Trends In Substance Use And Related Disorders: Analysis of the Epidemiological Survey of Substance Abuse 1995 to 2018

Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany - a large retrospective observational study

BACKGROUND

High-dose long-term opioid therapy (LTOT) has been associated with increased mortality and hospitalizations. Therefore, the evidence-based German guideline on LTOT for chronic non-cancer pain (CNCP) recommends to only exceed the maximum daily dose (MDD) of opioids in exceptional cases. This study aimed to determine the portion of LTOT patients who exceeded the guideline-recommended MDD and identify predictors of exceeding in administrative claims data.

METHODS

The retrospective observational analysis of opioid prescriptions in patients receiving LTOT for CNCP was based on administrative claims by a large German statutory health insurance company. Patients with at least two quarters of opioid prescriptions between January 2018 and June 2019 were included and followed up for two years. Predictors were identified by logistic regression. In addition, the number of patients still in opioid therapy and the extent of exceeded MDDs were analyzed over time.

RESULTS

The sample consisted of 113,475 patients. Overall, 10.5% of the patients exceeded the guideline-recommended MDD averaged over the observation period. Strong predictors for exceeding the MDD were receiving opioid prescriptions from > 7 physicians (OR = 7.66, p < .001), receiving predominantly strong opioids (OR = 6.79, p < .001) and receiving opioids for at least one year prior to inclusion (OR = 5.35, p < .001). Within the non-exceeding group, 28.1% discontinued opioid therapy. In contrast, 9.9% of patients in the exceeding group discontinued opioid therapy, whereas the vast majority remained on treatment until the end of the observation period. Furthermore, a slight increase in prescribed doses was observed over time.

CONCLUSIONS

The results indicate that a moderate proportion of patients exceeded the guideline-recommended MDD. However, certain patient groups were more likely to receive high doses. This applied in particular to those who were already on treatment at the time of inclusion and continued to receive opioids until the end of the observation period. Further research should examine whether the continuous opioid therapy among the patients with exceeding the guideline-recommended MDD might be related to specific indications, a lack of therapeutic options or avoidance of withdrawal.

TRIAL REGISTRATION

German Clinical Trials Register (drks.de/search/en). Identifier: DRKS00024854. Registered 28 April 2021.

Incidence trend of type 2 diabetes from 2012 to 2021 in Germany: an analysis of health claims data of 11 million statutorily insured people

AIMS/HYPOTHESIS

The aim of the study is to describe the time trend of type 2 diabetes incidence in the largest state of Germany, Bavaria, from 2012 to 2021, and to compare the incidence rates during the pandemic period (2020-2021) to the pre-pandemic period (2012-2019).

METHODS

This secondary data analysis uses health claims data provided by the Bavarian Association of Statutory Health Insurance Physicians (KVB), covering approximately 11 million insurees, accounting for 85% of the total population of Bavaria, Germany. Newly diagnosed type 2 diabetes cases in adults (≥20 years) coded as E11 (Diabetes mellitus, Type 2) or E14 (Unspecified diabetes mellitus) under ICD-10, German modification (ICD-10-GM) for the study period 2012 to 2021 were included. Annual and quarterly age-standardised incidence rates (ASIR) stratified by sex, age and region were calculated using the European standard population. Sex-specific crude incidence rates (CIR) were calculated using 10-year age groups. Regression analyses adjusted for time trends, seasonal effects, and pandemic effects were used to analyse the incidence trend and to assess the effect of the pandemic.

RESULTS

Overall, 745,861 new cases of type 2 diabetes were diagnosed between 2012 and 2021: 50.4% (376,193 cases) in women. The male/female ratio remained stable over the observation period, while the median age at diagnosis decreased from 61 to 58 years in men and from 66 years to 61 years in women. ASIR were consistently higher for men compared with women, with the yearly difference remaining stable over time (2012: 18%; 2021: 20%). An overall decreasing trend in ASIR was observed during the study period, with a strong decrease from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021 for both sexes. For men, ASIR decreased from 1514 per 100,000 person-years in 2012 to 995 per 100,000 person-years in 2021 (4.6% average annual reduction), and for women from 1238 per 100,000 person-years in 2012 to 796 per 100,000 person-years in 2021 (4.8% average annual reduction). This downward trend was also observed for age groups above 50 years. Regression analyses showed no significant change in incidence rates during the pandemic period (2020 and 2021) compared with the pre-pandemic period.

