MAINTENANCE WITH CODEINE IN GERMANY - THE SUPPORTIVE POSITION

by Urban Weber

Introduction

The German history of maintenance treatment of addiction is primarily a history of codeine, since methadone was not legally available to addicts until the end of the 80's. Even today, although methadone is considered an appropriate medication for opiate addicts in all Social Democratic and in some conservative States of Germany (the Laender), the ratio between methadone maintained and codeine patients is still about 1:1 (some 30,000 in each group). Presently, Germany faces a particularly emotional debate on this topic. The Federal Government is seeking to make codeine maintenance illegal, despite the insistence by advocates that this treatment works very well and should be expanded (cf. Gerlach and Schneider, 1994:53-57; Gruener, 1994; Ulmer, 1995). This paper provides to an international audience a short description of the structure and history of maintenance with codeine in Germany. Since maintenance with this substance is generally unknown in other countries, extensive references are given.

In the U.S., Nadelmann and McNeely (1996) have demanded ready access to "substitution" treatment by general practitioners. The fact that Newman made the identical plea almost 25 years ago (cf. Newman, 1972a:73) demonstrates clearly the lack of progress in the U.S. in this respect over the last quarter-century. Both, Newman's detailed plan to affiliate private physicians to methadone maintenance (cf. Newman 1972b), and very promising results of a - clearly limited - experiment (cf. Novick et al. 1988) remained unnoticed. Existing prescribing of codeine in Germany illustrates the feasibility of what both Nadelmann and McNeely, and Newman, have called for.

Legal Regulations of the Prescription of Codeine in Germany

Codeine is a controlled substance in Germany. In order to permit its use as an antitussive agent, however, an exception is provided by the regulations: as long as the concentration of the liquid preparation is no greater than 2.5%, or as long as pills or capsules contain no more than 100 milligrams, codeine may be prescribed with absolutely no special restrictions. Use of codeine in treatment of addicts is made possible by this exception in the German Narcotics Law (Betaeubungsmittelgesetz, Anlage 2; cf. Moll, 1990).

The Critics of Maintenance with Codeine

Typical of the current German debate is the almost total lack of empirical data presented by the opponents of codeine maintenance treatment. Critics (e.g., Buehringer et al., 1995:47) reject favorable reports of experience with codeine, while providing no data of their own to support their contention that it is inappropriate. Indeed, many critics have clearly not even read the studies they attack (Weber 1996:37). Those professionals in the drug treatment system who generally favour abstinence as the one and only "real" help regard codeine prescription as 'supplying addictive drugs to addicts in defiance of the intent of the Narcotics Law' (Taeschner, 1994:205; translation U.W.), while the Federal Government generally doesn't support the idea of maintenance with any medication outside of comprehensive programs.

History

After Vincent Dole and Marie Nyswander developed maintenance treatment for addicts in the middle of the 60's (cf. Dole/Nyswander, 1966), it took more than 20 years before Germany absorbed these ideas. Until about the middle of the 80's, the ideology of abstinence was absolutely predominant in the German drug help system. At that time, some pilot studies with methadone started and rapidly became a politically accepted method in the Social Democratic governed Laender (States). The conservative States and the Federal Government still favour strongly efforts that focus on abstinence.

Maintenance with codeine developed earlier and without great publicity, without official "programs", at a time when there was no other possibility of substitution. In the middle of the 70's, the northern German physician, Gorm Grimm discovered the maintenance qualities of codeine and shared his experiences with colleagues throughout the country (cf. Grimm, 1992; Ulmer, 1996; Grimm/Sievert, 1987). Thus, when maintenance with methadone started, there already was a ten year history of hidden maintenance in Germany with codeine. To this day, however, substitution with codeine still is not integrated into the well-structured German medical system. There is only little research and no common shared doctrine or practice, although regional associations of physicians have recently developed guidelines for maintenance with codeine (cf. Aerztekammer Hamburg, 1991 and Aerztekammer Westfalen-Lippe, 1993).

Albrecht Ulmer, a physician with extensive experience in maintenance with codeine, points out that this treatment was developed by general practitioners and spread from physician to physician by word of mouth, rather than through publication in professional journals. This, plus the fact that it involved prescribing narcotics to addicts (which is still viewed with great skepticism) has led to a situation of non-integration into accepted, well-structured German medicine, and thus to lack of an integrated concept of research, doctrine and practice (cf. Ulmer, 1996). Nobody is involved in this kind of substitution except the maintained patient and her personal physician, and the access to the treated population is quite difficult. Studies, therefore, are rare. There is no registration of the patients receiving codeine, and even the total number of patients quoted in different articles varies considerably: figures between 20,000 (Degkwitz et al., 1996:12) and 30-50,000 (Samui, 1996:33) are found.

