The System of Medical Treatment for Addiction in France

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The System of Medical
Treatment for Addiction in
France
Olivier Cottencin, Jean Harbonnier, Dewi Guardia,
Benjamin Rolland & Thierry Danel
Published online: 18 Mar 2014.
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To cite this article: Olivier Cottencin, Jean Harbonnier, Dewi Guardia,
Benjamin Rolland & Thierry Danel (2014) The System of Medical Treatment for
Addiction in France, International Journal of Mental Health, 43:3, 19-26, DOI:
10.1080/00207411.2014.1003734
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International Journal of Mental Health, 43: 19–26, 2014
Copyright © Taylor & Francis Group, LLC
ISSN 0020-7411 print/1557-9328 online
DOI: 10.1080/00207411.2014.1003734
OLIVIER COTTENCIN, JEAN HARBONNIER, DEWI
GUARDIA, BENJAMIN ROLLAND, AND THIERRY DANEL
The System of Medical Treatment for
Addiction in France
ABSTRACT: The French Addictions Treatment system was recently
reformed. The ministerial memo was clearly inspired by professionals and from
the clinical reality of patients. The main purpose of this reform was to reorganize
the treatments (fighting against the historical split of the different structures)
but also to fight against the substances approach in favor of a global approach.
Thus, this new plan allows addiction treatment professionals to be concerned
with the prevention and the detection of addictive behaviors (abuse and risk
use), which was relatively new in the French medical profession. We present
a brief history of the evolution of the system of treatment for addiction, and we
describe the new system of treatment for addiction as it is now defined in France.
English translation © 2014 Routledge Taylor & Francis Group, from the French
text, “Le système des soins adictologiques en France.”
Olivier Cottencin, M.D., Ph.D. is Professor of Psychiatry and Addiction
Medicine at the University Hospital of Lille in the Department of Psychiatry and
Addiction Medicine. Jean Harbonnier, M.D. is Psychiatrist specialized in Addiction
Medicine at the Psychiatric Hospital of Saint Andre in the Department of Psychiatry
and Addiction Medicine. Dewi Guardia, M.D., Ph.D. is Psychiatrist specialized in
Addiction Medicine at the University Hospital of Lille in the Department of
Psychiatry and Addiction Medicine. Benjamin Rolland, M.D., Ph.D. is Psychiatrist
specialized in Addiction Medicine at the University Hospital of Lille in the
Department of Psychiatry and Addiction Medicine. Thierry Danel, M.D., Ph.D. is
Psychiatrist specialized in Addiction Medicine at the University Hospital of Lille
in the Care Support and Prevention Center for Addiction.
Address correspondence to: Olivier Cottencin, Department of Psychiatry and
Addiction Medicine, University Hospital of Lille, 1 rue Verhaeghe, 59000 Lille,
France; e-mail: [email protected]
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http://www.tandfonline.com/mimh.
19
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20 INTERNATIONAL JOURNAL OF MENTAL HEALTH
The French system of treatment for individuals suffering from addictions
was recently reformed by a ministerial memo clearly inspired by addiction
treatment professionals [1]. The objective of this reform was not only to
reorganize the treatments (which were, until this time, limited to the substance approach) but also to suggest concern for the prevention and the
detection of addictive behaviors (abuse and risk use), which is relatively
new in the French concept of medical treatment.
In France, addiction treatment devices are numerous and concern both
the health system and the medical-social system, whether public or private
(including General Practitioner). The French organization of treatment
for individuals with addictions has today become a consistent tool with
the objective of providing a gradation of territorially distributed treatments
Its goal is the coverage of the needs of the whole population of individuals
with addictive behaviors both in preventive material, evaluation of needs,
and accompaniment, as well as the orientation toward the best system of
care in terms of skills and techniques.
A Brief History of the Availability of Addiction Treatment in France
The twentieth century has placed addiction at the crossroads of repression
and treatment. There have been three instances of important evolution the
first was marked by the priority was repression consumption of psychoactive
substances; the second was the introduction, in 1954, of health intervention,
contained in the law on dangerous alcoholics (which would be followed in
1970 by the legislation on users of illicit substances); and the third was the
opening of treatment to people suffering from addiction, from specialists
other than psychiatrists (or doctors in general), and also entrusting the burden to professionals of the medical-social field (educators and social
workers).
