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 - 2012

1. Drug policy: legislation, strategies and economic analysis

From 2011-2012, new legal provisions mainly focused on local and international trafficking and on the application of law-enforcement policies for narcotics use offences. In terms of demand-reducing policies, lawmaker’s concentrated their efforts on involving occupational medicine in preventing use at the workplace on the one hand and on reinforcing follow-ups by healthcare professionals within the scope of drug treatment order on the other hand. The decrees, circulars and orders that were adopted to put laws into effect in 2011 and 2012 were mainly within the scope of the prévention de la délinquance (delinquency prevention) law of 5 March 2007, of international framework conventions on cooperating to fight against international trafficking and of the provisions of articles L.5121-1, L.5132-1, L.5132-6, L.5132-7 of the French Public Health Code regarding the use of medications and potentially dangerous substances.

The 2011 national strategies of the governmental policy are set forth by the 2008-2011 government action plan against drugs and drug addiction. The forward-looking 2011 report by the MILDT (Mission interministérielle de lutte contre la drogue et la toxicomanie, or the French Interministerial Mission for the Fight Against Drugs and Drug Addiction) revealed that nearly all of the government’s objectives had been achieved. Furthermore, between 2011 and 2012, three other national plans integrated and reinforced the health measures set forth in the 2008-2011 drugs plan: the 2009-2012 “hepatitis” plan, the 2009-2013 “cancer plan” and the new 2010-2012 “detainee” plan supervised by the French Ministry of Health and Sports with the participation of the French Ministry of Justice.

Public expenditure on implementing the governmental drug policy and French national health insurance in 2010 was approximately €1,510 M. This estimate does not take into account expenditure attributable to prison administrative services or major hospital or primary care costs. These expense categories have been estimated within the scope of previous studies. Kopp and Fénoglio estimated the costs of treatment attributable to drug-related health problems at €21.58 billion in 2003; prison expenditures were estimated at €219.79 million (Kopp and Fénoglio, 2006b). After inflation, these estimates would have accounted for €26.66 billion and €0.25 billion in 2010 respectively. If we consider these latest categories of expenditure up-dated after inflation, public spending attributable to the drug and addiction prevention policy is somewhere close to €28 billion in 2010 (licit and illicit drugs). This estimate accounts roughly for 1.5 percent of the GDP in 2010 (GDP accounts for €1,931.4 billion in 2010) but also for 6.6 percent of the State’s budget which accounts for a spending of €435.37 per habitant.

The profits from the sales of drugs confiscated through drug-related criminal procedures are allocated to a “Narcotics” support fund managed by the MILDT. The fund received contributions of €21 M in 2010 and €23 M in 2011. This support fund represented revenue of €11 M for the MILDT in 2010 and €12 M in 2011. This amount was redistributed to the French ministries responsible for implementing drug policy.

2. Drug use in the general population and in specific targeted groups

The latest data available on the general population are those of the INPES Baromètre santé (the health survey of the Institut national de prévention et d’éducation pour la santé or the National Institute for Prevention and Health Education) from 2010, as well as surveys conducted amongst adolescent and school populations (ESCAPAD 2011, ESPAD 2011 and HBSC 2010).

Data from the general population aged 15 to 64 years of age shows a current overall stabilisation of the levels of cannabis use during the last twelve months (at around 8.3%). The “mechanical” increase in cannabis lifetime use of is linked to a “stock” effect of former generations of smokers. Amongst the rarer products, there was a significant increase in cocaine 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 heroin lifetime use (from 0.8% to 1.2%) and mushroom lifetime use (from 2.6% to 3.1%), whereas ecstasy lifetime use is on the decline.

Amongst youths aged 11 to 17, the youngest are very little affected by the use of illegal drugs (lifetime use in children under the age of 13 was less than 6.4%). Cannabis remains the most widely used substance by young French people aged 15 and older. Of the other illegal drugs, poppers, inhaled products and hallucinogenic mushrooms show the highest lifetime use (by age 17, 9.0%, 5.5% and 3.5% respectively, versus 44.4% for cannabis).

