ENTITIES AND PUBLIC POLICIES

THE IMPLEMENTATION

OF THE

“

CRACK PLAN

”

IN PARIS

Audit flash

Décember 2021

2

CONTENTS

EXECUTIVE SUMMARY

.................................................................................................

3

INTRODUCTION

...............................................................................................................

6

I

–

THE MAIN GOAL OF THE “CRACK PLAN”: MEDIC

O-SOCIAL CARE FOR

USERS

..................................................................................................................................

8

A. The commitment of public stakeholders from 2018 to intensify and better coordinate

their interventions

............................................................................................................

8

B - Reducing breaches of the peace: an indirect purpose of the plan

............................

10

C - The intrinsic limits of the plan adopted in May 2019

..............................................

10

II

–

REAL BUT PARTIAL RESULTS, WITHOUT EFFECTS ON BREACHES OF

PUBLIC PEACE

...............................................................................................................

12

A - The majority of actions implemented and budgetary resources are significantly

higher than expected

......................................................................................................

12

B - The uneven implementation of actions, from the first reception to emergency

accommodation

..............................................................................................................

14

C - The pathway approach often blocked by the lack of lodging

“downstream”

..........

20

D - The scarcity of human and land resources, two unanticipated bottlenecks

.............

21

III

–

THE URGENT NEED TO LEARN FROM A SYSTEM THAT IS NOW

OUTDATED

......................................................................................................................

22

A - Gradually weakened coordination after the intense mobilization at the start of the

pandemic (April-May 2020)

..........................................................................................

22

B -

The waning of the plan’s initial momentum

............................................................

24

C - Failure to monitor the execution of the plan, causing the loss of a shared vision ... 25

D -

Going beyond the “crack plan” by other bodies and in

itiatives

..............................

27

LIST OF ABBREVIATIONS

...........................................................................................

29

Appendix No. 1: The 33 actions of the crack plan

..........................................................

30

Appendix No. 2: Medico-social support

..........................................................................

32

Appendix No. 3: The frequency of meetings of the governing bodies of the plan

.......

33

EXECUTIVE SUMMARY

Since the 1990s, the trafficking and consumption of crack, a hard drug derived from cocaine,

has taken root in the north-east of Paris. Over the past decade, they have resulted in the concentration

of an increasing number of drug addicts in certain parts of the city’s 18

th

, 19

th

and 20

th

arrondissements.

When tensions with local residents become too high, the police move the groups of addicts from one

neighbourhood to another.

Faced with this thorny and nagging problem, both for public health and safety, the prefecture of

the Île-de-France region, the Paris police headquarters, the Interministerial Mission for the Fight

against Drugs and Addictive Behaviour (Mildeca), the regional health agency (ARS), the City of Paris

and the Paris prosecutor’s office decided to strengthen and better coordinate their actions by signing,

on 27 May 2019, a protocol in the form of a joint action plan covering the years 2019 to 2021.

The main goal of the plan was to try to get crack users off the streets and to deal with

the risks and harm to their health

The “crack plan” was structured around the central idea that offering users of this drug,

wandering on the public highway, a reception, lodging, medico-social support, was the best strategy

to keep them off the street. Also, the vast majority of the plan’s 33 actions fell under the field of health

and social care. It was a question of both giving more scope to actions already under way, such as

patrols, but also of experimenting with new support systems for people, aiming, initially, to shelter

them and then treat their addiction through a pathway approach.

Reducing attacks on public peace and security was an indirect, secondary goal, dependent on

the success of the medico-

social actions. The undeniable added value of the “crack plan” compared to

previous approaches, was to propose a comprehensive approach, bringing together all the public

stakeholders concerned and the associations of social workers and doctors, responsible for

implementing actions in the field.

With regard to its main objective, the plan produced real but partial results, without

any effect on the attacks on public peace

By June 2021, a majority of the actions planned (19 out of 33) had been implemented. The

expenditures incurred by the City of Paris, and especially the French Government from 2019 to 2021

greatly exceeded their initial com

mitments. They should ultimately amount to nearly €25 million, as

opposed to the €3 million a year initially budgeted. However, the implementation of actions has been

uneven.

The patrols carried out by associations, already practised before the plan, has developed and

diversified. Above all, the most striking result is the great development of sheltering in hotels, which

was favoured by the context of the pandemic. Thus, the increase in expenditures largely corresponds

to the increase in the number of places in emergency lodging and social reintegration systems

(ASSORE, PHASE) and lodging with health support.

On the other hand, the initial reception facilities (rest rooms, lower risk consumption rooms)

have not experienced the development expected. The plan did not anticipate the impact of two major

obstacles: on the one hand, the difficulty encountered by associations in recruiting more nursing staff

(nurses, addiction specialists, psychologists) but also educators and social workers; on the other hand,

the scarcity of land holdings available to set up new reception structures.

More fundamentally, the pathway approach, which was at the heart of medico-social treatment,

was hampered by the lack of lodging “downstream”, intended for a longer stay than emergency

lodging. Their number has been overrun by the influx of new users.

4

The plan adopted in May 2019 had inherent limitations that explain its incomplete

results

Some were related to its field of intervention, geographically delimited to Paris proper and,

above all, leaving aside the action of the police and court services in the fight against trafficking. Even

though the Paris police headquarters and the Paris prosecutor’s office were signatories, the “crack

plan” did not include any specific measures aimed at

increasing arrests of dealers. The police

headquarters believes that \mobilizing its services has made it possible to carry out an increased

number of arrests of dealers. The City of Paris considers the repressive action not effective enough.

In addition, the scope of the actions selected was limited in view of the proposals made in 2018

during the preliminary consultation organized by MILDECA. Regarding the rest areas, the plan did

not require them to be open at night, the most sensitive period however.

Regarding “lower risk

consumption rooms”, it only provided for a discussion on the opening of new structures, with only one

existing to date. In terms of emergency lodging and medical support, the plan was designed with an

experimental approach and was not designed to cover all crack users wandering in the street (700 to

800 precarious users).

Under these conditions, only the first reception systems such as patrols or distributing risk

reduction materials were likely to cover the majority of the population concerned, but without aiming

to reduce the number of drug addicts in public.

Consequently, even if the actions of the plan, by their nature, may appear relevant with regard

to the goals sought, their impact in terms of reducing the disturbances caused to public peace turns out

to be limited.

As the “crack plan” (2019

-2021) comes to an end, it appears urgent to learn from a

system that is now outdated

The desire to strengthen the coordination of public and association stakeholders was behind the

May 2019 protocol. In fact, this coordination was close at the start of the Covid-19 crisis (April-May

2020), which urgently required the intense mobilization of all stakeholders. Subsequently, it gradually

relaxed. The meetings of the plan’s governing bodies have be

come less frequent and above all less

conclusive. New actions have become scarce. Shortcomings appeared in the linking of the various

arrangements. The plan’s initial momentum has subsided.

In addition, the execution of the plan was insufficiently monitored. Admittedly, this could be

ensured by action, in the relationship between manager/financier and association operator, but the

information was not consolidated at the overall level. This resulted in the loss of a shared vision as

well as in a fragmented evaluation. The stakeholders took their distance when citizen initiatives

emerged in the face of continuing attacks on public peace.

In September 2021, with the support of the Prime Minister, the Mayor of Paris engaged her

services in the search for sites to make it possible to open new integrated spaces for the treatment of

crack users. However, the conditions of acceptance by local residents make that search difficult.

In conclusion, it appears that additional efforts must be made to reduce the presence of crack

users on the public highway. The coordination of public stakeholders (PRIF, City of Paris, ARS, PP,

MILDECA, Paris prosecutor’s office) and association operators must be stimulated. To this end, it

appears desirable to draw lessons from the 2019-202

1 “crack plan” immediately, based on an

assessment, shared by all the partners, of the achievements and limits of each of the actions carried out

and of the modalities of their implementation.

5

The key figures of the crack plan

Source: Cour of Accounts

6

INTRODUCTION

The presence of crack users in the north-eastern districts of Paris dates back to the 1990s, but

has sharply increased since then due to the wider availability of cocaine. The population involved in

public crack consumption in Paris is estimated in various studies at around 700 to 800 people.

This report relates to a protocol, hereinafter referred to as the “crack plan”, which was signed

on 27 May 2019 by the prefecture of the Ile-de-France region, the Paris police headquarters, the City

of Paris, the regional health agency (ARS), the Interministerial Mission for the Fight against Drugs

and Addictive Behaviour (Mildeca) and the Paris Prosecutor. Lasting three years (2019-2021), its goal

was

“better regulation of the public space”

and

“a coordinat

ed risk and harm reduction policy

targeting roaming crack users and multi-

drug users”

.

