Transcript MORTALITY AND DRUG ADDICTION

MORTALITY AND DRUG
ADDICTION
François Hervé
A.N.I.T.
Glasgow 8 août 2005
What are the facts?
• In the eighties, increase of the mortality
– Overdoses
– Aids
– By the time treatments where mainly
• Withdrowal (only 50 people in France in methadone
programs)
• Psychosociological treatments in rehabilitation facilities
• No much consideration for the health of the patients, beside
addiction
Time for debates
• End of the eighties
– Debates about harm reduction
• Interest for foreign models
– Switzerland (4 pillars: prevention, treatment, harm
reduction, repression)
– Nederland (organisations of drug users)
– England (involvement of gp’s)
• Needle exchange
• Methadone and substitution
1988: free access to serynges at chemists
Time for action:
new policies
• Early nineties:
– Beginning of harm reduction strategies
• Methadone (1994)
• Buprenorphine (subutex®)(1996)
– Harm reduction facilities
• Needle exchange
• Street work
EFFECTS ON THE NUMBER OF
DEATH
EVOLUTION OF DEATHS BY OD
600
500
400
300
200
100
0
1990
1991
1992
Héroïne
Solvants
Ecstasy
1993
1994
1995
1996
1997
1998
1999
2000
2001
Médicaments (dont méthadone et subutex)
Cocaïne
Autres et indéterminés
2002
2003
Nombre de décès UDVI
Number of deaths due to aids
among injecting drug users
1200
1044
1000
Apparition of treatments
Better acces to treatments
800
600
24% of the deaths
due to aids
473
400
181
268
200
119
118
?
0
1990
1991
1992
UDVI = usagers de drogue par voie injectable
1993
1994
1995
1996
1997
1998
1999
2000
2001*
2002*
2003*
* données redressées
New cases of Aids among drug users
1 600
1 493
1 400
1 200
Harm reduction
1 079
1 000
800
30% of the new
contaminations
2,8% of the new
contaminations
600
424
400
197
142
200
0
1990
1991
UDVI= usagers de drogues par voie injectable
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001*
2002*
* données redressées
2003*
Development of the substitution treatments
90000
84500
80000
High hdb estimates
(8mg)
71800
70000
low hdb estimate
(9,6mg)
60000
high methadone
estimate
50000
40000
low methadone
estimate
30000
20000
16900
10000
11200
0
1995
1997
1999
2001
2003
Rules for presciption
Méthadone
Buprénorphine
Initial 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
oui
Chevauchement
(overlapping)
if mentioned by the doctor
if mentioned by the doctor
Renouvellement
forbiden
forbiden
(renewal)
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.
• 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).
• 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).
Discussion: Some hypotheses
– Less interest of the users for heroin,
• since the avability of substitution treatments
• 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.
CONCLUSION PART 1
New problems:
• 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:
•
– 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 :
– injecting, 11% in medical protocols, 54% for those who expect a product for
getting « high »
– sniffing,
• Starting addiction with subutex®
 important to know more about the behavior of the users
 No incidence on the number of drug users
Evolution since 1992 of drug use, among 18-44 years old
population
%
3,5
3
2,5
Héroine
2
cocaine
1,5
hallucinogènes
1
amphé+XTC
0,5
0
1992
1995
2000
2002
Overmortality according to product involved in the
arrest
substance
Men
Women
smr
smr
Individuals arrested for héroin/cocaine/crack
use
5,19***
9,52***
Heroin
Cocaine
Crack
5,27***
4,31***
4,50***
1,0
9,74***
8,50***
5,39
1,0
French population as a whole
***:=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
Fighting drug related deaths:
Knowing more about addictions
• 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
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)
TREND
• Objectives:
– Give to the policy makers, professionnals and
drug users some elements of knowledge able
to modify their decisions or their practice
• Means:
– A network of several sites collecting
informations
– Continue collect and analysis
– Annual report
TREND 2
• Combination of differents tools:
– Focal groups
– Ethnographic observations
– Qualitatives questionnaries
– Quantitatives enquiries (in low threshold
facilities)
– Interviews of ressource people
– Interviews of users
TREND 3
• 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
TREND 4
• 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)
SINTES (Système National d’Identification
des Toxiques et des Substances)
• 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:
– 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
sintes
SINTES (Système National d’Identification
des Toxiques et des Substances)
• Diffusion of information : N+1week
• Annual report
Conclusion
56489 death (at least…)
What had an impact on drug
related deaths?
• To be as near as possible of the drug
users, when and where they use drugs
• More consideration for their health
• A better knowledge of behaviors and
substances
• A better communication betwen policy
makers, professionnals, and drug users
BUT
Have we solved the addictions
problems with new policies?
No.
We just change it.