3. Prevention

Alcohol and tobacco prevention policies largely employ an environmental strategy established by lawmakers. Subsequently, in addition to health education measures, policies employ controls on prices (through taxation), sales (through composition and packaging), distribution and use (in young populations, in certain locations or in certain situations), as well as advertising restrictions.

In 2011, at the end of the 2008-2011 governmental “drugs” plan, there were no new developments in terms of prevention. The school setting (and mainly secondary educational environments) remains the primary target for universal prevention, even though the plan has specific measures for the student environment, recreational athletic and cultural environments and so-called “sensitive” neighbourhoods. Tools have also been developed for the occupational environment. Current policy also encourages the development of the role of adult referents in prevention strategies.

The selective prevention of drug use is closely tied to the prevention of drug trafficking and recidivism. Indicated prevention measures largely overlap with the legal provisions aimed at drug users. Awareness-building training courses on the dangers of narcotics can be ordered to people who have been arrested on use charges (please refer to sections 9.1.1 and 9.4.1). Consultations jeunes consommateurs (Clinics for Young Users) are dedicated to the needs of young users and their parents.

Finally, the communication strategy of the 2008-2011 governmental plan comprises several media campaigns. Some of the main themes include targeting the role of parents and the family circle in preventing drug use in teenagers, reiterating the illegal nature of drugs and the harm caused to society by use and trafficking.

4. Problem drug use

A new multi-centre “capture/recapture” study was launched at the end of 2010 in six French cities: Lille, Lyons, Marseille, Metz, Rennes and Toulouse. The prevalence data collected in these cities enabled a new assessment to be performed on the number of problem drug users in 2011. The different evaluation methods led to a rather wide range of estimates, i.e., 275,000 to 360,000 people. The mean prevalence values for 2011 estimated by different methods seem to be on the rise. Nevertheless, it is difficult to confirm an increase given the wide, overlapping confidence intervals for these two years.

The 2010 ENa-CAARUD study (see appendix IV-F) demonstrated the significant social vulnerability of problem drug users who frequented harm reduction structures in 2010:
- Nearly half of these users experienced unstable housing conditions (i.e., were homeless or living in squats).
- One out of every five users did not have a legal source of income; half lived on welfare (“RSA” or the minimum income provided by the French government for those without an income or with minimal income, and “AAH” or the French government allowance for adult handicapped persons).
- Approximately 15% of problem drug users had been incarcerated at some point during 2010.

One third of problem users had taken heroin in the last month, nearly 40% had taken High-Dose Buprenorphine (HDB) in the last month (75% of these had taken HDB as a substitution treatment) and 46% had taken cocaine in hydrochloride or freebase form in the last month. According to the TREND observation system, there is increasingly widespread use of heroin by inhaling (chasing the dragon), and greater use of freebase cocaine, as well as a greater availability of ketamine.

5. Drug-related treatment: treatment demand and treatment availability

The figures on new patients admitted in outpatient centres in 2011 do not show marked changes in patient characteristics. As in previous years, average patient age has continued to increase, from 28.0 to 30.9 from 2005 to 2011, with significantly more people aged 40 and over and fewer people aged 20-24. The breakdown of the most problematic users by product posing the most problems remained stable. In 2011, 48% of new patients were being treated due to cannabis use, 41% for opiate use and 6.5% for cocaine or crack use.

Nearly 145,000 people received primary care reimbursements for opioid substitution treatments during the second half of 2010, with a clear predominance of HDB reimbursements (75% of the total, a phenomenon specific to France).

6. Health correlates and consequences

The number of new AIDS cases amongst injecting drug users (IDUs) has fallen continuously since the mid-1990s. In 2010, 6% of new AIDS cases were diagnosed in IDUs (versus 25% of people diagnosed in the mid 1990s and 8% in 2008).

The prevalence of HIV and HCV infection appears to have been falling for several years, both because of public health measures and because of changes in practices by most drug users. However, the reported HCV prevalence amongst IDUs is still high: it was around 40% in the late 2000s, and the percentage of IDUs unaware of their seropositivity is undoubtedly high at present.

According to the most recent data available, the number of deaths by overdose increased again in 2009 (305 deaths in 15-to-49–year-olds) thereby prolonging the upward trend observed since 2003. From 2006 to 2009, the rise in the number of overdoses seemed to be specifically related to an increase in the number of deaths by heroin and/or methadone overdose.

