Heroin Addiction and Related Clinical Problems 2005; 7 (1)
Point of view
In 2004, a public debate emerged on the misuse of, and trafficking in, prescribed drugs. Because of their positive outcomes, maintenance treatments were not officially questioned. A national evaluation showed that the decrease of 80% in fatal overdoses and of 67% in arrests for heroin use (1994-1999) were directly connected with treatment accessibility. This assessment resulted in a consensus among addiction and public health experts. These good results have not, however, been published by the mass media, and the general public still is unaware of them. Nor were the causes of these good results were not discussed among health professionals. They are not only due to the medications involved, but to good clinical practices. The first practitioners who started to prescribe maintenance treatment had followed extensive training, and were networking and building relationships of trust with their patients. Against the background of this public debate, a consensus conference on maintenance treatments organ- ized in 2004 recommended that the prescribing GPs should be better trained, and that they should be included in professional networks. Although these recommendations gave priority to the improvement of clinical practices, the authorities have decided to implement control measures over patients. These measures might make access to treatment more difficult, and they fail to sup- port the involvement of GPs and pharmacists. The effectiveness of substitution treatments could be affected.
Key Words : Maintenance treatment – Treatment accessibility – GPs training
Over the last 3 years, the misuse of, and trafficking in, prescribed drugs has given rise to public debate. It began with a Senate report published in 2001, but at that time the extent of the misuse was not known (4). In 2004, a study by the French Health Insu- rance (Caisse Nationale d’Assurance Maladie) showed that 5 to 10% of the patients, depending on their regions of origin, had been supplying most of the black market trade, with the help of more than three prescribing doctors and with a dosage that was much higher than needed. The cost of the treatment created a scandal, mainly because the treatments are reimbursed by French Health Insurance, but both the cost of treatments and the cost of diversion have been considered. No journalist, however, has noted so far that 90% of all patients have been following their treatment on a regular basis, a far higher percentage than had been estimated earlier. Nor did any journalist mention the national decrease in fatal overdoses linked with maintenance treatment, as demonstrated by a national evaluation study. Initially, the senators ignored the good results published in this official evaluation; within the framework of their inquiry, they had to admit that there was no controversy over the results among the experts.
In the light of the consensus among health professionals, the Senate report could not question the maintenance treatment or the harm reduction policy that have both been introduced in France; it only requested the introduction of controls.
A national consensus conference was organized in June 2004 by the ANAES (Na- tional Agency for Health Evaluation) and the FFA (French Federation on Addictology). The conference recognized the positive outcomes of maintenance treatment.
The essential problems have been confused in the public debate. The good results documented in the national evalation study are only known to the experts. Collective beliefs hostile to these treatments still prevail because of the widespread moral or purely psychological conception of addiction.
When public opinion has been consulted about maintenance treatment, 70% of those interviewed state that they are in favour of medical treatment for addicts, but do not understand why the diversion of drugs has not been stopped. The silence of the experts after years of violent debates did raise suspicions and questions, such as : ‘Is this a business affair or are some other interests being hidden?’
In 2001, senators had recommended a better control of patients, but this might im- pede access to patient care. Can we control medical prescriptions without affecting the positive outcomes of substitution treatment? This is the question I am addressing.
First, I will present the main data, then I will discuss the different explicative theories and conclude with proposalsa bout how to improve the results.
High dosage buprenorphine and methadone were legalized in 1995. During the first four years, maintenance treatment underwent a sizeable expansion. There are now approximately 100,000 patients. Subutex is prescribed for 83,000 patients and methadone for 12,000 ; other drugs like morphine and codeine are still prescribed for some patients. Subutex is the most frequently prescribed medication, as it can be delivered by any GP, without any special control. Methadone treatment can only be initiated by specialized care centres. Nine out of ten patients are followed up by GPs. Both treatments are reimbursed by the French Health Insurance.
An evaluation by the National Health Surveillance Institute has been published (Institut National de Veille Sanitaire, 2001). It is mainly based on the evolution of national statistics on fatal OD and heroin use arrests, as attested by the police and HIV national statistics.
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.
- 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.
- 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.
3) Faults in methodology: there can be no question about the national statistics reported by the police: the annual statistics are collected each year in the same way. Actually, misuse and injection may have been minimized in some follow-up studies. Seven follow-up studies have been synthesized by a library-published series (TOXIBASE, 2000). The outcomes are comparable with international ones, with a reduction of 70% in heroin use (national average). Percentages for the fall in the number of injection users vary from 46% to 12%, depend- ing partly on the length of treatment. Even taking errors in methodology into consideration, the fall in the use of injections is incontrovertible. This has been documented by the important fall in HIV contamination through the use of injection (3% of HIV contamination in 2003 versus 27% in 1991).
In the follow-up studies, patients followed by GPs organized as a network showed better results than those with isolated GPs. The retention rate averaged 70% but it rea- ched 82.7 and 96% in two follow-up studies carried out with patients treated by doctors organized as a network. There is no doubt that the network system has reinforced the successful pattern. Ten years ago, French practitioners had no experience in maintenance treatment. Rapid development with a new medication and inexperienced GPs could have been a disaster. That has not been the case. Because GPs had no experience and because they had to overcome prejudice and fear, networking was the answer. Guide- lines were elaborated and discussed in the networks.
The most significant fact over the last ten years has been «the interactional change» in the behaviour of doctors and drug users (3). The first step was the change in their relationship. Nowadays heroin users have much better access to care, as the 2/3 decrease in IDU HIV deaths shows. Heroin users no longer die in front of hospitals as they once did, thanks to prescribing doctors. «Drug users should be patients like any others» was the real fight to be fought by prescribing doctors.
At the same time, heroin users changed their behaviour, as has been shown by the fall in HIV contamination. AIDS and self-help organizations play an important role in spreading harm reduction behaviours.
The temptation is to control most patients and exclude bad ones, those who still inject or resort to misuse. We have to bear in mind that stabilization is a process, not a prerequisite.
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.
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- PARRINO M.W. (1993). U.S. State Methadone Maintenance Treatment Guidelines, Department of Health and Human Services, Rockville MD
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