MORTALITY AND DRUG MORTALITY AND DRUG ADDICTIONADDICTION

François HervéFrançois HervéA.N.I.T.A.N.I.T.

Glasgow 8 août 2005Glasgow 8 août 2005

What are the facts?What are the facts?

• In the eighties, increase of the mortalityIn the eighties, increase of the mortality– OverdosesOverdoses– AidsAids

– By the time treatments where mainlyBy the time treatments where mainly• Withdrowal (only 50 people in France in methadone Withdrowal (only 50 people in France in methadone

programs)programs)

• Psychosociological treatments in rehabilitation facilitiesPsychosociological treatments in rehabilitation facilities

• No much consideration for the health of the patients, No much consideration for the health of the patients, beside addictionbeside addiction

Time for debatesTime for debates

• End of the eightiesEnd of the eighties– Debates about harm reductionDebates about harm reduction

• Interest for foreign modelsInterest for foreign models– Switzerland (4 pillars: prevention, treatment, harm Switzerland (4 pillars: prevention, treatment, harm

reduction, repression)reduction, repression)– Nederland (organisations of drug users)Nederland (organisations of drug users)– England (involvement of gp’s)England (involvement of gp’s)

•Needle exchangeNeedle exchange•Methadone and substitutionMethadone and substitution

1988: free access to serynges at 1988: free access to serynges at chemistschemists

Time for action: Time for action: new policiesnew policies

• Early nineties:Early nineties:– Beginning of harm reduction strategiesBeginning of harm reduction strategies

•Methadone (1994)Methadone (1994)

•Buprenorphine (subutex®)(1996)Buprenorphine (subutex®)(1996)

– Harm reduction facilitiesHarm reduction facilities•Needle exchangeNeedle exchange

•Street workStreet work

EFFECTS ON THE NUMBER EFFECTS ON THE NUMBER OF DEATHOF DEATH

EVOLUTION OF DEATHS BY EVOLUTION OF DEATHS BY ODOD

0

100

200

300

400

500

600

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Héroïne Médicaments (dont méthadone et subutex)Solvants CocaïneEcstasy Autres et indéterminés

Number of deaths due to aids Number of deaths due to aids among injecting drug usersamong injecting drug users

118181

119

473

268

1044

0

200

400

600

800

1000

1200

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001* 2002* 2003*

* données redressées

No

mb

re d

e d

éc

ès

UD

VI

UDVI = usagers de drogue par voie injectable

Apparition of treatments

Better acces to treatments

?

24% of the deaths due to aids

New cases of Aids among drug New cases of Aids among drug usersusers

142

197

424

1 493

1 079

0

200

400

600

800

1 000

1 200

1 400

1 600

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001* 2002* 2003*

* données redresséesUDVI= usagers de drogues par voie injectable

Harm reduction

30% of the new contaminations 2,8% of the

new contaminations

84500

71800

16900

11200

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1995 1997 1999 2001 2003

High hdb estimates(8mg)

low hdb estimate(9,6mg)

high methadoneestimate

low methadoneestimate

Development of the substitution Development of the substitution treatmentstreatments

Méthadone BuprénorphineInitial prescription Specialised 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 days 28 days

Délivery 1 to 7 days (possibility until 14 days if mentionned)

7 days (possibility until 28 days if mentionned by the doctor)

Fractionnement (splitting up)

oui ouioui

Chevauchement (overlapping)

if mentioned by the doctor if mentioned by the doctor

Renouvellement

(renewal)

forbiden forbiden

Rules for presciptionRules for presciption

CONCLUSION PART 1CONCLUSION PART 1Good resultsGood results

• The number of deaths by overdoses registred by the police The number of deaths by overdoses registred by the police decreases since 1995, after a maximum (564) in 1994 , 89 deaths in decreases since 1995, after a maximum (564) in 1994 , 89 deaths in 2003.2003.

• In 2003, héroïne is still the drug the most often involved in death by 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 OD (39 % of the cases) but the part of heroine decreases regularly (90% in 1993 and 1994)(90% in 1993 and 1994)

• An increasing proportion of deaths involves the use of medecine An increasing proportion of deaths involves the use of medecine drugs, including méthadone and Subutex®, (31 % en 2003,15 % en drugs, including méthadone and Subutex®, (31 % en 2003,15 % en 1995).1995).

• The number of overdoses due to cocaïne and ecstasy is also The number of overdoses due to cocaïne and ecstasy is also increasing (11 et 10 % in 2003 against less than 1 % in 1995 for increasing (11 et 10 % in 2003 against less than 1 % in 1995 for cocaïne and 7,5 % in 2001 for ecstasy).  cocaïne and 7,5 % in 2001 for ecstasy). 

Discussion: Some Discussion: Some hypotheseshypotheses

– Less interest of the users for heroin, Less interest of the users for heroin, • since the avability of substitution treatmentssince the avability of substitution treatments• because a bad image of heroin and injectionbecause a bad image of heroin and injection

– Less injectionsLess injections

– Better knowledge of the treatment of OD by the Better knowledge of the treatment of OD by the emergengy medical units, and by the users.emergengy medical units, and by the users.

– The important rise of overdoses in the late The important rise of overdoses in the late 80ies early 90ies could be due to the context: 80ies early 90ies could be due to the context: aids, number of dying people, lack of aids, number of dying people, lack of treatments, leading to more self destructive treatments, leading to more self destructive behaviors: the treatments of aids may have behaviors: the treatments of aids may have had more incidence on the diminution of deaths had more incidence on the diminution of deaths than the substitution treatments.than the substitution treatments.

