Annual reports sent to the EMCDDA (European monitoring center for drugs and drug addiction), giving an overview of the latest developments on the drug problem in France.
National report to the EMCDDA - 2010
1. National policy: legislation, strategies and economic analysis
Several laws on addictions treatment and combating narcotics trafficking were adopted in France over the period covered by this report. The new legislation in 2009 mostly involved territorial reorganisation of the care offered, bringing the terms of the French sports code in line with the World Anti-Doping Code and strengthening international cooperation in the field of narcotics trafficking. In 2010, the National Assembly adopted a law intended to facilitate legal investigations and take sanctions against dealers with regard to their drug dealing profits.
In terms of the adoption of implementing legislation relative to current laws, the decrees, circulars and orders adopted in 2009 and 2010 mostly build on the dispositions of the French Delinquency Prevention Act of 5 March 2007. These texts concern measures increasing safety in educational establishments and the implementation of the mandatory treatment. In addition, new legal texts were adopted in 2009 and 2010 within the scope of other laws concerning the vigilance of public bodies towards the appearance of new potentially dangerous substances (list of narcotics, list of poisoning substances, lists of substances and methods prohibited in sports, etc).
In terms of government policy, the national strategies begun in 2009 by central government are those defined in the government’s 2008-2011 Combating drugs and drug addiction government action plan. With respect to addictions, the “drugs” plan restates the health measures from the 2009-2012 “hepatitis” plan and the 2009-2013 “cancer” plan. Nationally, the strategies of the government plan are broken down into inter-ministerial département plans, production of which is the responsibility of the département project leader. In terms of coordination, the département monitoring committee is responsible for seeking consistency with the specific plans in the département (contrats de cohésion, town contracts, public health programme, regional medical-social scheme, etc). It is the responsibility of the département project leader to mobilise local players in their efforts to apply the national strategies to prevent and combat trafficking. In health policy, the département project leader liaises with the regional project leader who is the special contact of the Regional Health Agency (ARS) which, since the adoption of the HPST law in July 2009, has become a sort of "one-stop-shop" for the national healthcare offering.
In terms of public expenditure, the overall State commitment to apply the drugs policy was estimated for the first time in 2009 to be €925.12 M, according to ministerial sources. The next financial year (draft finance law for 2011) should refine this estimate.
Application of the drugs policy is not the exclusive responsibility of the State. It is also part of the remit of the National Health Insurance Funds (Assurance maladie) which cover the common law health system for drug users. The main item of expenditure of the National Health Insurance Funds in this arena is the funding of addictology centres. Funding for this in 2009 was €286.67 M, €270.34 M of which were devoted to staff and operational expenditure for existing centres, 14.5 M€ were intended to fund the improvement or creation of new centres and €1.8 M to fund the introduction of new programmes in existing centres. The second leading item of expenditure for the National Health Insurance Fund was reimbursement of opiate substitution treatments. Because data is only published after four years, the reimbursement cost for opiate substitution treatments (OST) is not available for the year 2009. The cost of OST reimbursement in 2006 was €87 M. The third item of expenditure was the funding of health establishments to implement the measures stipulated in the addictions action plan: the hospital sector received funding of €24.67 M for this in 2009.
Profits from the sale of goods confiscated in criminal proceedings from narcotics cases produced an income allocated to a special fund (fonds de concours) administered by MILDT. In 2009, this fund was worth €11.4 M.
2. Drug use in the general population and in specific targeted groups
General population survey data were most recently updated in 2008. The last ESCAPAD survey (see Appendix V-K), conducted on 17-year-old youths during the day of defence preparation (JAPD), took place that year. The last ESPAD survey (see Appendix V-L) in schools with 16-year-olds took place in 2007, whereas the most recent data from the adult population date back to 2005 with Baromètre santé. In 2011, we will have the results of the Baromètre santé 2010 survey and the initial results of the ESCAPAD and ESPAD surveys conducted at the start of 2011.
The new information therefore only relates to the EROPP survey which provides information about beliefs, opinions and perceptions French people have with regard to psychoactive substances. Followings its third edition in 2008, the results of which came out in 2010, the EROPP survey highlights three major changes in the perceptions and opinions of French people with regard to drugs over the last decade. Firstly, greater awareness of French people to the “danger of drugs” was found, regardless of the legal status of the substance. Secondly, there was some slippage in beliefs about the origin of the phenomenon of drug use, which was considered less as an “external” illness but more as an abnormal individual behaviour. Finally, beyond the widespread agreement with the public policies implemented in this field, French people had less "tolerant" and "liberal" opinions about the policies which should be pursued: they are increasingly in favour of prohibitive measures and less open to a harm reduction approach.
