From Enthusiasm to Concern and From Top-Down to Bottom-Up: A Critical Qualitative Analysis of Constructions of the French Model of Opioid Use Disorder Care in the Scientific Literature

Abstract

The French Model of opioid use disorder care is frequently cited to advocate for policy responses to the opioid crisis. Prior research reveals a disproportionate emphasis in such citations on federal regulatory changes, raising concerns about overly narrow interpretations and potential missed opportunities for evidence-informed policymaking. We aimed to analyze how the French Model has been used to construct policy responses to the opioid crisis internationally, exploring how unique contexts may shape them. We conducted a qualitative content analysis of scientific references to the French Model, informed by Bacchi's “What is the problem represented to be?” policy analysis approach. We analyzed 120 documents authored by scholars in 21 countries. Two concepts were identified to explain problem–solution constructions within their context: (1) cultural enthusiasm versus cultural concern for pharmaceuticals and (2) top-down, bottom-up, and mixed approaches to change. We mapped the problem solution constructions on a schema developed by intersecting these concepts. The schema had six configurations. Four of the six configurations were represented in the analyzed documents. Solutions were shaped by the various contexts in which they were constructed. They varied from deregulation of opioid agonists as a rapid response in the context of overdose crises to prescription drug monitoring programs as a response to diversion and misuse of buprenorphine. The schema we developed based on two cross-cutting concepts may be used to foster alternative, context-sensitive policy solutions.

Keywords

Background

Opioid use disorder (OUD) is a significant public health issue, with high rates of morbidity and mortality globally (Boudreau et al., 2020; Bruneau et al., 2018). Despite the efficacy of opioid agonist therapy (OAT), only about 10% of individuals living with OUD have access to this therapy worldwide (Parida et al., 2019; World Health Organization, 2019). Numerous obstacles hinder access to effective treatment, including stigma, the lack of medical coverage, the lack of psychosocial services, and restrictive regulations on prescribing OAT (Buresh et al., 2021; Hall et al., 2023).

In the past decade, scholars and policymakers have targeted the deregulation of OAT in efforts to improve accessibility (Fiscella et al., 2019; Prathivadi & Sturgiss, 2021; Weimer et al., 2021). As one example, in May 2018, after a national consultation, the Canadian government removed requirements for prescribers to obtain an exemption from the federal Controlled Drugs and Substance Act in order to prescribe methadone (Campbell et al., 2023; College of Physicians and Surgeons of British Columbia, 2023). Likewise, the Mainstreaming Addiction Treatment Act passed by the US government in January 2023 removed both limitations on the number of patients a physician was allowed to treat with buprenorphine as well as requirements for mandatory training to prescribe buprenorphine (Substance Abuse and Mental Health Services Administration, 2023). The removal of these regulatory requirements holds the potential to decrease prescribing hesitancy, reduce stigma, and expand access (Jones et al., 2023; Woodruff et al., 2019).

The French Model of OUD care, extensively documented in Fatseas and Auriacombe's (2007) English-language publication entitled “Why buprenorphine is so successful in treating opiate addiction in France,” is frequently referenced in policy discussions on the deregulation of OAT (Prathivadi & Sturgiss, 2021; Weimer et al., 2021). Regulatory reforms in France in the early 2000s allowed buprenorphine to be prescribed by all registered physicians without additional training and dispensed in all community pharmacies. Concurrent with these prescribing policy changes, there were significant decreases in heroin use and improvements in the social functioning of those in treatment, in addition to lower opioid overdose mortality rates. Importantly, the authors identified additional contextual factors besides buprenorphine deregulation which impacted this success, including health system factors such as universal coverage and the deployment of harm reduction programs such as syringe exchanges (Fatseas & Auriacombe, 2007).

Previous quantitative bibliometric analysis has identified that scientific references to Fatseas and Auriocombe's article, particularly by authors based in the United States and other anglophone countries, have kept a relatively selective focus on regulatory changes as opposed to these other aspects of the French Model. This citation pattern raises concerns about narrow interpretations of the French Model and potential missed opportunities for evidence-informed policymaking across jurisdictions (Kankanam Gamage et al., 2023). Each jurisdiction has a unique mix of policies, programs, services, and financing models to address its resource constraints and populations. Narrow implementation of specific elements of the French Model, such as medication deregulation, without consideration of jurisdiction-specific sociopolitical factors and health systems may result in outcomes dissimilar to those of France, including possible unintended negative outcomes (Okma & Marmor, 2013).

As such, in this study, we aimed to analyze the specific policy constructions (Bacchi, 2009; Bacchi & Goodwin, 2016) in scientific references to the French Model and understand how they may have been shaped by unique cultural and institutional contexts (Bacchi, 2012). Doing so may foster a greater openness to exploring alternative ways of characterizing OUD-related problems and suggest novel policy solutions to opioid-related harms with due consideration of epidemiological, political, and other factors across jurisdictions.

Methods

Approach and Theoretical Framework

We conducted a qualitative content analysis of references to the French model in the scientific literature, using Fatseas and Auriacombe's (2007) publication to guide the identification of the relevant literature. Our approach was informed by the work of policy theorist Carol Bacchi (Bacchi, 2009; Bacchi & Goodwin, 2016). Bacchi suggests that policy solutions contain implicit representations of the problem(s) they are meant to address. These problem representations are often shaped by cultural norms and the interests of those in positions of power and influence (Bacchi, 2009, 2012; Bacchi & Goodwin, 2016). Thus, critical analysis of these problem representations can uncover why and how specific policy solutions have been proposed in particular contexts, and opens opportunities to propose alternative problem representations and solutions. This approach is called “What is the problem represented to be?” (WPR). Bacchi describes WPR as a “way of critical thinking” with six guiding questions designed to facilitate deeper examination of solutions (Table 1).