The problem of addiction in France was the victim of a double split:
firstly, a split between psychiatry and addiction medicine and secondly a
split within its organization.
Split between psychiatry and addiction medicine
The sectional organization of French psychiatry that was very effective for
the treatment of mental illnesses (screening, rehabilitation, and destigmatization) has failed (or not wanted) to adapt, outside of some specific services and
intersections, to the intricacies between addictions and psychiatric problems,
referring comorbid subjects to one or another field (while we estimate
the addictive comorbidity in patients suffering from psychiatric problems
at 50 percent). Additions, often considered a symptom of some psychiatric
problem or an attempt to self-medicate, were those that were not believed
FALL 2014 21
to improve with the help of psychiatric pathology. The future will show that
the two pathologies worsen the other and necessitate an integrated approach.
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Split within treatment of addiction system
The French treatment of addiction system has also suffered a split within its
organization. Indeed, because of the quasi-exclusive substance approach,
two large subspecialties distinguished themselves: one focused on the care
of alcohol-dependent individuals, essentially, those who were hospitalized
and, thus, principally in health management; and the second on addicts
(of cannabis, heroin, cocaine, and other illicit substances), in large part
taken care of by the ambulatory or residential medical-social system.
Changing in physicians’ attitudes followed the clinical evolution of patients
recognized today often as polyaddicts, abandoning the substance approach
in favor of a global and generalized approach (in an all-addictions and
bio-psycho-social sense) of the subject of addiction.
The Addiction Plan (2007–2011)
The addiction plan was conceived with the goal of structuring and
harmonizing addiction management in a transversal manner into a biological, psychological, and social vision. This approach connected health
and medical-social concerns along three levels of management, according
to the gravity of the situation, making services available to the largest
number of users. If some occasional resistance persisted, today the
receptions, orientations, and treatments are clearly organized around
a global concept of addiction.
The hospital (public or private) procedure for addiction treatment is
organized into three levels [1]:
•
•
•
The structure of level 1: proximity structures whose goal it is to fulfill
simple residential withdrawal treatment and to assure meetings,
consultations, and consultation-liaison;
The structure of level 2: structures of recourse for a given area.
In addition to the missions of level 1, level 2 must fulfill the complex
residential treatments (complete hospitalization or day hospitalization).
Health establishments that have developed a specific addictology
structure can assure these activities. This level also includes the treatments of rest and readaptation (addictological and cognitive), which
allow the seeking of residential treatment beyond the critical treatments;
The structure of level 3: structures of regional and academic recourse.
They assure, in addition to the missions of levels 1 and 2, teaching,
formation, research, and regional coordination.
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22 INTERNATIONAL JOURNAL OF MENTAL HEALTH
The method of access to treatment was also reorganized. The Center for
Cure, Accompaniment and Prevention in Addictions (CSAPA, Centres de
Soins, d’Accompagnement et de Prévention en Addictologie), which resulted
from the unification, in 2007, of the administrative setting that distinguished
Centers Specialized in the Treatment of Drug Addicts (CSST) and Centers
for the Ambulatory Course of Treatment for Alcoholism (CCAA), now
assures welcome, information, medical evaluation, and psychological and
social orientation of individuals who have a risky level of consumption, a
harmful level of usage, or who have a dependence on psychoactive substances as well as the help for their families (parents, spouses, other family
members, and friends). Therefore, CSAPA is a result of the unification of
the medical sector and medical-social sector. However, access to the treatment of addiction system is also possible through private practice (GPs, psychiatrists, and private clinics). Patients can benefit from ambulatory
treatment with their own GP, or enter a private addiction treatment program. In fact, a lot of patients (because of their social level and precarious
living conditions) prefer the public health system (medical or medicalsocial). The medical-social system is anonymous and free; the cost under
the public medical system is easily reimbursed by French social security.
Entrusted to the medical-social setting, both public and associations, is a
framework of treatments of proximity, suitable for patients for whom
neither the clinical state nor an intense level of treatment is necessary. For
them, the global approach is optimal, offering a variety of medicalmentoring, psychotherapeutic approaches for reducing the harm involved
with social reinsertion and accommodation. The old centers situated in town
had, as a mission (in the spirit of the psychiatric sector), access to treatment
closer to the population, to assure ambulatory treatments, the connection
with hospital addiction medicine departments, and harm-reduction
actions. Today, the addiction plan (because of the common substratum
of addictions) hopes not only to aggregate its thematic consultations,
but also to aggregate all of the types of addictions, whether with or
without substance.
