I recently learned of a supervised home detoxification protocol being implemented in France by two nurses, Miss Laurence Tisserand and Mister Francois David. The intervention, managed by Miss Tisserand and Mr. David, actually began in 1999. According to these nurses, it shows exceptional promise as a method of decreasing costs and improving care. These nurses are recognizing the need to further study these benefits in a more rigorous way by designing a comparison study to examine outcomes such as costs, efficacy, safety, and acceptability of this type of approach compared with usual care. It was a pleasure for me to learn of this approach being used in France and to be able to interview Laurence Tisserand. Her interview provides us with a glimpse of how nurses are addressing addictions in France and are taking the lead in addressing patient needs in alternative settings.

Can you tell us about yourself and your work in addictions nursing?

I have been a registered nurse for 26 years and began my career in addictions nursing 20 years ago. Initially, I worked between 1989 and 1994 in the Department of Vascular Neurology. I worked in the alcohol detoxification unit and the methadone delivery unit from 1994 to 1999. I currently work at CHRU-Le-Paris hospital in an outpatient addiction treatment center, which in France is called a CSAPA, which means "center for preventing, treating and accompanying addiction disorders."

Since 1999, with the help of a few physicians, notably Dr. Thierry Danel, I have been progressively implementing an outpatient nurse-based alcohol detoxification pioneer system, named PASBA ("Programme Ambulatoire de Sevrage en Boissons Alcoolisees"). This is an innovative approach in that it allows the advanced nurse, defined by the regional health agency, to entirely manage the detoxification process. The advanced nurse can autonomously adjust benzodiazepine doses according to the Cushman scale. The physician is alerted only if any complication occurs. In a sense, it is similar to the role of the midwife in our country during delivery. The midwife is largely autonomous and can adjust medications if everything is under control, but physicians may be called on in case of a problem.

Before we discuss your role in more depth, can you describe alcohol use in France? What is the extent of the problem? Who is most affected?

Drinking alcohol is inseparably ingrained in the French culture. Many families drink wine with meals, but in the northern part of France, there is no wine. The local beverage is more often beer. Anyway, there is an important social exposure to alcohol for young people, and early exposure is widely known to be a vulnerability factor in developing a subsequent alcohol use disorder. Paradoxically, there are some good points about how the French have historically consumed alcohol. Because experimentation of alcohol occurs around parents, there is, at least in some families, an education of sorts that is provided by adults on how to drink.

Now, however, we are observing a real change in current practices. The habits tend to progressively look like what they are in Anglo-Saxon countries. The experimentation of alcohol use during adolescence occurs more frequently within groups of teenagers, with no adult in the vicinity. Binge drinking is spreading among young people. Alcohol drinking is viewed less as a pleasant addition to food and more as a way of becoming stoned. These new drinking profiles increase risks for developing earlier alcohol dependence and for using other drugs of abuse. Moreover, there are also increased risks for complications such as cirrhosis. There are many unknowns about how this national evolution is going to impact alcohol-related health problems.

Can you tell us more about your advanced nursing role in your current position?

In France, there is no specific advanced nursing education as you have in the United States. Advanced practice roles are allowed only on an individual basis, under the expressed permission of the regional health agencies. Such permissions are based on written protocols and are to be renewed every year. Within the PASBA, advanced nursing practice consists of adjusting the detoxification treatment, notably the benzodiazepine doses, according to the immediate medical condition of the patient. Everything is strictly performed according to the protocol. Patients are evaluated on a daily basis, with the help of the Cushman scale, a validated tool for scoring alcohol withdrawal symptoms. According to the Cushman score and some other clinical measures, we can adjust benzodiazepine doses in a predefined way, on the basis of the national guidelines. In case of any complication, there is always a physician available who can evaluate the patient quickly and, if needed, can refer to a hospital.

Initially, I performed the entire follow-up of every patient. Quickly, however, we became victims of our own success. Currently, there are two advanced nurses, my colleague Francois and myself. We see approximately 250 patients per year. It has become impossible to manage all aspects and to monitor the patients entirely on our own. Consequently, although the advanced nurse must still meet every patient before the PASBA can begin, private practice nurses now help us with clinical reexaminations directly at a patient's home throughout the detox process. They join us by telephone, so that we may calculate the Cushman score and adjust the treatment dose with them. We still meet the patient face-to-face at several points of the detoxification process. The treatment is prescribed by the general practitioner (GP). In difficult cases, the advanced nurse, the home nurse, the GP, and the addiction specialist meet together to discuss the situation. When the PASBA is completed, we continue to organize multidisciplinary meetings, consisting of those who have cared for the patient and have been involved in the process.

Can you describe your career path? What has prepared you to function in this capacity?

I have been driven by my personal curiosity and by my wish to escape from being a mere executor. Maybe, I was helped by the fact that several physicians have trusted in my skills, my motivation, and my clinical experience.

