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 - 2011
1. Drug policy: legislation, strategies and economic analysis
In 2010 and 2011, there were new legislative provisions mainly with respect to drug trafficking profits (the "loi Warsmann" law of July 2010 on the confiscation of criminal assets) and domestic security (act of 14 March 2011).
With respect to non substance-related addictions, in May 2010 France authorised online gambling and games of chance. The relevant law entails provisions to prevent excessive or pathological gambling as well as measures to protect minors.
The decrees, circulars and orders that were adopted to put laws into effect between 2010 and 2011 were mainly within the scope of other laws on the vigilance of the public authorities regarding the appearance of new, potentially dangerous substances (e.g., list of narcotics, list of poisonous substances, list of substances and methods prohibited in sports).
The national governmental policy strategies that were implemented in 2010 are defined by the 2008-2011 'Fighting Drugs and Drug Addiction' Government Action Plan. In June 2011, the Mission interministérielle de lutte contre la drogue et la toxicomanie (MILDT or the Interministerial Mission for the fight against drugs and drug addiction) announced that nearly all of the 193 planned actions had been carried out. Three other national plans follow from this: the 2009-2012 "hepatitis" plan, the 2009-2013 "cancer plan" and the new 2010-2012 "detainee" plan, the latter being carried out by the French Ministry of Health and Sports with the participation of the French Ministry of Justice. The public health measures stipulated in these different plans reinforce the health section of the 2008-2011 governmental plan.
Nationally, the strategies of the government plan are broken down into inter-ministerial local plans, production of which is the responsibility of the "department project leader". The local department monitoring committee, which is responsible for coordination, seeks consistency with the specific plans in the department (such as cohesion contracts, town contracts, public health programmes and regional medico-social schemes). The department project leader mobilises the local stakeholders to apply national prevention or anti-drug trafficking strategies. In health policy, the department project leader liaises with the regional project leader, who is the special contact of the Agence régionale de santé (ARS, or Regional Health Agency) which, since the adoption of the HPST law in July 2009, has become a sort of "one-stop-shop" for the national healthcare offering.
Overall French public expenditure to implement the drug policy in 2010 was estimated at €1,086.13 M, according to ministerial sources (budget voted in the 2010 Loi de finance initiale, or government budgetary law – which determines the budget for all governmental expenditures).
The French government is not solely responsible for implementing the drug policy; it is also part of the remit of the National Health Insurance Fund (Assurance maladie) which covers the 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. In 2010, total Health Insurance Funds expenditure was €316.78 M, of which €295.3 M went to personnel expenses and operating costs for existing structures, €12.25 M went to strengthen or create new structures, €3.98 M went to creating new programmes in existing structures, and finally, €5.25 M went to addictology centres that cater specifically to treating addicts being handled in the justice system within the scope of "Health and Justice" agreements . The second leading item of expenditure for the National Health Insurance Fund was reimbursement of opiate substitution treatments. Since data take three years to be published, the amount of opioid substitution treatment reimbursements is not available for 2010. In 2008, these reimbursements reached €79.97 M. Despite the clear predominance of high dose buprenorphine (HDB) among opioid substitution treatment (OST) prescriptions, the proportion of methadone reimbursements rose from 8% in 2003 to 17% in 2008. In 2008, the percent change over the previous year reflected an overall decrease of 8% in OST reimbursements (all medications combined). The third largest area of expenditure was the funding of health establishments to implement the measures stipulated in the addictions action plan: in 2010, hospitals received €39.72 M. This funding was used for four types of actions: the implementation of new "addictology" liaison teams (especially within authorised psychiatric health establishments), the creation or reinforcement of specialised addictology consultations, complex care residential stays and even the operation of highly specialised hospital structures equipped with technical platforms.
The profits from the sale of goods confiscated from legal narcotics proceedings are allocated to a "Narcotics" support fund managed by the MILDT. In 2009, €3.57 M were contributed to the fund. The MILDT redistributed this sum to the ministries responsible for implementing the drug policy.
2. Drug use in the general population and in specific targeted groups
The latest data available for the general population come from the 2010 Health Barometer. The school surveys and surveys of adolescent populations are currently in progress (ESPAD 2011, ESCAPAD 2011 and HBSC 2010). Finally, a multisite quanti-festif study is underway in five French towns.
Data from the general population aged from 15 to 64 shows an overall stabilisation of the levels of current use of cannabis (around 8.3%). The "mechanical" increase in lifetime use of cannabis is linked to a stock effect of former generations of smokers. Among the rarer products, poppers and cocaine show a significant increase with regard to lifetime use and current use (from 2.4% to 3.6% and from 3.8% to 5.2% respectively). The survey furthermore reveals a significant increase in lifetime use of heroin, going from 0.8% to 1.2% and hallucinogenic mushrooms (from 2.6% to 3.1%), whereas ecstasy, in contrast, is in decline.
The Guide on preventing addictive behaviour in schools was updated in 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 French Department of National Education and the MILDT.
With the support of the MILDT, a conference on parenting and the role of parents in preventing drug use took place in May 2010. The aim was to update the discourse to support parents in their role as active players in the prevention of licit or illicit drug use. The debates guided the government awareness campaign entitled "Contre les drogues, chacun peut agir" ("Everyone can take action against drugs"), which took place from 13 December 2010 to 3 January 2011 and targeted all referent adults.
In order to define targeted measures suitable for professional settings and to provide consensual and appropriate changes to the labour laws, the MILDT also held a conference on the occupational risks related to the use of illicit drugs ("Drogues illicites et risques professionnels") on 25 June 2010.
