Medical treatments (substitution, withdrawal)

5.3.1. Withdrawal treatments provided or monitored by staff from the CSSTs.

In 2006, an average of approximately 17 patients per centre underwent withdrawal treatments provided via out-patient care at an out-patient CSST (table 5.1), and almost 13 patients underwent withdrawal in hospital with the support of the centre. The data in table 5.1 shows a significant increase in the number of withdrawal treatments between 2003 and 2004. However, this change is certainly linked to a change in the wording of the questions following the adoption of a new report in 2004. Nevertheless, we have been witnessing an upward trend since the late 1990s. This change must be taken in perspective as the total number of people seen by the specialised centres has also increased since the late 1990s.

Table 5.1. Total number of patients having undertaken a withdrawal treatment via a CSST (out-patient care), 1998-2006.

1998 1999 2000 2001 2002 2003 2004 2005 2006 Average number of patients (per CSST)

having undertaken out-patient withdrawal treatments provided by the CSST

6.8 5.7 6.2 8.4 10.6 11.0 16.8 16.1 17.5 Average number of patients (per CSST)

having undertaken withdrawal treatment in hospital, supported by the CSST (per centre)

na na na na na na 10.3 13.2 12.8

Source: Analysis of the standard activity reports from the out-patient CSST's-2005, DGS/OFDT.

Guide: on average, for each CSST 6.8 patients underwent out-patient withdrawal treatments provided by the CSST in 1998. Note: the calculation was carried out by excluding those centres organising more than 150 withdrawal treatments or which did not answer questions concerning their activity. The total number of patients having undertaken a withdrawal treatment is calculated by extrapolating the average number of people undergoing withdrawal treatments vis-à-vis all CSSTs having a monitoring system for patients undergoing withdrawal treatments of fewer than 150. To this figure we have added the total for those centres excluded from the previous calculation due to the scope of their monitoring system for patients having undergone withdrawal.

Based on the data supplied by the CSSTs, we can estimate the number of patients having undertaken withdrawal treatments in 2006 at somewhere between 8000 and 9000.

Substitution treatments among patients attending front line centres

At the time of the 2006 PRELUD survey, 60% of users declared that they were undergoing a medically prescribed substitution treatment. In the case of just under two thirds of these, this concerned HDB, while a third (32.4%) had been prescribed methadone. Finally, a minority (4%) declared a morphine sulfate-based treatment.

Those users receiving a substitution product tended on average to be older than those not receiving them. Although the average age of the latter stood at 32.1 years old, this figure rose to 33.6 years old for users receiving a substitution treatment based on HDB, to 34.7 years old for those receiving methadone and to 35.2 years old for the recipients of morphine sulfate.

In 79.4% of cases for morphine sulphate, 59.0% of cases for HDB but only 16.4% of cases for methadone, the medicine used for substitution purposes was also mentioned among the products consumed outside the scope of a programme of treatment. Thus, among those drug users receiving morphine sulphate and HDB, it appears that it is the prescribed medicine itself which is cited as the product causing the most problems by the drug users (66.2% and 42.2% respectively). Indeed, among the active drug users interviewed via the CAARUDs, a majority were using injection as the administration method and less often resorted to snort ing or smoking. On the other hand, among those persons receiving methadone, this medicine is mentioned in only a small number of cases (9.5%). It is mainly outstripped by heroin (24.3%

and cocaine/crack (19.5%). Unlike the two other substitution medicines, methadone (when used outside the scope of a programme of treatment) is almost exclusively taken orally (96.5%) (Toufik et al.,2008).

The issuing of substitution treatments

Two medicines are used for opioid substitution treatment s: methadone (for which a programme of treatment by prescription may only be initiated by the CSSTs and healthcare establishments), and High Dose Buprenorphine (HDB) or Subutex®, which can be prescribed right away by any doctor. Following its launch on the market in 1996, HDB has quickly become the leading treatment for opioid dependency in France in volume terms.

In 2007, HDB still represented 80% of substitution treatments even if methadone's share continued to rise based on Siamois data. Easier access to methadone was also one of the recommendations from the Substitution Treatments Consensus Conference held in June 2004. Since 2006, Subutex® is no longer the only product available as generic HDB specialities are now becoming available on the market.

Graph 5.1 below shows the estimated number of patients treated in France using HDB and methadone. The data is derived from refunds issued by the Social Security system, based on two separate hypotheses (with a lower and upper limit).

Graph 5.1. Opioid substitution treatments: the number of drug users treated with high-dose buprenorphine (Subutex®) and methadone – 1995-2006.

Subutex

83 174

Méthadone

18 607

0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 100 000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Sources: GERS/SIAMOIS/InVS and CNAMTS/ OFDT estimates.

However, it should be pointed out that a certain portion of the buprenorphine prescribed is misused, and is not always consumed as part of a programme of treatment. According to data from the health insurance system dating from 2002, out of 79,000 patients having received at least one prescription, it can be estimated at 65% of these were enrolled on a medical treatment programme, that 28% received prescriptions of substitution products illegally and that approximately 6% obtain prescriptions for these treatments (usually from several doctors) occasionally with the aim of reselling the products afterwards.

Substitution treatments administered within hospitals

A survey carried out in 2007 by the OFDT (Obradovic & Canarelli, 2008) in order to assess the impact of circular number 2002/57 dated January 30, 2002 concerning the first prescription of methadone by doctors practising in healthcare establishments (in hospitals and penitentiaries) made it possible to demonstrate that access to methadone had increased in both of these environments.

The part of the survey carried out in hospital environments revealed the key role played by general practitioners in providing opiate dependent drug users with access to specialised treatments, both "upstream" by referring their patients to the hospitals to receive treatment, and "downstream" by continuing the patient's treatment after he leaves hospital. The importance of an effective interface between the various partners in the drug treatment process in order to avoid the patient abandoning the substitution treatment after leaving hospital was another important aspect emerging from this survey.

Substitute treatments administered in penal establishments Please see 9.1