accused of narcotic use in France is about 164,000 against less than 160,000 in 2016. 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 (14,570), and user-dealers (17,700), increased by 7% compared to 2016. In 2010, 90% concerned simple cannabis use, 5% heroin use and 3% cocaine use.

Key drug supply reduction activities

The new national action plan on addiction (2018-2022) emphasises the importance of 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.

Download Workbook 4 : Drug Market and Crime


Prison

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As of 1st January 2017, France had 182 prison establishments with a total operational capacity of 58,581. With 66,432 inmates, there are 117 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).
Since 1994, the Ministry of Health is responsible for health in prisons and the treatment of addiction in prison settings is based on a three-tiered system: prison-based hospital healthcare units (UCSAs - now called health units in prison setting: USMP), which are responsible for monitoring the physical health of inmates; Regional Medico-Psychological Hospital Services (SMPRs) established in each French regions handle the mental health aspects of drug addicts in establishments where no national treatment and prevention centre for addiction (CSAPA) for prison exist, and finally, CSAPAs for prison have been established in the 16 largest establishments in France (and cover approximately a quarter of the incarcerated population). Furthermore, a reference CSAPA is appointed for each prison so as to offer support for inmates with addiction problems, particularly after their release.
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. First, inmates receiving opioid substitution treatment must not only be able to continue their treatment in prison, but should also be able to initiate treatment if they wish. 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.

The plan defining the health strategy for inmates, published in April 2017, aims to increase HIV, HCV and HBV screening resources, by proposing to develop the use of rapid diagnostic tests (RDT) and repeating screening during custody. It also encourages improving measures to identify addictive behaviours by introducing a routine health assessment “relating to the use of illicit drugs, psychoactive medicines, alcohol and tobacco” when entering prison.

The 2018-2022 national action plan on addiction also includes several specific measures targeting prison populations, with key approaches listed below:
- Ensuring that routine screening for addictive behaviour effectively takes place in the prison setting.
- Implementing a policy which facilitates indoor smoking bans and eliminating exposure to second-hand smoke.
- Introducing an inmate prevention programme for tobacco and cannabis use.
- Providing equivalent care in terms of addiction medicine in the prison setting to that provided in the general population: 1) by improving the skills of health unit workers and 2) by offering CSAPAs and CAARUDs a larger role within these institutions, by supporting health teams and/or directly working alongside inmates.
- Promoting access to care in terms of addiction medicine for individuals referred by the justice system outside the prison setting.
- Introducing a prevention programme and harm reduction measures, especially for alcohol, particularly with a view to leaving prison, for inmates or young people followed up by judicial youth protection teams.
- Implementing a policy aiming to reduce cannabis use and trafficking in a prison setting.
- Acting on the specific issue of diversion and misuse of medications in a prison setting.
- Promoting inmate access to telephone helpline services and digital content on addiction prevention.
- Supporting intervention by peer workers in assisting inmates with addictive behaviours.
- Increasing HIV, HCV and HBV screening, and ensuring that hepatitis B vaccines are up to date, based on risk factors; promoting treatment and access to treatment while in prison.
- Removing obstacles to conducting the PRIDE research on acceptability and feasibility of harm reduction measures in prison.
- Finalising the decree on the adaptation of harm reduction measures for inmates.

In 2015, HIV and HCV screening was provided for 70% of inmates, with results routinely reported in 72% of health units. Non-invasive methods for evaluating hepatic fibrosis are used in 84% of health units, and 56% benefit from specialist on-site clinics; 66% started at least one direct-acting antiviral treatment in 2015, and 130 patients were treated.

Approximately 14,900 inmates received opioid substitution treatment in 2013, i.e. 7.8% of individuals having spent time in the prison setting, with a stable prevalence relative to 2010. The most widely prescribed medication is still buprenorphine (61.6% of cases), although the proportion of methadone prescriptions are continuing to rise (38.4% of prescriptions in 2013 versus 15.2% in 1998), and is now at a higher level compared to outside the prison setting.

Download Workbook 5.1 : Prison


Research

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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.
The list of research projects in France has been carried out within the framework of the ERANID project for the years 2010-2013 but has not been renewed since.
This workbook therefore lists the bibliographical references illustrating the productivity of French researchers in the field of addictions for 2017 and the first quarter of 2018.

The national priorities in terms of research in the field of addiction are defined in the MILDECA governmental plan. The new national action plan on addiction, adopted over the period 2018-2022, defines five priority lines of research covering 1) drug use, 2) prevention, 3) harm reduction measures and treatment, 4) penal measures, together with 5) supply reduction.

1) As regards drug use, the plan promotes a general increase in knowledge, along with analysis of impact arising from environmental factors and health care delivery based on individual pathways.
2) In terms of prevention, the plan highlights the importance of having greater insight into prevention measures and the evaluation of the quality of prevention interventions in the school and occupational setting.
3) In terms of harm reduction measures and treatment, the main objective of this research is to document more clearly the cost-effectiveness of the policies and interventions. The authorities also draw attention to the importance of shedding light on the consequences of use on health (mental health, infectious diseases, morbidity related to misuse, other somatic consequences and death).
4) The authorities also wish to promote an impact assessment culture with regard to legal measures, based on the methods introduced in English-speaking countries.
5) As regards research relating to drug supply, the plan notably encourages improved monitoring of new psychoactive substances and studies on the changes in supply.

This new national strategy on addiction was adopted in December 2018 (see Policy workbook for more details).

Download Workbook 5.2 : Research

 

All reports :

Drugs in Europe


2018 EMCDDA European Drug Report

EDR2018web.jpgWhat 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 2018 EMCDDA European Drug Report.

  Country drug reports 2018

miniCountryProfiles.jpgDeveloped 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

miniFAQDrugsEurope.jpgThe European Union & the drug phenomenon : Frequently asked questions, joint publication between the EMCDDA and the European Commission, october 2010, 12 p.