Tobacco and precariousness: The central issue of access to care / Tabac et précarité : l'enjeu central de l'accès aux soins

The prevalence and severity of smoking are particularly high in populations in precarious situations and make smoking an essential determinant of social inequalities in health, due to its particularly catastrophic impact on the health of these populations. The general reduction in smoking, less significant in disadvantaged populations, contributes to further increasing these inequalities, and smoking tends to be concentrated in the most vulnerable populations. The relationships between tobacco and precariousness are examined by identifying, based on a review of the literature, the main common factors of vulnerability: stress and social adversity, self-stigma, a low feeling of self-efficacy, the social function of tobacco use, the ambivalence of demands, associated addictions, the severity of tobacco dependence, distance from support and care systems, etc. Specific attention is paid to certain particular conditions: mental health disorders, addictions (other than tobacco), inadequate housing, detention, migration. On this basis, courses of action are proposed to improve access to care and its effectiveness for the people concerned. Emphasis is placed on the mobilization of professionals who often tend to neglect issues of smoking in view of the immediate severity of the problems at the origin of the demands of the people received. A support offer for harm reduction (vaping in particular) seems particularly suited to often-ambivalent demands. The importance of networking and the involvement of CSAPAs/CAARUDs is also underlined. At the systemic level, all of this must be accompanied by political advocacy to reduce these inequalities and social determinants of health.

La prévalence et la sévérité du tabagisme sont particulièrement élevées dans les populations en situation de précarité et font du tabagisme un déterminant essentiel des inégalités sociales de santé, du fait de son impact particulièrement catastrophique sur la santé de ces populations. La réduction générale du tabagisme, moins importante dans les populations défavorisées, contribue à accroître encore ces inégalités et le tabagisme a tendance à se concentrer dans les populations les plus vulnérables. Les relations entre tabac et précarité sont examinées en identifiant, sur la base d'une revue de la littérature, les principaux facteurs communs de vulnérabilité : stress et adversité sociale, auto-stigmatisation, faible sentiment d'auto-efficacité, fonction sociale du tabagisme, ambivalence de la demande, addictions associées, sévérité de la dépendance au tabac, éloignement des dispositifs d'aide et de soins… Une attention spécifique est prêtée à certaines conditions particulières : troubles mentaux, addictions (hors-tabac), mal-logement, détention, migrations. Sur cette base, des pistes d'actions sont proposées pour améliorer l'accès aux soins et leur efficacité chez les personnes concernées. Un accent particulier est porté sur la mobilisation des professionnels qui ont souvent tendance à négliger les questions de tabagisme au regard de la sévérité immédiate des problèmes à l'origine de la demande des personnes accueillies. Une offre d'accompagnement à la réduction des risques (vapotage notamment) semble particulièrement adaptée à la demande souvent ambivalente des personnes. L'importance du travail en réseau et de l'implication des CSAPA/CAARUD est également soulignée. Sur le plan systémique, tout ceci doit s'accompagner d'un plaidoyer politique pour réduire ces inégalités et déterminants sociaux de santé.

Tabac et précarité : l'enjeu central de l'accès aux soins.

The prevalence and severity of smoking are particularly high in populations in precarious situations and make smoking an essential determinant of social inequalities in health, due to its particularly catastrophic impact on the health of these populations. The general reduction in smoking, less significant in disadvantaged populations, contributes to further increasing these inequalities, and smoking tends to be concentrated in the most vulnerable populations. The relationships between tobacco and precariousness are examined by identifying, based on a review of the literature, the main common factors of vulnerability: stress and social adversity, self-stigma, a low feeling of self-efficacy, the social function of tobacco use, the ambivalence of demands, associated addictions, the severity of tobacco dependence, distance from support and care systems, etc. Specific attention is paid to certain particular conditions: mental health disorders, addictions (other than tobacco), inadequate housing, detention, migration. On this basis, courses of action are proposed to improve access to care and its effectiveness for the people concerned. Emphasis is placed on the mobilization of professionals who often tend to neglect issues of smoking in view of the immediate severity of the problems at the origin of the demands of the people received. A support offer for harm reduction (vaping in particular) seems particularly suited to often-ambivalent demands. The importance of networking and the involvement of CSAPAs/CAARUDs is also underlined. At the systemic level, all of this must be accompanied by political advocacy to reduce these inequalities and social determinants of health..

Prevalence and Characteristics of Chronic Pain in Buprenorphine and Methadone-Maintained Patients.