Initially, I was not prepared to do this work, but it was a real combination of circumstances that led to it. Ten years ago, we experienced a significant decline in medical personnel at a time when there was a dramatic need for detoxification among patients. Dr. Danel proposed the idea of setting up a detox protocol in which I could work with him. This finally became the PASBA.

Has this role been embraced by nurses and other health providers in France?

Now, I am not alone anymore. My colleague Francois has joined me in the adventure. Moreover, within my institution and among my close collaborators, my role is perfectly understood and recognized. However, when we meet other nurse teams, there are often two opposing reactions; some teams are very enthusiastic and give their whole support to our work, whereas others are quite sceptical and think we go far beyond our appropriate scope and competences. Concerning physicians, advanced nursing practice induces some very ambivalent reactions in France. On one hand, many physicians understand that things are changing and that it may be both interesting and useful to transfer some skills to advanced nurses. On the other hand, one clearly feels a certain degree of high apprehension among physicians for fear of losing control over care decisions.

Advanced nursing roles tend to really be threatened currently because of the economical crisis. They have often remained an experimental system funded by the regional health authorities and are reconsidered every year based on considerations of interest, need, practicality, and also some very real budgetary considerations. The PASBA has been at risk on a yearly basis since 2009 when politicians tried to address budgetary restraints by cutting funds for the program and even discontinuing the program. We try to explain to them that our system actually does save money long term by avoiding many hospitalizations. Some decision makers can only consider things in the near term. Luckily, others understand that there is a long-term interest in keeping the PASBA alive.

What national reports in France have influenced these advanced nurse practices? How have they influenced the field of addictions nursing in France?

The Berland reports are two consecutive parliamentary reports, respectively published in 2003 and 2006. The reports pointed out that the lack of existing medical resources required a new system of care, that of developing predefined advanced nurse practices with skill transfers. These reports paved the way for the current system of setting up individualized advanced practice protocols. However, they dealt with the whole health system and were not specifically focused on addictions.

After these reports, several advanced practices have been developed in different health sectors. As an example, some nephrology nurses may now autonomously perform hemodialysis. However, in the field of addictions, we have been the first and, to date, the only one to implement with the PASBA an advanced nurse practice system based on protocols. The protocols were initially defined by Dr. Thierry Danel in this case and then approved by the regional health agency. Our goal is to ensure the continued existence of this practice and to attempt to spread it. There are so many impediments, so much reluctance, at so many levels.

This sounds like a very innovative role in addictions nursing? What factors have contributed to the success of developing this role?

Yes! The nurse's role within the PASBA is definitely innovative. Actually, the PASBA is a safe and efficient system. You may allow patients to be detoxified from alcohol without needing to be hospitalized. This system improves patient's comfort and is 10 times cheaper than if you refer them to a hospital. You need a doctor only in the case of complications.

The PASBA is very interesting on both practical and theoretical grounds. From a practical perspective, it shows that you may work simpler and cheaper and still maintain safety. From a theoretical perspective, it highlights and illustrates the total relevance of advanced nursing in a specific type of care situation. To the best of our knowledge, there is no similar system in addictions nursing anywhere in Europe.

Have you seen any improvements in care related to this practice? Are you conducting any nursing research?

The PASBA allows us to target a more widespread population. Many patients are directly referred to us by GPs, and some of these patients would have refused alcohol detoxification in a hospital. The PASBA allows us to offer a more diversified approach to meeting the needs of patients without hospitalization. Access to care is much faster than waiting for the hospital, because we can always meet the patient and start a PASBA program in less than a week. Moreover, GPs are deeply involved in the system. They often refer patients to us, and they are the main prescribers of the treatment used during the detox program. Thus, patients are often maintained within primary care and return to their GP for follow-up. The long-term follow-up is not transferred to an addiction unit. On average, detoxifying a patient through PASBA is cheaper than if they had been hospitalized.

Nevertheless, there is a point where we have failed. We have always focused on care. Until now, we have neglected communicating and publishing on the PASBA. That is why our goal, in the forthcoming years, will be to develop cost-benefit research that will focus on evaluating outcomes such as safety and costs of home detoxification in comparison with hospital detoxification. Of course, both systems are not competing. The PASBA is not recommended for patients with heavy somatic complications, and there are also absolute contraindications for outpatient detox with a history of seizures or delirium tremens for instance.

Do you think that other innovative nursing roles will develop in your country?

Theoretically, advanced nursing practices are allowed and framed by the law (the "Hopital, Patients, Sante, Territoire" 2009 law). Moreover, I believe that there will be no other choice. Such practices are developing in many countries all over the world. However, between fears, inertia, and budgetary constraints, there remains many impediments in France.

In expanding advanced practice roles in addictions nursing, our next project is to develop a system of care for nurse-based delivery and management of opioid maintenance treatment. Similar to the PASBA, the idea is that an advanced nurse may adjust the methadone or buprenorphine dose according to the daily clinical outcome of the patient. This project excites us very much. First, however, we have to ensure that the PASBA will continue!