This story is part of a series exploring harm reduction strategies and drug policies that have been successful in Western Europe.

By Taylor Knopf

BORDEAUX and PARIS, France — The gothic-style spire of the basilica of Saint Michel in Bordeaux stretches into the French sky not far from the famous Pont de Pierre stone bridge built by Napoleon. Needless to say, this area’s landmarks, restaurants and markets attract locals and tourists alike. Maybe unexpectedly, people who use drugs also frequent this part of town.

Planterose is a small street with cafes, businesses and a coworking space just behind the basilica. In the middle sits what appears to be a hipster, grunge-style cafe. A garage door opens up to an outdoor seating area covered in bright graffiti where people sit sipping coffee and smoking, while their dogs rest against the wall.

This is the Planterose DropIn Center, where drug users come to drink coffee, hang out and get clean needles and other materials for safe drug use. There’s a computer and small library for them to use, as well as toilets, showers and laundry. In the morning, there’s opioid substitution — such as methadone and buprenorphine — and counseling sessions available. Up a spiral staircase are offices for the doctors, social workers, nurses and educators who work with this population.

There isn’t anything quite like this facility in North Carolina or even in the U.S. But in France, there are more than 300 harm reduction centers and 480 clinics that offer opioid substitution treatment and other medical treatment to drug users anonymously and free of charge.

The French have deployed a number of strategies to reach and support drug users. Some of those include giving them safe places to sleep; checking their street drugs for unwanted substances; and reaching into the countryside to help rural users.

Driving down infections, overdoses

The goal behind harm reduction in France is to serve the immediate needs of a person using drugs, as well as make a meaningful connection and build trust.

This has been a successful model in France, which experienced a heroin and AIDS epidemic in the late 1980s and early 1990s. Heroin emerged into the drug market in the 1970s, and a decade later “drug use spread to all the social environments,” according to a 1997 report by The French Observatory for Drugs and Drug Addiction.

Other drugs entered the market as well and polydrug abuse developed.

“The health consequences of drug addiction got worse: the number of overdose-related deaths exploded, and the AIDS crisis emerged,” wrote authors of the report.

Driven mostly by heroin, drug-related overdoses deaths rose 63 percent in five years, reaching a total of 750 deaths in 1992. This increase of about 10 percent per year is on par with that in the United States currently.

The number of newly diagnosed HIV infections doubled to more than 2,000 a year over the same time frame.

According to the latest French data, overdose deaths have plateaued in the last decade and fluctuate between 300 to 400 a year in a country of 67 million people. In comparison, the U.S had more than 70,000 overdose deaths in a population of 325 million.

And in 2016, the number of new HIV infections in France related to injection drug use dropped to a total of 49. In the U.S. in 2017, that number was close to 2,400.

The next big goal in France is to eliminate hepatitis C by 2025.

opening to a building with graffiti on the inside.
The Planterose DropIn Center sits behind the basilica of Saint Michel and has a hipster, grunge-style feel. Photo credit: Taylor Knopf

The French are using hepatitis C treatment as prevention, the idea being that the more people you treat and cure, the less the disease spreads.

The goal is realistic, said Jean-Michel Delile, president of La Fédération Addiction, the French harm reduction network made up of more than 800 members, including hospitals, sleep centers, treatment facilities and needle exchanges.

Last year, harm reduction centers with licensed prescribers began treating for hepatitis C. Delile said that before, only hematologists could treat the infection. Harm reduction centers also conduct rapid tests for hepatitis C and HIV.

Additionally, the French health care system lifted restrictions on hepatitis C treatment reimbursement in 2016. Before, only those with more advanced stages of the disease could get coverage.

Delile, who is based in Bordeaux, said this has already started to work in his city. Prevalence of hepatitis C in Bordeaux has declined from 40 percent among drug users in 2000 to about 20 percent presently.

In 2016, France expanded it’s harm reduction laws to include a drug consumption room pilot project, drug checking sites, the dispensing of naloxone (an overdose reversal drug), and mail-order harm reduction programs.

Mail orders and mobile units

Now, there are 10 centers that have mail-order harm reduction programs that involve shipping needles and other supplies to residents in the countryside.

Morane Barbarat, a chemist, is in charge of the rural mailing program at the Planterose center in Bordeaux. She has cards with her name, the center’s address and contact information that she places everywhere, in hospitals, pharmacies and under bridges and corners where users gather.

