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Introduction
Drug abuse has a long history in Germany and China.
Drug abuse, mainly the abuse of heroin, has spread quickly
since re-emerging as a national problem in China in the late
1980s. The major drug-related problem is the spread of HIV,
which has caused major social and economic damage in
China. China approves the methadone maintenance
treatment (MMT) program, which began in 2003, and the number
of clinical sites of MMT exceeded 300 by November 2006.
The China Central Government adopted many strategies in
the antidrug campaign in the last 10 years; however, the
epidemic of drug abuse and spread of drug-related diseases
like HIV/AIDS in the country are still not completely under
control. With the progress of modernization, China is more
open to learn from developed countries such as Germany in
its struggle with drug abuse.
Germany, the largest developed European country, has
faced severe heroin abuse problems since the 1970s and has
had some successful experiences in controlling drug abuse,
particularly in controlling the spread of HIV/AIDS. For
example, the German Narcotics Act was revised in 1992 and
clarified that substitution treatment for opioid dependence
was legal. Since the early 1990s, substitution treatment has
been the most important part of the treatment options for
opioid dependence. The overall number of participants in
drug-substitution treatment has risen over the past decade
from about 1000 in the late 1980s to 65 000 in 2005. Although
the MMT has been evaluated comprehensively in Germany
with favorable outcomes, there is still a lack of availability of
and accessibility to substitution treatment. In addition to
opioids, the abuse of "new" types of drugs, including three,
4-methylenedioxymethamphetamine (MDMA), and ketamine
has spread recently in Germany. Drug abuse has caused
many problems for both abusers and the community. In
response, the Germany Cabinet adopted the "Action Plan
on Drugs and Addiction"; the China Central government
approved a similar regulation in the antidrug campaign in
2005.
Due to the increase of drug addicts and drug-related
diseases, the governments of these 2 nations have begun an
antidrug campaign, including legislative measures to
control drug abuse and enforce the MMT program. This review
will compare the characteristics of drug abuse in Germany
and China. The experiences of Germany and China have
provided many beneficial methods and these experiences
may be the foundation of future collaborations between
Germany and China.
Situation of population and economics in Germany and China
Facts and figures Germany is one of the most important
countries of Europe, both in economic power and population.
Located approximately at the center of Europe, Germany has
a population of 82 800 000 and area of 356 910
km2 (Figure 1). Germany is a society of immigrants. For economic,
demog-raphic, and humanitarian reasons, immigration has become
an important issue for German society over the past 50 years;
over 14 million people with a migrant background live in
Germany today. They are either immigrants themselves or
second generation immigrants. One of 5 marriages is
binational and 1 of 4 children born in Germany has at least 1
foreign parent. One in 3 teenagers in West Germany has a
migrant background, while in some areas, this is almost 40%
and increasing. Immigration has substantially changed the
constitution of Germany society; ethnic, linguistic, cultural,
and religious diversity have for a long time been a living
reality in Germany.
China is situated in eastern Asia on the western shore of
the Pacific Ocean, with an area of 9.6 million sq km. China is
the most populous country in the world with 1.25909 billion
people at the end of 1999, about 22% of the world's total
population. China is a united multi-ethnic nation of 56
ethnic groups. As the majority of the population is of the Han
ethnic group (accounting for 91.6% of the national total
population), China's other 55 ethnic groups are customarily
referred to as the national minorities. The Constitution of
China guarantees the basic rights and interests of its citizens.
Adopted in 1982, China's Constitution has been amended 4
times. The Supreme People's Court is the highest judiciary
agency in China and is responsible to the National People's
Congress and its Standing Committee.
Economic policy strategies Germany faces the challenges
of globalization, and the transition to a knowledge
investment in research and development amounts to 2.5% of its
gross domestic product (GDP), placing it in the upper third
among industrialized nations. Germany possesses an
efficient society only if there is a high level of dynamism for
innovation. Germany's overall economic infrastructure for
basic and applied research is among the top nations for
inventions. The German economy is more profound than
other countries characterized by a clear weakness in growth.
Unemployment figures remain high and a noticeable decline
in employment subject to social insurance contributions leads
to further gaps in the social security systems, thus
contributing to their considerable financial problems. More growth
is therefore an essential prerequisite for tackling Germany's
current and future economic and financial problems.
With its GDP growing at an annual rate of 9%,
economists predict that China's GDP will come second after that of
the USA. Such an economy market stands to offer exciting
business and capital market opportunities to foreigners over
the next 10 years or so. China's annual GDP growth has
averaged more than 8% in the past 25 years, and in 2005, its
GDP grew by a record-breaking 9% despite the outbreak in
2003 of severe acute respiratory syndrome (SARS).
Social assistance Social assistance in Germany is
intended not only to prevent poverty, but also to enable
recipients to lead a dignified life. Anyone unable to do so with
his or her own resources receives social assistance. There is
assistance from the community for everyone who is unable
to help themselves and cannot count on other support. For
this reason, the regulations to enhance this self-help are
particularly significant. It is fundamentally irrelevant whether
beneficiaries have caused the hardship themselves. There
is a legal right to almost all social assistance benefits.
Anyone who is in need receives individual assistance in which
his or her personal and economic conditions are
accom-modated. Social assistance can be provided as personal
assistance, a cash benefit, or as a benefit in kind.
