How can doctors legally prescribe methampetamine

"The substitution directive should help to reduce the number of drug deaths"

Saarlois - World Drugs Day, officially also called "International Day Against Drug Abuse and Illicit Drug Traffic", will take place on June 26th this year. The day of action was set in December 1987 by the General Assembly of the United Nations and is directed against the abuse of drugs. Doctors and psychotherapists treat addicts, but also play an important role in prevention. The German Medical Association (BÄK) supports them on various levels.

Five questions to Josef Mischo, who, together with the President of the Saxon State Medical Association, Erik Bodendieck, chairs the BÄK working group on addiction and drugs. Mischo is also President of the Saarland Medical Association.

DÄ: In Germany, 1,333 people died last year as a result of using illegal drugs; much of it was addicted to heroin. Many opiate addicts have been substituted with drugs such as methadone by doctors for years. With the change to the Narcotics Prescription Ordinance, the legal security of the substituting doctors is now being strengthened, among other things, the German Medical Association (BÄK) will soon publish a new substitution guideline. What exactly will change for doctors and patients?
Josef Mischo: A very important point is that the goals of substitution treatment are changing. It used to be said that the primary goal of addiction treatment was abstinence and if this is not achieved, treatment must be stopped. But we now know that this is only achievable in a few cases. Of course you have to work towards it, but the substitution can and should therefore still be continued.

Another point is the expansion of the so-called take-home regulation: In the future, the substitution drug may be given to stable patients for a requirement of up to 30 days. This is intended to enable the person affected to master more demanding professional activities, for example. And doctors will in future know much more clearly what they are allowed to do and what not, so that they will have significantly more legal certainty.

We hope, of course, that this will motivate more colleagues to devote themselves to treating opiate addicts and to take on these tasks. And we also hope that with the new substitution directive we will help to reduce the number of drug deaths.

DÄ: The topic of medical cannabis is very important to the public at the moment. Since April it has been possible for doctors to prescribe cannabis flowers to their patients at the expense of the statutory health insurance, if nothing else helps. For many doctors there is still a great deal of uncertainty here
Mischo: The German Medical Association has recently published an FAQ list that provides answers to the most important questions: What do I have to prescribe, what can I prescribe, what does the approval process look like? I think that is a great relief for my colleagues. We are also trying to allay the fears of many doctors.

On the other hand, the expectations of many patients are high, and at the same time the scientific basis for which diseases cannabis can safely be used for is rather weak. The accompanying survey from practice will certainly now provide more knowledge. Cannabis can certainly be used in any case with a pain patient for whom all other therapy options have been exhausted.

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We are planning a conference in autumn with the addiction and drug officers of the state medical associations, where we will also discuss the problems with prescribing and dealing with the approval process of the health insurance companies. We are also planning a scientific part on the topic of the consequences of recreational use of cannabis.

DÄ: That is a good transition. Various legislative initiatives by the Greens and the Left have called for a regulated release of cannabis for adults in Germany in recent years. The position of the BÄK is clearly negative. Would you like to underpin this by presenting the current study situation?
Mischo: A scientific study is currently running on behalf of the Federal Ministry of Health, the results will be communicated to us. What we currently know is that there is no all-clear. Cannabis use is problematic and the younger the user is, the more problematic it is. We will discuss this in detail at this conference and then the working group on addiction and drugs will submit a corresponding recommendation to the board of the BÄK. It is very likely that this recommendation will be just as restrictive as the previous one.

DÄ: Alcohol is a legal drug, but according to the Addiction Yearbook it causes around 74,000 deaths each year. How can doctors help counteract excessive alcohol consumption by their patients?
Mischo: I would like to encourage colleagues to speak to patients if they suspect their alcohol consumption. Patients who come to the clinic or practice and suspect chronic alcohol abuse must be addressed about it. Of course, we have the problem that there is little time for such discussions in everyday practice.

Basically, it is important to limit the supply of alcohol at night, for example at petrol stations, and to prohibit it for young people. I am glad that the trend towards comatose drinking is declining among young people. Nonetheless, alcohol abuse remains a major problem and we must continue to raise awareness among doctors and patients.

DÄ: Crystal meth is another drug that is highly addictive and appears to be neurotoxic. Every year around 3,000 people become suspicious of their crystal meth consumption. In order to give doctors and psychotherapists more confidence in dealing with patients, the world's first S3 guideline "Methamphetamine-related disorders" was published at the end of 2016, in which the BÄK was involved. Are there any initial experiences from the medical associations as to whether the treatment guidelines are being used in practice?
Mischo: So far we have not yet received any clear feedback from the medical associations, but we will discuss this at the conference in autumn. We have the phenomenon here that the medical associations are affected very differently. The doctors who work in the border regions to the Czech Republic are much more affected than we are here in Saarland, for example.

As the German Medical Association, we are planning to include the topic of crystal meth as a module in the “Basic Psychosomatic Care” curriculum in accordance with the guideline. We have received very positive feedback on the S-3 guideline from the professional associations. Also from the international area, so that this guideline will soon also appear in English.

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