Transcript Jean-Michel Delile

EFTC 11th European Conference
Ljubljana, June 6-8th, 2007
The French government’s decision to
open TCs in France
Dr Jean-Michel Delile
CEID Bordeaux, France
[email protected]
with the assistance of Georges Van Der Straten (Be)
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TCs in France ?
 TCs have been almost completely absent
from France for 30 years.
 In 2004, the governmental plan 2004-2008 of
fight against drugs (Prime Minister Raffarin)
decided to open 25 TCs in France in order to
meet the clinical needs of addicted people
asking for drug free treatment
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How ?
 In August 2005, the MILDT (Interdepartmental
Mission of fight against drugs and drug addiction)
has published a call for projects upon the basis of a
schedule of conditions worked out with the
professionals
 In 2006, the MILDT lead a commission to study the
received projects (more than 20) and to organize the
introduction of TCs within the range of service
responses offered in France
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A real start in 2007
 Four projects have been selected to start in 2007
and the MILDT has made a call for training projects
to train 60 staff members in 2007.
 This paper examines the motivation behind this
groundbreaking change and reflects upon the
possibility of the TC becoming established within a
network of existing services and treatment
modalities.
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Drugs and drug addiction
in France
-Estimate of the amount of regular users of
psychoactive substances among the 12-75
year-olds in Metropolitan France
-Heroin and cocain use
-Care system
OFDT, 2005
(French monitoring centre for drugs and drug addiction)
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Regular users
(10 uses or more during last 30 days)
 Alcohol :
13.1 millions
 Tobacco :
13.0 millions
 Psychotropic medicines : 3.8 millions
 Cannabis :
850 000
 Cocain :
150 000
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Heroin use
 150 000 to 180 000 users
 Relatively young (around 30)
 Mainly male (4 men vs. 1 woman)
 Frequent psychiatric comorbidity
 Socially challenged
 Main substance inducing a socio-sanitary
care for illicit drug users
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Care system
 80 000 new patients each year
(½ alcohol, ½ illicit drug)
 150 alcoholism outpatient treatment centres (CCAA)
 201 drug addiction outpatient treatment centres (CSST)
 46 residential centres : 570 beds
 Other settings (flats or family networks…)
700 beds
 Biopsychosocial model, pluridisciplinary teams
 Administrative fusion (Decree 2007-877) of
CSST and CCAA in 2007 : CSAPA (including TCs),
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Opiates substitution treatment
programs
 Methadon : 1992
 Buprenorphin HD (Subutex®) : 1996
 100 000 patients in treatment
 Good efficacy if


psychosocial support
monitoring
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Substitution treatments in France
Nombre équivalent de patients sous traitement de
substitution 1993 - 2003 (source SIAMOIS/InVS, DGS, Bouchara)
BHD + Méthadone
120000
101 800
100000
BHD
80000
86 600
60000
40000
Méthadone
15 200
20000
0
déc- juin- déc- juin- ja juin- déc- juin- déc- juin- déc- juin- déc- juin- déc- juin- déc- juil- déc- juin93 94 94 95 nv- 96 96 97 97 98 98 99 99 00 00 01 01 02 02 03
96
Nombre total de patients sous traitement de substitution
dont Subutex® ( 8 mg)
dont Méthadone® (65 mg)
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Prévalence départementale standardisée des patients sous traitement de BHD
au 4ème trimestre 2000 (données du régime général de l’Assurance Maladie)
Taux pour 100 000 personnes
Moins de 89,9
90,0 - 124,9
125,0 - 179,9
180,0 et plus
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CEID
 Association founded in 1972 in Bordeaux by
Professor Maurice Serisé
 President : Pr Jean-Pierre Gachie (Professor of
Public Health at the University of Bordeaux)
 Director : Dr Jean-Michel Delile
 70 employees including 7 MD (2 psychiatrists), 6
psychologists, 7 nurses, 43 Social W, 7 Adm-Dir
 Budget 2006 : 2.6 million €
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Main activities
 2 outpatient centres
(Bordeaux, Périgueux)
with 3 antennas
 2 residential programs
(Bègles and Bordeaux, 12
beds in each one)
 2 harm reduction programs
(Bordeaux, Périgueux)
 1 needle exchange mobile
program
 Pole of OFDT in Aquitaine
 3 697 patients in 2006