CONCLUSIONS/INTERPRETATION

For the first time, a 10-year incidence trend of type 2 diabetes is reported for Germany, showing a strong decline from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021. The incidence trend of type 2 diabetes appears not to have been affected by the first 2 years of the COVID-19 pandemic. Despite an overall increasing prevalence, the incidence is decreasing, potentially resulting from robust screening by family physicians, reducing the median age at diagnosis by 3 to 5 years. However, further investigation is needed to fully identify the reasons for the declining incidence trend. Continued incidence monitoring is necessary to identify the long-term trend and the potential effect of the pandemic on diagnoses of type 2 diabetes.

Clustering care pathways of people with alcohol dependence using a data linkage of routine data in Bremen, Germany

BACKGROUND

Although many individuals with alcohol dependence (AD) are recognized in the German healthcare system, only a few utilize addiction-specific treatment services. Those who enter treatment are not well characterized regarding their prospective pathways through the highly fragmented German healthcare system. This paper aims to (1) identify typical care pathways of patients with AD and their adherence to treatment guidelines and (2) explore the characteristics of these patients using routine data from different healthcare sectors.

METHODS

We linked routinely collected register data of individuals with a documented alcohol-related diagnosis in the federal state of Bremen, Germany, in 2016/2017 and their addiction-specific health care: two statutory health insurance funds (outpatient pharmacotherapy for relapse prevention and inpatient episodes due to AD with and without qualified withdrawal treatment (QWT)), the German Pension Insurance (rehabilitation treatment) and a group of communal hospitals (outpatient addiction care). Individual care pathways of five different daily states of utilized addiction-specific treatment following an index inpatient admission due to AD were analyzed using state sequence analysis and cluster analysis. The follow-up time was 307 days (10 months). Individuals of the clustered pathways were compared concerning current treatment recommendations (1: QWT followed by postacute treatment; 2: time between QWT and rehabilitation). Patients' characteristics not considered during the cluster analysis (sex, age, nationality, comorbidity, and outpatient addiction care) were then compared using a multinomial logistic regression.

RESULTS

The analysis of 518 individual sequences resulted in the identification of four pathway clusters differing in their utilization of acute and postacute treatment. Most did not utilize subsequent addiction-specific treatment after their index inpatient episode (n = 276) or had several inpatient episodes or QWT without postacute treatment (n = 205). Two small clusters contained pathways either starting rehabilitation (n = 26) or pharmacotherapy after the index episode (n = 11). Overall, only 9.3% utilized postacute treatment as recommended.

CONCLUSIONS

A concern besides the generally low utilization of addiction-specific treatment is the implementation of postacute treatments for individuals after QWT.

[Effectiveness of a cannabis prevention program in school: results of a randomized prospective study]

BACKGROUND

In the current debate about legalized access to cannabis for adults in Germany, there is widespread agreement about the need for increased prevention among children and young people. The aim of this work is to examine the effectiveness of a school-based cannabis prevention program on knowledge, attitudes, and behavior.

METHOD

Cluster-randomized waiting list control group study with two study arms: "participation in the 'Der grüne Koffer' prevention program", a collection of methods for cannabis prevention, vs. "no participation" and two measurement time points before and four months after the intervention in four German states.

RESULTS

The mean age of the sample of 3976 adolescents from 280 school classes in grades 8 and 9 was 14.02 years (standard deviation = 0.89). The sex ratio was balanced (49.5% female). Cannabis-related knowledge increased significantly more in the intervention group compared to the control group from the first to the second measurement time point (adjusted beta = 0.25 [95% confidence interval: 0.14-0.37]). Attitudes toward cannabis use did not change significantly in either group. In the 8th grades of the intervention group, significantly fewer adolescents (2.9%) started experimenting with cannabis use for the first time during the observation period than in the control group (5.3%), whereas no group difference was detectable in the 9th grades (interaction grade level x group: odds ratio = 2.17 [1.13-4.15], p = 0.019).