CONCLUSION PART 1CONCLUSION PART 1New problems:New problems:• Trafic: 6 to 10% of the users divert 25% of the treatmentsTrafic: 6 to 10% of the users divert 25% of the treatments black black

marketmarket– 6% of the individuals receiving a prescription over a 6 month period carry on a significant 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)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: 52000Patients really engaged in long term treatment: 52000– Patients receiving precriptions on an irregular basis: about 22000Patients receiving precriptions on an irregular basis: about 22000– Users of buprenorphine without precription: at least 4000Users of buprenorphine without precription: at least 4000

• Misuse : Misuse : – injecting, 11% in medical protocols, 54% for those who expect a product injecting, 11% in medical protocols, 54% for those who expect a product

for getting « high »for getting « high »– sniffing, sniffing,

• Starting addiction with subutex®Starting addiction with subutex®

important to know more about the behavior of the usersimportant to know more about the behavior of the users

No incidence on the number of drug usersNo incidence on the number of drug users

Evolution since 1992 of drug use, among 18-44 years Evolution since 1992 of drug use, among 18-44 years old populationold population

0

0,5

1

1,5

2

2,5

3

3,5

1992 1995 2000 2002

Héroine

cocaine

hallucinogènes

amphé+XTC

%

Overmortality according to product involved Overmortality according to product involved in the arrestin the arrest

substancesubstance MenMen WomenWomensmrsmr smrsmr

Individuals arrested for Individuals arrested for héroin/cocaine/crack usehéroin/cocaine/crack use 5,19***5,19*** 9,52***9,52***

HeroinHeroin 5,27***5,27*** 9,74***9,74***

CocaineCocaine 4,31***4,31*** 8,50***8,50***

CrackCrack 4,50***4,50*** 5,395,39French population as a wholeFrench population as a whole 1,01,0 1,01,0

***:=p<0,001***:=p<0,001Reading: men arrested for heroin cocaine crack use have a risk of dying 5,19 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 populationtimes higher than men of the same age in the french population

Fighting drug related deaths: Fighting drug related deaths: Knowing more about Knowing more about addictionsaddictions

• Importance to have a good knowledge Importance to have a good knowledge of:of:

– The new drugs arriving on the marketThe new drugs arriving on the market– Their diffusionTheir diffusion– The new ways to use themThe new ways to use them– The expectations and behaviors of the usersThe expectations and behaviors of the users

Two Main systems of Two Main systems of observationobservation

– TREND (tendances récentes et nouvelles TREND (tendances récentes et nouvelles drogues) (drogues) (New tendancies and new New tendancies and new drugsdrugs))

– SINTES (Système d’identification national SINTES (Système d’identification national des toxiques et des substances)(des toxiques et des substances)(National National System of identification of toxics and System of identification of toxics and substancessubstances))

TRENDTREND

• Objectives:Objectives:– Give to the policy makers, professionnals and Give to the policy makers, professionnals and

drug users some elements of knowledge able drug users some elements of knowledge able to modify their decisions or their practiceto modify their decisions or their practice

• Means:Means:– A network of several sites collecting A network of several sites collecting

informationsinformations– Continue collect and analysisContinue collect and analysis– Annual reportAnnual report

TREND 2TREND 2

• Combination of differents tools:Combination of differents tools:– Focal groupsFocal groups– Ethnographic observationsEthnographic observations– Qualitatives questionnariesQualitatives questionnaries– Quantitatives enquiries (in low threshold Quantitatives enquiries (in low threshold

facilities)facilities)– Interviews of ressource peopleInterviews of ressource people– Interviews of usersInterviews of users

TREND 3TREND 3

• Who collects the data?Who collects the data?– Drug UsersDrug Users– Ethnographic professionnalsEthnographic professionnals– Members of the teams from harm reduction Members of the teams from harm reduction

actionsactions– Teams involved in harm reduction on the Teams involved in harm reduction on the

techno scenetechno scene– Medical teamsMedical teams– policepolice

TREND 4TREND 4

• Data collected:Data collected:– Characterics of usersCharacterics of users– Ways to use drugsWays to use drugs– Social and health damagesSocial and health damages– Perception of the drugsPerception of the drugs– Ways to get drugsWays to get drugs– New populations of usersNew populations of users– Treatment of the information about drug Treatment of the information about drug

by the media (press) by the media (press)

SINTES (Système National SINTES (Système National d’Identification des Toxiques et des d’Identification des Toxiques et des Substances)Substances)

• Objectives: Objectives: – identify new tendencies or new drugs identify new tendencies or new drugs

(identification of new molecules or new (identification of new molecules or new association of molecules, by the mean of association of molecules, by the mean of analysis of synthetic drugs)analysis of synthetic drugs)

• Methodology:Methodology:– Continue Collect of the drug by a network of Continue Collect of the drug by a network of

actors (involved in prevention, harm reduction…)actors (involved in prevention, harm reduction…)– Files coming from the laboratories of the police Files coming from the laboratories of the police

and the customs and the customs

sintessintes

SINTES (Système National SINTES (Système National d’Identification des Toxiques et des d’Identification des Toxiques et des Substances)Substances)

• Diffusion of information : N+1weekDiffusion of information : N+1week

• Annual reportAnnual report

ConclusionConclusion

56456489 death (at least…)89 death (at least…)

What had an impact on drug What had an impact on drug related deaths?related deaths?

• To be as near as possible of the drug To be as near as possible of the drug users, when and where they use drugsusers, when and where they use drugs

• More consideration for their healthMore consideration for their health

• A better knowledge of behaviors and A better knowledge of behaviors and substancessubstances

• A better communication betwen policy A better communication betwen policy makers, professionnals, and drug usersmakers, professionnals, and drug users

BUTBUT

Have we solved the Have we solved the addictions problems with addictions problems with

new policies?new policies?

No.No.

We just change it.We just change it.