BackgroundAfter a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987. The number of patients in MMT – first low because of strict admission criteria – increased considerably since the 1990s up to some 65,000 at the end of 2006. In Germany each general practitioner (GP), who has completed an additional training in addiction medicine, is allowed to prescribe substitution drugs to opioid dependent patients. Currently 2,700 GPs prescribe substitution drugs. Psychosocial care should be made available to all MMT patients.ResultsThe results of research studies and practical experiences clearly indicate that patients benefit substantially from MMT with improvements in physical and psychological health. MMT proves successful in attaining high retention rates (65 % to 85 % in the first years, up to 50 % after more than seven years) and plays a major role in accessing and maintaining ongoing medical treatment for HIV and hepatitis. MMT is also seen as a vital factor in the process of social re-integration and it contributes to the reduction of drug related harms such as mortality and morbidity and to the prevention of infectious diseases. Some 10 % of MMT patients become drug-free in the long run. Methadone is the most commonly prescribed substitution medication in Germany, although buprenorphine is attaining rising importance. Access to MMT in rural areas is very patchy and still constitutes a problem. There are only few employment opportunities for patients participating in MMT, although regular employment is considered unanimously as a positive factor of treatment success. Substitution treatment in German prisons is heterogeneous in access and treatment modalities. Access is very patchy and the number of inmates in treatment is limited. Nevertheless, substitution treatment plays a substantial part in the health care system provided to drug users in Germany.ConclusionIn Germany, a history of substitution treatment spanning 20 years has meanwhile accumulated a wealth of experience, e.g. in the development of research on health care services, guidelines and the implementation of quality assurance measures. Implementing substitution treatment with concomitant effects and treatment elements such as drug history-taking, dosage setting, co-use of other psychoactive substances (alcohol, benzodiazepines, cocaine), management of 'difficult patient populations', and integration into the social environment has been arranged successfully. Also psychosocial counseling programmes adjuvant to substitution treatment have been established and, in the framework of a pilot project on heroin-based treatment, standardised manuals were developed. Research on allocating opioid users to the 'right' form of therapy at the 'right' point in time is still a challenge, though the pilot project 'heroin-based treatment' brought experience with patients who do not benefit from methadone treatment. There is also expertise in the treatment of specific co-morbidity such as HIV/AIDS, hepatitis and psy...

Within a global context, Germany was relatively late in its acceptance of substitution treatment, having first introduced methadone maintenance treatment (MMT) in the late 1980s. Since the early 1990s, Germany has taken a number of legal steps which favor harm reduction, assistance and treatment, rather than the law enforcement approach that was dominant before. As a result of this new commitment, Germany now also allows the use of non-methadone substitutes, such as buprenorphine, LAAM, dihydrocodeine (DHC) and codeine. A heroin maintenance trial has been scheduled to begin in early 2002. Despite the fact that the overall number of participants in drug-substitution treatment has risen over the past decade from about 1,000 in the early 1990s to more than 55,000 in 2001 and that MMT has been comprehensively evaluated in Germany with favorable outcomes, there remains a lack of availability of and accessibility to substitution treatment, due to rigid entry and treatment criteria imposed by the social health insurers (SHI).

Doctors who prescribe methadone to heroin addicts in the Westfalen-Lippe region of Germany were surveyed in 1996 to develop and use German versions of existing Australian and American scales. Two scales were developed from 247 responses using confirmatory factor analysis and Cronbach˜s alpha. The 10-item abstinence orientation (AO) scale measures strength of commitment to abstinence-orientated treatment policies, and the five-item disapproval of drug use (DDU) scale measures disapproval of illicit drug use. Half the respondents supported and a quarter strongly supported abstinence-orientated policies, while a quarter supported a punitive societal response to illicit drug use. Scores on the two scales were highly and positively correlated; the stronger the support for abstinence-orientated policies, the greater the disapproval of illicit drug use. The doctors˜ median score on a test of knowledge of the risks and benefits of methadone maintenance was six of a possible 10. While allowing for DDU scores, support for abstinence-orientated policies was stronger among the less well-informed doctors. The attitudes and beliefs and lack of knowledge identified in the survey are a cause for concern. Previous work has shown there were similar problems among methadone prescribers and staff of methadone units in Sydney, Australia and New York City, USA. [Gerlach R, Caplehorn JRM. Attitudes and beliefs of doctors prescribing methadone to addicts in the Westfalen-Lippe region of Germany. Drug Alcohol Rev 1999;18:163 170]

It is hardly surprising that, compared to international standards, the Federal Republic of Germany holds an exceptional position in the area of drug policy. For decades, the majority of so-called 'drug experts' in Germany have deliberately ignored the findings of international research and, often despite their better knowledge, pursued a policy of misinformation which has remained unaffected by international research findings and standards of practice. This policy is essentially characterised by a rigid adherence to the abstinence paradigm.

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