Table 1.

Bacchi's “What is the Problem Represented to be?” Approach—Six Questions.

1. What's the “problem” (for example, of “drug use,” “gender inequality,” “domestic violence,” “global warming,” etc.) represented to be in a specific policy or policy proposal?

2. What presuppositions or assumptions underpin this representation of the “problem”?

3. How has this representation of the “problem” come about?

4. What is left unproblematic in this problem representation? Where are the silences? Can the “problem” be thought about differently?

5. What effects are produced by this representation of the “problem”?

6. How/where has this representation of the “problem” been produced, disseminated and defended? How has it been (or could it be) questioned, disrupted and replaced?

WPR is most commonly used to analyze explicit policy proposals, for example as seen in government policy documents, where scholars apply selected questions to critically evaluate policy proposals. Using Bacchi's recommendations, WPR can be applied to interrogate a wide scope of governmental and knowledge practices (Bacchi, 2017). For example, some researchers have used this approach to analyze mass media documents, given their role in influencing policy (Atkinson et al., 2019; Whiteside & Dunn, 2022). Scientific literature serves as an important platform for identifying, evaluating, promoting, and disseminating health policy solutions, thus contributing to the construction of health issues as distinct problems. While it is challenging to track and analyze the specific use of scientific evidence in policymaking (Yanovitzky & Weber, 2020), there are theoretical explanations of the ways scientific evidence is utilized in policymaking (Brown, 1991;Weiss, 1979;Weiss & Weiss, 1981) and instances of policymakers using scientific evidence in OUD-related policymaking (Drug Enforcement Administration, 2018; McCarty et al., 2018; Canadian Research Initiative in Substance Matters, 2018; Centers for Disease Control and Prevention, 2023; Substance Abuse and Mental Health Services Administration, 2023; The White House, 2022; Stancliff et al., 2019).

We considered all scientific documents that cited Fatseas and Auriacombe's (2007) publication (index study) as “proposals” that deployed the French Model for different policy solutions, thereby constructing different problem representations. Our focus for the analysis was on the first through third WPR questions, namely to characterize the problem representation, uncover the assumptions underlying these representations, and understand how these representations have come about.

Sampling and Data Sources

We used the Dimensions, Scopus, and Google Scholar databases to identify and compile all the documents that referenced the index study. For this analysis, we prioritized the Dimensions database due to its extensive coverage of research publications, spanning millions of entries linked by over 1.6 billion citations. Additionally, it includes a wide range of documents such as book chapters, datasets, clinical trials, and policy documents (Chambers, 2019; Mouratidis, 2019).

In our search process, we used Scopus and Google Scholar to identify eligible documents that were not included in Dimensions. The index study was not indexed in the Web of Science database and so this database was not used for this analysis. Our inclusion criteria encompassed all scientific documents that cited the index study from the time of its publication up until the end of 2022. Based on the results of previous scientometric analysis using the same corpus, this sample is representative of a variety of jurisdictions and contexts (Kankanam Gamage et al., 2023).

We used the reference manager Paperpile to retrieve full-text records for the identified documents, while the remaining full-text articles were retrieved manually. Each retrieved full-text article was examined to confirm that it cited the index study. We incorporated documents employing scientific methodologies, encompassing both quantitative and qualitative approaches. These documents were sourced from peer-reviewed academic publications, which included opinion pieces, as well as from summaries of existing primary research studies with a scientific basis, such as narrative reviews and book chapters. Excluded were opinion pieces published in nonpeer-reviewed journals and websites. Google Translate was used to translate all non-English articles.

Data Analysis

We used NVivo (QSR International, version R1) for data management. Our focus for the analysis was the first, second, and third questions of WPR. All five authors (KG, SL, JW, KC, and AS) conducted three rounds of pilot coding, in which data were coded into four predetermined primary nodes (problem representation, solutions, assumptions and presuppositions, and context) that encapsulate the three WPR questions. Table 2 describes the criteria for coding.

Table 2.

Coding Criteria for Main Nodes.

	WPR question	Description of WPR question	Main nodes
1	What's the “problem” represented to be?	The implicit problem representation within a specific policy or policy proposal Policy solutions implicitly define specific kinds of problems (i.e., Implementing Universal Basic Income (UBI) implies that the problem of poverty is primarily rooted in income insufficiency. Conversely, investing in education and job training programs suggests that the problem is more about skills and employment opportunities, aiming to empower individuals to earn a sustainable income) (Bacchi, 2009; Bacchi & Goodwin, 2016)	Solution, Problem Representation
2	What presuppositions or assumptions underlie the representation of the “problem”?	Reflection on the underlying premises in the “problem” representation This question aims to uncover the “deep-seated cultural values” that often go unnoticed but profoundly shape “problem” representations (i.e., some representations of the drug problem assume people who inject drugs choose to inject illicit drugs, therefore they can choose not to inject illicit drugs. However, this binary representation fails to consider factors that facilitate or motivate drug use) (Bacchi, 2009; Bacchi & Goodwin, 2016)	Assumptions and presuppositions
3	How has the representation of the problem come about?	Reflect on the contingent practices and processes through which the understanding of the “problem” has emerged. Challenges might be noticeable for extended durations before evolving into matters necessitating government action. Reasons prompting intervention may encompass alterations in societal perspectives or focus, shifts in governmental administrations, the emergence of new data, and advancements in technologies, which alter social dynamics or enable novel interventions. (Bacchi, 2009; Bacchi & Goodwin, 2016)	Context

Subsequently, the full corpus was coded in duplicate by multiple authors (primarily KG and SL). The matrix function of NVivo was used to identify possible problem representation/solution constructions using main nodes (solution, problem representation, assumptions and presuppositions, and context) in each axis. KG and SL developed narrative summaries of problem representation/solution constructions based on this coding, and accounting for any differences in duplicate coding.

