[New tools for preventing and evaluating risk practices for hepatitis C transmission among injection drug users: some reflections on injection rooms and the measurement of risk-taking behaviors]. / Quels nouveaux outils pour prévenir et évaluer les pratiques à risque chez les injecteurs de drogue face au VHC? Réflexions sur les salles d'injection et les outils de mesure des prises de risques.

Injection rooms should be able to contribute to the prevention of the risks of transmission of hepatitis C (HCV) among intravenous drug users (IDUs). However, these services have yet to be set up and tested in France. This article presents a literature review of injection rooms and explores possible ways of evaluating the effects of this type of service on risks for HCV. Given the difficulties of estimating the service's impact on the incidence of HCV, evaluations could target injection-related risk taking behaviors. The second part of the article addresses the issue of risk taking practices and presents a new research tool able to explore out-of-the-ordinary situations involving risk-taking. Tested on a population of IDUs in Marseille, this tool detects forms of risk-taking and contexts in which injection is performed, which are always missed by the usual measures of risk practices. It could therefore be added to these measures and be useful for evaluating injection rooms.

[Collaboration between general practitioners and pharmacists in the management of patients on high-dosage buprenorphine treatment. Prescribers' practices]. / Collaboration entre médecins et pharmaciens pour le suivi des patients sous buprénorphine haut dosage. Pratiques des médecins prescripteurs.

OBJECTIVES: This paper examines the collaboration between general practitioners (GPs) and pharmacists in the outpatient management of patients on high-dosage buprenorphine (HDB) treatment. METHODS: A telephone survey of a sample of HDB prescribers in southeastern France questioned them about their knowledge, practices, and opinions about HDB treatment in October 2002; data from the national health insurance fund and the national statistics institute completed the study. Logistic regression was used to investigate factors associated with collaboration with pharmacists. GPs' practices were compared to assess their correlation, if any, with this collaboration. RESULTS: 345 GPs participated in the study. Only 54% reported collaborating with dispensing pharmacists in managing patients on HDB, despite official guidelines encouraging it. Collaboration was independently related to training in addiction treatment, a favorable opinion of maintenance treatment by GPs, long experience in HDB prescription, and participation in a specialized medical network. CONCLUSION: Implementation of recommendations on physician-pharmacist collaboration requires additional training in addiction medicine for GPs and the encouragement of their participation in medical networks. On the other hand, increasing the constraints on GPs may negatively affect patients' access to care.

[Prescription of high dose buprenorphine by general practitioners]. / Prescription de buprénorphine haut dosage par des médecins généralistes.

BACKGROUND: Since 1996, prescribing buprenorphine in high dosage as a drug maintenance treatment has been allowing French general practitioners to undertake drug addicts with a pharmacological support. In France, buprenorphine prescriptions seem to spread over general practitioners (buprenorphine was given to 74,300 patients in 2001). This paper assesses the different factors associated with buprenorphine prescription by general practitioners and with the different degrees of general practitioners' commitment in actually caring drug addicts with the help of buprenorphine. METHODS: Two representative samples of private general practitioners, either prescribing buprenorphine (345 over a population of 876) or not prescribing (355 over a population of 1380) have been questioned through a phone interview in the department of South-Eastern France in November and December 2002. Samples have been constituted with the help of a random stratified survey according to sex, age and volume of services (acceptance rate: 65.5%). Survey data have been completed with general practitioners' activity data from Health Insurance and local socioeconomic data from Insee. RESULTS: 37.5% of general practitioners have at least once prescribed buprenorphine during the considered period, but only 26% of the prescribers treated 75% of patients. Prescribers are most often men, younger than 49 years, working in the fixed fees sector and having group practice. They are also most often members of a health care network, trained for drug maintenance treatments and, from an individual point of view, have relatives suffering cancer, or having HIV, or hepatitis C, or who are drug addicts. Low socioeconomic status of the area where GPs exert seems to be particularly associated with general practitioners' prescription of buprenorphine. CONCLUSION: Data handled in this paper show that supply of substitutive treatments is concentrated among a reduced number of general practitioners and in particularly deprived geographic areas. Workload in deprived areas combined to great professional commitment in maintenance treatment reveals unexpected and unwanted specialisation behaviours by general practitioners, as well as more isolated behaviours by general practitioners who do not ask for particular training program or help by colleagues. These results question the consistency of the general framework of support to general practitioners proposed by health authorities with general practitioners actual practice and needs.

[Withdrawal syndromes of newborns of pregnant drug abusers maintained under methadone or high-dose buprenorphine: 246 cases]. / Syndromes de sevrage des nouveau-nés de mères toxicomanes substituées par la méthadone ou la buprénorphine haut dosage.

UNLABELLED: Perinatal prognosis of pregnant drug abusers is better with intensive prenatal care and substitution maintenance programs. There is a large body of data in the literature on methadone (MTD), but very little on high-dose buprenorphine (HDB). The objective of this study was to compare 2 groups of pregnant women maintained on MTD or HDB for perinatal events. STUDY DESIGN: Prospective multicentric study; all neonates (NN) whose mothers has been maintained during pregnancy on MTD or HDB were included by 34 French perinatal centers with specialized staff for care of these pregnant drug abusers. RESULTS: Two hundred and forty-six pregnant women were included: 93 (38%) MTD and 153 (62%) HDB. Social and perinatal data, prenatal care and factors correlated with poor prenatal care are reported. Forty-six percent of the pregnant women had good prenatal care; 88% had peridural analgesia; mean birthweight=2838g; mean gestational age=38.7 weeks; prematurity<37 weeks=13; intra-uterine growth retardation=32%. Sixty-five percent neonates had withdrawal neonatal syndrome (WNNS) at a mean age of beginning at H40, mean highest Lipsitz score was 8.2 at H78. Half of the neonates with WNNS received treatment, mainly with morphine chlorhydrate. Neonatal mortality was 0/246. Discharge of the neonates was 60% with their father and their mother, and 32% with their mother alone; 4% were placed in foster homes by judicial decision. The only statistically significant differences between the MTD and HDB groups were: maintenance program was more frequently initiated before this pregnancy for the HDB vs MTD group (p<0.03); MTD maintenance was more often supervised by maintenance specialized centers and HDB by general practitioners (p<0.001); prematurity was 18% for MTD group vs 9% for HDB group (p<0.04); mean age of maximum Lipsitz score was H92 for MTD group vs H70 for HDB group (p<0.001). CONCLUSIONS: The perinatal medical and social prognosis of these 246 pregnant drug abusers and of their neonates appeared to be improved by the specialized prenatal care, comparatively with literature data. Perinatal impact of substitution program during pregnancy would be similar with MTD or HDB.