How Germany Averted an Opioid Crisis

HAMBURG, Germany — In 2016, 10 times as many
Americans as Germans died as a result of drug overdoses, mostly opiates.
Three times as many Americans as Germans experienced opioid addiction.

Even as the rates of addiction in the U.S. have risen dramatically in the past decade, Germany’s addiction rates have been flat.

That contrast, experts say, highlights a significant
divergence in how the two countries view pain as well as distinct policy
approaches to health care and substance abuse treatment.

Unlike in the United States, where these pills are
commonly dispensed after surgeries and medical procedures, opioids have
never emerged as a front-line medical treatment in Germany.

“Among the most important reasons we do not face a
similar opioid crisis seems to be a more responsible and restrained
practice of prescription,” said Dr. Peter Raiser, the deputy managing
director at the German Center for Addiction Issues.

Doctors must first try alternative treatments, which
the nation’s universal health insurance system typically covers. Before
prescribing opioids, physicians must get special permission and screen
patients to make sure they aren’t at risk for addiction.

“Here in Germany, they prescribe opiates if all the
other drugs don’t work,” said Dr. Dieter Naber, a psychiatrist and
researcher at the University of Hamburg. “It’s much, much, much more
difficult.”

Analyses show that opioid painkillers in Germany are
prescribed somewhat more than they were 30 years ago. But that boost
hasn’t fueled abuse.

Research published this spring shows that the number
of Germans addicted to opioids has changed only slightly in the past 20
years. In 2016, 166,300 Germans experienced opioid addiction — about
0.2% of the population. In 1995, between 127,000 and 152,000 Germans
were believed to have used heroin, specifically; in 2000, the range of
Germans addicted to opioids was estimated between 127,000 and 190,000.

In the United States, in 2008, the
government-administered National Survey on Drug Use and Health found
that about 10,700 people took pain relievers or heroin for nonmedical
purposes (even if they weren’t necessarily addicted). By 2016, about 2.1
million Americans — 0.6% of the population — experienced full-on opioid
addiction.

The contrast speaks to differences in how the two
countries approach medical care. Because of Germany’s health system —
which emphasizes primary care and keeps cost sharing low — people who
are prescribed opioids are more likely to keep up with their doctors’
visits. If they exhibit warning signs of addiction, physicians have a
better chance of noticing.

To be sure, illicit drug use also occurs in Germany,
and opioids are the main killer in drug-induced deaths. Still, the
drug-induced mortality rate has gone down here, per the most recent
European figures.

Even when people here get addicted, they are far less
likely to die as a result. In 2016, 21 per million Germans died from
drug-induced overdoses (of which most were opioid-induced). That same
year, 198 per million Americans died from the same cause.

Experts said this speaks to differences in how the countries view the issue of addiction.

Because of Germany’s generous public coverage, it is
easier to get treatment — which, in the United States, can be hard to
find, and expensive if you don’t have a health plan that covers it.

“Money regarding treatment is really not an issue here,” Naber said.

That said, Canada and Scotland both insure everyone and still face substantial addiction rates.

But, in Germany, drug addiction is treated with
medication and “harm reduction” approaches, including so-called
safe-injection sites — people experiencing addiction take drugs under
medical supervision, with clean needles to prevent the spread of
disease. These facilities even have protocols in place to prevent
overdose. Germany has more than 20 such sites, with four in Hamburg. The
approach has “certainly reduced mortality,” Naber said.

Such strategies are controversial in the United
States. A federal judge ruled early in October against a Trump
administration effort to block a safe-injection program in Philadelphia.
The administration argued that such efforts enable and encourage
addiction, and pledged to continue efforts to block safe-injection
sites.

But “harm reduction,” generally, and supervised
injection, specifically, have been cited as best practices by the
Organization for Economic Co-Operation and Development, a coalition of
developed, mostly Western nations.

“We know harm reduction works in terms of dealing
with the problem of mortality,” said Dr. Andres Roman-Urrestarazu, a
researcher at the University of Cambridge who studies addiction in the
global context.

He added that Germany’s success with its multipronged
approach illustrates that addiction is “a more complex problem” than
the current American response has acknowledged.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. Luthra reported this article from Germany as a 2019 Arthur F. Burns Fellow. The Arthur F. Burns Fellowship is an exchange program for German, American and Canadian journalists operated by the International Center for Journalists and the Internationale Journalisten-Programme.

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©2019 Kaiser Health News

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