China's social affairs have fallen far behind its quick
economic development. About 85% of investment in sanitation
flows into the urban area, while only 15% is invested in the
rural area where three-quarters of the population live. Social
administration in China remains at a low level due to the
legacy of planned economy. The private economy needs to
move into the social services, including hospitals, schools,
and scientific research institutions.
Health insurance In Germany, an insured person can
claim measures for the prevention and early detection of
certain diseases; medical and dental treatment, with free
choice among panel doctors and dentists; medicines;
hospital treatment; and social therapy for insured persons who
have a severe mental affliction that prevents them from
accepting or taking medical treatment. State health insurance
also covers the family at no extra charge. From 1 January
2004, health insurance met the cost of medical treatment for
social assistance recipients who lacked statutory health
insurance. Their equal status with members of the statutory
health insurance schemes brought recipients of social
assistance under the statutory guarantee of appropriate and
affordable health-care provision.
The Chinese health-care system was originally a highly
centralized one. It had great success in improving people's
health. The county-township-village 3-tier health-care
system has contributed much to rural primary health care and
has set an example of primary health care to developing
nations. In the 1980s, this system experienced
transformations along with changes of the country's administrative
system and economic policy. The long-existing health
administrative problems that were aggravated in the last
decade are the rural-urban differences in resource allocation
and the large proportion of people without health security.
With the increase of medical service prices in recent years
due to the inflation of the economy, it is believed that the
cost of health care will create an economic burden to
low-income, fee-for-service paying individuals and will further
affect the health of the population. In the process of the
national economic reform, it is an important and difficult task
for the health administrators to adjust the health-care
system promptly and properly. Continuously carrying forward
good traditions, correcting mistakes, and consistently
persisting in health reforms can further raise its health care to a
new, prosperous stage[1].
Drug abuse in Germany and China
Consumption and abuse of psycho-active substances
After heroin had found its way onto the illegal drug market
in Germany around 1970, there was a rapid increase in the
number of heroin users and addicts from none to around
30 000_40 000 within only a few years. This number increased
until the 1990s to 150 000_170 000 and is now slowly
decreasing. During the early 1970s, "psychedelic"
substances like cannabis and Lysergids (LSD) became part of a
youth subculture movement, although LSD nowadays plays
only a marginalized role.
With respect to illicit drugs, the use of cannabis
outranks all other drugs in Germany. More than one-quarter of
all young people have had experience with the drug and
around 200 000, most of whom are young people, are daily
users. Reports of risky consumption patterns and multiple
drug use of youths and drug addicts are on the rise. The
number of people seeking drug counseling centers has
doubled in recent years. There is an estimated
150 000 people addicted to heroin and other opiates and about
300 000 people use cocaine regularly. In some cities, there is an increase in
the consumption of crack. In the party and techno scene,
the prevalence of cannabis and ecstasy consumption is
almost 10 times as high as in the same age bracket outside of
this "scene". Around 500 000 people, predominantly young
people, consume what is known as party or club drugs, such
as ecstasy; most often mixed with other illicit drugs, such as
cannabis and cocaine, but also with legal drugs such as
alcohol[2].
Drug abuse in China can be traced to the late Qing
Dynasty (1644_1911 AD), when British colonists forcefully
brought Indian opium into China in exchange for silk, tea,
and cash. Opium was then locally planted. By the founding
of new China in 1949, more than 20 million Chinese people
were opium addicts, representing 5% of the total
population[3]. After a short nationwide antidrug campaign, drug abuse was
reported to be eliminated from the mainland in the early
1950s, and for the next 3 decades, China was believed to be
a drug-free nation[4].
Illicit drugs re-emerged in China in the 1980s as China
adopted an open-door policy, and the re-emergence was
mainly connected with global drug trafficking activities. Since
the late 1990s, increasing amounts of amphetamine-type
stimulants (ATS) and other chemically-related synthetic
drugs, including amphetamine, methamphetamine, and
ecstasy have been locally manufactured and consumed in
China[5].
The number of drug users officially documented by
Chinese public security departments increased from
70 000 in 1990 to 1.16 million in
2005[6], while the estimated number is currently 3.5 million. The lifetime prevalence rates of illicit
drug use among residents aged 15 years or older in high
prevalence Chinese cities increased from 1.1% in 1993 to
1.6% in 1996, and the 1 year prevalence rate increased from
0.9% to 1.2% during this period[7].
The main drug of choice in China is heroin. According to
a report of the National Narcotic Control Commission, 87.6%
of drug users abused heroin in 2002[8]. The abuse of ATS
and MDMA (methylenedioxymethamphetamine or ecstasy)
has become popular in city nightclubs in recent
years[9].
Heroin abuse Calculations based on the figures collected
from treatments, police contacts, and drug-related deaths
have led to the number of problem heroin users in Germany
estimated at being between 70 000 and 172 000 people. This
corresponds to a rate of 1.6_3.0 people per 1000 inhabitants
between the ages of 15 and 64 years[10]. Calculations based
on treatment data, including clients with cocaine and
amphetamine problems, produce a prevalence of 137 000_
221 000 (2003: 132 00_214 000).
With heroin, intravenous use slightly decreased to
66.6% relative to the previous year (2003: 70.2%; 2002: 68.4%;
and 2000; 69.5%). With cocaine, the portion of injection
drug users (IDU) slightly increased to 34.3% (2003:
33.8%, 2002: 29.7%; 2001: 32.5%; and 2000: 32.8%). For
the year 2004, the German addiction aid statistics recorded
data based on International Classification of Diseases (ICD)
10 of a total of 38 978 people who started treatment in an
outpatient psychosocial addiction aid facility because of
problems with illicit drugs. More than half of the cases have
been diagnosed as being opiate addicts, followed by
cannabis and cocaine. For people treated for the first time,
cannabis ranks first among these
clients[10].