The stakeholders of the crack plan

Source: Court of Accounts

The “crack plan” is focused on supporting drug users and reducing the risks and harm to which

they are exposed

1

. It seeks to embark on a path of reintegration. It is not directly aimed at stopping

drug addiction or eliminating trafficking.

1

Definition of the concept of risk and harm reduction by Mildeca. This is

“a policy between humanism, science

and pragmatism. The consumption of psychoactive substances (alcohol, tobacco, drugs) carries health risks and

can cause social harm. The reduction of risks and harms (RDRD), without denying the illegal nature of certain

uses, makes it possible to consider addiction a chronic disease. It is also intended for non-dependent people

whose practices are particularly dangerous. It recognizes that stopping consumption is not possible for some

people, at certain points in their trajectory, and that it is therefore necessary to mobilize pragmatic and

appropriate levers to improve their quality of life”.

7

It includes 33 actions, the majority of which relate to medico-social care by increasing patrols,

reception, lodging, social and health support.

The flash audit conducted by the Court of Auditors and the regional chamber of accounts of the

Paris Metro Region attempted to analyse the degree of implementation of the actions included in the

plan.

The magistrates conducted inter

views with the representatives of the plan’s signatories and with

those of the associations which ensured its operational implementation (Aurore, Gaïa, Nova Dona,

SAFE)

2

. Despite the pandemic, the majority of interviews took place on site. The rapporteurs carried

out field visits. They also met with representatives of the Citizen’s Drug Addiction Observatory.

The finalization of this report depended on the quality of the information provided, for which it

was not always possible to verify its reliability and consistency within the time limits set. As part of

the multi-party procedure, it took into account the responses to the provisional report, including the

latest ones, from the signatories of the plan and from the association operators.

What is crack?

“Crack” or “free base” is the name commonly used to designate a drug obtained from the same

psychoactive substance, cocaine base, obtained from a mixture of cocaine, water, salt and a base (ammonia or

sodium bicarbonate). On heating this mixture, the cocaine precipitates out and solidifies. The solid residue is

then extracted from the water. Crack is consumed by being smoked using a crack pipe, but it can also be injected

with the addition of citric acid to make it soluble. The only elements essential for the production of the basic

cocaine are a little water, a container, a mixing tool and a flame. Specific know-how is important, but users often

say that it is quick to get a “knack” for it. Dealer networks are of little importance. The quantities of drugs an

d

money seized in arrests are generally modest. The crack dealers, called “modous”, are generally from West

Africa, particularly Senegal. This traffic is closely dependent on that of cocaine.

The use of crack has a powerful mental stimulation and an almost immediate effect. This effect only

persists for a few minutes, which gives the user a compulsive desire to smoke more. The use of crack is frequently

associated with the use of alcohol or other drugs such as cannabis. Crack causes strong psychological dependence

and, when used intensively, rapid desocialization. The user’s entire life revolves around finding and using crack

cocaine. In addition, there is no substitution treatment, as with opiates.

Crack can be made by the user themself. When it is bought already prepared, it is less pure in cocaine

(generally 50 % to 70 %) because it is cut with various products. Per dose, it costs much less than cocaine. Even

if it can be done by socially-integrated users, the purchase of prepared crack from dealers mainly concerns poor

or precarious populations, and even more so when it is consumed in the street. The crack consumed in Paris is

prepared in the region, often in Seine-Saint-

Denis, by “cooks”. The places where it is sold, which are exclusively

dedicated to crack, are currently in the 10

th

, 18

th

and 19

th

arrondissements. Buyers usually consume crack

immediately and on the spot.

Users sometimes sell small amounts of crack cocaine to each other, in small-scale sub-trafficking. The

classic unit of resale of crack i

s the “galette” which corresponds on average to two uses. The most desocialized

users, who live on the streets, buy about two to three “galettes” a day. In 2017, a “galette” sold for around €14

on the street or in the Paris metro, and could be bought for €

20 at certain resale points. Other quantities may be

sold at retail. One dose, called a “kiff”, is sold between users at a price of €5. A “kiff” can also be exchanged,

transferred. Other types of larger “gallettes” can sell for €30 to €50.

2

The association Oppelia did not follow up nor did Samusocial.

8

I

–

THE MAIN GOAL OF THE

“

CRACK PLAN

”:

MEDICO-SOCIAL CARE FOR USERS

The trafficking and consumption of crack in the north-east of Paris is a long-standing problem

that has become increasingly acute. The places of consumption have undergone two significant

changes over the past ten years with, on the one hand, the arrival of users from Eastern Europe, mainly

Georgia and Russia, and on the other hand, the direct and indirect consequences of the flow of migrants

in the mid-2010s, some of whom are on French territory illegally.

A. The commitment of public stakeholders from 2018 to intensify and

better coordinate their interventions

Faced with the growing acuteness of the crack problem in Paris, in 2018 the regional prefecture

and the Interministerial Mission for the Fight against Drugs and Addictive Behaviour (MILDECA)

organized a first phase of consultation with all institutional stakeholders and associations concerned,

intended to address subjects considered to be inseparable: the social disconnection of crack users

(wandering and social exclusion, difficulties in accessing healthcare, accommodation, housing,

integration) and the impact of that consumption on the urban areas concerned.

A document drawn up at the end of that period made an initial assessment of existing actions

and proposed new ones. It noted the disconnect between the responses provided and the extent of the

phenomenon. The conclusion was based on the idea that

“only a collective work dynamic, over the

long term, in close and permanent connection with users, will make it possible to refine the

understanding of the phenomena which put in difficulty or even in failure all the stakeholders

concerned, to precisely identify the obstacles and the levers and to quickly, efficiently and sustainably

activate the solutio

ns identified which must be scalable and adapted as they are implemented”

3

.

Mildeca then proposed that the stakeholder concerned continue this work and formalize a

common strategy. After a new phase of consultation and the creation of a

“Strategic committe

e on

crack in the north-

east of Paris”

, a complete plan has been drawn up.

A protocol that brings institutional stakeholders together around a comprehensive approach

The 33 operational actions of the “crack plan” are organized around four focuses (see Appe

ndix

No. 1): increasing patrols, emergency lodging, social and health support, better identification of the

public. In 2019, for the plan’s first year of implementation, the total financial commitments amounted

to €3 million, divided between ARS (€ 1.4 million), the City of Paris (€1 million) and PRIF (€1.2

million over two years).

The intention was to pursue two priorities: on the one hand, the need to find responses adapted

to a specific public health problem and, on the other hand, the imperative to provide local residents, in

conjunction with the town halls of district, concrete responses to maintain public peace.

3

The proposals of the working groups are detailed in Appendix 2 of this report.

9

Public unrest caused by crack use

In addition to drug trafficking and consumption, crack generates various associated problems that

affect public order, public peace, and public health.

Crack users cause a lot of noise (screams, cries of rage) linked in particular to the consumption of

alcohol or to the state of craving. To buy and consume their drugs, they occupy public spaces (streets,

parks, metro stations) and private spaces (parking lots, common areas of buildings, squats), sometimes

causing damage. They often leave waste, including used gear that can represent a health risk (particularly

syringes). Violence between users sometimes occurs, including sexual assault that can go as far as rape.

The vast majority of users, precarious and without resources, obtain money through begging,

frequently aggressive, theft (including purse snatching) and prostitution (employed by the majority of

female street users).

All of these disturbances occur on public streets, in densely populated areas, and are highly visible.

They greatly disrupt the life of the neighbourhoods and give rise to a strong feeling of insecurity among

residents which, even without any established disturbance, can result from the degraded appearance and

erratic behaviour of certain users.

When tensions with residents become too high, the police disperse the groups and evacuate crack

users to other places. This was the case with the Porte de La Chapelle in the Place de Stalingrad, then in

the Jardin d’Eole and, finally, on 24 September, in the Rue Riquet in the Square de la Porte de La Villette.

A plan targeting the medico-social care of crack users

The plan revolved around the central idea that removing crack users from the streets was the

best way to meet the dual challenge of their social and health care and respect for public peace and

order, especially for residents. It was also based on the idea of a progressive pathway intended initially

to protect crack users, then to treat their addiction medically.

Thus, the actions provided for by the crack plan mainly pertained, particularly in terms of

resources, to the medico-social care of street users (see Appendix No. 2). They were mainly of two

types.

A first group of 13 actions aimed to support users, with the help of social workers, to reduce the

risks to their health and promote treatment pathways: increasing patrols, extension of initial reception

systems (rest rooms

4

,

lower risk consumption rooms

5

), improved access to risk reduction materials (in

particular through the distribution of the “crack kit”).

A second group of 11 actions focused on shelter and accommodation: increase in the number of

people supported under the ASSORE system

6

, of the PHASE system,

7

and specialized accommodation

units, improved access to day care centres and common law accommodation centres, strengthening of

residential care through the creation of accommodation places, places for drop-in-health-care beds

(LHSS) and nursing home beds (LAM).