The guide on the prevention of drug use in schools was updated in 2009-2010. It introduces the principle of a prevention programme lasting from the last year of primary school to the last year of secondary school. This guide was first published in 2005 under the auspices of the Ministry of Education and MILDT.
During 2009, MILDT organised parenting conferences which took place in May 2010 with the aim of updating the communication strategies to support parents in their role as active players in the prevention of legal and illegal drug use. The debates arising from these conferences were intended to enrich a government awareness campaign for parenting adults in 2010.
In order to define targeted measures suitable for professional settings and to provide consensually agreed appropriate changes to the labour laws, MILDT also held conferences on occupational risks related to the use of psychoactive substances.
MILDT organised two press campaigns in 2009. The first was on the subject "Drogues : ne fermons pas les yeux", which was intended to "combat positive beliefs about drugs". The second had two arms, alcohol and illegal drugs, in order to "emphasise the protective role of the law against the health and social dangers of high risk behaviour".
4. Problem drug use
A new multi-centre “capture/recapture” study will be started at the end of 2010 in 6 French cities: Lille, Lyon, Marseille, Metz, Rennes and Toulouse. A new national estimate (based on all PDU, injectors and opiate users) should therefore be available in 2012. The 2008 ENa-CAARUD study (see Appendix V-F) shows the considerable social vulnerability of the harm reduction centres’ clients in 2008.
The most striking changes in drug use and methods of use in 2008-2009 were:
- increasingly diverse user populations;
- extension of cocaine diffusion, particularly to young people from working class areas and the suburbs;
- use of heroin by a wider variety of population groups, in particular younger users, those in the party scene and those that are socially well-integrated;
- wider distribution of ketamine.
Although more marginal, the spread of GHB/GBL use to young groups of “party-goers” resulted in several cases of coma during 2009.
5. Drug-related treatment
Treatment demand and treatment availability A circular published at the start of 2008 described the missions of the Health Care, assistance and addictology prevention centres (CSAPA). From 2009, this name was used to describe the centres which previously received illegal drug users (CSST) and the centres which only received people with alcohol difficulties (CCAA). The missions of the CSAPA are much the same as those of the CSST and CCAA. The CSAPA, however, are required to receive all people with an addiction problem, regardless of the problem substance.
The figures on new patients received in 2009 in the outpatient centres do not show marked changes in their characteristics. As in previous years, their average age has continued to increase. The average age of patients who have never previously been treated however appears to have remained stable since 2007. A small increase in the proportion of those taking opiates as the substance causing the greatest problem was found in 2009 with a fall in the proportion of those with problem cannabis use. Intravenous use of opiates and cocaine has again fallen after increasing in 2008.
In terms of opiate substitution treatments, almost 125,000 people received primary care reimbursements for these during the second half of 2008, with a clear predominance of HDB (specific to France), still making up 80% of all reimbursements. Whilst a proportion of prescribed HDB is misused, and is not always taken as a treatment, misuse has fallen considerably since the introduction of a control plan for opiate substitution treatments by the National Health Insurance Funds. The proportion of people receiving an average daily dose of more than 32 mg/D fell from 6% in 2002 to 1.6% in 2007 according to a recent study.
6. Health correlates and consequences
The number of cases of AIDS in intravenous drug users (IVDU) has fallen continuously since the middle of the 1990s. This was confirmed in 2009 with less than 5% of intravenous drug users (IVDU) amongst new AIDS cases (compared to 8% in 2008).
The prevalence of HCV infection appears to have been falling for several years, both because of public health measures and because of changes in practice by most drug users.
The number of overdose deaths increased again in 2008, confirming the continued upward trend in overdose deaths since 2003. Between 2006 and 2008, the increase in the number of overdoses appears specifically related to an increased number of deaths from heroin and methadone overdose. Several factors may explain this rise: greater availability of heroin, fall in the price of cocaine, new users with poor awareness of harm reduction, increased methadone prescription.
7. Responses to health correlates and consequences
2009 saw a marked rise in the activity of the psychoactive substance health alert system which was started in 2006. Three public alerts were issued (heroin and GHB/GBL) through press releases and several communications only targeting professionals and user associations.
The new 2009-2010 hepatitis plan broadened the scope of infectious disease prevention according to several themes: firstly, with the objective of preventing the first injection; and secondly, by extending the measures targeting drug users to the entire population of the most vulnerable people (street youths, new migrants) and by including routes of drug administration other than injection in high risk practices. Similarly, a reintroduction of early vaccination against hepatitis B in the general population should help to protect future DU.
In terms of practices, the continuing fall in the estimated number of syringes distributed to DU between 1999 and 2008 suggests a lower prevalence of injection, but this fall cannot currently be interpreted with certainty.