Results

In total, 120 documents were included for this analysis (Figure 1). Out of 120 included documents, 107 (89%) were published in English. The remaining 13 were in French (10), Czech (1), Norwegian (1), and Mandarin (1). And 63.3% (n = 76) were empirical studies involving primary or secondary data collection and/or analysis and 36.7% (n = 44) were nonempirical studies that presented authors’ opinions and reflections or presented findings of already published primary research.

Figure 1.

Summary of document selection.

The included documents were predominantly from authors with affiliations in the United States (n = 50, 42%) and France (n = 36, 30%). Other authors were affiliated with Canada, Australia, Norway, the United Kingdom, the Czech Republic, Algeria, Tunisia, Finland, Romania, Germany, Switzerland, Sweden, Taiwan, Spain, New Zealand, Mexico, Italy, Portugal, and Georgia (n = 44, 37%). The total document count in the analysis based on location (n = 130) is noncumulative because we didn't prioritize author order, and included articles based on their locations. For instance, if an article had authors from both Canada and Australia, it was categorized under Canada and Australia.

When reviewing the narrative summaries, we observed that each problem–solution construction aligned with two existing concepts from the literature: (1) cultural enthusiasm versus cultural concern for pharmaceuticals and (2) top-down, bottom-up, and mixed top-down and bottom-up approaches to change.

Cultural Enthusiasm Versus Cultural Concern for Pharmaceuticals

The adoption of pharmaceuticals follows cycles of enthusiasm and concern, shaped by industry, regulators, and medical experts. Enthusiasm arises when new drugs are framed as transformative, with benefits emphasized and risks downplayed in media and scientific discourse. Concern emerges when adverse effects surface, leading to public skepticism and resistance. Initially, vested interests may dismiss criticism, but growing opposition can force acknowledgment and reform. If trust is restored, enthusiasm resurges; if not, the drug may lose legitimacy. This cycle, seen in cases like psychotropics and opioids, reflects shifting societal perceptions of pharmaceuticals (Cohen et al., 2001; Geels, 2011; Geels et al., 2007).

Top-Down, Bottom-Up, and Mixed Top-Down and Bottom-Up Approaches to Change

Top-down and bottom-up approaches represent two distinct strategies for implementing change (de Jong & Strikwerda, 2021; Hayward & Cutler, 2007; Johnson et al., 2022; Kipo-Sunyehzi, 2022; Morton et al., 2017; Mukamel et al., 2014; Ogunlayi & Britton, 2017; Patey & Soong, 2023).

The top-down approach is centrally driven, where decision-makers at the highest-level set policies and expectations. It is valued for its efficiency and broad implementation, particularly in healthcare policy and regulatory structures (Mukamel et al., 2014; Patey & Soong, 2023; Yarbrough, 2017).

Conversely, the bottom-up approach originates at the grassroots level, allowing for locally tailored solutions that address specific needs. While more adaptable, it often requires longer implementation periods. In healthcare, this may involve modifying clinician behaviors or addressing community-specific challenges (Morton et al., 2017; Ogunlayi & Britton, 2017; Senot et al., 2016).

A mixed approach integrates both strategies, balancing centralized decision making with local adaptability. For example, in New Mexico, a statewide naloxone distribution policy (top-down) was paired with pharmacist training and peer coaching (bottom-up) to ensure effective implementation of change (Morton et al., 2017).

Problem–Solution Configurations

When cultural enthusiasm and concern for pharmaceuticals, and top-down, bottom-up, and mixed top-down and bottom-up approaches to change are intersected, there are six possible configurations (Figure 2). For instance, one configuration could be a top-down approach to change with cultural enthusiasm for pharmaceuticals, while another might involve a bottom-up approach with cultural concern for pharmaceuticals. When we mapped the problem solution constructions in this schema, they spanned across four out of six configurations. For each configuration below, we provide a comprehensive description of the problem represented in the proposed solution, underpinning presuppositions and assumptions and the context from which they have emerged as per the WPR approach (Table 3). Supplemental File 1 comprehensively captures the included articles that have contributed to each configuration described below.

Figure 2.

The intersection of two primary concepts of orientation to pharmaceutical interventions and approaches to change with six possible configurations.

Table 3.

Problem-Solution Configurations.

