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