Le manque de consensus dans les pratiques de soins en matière de traitements de substitution en milieu carcéral participe aux difficultés rencontrées par les équipes sanitaires et à l’insatisfaction exprimée par les détenus. Le travail que nous présentons ici est une proposition de Guide des Bonnes Pratiques applicable à l’ensemble des établissements pénitentiaires et reposant sur la confrontation des textes réglementaires, documents et rapports officiels avec les résultats d’une enquête effectuée auprès d’équipes sanitaires (22 établissements pénitentiaires), pénitentiaires (3établissements) et de détenus (7établissements). Les recommandations formulées (1transversale et 13 sur divers aspects de la prise en charge sanitaire des détenus bénéficiant d’un traitement de substitution) sont le reflet des pratiques consensuelles relevées lors de l’enquête, dans les limites d’un cadre réglementaire opposant préoccupations sanitaires et impératifs sécuritaires. Les difficultés relevées traduisent essentiellement l’accentuation de problématiques préexistantes en milieu libre (mésusage, accès au soin, réduction des risques, secret médical…) et soulignent d’autres carences dans le domaine sanitaire en prison. Elles soulèvent également des questions plus générales sur le dispositif de soins aux toxicomanes en France.

Care access for the drug addict patients in prison (in particular for the treatments of substitution) in France is very unequal from one establishment to another. This reflects the great variability of the practices of substitution and especially the absence of consensus on the methods of adaptation of these practices to the prison environment. Because of difficulties expressed by prisoners and medical staff on this subject and of stakes (let us recall that approximately 30 % of the prisoners are dependent or abusers of one or more psychoactive substances), the formulation of recommendations or of a good practices guide of substitution in prison appeared necessary. Work that we detail here answers a ordering of the Advisory Commission of the Treatments of Substitution (September 2001) whose authors are members. It was presented at the session April 2003. It results from the confrontation of a review of the literature (including legal texts and official reports concerning substitution, the organization of the care in prison environment and the lawful framework), with a vast investigation. The latter was carried out near medical staff (22 prisons), penitentiary staff (3 prisons, 27 people met including directors of these establishments) and prisoners (7 establishments, 28 prisoners met) in the form of individual talks (semi-directing interviews with evaluation of the type of existing device and its knowledge by the penitentiary staff and the prisoners ; statement of the suggestions, needs and requests of the medical, penitentiary staffs and of the prisoners). In the whole visited prisons, 7.8 % (870) of the prisoners received substitution treatments (6.35 % by buprenorphine, 1.44 % by methadone), representing a proportion of substituted drug addicts (870 substituted for an evaluation of 3 350 prisoners drug addicts among the 11 168 prisoners of the 22 visited prisons) notably lower than that in free environment (56 %, ie 96 000 substituted for an evaluated population of drug addicts for heroin of 160 000). There are however considerable variations (from 0 to 16.2 %) of the proportion of substituted of one establishment for the other according to the type of prison, of its size, its localization and the type of medical device present. If a consensus exists for methadone (daily delivery with sanitary control), the organization of the care relating to the buprenorphine is extremely variable from one establishment to another, often putting in difficulty as well the medical teams as the prisoners. One recommendation is essential : the formulation of an individualized therapeutic project. Thirteen other recommendations are made in the following fields : renewal of substitution treatments, initiation of substitution treatments, urinary controls, methods of prescription, methods of delivery, co-prescriptions, global care, confidentiality, files, exits and transfers, extractions, formation, accompaniment of the teams. These recommendations being formulated, many medical concerns remain present and several questions open. The report of joint mission IGAS/IGSJ of June 2001 on the health of the prisoners underlines the principal persistent gaps : hygiene and public health, treatment of the mental disorders, the follow-up of the sexual delinquents, handling ageing, handicap and the end of lifetime. In the same way, the difficulties listed in prison environment concerning substitution are only the exacerbation of those existing outside : the misuses and traffics are common in free environment, risk reduction in prison, as outside, handle with obstacles related to the penalization of the drug use and can hardly evolve except questioning the law of 1970. The prison practice opens also questions : that of the « duration » of the substitution, frequently posed by the prisoners ; concern to see the prison becoming a privileged place of access to the care, combining sanction and care whereas the law of 1970 allows the alternative (care or sanction); that of the clinic of the misuse, particularly «readable» in prison environment ; and finally the question of the shared secrecy, extremely delicate in prison context although clarified by the law of March 04, 2002.