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1 800 in outpatient treatment
28 400 consultations
568 in substitution programs
62 in residential programs
1 800 in harm reduction p.
100 000 syringes
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And the TCs ?
-Historical background in France
- Le Patriarche
-First experiences
-New approach (Plan 2004-2008)
-Perspectives
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Historical background
 First treatment centres opened in France during the 70s
(Marmottan Paris 1971, CEID Bordeaux 1972…)
 Alternative institutions, free clinics
(Haight-Ashbury model)
 Antipsychiatry, communautary experiments
 Great interest for the first TCs
 CEID participation to the 1st (Norrköpping, 1976), 2nd
(Montréal, 1977) and 3rd (Rome, 1978) World Conferences
on TCs (WFTC)
 And yet…nothing happened. The French « Post-cures »
evolved separately from TCs world movement
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Why ?
 Le Patriarche is the first reason
 Organisation Internationale Lucien
Engelmajer
 La Boère, 1972
 200 centres in 17 countries
 Very bad image of TCs in France :


Sectarian and authoritarian drifts, guru
autocrat, sexual and physical abuses, rapes,
violences, economic exploitation, etc.
Condemned to 5 years of prison, in escape in
the Belize
 See self-criticism in Dianova
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Other reasons…
Another « French exception » ?
 Mistrust toward authoritative and humiliating practices (Patriarche,
Synanon…) and behaviorist approach…
 Psychoanalysis was then very dominant among psychologists and social
workers in the addiction field in France.
 French reserve in front of the American standardization (Daytop Village,
Phoenix House…) and the religious background of many TCs (AA,
Catholic Church, …)
 The weakness of AA tradition and, overall, of the community approaches
in France
 The rupture thus took place after the 1978 Rome
Conference in spite of an audience with Pope John-Paul I
and of Louise Nadeau’s efforts…
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The reasons of the present
evolution in France
 Le Patriarche has disappeared from the institutional scene
and so opened the way for TCs
 The psychoanalytical approach is not hegemonic any more
in France and other methods of intervention (more
compatible with the TCs) developed : CBT, systemic…
 The TC standards have evolved in a more acceptable way
for French professionals, staff code of ethics (WFTC/EFTC)
 The lack of residential programs
 The total absence of residential centres without substitution
programs (DGS Note 1998-659, Nov 5th 1998 and Decree
2003-160 on CSST, Feb 26th 2003)
 The limits of substitution programs
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And…
 Many patients’ request for drug free programs
 Political claim (in particular right wing politicians,
Senate…) in front of a health policy judged too
much harm reduction and substitution oriented with
the detriment of drug free programs
 Will of rebalancing
 Didier Jayle’s (President of the MILDT)
real interest for the CT approach
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And professional support
 In France :
 ANIT : Association nationale des intervenants en toxicomanie
President : Jean-Pierre Couteron
 T3E : Toxicomanie Europe Echanges Etudes
President : Jean-Pierre Demange
 In Europe :
 Georges Van der Straten (Trempoline, Be)
 Proyecto Hombre (Sp)
 Paolo Stocco (Irefrea, I)
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2007 : 4 new TCs in France
 CEID : Barsac (near from
Bordeaux, SW)
 Aurore : Brantôme (Dordogne,
SW)
 Espace du Possible : Cateau
(Nord)
 APTE/EDVO : Île de France
 For 35 places each (140 in the
whole)
 after 2 openings in 2006 (SATO
Picardie, SOS DI in French
Guyana) and 4 in 1994 (SATO,
APTE, SOS DI).
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Communauté du Fleuve
(CEID, Barsac)





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Opening : end of 2007
35 beds
18 employees
30’ from Bordeaux (SW)
Close to the Garonne river
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A network in progress
 These TCs will opened as treatment centres with
real links with the other services and treatment or
social facilities
 They will mix residents, ex-addicts staff and
professionals
 Staff members will benefit of a common training
program
 European network : EFTC, ERIT, ECEtt, T3E…
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Prospects
 Perhaps not 25 openings before 2008 but
 A real evaluation of feasability and efficacy of this
approach in French context
 and a real diversification of service responses
offered in France in order to meet the clinical needs
of addicted people with all their own diversity :
 The new Decree 2007-877 (May 14th 2007) on
CSAPA (addictology centres) mentioned explicitly
TCs and specifies that they have not the obligation
of providing substitution treatments…
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