“We must not “supervise” drug consumption, but put an end to it”

François Diot is a therapist, specialist in addictive behaviors.

In particular, he directed a reception and support center for risk reduction for drug users (CAARUD), a help center for drug addicts

.

For thirty years, seizures of cocaine have been steadily increasing in France, as shown by the figures of the OFDT.

And it is cocaine which, after a certain mixture, allows the manufacture of crack.

If during the 1990s, seizures on national territory amounted to an average of 1.8 tonnes per year, they rose to 5.3 tonnes in the 2000s and to more than 11 tonnes in the 2010s. 2021, they reached a record with 26.5 tonnes, twice as much as in 2020. This spectacular development is the result of several factors.

The first is the very strong growth in cocaine production in Latin America and particularly in Colombia, where most of the cocaine hydrochloride consumed in France comes from.

Since the start of the 2010s,

Read alsoCrack, a drug with formidable addictive potential

The second factor is a very clear increase in the purity of cocaine observed over the past ten years with, in France, an average purity rate of 63.5% in 2021, against 45.8% in 2011. The rest of this cocaine contains usually cutting products that also have psychoactive effects (levamisole, paracetamol, caffeine, hydroxyzine, lidocaine).

Finally, the third explanatory factor is the selling price.

The price per gram of cocaine hydrochloride has increased since 2010 but has gradually decreased since 2018, reaching today between 60 and 70 euros per gram.

The crack "

" (which can allow 3 to 5 drinks) can be bought between 10 and 20 euros.

Today, risk reduction and the discourse of its promoters are an obstacle to treatment and to quitting drug use.

Francois Diot

From a medical point of view, the addictology care system is currently facing a major difficulty concerning the medico-social care of crack users, because there is no substitution treatment for this drug.

In addition, these crack users accumulate significant social difficulties, traumatic life courses, as well as psychiatric pathologies that are not treated.

To enable appropriate care for users of this highly addictive drug, it is essential that there be a break with its use, a break with the places of consumption and dealing, in short, a distancing from all temptations and a shelter.

Wanting to regulate and support crack consumption,

as argued and practiced by harm reduction proponents, is totally illusory.

More seriously, it is a dead end.

Why ?

Put in place, rightly, 30 years ago to fight against the ravages of HIV and HCV, risk reduction remains necessary, even if HIV can now be treated and HCV can be cured.

It is therefore not a question of calling it into question.

But today it is the almost exclusive option, advocated by the addictology sector in France.

This bias is explained by the ideology that largely prevails in this sector, according to which one must "

» : the consumers being supposed to be free of their choice and the evil coming not from the narcotics, but from the conditions of their consumption, it is advisable to put up with the addiction by reducing the risks of this one.

Let us add that in France, there are today 1080 structures dedicated to risk reduction.

They are managed by associations which are financed by the public authorities.

The territorial network of risk reduction is very high.

However, the use of crack and other hard drugs continues to grow.

It is no longer the prerogative of large French cities.

Now it also affects medium and small towns.

Today, risk reduction and the discourse of its promoters are an obstacle to treatment and to quitting drug use.

Indeed, these consider that the drug addict is free, and that it is necessary to wait until he has the desire to stop consuming to consider withdrawal and the exit from addiction.

But how can we still speak of freedom and discernment for people who - in addition to suffering from comorbidities, psychiatric disorders and heavy social handicaps - are totally alienated from crack and spend their time obtaining, by all means , the next dose to consume?

Shooting rooms and their criminal immunity zone

normalize drug use by making it safer.

Francois Diot

The current crack crisis testifies to the impasse of this approach.

The various crack plans essentially consisted of investing massively in accommodation for drug addicts.

This hosting obviously has its uses but it does not solve the problem.

On the one hand because, in spite of housing, most users have a propensity to regroup, because the consumption of crack is done according to a community mode.

On the other hand, because the addicts to whom crack kits and injection kits are distributed, are not offered treatment and detoxification, followed by a recovery course.

Without counting, that they are the obvious prey of the dealers.

Next to the crack plans, the solution proposed by the mainstream of the

Regulating drug consumption, is this the solution?

Are these HSAs the solution to get out of the current crisis both in terms of health and security and public tranquility?

And do they allow the state to make financial savings?

The answer is no.

In terms of health, concerning the Paris room located in the heart of a very dense district of housing, schools and shops, this one, according to the Inserm report (2021):

.

Based on a simulation covering a period of ten years between 2016 and 2026, we note that it only allows

.

In addition, it achieves a result – also very modest – concerning life expectancy: 22 deaths avoided over ten years, ie a reduction of 6.7% in the number of deaths that would have been observed without the room.

The promoters of these rooms claim that they are the first step towards a course of care that can lead to withdrawal and the exit from addiction.

But how many years does this “

” take?

The Parisian room has not presented any concrete results concerning the exit from addiction and this since 2016, that is to say for more than six years.

In short: the HSAs confine drug addicts to drug use by normalizing it, which is paradoxical for a sector whose objective should be treatment and recovery from addiction.

In terms of safety and public tranquility: in 2018, i.e. two years after the opening of the Parisian HSA, the "

" district was integrated into the Priority Safety Zone ( ZSP) 10-18, proof that the situation has not been improved by the room.

Better still, according to 2020 data from the 10th arrondissement police station, this part of the ZSP

.

Finally, when this HSA was opened, an appropriate criminal policy was defined by a circular from the Ministry of Justice.

This provides for a perimeter of criminal immunity for people who go to the room with the quantity of product to be consumed there.

But no permanent control is exercised, so that this perimeter allowed the deal to prosper openly.

The action of law enforcement is thus limited by this legal framework.

