Drug use and abuse of medicines are on the rise

As the lead­ing cause of a dereg­u­la­tion in the brain’s reward cir­cuit, addic­tions are still wide­spread among the French pop­u­la­tion. This is large­ly due to the wide­spread use of legal psy­choac­tive sub­stances: tobac­co and alco­hol, which are the two lead­ing caus­es of pre­ma­ture death in France. In 2020, near­ly 25.5% of adults smoked every day (12 mil­lion peo­ple) and 10% drank at least one glass of alco­hol a day (5 mil­lion peo­ple). So, what is the sit­u­a­tion for sub­stance addic­tions in France for the com­ing year?

First of all, to qual­i­fy as an addic­tion, a per­son must meet at least 2 of the 11 cri­te­ria set out in the Diag­nos­tic and Sta­tis­ti­cal Man­u­al of Men­tal Dis­or­ders (DSM‑5), includ­ing: crav­ing, a com­pelling need to con­sume the sub­stance or per­form the activ­i­ty; loss of con­trol over the quan­ti­ty and time devot­ed to con­sump­tion; increased tol­er­ance to the prod­uct; a strong desire to reduce dos­es; con­tin­ued use despite the dam­age; or the pres­ence of a with­draw­al syn­drome when the addic­tive behav­iour is abrupt­ly stopped…

To date, only addic­tions to sub­stances (tobac­co, alco­hol, cannabis, cocaine, opi­um and deriv­a­tives) or to video games and gam­bling are recog­nised as “addic­tions”. Social net­work­ing, sex­u­al hyper­ac­tiv­i­ty and sug­ar are not con­sid­ered as such due to a lack of data and sci­en­tif­ic evidence.

In France, the most wide­ly used addic­tive sub­stances are still tobac­co, alco­hol and cannabis. The first two are respon­si­ble for 75,000 and 41,000 deaths a year respec­tive­ly. These are ter­ri­fy­ing fig­ures, known but ignored because of habit.

In an arti­cle pub­lished on 20 Octo­ber 2024¹, Doc­tor Bernard Bas­set, chair­man of the Addic­tions France asso­ci­a­tion, and psy­chi­a­trist and addic­tol­o­gist Amine Benyam­i­na, chair­man of the Fédéra­tion Française d’Ad­dic­tolo­gie (FFA), pro­posed a series of mea­sures com­bin­ing pub­lic health and gov­ern­ment debt, such as tax­ing drinks accord­ing to their alco­hol con­tent, or intro­duc­ing a min­i­mum price per drink based on the Scot­tish mod­el. “In France, we have a real cul­tur­al prob­lem with alco­hol and very pow­er­ful lob­bies,” says Amine Benyam­i­na. “All pub­lic pre­ven­tion poli­cies are sti­fled or cen­sored.” And yet, accord­ing to data col­lect­ed by the Con­stances² epi­demi­o­log­i­cal cohort, which num­bered almost 200,000 peo­ple in 2018, 19.8% of men and 8% of women in the work­ing pop­u­la­tion are thought to have a harm­ful use of alcohol.

While the prob­lem per­sists, it is chang­ing. Start­ing with a major pos­i­tive point made by Guil­laume Airagnes, Direc­tor of the French Obser­va­to­ry of Drugs and Addic­tive Ten­den­cies (OFDT) and Doc­tor of Psy­chi­a­try and Addic­tol­ogy: “The gen­er­al con­sump­tion of sub­stances such as tobac­co and alco­hol has been falling among young peo­ple since 2010.” How­ev­er, there was a down­side at the time of Covid, when sev­er­al addic­tive activ­i­ties were on the increase dur­ing con­fine­ment³.

On the oth­er hand, a clear increase in the use of psy­chos­tim­u­lant drugs has been observed among adults since 2010, “although the lev­els of use in the gen­er­al pop­u­la­tion remain incom­pa­ra­bly low­er than those for tobac­co, alco­hol or cannabis” points out Guil­laume Airagnes.