Opiate abuse in China dates back several centuries. The
British supplied Indian opium to China as early as the 16th
century[11], and the growth of opium use resulted in huge
public health problems. By 1906, China had 13.5 million
addicts consuming some 39 000 tons of opium, and an
estimated 27% of its adult males were dependent on opium. This
astounding level of mass addiction was probably the largest
in world history[12]. By the time of the founding of the People's
Republic of China in 1949, there were over 20 million opium
abusers (5% of the population) in the country and 25% of
the population of the Yunnan province were opium
abusers[13]. Throughout history, Chinese governments have embarked
on numerous campaigns to control opium. These attempts
included the well-known Opium
Wars[13,14]. However, only 1 such attempt succeeded. In the early 1950s, the Chinese
Government took a series of dramatic steps to combat
wide-spread opium abuse, carrying out a nationwide antidrug
campaign[13, 15] that included the following measures: (i) a circular
order was issued by the new Government in 1950 mandating
governments at all levels to fight opium abuse; (ii) those
involved in the cultivation, manufacture, or sale of opium
were subject to severe punishments, including forced labor
and execution; (iii) compulsory "treatment" was instituted
(consisting largely of enforced abstinence) for opium
abusers combined with psychological "rehabilitation" and
vocational training programs (involving forced labor); and (iv)
the cultivation, manufacture, and use of medicinal opium
was closely controlled to ensure medical
use[16]. During the campaign, people involved in growing opium, transporting,
or trafficking illegal drugs were punished. Labor camps and
executions were among the measures employed. The
campaign lasted 3 years from 1950 to 1952. According to official
accounts, 20 million opium addicts were detoxified and
returned to healthy, useful lives[13]. Some US authors
celebrated the success of the Chinese Government's approach
to the opium epidemic[17]. Official accounts, as well as some
US authors, also claimed that the value system of young
people had changed so that there was no new supply of
addicts[17]. However, there were no rigorous
epidemiological studies measuring the prevalence of opiate dependence
before and after the campaign. Despite those serious
limitations in our ability to rigorously evaluate how patterns of
opiate use changed in the 1950s, it seems clear that the rates
of dependence did decline precipitously, as the risks
associated with the trade and use of opium climbed considerably.
In addition, the availability of opium was curtailed
dramatically by the aggressive eradication of opium planting and
domestic manufacturing domestically and blocking
international trafficking. China's political and economic isolation at
that time was a key factor which excluded foreign supplies of
opiates.
Opiate abuse was thus rare in China prior to the
establishment of closer ties with the West, beginning in
1978[11]. However, as Chinese economic development accelerated in
the 1980s and China began to open its borders, opium and
heroin once again entered China from the Golden Triangle
region, especially through Myanmar, through the Yunnan
and Guizhou provinces, to Canton (Guangzhou) and Hong
Kong[18]. In the 1990s, drug-related crime grew dramatically
and opiate abuse spread quickly. During the last decade,
China has experienced a rapid increase in illicit drug use,
predominantly heroin. From 1990 to 2006, the numbers of
drug abusers officially documented in China increased more
than 11-fold from 70 000 to 1 160
000[19,20].
In contrast to the information available from the
1950_1980s, which consists entirely of Government estimates,
some well-designed independent epidemiological studies
of more recent rates of opiate abuse are beginning to emerge.
Hao et al[7,21] reported the prevalence, patterns, and trends
of illicit drug use in the general population of selected
high-prevalence areas (Yunnan, Sichuan, Gansu, and Gungdong
provinces) in China between 1993 and 2000. They screened
more than 50 000 individuals aged 15 or above in the
community and interviewed possible abusers. They found the
lifetime prevalence of illicit drug use to be 1.08%, 1.60%, and
1.52% in consecutive surveys conducted in 1993, 1996, and
2000, respectively. The 1 year prevalence rates were 0.91%,
1.17%, and 1.17%, respectively. Heroin was the most
common drug of abuse (51.8% in 1993, 83.4% in 1993, and 95.9%
in 2000). The 2 most frequent routes of drug administration
were inhalation (89.2% in 1993, 60.1% in 1996, and 93.5% in
2000) and intravenous injection (27.2% in 1993, 31.0% in 1996,
and 25.7% in 2000).
Many reports have shown that the majority of addicts in
China are young (30 years or younger), single (60%) males
(60%_70%) with little education and without stable
jobs[22_25]. Routes of administration vary depending on geographic area
and year of survey. Most studies conducted after 2000
showed that intravenous injection accounted for 50%_70%
and "chasing the dragon" (zhui-long: ingestion of the drug
by inhaling the vapor produced when the drug is heated to a
level at which it sublimates) accounts for 25%_50% of
opiate administration by users. The use of intravenous heroin
is growing, with many users changing from zhui-long to the
intravenous route. Finally, new drugs are now making their
way into China, especially in urban areas where
methamphetamine and other synthetic stimulants, as well as
dissociative anesthetics, such as ketamine, are increasingly
popular among young people[4,24].