4

The rest areas that offer a stopover during the day and offer beds, showers, a washing machine and some

activities.

5

The lower risk consumption room (SCMR), often incorrectly called a “shooting room”, allows consumption to

be taken off the street, in safety, with safe equipment and under supervision. users present the narcotic product

and then consume it in individual stalls.

6

ASSORE: system for referring people to emergency accommodation facilities and to hotels in order, first of

all, to shelter them, and then to consider medico-social support.

7

PHASE: accommodation system managed by the Aurore association, intended for isolated, homeless, sick

adults who are addicted to psychotropic drugs.

10

In addition, six actions aimed to intervene in the public space to meet users and meet the needs

of residents, and three actions aimed to better understand the uses, profiles and needs of crack users,

in order to adapt intervention strategies.

For each action, the plan details, on the one hand, the pilots and funders, mainly the regional

prefecture, the ARS and the City of Paris, and on the other hand, the operators, generally associations

accustomed to intervening with the target audiences, as well as the services of the City of Paris for the

urban development component and the provision of land resources. The Paris police headquarters and

prosecutor’s offic

e contribute in the exercise of their respective attributions, without providing

dedicated funding

8

.

The adoption of the crack plan is therefore characterized at the outset by the stated desire for

joint work and reinforced coordination of the various public and association stakeholders involved,

sometimes with very different professional cultures.

B - Reducing breaches of the peace: an indirect purpose of the plan

The protocol subtitle

(“for a better regulation of the public space and a coordinated risk and

harm reduction policy targeting roaming crack users and multi-drug us

ers”)

shows its main

dimension, namely the health and social care of crack users. More specifically, the plan aims neither

to eliminate trafficking nor to stop consumption, but to reduce the associated health risks.

Behind the vague expression

“better regulation of the public space”

, it also aims, in

conjunction with the district mayors, to mitigate the impact of crack use on residents, despite the

existence of of trafficking and consumption places, by striving to prevent the wandering of drug

addicts.

In other words, the plan was designed to enable a form of coexistence in the public space

between crack users and residents. Limiting breaches of public peace was a hoped-for result of the

medico-social care of drug addicts.

C - The intrinsic limits of the plan adopted in May 2019

The protocol of 27 May 2019 made choices relating to the types of actions chosen and their

scope, which somewhat explains the partial nature of the results obtained (see Part 2).

The absence of a section on the fight against trafficking

The consumption of crack in the public space is favoured by its great availability. However, the

plan does not include actions relating specifically to the repression of trafficking by the police and

court services, to the arrest of dealers and the dismantling of networks. Such actions are carried out

with no apparent link to the implementation of the plan. This is generally the case with public security,

which is not dealt with directly.

In response to the Court’s provisional report, the police headquar

ters referred to the deployment

of staff from the 18

th

and 19

th

arrondissements, its specialized services, in particular the judicial police,

and mobile forces units. According to the police headquarters, this mobilization enabled

“a very

significant impro

vement in public peace”

in the sectors targeted and

“a very strong action against the

crack trafficking networks”

, allowing the referral of 42 defendants in 2021 (from January to

September) compared to 46 in 2020 (full year).

However, in his letter to the Mayor of Paris, dated 16 June 2021, the Prime Minister deemed it

useful to inform her that

“Legal action will be reinforced under the authority of the public prosecutor

with an intensification of the action of the local crime treatment group dedicated to the consumption

8

See the plan’s implementation protocol in Appendix 1.

11

of crack, the continuation of the policy of systematic deferral of dealers and users and the

strengthening of the effectiveness of restraining orders with a greater geographical distance”

.

Some of the initial proposals discarded or limited in medico-social matters

The crack plan is based on the diagnosis made by the working groups set up in 2018 as part of

the consultation conducted by Mildeca. It took up some of the proposals made. Emphasis is placed on

increasing patrols and creating a substantial number of accommodation places.

However, while the working groups advocated

“the establishment of consumption areas

adapted to crack users”,

the plan simply proposes to think about the implementation of

“Lower risk

consumption rooms”

9

. While it is not for the Court to judge the advisability of setting up such a system,

it should be noted that the value of consumption rooms intended for “inhalers” is mentioned in all the

studies preceding the crack plan and was the subject of numerous exchanges between institutional

stakeholders in meetings or by mail.

Likewise, while the working groups proposed the creation of rest areas accessible during the

day and at night, the crack plan restricts this measure to daytime, with night reception becoming

optional (

“and/or at night”

)

10

. However, the main nuisances for public peace are mainly observed at

night.

Finally, contrary to the proposals made by the working groups in 2018, the principle of

coordination prior to evacuating places of consumption, identified as central to controlling the

development of nuisances in the public space, is only addressed marginally in the plan.

The sizing of actions below the size of the target audience

The proposal for a change of scale, advocated by the 2018 working groups, was taken up

unevenly in the “crack plan”. The actions were not adopted with a view to covering the entire user

population, which is moreover growing, but to design pathways. This pathway approach involved

carrying out experiments. The action generalization phase exceeded the time horizon of the plan.

Thus, the plan initially provided for the creation of 145 additional accommodation places. This

measure was de facto developed under the effect of the pandemic, which led to the mobilization of

more than 400 rooms (see below). However, the managing association estimates that there are still 300

to 350 users on the street. The need for accommodation is much greater than the supply. The same

observation can be made for all of the sheltering and medico-social care actions.

The various systems were not sized according to the total population concerned (700 to 800

precarious users). For example, the rest area at Porte de la Chapelle reports an “active queue”, i.e., a

user group of around 200 people. The other rest area is more frequented but the orders of magnitude

are comparable. The Paris prosecutor’s office follows up on around 400 court orders to receive

treatment. Other crack users, not affected by these different

arrangements, are found at both ends of

the spectrum: socially-integrated users, who are moreover not demanding support and generate limited

disturbance, and the more desocialized users, who are not able to adapt to accommodation, refuse

treatment, and are more likely to cause trouble.

Only the first reception systems, such as patrols or the distribution of risk reduction materials

are likely to date to cover the majority of the population concerned. However, they are not enough to

reduce the number of crack users in public.

The geographic scope of the plan delimited to Paris

Street consumption mainly concerns the north-east of Paris but spills over into Seine-Saint-

Denis. The supply chains, for their part, extend over the entire Paris Metro region. The question of

9

Action 13.

10

Action 12.

12

extending the plan beyond Paris proper was asked during its development but only the City of Paris is

among the signatories of the protocol. In June 2021, the Paris Council also considered that other

communities (metropolitan area of Greater Paris, Ile-de-France region, neighbouring departments)

“should take up this question”

. The question of including hospitals was also raised. The choice of a

narrower scope prevailed. Coordinating the six signatories was already a significant challenge.

II

–

REAL BUT PARTIAL RESULTS, WITHOUT

EFFECTS ON BREACHES OF PUBLIC PEACE

Overall, a large part of the actions included in the plan were effectively implemented and

achieved results in relation to the goals of medico-social treatment for crack users. The budgetary

resources allocated to the plan by the French Government and the City of Paris have greatly exceeded

their initial commitments, particularly due to the very strong increase in actions in terms of

accommodation and shelter.

However, faced with the increase in the number of crack users and their concentration in a few

places in the public space, the means implemented have not sufficiently removed them from the streets

and thus reduce the public disturbances.

A - The majority of actions implemented and budgetary resources are

significantly higher than expected

In July 2021, five months before the expiry of the 2019-2021 plan, the implementation of 20 of

the 33 planned actions was completed or in the process of being completed; five actions were partially

implemented. For height actions, implementation had not yet started or was only in its early stages.

This overall observation must be qualified, since all the actions do not have the same scope. In

addition, not all of them lend themselves to monitoring their completion in the same way: only nine

included a quantified objectiv

e, a “deliverable” or an objective result. Of those, seven have been

completed.

Implementation status

11

of the crack plan (july 2021)

Source: Court of Accounts

11

Reading note: Focus 1 -

“Supporting users to reduce risks and harms and promote treatment pathways”; Focus

2 -

“Housing, shelter, creating rest areas and dedicated residential accommodation and treatment units in order

to allow people to get off the street”; Focus 3

-

“Intervening in the public space to meet users and meet the needs

of residents,

with a view to improving public peace and fighting against trafficking”; Focus 4

-

“Improving

knowledge”

13

Finally, a not insignificant part of the actions were already in progress before the adoption of

the plan, while others were new. Thus, 15 actions out of 33 had already started at the end of 2018 or

the beginning of 2019 before the signing of the protocol which, concerning them, came more to

establish a dynamic than to give impetus to them. In addition, among these actions started early, quite

logically are those extending existing actions. On the other hand, the new projects are behind schedule

and are far from being finalized.