DISCUSSION

The evidence of an effect of participation in the "Der grüne Koffer" prevention program on knowledge and first-time use of cannabis in the 8th grade can be considered promising against the background of previous national and international studies, which could not provide evidence of effects of school-based cannabis prevention in middle and late adolescence.

When Public Will Meets Legislative Resistance: Five Lessons from Ohio's Issue 2 Cannabis Legalization Controversy

In this paper, I explore the challenges of legalizing cannabis in Ohio, focusing on the passing of the Issue 2 Bill, legislative resistance, and public response. I propose five strategies for effective policy change: persistent advocacy post policy change success, establishing strong coalitions, empowering grassroots movements, promoting rigorous data-driven research, and launching public education campaigns. I offer a detailed analysis of the interaction between public opinion and legislative action in cannabis legalization and its implications for substance-related policy change.

Prevalence of substance use disorders and associations with mindfulness, impulsive personality traits and psychopathological symptoms in a representative sample of adolescents in Germany

Adolescence is a critical phase for the development of substance use disorders (SUDs). For Europe and Germany, there are limited data on problematic substance use from representative youth samples. Trait mindfulness is relevant in buffering against substance use-related problems and associated deficits in self-regulatory control. The objective of this study is to estimate 12-month prevalence rates for SUDs in a representative sample of adolescents in Germany and to examine associations with mindfulness and related factors such as stress, impulsivity, sensation seeking and symptoms of psychopathology. A sample of 4001 adolescents aged 12-18 years from Germany was surveyed based on DSM-IV diagnostic criteria for SUDs. Logistic regression analyses were used to examine associations with mindfulness-related variables. Criteria of at least one of the assessed SUDs were endorsed by 11.2% of the adolescents. Alcohol use disorders had the highest prevalence rate (10.1%) followed by cannabis use disorders (2.6%). For both substances, the criteria for abuse were met about twice as often as those for dependence. The prevalence of cigarette dependence was 1.7%, while the prevalence for e-cigarette dependence was only 0.1%. Prevalence rates were higher for male youth and increasing with age. SUD prevalence was also related to mindfulness, impulsivity and sensation seeking and externalizing symptoms of psychopathology. The statistically significant associations varied across different SUDs. SUDs appear highly prevalent among German adolescents. The results have public health implications with regard to treatment needs and prevention measures in the youth population in Germany.

Population-based examination of substance use disorders and treatment use among US young adults in the National Survey on Drug Use and Health, 2011-2019

Background

Compared with adults of other age groups, young adults are more likely to have substance use disorders (SUDs) but less likely to receive treatment. Untreated SUDs can lead to lethal consequences, particularly deaths related to drug overdose.

Objectives

This study aimed to examine trends and sociodemographic differences in the prevalence and treatment use of SUDs among US young adults aged 18 to 25 in the National Survey on Drug Use and Health 2011-2019.

Methods

Bivariable logistic regression analyses were conducted to examine annual changes in the prevalence and treatment use of SUDs, and multivariable logistic regression was used to examine sociodemographic differences in SUD prevalence and treatment use in the pooled sample of young adults from 2011 to 2019.

Results

From 2011 to 2019, the overall SUD prevalence increased significantly from 5.4% to 6.2%. Cannabis use disorder was the most common SUD annually. Groups with lower prevalence of SUDs included females, young adults aged 22-25, and Hispanic, Black, and Asian participants. Across the survey years, the prevalence of treatment use fluctuated insignificantly between 10.9% and 16.9% among young adults with SUDs, and most young adults received SUD treatment in self-help groups and residential and outpatient rehabilitation facilities. Compared to White participants, treatment use was lower in Hispanic, Black, Asian participants, as well as young adults of two or more races. Young adults covered by Medicaid/CHIP were more likely to use treatment.

