Abstract
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 psychiatric disorders. The promotion and involvement of self-help groups plays an important part in the process of successful substitution treatment.
Highlights
After a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987
The first experimental methadone project had already been carried out in Hanover in the mid 1970s, substitution treatment for heroin users remained a controversial issue in Germany for a very long time, because the study's conclusions were misguided by the majority of drug experts and politicians
The number of patients in MMT was low at the beginning because of strict admission criteria, but it has been constantly rising since the 1990s reaching 65,000 at the end of 2006
Summary
After a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987. On a larger scale this treatment option was introduced relatively late, primarily in response to the threat of the increasing prevalence of HIV and AIDS among injecting drug users (IDU) in Germany in the mid 1980s. It reflected rising public nuisance associated with drug use, increasing mortality rates among drug users, the lack of attractiveness of abstinence-oriented services and strong advocacy by a handful of dedicated parents of addicts in collaboration with an small number of GPs. it reflected rising public nuisance associated with drug use, increasing mortality rates among drug users, the lack of attractiveness of abstinence-oriented services and strong advocacy by a handful of dedicated parents of addicts in collaboration with an small number of GPs These factors led to the implementation of harm-reduction-oriented services, i.e. low-threshold drop-in centres and syringe exchange schemes. The first large-scale methadone maintenance treatment programme (MMTP) was started in 1987 within the scope of a model project in one federal state (North-Rhine Westphalia). [7,8]
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