People who live far away from the center call her and they talk.

“We can just speak about it,” Barbarat said. “How do you take drugs? Do you inject? Smoke? He tells me his history and how he got into the life.”

Young woman holds box with needles, condoms and other harm reduction supplies
Morane Barbarat, a chemist, shows the standard harm reduction package originally created in the 1990s during the HIV outbreak, but the Bordeaux harm reduction center has all sizes of needles. Photo credit: Taylor Knopf

Barbarat ships the supplies they request to a given address. She started mailing orders in the summer last year and had shipped 87 orders to 53 people by November.

She encourages those with mail orders to call her whenever they need something or are experiencing a problem. Sometimes people order supplies for their friends as well. Barbarat said that is fine, but she urges the person placing the orders to have their buddies call her so they can talk.

It’s all about building a connection, she said.

The Planterose center’s rural strategy also includes mobile harm reduction units that travel into the smaller towns and squatting areas.

Thibaut, a drug educator and social worker (who asked we only use his first name), is in charge of the two trucks that go into the rural areas surrounding Bordeaux. He has some regular stops and he also looks for opportunities to meet new groups of drug users who may be squatting in abandoned buildings or at camping sites.

Two men standing together, smiling, facing the camera
Thibaut (right) is a social worker who heads of the rural mobile outreach program from Bordeaux. Here, he’s with a guy visiting the harm reduction center in Bordeaux last November. Photo credit: Taylor Knopf

Every other week he meets up with another truck that provides showers and help to homeless people. Regular visitors know to expect him there. He brings harm reduction supplies, conducts rapid HIV and hepatitis C tests, and gives prevention advice.

His truck is from the Red Cross and still has the old signage on it. He said the familiar logo helps ease people’s minds. Occasionally, his team will take regular unmarked cars into neighborhoods to be more discreet when needed.

Marie, a nurse with another truck from the center, said she encounters a lot of seasonal farm workers from the wine industry around Bordeaux. She said many are from Spain or Portugal. Due to the economic situations in those countries, many come work in the French fields.

Thibaut said he wants to help drug users make social connections again and build up their character so they feel valuable to society.

“What we’ve observed is the more people socialize and the more community they build, the drug use diminishes,” he said. “When they are lonely and depressed, that’s when their use comes back.”

But Thibaut said it takes a long time to see change in a person.

“The very first victory we can observe is someone who has not been sleeping at all for weeks in the streets, they come here, they get a hot coffee and sit on the couch and relax, that’s the first step,” he said. “They feel comfortable right here, right now.”

In 2016, France authorized drug check sites, safe places drug users can bring their samples to see if there are any unknown substances in them. Warnings of dangerous discoveries are put out through the country’s extensive harm reduction network. Photo credit: Taylor Knopf

Marie told the story of one man in his 50s who had been living on the streets a long time with extreme paranoia. She said he refused treatment or psychological help and every social institution in town knew him. Eventually, they had him hospitalized in a psychiatric facility where he got treatment for his paranoia for the first time.

“He became a new man,” Marie said.

They secured permanent housing for him, and he is a very “peaceful” person now, Marie said. He was recently diagnosed with terminal cancer. But she takes comfort in the fact that his life will end in the nicest environment.

Finding harmful substances and warning others

Another newer development in the French harm reduction landscape is drug checking. There are about 10 harm reduction centers with a chemist on site to check drugs for unknown and unwanted substances. And about 50 sites collect samples and send them to a lab for the same purpose.

One cold evening last November, two men brought a portion of their MDMA (ecstasy) to a harm reduction center in Paris, just north of the city center. One of the men had a bad reaction to his recent supply and wondered if there was something else in it.

Sebastian Roquian, a chemist, has spent the past two years doing on-site drug analyses for up to 15 harm reduction facilities across Paris. He took a crumb-size sample of both and ran a few tests comparing them to standard MDMA.

He ultimately determined that there was nothing different about the MDMA the men brought in and talked to them about their use of the drug. How often they use it? Did they mix it with alcohol, if so how much? All of these factors could result in a bad reaction.