Based on the information communicated by the various signatories of the plan, the total

budgetary expenditure made for its implementation from 2019 to 2021 can be estimated at a minimum

of €24.6 million, which can be broken down as follows:

O

verall breakdown of the expenditures identified in the plan (in €M)

Source: Court of Accounts

These sums correspond mainly to expenses relating to new actions and subsidies paid to

association operators. Expenses corresponding to extending or strengthening existing actions carried

out directly by the signatories could not always be quantified

12

.

12

This is particularly the case of Focus 3 to which the City of Paris has indicated it devotes substantial resources

but which it cannot quantify.

14

I

dentified expenses of the crack plan by funder (in €M)

Source: Court of Accounts

Note: Mildeca credits are executed by the regional prefecture

B - The uneven implementation of actions, from the first reception to

emergency accommodation

Over the life of the plan (2019-2021), actions devoted to accommodation (Focus 2) consumed

70% of the credits identified due to their considerable growth. In particular, their weight increased

significantly in 2021. Patrols (Focus 2) have consumed almost all of the remaining credits. In budgetary

terms, the other actions have a marginal weight, even if it is probable that the resources devoted to

Focus 3 are underestimated insofar as the related expenditures have not been distinguished within the

budget of the City of Paris departments concerned.

15

Breakdown of expenses incurred

Source: Court of Accounts

It appears that the signatories eventually incurred sums much greater in total than those provided

for when the plan was signed (€3 million per year).

The emphasis first of all on the first reception

More numerous, more coordinated, and “equipped” patrols

Ultimately, patrols represent around 30% of the budgetary resources allocated to the crack plan

over the period 2019-2021.

Their increase was at the heart of Focus 1

“Suppo

rting users to reduce risks and harms and

promote treatment pathways”

. The plan (actions No. 1 to 7) provided for increasing the number of

patrols and extending their time range. Focus 1 also included actions relating to the first reception,

namely rest areas and user monitoring.

Previously limited to weekdays, patrols now take place seven days a week, thanks to the creation

of three walking patrols on Saturday afternoon and three others on Sunday afternoon, supplemented

by three bus patrols and one on Sunday evening. A few weekly evening patrols have also been created.

The plan did not provide for night patrols, when noise is most noticeable and disturbing. Thus,

most of the patrols take place during the week (Monday-Friday) and during the day, particularly

because of the additional salary costs associated with interventions in the evening or on weekends.

16

The patrols in the metro, which existed before the plan, have been continued. New lines are now

covered. Their organization

“on an experimental basis”

13

was renewed by an agreement of 27 May

2019, separate from the crack plan, which binds the ARS and the City of Paris to the initial signatories

(RATP, PRIF, MILDECA, the Charonne, Nova Dona, Aurore, and Gaïa associations).

Finally, a so-called

“Mediation”

patrols for residents has been set up by the City of Paris to

collect and process their reports.

More numerous, these patrols also had to be multidisciplinary in order to integrate the significant

health issues of users, particularly mental health. Although the associations operating the patrols

indicate that they have recruited nurses and psychologists, such profiles are still too rare to allow

patrols in pairs, with a caregiver accompanying a social worker. Likewise the

“medico

-social,

psychiatric, and social

coordination around complex cases”

still remains to be developed.

The coordination of specific campaigns for crack users is ensured in particular through the

monitoring space piloted by MMPCR, in conjunction with ARS and MILDECA. The coordination of

other social patrols is carried out according to the previous modalities. The increase aimed at by the

plan was hardly prefigured by a few preparatory meetings.

Some of the patrols among crack users contribute to the risk and harm reduction strategy,

through th

e distribution of materials. The most common is the “crack kit”, consisting of a glass crack

pipe, a few tips and a spare filter. It avoids the use of unsafe DIY equipment, the sharing of crack pipes

between users and the associated infectious risks as well as degradation caused by manufacture of such

DIY equipment (tearing out electrical wires to make filters in particular).

The actions planned for the distribution of equipment have been implemented: the number of

automated machines distributing crack kits has increased from four to ten. These materials have

received a scientific evaluation carried out by the SAFE association with university research

laboratories, which has led to the improvement of the “crack kit” currently being tested with users.

The first reception structures have struggled to take off

The actions relating to the first reception sites are much less advanced than those relating to the

patrols.

13

Under the framework agreement of 9 November 2017.

17

Map of CAARUD, CSAPA, SCMR and rest areas in Paris

Source: MMPCR - City of Paris; updated 24 October 2019

The rest rooms

One of the innovations of the “crack plan” was the opening of rest rooms during the day to

accommodate wandering users. Of the six planned rest areas, only two have been opened: the sleep-

in, located near the Jardin d’Eole, with

15 places, which already served as overnight accommodation,

and the Porte de la Chapelle area with 26 places, built on land owned by the City of Paris. A third area

has been mentioned since the launch of the “crack plan” without any concrete follow

-up to date.

The lower risk consumption room

Although the lower risk consumption room (SCMR), near the Lariboisière hospital (10

th

), is now

open in the morning, it is intended to accommodate intravenous drug users. However, a small number

of crack users consume it by injection. INSERM

14

, in its assessment report drawn up in April 2021,

considers however that the demand for using such places for consumption by inhalation exists

15

. The

discussion that should be initiated on the opening of new spaces called

“Supervised consumption”

spaces is at a standstill, despite several meetings in 2019, due to disagreements in principle between

the stakeholders.

14

INSERM: National Institute of Health and Medical Research (Institut national de la santé et de la recherche

médicale)

15

The officials of the SCMR thus mention having encountered multiple cases of users who came to inject a

narcotic for their first visit only in order to be able to access the consumption room, or even pretending to use

the injection stations just to access the inhalation drug stations.

18

IT tools

Finally, one of the actions of Focus 1 of the plan concerned the creation of an IT system,

reinforcing the emphasis placed on knowledge of the field. The application developed by the

Metropolitan Mission for the Prevention of Risky Behaviours (MMPCR)

16

with the services of the

City of Paris, called GEOCODER, has not yet been rolled out. It is still in the testing phase. On the

other hand, another application, called MANO, developed by the Aurore association, is now active. It

is used during patrols and in reception areas. It makes it possible to follow users (who identify

themselves under the identity of their choice), their requests, and their needs. Association operators

emphasize its usefulness in their work. In addition, a mapping application is under development.

The great development of hotel accommodation under the effect of the pandemic

The development of accommodation was the priority of Focus 2 of the plan which provided for

the creation of an

“Integration path”

, after the first contact stage, thanks to accommodation and

support solutions aimed at getting vulnerable users off the street. The actions of Focus 2 present the

most variable degree of implementation.

Emergency accommodation and social reintegration

The plan called for the strengthening of two of the most important lodging arrangements,

ASSORE and PHASE. When the crack plan expired, they were to double capacity for ASSORE (from

60 to 120 places) and benefit from 11 new places for PHASE.

From April 2020, the pandemic rocked those projections and gave accommodation in hotel

rooms an unprecedented scale: to meet the shelter priority set by the government, a much higher

number of hotel rooms, up to 426 (accommodating 440 people), were mobilized for several months.

The vacancy of hotels during lockdown and the loss of tourist interest in Paris facilitated this expansion

of the ASSORE system, which has since been reduced somewhat but remained at a low level of 400

rooms in 2021.

The context of the pandemic in spring 2020 made it possible to go beyond what the plan

provided, enabling a fairly radical form of experimentation.

Thus, the restriction consisting of not concentrating users accommodated in the same hotels and

preventing them from constituting their exclusive clientele has been lifted by means of securing hotels

and increased mediation work. At the individual level, the Aurore association in cooperation with the

Partner CAARUDs

17

welcomed more difficult user profiles into ASSORE for whom the ability to stay

in fixed accommodation and comply with its rules was not guaranteed. After the periods of strict

lockdown, the considerable investment in accommodation and support for the ASSORE system

continued.

Concerning PHASE, five additional places compared to those listed in the plan were created,

resulting in 31 places. Likewise, six accommodation places intended for users undergoing court-

ordered treatment have existed since 2019, attached to an emergency accommodation centre managed

by the Charonne-Oppélia association, just like the 30 hotel accommodation places backed by

CAARUDs, which now target only female users. Finally, in July 2021, 26 additional places in

specialized accommodation units were opened out of the 68 provided for in the plan.

Accommodation with health support

On the other hand, places within other systems are still struggling to emerge, particularly health-

oriented systems. The call for projects for specialized accommodation units, which aspire to replicate

the 26 diffuse apartment places of the PHASE system, has been launched. The Aurore association was

16

MMPCR: Metropolitan Mission for the Prevention of Risky Behaviours.