7. Responses to health correlates and consequences

A system of health warnings related to the consumption of psychoactive products was created in 2006. Its purpose is to identify signs indicating the abnormal appearance of acute health problems related to substance use and to disseminate warning messages if such problems are detected. This system has been fully operational since 2008.

The prevention of drug-related infectious diseases is based on the harm reduction policy, and particularly the distribution of sterile, disposable injection equipment as well as information on the risks related to drug use and on access to opioid substitution treatments (OST). Another objective is to encourage people to undergo screening for HIV, HCV and HBV, as well as urging people to get vaccinated against HBV.

In 2008, an estimated 14 million syringes were sold or distributed to drug users. This number has been consistently declining since 1999, suggesting a lower injection frequency. The proportion of drug users who have undergone HIV and HCV screening, which had been on the rise, seemed to stagnate between 2008 and 2010. During this same period, there was better access to treatment for HCV-infected drug users.

8. Social correlates and social reintegration

Indicators in 2011 on the social situation of users admitted to CSAPAs (Centres de soins, d’accompagnement et de prevention en addictologie, or National treatment and Prevention Centres for Substance Abuse) and CAARUDs (Centres d’accueil et d’accompagnement à la réduction de risques pour usagers de drogues, or Support Centres for the Reduction of Drug-related Harms) seemed to indicate a slight decrease in the precarious lifestyle of users. However, this decline may be the result of an increase in average age and in the proportion of people seen for alcohol consumption in CSAPAs and seen for inclusion difficulties in the survey of the most disadvantaged users in CAARUDs.
In France, there are rehabilitation policies for all disadvantaged people in a situation of exclusion from society. Enabling drug users to benefit from these policies by helping them carry out sometimes-complex administrative procedures is a significant first step in the rehabilitation process.

The issue of employment is the one that most weighs on treatment structures. Some centres implement so-called “occupational” activities as part of workshops that mainly have a therapeutic aim. Professional rehabilitation itself is a problem that is generally addressed through measures that help restore communication and implement coordination and networking between treatment centres and rehabilitation enterprises.

9. Drug-related crime, prevention of drug-related crime and prison

In 2011, the number of arrests for narcotics use was slightly over 143,000, which was an increase compared with 2010 (+ 6%). These arrests represent 89% of all drug related offences. The remaining 11% were arrests for use-dealing, international trafficking and local trafficking, which are declining compared with 2010 (- 20% for use-dealing, - 17% for international trafficking and - 16% for local trafficking). Cannabis is the reason for 90% of use arrests and 70% of use-dealing and trafficking arrests.

The number of convictions for drug related offences doubled from 1990 to 2010 to reach 50,000, of which over 28,000 arrests were for simple use. The number of convictions for simple use experienced the biggest increase, tripling since 1990 and experiencing a real jump since 2004 (+ 16% of annual mean increase).

Convictions for driving under the influence of drugs also rose sharply in recent years (12,428 in 2010 versus 8,988 in 2009 and fewer than 6,600 in 2008), representing a 38% increase over the previous year. Of these convictions 34% resulted in a prison sentence (usually a suspended sentence), nearly half resulted in a fine (a proportion that is rising) and 17% in an alternative sentence (usually driver’s licence confiscation).

The range of alternatives to prosecution offered to drug offenders has been expanded since the law of 5 March 2007: people arrested on charges of use or possession may be ordered by the courts to pay for and undergo a drug awareness training course. From 2008 to 2011, 18,000 to 19,000 people took part in such a course.

10. Drug markets

Sales of cannabis, heroin and cocaine are worth, according to some estimates, €3 billion. In 2011, the value of narcotics seized on French soil was approximately €1 billion, representing a 65% increase since 2010.

Some substances, such as heroin and cocaine, were readily available and accessible in 2011. This situation was intensified by the strong presence of networks importing heroin from Afghanistan through the Balkans into Europe and the ongoing switchover of certain trafficking organizations from cannabis resin to cocaine hydrochloride. In addition, the proximity of storage countries (Belgium, Netherlands, Spain) for these two substances enabled a direct supply to border wholesalers. Hundreds of dealing micro-networks mostly run by user-dealers therefore ensured the widespread distribution of cocaine and heroin throughout the whole of France, including rural and periurban areas.