Man uses chemistry equipment to test drugs
Sebastian Roquian, a chemist, tests two drug samples for unknown substances at a harm reduction site in Paris. The walls behind him are covered with art from drug users and an artist who comes in to work with them once a week. Photo credit: Taylor Knopf

Had the chemist found something different, he would have let the men know and reported the discovery to France’s harm reduction network. Warnings about new substances in the black market supplies are spread to France’s 800 harm reduction and treatment facilities.

“People who use drugs usually want to know what’s inside the drugs they buy,” he said. “Since they are not legal, they are not controlled. A lot of times they are cut with cutting agents. Sometimes they are very harmful, sometimes not. Sometimes they are strong, sometimes not.

“Being exposed to a variety of qualities is dangerous. If you don’t know much about drugs, you will have behaviors that put you in danger. What we do is analyze drugs to meet people, that’s our first goal,” Roquian said. “We tell them about what’s inside their sample and what’s in the current market.”

Currently in Paris, 50 percent of the drugs analyzed are cocaine, 20 percent are heroin, the rest are ecstasy, other psychoactive substances and stimulants.

A few decades ago, the Paris market was saturated with heroin, he said. But now it’s very localized in the northern part of the city. Most people who take opioids in Paris use morphine tablets, he said.

Across the Paris network, he said there have been about five samples with fentanyl in the last two years. The people who brought it in said they bought it on the dark web. Because morphine is so easily accessible in France, there’s been little room for fentanyl to enter the market, he said.

Roquian said the costs of drug testing vary depending on the equipment. There are some machines that can process many tests without an expert present, but they are costly and don’t always catch low quantities of substances. That’s not a huge deal with an additive such as caffeine, but a small dose of fentanyl could kill you, he said.

The method Roquian uses costs about 10 euros for each test, however he added that you also have to pay the salary of the person conducting the analysis.

Housing Paris’ most vulnerable drug users

There is another harm reduction center that doubles as a housing facility located between Gare du Nord and Gare de l’Est, two major Paris train station on the northside of the city.

This area is considered “high priority” for harm reduction resources due to the increased level of drug activity in the neighborhood. There are two major crack dealing sites close to the SOS SleepIn Center.

During the day, the facility acts as a harm reduction center with clean supplies for injectors and smokers. There are social workers, nurses on staff, and a psychologist who comes once a week.

man on a bike stops at a large wooden gate
A man rings the bell outside the gate to the SleepIn Center in Paris to ask for harm reduction supplies. Photo credit: Taylor Knopf

The staff said they don’t like to use the term “drug users,” instead they say “people who come and ring the bell.”

Also during the day, social workers hold workshops, covering topics such as well being, cooking classes, cultural outings and sports.

The cultural outings are opportunities to take them out of the neighborhood to socialize.

The workshops are also important because it’s a time when they are not using drugs and a time to establish different types of relationships. The social workers said some clients open up and share more during workshops than in counseling sessions.

Every day at 2:30 p.m., people call by phone to reserve one of the 30 beds for that night. The spots fill up in 10 minutes. In the winter, staff frequently have to turn people away. But there is a chance for a bed later in the evening if someone doesn’t show up to claim their spot.

Admission is 1.50 euros per night, but it more of a symbolic price to help build responsibility among those who stay. More and more people are using the kitchen at night to cook. They can do their laundry and shower.

The SleepIn center serves more than 300 different people in a year between housing and day services.

There’s not enough housing for everybody. The only place that can house people who are homeless and actively using drugs is the SleepIn Center, and there’s only 30 beds, said Luc Bisset, director of the facility.

Very tall man at the end of a row of beds
Luc Bisset, director of the SleepIn Center in Paris, says the center’s 30 beds are not enough to serve the homeless population who use drugs. Photo credit: Taylor Knopf

Bisset said that one of the challenges, but also strengths of the night team, is that they can work with someone who has clearly used a lot and is actively high. Other homeless shelters would turn those people away.

The night staff also give out harm reduction materials until 1 a.m., the only place in Paris to get these materials that late into the evening.

There is a rule against using drugs inside the SleepIn center, but Bisset said they know that some do, and there are safe disposal buckets throughout the facility, including the bathrooms.

“The stance in France is that we work with population and they’re going to be using. Even though we may hope that they stop using, fundamentally we just hope that they’re going to be safe,” he said. “We’re not advocating that they stop using or abstinence of any kind because that’s not realistic.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...