Psychostimulants, cannabis, and other new-type drugs
Experience with cannabis is most common among young
people in Germany, followed by mushrooms, amphetamines,
and ecstasy with markedly lower prevalence; all other drugs
are even less commonly found. The development of drug
consumption during the lifetime and in the previous 12
months can be well compared with the data of the drug
affinity study which has been collecting comparative data for the
12_25 year age group since 1979 (Figure 2). While drug
experience during the lifetime increased from 16% in 1979 to
32% in 2004, current consumption in the last 2 surveys was
below the level of 1997. This clearly indicates that a similar
or even higher number of people have used drugs once in
their lifetime, but frequency or at least the duration of
consumption must have declined considering the lower
prevalence figures for current
consumption[10].
In the late 1990s, studies about the use of ecstasy and
other so-called party drugs in Germany showed that the most
common age for using ecstasy for the first time was between
16_18 years[26_31]. The motives given as "highly applicable"
and "applicable" are feelings of happiness, elation, and more
intense hearing and feeling. In addition, over 50% of
ecstasy users report expanded consciousness, greater ease of
making contact, relaxation, and overcoming personal inhibitions
as being applicable to
themselves[2,32,33]. About 80%_95% of people have already experienced nicotine, cannabis, and
alcohol prior to using ecstasy for the first time. About 40%
have experience with speed, cocaine, and LSD. Experience
with psilocybin and heroin is found only very
rarely[34].
In the non-organized leisure-time sector, drug
prevention and especially measures relating to night life is an
exception to the regular help offer in contrast to schools and
working life where drug prevention activities are firmly
embedded[35]. The goal of the projects and measures is to reach
young people at risk (especially by involvement of peers),
prevent them from starting to take addictive substances, or
respectively motivate them to quit early. The activities
deployed at parties range from information stalls, counseling,
cultural offers, and relaxation techniques to structural
measures like the sale of alcohol-free drinks at a lower price than
alcoholic drinks, freely available cool drinking water,
chill-out areas, cooperation with local players (eg competent
authorities), as well as trained staff for medical emergencies.
It is being tried to an increasing extent to use the Internet
to establish low-threshold contact with young people
having a drug affinity in order to inform them, to promote critical
reflection of their own consumption behavior, and to
provide online support to reduce or stop their consumption or
to refer them to other local help
services[34,36].
In China, as the number of drug addicts increases and
the drug abuse problem spreads, the consumption of
traditional drugs grows alongside increasing use of new kinds of
drugs. It has been reported that although opiates,
especially heroin, remain the most commonly used drugs, MDMA
and methamphetamine have recently become popular
recreational drugs in large or medium-sized Chinese
cities[37,38]. MDMA belongs to the class of ATS and is a synthetic drug
that can be manufactured in 2 ways: from benzyl methyl
ketone or from ephedrine extracted from the medicinal herb
ephedrine[39_41]. The increasing illicit manufacture of ATS,
particularly methamphetamine, in East and South-East Asia
is a major concern. It has been estimated that more than 70%
of all seizures of amphetamine in the world took place in East
and South-East Asia, mainly in South Korea, Japan, China,
and Thailand[9,42,43].
A dramatic increase in MDMA trafficking has occurred
throughout the region and illegal MDMA laboratories have
been discovered in mainland China, Hong Kong, Taiwan,
Malaysia, and most notably,
Indonesia[9]. The increased demand for ecstasy and the ready availability of precursor
chemicals from China and Vietnam make South-East Asian
nations increasingly vulnerable to becoming havens for
large-scale MDMA manufacture[9,42]. In China, the countryside
also faces a growing problem of ATS
abuse[44].
HIV/AIDS and hepatitis in Germany and China
Drug users are the fourth largest risk group for HIV
infections in Germany. HIV incidence is at 6% in the group of
injecting drug users. Until the year 2000, the figure was at
10% and in the mid 1980s it was at 20%. Data from outpatient
counseling facilities show a prevalence of 3%_4%. However,
it should be noted that recent, large-scale studies allowing
for a certain generalization of data are missing.
Basic data on viral hepatitis are available for the general
population. According to the Federal health report, 5%_8%
of the German population aged between 18 and 79 years is
affected by a hepatitis B infection. A total of 0.5%_0.7% of
the population carries hepatitis C
antibodies[10,45]. As for the possible methods of transmission, intravenous drug use was
the most commonly used method as reported by 7% of
hepatitis B cases. With respect to hepatitis C, intravenous drug
use at any time was most frequently reported by 37% of the
cases as the most preferred route of transmission. In the
20_29 year age group for male cases, intravenous drug use was
reported to be the commonly used method by 71% of cases.
In summary, the antibody prevalence (infection rate) of
hepatitis B among IDU in Germany is estimated to range between
40% and 60%, and for hepatitis C, the range is between 60%
and 80%. While the data do not permit precise estimates, it
is clear that the antibody prevalence in IDU is very high for
hepatitis B and C.
MMT is the major basis for treatment of HIV/AIDS-related illnesses among drug users. The high retention rate
and good compliance with treatment regimes makes
treatment with antiretroviral medications feasible, whether or not
it is carried out in the specialized outpatient
clinics[46]. Long-term substitution programs allow observations of the
antiretroviral treatment and a better response to side-effects.
There are numerous potential drug interactions between
antiretroviral medications and methadone and other
substitute substances. Adaptations of the methadone dosage may
be necessary. The analgesic properties of opioid may mask
early symptoms of serious side-effects of HIV medications.
