REPORT – In France, the prevention of overdoses goes in particular through the Csapa, these care structures which take care of people suffering from addiction.
This is the question that all users ask themselves when they ingest a drug. How far to go? What is the dose that will achieve the optimal effects without generating a negative reaction? When testing their limits, consumers fear two things: “badtrip” for their psyche, and overdose for their body. It is a risk that he takes, that he thinks he has mastered. Sometimes, however, he is wrong.
When we talk about overdose, we imagine the most terrible situations. We think of morphine, heroin, all those opiates to which a more or less important handful of consumers are dependent. In France, cases are rare. In the United States, on the contrary, an epidemic of opioid overdoses is decimating the youth; 28,000 people died in 2014. This worries, but also reassures: it is far from home.
But overdose is not the fate of injectors and marginal drug addicts, far from it. Its shadow hangs over all substances – alcohol, cocaine, amphetamines, etc. – and threatens all audiences who consume them, to varying degrees and according to variable mechanisms. August 31 is International Overdose Prevention Day. Why Doctor is devoting a series of articles to it in order to go around this little-known and underestimated accidental phenomenon.
From the outside, the building goes unnoticed. A gray facade, a swinging door that opens and closes punctually. The discreet inscription on the front, “Espace Emergence Tolbiac”, does not put more on the way. It’s hard to imagine that in this apparently unwelcoming space, we strive to follow patients, with a benevolence and a humanity that sometimes go beyond comprehension.
In fact, taking care of drug addicts, addicts and drug addicts is not easy. One only has to see the difficulty with which public risk reduction policies see the light of day in France. Those who support this population are regularly accused of encouraging consumption.
In the name of the ban, we refuse to help subjects whose state of health is considered to be linked to bad behavior, which is also legally reprehensible when it comes to illegal products.
This philosophy has no place in the Csapa (1), these care structures which welcome and take care of people dependent on substances whatever they may be. Here, for example, we teach injectors to prick themselves cleanly. A booklet placed in the waiting room specifies every detail of the operation: how to put on a tourniquet, which vein to favor, which orientation to give to the syringe, the actions to adopt to avoid the risk of transmission of HIV and hepatitis vs.
Supporting lifestyles
The Emergence center, in the 13th arrondissement of Paris, opened in 1995 as a methadone unit. It was one of the first to emerge in France when opioid substitution therapy was authorized. From now on, the Csapa receives a larger audience. “Most of our patients are addicted to illicit drugs – heroin and codeine for opiates, as well as crack, cocaine, amphetamines and cannabis”, explains Xavier Aknine, addictologist at this center.
It is with pragmatism that we take care of the patients here. The cult of weaning has lived; now, the programs are adapted to the desires and lifestyles of users. “We are not necessarily aiming for an immediate end to consumption,” explains Xavier Aknine. Sometimes it is not even desirable, because it is too violent, too hard. You have to go at their own pace and aim first and foremost to reduce use ”.
The same goes for the prevention of opioid overdoses. Heroin users, for example, are put on methadone, but doctors are well aware that the risk of relapse and overdoses does not go away on the pretext that the person engages in a process of care. “For example, she can keep in touch with other users. So consumption may continue ”.
Thus, it is natural to provide means of overdose prevention to this population which is still at risk. With regard to the medical and paramedical teams, all are trained in first aid and know how to perform life-saving actions in the event of an overdose or a deleterious effect linked to the drug – emergency lateral position, airway clearance, cardiac massage, manipulation the defibrillator …
For users, a number of tips and tools provided by professionals at the center help limit risks. “We explain the situations where the risk of overdose is the highest; sterile injection kits are distributed, betting that if the user takes the trouble to perform these actions while limiting the damage associated with his consumption, then he will have a greater propensity to avoid overdose by having acquired good reflexes ”. In addition, Naloxone, this antidote to overdoses of opiates, will soon make its entry into the Csapa and will serve as a reference tool in an emergency.
> Watch the interview with Dr Xavier Aknine, addictologist from Csapa Emergence (Paris 13), on practical advice and kits issued to opiate users to avoid overdoses.
“The user hears”
Of course, the management of addiction does not boil down to this one approach. The team encourages consumers to take overall care of their health, through good sleep or a balanced diet, for example. “When users take products, they lose appetite and weight,” recalls Xavier Aknine. In the waiting room, other brochures offer recipes that are easy to prepare at a lower cost.
Moreover, the consumption of illicit drugs is not the only reason for consultation. Several patients come here to treat an addiction to this legal drug that is alcohol, but also to master addictive driving without a product – gambling, sex, etc.
Risk reduction also involves very practical advice. To people suffering from alcoholism, doctors remind that in the absence of benzodiazepines, there is a risk of delirium tremens or pre-DT (pre-delirium tremens), but also of epileptic seizure. “We tell them to always have Valium on them.”
As for those who follow a course of Baclofen, this drug against alcohol dependence issued for the moment under restricted conditions, they receive targeted information on the risks of overdoses. “If you forget a tablet, we explain to them that it is important not to catch up by taking two tablets at once, because they risk overdose”.
“A relationship of trust is established between the healthcare teams and the users, who are asking for this advice,” insists Xavier Aknine. We tend to think that anyway, the user does anything and does not listen to these health recommendations, but this is totally false. Not only do they hear them, but thanks to this relationship of trust, they apply them. We have to rely on that ”.
>> Watch an alcoholic consultation at Csapa Emergence.
Difficult communication
In terms of prevention and care, the Csapa have proven themselves; No one now questions the legitimacy and relevance of their existence, which was not the case when they started. However, communication around these structures remains very limited.
“The law of 1970 imposed a very strong prohibition which prevents any debate,” explains Jean-François Bowen, director of this center. We start from the principle that since it is forbidden, people should not consume, and therefore do not consume… As soon as someone dares to raise the question, especially in politics, they are accused of being lax. In this context, it is very difficult to communicate and deploy preventive actions ”.
Result: the Csapa remain poorly known to the general public, and in particular to a large part of users “who do not consider themselves dependent because their use reflects a common, banal way of life”, relates Jean-François Bowen.
Somehow, the centers carry out their mission, and this, at an early stage, through interventions in schools. “We take care of it, but we want more than anything to prevent risky behavior. Failing to avoid consumption, the objective is to delay it ”. Without ideology but with pragmatism, the only weapon adapted for this fight.
(1) Addictology Care, Support and Prevention Center,
Read the rest of our series
Naloxone: the long journey of the antidote to overdoses
Alcohol, cocaine, NPS: sensations taken to the extreme
Addictions: Australians committed to harm reduction
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