17

CAARUD: Support and Reception Centre for Reducing Risks for Drug Users.

19

selected in November 2019. However, the search for locations has still not been successful. The

creation of places for LHSS (drop-in-health-care beds) and LAM (nursing home beds) is still in the

planning stage, as are the therapeutic coordination apartments. Finally, the exit of users from these

ad

hoc

lodging arrangements towards common law measures has not seen any appreciable improvement

due to the saturation of said lodging. In addition, for foreigners, moving to a social or medico-social

establishment may require bringing their residence status into compliance.

The degree of implementation of other actions is more difficult to assess

As noted above, the actions of Focuses 3 and 4 of the plan appear to be more peripheral in their

ambitions and less well-defined in their methods. Focus 3 is the one for which the degree of

implementation is the most difficult to determine, because it is the only one that does not include any

action associated with a quantified objective or an identified “deliverable”. We can see real progress

for actions carried out by a single pilot, but coordination is more formal than effective.

The physical appearance of public places

The two actions relating to cleaning and urban planning have been largely implemented by the

services of the City of Paris, which is vigilant on such issues: the Porte de la Chapelle and the Place

Stalingrad have thus been rearranged and benefited from urban equipment intended to prevent

disturbances and trafficking.

Training and awareness

The two actions of training stakeholders and informing local residents had a general wording so

that the City of Paris and certain associations were able to identify their own activities as emerging

from them

. Thus, the City of Paris indicates that it has organized sessions to present the “crack plan”

to its departments but also to RATP and SNCF agents, who also form the audience for training sessions

conducted by certain associations. These actions carried out in parallel highlight that coordination is

still insufficient. However, they show that different stakeholders were convinced by the need for this

awareness raising and wanted to get involved. On the other hand, the police, although in frequent

contact with users, did not ask to receive this training.

Coordination of stakeholders

The implementation of the other two actions of Focus 3 reveals shortcomings. Thus, in practice,

the

“Regular feedback”

on the dealing and trafficking points took place outside the governing bodies

of the “crack plan”. As for

“setting up monthly videoconferences”

aimed at improving operational

coordination and

“ensuring consistency between the different actions”

, the vague wording of this

action allows the City of Paris to consider that it refers to the role of the various committees responsible

for steering the plan.

Building a body of knowledge

Focus 4 of the plan concerned knowledge of the field through three actions corresponding to the

completion of a joint study by INSERM and OFDT

18

on the trafficking and consumption of crack in

Ile-de-France and the user pathways, maps of patrols and addiction studies structures. These

“deliverables” were produced and distributed: the maps were integrated into information leaflets and

the study was the subject of an easily accessible summary.

18

OFDT: French Observatory for Drugs and Drug Addiction.

20

C - The pathway approach often blocked by the lack of lodging

“downstream”

Crack user care pathway

Source: Court of Accounts

Shelter appears to be the prerequisite for all medical work. Thus, according to the Aurore

association, 70% of users accommodated have started health or social procedures in 2021, whereas

only 30 % were when the plan started in 2019. This support strategy is all the more essential given that

the public received is extremely vulnerable: 72% of users accommodated have spent more than a year

on the street and 20% have spent more than five years on the street.

In turn, the lodging arrangements have succeeded in stabilizing a large proportion of the users

received, including those with more difficult profiles than before. Once accommodated, a majority of

users undertake treatment programs and administrative and social procedures (establishing an address,

renewal of identity papers, reopening of rights, procedure for bringing immigration status into

compliance or return to the country of origin for people in the country unlawfully, etc.). They are more

likely to do so the longer they stay, which testifies to the effectiveness of the support. A small majority

of sheltered and supported users succeed in reducing their consumption of narcotics. On the whole,

the population crack users is thus better known both collectively and individually.

Insufficient “downstream” lodging capacities in view of the influx of new users

Since the start of 2020, the number of crack users in the public sphere has increased due to the

arrival of a new population. Added to this is a phenomenon of concentration linked to the successive

evacuations which gradually merged the different consumption places, grouped together in the Jardin

d’Éole and then, after the evacuation of the latter, around Place Stalingrad. The evacuation of Place

21

Stalingrad in May 2021 brought t

hem back to the Jardin d’Éole, then to its gates during its evacuation,

and then to the Square de la Porte de La Villette. Stabilized users have been replaced by new, more

numerous wandering users.

The “crack plan” had not been sized to absorb this influx.

Reception capacities were saturated.

Thus, for accommodation in ASSORE hotels, the plan provided for

“striving for a goal of three to ten

new treatments per week”

, which implied, given the initial objective of 120 places, an average stay of

between 12 and 40 weeks. However, the reports provided by the Aurore association indicate that, at

the end of April 2021, 85% of users had been accommodated for more than six months. To a large

extent, this stabilization of users in lodging reflects the lack of “downstream” solutions. From January

to October 2020, the ASSORE system recorded a hundred exits (positive, to other accommodation

solutions, or negative, such as returning to the street, incarceration, death, etc.) and a hundred others

between October 2020 and May 2021. Given this rate, we can estimate that on average, a user stays

accommodated for two and a half years before finding an outlet. As just under half of exits are positive,

the average length of stay before obtaining a “downstream” place can be estimat

ed at five years.

The same problem arises for the 26 places in apartments of the PHASE system, from which the

stabilized users cannot leave to go to social housing or medico-social accommodation under common

law, both saturated. The congestion of lodging solutions has upstream repercussions on the efficiency

of other systems, as lodging stands out as a key stabilizing factor.

Thus, the lack of “downstream” accommodation solutions compromised the implementation of

the pathway approach, which was supposed to keep crack users off the street for a long time.

D - The scarcity of human and land resources, two unanticipated

bottlenecks

The scarcity of land resources and human resources turned out to be the two main obstacles,

structurally limiting the creation of new places under medico-social care.

Crack users stay very close to where they can resupply and meet other users. Consumption in

common is frequently practised. However, the north-east of Paris is one of the densest urban areas in

Europe. The land holdings that can be devoted to a social purpose are very limited and almost

exclusively public. The rights-of-way necessary for the structures responsible for treatment of crack

users are in competition with all the other social needs (housing, emergency accommodation, etc.),

especially since these structures involve particular constraints, in particular in terms of acceptability

a

priori

by local residents. The rights-of-way relatively far from residents, such as the one

accommodating the rest area of the Porte de la Chapelle, under the ring road, are rare and present other

drawbacks (in this case, noise). For this reason, the public stakeholders favour their establishment

within existing structures to the extent possible.

All in all, the land shortage is the cause of most of the delays in implementing the actions under

Focus 2 of the plan. In his letter to the mayor of Paris, dated June 16, 2021, the Prime Minister notes

that

“operators are at an impasse due to the lack of available facilities. Thus, only 10 places

out of 26

in therapeutic apartments and 26 places out of 68 in specialized accommodation units are covered;

the 50 LAM and LHSS places planned are not installed; 3 rest rooms are lacking out of the 6 planned;

the CAARUD in the 18

th

is awaiting relocation”

.

In this regard, one of the major shortcomings of the plan was that it did not include a prior census

of the land that could be mobilized and that it did not provide for the rights-of-way intended for the

new medico-social support structures.

The second major obstacle, which has particularly affected the implementation of the actions of

Focus No. 1, lies in the shortage of human resources in the specific niche of treating crack users. There

are few associations able to deal with these issues. They report their recruitment difficulties,

particularly accentuated for the profiles of caregivers (nurses, addiction specialists, psychologists) but

also educators

and social workers. These difficulties constituted an obvious limit to the implementation

of the multidisciplinary approaches advocated by the plan. They were identified as such by the

22

signatories of the “crack plan” during its execution. We can regret that they were not anticipated during

its development.

All in all, the actions of the plan have succeeded in improving the social and health situation of

some of the crack users wandering in the public space. On the other hand, the actions did not make it

possible to appreciably change the perception of the residents of the districts concerned, who remained

perennially exposed to the continued breaches of public peace and safety.

III

–

THE URGENT NEED TO LEARN FROM A

SYSTEM THAT IS NOW OUTDATED

The audit conducted by the Court and the regional chamber of accounts tends to show that the

desire to more closely coordinate the interventions of the various stakeholders, which was the basis of

the plan, has gradually faltered. Admittedly, initially, the operational requirements imposed by the

pandemic in terms of assistance to the homeless led to an intensification of exchanges. Subsequently,

however, the meetings of the coordinating bodies became more spread out and less conclusive. The

articulation of the different support systems has revealed shortcomings. The initial momentum of the

plan has waned. Few new actions have been taken.