The CSAPA is not simply a place of ambulatory treatment. Actually, the
CSAPA is as well a place for prevention, risk reduction and information, which
now clearly belong to specialists of the treatment of addiction. This point is
clearly a change in culture, above all, for the medical profession that, until
now, was in the habit of working only with known dependent patients. Today,
the French system of treatment for addiction may also meet abusers or
excessive consumers. It can also enroll in general hospital (maternity, medicine,
surgery). It can provide also information to general population, in the scholarly
and educational environment, in the workplace, and is able to focus on
populations with specific needs: precarious, detained, young, parenthood, etc.
Thus, the main objective of such a system of treatment is, indeed, for the
most operative improvement of the management of patients. This goal is
FALL 2014 23
accomplished using a more fluid course within the different structures, while
considering the degree of gravity of addiction.
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A Coherent and Supervised Organization
With the desire to reduce divisions, to avoid redundancies, and to develop
a global approach to addiction treatment (substance or other), the addiction
plan has also defined the missions of each field in order to assure that they
better complement each other. A national and several regionals jurisdictions
were created (National Addictions Commissions and Regional Addictions
Commissions). These authorities are charged with putting together a notebook of the regional responsibility to watch over the global amelioration
of responses, identifying needs in terms of resources, distributing those
resources, and facilitating access to treatments. The distribution of tasks
between the different centers of addiction treatment depends on international recommendations, such as those of the American Psychiatric
Association [2], that suggest that the choice of treatment center to be
founded on the capacity of the patient to receive treatment and to cooperate
in the center that is the least restrictive possible, assuring, at the same time,
security and efficiency.
Thus, hospitalization is recommended for severe intoxications, complex
withdrawal symptoms (e.g., the risk of physical decompensating such
as delirium tremens, major alcoholic dependencies, polydependence),
physical and psychiatric comorbidities, past treatment failures (residential
or ambulatory), polydrug use or associated behavior, the intermediaries
before the admission to follow-up care and readjustment to the community,
and induced cognitive disorders (when applicable).
Regional commissions, newly created in Regional Health Agencies, must
oversee the complementarity of the structures at all levels of the organization. Thus, like all the other structures of responsibility, rest and rehabilitation care units, classically oriented toward the care of alcohol-dependent
individuals, are now eligible to receive patients with other types of addictive
behaviors or who are polydrugs consumers. These units must orient the
individual toward reinsertion structures that offer longer stays. Residential
treatment center is indicated for patients who do not require hospitalization,
but who present a high risk of relapse, cognitive disorders, lack of
socio-professional competence, and lack of environmental support. A stay
of at least 3 months is associated with better outcomes.
Finally, outpatient centers (CSAPA) are a part of an appropriate treatment for patients whose clinical condition or social environment does not
require an intensive level of care. The global approach is optimal, providing
a variety of pharmacological and psychotherapeutic treatments, harm
reduction, and support for rehabilitation.
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24 INTERNATIONAL JOURNAL OF MENTAL HEALTH
France is also a country of medical networks, and the addiction plan
provides that this peculiarity to be maintained. A medical network aims
to increase access to care, coordination, continuity, or interdisciplinary
treatment of certain populations. Thus, it is proposed that all collaborations
between the care establishments and the medical-social correspondents be
recorded and spelled by conventional preference in order to clarify the terms
of work and possible partnerships: common formations, common documents, possibilities of shared activities, and others. General practitioners,
the pivot of medical care in our country, are considered to belong to the
organization of addiction treatment system. Thus, general practitioners
are clearly identified for assessment, evaluation, and treatment of addiction.
When their own abilities to treat are overwhelmed (e.g., complex comorbid
cases) they can refer patients toward specialized centers of care. The
connection between specialist and generalist must be reinforced by means
of network structures, with intervision and supervision meetings. These
networks reinforce the idea of a global approach, which is seen as an object
of political and medical goodwill in France.
Nevertheless, the addiction plan has not created a blank slate of the existing
plan and, instead, utilizes it to reinforce and facilitate access to care. One can
see, despite an apparent lack of order, to what extent it is possible in France to
gain access, in different degrees and in graduated ways, to the most specialized
structures for the most complex treatments (see Figure 1).