Chronic pain and substance use disorders frequently co-occur. Indeed, chronic pain is highly prevalent, affecting 23-68% of patients receiving opioid agonist treatments (OAT) worldwide. The majority of available estimates come from American studies, but data are still lacking in Europe. We aim to provide European estimates of the prevalence of chronic pain in patients receiving OAT using French data, since France is the first European country in terms of number of patients with OAT. The secondary objectives were to characterize the features and management of chronic pain, as well identify associated risk factors. We conducted a multicenter, cross-sectional study, recruiting patients treated either with buprenorphine or methadone in 19 French addiction centers, from May to July 2016. All participants had to complete a semi-directed questionnaire that collected sociodemographic and medical data, pain characteristics, and licit or illicit drug consumption. In total, 509 patients were included. The prevalence of chronic pain was estimated at 33.2% (95% CI: 29.1-37.3). Compared to non-chronic pain patients, chronic pain patients were older (38.4 vs. 36.1 years, p = 0.006), were more unemployed (66 vs. 52%, p = 0.003), had more psychiatric comorbidities (50 vs. 39%, p = 0.02), and split their OAT for pain management more frequently (24 vs. 7%, p = 0.009). Pain intensity was moderate or severe in 75% of chronic pain patients. Among patients with chronic pain, 15.4% were not prescribed, and did not self-medicate with, any analgesic drugs, 52.1% were prescribed analgesics (non-opioid analgesics, 76.3%; codeine, tramadol, opium, 27.2%; and morphine, fentanyl, oxycodone, 11.8%), and 32.5% exclusively self-medicated with analgesics. Moreover, 20.1% of patients with chronic pain also used illicit drugs for pain relief. On multivariate analysis, variables that remained significantly associated with chronic pain were age [OR = 1.03 (95% CI: 1.00-1.05], p = 0.02], anxiety [OR = 1.52 (1.15-2.02), p = 0.003], and depression [OR = 1.25 (1.00-1.55), p = 0.05]. Chronic pain is a highly prevalent condition in patients receiving OAT, and its appropriate management remains uncertain, since insufficient relief and frequent additional self-medications with analgesics or illicit drugs were reported by these patients. Increased awareness among caregivers is urgently needed regarding a systematic and careful assessment, along with an adequate management of chronic pain in patients receiving OAT.

Hepatitis C virus prevention and care for drug injectors: the French approach.

After France removed hepatitis C treatment reimbursement restrictions on 25 May 2016, an expert report presented recommendations, which focused on vulnerable groups including people who inject drugs (PWID). This commentary presents the key points of the chapter with a particular focus on policy. Thanks to the official lifting of restrictions based on disease stage and to the excellent efficacy and tolerance of the new DAA (Direct-Acting Antivirals) among PWID, the main issue is to improve the HCV care cascade. In France, many HCV-infected PWID, especially active/current PWID, remain undiagnosed and unlinked to care. Our challenge is to improve HCV screening by point of care testing (POCT), outreach methods with mobile teams, rapid tests, FibroScan, etc. and to provide PWID with appropriate services in all the settings they attend, such as drug treatment or harm reduction services, social services, prisons, etc. Another important issue is the prevention of reinfection through comprehensive and long-term follow-up. The report recommends a new national policy: testing and treating PWID as a priority, since this is the best way to eliminate HCV infection. It requires a global strategy consisting of combined and long-term interventions: prevention, outreach, screening, DAA, drug treatment programs including opiate substitution treatment (OST) and various harm reduction programs, including needle exchange programs (NEP). Ideally, these services should be delivered in the same place with an integrated approach. This should lead to meeting the national objective set by the government of eliminating hepatitis C by 2025.

Medicine or ecstasy? The importance of the logo.

Some pharmaceutical tablets have an appearance that resembles that of ecstasy (a logo and often a name referring to it, a given shape and/or a colour). These are sometimes sold in the street as 'ecstasy'. In order to assess the knowledge of this phenomenon, surveys were conducted among designer drug users (DDUsers), pharmacists and pharmaceutical firms. Three surveys were conducted: the first one was conducted among DDUsers by means of an anonymous questionnaire; the second one consisted of a 1-month postal survey within a network of 155 community pharmacies in the Aquitaine region, Southwestern France and the third one consisted of a postal questionnaire sent to 71 pharmaceutical firms. Nineteen users, 77 pharmacists and 25 pharmaceutical firms participated in the surveys. All DDUsers knew the existence of what they call ecstasy 'swindles', but less than one quarter of the pharmacists and one third of pharmaceutical firms were aware of the potential recreational and involuntary misuse of medicines. The phenomenon of 'swindle' in the illicit market is not new. However, the sale of medicines because of their appearance or logo seems to be quite rare. In order to limit this diversion, prevention should be reinforced. In addition, recommendations on the appearance of medicine tablets should be set up by regulatory agencies in charge of medicine approval.

[Use of cannabis: screening strategy and evaluation of severity factors]. / Usage du cannabis: repérage et évaluation des facteurs de gravité.

Cannabis consumption occupies a front place in the field of addictions in France, not only by the levels of consumption but also by the related health harms induced with a growing potentially problematic use of cannabis among young men (14% of those aged 14 to 18 in 2001). Therefore, it is not only an educational problem but also a public health issue. Harmful cannabis use must be systematically researched by history taking on the consumption of tobacco, alcohol and drugs as an integrated part of the patient's social history. The diagnostic of cannabis abuse is made by a clinical evaluation of harmful use, the frequency and quantity of consumption, the search for complications. The practitioner must also evaluate the factors of severity (modalities of consumption and parameters predictive of poor outcome like precocity of first experiences, auto-therapeutic use and the various types of individual and social vulnerability: personality characteristics, psychiatric pathology, family characteristics and social environment). The physician may also be helped by drug screening diagnostic and evaluation instruments like validated autoquestionnaires. Urinary screening can be used especially in public health or forensic medicine fields. Some situational risks must be known while cannabis intoxicated: pregnant women, mentally ill, driving, working. Finally, professionals must know that present situation is very different from what we knew in the seventies and that they have to cope with this fast moving issue.