In France, the provision of drug treatment is the responsibility of the regional and local authorities. Since 2003, it has been financed by the social security system. Two systems are involved in drug treatment: a specialised treatment system and the general healthcare system comprising hospitals and general practitioners (GPs). Some care is also provided through the harm reduction facilities of the low-threshold network (Centres d’accueil et d’accompagnement à la réduction des risques pour usagers de drogues).
Almost all of the 100 sub-regional administrative areas have at least one specialised treatment centre (Centre de soins, d’accompagnement et de prévention en addictologie, CSAPA). These centres, managed mainly by not-for-profit non-governmental organisations, provide both outpatient and inpatient care, and also provide care for prison inmates. Both pharmacologically assisted and psychosocial treatments are provided in the same centres. There are also eight ‘drug-free’ therapeutic communities, which operate separately from CSAPAs, and about 540 services for young drug users, which provide early intervention and psychological care on an outpatient basis.
The general addiction care system through hospitals is organised across three levels, with each new level building on services available at the previous level. First-level care manages withdrawal and organises consultations; the second level includes the provision of more complex residential care; and the third level expands the services to research, training and regional coordination.
Since 1995, opioid substitution treatment (OST) has been the main form of treatment for opioid users and has been integrated into a total therapeutic strategy for drug dependence, including for drug users in prison. Methadone and high-dose buprenorphine are used for OST, although in rare cases morphine sulphate is used for substitution treatment. Several directives regulate the dose, place of delivery and duration of OST, which is mainly prescribed in a primary care setting by GPs and is usually dispensed in community pharmacies. Methadone treatment can be started only in specialised centres or in hospitals.
In France, treatment demand data are mainly collected from CSAPAs. Since 2016, the proportion of first-time clients requesting treatment for cannabis use has increased, while the proportion of first-time opioid users beginning treatment has declined. Among all treatment clients, the proportion of primary cannabis users entering treatment increased between 2011 and 2016, while the proportion of primary opioid users decreased. Four out of five first-time clients in 2016 entered treatment for cannabis use-related problems, while among all clients four out of six entered treatment because of cannabis use.
The high number and proportion of cannabis users among treatment clients in France may be attributed to several factors, including an increased number of people with problems related to cannabis use; the opening of specialised consultation centres for young users, mainly cannabis users; and a high number of referrals for treatment from the criminal justice system.
Many drug users, particularly opioid users, are treated in the general healthcare system at hospitals and by GPs rather than in CSAPAs, and therefore are not covered by the French system for data collection on addictions and treatments.
The number of OST clients steadily increased between 1995 and 2013, although since then it has remained rather stable with an estimated number of about 170 000 clients receiving this treatment. Buprenorphine, introduced in 1996, is still the most widely prescribed substance for OST, although the proportion of clients receiving methadone for OST is increasing.