In addition, the proportion of DU who have had a screening test has continued to increase, with a fall in the late diagnosis of hepatitis C. The important issue now is repeating these tests (at least annually) and increasing access to treatment.
8. Social correlates and social reintegration
Drug users seen by the specialist services experience major difficulties in terms of their social integration (employment, housing, income, etc.). Whilst common law services (social services, free care, etc.) help alleviate certain problems, drug users find themselves in far more adverse situations than the general population.
Beyond their mission to support access to common law services, the specialist centres are developing innovative social integration programmes and activities, fostered in recent years by the guidelines set out in the MILDT national 2008-2011 plan.
9. Drug-related crime, prevention of drug-related crime and prison
Major trends seen in previous years remain stable. Cannabis is still the substance responsible for the largest number of arrests for drug offences, ahead of heroin and cocaine. The number of arrests for simple use remains high (approximately 140,000 procedures annually) as does the number of arrests for misuse of pharmaceutical drugs. The penal response to drug use is increasingly taking the form of measures other than prosecution, or in the event of prosecution, penalties involving substitution orders or fines. Prison sentences (including imprisonment) for drug users have remained relatively stable over the last 5 years: a lack of information about the application of these sentences makes it impossible to establish whether or not they are actually served.
For road accidents, 34.6% of the 63,500 tests performed in 2009 were positive. Major changes in testing are to be introduced in 2010: the number of tests performed will be increased to 100,000 because of the extensive use of salivary testing. Moreover, tests will become mandatory for all road accidents, for both fatal injuries and minor injuries.
10. Drug markets
As France is both a transit country and one where the main illegal substances produced world-wide are used, its narcotics market is particularly dynamic.
Substances such as cocaine and heroin are both widely available and accessible. This is promoted particularly by the current switching of importing networks back from cannabis resin towards cocaine hydrochloride and heroin. In addition, the proximity of storage countries (Belgium, Netherlands, Spain) for these two substances enables direct supply to border wholesalers, hundreds of dealing micro-networks, mostly run by user-dealers, who therefore ensure widespread distribution of cocaine and heroin throughout the whole of France, including rural areas.
For the greater part of 2009, the synthetic drugs market saw a severe shortage of MDMA both in “powder” and “tablet” form. With regard to this latter galenic form, dealers continued to supply the market with “ecstasy”, but used MCPP instead of the traditional active substance. MCPP, which is legal in France, has relatively similar effects to MDMA. This phenomenon has led users to switch to amphetamines (speed) and cocaine, the latter spreading further into the population.
Although more marginal, 2009 saw the development of the use of ketamine outside the group of regulars in the alternative party scene. Ketamine appears to benefit from an improving image because of better management of the effects of the substance through a harnessing of its use.
The striking finding in 2009 in terms of the composition of substances was the doubling in the proportion of heroin samples seized containing more than 30% purity, while the proportion of samples containing very low doses also increased.
Summaries of ‘Selected Issues’:
History, methods and implementation of national treatment guidelines
The first professional recommendations in France for the care of DU date back to 2002-2004. These concern substitution treatments and supplemented the initial ministerial directives of 1995 for the marketing of methadone and HDB. Polydrug use in 2007 and cocaine use in 2010 have led the authorities, professionals and institutions more recently to produce new professional good practice recommendations. This selected issue describes the process for producing and applying the main recommendations and emphasises the methodological procedures used. An ad-hoc literature review and a series of semi-structured face-to-face interviews with key experts enabled this investigation to be carried out.
A wide range of methods were used to produce the recommendations: small working group, consensus conference on “Clinical practice recommendations”, etc. An equally wide range of methods were used to examine the validity of the recommendations: in-house expertise, independent reviewers, etc. According to the information collected, the main weakness of these experiments is that the distribution of the recommendations usually ended with their publication. In future, the Higher Health Authority (HAS), the agency responsible for producing medical recommendations in France, intends to move increasingly towards scientifically validated methods.
Mortality related to drug use: a comprehensive approach and public health implications
Official data on deaths from the use of psychoactive substances place France in an apparently enviable position, with a particularly small number of overdoses compared to other Western European countries. The peak in deaths seen until the middle of the 1990s has been followed by a significant fall in these overdoses, which has been interpreted as the direct result of an intentional harm reduction policy including the distribution of OST and deregulated prescription of HDB in particular.
Since 2003, a further rise in these overdoses has been seen, particularly associated with increasing availability of heroin and cocaine, together with new users, not as yet known to the care centres or low threshold services. This phenomenon is combined with occasionally conflicting findings, raising a suspicion that the actual number of overdoses is in fact under-estimated. A need for better knowledge of the causes of deaths in drug users has led to cohort studies being set up, one of which is currently underway.
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