Figure 1
Illustration of Different Possibilities of Access to the System of Treatment
for Addiction in France
FALL 2014 25
The patient’s entrance into the system is allowed at all levels. This health
collaboration (private and public) with the medical-social sector allows the
cohesion of the group (even if a network is still fragile and must constantly
be stimulated).
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Addictions and Psychiatry
Sectional Organization of Psychiatry
In France, addiction treatment is not left just to psychiatrists; addiction
treatment structures are required to work with psychiatric structures (by
means of consultation-liaison teams and the connection with the available
psychiatric sector) so as to propose a guarantee of responsibility for the
degree of difficulty of each case. In the 1960s, psychiatry was also in its
mission the management of patients suffering from drug addiction, alcoholic
behaviors, and eating disorders. Unfortunately, these responsibilities did not
seem compatible with the organization of general psychiatric treatments
because of the difficulties of mixing psychiatric populations, the lack of
formation of teams, the principles of psychiatric sector, the psychopathological specifics, when compared to the methods of specific treatment.
The psychiatric sector was and is still very efficient for the management
of complex psychiatric disorders (from their appearance to their rehabilitation), but addictions were not taken care of specifically by psychiatric
units, other than in rare exceptions. This lack of interest in the addiction
comorbidities within psychiatric units is surprising as addictions and
psychiatric comorbidities are common [3]. However, some specific treatment
structures for drug addicts or alcoholics created in the psychiatric hospitals
have naturally become the structures of the second level in the addiction
plan (cf. above).
Anorexia Nervosa and Eating Disorders
Another title for this chapter could have been “the problem of the management of anorexia nervosa in France”. While many academic psychiatric
departments treat anorexia nervosa, it is clear that many gaps remain in care
of this psychiatric illness which is very serious (lack of departments, lack of
specialists, lack of networks, etc.)
Professional references actually recommend ambulatory treatment,
considering that hospitalization is allowed only if ambulatory treatment
fails. However, the reality clearly shows that anorexia nervosa is a disease
of denial and concealment (which is very difficult to manage in ambulatory),
and requires a strong institutional setting and, consequently, a familial
approach. Recent findings confirmed by Papadopoulos et al. [4] have
26 INTERNATIONAL JOURNAL OF MENTAL HEALTH
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suggested that, at the outset, a younger age and a longer hospital stay were
associated with better outcomes.
Finally, regarding other eating disorders (e.g., binge eating disorder),
Endocrinologists or Nutritionists manage most of them (but rarely Psychiatrists) and they are rarely diagnosed as an addictive disorder.
Conclusion
After numerous years of using an approach only focused on the substances
and many years of division between Addiction Medicine and Psychiatry,
Addictions Treatment in France evolved toward a global beneficial vision.
What is remarkable in this evolution is that it does not follow ministerial
directives enacted on the simple advice of experts, but benefits from the
constant observation of the evolution of both patients and their behaviors.
Today, that includes polyconsumers associated with alcohol, tobacco,
and cannabis (in the most simple of situations), or that reveals medical
and psychiatric intricacies of complex personality disorders. The global
concept of addictions is not purely a view of hope; it is the fruit of long-time
clinical observations to which the addiction plan brings responses. However,
we must be attentive to the barriers of which we ourselves can be the
creators. Prevention is still not well written into our French medical culture,
and the intrinsic fragility of our networks necessitates an accrued vigilance of
the different partnerships with a good readability of the health care system.
References
1. Memo from the Minister of Health, DGS/6B/DHOS/o2/2007/203, May 16, 2007.
2. Kleber, H.D.; Weiss, R.D.; Anton, Jr., R.F., (2007) Treatment of patients
with substance abuse disorders. American Psychiatric Association, 164(Suppl 4),
5–123.
3. Drake, R.E.; Mueser, K.T.; & Brunette, M.F. (2007) Management of
persons with co-occurring mental illness and substance use disorder: Program
implications. World Psychiatry, 6(3), 131–136.
4. Papadopoulos, F.C.; Ekbom, A.; Brandt, L.; & Ekselius, L. (2009) Excess
mortality, causes of death and prognostic factors in anorexia nervosa. Br J
Psychiatry, 194(1), 10–17.