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Swaps Europe 1: Harm Reduction in Practice

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Swaps Europe 1: Harm Reduction in Practice HARM REDUCTION FRANCE / GERMANY / UK / NETHERLANDS / ITALY / SPAIN / IN PORTUGAL / SWITZERLAND PRACTICE EUROPEAN N o1 / JUNE 2018 EDITION 1 PREFACE European Drug Wars Didier Jayle / MD, Swaps editor and former president of the French Mission against Drug and Behavioral Dependence (MILDT) Gilles Pialoux / MD, Swaps editor, head of the department of infectious and tropical diseases at the Hôpital Tenon in Paris Changes in drug policy forced their way into almost every By 2003, 62 DCRs operated in 36 cities in Switzerland, European country in the ‘80s under threat of the AIDS the Netherlands, Germany and Spain. epidemic. The virus-induced crisis, the rise in mortality The HIV/AIDS epidemic has dismantled some dogmas rates among people who use drugs (“heroin depen - surrounding drug use, and today no one in Europe can dents,” one of the “4H” populations particularly affected reasonably refute the benefits of harm reduction policies. by AIDS in the ‘80s), and the obvious incapacity of past What remains to be seen is whether we can mark out the policy — based on “detoxifying” people who use political boundaries of this concept. Although the crisis drugs — all made it necessary to develop new public appears to have subsided — states are funding harm health approaches that could protect users’ health while reduction organizations and interventions, and there curbing transmission risks (whether sexual or injection- seems to be a solid consensus within the European related). Union — we still get a sense of routine and institutional - These new measures directly contradicted existing drug ization, which seems logical as both PWUD and harm policy, whose stated objectives were to prohibit and erad - reduction professionals become older. This is why we icate drugs. In the UK, harm reduction first emerged in think innovative experiments in Europe could inspire cre - 1987. Starting in 1990, Switzerland adopted a new ativity in neighboring countries. In this first European approach that combined prevention, repression, health - issue of the French harm reduction journal Swaps , we care, and harm reduction. Harm reduction policies were have decided to promote the visibility of such experi - largely successful, especially against HIV transmitted ments. through injection — in fact, much more successful than The free circulation of individuals, the ease with which they were against HCV. designer drugs can be obtained, and the issues’s shifting In France, change came both later and more progres - epicenter towards Eastern Europe make exchanges of sively. In 1987, Health Minister Michèle Barzach imposed information, data, practices, and innovative experiments the liberalization of syringe sales. For a long time, the more important than ever. The European Monitoring struggle against HIV rested on this political measure Center for Drugs and Drugs Addictions (EMCDDA), in its alone. France waited until 1994 to authorize opioid sub - 2017 drug report, highlighted major European trends. stitution treatments, and until 2017 to authorize the Among these was the rise in deadly overdoses. Instances opening of its first drug consumption room (DCR). The of death by overdose, estimated at 8,441 in 2015, are first DCR had opened in Berne in 1986 (see Swaps no38). mostly related to heroin and other opioid use in the 1 2 Figure 1. Number of new psychoactive drug ( NPS ) seizures recorded by the European Early Warning System ( EWS ) declined into categories Source: https://eurotox.org/2017/06/06/rapport-europeen-sur-les-drogues-2017-de-lemcdda 90,000 Number of seizures Cathinones 33% 80,000 Cannabinoids 29% 70,000 Benzodiazepines 11% 60,000 Phenethylamines 6% 50,000 Piperazines 6% 40,000 Other substances 5% 30,000 Arylalkylamines 4% 20,000 Arylcyclohexylamines 2% 10,000 Tryptamines 1% 0 Piperidines & pyrrolidines 1% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Opioids 1% 28 European member states, Turkey, and Norway (see We acknowledge this situation by offering leads, as a way figure 1), a 6% increase since 2014. Other trends include to create dialogue around the focus for this issue (“Harm ubiquitous access to synthetic drugs and the growing Reduction in Practice”), which will center on substitution health risks of high-content synthetic opioids. treatments. We decided to examine eight countries: National estimates of annual prevalence rate of high-risk opioid use Source: adapted from EMCDDA, European Drug Report, 2018 Per 1,000 population 0–2.5 2.51 –5.0 >5.0 No data 3 France, Germany, the UK, the Netherlands, Italy, Spain, explore further areas of harm reduction as it responds to Portugal, and Switzerland. For each country, local profes - evolving modes of drug use and