The year 2011 was also characterized by two noteworthy phenomena. The first was the development of “cannabis factories” similar to those in the Netherlands and Belgium. These factories are created when structured criminal organisations begin large-scale cannabis production. The second pertains to the synthetic drug market, which has been shaken up in recent years with the continuous arrival of New Psychoactive Substances (NPS) distributed over the Internet. Since they are sometimes not classified when they appear, these substances are sometimes known as “designer drugs”, “research chemicals” or “legal highs”.

Summaries of "Selected Issues":

Selected Issue 1: Residential treatment programmes for drug users

Given the communal, countercultural spirit of the early 1970s, the authorities were open to new ideas, and residential treatment centres with varying approaches sprung up. These centres became increasingly professionalised in the 1980s, but their missions did not become clear until the early 1990s: a decree indicated that medical, psychological, social and educational treatment must be ensured. These centres, which primarily admitted opiate users who had undergone withdrawal, had been central to drug treatment until now. Changes in use practices amongst relevant populations, the shock of AIDS, the involvement of primary care and the development of substitution treatments changed this situation; outpatient care is now the norm. Residential treatment centres are now driven to become integrated into networks, to become medicalised and to accept the treatment of users receiving substitution treatments, as well as to redefine their actions amongst populations for which outpatient treatment seems to be insufficient. Long term, these changes will require better definitions of the criteria for referring users to residential treatment structures. The 2000s were characterised by the authorities' consideration of residential treatment needs and resurgence in therapeutic communities, which until then had been subject to suspicion in France following sect-like abuse by a now-defunct association that ran several such communities. In order to meet varying needs, residential treatment programmes have diversified. In addition to group residential treatment programmes (residential treatment centres and therapeutic communities, short-term admission centres for recently released ex-convict drug and alcohol users), there are also individual residential treatment schemes: follow-up therapeutic apartments and foster families.

There are no good practice guidelines or frameworks recognised by the authorities for implementing medico-social establishment missions. However, at the initiative of the federation of professionals in this sector, these documents are being created. The therapeutic approaches in France are still widely diverse. Each centre defines their project, which must correspond to the essential treatment modalities established by the authorities. They must also specify the chosen therapeutic approaches; some projects are required to define the target population. The renewal in therapeutic communities created an opportunity to reconsider the special type of treatment offered by such institutions: stays are organized according to the residents' progressive ability to manage the tasks with which they are entrusted; the group plays a central role and responsibility is key.

Residential treatment and the organizations that offer it are faced with changes today: the recent spread in France of a concept of addiction that leads those addicted to alcohol and/or illegal drugs to be admitted to the same residential treatment centres; an increase in cocaine, crack and stimulant use that raises questions about the current therapeutic models which are geared mainly towards opiate users; an economic crisis that has made already vulnerable drug using populations even more fragile and has generated over-exclusion. These changes imply a need for residential measures to adapt to the new realities.

Selected Issue 2: Recent trends in drug-related public expenditure and drug-related services in France

This chapter discusses recent trends in public spending (law enforcement and security, treatment and prevention) and specifically addresses the reliability of the collected data. It aims to examine the extent to which the 2007-2009 recession affected public spending on fighting drug use and preventing addictions in France. The first part of the chapter describes the economic context in France at the time the recession started (e.g., sharply declining exports, low levels of private investment, significantly increasing unemployment) as well as how this situation led the government to increase public spending to support activity, thereby further deepening the government’s debt crisis. Next, the chapter reveals the recent trends in public spending on the drug policy in terms of law enforcement and security as well as prevention, focusing particularly on the methods used to estimate the presented data.

The last part of the chapter discusses the change in spending on universal or selective prevention efforts, which were severely curtailed after the crisis. The most significant spending cuts were in prevention, for which 2012 funding was considerably reduced. Increases in spending were recorded for the supply reduction policy. However, even this increase was limited between 2009 and 2010. Finally, the slowdown in public spending has also affected healthcare and indicated prevention.

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