	Cultural enthusiasm			Cultural concern
	Top down	Bottom up	Mixed top down and bottom up	Top down	Bottom up	Mixed top down and bottom up
	Configuration A	Configuration B	Mixed top down and bottom up	Top down	Configuration C	Configuration D
Contexts	Crisis of overdose deaths OAT tightly regulated or not legalized	Not in a crisis of overdose deaths Top-down interventions are already in place			Diversion and misuse of buprenorphine Concerns about OUD care quality	Shifting toward less restrictive treatment policies Diversion and misuse of buprenorphine in EU countries with lenient prescribing regulations for buprenorphine
Solutions	Less stringent OAT regulations Legalizing buprenorphine	More training opportunities for healthcare providers Innovative care pathways, innovative distribution, storage, and administration pathways to integrate new forms of buprenorphine			Initial and ongoing training and targeted training programs for experienced providers to disseminate expertise Closely supervised dispensing of OAT More collaboration among HCPs to provide nonpharmacological care	Closely supervised dispensing of OAT Prescription drug monitoring programs
Problems	Treatment gap •Many individuals in need of OAT did not receive it	Low rates of initiation of buprenorphine Suboptimal buprenorphine dosing Diversion and misuse of high-dose buprenorphine			Diversion and misuse of buprenorphine Inconclusive evidence regarding the level of supervision required for OAT Poor quality of care with unmet needs i.e., pain management in patients on OAT	Diversion and misuse of buprenorphine
Assumptions	The treatment gap was primarily due to stringent regulations Rapid transformative actions were needed to address the overdose crisis The benefits of the wide availability of buprenorphine outweigh the harms	Low rates of initiation of buprenorphine and suboptimal dosing were due to a lack of training New buprenorphine formulations would address the misuse and diversion of buprenorphine			Liberal availability of buprenorphine and deficiencies in supervision contributed to diversion, misuse Nonpharmacological measures are an important part of OUD care	Widespread medication availability leads to diversion and misuse of buprenorphine
Uses of French Model	Deregulation of buprenorphine and positive outcomes of widespread availability of buprenorphine were mobilized	Positive outcomes of wide availability of buprenorphine and challenges in sustaining positive outcomes of the French Model were mobilized			Diversion and misuse of buprenorphine in France and unmet needs of people with OUD on OAT were mobilized	Diversion and misuse of buprenorphine in France were mobilized

HCP: health care provider; OAT: opioid agonist therapy; OUD: opioid use disorder.

Configuration A: Cultural Enthusiasm for Pharmaceuticals and a Top-Down Approach to Change

This configuration—cultural enthusiasm for pharmaceuticals and top-down approaches to change—is primarily found in articles from the United States, Canada, and Australia after 2014 (Table 3). Each of these countries had tight regulations on OAT compared to France and faced a crisis of opioid-related harms where scholars promoted policy change from the highest level of the system and expected this top-down approach to bring about rapid and uniform responses in large jurisdictions. They have drawn on the French Model to express enthusiasm toward the widespread availability of OAT, promoting OAT as a catalyst for social improvement and often downplaying or ignoring possible negative effects of OAT.

In this configuration, the French Model was often referenced to propose less stringent OAT regulations, such as through removing mandatory requirements for prescribing training, urine drug screening, supervised dosing, or caps on the number of patients a prescriber can treat. Efforts such as the US Drug Addiction Treatment Act of 2000, which permits physicians who meet certain qualifications to treat OUD with buprenorphine, were considered important but insufficient steps in addressing crises of opioid-related harms.

In constructing these solutions, scholars often highlighted the problem of a significant treatment gap—many individuals in need of OAT did not receive it. This gap was primarily attributed to stringent regulations:

“Although, in 2021, the education requirement was removed, the requirement of a special waiver perpetuates an insistence on separating substance use disorders from other medical problems, stigmatizing its sufferers and fragmenting their care.” (Leiser & Robles, 2022)

Scholars believed rapid transformative actions were needed to address the treatment gap and reduce overdose deaths. They assumed that OAT prescribing was simple, and training should not be mandated. Some believed basic upskilling would be enough to prescribe buprenorphine, and others recognized eliminating obligatory training as the initial measure to be adopted in improving access to OAT. They believed the less stringent regulations would increase prescriber capacity.

“Since 1995, all registered doctors can prescribe buprenorphine without additional licensing. As a result, one in four French physicians prescribes OAT, and by 2006 more than 67% of people with opioid use disorder were receiving methadone or buprenorphine. The successful French approach shows that the burdensome training required in Australia is unnecessary. Basic upskilling may sufficiently equip Australian General Practitioners (GPs) and pharmacists to confidently follow OAT protocols.” (Prathivadi & Sturgiss, 2021)

They discussed the positive outcomes of the French Model and assumed deregulation led to positive outcomes in France. Some avoided discussion of potential problems of the French Model (e.g., extramedical use) and those who mentioned the problems assumed the benefits of deregulation outweighed the harms. Drawing from the French experience they expected similar positive outcomes in their respective countries.

“Removing buprenorphine prescribing regulations in France yielded increases in its use by persons with OUD. Notably, deaths from opioid overdoses in France declined 79% over the subsequent 3 years. If extrapolated to the United States, this translates to more than 30 000 fewer annual deaths from opioid overdoses.” (Fiscella et al., 2019)

As another example of this configuration, scholars proposed changes to healthcare professional scope of practice laws to allow nonphysicians (e.g., physician assistants, nurse practitioners, and community pharmacists) to prescribe OAT. They assumed mobilizing other health care providers (HCPs) to prescribe OAT would provide a rapid means to increase access to care, particularly in rural areas with higher relative densities of nurse practitioners and community pharmacists.

In countries where methadone was the primary choice for OAT and in places where buprenorphine uptake lagged behind methadone, the French model was deployed to propose low threshold buprenorphine as preferable over other types of OAT. For example, one study claimed, “[t]he French system serves as an example of the success that implementation of buprenorphine can have in mitigating the opioid epidemic. [Opioids Maintenance Therapy] prescribers’ overwhelming preference for methadone over buprenorphine in Ontario is striking” (Guan et al., 2017). These scholars assumed the superiority of buprenorphine over methadone, considering the experience of wide use of this drug in France. They also believed that expanding methadone treatment posed challenges due to the need for specialized centers, unlike buprenorphine.

