Good practice, good results. Maintenance treatment outcomes in France

Between 1994 and 1999, the national statistics show :

– An 80% decrease in fatal overdoses;
– A 67% decrease in arrests for heroin use;
– A 2/3 decrease in IDU Aids-related deaths.

These decreases are most impressive; this is the first time that the drug policy has achieved good results. From 1970 to 1995, each year was worse than the previous one, with a continuous increase in arrests and fatal overdoses. Of course, the decrease in HIV deaths is due to HIV treatment, but it proves that heroin users do get proper access to health care. These positive outcomes also show that the damage done to the health and social status of heroin users over these last two decades was due not only to addiction itself, but, in a measure as high as 80%, to drug policies and lack of treatment.

Why is this information not made more widely available? First, these results go against popular beliefs about drugs. The second point is the contradiction between the results and the actual Drug Scene. Field studies show that Subutex can be bought on the black market. It can be injected, sniffed or misused together with other drugs, specially benzodiazepine (6).

That is what outreach services or field researchers can observe, but we must not forget that once a patient is stabilized, he is no longer part of the Drug Scene. He has become invisible.

In France as in other countries, scepticism is rampant, and everyone has their own interpretation of the decrease in arrests and cases of fatal OD. For some, this pheno- menon can be explained by the fall in heroin use; for others, the available studies do minimize the Subutex black market and misuse in injections, as they do not follow a rigorous methodology. For anti-prohibitionists, it is access to the product that managed to reduce the harm.

Each interpretation has good arguments on its side. There are several factors that contribute to these good resutls. I will now discuss these explicative theories.

1. The fall in heroin use: actually, stimulants like cocaine and synthetic drugs are now being used more often, and this new trend creates a favorable con- text. Heroin users get age; most of them are ill and this certainly favours the demand for treatment coming fom them, but users did not stop using heroin because it was no longer a fashion, but because treatment became possible. It is supposed that approximately one out of every two oheroin users took this opportunity and about 100,000 of them are now being treated. This too contributed to the fall in heroin use, but this is not a major factor in the fall recorded in the national statistics. A comparison between the outcomes for the various French regions shows that the main factor gaving rise to the fall in numbers of fatal overdoses is improved treatment accessibility: the more patients there are in treatment, the greater the fall in overdoses and arrests for heroin use.
2. Legal access to the product: of course, prohibition does a great deal of harm by creating problems like unsafe injection and the adulteration of drugs; currently, drug usersʼ behaviour is largely patterned by prohibition. Actually, providing access to the product is not enough to change behaviour. The drug prescribed can be used with other drugs, with no change in behaviour or very little. International evaluations of methadone treatment show that positive outcomes are mainly due to good clinical practices, such asadequate dosing policies, individualized treatment, comprehensive services and adequate training (5). It is clear that within any treatment, inadequate dosing destroys effectiveness, but, indirectly, evaluation studies on maintenance treatment have also shown that the product itself is not enough to change behaviour. The crucial factor is how to use it. This is true for prescribed medicines as well as for street drugs.

Considering first the need to conserve financial resources and then the need to avoid risks such as non-opiate dependent use, the Social Security services should not reimburse clients with multiple prescriptions. Administrative controls are necessary for the 5 to 10% of drug traffickers identified by the study, but the remaining 90% of all patients are the concern of practitioners. Easy health-care access should be preserved. Essentially, clinical pratices should improve. Doctors’training and network organizations must be given priority. In France, we need better access to methadone treatment. My opinion is that when GPs are organized in networks, they should be able to prescribe methadone for non-stabilized buprenorphine patients.

Heroin prescription would be useful when heroin users have not yet been stabilized with a current treatment. The Swiss experiment shows that a low rate of patients are in need of heroin medical prescriptions when current treatments have been adapted to individual patients.

Unfortunately, a new law has imposed a declaration of treatment for each single patient to the director of French Health Services. Nobody knows what the results of these new measures will be, but they have already limited the involvement of health professionals, instead of supporting it.

The honeymoon with maintenance treatment that had experienced in France until recently is over. Patients and doctors now have to live together for years. So the thera- peutic alliance must be protected. The effectiveness of treatment depends on it.

References

1. COPPEL A. (2002). Peut-on civiliser les drogues? De la guerre à la drogue à la réduction des risques, La Découverte, Paris
2. EMMANUELLI J (2001). Contribution à lʼévaluation de la politique de réduction des risques, SIAMOIS, Institut National de Veille Sanitaire, tome I
3. GOFFMAN E (1961) Encounters. The Study in the Sociology of Interaction, Indianapolis: Bobbs-Merill.
4. OLIN N, PLAISAT B. (2002-2003). Drogue, lʼautre cancer, Les Rapports du Sénat, n° 321, Paris.
5. PARRINO M.W. (1993). U.S. State Methadone Maintenance Treatment Guidelines, Department of Health and Human Services, Rockville MD
6. TREND (2001)