The third communication measure of the governmental plan took place at the end of 2010. It aimed at encouraging parents and those close to teenagers to ponder their role in prevention. Three different, complementary television spots were broadcast from 13 December 2010 to 3 January 2011. A partial analysis of calls to Drogues info service (national telephone helpline) shows the unquestionable, immediate effect of these spots (a 250% increase in calls compared to the week preceding the broadcast of the TV spots). An updated version of the brochure, "Cannabis, les risques expliqués aux parents" ("Cannabis, explaining the risks to parents"), was distributed in structures intended for young people or for the professionals likely to be in contact with them. Another communication effort, this time targeting young people in the form of a contest, was conducted by the MILDT in 2010.
4. Problem drug use
A new multi-centre "capture/recapture" study started at the end of 2010 in 6 French cities: Lille, Lyon, Marseille, Metz, Rennes and Toulouse. A new national estimate (based on all problem drug users, injectors and opiate users) should therefore be available in 2012. The 2008 ENa-CAARUD study (see Appendix IV-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 diffusion 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 high dose buprenorphine (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 AIDS cases among injecting drug users (IDUs) has fallen continuously since the middle of the 1990s. This was confirmed in 2010 with less than 5% of injecting drug users amongst new AIDS cases (versus a quarter of persons found positive by the mid-1990s and 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 risk practice by most drug users.
The number of overdose related deaths increased again in 2009, 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 drug users.
In terms of practices, the continuing fall in the estimated number of syringes distributed to IDUs between 1999 and 2008 suggests a lower prevalence of injection, but this fall cannot currently be interpreted with certainty.
In addition, the proportion of drug users 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
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 135,000 procedures annually). It represents nearly 9 arrests for drug offences out of 10. 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.
In contrast to this relative stability in the number and structure of arrests, criminal conviction of drug users, including prison sentences (with a partial effective imprisonment) have increased. The number of convictions for drug-related offences has more than doubled between 1990 and 2009: of this total, convictions for drug use have increased most, since their number has tripled since 1990, and especially since 2004. In 2009, 24,420 convictions have been pronounced for simple use (an increase of nearly 25% compared to previous year). Convictions for drug use represent now half of conviction for drug-related offences, as against one third during the 1990s and the beginning of the 2000s. 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, the convictions for driving under the influence of narcotics have also increased during the previous years (nearly 6,600 in 2008), which represents an increase of 27% compared to the previous year. Among these, around 40% have ended in prison sentencing (most often with suspension), around 40% ended with a fine and 16% ended with measures other than prosecution (most often the confiscation of the driving licence). Sentencing tends to be less severe when it is for an offence of driving under the influence of narcotics alone, or in case of refusal to cooperate; they are more severe in case of body injury.
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 (especially brown 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, and a part of 2010 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" and 2010 saw a return of tablets containing MDMA which are once again present on the festive scene.
Although more marginal, it seems that since 2008 there has been increased ketamine availability. There has been of 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.
Summaries of "Selected Issues":
Selected Issue 1: Drug-related health policies and services in prison
On 1 January 2010, there were in France, 61,604 prisoners distributed among 191 prisons, the highest figure since the mid-nineteenth century (96.8 prisoners per 100,000 inhabitants). This population includes about a quarter of defendants. The state of overcrowding in prisons (108 prisoners per 100 places, on average) varies considerably between the types of institutions and geographical jurisdictions: it mainly concerns remand centres, the most numerous types of establishment in the prison system, that host a majority of defendants (pending a final decision) and of convicted of shorts imprisonment sentences.
The prison population is characterized by demographic, social and health profile very different from that of the general population. Disorders related to mental health and addictions, in particular, are higher than outside prison: half of the inmates suffer from anxio-depressive and addictive disorders. The inmates are also more affected by infectious diseases: people who have experienced at least one episode of incarceration in their lifetime have a prevalence rate of hepatitis C almost 10 times higher than the general population (7.1% vs 0.8%). These observations reveal a contradiction between the objectives set by the Act of January 18, 1994 affirming the principle of equivalence of care between the prison environment and the free environment, and the reality of care practices in detention, as determined by the terms and conditions operating the prison system and constrained by the difficulties of organization of care in some institutions.
This Selected Issue attempts to articulate the policy recommendations and clinical practice developed for the prison (both by WHO and by the French authorities) to reflect on the difficulties of organizing care in the prison context, highlighting the importance of monitoring information on the care of drug users in prison.
Selected Issue 2: Cross-border travel, drug use and drug services
France has 2,970 km of borders with six European countries. There are two types of borders, the first corresponding to the "border melting pot" (an area of contact that associates the territories located on either side into a community of destiny and daily life" (for example, the Nord-Pas de Calais and Belgium, the Lorraine region and Belgium, Luxembourg and Germany), and the second corresponding to the "glacis border (marked by a geographical barrier).
There are movement of French drug users to Dutch coffee-shops although it is difficult measure such movements. There also movements to Barcelona (and its commercial cannabis fairs). But the travelling is above all related to the dance events party scene. Two areas are concerned in France, the south west and the north (from Nice to Italy, from Lille to Belgian night clubs or alternative techno events, for example). The primary motivation for weekend cross-border migration in the north and south-west of France is the search for an appropriate place to party.
Finally, there are cross border travels on the drug users' initiative which generally involved French people seeking treatment in the border countries of the north and east. There is in particular a significant flow of French people to Belgium each month to receive methadone. On the other hand, there is cooperation between hospital establishments on both sides of the borders and even cooperation between associations and professional networks.
What is striking, from the French viewpoint, is still the significant dis-symmetry of the drug related "exchanges" between France and its neighbours: whether regarding using or procuring substances, partying or seeking treatment, travelling mainly occurs from France to a foreign country.
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