A good relationship between doctor and patient is essential
to deal with these problems. While in the past, IDU have
usually been excluded from standard HCV therapy with
interferon and ribavirin in Germany, recent results suggest a
different approach[47]. Comparisons were made regarding
the use of medication among drug users and non-drug users
because of the following criteria: response rate, outcome of
the HCV standard therapy, as well as the severity of
neuropsychological side-effects[48] .
In a controlled prospective study, no differences were
found in people displaying an addiction-related or
psychological disorder or in a control group without such disorders
with regards to psychiatric complications and response rates.
However, drug users had a higher dropout
rate[49]. Based on these studies and other surveys, the provisional conclusion
is that HCV-infected patients who intravenously take drug
may be successfully treated with standard therapies. Even
in the case of light or moderately severe additional
psychological disorders, HCV treatment may be carried out
successfully provided on an interdisciplinary basis. The MMT
is generally a prerequisite for the successful additional
treatment of HIV or hepatitis in opiate-addicted
individuals[48].
In Asia and the Pacific, drug abuse has led to many
problems, in particular HIV/ AIDS. More than 1 million people
were diagnosed with HIV in 2003, bringing the total to 7.2
million infected people in the
region[50,51]. The growth of the epidemic in this area is largely due to the growing epidemic
in China, in which 1 million people are living with HIV. China's
AIDS epidemic began in the early 1990s among injecting
heroin users[52,53]. Injecting drug users account for more
than half of China's HIV infections. In addition, many of
China's sex workers inject drugs, and thus provide a bridge
for HIV transmission to the general
population[54_56]. As the commercial sex industry has exploded in China over the
past 2 decades, HIV infection rates have also increased
dramatically[52,55]. By the end of 2003, the number of
registered HIV infections was 62 159 (including 2693 cases of
AIDS from which 1047 people died). An estimated
106 990 Chinese people were HIV positive by the end of 2004.
HIV infections have been reported in 31 provinces,
autonomous regions, and municipalities, and the actual number of
cases and spread of infection is much likely to be
greater[52,53]. Drug abusers accounted for 63.7% of HIV cases. China is
now one of the 6 South-East Asian countries in which there
is growing ATS use, and vulnerability to HIV/AIDS appears
to have increased[52,57]. It is well known that AIDS affects
not only patients, but also their families, society, and the
economy. China's first law targeting the disease was passed
by the Standing Committee of the National People's
Congress in 2004. Discrimination against the victims of
infectious diseases has also been outlawed. Many efforts and
measures have been adopted by the Central Government to
help patients obtain effective treatment. As for preventing
HIV spread among drug addicts, some places in China, such
as Guangzhou province, are instituting needle exchange
programs among drug abusers in order to break the HIV_heroin
connection. Some areas are also advocating 100% condom
use among sex workers.
About 170 million Chinese are infected chronically with
the hepatitis B virus (HBV) and 10% suffer from chronic
hepatitis. Around half a million Chinese people die from
hepatitis B because of hepatocellular carcinoma and
end-stage cirrhosis each year. A pilot study demonstrated that
the HBsAg rate reached the adult level before the fifth year
of age, and neonatal vaccination with either plasma-derived
or recombinant hepatitis B vaccines provided a similar 75%
protective efficacy against HBV infection. The high rate of
follow up and blood test coverage of the cohorts provided
data showing 75% protection at the tenth to eleventh year of
age against serum HBsAg and against prolonged hepatic
dysfunction. The strategy of controlling hepatitis B
nationwide was based on the universal immunizations of newborns,
beginning in cities and then rural areas. The large-scale
vaccine source was provided by domestic plants through
technology transfer, first providing plasma-derived vaccine
that was replaced completely by recombinant DNA vaccine
in 1997. An official survey in 1999 using a sample of
25 878 children from 31 provinces reported an average coverage
rate of 70.7% using 3 doses of hepatitis B vaccination, and
was found to be higher in urban areas. The Ministry of the
Public Health of China has planned to integrate hepatitis B
vaccination into the nationwide expanded program on
immunization (EPI) program with Government-provided
vaccines starting 1 January 2002[58].
MMT in Germany and China
Government policy for MMT In Germany, substitution
treatment has meanwhile become a central element of opioid
dependence management[59_63]. Throughout the 1970s and
1980s, the drug policy of German governments remained
dominated by a rigid adherence to the abstinence paradigm.
The therapeutic ideal of permanent abstinence for all opiate
users was considered the only valid premise for providing
practical survival support and the only valid criterion for
successful addiction treatment. There was an overall
predominance of drug-free therapy and therapeutic community
(TC) was proclaimed as the "royal road to recovery". Until
the early 1990s, methadone could only be administered to
drug users when highly specific indication criteria were met
(eg emergency cases, such as life-threatening conditions of
withdrawal or conditions of severe pain). In general medical
practice, however, German doctors were prevented from
using methadone to treat heroin addicts, since MMT was
considered medical malpractice. Nevertheless, there were a few
general practitioners (GPs) who ignored the legal regulations
and prescribed methadone to opiate addicts. The legal basis
of substitution treatment was established in 2001 in the
Narcotics Act and the Narcotic Drugs Prescription Ordinance.