Conclusions

This study revealed an alarming level of unmet treatment need and significant disparities in treatment use among young adults with SUDs. To reduce barriers to treatment utilization, more coordinated efforts that leverage policy and structural changes alongside innovations to engage young adults with SUD care are needed.

Spatio-Temporal Trends in the Incidence of Type 2 Diabetes in Germany

BACKGROUND

There are no data on recent trends in the incidence rate of type 2 diabetes (T2D) in Germany. The aim of this study was to determine the sex-, age-, and region-specific trends in the T2D incidence rate between 2014 and 2019.

METHODS

Based on nationwide data from statutorily insured persons in Germany, negative binomial regression models were used to analyze age- and sex-specific trends in the T2D incidence rate. Age- and sex-adjusted trends were calculated for 401 administrative districts using a Bayesian spatio-temporal regression model.

RESULTS

During the period concerned, approximately 450 000 new cases of T2D were observed each year among some 63 million persons. Taking all age groups together, the incidence rate decreased in both women and men, from 6.9 (95% confidence interval [6.7; 7.0]) and 8.4 [8.2; 8.6] respectively per 1000 persons in 2014 to 6.1 [5.9; 6.3] and 7.7 [7.5; 8.0] per 1000 persons in 2019. This corresponds to an annual reduction of 2.4% [1.5; 3.2] for women and 1.7% [0.8; 2.5] for men. The incidence rate increased in the age group 20-39 years. The age- and sex-adjusted incidence rate decreased in almost all districts, although regional differences persisted.

CONCLUSION

The T2D incidence rate should be closely monitored to see whether the decreasing trend continues. One must not forget that the prevalence can rise despite decreasing incidence. For this reason, the findings do not necessarily mean a decrease in the disease burden of T2D and the associated demand on healthcare resources.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

BACKGROUND

Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany.

METHODS

We assessed data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality.

RESULTS

The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts.

CONCLUSIONS

Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

Smoking behaviour and passive smoke exposure of adults - Results from GEDA 2019/2020-EHIS

Background

Smoking is a significant health risk and the leading cause of premature death. Passive smoke causes the same negative effects on health as smoking, albeit to a lesser extent. The reduction of tobacco consumption and the protection against passive smoke are thus important health objectives.

Methods

The study German Health Update (GEDA 2019/2020-EHIS) is a cross-sectional telephone survey (04/2019 to 09/2020) of the resident population in Germany with questions relating to the current smoking behaviour and relating to the passive smoke exposure. The analysis sample comprises 22,708 persons from 18 years of age.

Results

24.0% of women and 33.9% of men from 18 years of age smoke currently, at least occasionally. Among both sexes, adults from 65 years of age smoke significantly more rarely than adults in the younger age groups. 4.1% of adults, who do not smoke themselves, are subjected daily to passive smoke exposure indoors. This affects in particular young adults and men. There are educational differences in tobacco consumption and in passive smoke exposure to the disadvantage of adults from lower educational groups.

Conclusions

In Germany, there is still a need for action for effective measures for tobacco prevention, smoking cessation and tobacco control policy, which are effective in all population groups and which take into account the concerns of socially disadvantaged groups.

The Use of Psychoactive Substances in Germany

BACKGROUND

Monitoring the use of psychoactive substances and substance-related problems in the population allows for the assessment of prevalence and associated health and social consequences.

METHODS

The data are derived from the Epidemiological Survey of Substance Abuse (ESA) 2021 (n = 9046, 18-64 years). We estimated prevalence rates of the use of tobacco, alcohol, illegal drugs, and psychoactive medications, as well as the prevalence rates of their problematic use (indicating dependence) using screening instruments, and extrapolated the results to the resident population (N = 51 139 451).