The implementation of medico-social actions was monitored, on a case-by-case basis, between

the pilot/funder and the association operator concerned. But this monitoring, all the more essential

since the plan had a strong experimental dimension, was not sufficiently ensured at the global level. It

did not focus enough on the consistency and proper articulation of the whole.

As a result, the convergence of professional cultures has withered away. The exchanges between

the stakeholders took place outside the framework prescribed by the plan while the protests from local

residents required new initiatives to be taken. The plan was found to be outdated.

A - Gradually weakened coordination after the intense mobilization at the

start of the pandemic (April-May 2020)

Essential coordination initially entrusted to governing bodies

The first virtue of the protocol signed in 2019 was to show the willingness of public and

association stakeholders, very diverse, with sometimes very distant professional cultures, to work

together and coordinate their interventions. The diagnosis made by the working groups set up by

MILDECA in 2018 insisted on this need to coordinate existing actions, as a condition for dealing with

subjects deemed inseparable.

The coordination of the stakeholders constitutes the object of some of the actions of the plan

(Action 30, for example) but it is above all the key condition for the success of the plan.

The governance of the plan, i.e. the pace and format of meetings between stakeholders, was

organized into three levels:

-

a strategic committee, chaired by the regional prefect, responsible for determining the main

orientations and priorities of the plan: it brings together the administrations, association

stakeholders and elected officials of the City of Paris and the districts concerned. After the start-

up phase, the strategic committee was to meet at least once a year;

-

an operational committee, chaired by the secretary general of the regional prefecture, prefect of

Paris, whose mission is to monitor the implementation of measures and remove blocking points.

The frequency of its meetings was to be monthly, at least during the start-up phase, then regularly

as needed;

23

-

finally, a technical committee bringing together the associations present in the field and some of

the administrations involved in the plan according to the appropriateness of the subjects discussed.

Its work was to focus on the concrete terms of cooperation and roll-out of measures. The frequency

of its meetings was to be monthly.

The coordination of all the stakeholders has been entrusted to the regional prefecture and, in

practice, to the secretary general, the Prefect of Paris.

Less frequent meetings of the coordinating bodies and especially less conclusive ones at the end

of the period

In reality, the governance of the plan quickly moved away from this announced arrangement:

the technical committee never met; the operational committees were numerous in the first weeks (three

between March and May 2019) but much less regular after that (one at the end of 2019 and two in

2020)

19

.

The signatories argue that numerous informal exchanges have been held, on the sidelines of the

bodies provided for by the plan, intended to deal with operational issues between state stakeholders in

particular. Those informal exchanges did not result in reports generated. In fact, it is clear that at the

start of the period, the meetings of the planning committees validated decisions taken jointly but also

that this decision-making dynamic no longer appears after spring 2020.

The impoverished role of the bodies, more than the number of their meetings, signals the eroding

coordination between stakeholders after the exceptional period of spring 2020. This point is

corroborated by the meeting minutes, which testify to less intense exchanges than at the beginning of

the plan’s implementation. They attest that meetings are increasingly taking the form of a round table,

with each stakeholder describing their actions and airing their own issues. In their responses to the

Court’s provisional report, the regional prefect and the police prefect disputed this running out of

steam. The City of Paris indicated that the reports do not fully reflect the reality of the exchanges.

However, they should have been an essential tool for tracing decisions and disseminating information

in the departments concerned and the association operators.

The subsequent contrast with the tight management of the plan during the heart of the

pandemic

The growing coordination deficit is evident in comparison with the exceptional period of the

pandemic at its peak, in spring 2020. Even though the institutional players were also very active, the

plan’s steering bodies were strongly and effectively

reinvested. In an

ad hoc

format, six meetings were

held between April 14 and May 26, 2020 as well as three operational updates, to organize and

coordinate actions intended for drug addicts. The reports reflect real management. The meetings of

this period are distinguished by their operational, conclusive nature. Sharing accurate, quantified

information supports strategic decision-making. The difficulties and obstacles are clearly identified

and lead to a collective search for solutions, accompanied by firm, concrete commitments from the

parties. The

contacts and cooperation that already existed between stakeholders in the “crack plan”

facilitated the rapid, massive response provided through the exceptional extension of hotel

accommodation and social support managed by the Aurore association. The priority attention paid to

the most vulnerable people made it easier to finance their lodging. But coordination has not been

maintained at this level, or even restored to the level initially planned, after spring 2020.

19

It should be noted that five meetings have been held since 24 September 2021, at the initiative of the Prefect

of the Ile-de-France region, i.e. after the closure of this investigation.

24

Shortcomings appearing in the articulation of the different systems

In practice, the pathway approach that underlies the overall logic of the plan has been applied

with some difficulty in individual cases. Thus, court-ordered drug treatment, which consists of medical

follow-up by psychologists and possibly psychiatrists, is not necessarily accompanied by a lodging

solution whereas it is nevertheless a key factor in continuity of care.

In addition, delays in setting up the various stages of the pathway disrupt its flow and can give

the impression of its ineffectiveness due to the continuation or resumption of disturbances caused by

users left or returned to the public space.

At the start of the plan’s implementation, priority was given to patrols, which initially had

scarcely any orientation solutions to offer due to already being unable to complete the rest of the

pathway. The disconnect between the actions is evident particularly for the Porte de la Chapelle rest

area: intended for users from “Crack Hill”, it opened just after the latter’s evacuatio

n and therefore

struggled to find its audience.

B -

The waning of the plan’s initial momentum

The decline in the implementation of new actions

The weakening of coordination appears to be correlated with the waning of the dynamics of

carrying out actions, both temporally and functionally. Actions depending on a single actor or on

operators of the same nature are also more advanced than those involving the cooperation of several

of them.

The pace of implementation experienced an initial decline in the second half of 2019. After the

intense mobilization in spring 2020, the only achievement concerns the extension of the 400 hotel

accommodation places of the ASSORE system. On the other hand, the implementation of new actions

has run out of steam. Likewise, the state of play and the decisions taken differ little between two

meetings, which are even more spaced apart. While the operational committee of November 2020 had

decided to create three working groups (preparing a communication document, acceptability with

regard to residents, managing the occupation of public roadway), none emerged in the spring.

However, the decisions of the committee meeting on 10 May 2021 were limited to creating two other

working groups: the first one, dedicated to the theme of public space brought together stakeholders,

including residents, under the leadership of the regional prefecture, linked with the City of Paris and

the ARS; the second one, devoted to the treatment pathway for crack users was run by ARS in

conjunction with the regional prefecture and the City of Paris. These working groups met in June 2021,

possibly hinting at a revival of momentum at the end of the plan, as evidenced by the opening of new

UHS places in July 2021.

The failure to update plan that was designed to be scalable

As originally conceived, the implementation of the plan involved periodic updating or review.

Indeed, the timeline associated with each action did not generally run beyond 2019. The few measures

scheduled for 2020 or 2021 related to monitoring or evaluation. This requirement was recalled from

the operational committee meeting of 15 March 2019 by the director of the ARS:

“by virtue of its

innovative nature, this policy should be continuously and transparently evaluated, especially since it

relies on a

multitude of stakeholders”.

However, the actions included in the plan in May 2019 and not

initiated in 2020 and 2021 have not been relaunched or even reviewed. The unanticipated blocking

factors were not analysed further. No update has yet taken place, while the pandemic has led to a

profound change in the plan’s priorities.

25

C - Failure to monitor the execution of the plan, causing the loss of a

shared vision

Monitoring indicators adapted to an experimental plan

The “crack plan” had an innovative, experime

ntal dimension. One of its contributions was to

assess the effectiveness of the measures selected, to identify those which yielded the best results, to

draw lessons from them about the conditions of their implementation.

For each of the planned actions, the plan defines one or more indicators, often quantitative but

generally descriptive and not prescriptive: few quantified objectives have been set. At its conclusion,

this choice was justified and demanded by the signatories because of their relative ignorance at the

time of the number and characteristics of crack users, hence the focus devoted to a better knowledge

of their profiles and uses. This option seems consistent and adequate: management by indicators

presents many known and documented biases and does not lend itself to the experimental ambition of

a plan including a strong qualitative dimension.

However, monitoring the implementation of the plan and its evaluation were essential to the

approach adopted. Yet, the investment of the various stakeholders in the plan in monitoring its

implementation appears to clearly lag behind their commitment to its development, and then its

operational implementation.

Indicators informed but not followed at the global level

The plan included an inventory of the resources that could be mobilized, particularly in terms

of accommodation, but the initial level of the indicators chosen was not entered and presented within

the governing bodies, which then complicated the measurement of its effectiveness.

Above all, the monitoring of these indicators took place separately: they were entered by the

operators in the field and discussed device by device with the funder(s), but that monitoring is

fragmented, not consolidated, and does not lead to an overall vision of the plan’s ex

ecution that was

intended to be integrated.