The French legislator could however have taken inspiration from the Portuguese example, which did not wish to set up these HSAs near dwellings.

Moreover, the Strasbourg HSA is not in a residential area and therefore does not penalize local residents.

The objective of the Ministry of the Interior is to

prevent drug consumption scenes from taking place and arrest the dealers.

But the HSAs and their Criminal Immunity Zone go against this policy which normalizes

drug use by making it safer.

It is necessary to change the paradigm, with the first objective and explicitly displayed the break with drug use rather than its accompaniment.

Francois Diot

In financial terms, the annual budget of the Parisian HSA, supplemented by public finances, was in 2019 2.5 million euros, according to the latest known figures.

However, this one, since 2016, has not released anyone from addiction.

By way of comparison, the Espoir du Val d'Oise center (EDVO), which welcomes addicts who have first gone through essential withdrawal and aftercare, manages to maintain abstinence and reintegrate socially and professionally four out of five residents, for an annual budget of 300,000 euros, with only state aid of 53,800 euros in temporary housing allowance.

In view of the excellent results obtained by EDVO over the past thirty years, isn't it time for the public authorities to correct this unequal treatment?

What to do ?

It is necessary to change the paradigm, with the first objective and explicitly displayed the break with drug use rather than its accompaniment.

Outpatient care, particularly by HSAs, is not suitable for a population that combines many disabilities.

Individual treatment in hospital for detoxification should be a priority.

This first stage is insufficient if it is not immediately followed first by aftercare, to stabilize the weaned person and treat his probable psychiatric comorbidities, and then by a stay in a therapeutic community offering a Minnesota-type program which has demonstrated its effectiveness in Anglo-Saxon countries.

Such a change of model presupposes questioning the therapeutic option advocated by the associations which take care of drug users, and which is clearly broken down today.

This questioning is all the more necessary as the public authorities grant them generous subsidies (overall: 913 million euros this year).

The State has so far supported the only approach proposed to it by these associations, which are necessarily judges and parties because they are financed by the State itself, with regard to which they have no obligation of result.

The associative sector thus has, in fact, a delegation of public service mission without having the obligations.

For example, it is essential that discourses trivializing the

drug use or presenting it under a festive image are prohibited.

It is not the role of caregivers to advocate for supervised drug use.

Similarly, some sociologists in this field, whose studies are funded by the state, should not confuse sociology with activism.

To this, it should be added that the question of the obligation of care in closed centers must be raised.

The characteristic of crack addiction is that it makes it impossible for users to consider quitting.

It is therefore illusory to expect a request for care from them, especially when psychiatric pathologies are associated with their consumption.

The obligation of care as an alternative to incarceration is an avenue to explore for those who are unable to make the request.

No one questions the need to hospitalize a schizophrenic who is delirious on the public highway.

Why do addictology practitioners consider coerced care for crack users to be reprehensible?

Addicts deserve respect:

It is necessary to take care of drug addicts in a more ambitious way, with the stated objective of getting out of addiction, maintaining abstinence and social reintegration.

Francois Diot

Moreover, there can be no contradiction between the ministries in charge of drug addiction and its effects: health, interior and justice.

However, there is an inconsistency between the objectives of these departments.

The one inside is hostile to supervised drug consumption rooms because they are inseparable from trafficking;

that of health is favorable to these rooms as evidenced by its decree of January 22, 2022;

and that of justice is the author of the circular of criminal policy adapted around these rooms, of July 13, 2016. Without an urgent change of model, and without a coherence by the government of its global policy on drug addiction , is it acceptable that in Paris, in the suburbs or elsewhere in France,

citizens are condemned to live with drug users and dealers, and to suffer the resulting increase in delinquency and even crime?

Is it acceptable that they are reduced to asking the municipal or national police to secure their children on the way to school, as is happening more and more?

What do we actually offer?

It is necessary to take care of drug addicts in a more ambitious way than it is today, with the stated objective of getting out of addiction, maintaining abstinence and social reintegration.

We then propose to invest massively in prevention, in colleges, high schools, universities, vocational training centers, etc.

It is necessary to amend the decree of the Ministry of Health (January 23, 2022) relating to "

(HSA) so that it stipulates that they must be far from homes, shops, schools... For consumers, we must organize without interruption: detoxification in hospital structures;

stabilization in an aftercare service;

then transfer to a therapeutic community-type structure, in order to maintain the person in abstinence, far from places of consumption and dealing and to help him reintegrate socially.

Next, we recommend increasing the number of places in detoxification, in aftercare services, and in centers that provide abstinence and social reintegration.

We also believe it is necessary to strengthen coordination between the police and justice concerning the expulsion of drug dealers in an irregular situation on French territory.

Francois Diot

The government should also open calls for study and research projects from the Mildeca (Interministerial Mission for the Fight against Drugs and Addictive Behaviours), and those directly operational from the ARS (Regional Health Agencies), to alternative projects such as therapeutic communities.

We recommend ensuring an independent audit of the 1080 structures dedicated to risk reduction, in order to increase their efficiency and the articulation between them.

At the same time, the results obtained in terms of detoxification, care pathways and psychological and social reconstruction should be taken into account, in order to establish a standard that can be assessed each year, conditioning the granting of subsidies.

We also believe it is necessary to strengthen coordination between the police and justice concerning the expulsion of drug dealers in an irregular situation on French territory.

But it is also urgent to pose without taboo the questions of the obligation of care as an alternative to the incarceration of the drug addict, and of the hospitalization under duress of users of crack or other hard drugs presenting psychiatric comorbidities, followed by a reconstruction stay in a therapeutic community for the necessary time.

This is a societal choice.