In countries such as Tunisia and Georgia, where OAT was not legalized, there were increasing rates of OUD and related harms such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections. The growing nonmedical and illicit use of high-dose buprenorphine was identified as a risk factor behind the growing hepatitis and HIV epidemics. Scholars proposed legalizing buprenorphine as a solution for this crisis.

Through these positive narratives, scholars fostered a favorable environment for expanding the availability of buprenorphine through macrolevel policy changes. However, most of these scholars did not consider potential differences in health system structures and resources available at the ground level, potentially overlooking contextual factors that could affect the transferability of policy changes across jurisdictions.

Configuration B: Cultural Enthusiasm for Pharmaceuticals and Bottom-Up Approach to Change

This configuration—of cultural enthusiasm for pharmaceuticals but with bottom-up approaches to change—was found primarily in articles from France since 2010, as well as a few other countries like Taiwan and Germany (Table 3). There were positive forecasts about how further increasing the availability of OAT would help maintain positive outcomes of the French Model. Likewise, new products, such as long-acting injectable buprenorphine, were proposed to address the societal concerns about the diversion and misuse of oral buprenorphine in France.

Even though France had top-down interventions such as less stringent regulations and universal coverage, France faced challenges in sustaining positive outcomes. Such challenges were highlighted to propose bottom-up solutions targeting physician knowledge, attitudes, and behaviors to increase the availability of OAT. In particular, after 2011, France saw less engagement of GPs with OUD care and in particular low rates of initiation of buprenorphine in primary care. Scholars suggested that this stemmed from a lack of addiction training, a lack of support for HCPs, and a lack of clarity in guidelines on OUD care:

“Concerning the initiation of buprenorphine, it appears very significantly that the main obstacle is the fact of not having had any training in addictology. In our study, having been trained in addictology is strongly associated with being the initiator of buprenorphine. We can assume that GPs without specific training in addictology prefer to refer their patients with OUD to specialized structures or to another colleague for initiations, while those who are trained are more comfortable handling these situations alone.” (Lépine et al., 2022)

Scholars suggested that the decrease in buprenorphine prescription reflected a transfer of OUD care toward specialized addiction centers. So, by proposing more training opportunities for more HCPs, they expected that more HCPs would engage in prescribing buprenorphine. Retention of patients in treatment programs was also found to be challenging. Scholars believed more training would help HCPs optimize prescribing and provide better care that would eventually help to keep patients in OAT treatment programs.

Scholars from other countries who discussed the clinical management of OUD in their articles proposed that HCP education on available OAT was important. They provided favorable results achieved with buprenorphine in OUD management, oftentimes citing the French Model as an exemplar in which general practitioners prescribed buprenorphine and made it widely available.

With the introduction of new forms of OAT in the market, such as extended-release injectable buprenorphine, scholars from France proposed increasing awareness among physicians about these new forms, HCP education on how to prescribe and administer them, innovative care pathways, innovative distribution, storage, and administration pathways to integrate new forms of OAT. They postulated that these new medications could be particularly beneficial for patients who lack privacy, such as young individuals living with their parents, homeless individuals, and prisoners. Scholars mentioned that it is important for addiction specialists, pharmacologists, public health specialists, and people who use drugs themselves to closely follow the evolution of these treatments. They suggested that new buprenorphine formulations were warranted to bridge the gap of unmet needs. They also discussed briefly about side effects of new forms and reassured that these can be addressed by HCP education and empowerment to prescribe them.

Configuration C: Cultural Concern for Pharmaceuticals and Bottom-Up Approach to Change

A distinct set of documents from France constituted another configuration of cultural concerns for pharmaceuticals and bottom-up approaches to change (Table 3). French scholars highlighted and problematized some consequences of widespread medication availability. They extensively discussed the diversion and misuse of agonist medications and the inconclusive evidence regarding the level of supervision required for OAT. They speculated that the liberal availability of buprenorphine and deficiencies in supervision contributed to this problem. Consequently, they proposed strategies that would empower HCPs to prevent misuse and diversion of OAT including better compliance with guidelines and ensuring safe practice. These strategies included initial and ongoing training and targeted training programs for experienced providers to disseminate expertise. They believed the training would empower HCPs with optimal dosing, and knowledge about safe prescribing and monitoring. Guidelines were proposed to manage analgesic, polydrug use, and OUD, along with training for multidisciplinary groups involved in OUD care. They expected these measures would prevent misuse and diversion of OAT.

Scholars also emphasized the significance of urine drug screening and supervised dosing in OUD care. Some identified challenges of retention of patients, diversion, and misuse of OAT in France stemming from lack of supervision of OAT.

“Results from this study showed that retention in treatment at the 6-month follow-up was highest for those patients in the 6-month daily supervised dosing group (80%) and lowest for those patients in the 2-week daily supervised dosing group (46%). Rates of opiate-positive urine samples were lowest for the 6-month daily supervised dosing group, compared to the 3-month daily supervised and 2-week daily supervised groups. Finally, average daily buprenorphine doses at the 6-month assessment were similar for the three groups. These results suggest that initial efficacy for office-based buprenorphine treatment may be enhanced by a more closely supervised dispensing of medication and that this may be acceptable to patients.” (Fatseas & Auriacombe, 2009)

While self-reports may have limitations in accurately estimating psychoactive substance consumption, urine drug screening has been considered a useful tool for informing treatment decisions and facilitating patient-provider discussions: “[On-site Urine Drug Tests] should be of significant use for GPs treating opiate-addicted patients by promoting dialogue, further educating patients in treatment-related issues and network-based work” (Dupouy et al., 2012).