While the protocol provided for

“a follow

-up of the implementation and an evaluation every

year”

, no item on the agenda of the various bodies was devoted to it. Here again, only the meetings

imposed by the context of the pandemic led to the reporting and monitoring of figures, mainly on hotel

accommodation (ASSORE).

The examination of interim reports were on the agenda of the meetings of the operational

committee on 28 November 2020 and of the steering committee on 10 May 2021. During the first

meeting, some of the signatories presented some figures but no review of the indicators took place. In

the second meeting, the examination turned out to be even more brief, reduced to the expression by

each signatory of their impressions with regard to the actions concerning them. No materials or papers

were produced or discussed during these two meetings.

A survey of the plan’s indicators was undertaken in October 2020 but only the City of Paris, in

conjunction with ARS, provided information on the document for the actions under its responsibility.

This statement has never been mentioned within the governing bodies.

In financial terms, it is difficult to monitor the credits allocated to the “crack plan” and above

all to distinguish them from the monies already committed previously, no specific monitoring of the

consumption of credits allocated to the plan having been carried out. Failure to follow up prevents

ex

post

drawing lessons from the achievements and interpreting their results.

A common culture that has faded

In the absence of an objective basis for discussion, disagreements arose concerning the degree

of implementation of some actions. Their managers identified them as largely achieved while the

26

operating associations considered them barely started. This gap calls into question the shared

understanding of the plan’s implementation.

Beyond that, the prospect of a common vision has receded, while the approach underlying the

plan aimed to bring together players with different, even divergent, professional cultures. Several

stakeholders shared with the Court their feeling that the issues for which they are responsible are

insufficiently considered by the other stakeholders or that the expectation of their actions exceeds their

capacity to act.

In addition, the Court noted discordant visions relating not only to users and their problems but

also to the actions taken against them and their perception by the other stakeholders in the plan. The

police headquarters, for example, considers that the action of the police is felt by the associations as

upsetting their relationship with users, while the associations express a much more nuanced

assessment, or even praise the police work and the good field communication. However, the police

headquarters considers cooperation with associations to be essential to the success of police missions:

the objectives of the parties are in agreement but not common and shared.

The vision that the various stakeholders have of the crack user public is necessarily incomplete:

for example, the police headquarters mainly deal with users on the street and find themselves having

little contact with stabilized users who generate much less disturbance. Consequently, it perceives the

chances of success of medico-social care less clearly than the associations managing support systems.

Regular feedback on the implementation of the various actions and their impact would undoubtedly

have made it possible to ensure better understanding of the action of each of the parties, and thus

develop a shared culture and vision.

This lack of a common base can go so far as to hamper the effectiveness of the actions. Thus,

according to the minutes of the operational committee meeting on 8 January 2020, the police

headquarters concluded that the rest area at the Porte de la Chapelle had a positive outcome, based on

its lack of attendance, which completely contradicts the objective assigned to this system, clearly

reflected in the indicators selected. However, since those were not recalled, the contradiction was

evaded and the failure to share objectives by all the signatories set in.

In the absence of a global vision, the activities of the stakeholders can come to be thwarted.

Thus, arrests of crack users generally give rise, in accordance with the directives of the Paris

prosecutor’s office (despite being a signatory to the plan, like the police headquarters), to the

destruction of crack pipes which are found by the police on the people arrested. However, these are

often part of the lower risk inhalation equipment distributed by the CAARUDs or the SAFE association

and financed by the ARS, the City of Paris and MILDECA.

An assessment that is still fragmented

The same applies to the evaluation of the plan, which constitutes the logical outcome of the

comprehensive, experimental approach adopted. Although mentioned in the protocol itself, the

evaluation has not yet been defined in its terms. The signatories agree on the need for an evaluation, a

report or at least some feedback but none of them has yet prefigured the exercise.

Reviews of specific arrangements, particularly the most important in terms of funding, have

been drawn up by the managing associations (in particular on accommodation in ASSORE hotels,

PHASE therapeutic apartments and patrols) as part of their obligations towards funders. The City of

Paris also commissioned an independent expert to assess the method of hotel accommodation during

the pandemic, who concluded that the result is positive overall, subject to sufficient support for users

and hoteliers.

However, no evaluation of the plan as a whole, with a view to the pathway, gathering the voices

of all the stakeholders, has been planned to date.

27

D -

Going beyond the “crack plan” by other bodies and initiatives

Due to its relative loss of interest over time, especially over the past year, the framework set by

the plan has seen competition for legitimacy and is no longer necessarily recognized as the right level

of treatment for the crack problem. There is a movement to go further, and the emergence of competing

bodies.

More distant stakeholders

The withdrawal of certain players into their strict field of competence and their withdrawal from

certain projects carried out under the crack plan reflects this circumvention. Thus, the police

headquarters did not wish to see its logo appear on the “Crack on Seine” study provided for in Action

31, and justified its refusal by the fact that

“[The] report [is] centred on a social, sociological and

medical study of the user population, an object which is very far from its field of competence. It is

neither a disengagement nor a disavowal, but the effect of an administrative reasoning”

.

Competition from other decision-making bodies and circuits

Other bodies take precedence over those put in place around the crack plan. The Paris

prosecutor’s office and the police headquarters usually refer to the “crack” Local Crime Treatment

Group (GLTD)

20

than the plan’s operational committees and steering committees. The associations

responsible for implementing the plan also have their own coordination and governance bodies,

particularly via the monitoring space set up by the City of Paris, which brings together all the

CAARUDs and ARS.

The result is obvious concerning the procedure followed during the evacuations: initially

discussed in the preliminary operational committee, in the presence of institutional and association

stakeholders, since September 2020 they have been discussed only between the police headquarters,

the regional prefecture and the Paris city hall, as the police headquarters confirmed to the Court. The

associations and the City of Paris lament this, considering that this organizational work was useful

because it allowed them to anticipate the reception and treatment of some of the evacuated users. The

City of Paris considers, moreover, that it would be advisable to

“clarify the comitology”

of the crack

plan and in particular, in addition to

“the regular programming of the bodies”

,

“the level of

representation expected for each body”

.

T

he “crack plan” now overwhelmed by citizen initiatives

The questioning around the efficacy and even the effectiveness of the plan motivated the

creation of a citizen observatory for drug addiction in February 2021 at the initiative of the mayor of

the 19

th

arrondissement in order to

“assess and guide the actions undertaken or to be initiated”

in view

of

“citizen expertise”

. This observatory, led by Jean-Pierre Couteron, psychologist within the

association Oppélia-Charonne, brings together members of local re

sidents’ associations as well as

citizens drawn by lot. He leads working groups which have heard from various stakeholders in the

plan. However, neither the feedback nor even the existence of this observatory was discussed in the

governing bodies. They were also not mentioned during the interviews conducted by the Court. It is

not neutral, moreover, that the residents were not represented in the bodies of the plan.

A new non-institutional body, involving citizens, has been set up. It could lead to the emergence

of other competing initiatives. To counter this risk, the City of Paris announced its intention in June

2021 to extend a citizen monitoring committee.

20

The members of the “crack” GLTD are: the Paris prosecutor’s office, the City of Paris, the RATP, SNCF, the

Department for local security in the Paris area (DSPAP), the Regional Department of the judicial police (DRTJ)

of the Paris police headquarters, ARS IDF, and MILDECA.

28

The off-plan resumption by the signatories themselves

The protocol concluded in 2019 is also overwhelmed by the antagonistic public positions of its

signatories or by their initiatives taken outside its framework. Thus, the City of Paris withdrew from

the specific dialogue of the “crack plan” to directly contact the Prime Minister and request a revival o

f

public action with the support of the government. This initiative led to the inclusion of a provision in

the social security financing bill (PLFSS) for 2022 relating to the creation of “addiction treatment

stopovers”.

In response to the Court’s provision

al report, the mayor of Paris indicated that this provision

incorporates her proposal

“to get out of a compartmentalized logic between the various outpatient first

reception systems (...) and to integrate supervised consumption into a comprehensive approach to the

stabilization and reintegration process for crack users”

. This statement resonates as the implicit

recognition of the failure, however partial, of the “crack plan” insofar as giving priority to a

comprehensive approach to the treatment process over the compartmentalized logic was one of its

major objectives.

For the City of Paris, it is now a question of developing a

“network of small units open day and

night, combining temporary accommodation, care and supervised consumption”

. In September, in

accordance with this orientation, after having appraised 35 places during the summer, the City of Paris

proposed four sites with a view to opening new integrated spaces for the treatment of crack users.