These sub­stances, like ecsta­sy, have ben­e­fit­ed from their image becom­ing much more com­mon­place. This is also the case for cocaine, the avail­abil­i­ty of which has risen steadi­ly over the last ten years, and which used to be the social mark­er of a wealthy eco­nom­ic cat­e­go­ry. In 2021, 26.5 tonnes of cocaine were seized, a 67% increase on 2018. “Cocaine ben­e­fits from the tena­cious stereo­type that it does not pro­duce depen­dence. In real­i­ty, while the signs of phys­i­cal with­draw­al are almost non-exis­tent, it is one of the most psy­cho­log­i­cal­ly tyran­ni­cal sub­stances, with extreme­ly pow­er­ful crav­ings,” describes Amine Benyam­i­na, who is also head of the psy­chi­a­try and addic­tol­ogy depart­ment at the Paul-Brousse hos­pi­tal in Paris. This increase is set to con­tin­ue. The 2020 lock­downs demon­strat­ed the adapt­abil­i­ty of the drug trade, with home deliv­ery ser­vices, mar­ket­ing, attrac­tive pack­ag­ing, the use of social net­works and instant mes­sag­ing, and even pay­ments in cryptocurrency.

Anoth­er less well-known devel­op­ment is the mis­use of cer­tain opi­ate-based drugs, such as codeine or tra­madol, which are intend­ed for ther­a­peu­tic pur­pos­es. These are mor­phine deriv­a­tives with a less pow­er­ful anal­gesic effect than mor­phine. “Para­dox­i­cal­ly, this makes them more addic­tive,” explains Guil­laume Airagnes. “As the psy­choac­tive effects are less intense, this leads to greater com­pul­sive con­sump­tion.” Mis­use of these drugs has been doc­u­ment­ed for around ten years and remains under close sur­veil­lance, although it still only con­cerns a “very small pro­por­tion of users” the direc­tor of the OFDT points out.

In his depart­ment, Amine Benyam­i­na also sees new types of drug mis­use: “More mar­gin­al but just as prob­lem­at­ic is the use of pre­ga­balin or LYRICA. This is a prod­uct designed to treat neu­ro­path­ic pain or post-trau­mat­ic stress syn­dromes.” This anal­gesic, which this time is not a mor­phine deriv­a­tive, also has a strong addic­tive poten­tial, encour­ag­ing patients to con­tin­ue tak­ing it beyond the pre­scrip­tion period.

One of the first prob­lems fac­ing car­ers is the lack of infor­ma­tion about drug users them­selves. In fact, most of the data on addic­tion in France comes from sur­veys car­ried out on the gen­er­al pop­u­la­tion to be more rep­re­sen­ta­tive. But not for much longer! In April 2024, the first nation­al e‑cohort open only to drug users was launched: Com­PaRe Pra­tiques Addic­tives⁴. “We already have sev­er­al thou­sand sub­scribers,” says Guil­laume Airagnes, who is head­ing up the study. “The only con­di­tion to be eli­gi­ble is to be a psy­choac­tive sub­stance user at the time of inclu­sion in the study. Of course, our aim is to fol­low up par­tic­i­pants for at least 5 years, regard­less of whether they con­tin­ue to use substances.”

The respons­es and the long-term fol­low-up will enable Guil­laume Airagnes and his teams to explore sev­er­al avenues of research: the ques­tion of mul­ti­ple drug use, which seems to be the rule rather than the excep­tion; the rela­tion­ship between drug use and eco­nom­ic, demo­graph­ic or pro­fes­sion­al sit­u­a­tion; the study of the very strong stig­ma­ti­sa­tion phe­nom­e­non among these users, etc. These data will also enable us to bet­ter tar­get effec­tive ther­a­pies that are adapt­ed to each profile. 

In its Guide pra­tique de psy­chothérapies les plus util­isées en addic­tolo­gie of May 2022⁵, the Fédéra­tion Française d’Ad­dic­tolo­gie lists and ranks the dif­fer­ent ther­a­pies accord­ing to their clin­i­cal rel­e­vance. The behav­iour­al and cog­ni­tive ther­a­py (BCT) approach remains the most pop­u­lar, with a method that can be adapt­ed to addic­tions with and with­out sub­stances and sol­id results con­firmed by sci­en­tif­ic studies.

But oth­er avenues of treat­ment are being explored, such as the sur­pris­ing use of LSD deriv­a­tives. “The ini­tial results are sur­pris­ing and encour­ag­ing,” says Pro­fes­sor Amine Benyam­i­na with sat­is­fac­tion. “Of course, it’s impor­tant to remem­ber that these stud­ies are very close­ly super­vised” warns the pro­fes­sor, who is work­ing with his team on the effect of psilo­cy­bin on alco­hol addic­tion. “They should not be repro­duced at home!”

Sophie Podevin