French scholars also advocated for improving collaboration among HCPs to improve the quality of OUD care. They proposed that collaboration could improve the comprehensiveness of care and facilitate the incorporation of nonpharmacological interventions:

“Nurse care managers can use a stepped-care approach, combining cognitive behavioural therapy methods with medication and improvement of pain-related disability, in collaboration with GPs. The development of primary care multi-professional centres in France, including nurses, could probably help to improve the management of acute pain among patients on OMT.” (Guillou Landreat et al., 2021)

Scholars expressed confidence that the proposed bottom-up solutions would significantly enhance the quality of care the patients with OUD receive, improve HCPs’ engagement in OUD care and promote homogenous practices throughout France:

“In the current context of the French experience, strategies to reduce buprenorphine diversion and misuse should focus on quality of treatment provision more than on regulatory changes. Among these strategies, helping health professionals, especially general practitioners, may play a crucial role allowing specific training in addiction treatment and facilitating interactions between primary care settings and specialized facilities.” (Fatseas et al., 2015)

Configuration D: Cultural Concern for Pharmaceuticals and Mixed Top-Down and Bottom-up Approaches to Change

We identify cultural concerns about pharmaceuticals as well as a mixed top-down and bottom-up approach to change in this configuration (Table 3). These concerns came from scholars from various countries including the United States, the United Kingdom, Norway, Finland, Germany, and Switzerland who conducted systematic reviews and detailed analyses of the positive and negative outcomes of OAT. They have mobilized negative outcomes of the French Model such as diversion and misuse of OAT in raising these concerns and proposing solutions. In comparing configurations C and D, both acknowledge the challenges of diversion and misuse of prescription drugs. They advocate for bottom-up measures such as enhanced training, increased supervision, and utilization of urine drug screen (UDS), even though the latter is not obligatory. Furthermore, both configurations emphasize collaborative efforts with multiple HCPs to deliver more holistic and comprehensive patient care. However, configuration D distinguishes itself by introducing a top-down approach through the inclusion of Prescription Drug Monitoring Programs (PDMPs). This addition reflects a broader, systemic strategy to address issues of extramedical use by implementing monitoring initiatives from a higher organizational level.

These scholars expressed concerns about the downsides of widespread medication availability. They extensively discussed issues related to the diversion and misuse of OAT and the inconclusive evidence regarding the level of supervision required for OAT, especially in the context of shifting toward less restrictive treatment policies in certain countries. They emphasized the increasing misuse of OAT in EU countries including France:

“Despite the laboratory evidence reviewed in the preceding section that confirmed the expected lower euphoric effects and reduced abuse potential of buprenorphine and buprenorphine/naloxone, in the real world, abuse of these agents has been reported in many countries.” (Li et al., 2016)

The researchers emphasized that the ease of access to buprenorphine can lead to its diversion and misuse. Consequently, they proposed using any of the top-down or bottom-up measures would likely reduce diversion and misuse:

“Taking France as an example of a country with relaxed prescribing regulations for buprenorphine substitution, the diversion and misuse of buprenorphine (e.g., black market, doctor shopping) may also result from its rather liberal availability as Fatseas and Auriacombe have pointed out. One way to curb misuse without hindering access to treatment could include the implementation of prescription-monitoring programs. A recent French study on the impact of a prescription-monitoring program on doctor shopping for high-dose buprenorphine found that monitoring can contribute to controlling doctor shopping without necessarily reducing access to treatment. Another way to help optimize treatment could involve comparing physician and patient assessments of buprenorphine treatment.” (Casati et al., 2012)

Discussion

Our previous scientometric analysis identified citation patterns for Fatseas and Auriacombe's article (Fatseas & Auriacombe, 2007), and suggested provisional problem–solution constructions. Through this current analysis, using two concepts of cultural enthusiasm versus cultural concern for pharmaceuticals and top-down versus bottom-up approaches to change, we were able to explain how the French model has been mobilized in the scientific literature. We identified selective uptake of information on the French Model which was shaped by the distinctive contexts in which the problem–solution constructions were developed.

Drawing on Bacchi's What's the Problem Represented to Be? (WPR) approach, we move beyond assessing whether solutions effectively address a given problem. Instead, we critically examine how the problem itself has been constructed, shedding light on the underlying assumptions that shape proposed solutions. This perspective enables us to identify potential limitations of proposed solutions and consider alternative ways of framing substance use treatment and policy.

With this in mind, we continue to explore how and why specific problem–solution constructions take shape and, ultimately, assess alternative approaches that may better address addiction-related challenges.

Why is There Selective Uptake of Information?

