1. MORTALITY AND DRUG ADDICTION François Hervé A.N.I.T. Glasgow 8 août 2005

2. What are the facts? In the eighties, increase of the mortality In the eighties, increase of the mortality –Overdoses –Aids –By the time treatments where mainly Withdrowal (only 50 people in France in methadone programs) Withdrowal (only 50 people in France in methadone programs) Psychosociological treatments in rehabilitation facilities Psychosociological treatments in rehabilitation facilities No much consideration for the health of the patients, beside addiction No much consideration for the health of the patients, beside addiction

3. Time for debates End of the eighties End of the eighties –Debates about harm reduction Interest for foreign models Interest for foreign models –Switzerland (4 pillars: prevention, treatment, harm reduction, repression) –Nederland (organisations of drug users) –England (involvement of gp’s) Needle exchange Needle exchange Methadone and substitution Methadone and substitution  1988: free access to serynges at chemists

4. Time for action: new policies Early nineties: Early nineties: –Beginning of harm reduction strategies Methadone (1994) Methadone (1994) Buprenorphine (subutex®)(1996) Buprenorphine (subutex®)(1996) –Harm reduction facilities Needle exchange Needle exchange Street work Street work

5. EFFECTS ON THE NUMBER OF DEATH

6. EVOLUTION OF DEATHS BY OD

7. Number of deaths due to aids among injecting drug users 118 181 119 473 268 1044 0 200 400 600 800 1000 1200 199019911992199319941995199619971998199920002001*2002*2003* * données redressées Nombre de décès UDVI UDVI = usagers de drogue par voie injectable Apparition of treatments Better acces to treatments ? 24% of the deaths due to aids

8. New cases of Aids among drug users 142 197 424 1 493 1 079 0 200 400 600 800 1 000 1 200 1 400 1 600 199019911992199319941995199619971998199920002001*2002*2003* * données redressées UDVI= usagers de drogues par voie injectable Harm reduction 30% of the new contaminations 2,8% of the new contaminations

9. Development of the substitution treatments

10. MéthadoneBuprénorphine Initial prescriptionSpecialised centers, hospitals (possibility to hand over to gp’s after stabilisation of the treatment)) Any doctor (91 to 99% of the prescriptions) Duration maxi of prescription 14 days28 days Délivery1 to 7 days (possibility until 14 days if mentionned) 7 days (possibility until 28 days if mentionned by the doctor) Fractionnement (splitting up) ouioui Chevauchement (overlapping) if mentioned by the doctor Renouvellement (renewal) forbiden Rules for presciption

11. CONCLUSION PART 1 Good results The number of deaths by overdoses registred by the police decreases since 1995, after a maximum (564) in 1994, 89 deaths in 2003. The number of deaths by overdoses registred by the police decreases since 1995, after a maximum (564) in 1994, 89 deaths in 2003. In 2003, héroïne is still the drug the most often involved in death by OD (39 % of the cases) but the part of heroine decreases regularly (90% in 1993 and 1994) In 2003, héroïne is still the drug the most often involved in death by OD (39 % of the cases) but the part of heroine decreases regularly (90% in 1993 and 1994) An increasing proportion of deaths involves the use of medecine drugs, including méthadone and Subutex®, (31 % en 2003,15 % en 1995). An increasing proportion of deaths involves the use of medecine drugs, including méthadone and Subutex®, (31 % en 2003,15 % en 1995). The number of overdoses due to cocaïne and ecstasy is also increasing (11 et 10 % in 2003 against less than 1 % in 1995 for cocaïne and 7,5 % in 2001 for ecstasy). The number of overdoses due to cocaïne and ecstasy is also increasing (11 et 10 % in 2003 against less than 1 % in 1995 for cocaïne and 7,5 % in 2001 for ecstasy).