new substances that can sionals will present an overview of substitution treat - and should prompt innovative approaches. ments, as well as innovative experiments in harm reduc - We are not losing sight of the fact that the front line for tion. We also provide tables of the most recent available the advancement harm reduction has shifted. While data from the EMCDDA, with a review on the latest trends there have been remarkable political advances in in overdoses by Isabelle Giraudon. Western Europe and in Switzerland, everything remains This Swaps issue was able to lend an independent voice to be done in Eastern Europe. As Michel Kazatchkine to those who work at the heart of harm reduction through - points out in his editorial: “reducing harm is also fight - out Europe thanks to a grant from Indivior Ltd (London) ing poor policies; it is about advocating for decriminal - and from Gilead Sciences (Paris). All the articles are ization of use and low-level non-violent actors in the available for download in English and French at vih.org. drug trade and for changing the roles and behavior of We hope to publish more English-language issues and to law enforcement.” Interventions in place in European countries that can reduce opioid-related deaths Source: adapted from EMCDDA, Health and social response to drug problems, 2017 NB: Year of data, 2016 Take-home naloxone Drug consumption Heroin-assisted Opioid substitution programmes rooms treatment treatment Austria • Belgium • Bulgaria • Croatia • Cyprus • Czech Republic • Denmark •••• Estonia •• Finland • France •• • Germany •••• Greece • Hungary • Ireland •• Italy •• Latvia • Lithuania •• Luxembourg •• Malta • Netherlands ••• Norway •• • Poland • Portugal • Pomania • Slovakia • Slovenia • Spain •• • Sweden • Turkey • United Kingdom ••• 6 FRANCE Substitution in France: the emergence of a modern harm reduction system Didier Jayle / MD, Swaps editor and former president of the French Mission against Drug and Behavioral Dependence (MILDT) William Lowenstein / President of “SOS addiction” and drug dependence specialist France has evolved significantly since the days of psychoanalytical approaches to drug use. The shift toward harm reduction has led to a system that works — though it needs to be defended and improved. HIV and the emergence of harm reduction At first methadone, which had proved itself internation - When passing a cornerstone drug law in 1970, French ally in the US, the UK, and the Netherlands, was offi - legislators opted for a public health policy that included cially recommended in 1994 (and approved for distribu - little medicalization, no options for substitution treat - tion in 1995). Initially, methadone was meant to be ment, and a psychological rather than social approach to distributed in specialized centers (CSST, or Centers for drug dependence. With the advent of HIV/AIDS, harm Drug Addiction Treatment). As it faced continued opposi - reduction emerged in France largely thanks to the efforts tion, methadone treatment would not become widespread of associations, and then very slowly made its way into for another while. public policy. General practitioners were then allowed to prescribe In 1994, under pressure from associations and doctors methadone to stable patients. One year later, noting the treating HIV, who teamed up with a small group of gen - slow propagation of methadone treatment, public offi - eral practitioners, Bernard Kouchner (health minister at cials allowed to high-dose buprenorphine (known in the time) and Simone Weil (former health minister) France as BHD or Subutex ®), which was approved for dis - endorsed a brand new approach to dependence based on tribution in 1996. Since, in theory, buprenorphine pre - substitution treatment and harm reduction. This revolu - sented no risk of overdose, general practitioners were tion happened despite the opposition of a number of allowed to prescribe it directly to their patients (“primo - addiction professionals who had not measured the grav - prescription”). ity of the HIV/AIDS epidemic. These professionals swore by the sanctity of abstinence as the only path towards New healthcare for drug dependence real recovery. For them, prescribing and distributing This extremely flexible setup gave general practitioners a drugs to addicts amounted to “handing out drugs to drug lot of leeway, and revolutionized medical care for people addicts.” who use drugs. For the first time, doctors had an effective 7 tool to wean patients off heroin, while responding to of drug addictions, since 2005) to meet their responsibil - users’ need. Beyond treatment, the relationship between ities as prescribers of substitution treatments and advo - doctor and patient evolved: the doctor’s role went from cates of harm reduction practices. simply treating the most dramatic consequences of intra
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