By CEANDRA FARIA
When Eric Legoudail* travelled from London to Marseille to clean out his mother’s rental apartment, he found enough unused prescription medications to fill three rubbish bags.
“There were as many full unopened boxes as half used ones and we threw it all out. I think my mother didn’t have the reflex to say I have enough,” Mr Legoudail says.
“It was mostly boxes of high dose pain relief medication – Doliprane, aspirin and ibuprofen.”
Mr Legoudail now lives in Paris. He has allergies and asthma. A visit to the GP costs him €23 (A$35) but is effectively free as the state reimburses €16 (AUD $24) and his mutuelle reimburses €7(AUD $11). Most people in France have mutuelle which is compulsory semi-private insurance paid in part by employers.
He leaves each visit with a prescription for enough repeats of emergency Ventolin, medicated skin cream, anti-allergen and Dolipran (paracetamol) to last three months. Medication for treatment of a condition is 100 per cent reimbursed by the public health system called Securite Sociale. So Mr Legoudail pays nothing.
The green cross is never far, a pharmacy can be found almost every 200m in Paris All pictures: Ceandra Faria
The French consume prescription medication at a rate 22 per cent higher than neighbouring European countries, according to the European Observatory on Health Systems and Policies.
It costs Securite Sociale €22.6 billion a year.
French doctors say it's not reasonable to just point a finger at doctors and accuse them of over-prescribing.
“The pharmaceutical companies sell boxes of medication for 15 days, three weeks, a month. The patient only needs a dose for five days but I still have to prescribe the box,” Paris GP Dr Jean-Louis Busch says.
He says patients profit from a system that helps too much.
“Everything is free, so people consume more. The mentality is, ‘I have two boxes of this medication at home, if I get a third I don’t mind, it’s free. I pay my tax, I have the right’. It’s completely ridiculous,” he says.
France’s universal health system was ranked the best in the world by The World Health Organisation in its ambitious 2000 study of the world’s health systems. In 2013, France spent 12 per cent of its GDP on health care, the highest in Europe after the Netherlands at 13 per cent, according to OECD data.
France also has the fifth highest life expectancy among OECD countries, just ahead of Australia at six.
For French-born Perth resident Karine Passal, the French system trumps the Australian system on quality of care, cost and access to specialists.
“In Australia I always rush doctors’ appointments so they don’t charge me for a long one …I hate it. In France it doesn’t matter how long appointments last for and how many questions you want to ask, it will be the same fee,” Ms Passal says.
“Most French people I know have large amounts of stored medications. Anti-depressants and sleeping pill consumption seems higher in France. People tend to be overmedicated, they see their doctors for small concerns even if they don’t really need to.”
From November 2017, there will be no upfront fees for patients seeing their GPs, instead the state and the mutuelle companies will pay doctors direct. Health practitioners went on strike against the law on November 12, 2015.
They fear it will double the number of patients they see each day who are not really ill and ultimately add to the public cost of health care.
In 2011, France was in the spotlight for allowing a dangerous diabetes drug called Mediator, widely misprescribed as an appetite suppressant, to stay on the market years after other EU states took it off the shelves.
Health authorities placed the death toll related to the drug at 500 but researchers estimated there were 3100 hospitalisations and 1300 deaths.
More than 80 million boxes were sold from 1999-2009, at a cost of €423m (A$654m) to security sociale.
The national health regulatory agency at the time, AFSSAPS and additional reform included the creation of the Transparence Sante website, live since June 2014. Citizens can search for and view any and all of the gifts and contracts exchanged between pharmaceutical companies and their health practitioners above the value of €10.
In March 2015, after two years of collating data, Regards Citoyen published findings of €245 million (A$379 million) in gifts and contracts given to 495,951 health professionals by 894 pharmaceutical companies between January 2012 to June 2014.
Regards Citoyen documented 2,527,854 gifts (meals, accommodation, donations, transport, presents).
French firm Servier, producer of the Mediator drug, ranked second.
A Health Action International report found that the more a prescriber is in contact with the pharmaceutical industry, the more likely they will add a drug to the their prescribing practice – even if the drug has little or no therapeutic advantage over the drug already available.
Another issue for overprescription is the environmental impact.
Pharmaceutical compounds, especially antibiotics, are increasingly present in the environment and carry significant risks for public health.
EU medicinal legislation has required take-back schemes for unused and expired human medicinal products since 2004, where they are incinerated safety, and used to provide energy for households.
In reality, lack of public awareness that these schemes exist and how to participate in them limits their effectiveness. Even so, in 2015 the medications disposed of by Cyclamed, the company responsible, totalled 12,108 tonnes.
According to a European Union report, there is an undeniable link between the increasing amount of antibacterial medicinal products (antibiotics, anti-cancer) found in wastewater and sewage sludge, and increasing human resistance to antimicrobial medicinal products.
"Antimicrobial resistance is a major European and global societal problem," according to the report by the BIO Intelligence Service prepared for the Executive Agency for Health and Consumers.
The French National Agency for medicines and health product safety issued a national alert, calling for a reduction in the consumption of antibiotics.
France's ageing population is another issue. Twenty-four per cent of the French population in 2013 were above the age of 60, compared to 20 per cent in Australia, according to WHO statistics.
Pharmacist Nicholas Bichon says an aging population contributes to high consumption of medication.
“People are still in their homes at 80, where before you retired and went to an old age home at 60. Doctors rarely do home visits now, so it is easier to write a prescription for three months of medication so the elderly patient does not need to return,” Mr Bichon says.
Christiane Devaud* is 77 and lives alone in a small town in the south of France. She has survived cancer and suffers from severe arthritis, osteoporosis and high blood pressure.
Her medication fills four drawers and besides her daily treatment she self-medicates as required. Often she needs to take tablets prescribed by the doctor to sleep. When the pain is particularly bad, she takes Dolipran 1000mg of which she currently has 26 boxes.
“I’ve paid my tax all my life. I know that people say the old are costing too much but Securite Social could save a lot of money if it was better organised,” Ms Devaud says.
Ms Devaud at her home in the Du Gard region. Most of the boxes in her store of unopened pain relief medication have a 2017 expiry date.
According to a government report on Sales Analysis of drugs in France in 2013, Dolipran dominates the top ranking with sales of more than 500 million boxes. The report also shows that the average French person consumes 48 boxes of medication per year. This does not take into account the number of boses issued when only a fraction of their contents are needed.
“In the UK doctors prescribe meds and calculate the number of pills needed based on the duration and quantity per day. Pharmacists give the patients the exact amount. Doctors have more pressure on them to cost save,” says Elaine Baird*, a Scottish marketing executive living in Paris.
Academic Benjamin Besse says more efficient packaging would help avoid unnecessary consumption, would cost less, prevent generation of unused medicines and reduce the environmental impact.
However, the costs to pharmaceutical companies associated with this option make it unlikely to transpire without immense political and public pressure.
*name changed by request