The substitution guidelines developed by the German
Medical Association in 2002 are the technical basis for
substitution treatment. They uphold abstinence from the substance
of addiction as the prime treatment endpoint, whereby
securing the individual's survival, stabilizing their health and
social situation, and enabling their professional
rehabilitation and social reintegration are considered preliminary stages
within a comprehensive treatment concept. Substitution
treatment also fulfils preventative functions, such as
prevention of infectious diseases. Substitution treatment is
supposed to be accompanied by psychotherapeutic and
psychosocial measures[62,64]. The Federal Institute for Drugs
and Medical Devices keeps the substitution register on
behalf of the Federal Laender. The tasks of the substitution
register include, in particular, to prevent the multiple
prescription of substitutes by several medical practitioners to 1
patient, checking compliance with the minimum requirements
for the addiction therapy qualification of medical practitioners,
and circulating statistical evaluations to the competent
regulatory authorities and higher health authorities of the
Laender. In 2002, 46 000 patients were recorded; the total
number became 61 000. The number of physicians providing
substitution treatment is currently around 2700. The most
widely reported substitute is methadone. It is notable,
however, that the proportion of buprenorphine has been
rising over recent years[65,66].
Meanwhile, in accordance with the World Health
Organization (WHO) "Guidelines of HIV and AIDS in Prisons",
which recommend that "prisoners on methadone maintenance
prior to imprisonment should be able to continue this
treatment while in prison", substitution treatment is available in
prisons in Germany. However, the implementation is the
responsibility of each of the 16 Federal states (Laender) and
even varies from prison to prison. Only 6 of the 16 Federal
states provide substitution treatment in prisons. It is
estimated that less than 700 inmates participate in substitution
treatment whereas at least one-third of the 10 000
intravenous drug users in prisons on an average day should be
eligible for substitution treatment. Admission criteria vary
between the states and long-term maintenance treatment is
often not an option. Substitution treatment is known to be
an effective response in lowering the risks and harms of
opioid-dependent prisoners by reducing heroin use, drug
injecting and needle sharing, and prison-based drug trade.
The provision should be
broadened[67_70].
To what extent MMT should be included in China in the
treatment strategy has been the subject of controversial
discussion for a decade. Physicians involved in the
management of drug addicts and investigators usually support this
form of treatment, since it has clear positive effects, such as
preventing HIV infection or other harm related to drug
addiction. However, considerable moral objections persist
over whether it is justifiable to supply drug-dependent people
with an addictive substance for a prolonged period of time
or for life at the tax payers' expense. On the other hand, high
recidivism rates in short-term methadone treatment and
drug-free forms of treatment highlight the need to introduce
maintenance treatment. Insofar, it was only consistent that the
Chinese Government should have decided to carry out pilot
studies in particularly affected regions (Yunnan, Guizhou,
Sichuan, Zhejiang, and Guangxi). The first results show
that MMT leads to a reduction in injecting drug use and
criminal behaviors as well as an improvement in social
behavior. Some author[71,72] advocate the combination of
methadone treatment with motivating discussion techniques
(motivational interviewing) and behavioral therapy elements
to enhance retention rates and outcome.
In recent years, China has seen an expansion in harm
reduction-oriented programs as a strategy for addressing
the drug and HIV problem. Nevertheless, there is scant
experience with long-term maintenance treatment.
Methadone-based withdrawal regimens have been performed in China
since 1993. At first, methadone was very difficult to
procure and only a few facilities (clinics) had trained staff to
implement them. While treatment safety and effectiveness
are also acknowledged in China, long-term treatment
regimens are still being piloted. The first 8 MMT clinics were set
up in early 2004, with another 26 in late 2004. In late March
2006, it was reported that 128 methadone clinics had been
set up in the 3 preceding years and the number had increased
to more than 300 by the end of 2006.
In the framework of the "WHO Collaborative Study on
Substitution Therapy of Opioid Dependence and HIV/AIDS
in developing countries in Asia and transition countries in
Europe", the Beijing Drug Withdrawal Center and the
Chinese National Institute on Drug Dependence participated in
the implementation and evaluation of long-term methadone
maintenance treatment. In Beijing in 2005, 10 275 heroin
addicts were registered as undergoing treatment (largely
short-term substitution for detoxification). The average age was
32 years (men: 32.4 years, women: 30.1 years) with a marked
increase over 1998 (when it was approximately 29 years).
About 67.4% of heroin addicts were unemployed, 21.4% were
in private business (self-employed with a low income), 2.9%
were farm workers, 2.2% blue- and white-collar workers, and
1.6% were employed in the public service.
The results of the methadone treatment are convincing;
both the health status and quality of life of addicts have
improved significantly. The severity of dependence clearly
decreased by more than half. The development of
depression fell from 51% to 33%. Neither the HIV rate (3.9%) nor
hepatitis C rate (46%) increased. Moreover, high-risk
consumption patterns, such as injecting, were reduced
signi-ficantly. However, there were no effects in terms of less
risk-fraught sexual behavior. By contrast, crime rates dropped to
0 and the rate of employment increased from 25% to 31%.
Retention rates were 97% after 3 months and 85% after 6
months. The average methadone dose was 39 mg at the
beginning and stabilized at 49 mg per day after 6 months.
MMT is an effective method for reducing illicit opiate
consumption. MMT can substantially improve the health
status of those affected and enhance individuals' quality of
life. However, there are yet only 2 minor MMT programs in
Beijing and they need to be expanded. Although treatment
costs are 10 Yuan (about 1 Euro) per day, the financial
resources needed to scale up the program are not available.