In times of crisis, expediency and feasibility may be prioritized when seeking solutions. Crisis thinking involves adopting reactive measures focused on immediate problem-solving and short-term goals (Smith & Upshur, 2019). Scholars from countries dealing with an identified drug poisoning crisis have shown a greater openness to the deregulatory aspects of the French Model. This preference may stem from the perceived efficiency and broad applicability of top-down deregulation approaches. Studies on crisis responses, including responses to the COVID-19 pandemic, reveal that top-down approaches driven by crisis thinking are common and often overlook the need to identify root causes, tailor responses to local needs, or address unique challenges (Blanco et al., 2020; Haldane et al., 2021; Kayman & Logar, 2016; Kelly Strader, 1994; Parker & Stern, 2022; Van Dijk et al., 2022). This tendency was replicated in this study where scholars from countries with drug poisoning crises generally failed to reference other key facets of the French Model, such as universal coverage and physician payment models, likely due to perceptions of these being both time-consuming and challenging. Such reactive, expediency-, and feasibility-focused approaches may hinder the thorough reflection necessary for learning and improvement. In contrast, when not faced with a crisis, scholars exhibited greater consideration for exploring bottom-up approaches that could address ground-level challenges. This preference for bottom-up strategies aligns with a broader trend observed in decision-making paradigms during noncrisis periods, emphasizing a shift away from immediate expediency toward a more deliberative and sustainable approach, even if these required more time to produce results (Amendola, 2002; Haier et al., 2022).

Approaches rooted in cultural enthusiasm for pharmaceuticals reflect the significance attributed to biomedicine, wherein OUD or other conditions are conceptualized as a biomedical condition with the potential for pharmaceutical remedy (Fuller, 2017; Gaines & Davis-Floyd, 2003; Whyte et al., 2002). Pharmaceuticalization reflects a general shift in OUD care when compared to prohibitive or punitive policies which have dominated in the past globally (Drug Policy Alliance, 2015; FXB Center for Health and Human Rights at Harvard University, 2020; Gottschalk, 2023; Humphreys et al., 2022; Kennedy-Hendricks et al., 2017). Pharmaceutical dominant approaches, however, may come at the cost of diverting much-needed attention from other important aspects of OUD care such as psychosocial support (Blanco et al., 2020; Durpoix et al., 2023; Hooker et al., 2020). Such a process may be comparable to the biomedicalization of chronic pain, which has seen a shift to the liberal availability of opioid analgesics coupled with a relative neglect of psychosocial approaches (Bernard et al., 2018; Jones et al., 2018).

Overall awareness about the French Model among scholars may also influence its selective uptake. In a previous scientometric study (Kankanam Gamage et al., 2023), researchers have found that the articles by scholars affiliated with the United States and other anglophone countries had higher citations and higher altmetric scores indicative of their predominant influence in scientific literature. When the dominant scientific discourse portrays the French Model primarily as a successful deregulation model, other aspects, that is, other harm reduction interventions like syringe exchange programs, may become silenced. Dissemination of narrow interpretations has the potential to impede the extraction of crucial policy insights from exemplar cases like the French Model of OUD care.

What are the Alternative Policy Solutions?

The two configurations not accounted for in this study are reflective of potential alternative ways to frame OUD-related problems and thereby look for alternative policy approaches. Each of these missing configurations could encompass multiple kinds of problem–solution constructions. These constructions may or may not have the potential to mobilize the French Model, but do represent important alternative policy solutions.

The cultural concern for pharmaceuticals and top-down configuration could encompass allocation of funds toward nonpharmacological interventions, such as psychosocial support or focusing on important determinants of health such as income, housing, employment, education, as well as access to healthcare. Remarkably, while these were integral components of the French Model as discussed by Fatseas and Auriacombe, such approaches have not been mobilized within the citing literature. The overall evidence base for nonpharmacological interventions is comparatively less robust when contrasted with that for OAT (Brown, 2018; Dugosh et al., 2016; Samples et al., 2022; Zerden et al., 2020). While constructing solutions based on solid evidence is paramount, it is also important to recognize potential biases in research. Studies might be influenced by the interests of funders, researchers, or political agendas, leading to a possibly skewed or selectively presented body of evidence (Fabbri et al., 2018; May, 2021; Parkhurst, 2017). For instance, research on OAT may have garnered more financial support than investigations into psychosocial support in OUD care thus tipping the evidentiary balance toward pharmaceutical interventions. This is particularly important to note considering that people living with OUD consistently identify the importance of nonpharmacological interventions as integral aspects to effective care (Substance Abuse and Mental Health Services Administration, 2018; Sofuoglu et al., 2019; Taha & Broker, 2019). Likewise, previous comparative analyses have suggested that structural health system reform focused on access to care may be a more effective strategy than medication deregulation when considering possible lessons from France for improving OUD care in the United States (Sud et al., 2023).

The cultural concern for pharmaceuticals and top-down approaches to change configuration may also include the criminalization, prohibition, or strict regulation of OAT as solutions. Even though criminalization of drug use and the prohibition of OAT were not part of the French Model, misuse and diversion in the context of widely available buprenorphine could possibly have been cited as supportive evidence to propose such solutions. However, extensive evidence from various countries suggests that criminalizing drug use tends to exacerbate the negative consequences associated with OUD (Daniels et al., 2021; American Public Health Association, 2013). The criminalization of substance use further stigmatizes people who use drugs, making it more difficult to engage people in healthcare. Criminalization can also exacerbate social marginalization and encourage high-risk behaviors such as polydrug use, binge use, and injecting in unhygienic, unsupervised environments (Khenti, 2014; Jesseman & Payer, 2018; Wogen & Restrepo, 2020). Therefore, the absence of criminalization, prohibition, or strict regulation of OAT in the analyzed literature might be grounded in the acknowledgement that there isn't sufficient evidence to support criminalization of drug use and the prohibition of OAT.