How It Works

The treatment regimen itself is very simple, and is based on a personal agreement between physician and patient. The physician prescribes codeine, and the patient buys her medication in any pharmacy or gets it free of charge if (in rare cases) the health insurance company is willing to pay. In most cases, each prescription is for enough medication for several days, or even weeks, i.e., take-home is very liberal. Dosage varies considerably according to patient needs and duration of treatment. Patients receiving high dosages - e.g., 800 milligrams codeine daily, have to swallow huge quantities of pills, since each pill generally contains only 30 milligrams. Different preparations are available, including liquid, but volume is still a major problem because of the low concentration. Patients normally have to pay for their medication, since in general health insurance agencies and companies refuse to pay for the medication when used in maintenance treatment of addiction. In the author's drug help project the average cost for those in codeine maintenance is about 300 German Marks (US $200) per month, about as much as a heavy smoker spends on cigarettes. A 1995 decision of the highest German court for social and welfare matters (cf. Bundessozialgerichtshof, 1995 and Haffke, 1995) ruled against the insurance companies and required them to pay for the treatment if the goal of maintenance is abstinence. Until recently, such a decision would have been considered highly unlikely (cf. Bausch, 1993).

Target Groups of Codeine Maintenance

Based on personal experience, Elias (1996:26-27) sees three groups of patients who can and should be treated with codeine. First of all, there are those who do not tolerate methadone. Second, those who are well-integrated into the mainstream of society and who are not known by police as opiate users; these users seldom are infected with blood-born diseases and often have consumed opiates by snorting or smoking (Elias, 1996:26, refers to them as patients with good prognosis). And there is a third group of patients, who are treated with this substance because a more suitable treatment with methadone is denied them by arbitrary regulations or because of a lack of physicians willing to prescribe methadone. On the other hand, Degkwitz et al. (1996:14-15) compare different studies conducted in recent years and conclude that there are no differences between codeine and methadone maintained patients with respect to the duration of their drug using career and the intensity of their opiate consumption, education and professional training. They do note, however, better health status at the start of treatment among codeine patients (e.g., lower HIV infection rates), lower rate of court sentences, higher employment rates and better conditions of housing. Nevertheless, they state that the codeine patient population as a whole, if untreated, faces the same career of addiction and, ultimately, the panoply of well-known negative side-effects accompanying such a career.

The Results of Codeine Maintenance

Degkwitz et al. (1996) present the results of three studies conducted during recent years in German cities and compare them, where possible, with the results of methadone maintenance. In the first, 84 codeine patients were compared with 362 methadone patients in the city of Hamburg (Degkwitz et. al, 1996:13, cf. Verthein, 1994 and Raschke, 1994). The second study focused on 152 codeine patients in the city of Frankfurt in 1992 (cf. Schwarz, et al., 1992), and the third analyzed 416 maintained patients, of whom 399 received codeine. The patients of the third study were maintained by altogether four general practitioners in various German metropolitan areas (cf. Degkwitz and Krausz, 1994, and Krausz, et al., 1995). Degkwitz et al. (1996:15) report a significant improvement in the state of health in all studies and a lesser, but still considerable, improvement in social aspects like partnerships, employment, finances, housing, and involvement in criminality. The reduction of additional drugs used is impressive in all studies. Use of heroin, alcohol and cannabis decreased in the third study by 50%, and the use of cocaine ceased almost totally. Before maintenance, the percentage of those who used heroin continuously (more or less daily) or "often" was 90%, and after some time in treatment only 13% continued such use. Among those who still had additional use of heroin, more than one third refrained from i.v. use. The Hamburg results (the first mentioned study) were less impressive, but still very significant. Compared to the group of methadone patients, however, use of heroin was significantly higher (Degkwitz et al., 1996:16). The reason for this might lie in the recruitment of the Hamburg codeine sample: The basic requirement for eligibility was voluntarily seeking psycho-social support during maintenance, i.e., those without self-reported need for such support were not part of the study. On the other hand, methadone patients in Hamburg (and elsewhere in Germany) receive mandatory psycho-social support, whether or not they need it. It might well be, therefore, that the less severely addicted are under-represented in the Hamburg codeine sample, compared to the methadone sample (cf. Raschke, 1994:48).

Although the side effects are worse with codeine compared to methadone (mostly constipation, nausea, sleep disorders), more than 90% of the patients report that they cope well with the substance (Degkwitz et al., 1996:17). The retention rate is very high (more than 90% after one year), and doesn't show any difference when compared to methadone maintenance.

The general conclusion is obvious: Codeine is a suitable substance for maintenance, and there is no scientific evidence supporting the demand of a prohibition in Germany. In fact, the opposite is the case: maintenance with codeine shows similar results to methadone maintenance in all desired respects in a significant way. Additional use of drugs as well as criminal behaviour is reduced to a large extent, and state of health as well as integration into societal mainstream improves considerably. On the other hand, the result of prohibition of codeine maintenance would be disastrous, since the availability of methadone is particularly limited in areas where codeine plays the dominant role: in smaller cities and conservatively governed Bundeslaender of Germany (cf. Akzept e.V., 1996:30). In these areas, it is far easier for an addicted patient to find a general practitioner willing to prescribe codeine than to convince governmental commissions which, in any event, are reluctant to extend the availability of methadone maintenance.

Acknowledgement

Many thanks to Robert Newman for his critical review of this paper's manuscript.

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