Number of MMT sites It is estimated that about 90% of
substitution patients in Germany receive their medication
from doctors in independent medical practices (GPs), not in
clinics. However, specialized teams mostly run these
practices and the clients are nearly exclusively drug addicts. In a
survey from spring 1996 in a West German region, 70% of all
social health insurance-approved methadone prescriptions
in the area were from GPs, 20% from specialists in internal
medicine, and 6% from psychiatrists. About 50% of GPs in
MMT have up to 10 patients, 40% up to 40 patients, and
10% have more than 40 patients. Seven eight percent of the
61 000 patients get treatment in specialized outpatient
services (with their own psychosocial staff), 20% in practices
which are also treating other patient groups, but that offer
special services for drug users, and (only) 4% in "normal"
practices with family doctors (Table
1)[59]. Therefore, nearly 40%_60% of heroin addicts are reached by MMT.
In order to control spread of AIDS among drug takers,
China plans to set up 1000 clinics that offer methadone
maintenance treatment in next 5 years, and 200 000 drug takers
will receive such treatment. So far, more than 10
000 people have received the treatment in China (Table 2). The working
group has approved establishing the second batch of 300
clinics by June 2006. It is predicted that the number of
clinics will reach 1000 by the end of 2007. There are about
840 000 HIV carriers in China in 2006 and sharing injection
equipment has become the principal way for the spread of AIDS.
In the MMT, drug takers will eventually reduce their
dependence on heroin by taking methadone under doctors'
instructions. The treatment can also decrease the spread of
AIDS caused by the sharing of injecting
equipment[73].
Implication of MMT in China An important factor for
the success of the MMT is support from the municipality
involved. This would also include training for the local
political leadership. Moreover, the dropout rate in the Chinese
programs is too high (30%_40%), and unfortunately, the good
results in Beijing cannot be transferred to all provinces. In
order to reduce the dropout rate requires training of clinic
staff and in addition, training centers should be set up in all
provinces affected. Another requirement is the regular
exchange of experience among the clinics. Moreover, some
clinics have problems in obtaining methadone. It is
necessary to introduce ethical standards for treatment and to
involve nursing staff more strongly. Experience in Hong Kong
specifically indicates that nurses are vital and their work is
more cost-effective. In addition, there is the need for easy
access to clinics and additional psychosocial interventions,
such as motivational interviewing. It is assumed that a
positive, basic attitude of staff towards the program
critically contributes to its success. Moreover, we should bear
in mind that this is a long-term program. In Hong Kong, for
instance, some patients have been attending this program
for as long as 20 years, which is life-maintaining for them,
even though they continue to take opiates.
Experiences of methadone clinics from Yunnan (one of
the most affected regions) indicate the importance of
supporting self-help groups, such as Narcotics Anonymous, for
sustained treatment success. The clients are given the
opportunity to express their points of view. Moreover,
methadone treatment in Yunnan was also integrated in drug-free
programs that the methadone-maintained individuals can use.
Time will tell if China can manage to implement its ambitious
plans. This will result in cooperation options with other
countries that have longer and positive experience with
maintenance and substitution programs. This will certainly
include the experience of Germany and the expert knowledge
available there.
Current drug policy for harm reduction Over the past
decade, Germany has moved towards harm reduction in its
policies and practices regarding illicit drug use and related
problems. This has been in response to the rising rates of
HIV/AIDS, drug-related crime, and mortality. Germany
approved the prescription of
methadone[74-76] and legalized needle/syringe exchanges in the early
1990s[10]. More recently, the Federal Government legalized supervised
injection sites and approved heroin
trials[14,15]. The Social Democrat/Green Party Coalition Government of Chancellor
Schroeder, which came to power in 1998, established new
national priorities and shifted responsibility for demand and
harm reduction from the Home Office to the Ministry of
Health. The Government also appointed a drug
commissioner and established a multidisciplinary advisory body
made up of experts from the field. The Drug Commissioner's
reports address issues concerning both legal and illegal drugs
and propose a greater focus on the social and health
consequences of tobacco and alcohol use. The reports also
emphasize that a variety of measures are needed to address
legal and illegal drug problems, including increased public
awareness, pilot projects, research, coordination with the
Laender, and international cooperation.
Within the Federal structure of Germany, the
responsi-bility, including financial affairs for the areas of health and
prosecution, lies mainly with the Federal Laender. The
Federal Government has the competence for the narcotic
law, the penal law, the law on the execution of penalties, and
the law on social security. On this basis, it defines a legal
framework for drug policy and proposes certain standards.
In June 2003, the Federal Cabinet approved the "Action
Plan Drugs and Addiction" presented by the Federal Drug
Commissioner. It served as a framework plan of addiction
policy for the next 5_10 years and replaced the "Plan to
Combat Drugs" from 1990[10].
In China, in addition to cost and availability, other
factors might also affect acceptability of methadone
maintenance therapy, such as concerns about the safety and
efficacy of the therapy[77]. Greater retention in treatment has
been found to result in greater decreases in drug use,
criminal activity, and unemployment[78]. The length of drug
treatment has a positive association with better post-treatment
outcomes[78]. However, limited experience with MMT in
China shows a high rate of dropouts. International studies
have shown that motivational enhancement therapy or
motivational interviewing enhances treatment initiation, retention,
and outcomes in MMT program[79], and adding behavioral
intervention components into MMT programs increases
abstinence and reduces HIV risk
behaviors[80]. Policy-oriented operational research is needed in China to better
understand how to increase the effectiveness of MMT and
other harm reduction interventions in the Chinese context.