12. Discussion: Some hypotheses –Less interest of the users for heroin, since the avability of substitution treatments since the avability of substitution treatments because a bad image of heroin and injection because a bad image of heroin and injection –Less injections –Better knowledge of the treatment of OD by the emergengy medical units, and by the users. –The important rise of overdoses in the late 80ies early 90ies could be due to the context: aids, number of dying people, lack of treatments, leading to more self destructive behaviors: the treatments of aids may have had more incidence on the diminution of deaths than the substitution treatments.

13. CONCLUSION PART 1 New problems: Trafic: 6 to 10% of the users divert 25% of the treatments  black market Trafic: 6 to 10% of the users divert 25% of the treatments  black market –6% of the individuals receiving a prescription over a 6 month period carry on a significant traffickng activity: they receive more than 32 mg of HDB per day (51 mg on average) (CNAMTS) The average daily treatment is 9.6mg. On this basis: The average daily treatment is 9.6mg. On this basis: –Patients really engaged in long term treatment: 52000 –Patients receiving precriptions on an irregular basis: about 22000 –Users of buprenorphine without precription: at least 4000 Misuse : Misuse : –injecting, 11% in medical protocols, 54% for those who expect a product for getting « high » –sniffing, Starting addiction with subutex® Starting addiction with subutex®  important to know more about the behavior of the users  No incidence on the number of drug users

14. Evolution since 1992 of drug use, among 18-44 years old population %

15. Overmortality according to product involved in the arrest substanceMenWomen smrsmr Individuals arrested for héroin/cocaine/crack use 5,19***9,52*** Heroin5,27***9,74*** Cocaine4,31***8,50*** Crack4,50***5,39 French population as a whole 1,01,0 ***:=p<0,001 Reading: men arrested for heroin cocaine crack use have a risk of dying 5,19 times higher than men of the same age in the french population

16. Fighting drug related deaths: Knowing more about addictions Importance to have a good knowledge of: Importance to have a good knowledge of: –The new drugs arriving on the market –Their diffusion –The new ways to use them –The expectations and behaviors of the users

17. Two Main systems of observation –TREND (tendances récentes et nouvelles drogues) (New tendancies and new drugs) –SINTES (Système d’identification national des toxiques et des substances)(National System of identification of toxics and substances)

18. TREND Objectives: Objectives: –Give to the policy makers, professionnals and drug users some elements of knowledge able to modify their decisions or their practice Means: Means: –A network of several sites collecting informations –Continue collect and analysis –Annual report

19. TREND 2 Combination of differents tools: Combination of differents tools: –Focal groups –Ethnographic observations –Qualitatives questionnaries –Quantitatives enquiries (in low threshold facilities) –Interviews of ressource people –Interviews of users

20. TREND 3 Who collects the data? Who collects the data? –Drug Users –Ethnographic professionnals –Members of the teams from harm reduction actions –Teams involved in harm reduction on the techno scene –Medical teams –police

21. TREND 4 Data collected: Data collected: –Characterics of users –Ways to use drugs –Social and health damages –Perception of the drugs –Ways to get drugs –New populations of users –Treatment of the information about drug by the media (press)

22. SINTES (Système National d’Identification des Toxiques et des Substances) Objectives: Objectives: –identify new tendencies or new drugs (identification of new molecules or new association of molecules, by the mean of analysis of synthetic drugs) Methodology: Methodology: –Continue Collect of the drug by a network of actors (involved in prevention, harm reduction…) –Files coming from the laboratories of the police and the customs

23. sintes

24. SINTES (Système National d’Identification des Toxiques et des Substances) Diffusion of information : N+1week Diffusion of information : N+1week Annual report Annual report

25. Conclusion 564  89 death (at least…) What had an impact on drug related deaths?

26. To be as near as possible of the drug users, when and where they use drugs To be as near as possible of the drug users, when and where they use drugs More consideration for their health More consideration for their health A better knowledge of behaviors and substances A better knowledge of behaviors and substances A better communication betwen policy makers, professionnals, and drug users A better communication betwen policy makers, professionnals, and drug users

27. BUT

28. Have we solved the addictions problems with new policies?

29. No. We just change it.