29

LIST OF ABBREVIATIONS

ACT:

Therapeutic Coordination Apartment (Appartement de coordination thérapeutique)

AHI:

Home Accommodation Integration

ARS:

Regional Health Agency (Agence régionale de santé)

CAARUD

:

Support and Reception Centre for Reducing Risks for Drug Users (Centre d’Accueil

d’Accompagnement

à la Réduction des risques pour Usagers de Drogues)

CSAPA

:

Addiction Treatment, Support, and Prevention Centre (Centre de soin, d’accompagnement et

de prévention en addictology)

DGS:

General Directorate of Care (Direction générale des soins)

DIHAL:

Interministerial Delegation for Accommodation and Access to Housing (Délégation

interministérielle à l’hébergement et à l’accès au logement)

DRIHL:

Regional and Interdepartmental Directorate for Accommodation and Housing (Direction

régionale et interdéparte

mentale à l’hébergement et au logement)

ELSA

:

Addiction Studies Liaison and Treatment Team (Équipe de Liaison et de Soins en

Addictologie)

EMPP

:

Mobile Psychiatry and Vulnerability Team (Équipe Mobile Psychiatrie Précarité)

ESMS PDS:

Medico-Social Establishments and Services Welcoming People Facing Specific Difficulties

(Établissements et Services Médico-Sociaux accueillant des Personnes confrontées à des

Personnes en Difficultés Spécifiques)

FTE:

Full-time equivalent

GLTD

:

Local Crime Treatment Group (Groupe Local de Traitement de la Délinquance)

ILS

:

Narcotics Law Violation

INSERM:

National Institute of Health and Medical Research (Institut national de la santé et de la

recherche médicale)

LAM

:

Nursing Home Beds

LHSS

:

Health Care Stopover Beds

MILDECA:

Interministerial Mission for the Fight against Drugs and Addictive Behaviour (Mission

interministérielle de lutte contre les drogues et les conduites addictives)

MMPCR

:

Metropolitan Mission for the Prevention of Risky Behaviours (Mission Métropolitaine de

Prévention des Conduites à Risques)

OFDT

:

French Observatory for Drugs and Drug Addiction (Observatoire Français des Drogues et des

Toxicomanies)

PASS

:

Permanent Access to Health Care

PHRH

:

Accommodation and Hotel Reservation Department of Samusocial de Paris (Pôle

Hébergement et Réservation Hôtelière du Samusocial de Paris)

PP:

Police headquarters (Préfecture de police)

PRIF:

Prefecture of the Ile-de-France region (Préfecture de la région Ile-de-France)

RDRD

:

Risk and Harm Reduction

SAIP

:

Population Information Alert System (Système d’Alerte d’Information aux Populations)

SCMR

:

Lower Risk Consumption Room (Salle de Consommation à Moindre Risque)

SIAO

:

Integrated Reception and Orientation Service (Service Intégré de l’Accueil et de l’Ori

entation)

TAPAJ

:

Alternative Work Paid by the Day

UASA

:

Homeless Assistance Unit (Unité d’Assistance aux Sans Abris)

UHS

:

Specialized Accommodation Unit (Unité d’Hébergement Spécialisé)

30

Appendix No. 1: The 33 actions of the crack plan

Focus 1 - Supporting users to reduce risks and harms and promote treatment pathways

1.1.

Increasing medico-social patrols

for risk reduction (Action 1) and underground (Action 3),

and create two new types of patrols: a specialized patrol on local mediation with residents, traders

and users of public spaces (Action 2) and interdisciplinary psychiatric and social patrols (Action

5). Coordination with social patrols must be strengthened (Action 4) and medico-psycho-social

interventions must promote the monitoring of complex cases, particularly dual diagnoses (Action

6). An IT system making it possible to put in place methods of assessing the situation of people,

their monitoring, and their pathways must be developed (Action 7).

1.2.

Improving access to risk and harm reduction materials

by

strengthening existing actions in

terms of access to user equipment (Actions 8 and 9) and a qualitative assessment of the crack kit

(Action 10).

1.3.

Strengthening the first reception systems

(

CAARUD, CSAPA, lower risk consumption room)

by expanding the opening hours of structures, morning and evening) (Action 11), by opening six

rest areas during the day and/or night (Action 12) and by thinking about new supervised

consumption areas in line with the development of the national specifications relating to the

experimentation of lower risk consumption rooms (Action 13).

Focus 2 - Host, shelter, create rest areas and dedicated residential accommodation and treatment

units to

make it possible to get off the street

2.1

Increasing the number of people followed and sheltered

as part of the ASSORE scheme

(Action 14).

2.2

Strengthening accommodation

through two existing systems, PHASE, (Action 15) and

specialized accommodation units (Action 16), improving access to day care centres and common

law accommodation centres (Action 18) and creating six additional accommodation places

dedicated to users of illicit psychoactive substances subject to court-ordered treatment (Action 17).

2.3

Strengthening residential treatment

thanks to the creation of accommodation places backed

by CAARUDs (Action 19) and places for health care stopover beds (LHSS) and nursing home beds

(LAM) (Action 20), and the development of bridges between risk and harm reduction arrangements

(RDRD) and “therapeutic coordination apartments

- a home first

” (Action 21).

2.4

Accessing the integration schemes

with the setting up of an experimental insertion scheme

such as “TAPAJ adults” (Action 22).

2.5

Setting up a support system for persons under court order

: therapeutic injunction measures

(Action 23); experimental scheme to fight against recidivism intended for people with addictive

behaviours (Action 24).

31

Focus 3 - Intervening in the public space to meet users and meet the needs of residents in order

to improve public peace:

strengthening vigilance by regularly reporting information (Action 25);

strengthening of information and training actions for local stakeholders (Action 26) and residents

(Action 27); strengthening of cleaning and urban development (Actions 28 and 29); improvement of

operational coordination by setting up monthly videoconferences (Action 30).

Focus 4 - Improving knowledge

: conducting the “Crack on Seine” study on uses, user profiles and

their needs (Action 31); drawing up a map of medico-social and health structures and patrols (Actions

32 and 33).

32

Appendix No. 2: Medico-social support

Medico-social support is presented as a form of user pathway towards reintegration and weaning

off of crack. This pathway is not always linear: many users need several round trips before definitively

taking a step and stabilizing.

The entry point is made with the patrols and more generally the various schemes which fall

under the “to” direction. The

patrols

take place in pairs, usually made up of a social worker and a

nurse. They make it possible to get in touch with users or to maintain a link established previously, to

assess their requests, to identify their needs and to direct them towards structures capable of responding

to them. They can also distribute harm reduction materials or provide some basic care (including

treating wounds related to crack pipe burns or violence in street life).

Contact can also be established during the first reception organized in the

rest areas

which offer

a stopover during the day and offer beds, showers, a washing machine and some activities.

The

lower

risk consumption room (SCMR)

allows consumption off the street, in safety, with safe equipment

and under supervision. users present the narcotic product and then consume it in individual stalls. In

both types of structures, social workers welcome and guide users.

Treatment for crack addiction is carried out on an outpatient basis in

CAARUDs

(Support and

Reception Centre for Reducing Risks for Drug Users) and the

CSAPA

(addiction treatment, support,

and prevention centre). The first are receptions making it possible to dispense risk reduction material,

to meet basic needs (access to hygiene, basic care, social contacts) and to guide the user toward the

rest of the pathway. The second ones involve engaging in a process of treatment and/or management

of their consumption. They bring together multidisciplinary teams to assess the medical situation of

users and to treat or prevent addictive behaviour. They generally operate by appointment.

Accommodation in a hotel room, as within the

ASSORE

system, or in a therapeutic

coordination apartment, as in the shared apartments of the

PHASE

system, are aimed at users with

significant health problems. These structures are said to be “low threshold” because no conditions are

required to enter them. Accommodation is considered a prerequisite that facilitates engagement in a

process of treatment, reintegration, reduced consumption. It is accompanied by significant monitoring

of users (psychological monitoring and reintegration activities in particular) aimed at facilitating their

access to treatment, helping them to recover their rights (identity papers, establishing an address,

CMU, RSA, etc.) or to prepare a plan for the return to the country of origin for people in France

illegally. These structures work in conjunction with the CAARUDs and CSAPAs.

Once the user has stabilized, they can move on to other, more engaging, accommodation systems

such as social or medico-social accommodation under common law, or returning to their family.

Users with degraded health can benefit from more intensive treatment accommodation in the

form of temporary accommodation in

Health care stopover beds (LHSS)

, for those whose health

condition does not justify hospitalization but is not compatible with a life on the street, or a long-term

reception in

nursing home beds (LAM)

, for those suffering from serious and chronic pathologies,

handicaps, or presenting a vital prognosis engaged in the medium term.

33

Appendix No. 3: The frequency of meetings of the

governing bodies of the plan

Source: Court of Auditors according to reports communicated by the regional prefecture