There are still persistent conflicts in the policy and legal
landscape. The Central Government has given explicit
support for harm reduction, as stated in the medium- and
long-term strategic plan and the action plan. Some programs have
been implemented successfully. However, in China, as in
many other countries, public health and public security
authorities frequently approach drug abuse from different
perspectives, leading to conflicting approaches at local levels.
The crackdown philosophy and detention of drug users in
China reflect inconsistent interpretations of "harm
reduction" and present a challenge to public health officials in
implementing methadone substitution and needle-exchange
programs[81]. Drug users may be reluctant to participate in
these programs due to fear of being caught by police officers.
It might be impossible to completely solve the dilemma in the
near future, but this conflict is expected to gradually reduce
for the following reasons. First, Chinese national policies
for HIV prevention and control have become much more
pragmatic in the past years. MMT and needle exchange
programs were almost unimaginable several years ago, but now
they are ready to be expanded across the country. We
expect that the open policy trend will continue as the Chinese
economy increasingly merges with international markets, and
this trend will favor harm reduction programs. Furthermore,
China's Central Government may achieve an advantage in
promoting public health policies if these policies are believed
to be correct. Second, inter-agency coordination on the
public health crisis has been enhanced at both the central
and local governmental levels since the SARS outbreak in
2003, which reduced the potential conflict of public health
policies. Public health workers should provide policy
advocacy to public security authorities and help them change
their traditional norms about illicit drug control and obtain
their support for harm reduction. Third, operational research
is needed to provide evidence on the benefits of harm
reduction programs and convince policy enforcers of the need for
the revision of unfavorable policy components.
Experiences of Germany and future collabo-ration between Germany and China
One important health policy aim is to do the utmost to
prevent or at least considerably reduce risky and damaging
consumption patterns as well as dependence on addictive
substances in our society. Addiction prevention therefore
occupies a prominent place in policy efforts. However, it is
also an objective to be able to recognize risky consumption
patterns at an early stage and reduce them, ensure the
survival of those affected, and treat cases of dependence with
all of the possibilities available according to the current level
of scientific knowledge: from abstinence to
medically-supported therapy. Addiction is a disease that requires treatment.
In Germany, addicts have a legal right to assistance. The
bodies responsible for providing social security benefits (the
health insurance funds, pension insurance funds,
institutions responsible for social assistance, and the municipalities)
are obliged to finance such assistance. Together with the
service providers and self-help groups, they have succeeded
over the past decades in making available a differentiated
range of addiction and drug assistance offers that provide
addicts in need of assistance with a broad spectrum of
different services. Over the past 30 years in Germany, a high
quality and differentiated treatment system has been
developed in the area of addict assistance. This system
comprises outreach and low-threshold forms of assistance,
outpatient counseling and treatment offers, qualified withdrawal
treatment, inpatient detoxification treatment with a
subsequent adaptation phase and follow up, and post-inpatient
care within the framework of integration (eg outpatient
rehabilitation, special care housing, occupational
rehabilitation projects, follow-up care, and self-help
groups)[28,82,83]. These offers are supplemented by a medication-assisted
outpatient treatment system especially for opiate addicts.
Cooperation between the non-institution doctors and the
addict-support system is to be promoted at the interface
with acute medicine. The treatment aims are realistic and
pragmatic and include the following aims:
1. To assist the patient to remain healthy until (with the
appropriate care and support) they can achieve a life free of
drugs.
2. To reduce the use of illicit and non-prescribed drugs
by individuals.
3. To deal with the problems related to drug misuse.
4. To reduce the dangers associated with drug misuse,
particularly the risk of death by overdose and HIV, hepatitis
infections from injecting, and sharing injecting paraphernalia.
5. To reduce the duration of episodes of drug misuse.
6. To reduce the chances of future relapse to drug
misuse.
7. To reduce the need for criminal activities in order to
finance the drug misuse.
8. To improve overall personal, social and family
functioning.
In Germany, a history of substitution treatment
spanning 20 years has meanwhile accumulated a wealth of
experience in the following areas:
· The development of health care services research
· The development of guidelines and the
implementation of quality assurance measures
· The practical implementation of substitution treatment
with the concomitant effects and treatment elements, such
as drug history taking, dosage setting, course of other
psychoactive substances (alcohol, benzodiazepines, cocaine),
management of "difficult patient populations", and
integration of the social environment
· The development of a program for psychosocial
therapies adjuvant to substitution treatment and in the
framework of the pilot project of "heroin-based treatment", also
with standardized manuals
· Allocation research to find the "right" therapy form
at the "right" point in time[84]
· The pilot project "heroin-based treatment" through
experience with clients who do not benefit from methadone
treatment
· Through expertise in the treatment of specific
comorbidities, such as HIV/AIDS and hepatitis and
psychiatric comorbidity
· The (Europe-wide) use of substitution treatment in
prisons
· The promotion and involvement of self-help groups
that are highly relevant
· The production, licensing, distribution, and control
of substitution agents, including the setting up of a
substitution register
· The framework of cooperation with the European
Monitoring Center of Drugs and Drug Addiction in Lisbon,
in the development of Europe-wide standards for
substitution treatment.
China will definitely benefit from the successful
experiences of Germany and other developed countries in
controlling drug abuse and drug-related diseases.
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