One pertinent example of the intersection of cultural enthusiasm for pharmaceuticals and mixed top-down and bottom-up approaches includes initiatives for the safe supply of opioids, wherein opioid analgesics are prescribed by physicians to people who use drugs as an alternative to the highly toxic and contaminated drug supply (Ontario Drug Policy Research Network, 2023). The successful execution of safe supply initiatives has necessitated both bottom-up community support and advocacy which have then driven top-down regulatory changes and resource allocation (Ivsins et al., 2020; Mansoor et al., 2023; Nguyen et al., 2024; Ontario Drug Policy Research Network, 2023). The mobilization of the French Model in discussion of the safe supply of opioids is improbable as the index study does not explicitly discuss the safe supply of opioids. However, this capture of an important opioid crisis response, including one that specifically has been driven by people who use drugs (Sud et al., 2022), reinforces the value of the schema we have developed to capture the landscape of problem–solution constructions and policy responses to the larger challenge of increasing opioid-related harms.

In addition to identifying the two missing configurations, we can also examine gaps in problem–solution constructions within existing configurations to explore alternative solutions. For example, we observed that top-down solutions framed with cultural enthusiasm were proposed in the context of the overdose crisis. However, we did not find bottom-up approaches with cultural enthusiasm in similar contexts. For instance, community-based treatment networks, mentioned in the index article, could have been cited as an example of a bottom-up approach to addressing the overdose crisis.

Strengths and Limitations

To our knowledge, this is the first qualitative analysis of the French Model of OUD care that informs how policy problems are constructed within the scientific literature. This study was novel in that it used a policy theory-driven approach—Carol Bacchi's WPR framework (Bacchi, 2009)—to analyze scientific literature. This work compliments the previous scientometric analysis and provides a more nuanced and in-depth understanding of how scientific evidence is mobilized for solutions. Also, the study thoroughly examined all articles located and accessible from three databases, regardless of their country of origin or the language in which they were published. Further, the data analysis was rigorous because all the documents were coded in duplicate by two authors independently.

The index study is one of several articles discussing the French Model. Therefore, this analysis does not capture the entire picture of how the French Model has been mobilized for solutions. Analysis of other articles that discuss the French Model would offer a broader perspective.

We also have not included gray literature in our analysis, potentially causing us to overlook important insights that may not be found in scientific literature. Finally, Google Translate was used to translate several non-English articles. Errors in translations could lead to errors in interpretation.

Conclusion

The selective uptake of information on the French Model for problem–solution constructions has resulted in notable gaps between what actually happened in France and what is represented in the scientific literature. These gaps represent missed opportunities for cross-jurisdictional policy learning, emphasizing the importance of understanding the contextual factors contributing to the selective uptake of evidence. This understanding is crucial for fostering a more open and comprehensive exploration of alternative solutions to the opioid crisis.

The schema we developed based on two cross-cutting concepts provides a useful frame from which to both understand existing policy solutions and why they have arisen in particular contexts, and to explore alternative, context-sensitive policy solutions.

Moving forward, it is imperative to consider the complexities of OUD care. Recognizing the significance of both top-down and bottom-up approaches, along with maintaining a balanced perspective on pharmaceutical interventions, is essential. This holistic approach is necessary to develop effective and resilient strategies for addressing growing opioid-related harms.

Supplemental Material

sj-docx-1-cdx-10.1177_00914509251346144 - Supplemental material for From Enthusiasm to Concern and From Top-Down to Bottom-Up: A Critical Qualitative Analysis of Constructions of the French Model of Opioid Use Disorder Care in the Scientific Literature

Supplemental material, sj-docx-1-cdx-10.1177_00914509251346144 for From Enthusiasm to Concern and From Top-Down to Bottom-Up: A Critical Qualitative Analysis of Constructions of the French Model of Opioid Use Disorder Care in the Scientific Literature by Kasunka Kankanam Gamage, Shania Liu, Kellia Chiu, Jenny Wang and Abhimanyu Sud in Contemporary Drug Problems

Footnotes

Acknowledgments

Dr. Quinn Grundy and Justin Ryk provided helpful comments during the scientometric analysis. Keshi Maheswaran provided helpful feedback on a previous version of the manuscript.

Authors’ Contributions

KG was involved in conceptualization, data curation, formal analysis, methodology, visualization, and writing (original draft, review, and editing); SL in data curation, formal analysis, investigation, visualization, and writing (review and editing); KC in conceptualization, data curation, formal analysis, investigation, methodology, visualization, and writing (review and editing); JW in data curation, formal analysis, visualization, and writing (review and editing); and AS in conceptualization, formal analysis, investigation, methodology, project administration, funding acquisition, resources, supervision, visualization, and writing (reviewing and editing). All authors read and approved the final manuscript.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Substance Use and Addiction Program, Health Canada (grant number grant number 1920-HQ-000031).

Informed Consent

The study involves analyzing scientific documents. There was no participant involvement. So, informed consent is not applicable.

ORCID iDs

Kasunka Kankanam Gamage

Shania Liu

Kellia Chiu

Abhimanyu Sud

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Kasunka Kankanam Gamage is a resident in public health and preventive medicine. Her areas of research include addiction, health services and health policy.

Shania Liu is a postdoctoral fellow in pharmacy practice. Her areas of research include opioid use for pain management and pharmacy practice research.

Kellia Chiu is an associate lecturer in health policy. Her areas of research include pharmacy practice policy, comparative drug policy analysis, and commercial influences in health policy and practice.

Jenny Wang is an undergraduate student in health sciences. Her areas of research include addiction, health services and health policy.

Abhimanyu Sud is an assistant professor in family and community medicine and Research Chair in primary care and population health systems. His areas of research include chronic pain, mental health, addictions, health services, and health policy.

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