RESULTS

Alcohol was the most frequently used substance, with a 30-day prevalence of 70.5% (36.1 million people), followed by non-opioid analgesic drugs (47.4%; 24.2 million) and conventional tobacco products (22.7%; 11.6 million). E-cigarettes were used by 4.3% (2.2 million) and heat-not-burn products by 1.3% (665 000). Among illegal drugs (12-month prevalence), cannabis was the most frequently used (8.8%; 4.5 million), followed by cocaine/crack (1.6%; 818 000) and amphetamine (1.4%; 716 000). Rates of problematic use among the study participants were 17.6% for alcohol (9.0 million), 7.8% for tobacco (4.0 million), 5.7% for psychoactive medications (2.9 million), and 2.5% for cannabis (1.3 million).

CONCLUSION

The consumption of psychoactive substances continues to be widespread in Germany. In view of the imminent legal changes, the high prevalence of cannabis use and its problematic use need to be taken into consideration.

Changes in the Use of Tobacco, Alternative Tobacco Products, and Tobacco Alternatives in Germany

BACKGROUND

Due to the increasing use of alternative tobacco products (waterpipes, heat-not-burn) and tobacco alternatives (e-cigarettes), we studied recent changes in the prevalence of conventional tobacco use and alternative products.

METHODS

Data come from ten waves of the Epidemiological Survey of Substance Abuse (ESA) from 1995 to 2021, with representative samples collected via paperpencil questionnaires, telephone interviews, or online. We compared the prevalence of conventional tobacco use and alternative products by gender and age (18-24, 25-39, 40-59 years).

RESULTS

In all age groups, the use of conventional tobacco products decreased. The prevalence of the exclusive use of one of the three alternative products differed statistically significantly between age groups and in 2021 was higher for ages 18-24 (females: 11.1%, males: 12.4%) compared to ages 25-39 (females: 2.9%; males: 4.9%) and ages 40-59 (females: 1.4%; males: 2.0%). The use of alternative products was mainly due to the exclusive use of waterpipes among individuals aged 18 to 24 and 25 to 39 and the exclusive use of e-cigarettes among individuals aged 40 to 59.

CONCLUSION

The higher prevalence of alternative product use among young adults implies a turning point that needs to be considered in prevention. Because of the addictive potential of these products, young adults can be expected to maintain their use into middle and older adulthood. There is a need to monitor the use of alternative products, identify the risks associated with them, and develop effective prevention and cessation interventions for adults.

Age, period, and cohort effects on trends in outpatient addiction care utilization in the general Berlin population from 2008 to 2016

Background

The aim of this study was to decompose independent effects of age, period, and cohort on trends in outpatient addiction care utilization resulting from alcohol (AUD) and illicit substances use disorders (ISUD). Decomposing trends in addiction care utilization into their independent effects by age, period, and cohort may lead to a better understanding of utilization patterns.

Methods

Individuals seeking help in Berlin outpatient addiction care facilities between 2008 and 2016 with an age range of 18–81 years for AUD (n = 46,706) and 18–70 years for ISUD (n = 51,113) were standardized to the general Berlin population using data from the German Federal Statistical Office. Classification of utilization as AUD- (F10) or ISUD-related (F11, F12, F14, F15, F16, F18, F19) help-seeking was based on primary diagnoses according to the International Statistical Classification of Diseases and Related Health Problems. Age was measured in years and period as year of data collection. Cohort was defined as the mathematical difference between period and age. Age, period, and cohort analyses were conducted using the intrinsic estimator model on AUD- and ISUD-related outpatient addiction care utilization.

Results

Age effects on AUD-related utilization were highest in 18- to 19-year-old and in 39- to 59-year-old individuals. ISUD-related utilization declined almost continuously with increasing age. Period effects on AUD- and ISUD-related utilization were small. AUD-related utilization was highest in cohorts born from 1951 to 1986. ISUD-related utilization increased in cohorts born between 1954 and 1973 where utilization peaked, followed by a decline of the same order.

Conclusions

Age and cohort effects were the strongest drivers of trends in AUD- and ISUD-related outpatient addiction care utilization. Onset of help-seeking in earlier phases of AUD development should be enhanced as well as help-seeking for AUD and ISUD in general. The highest cohort-related rates in the baby boomer and following cohorts for AUD and ISUD underline an increased demand for addiction care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12744-6.

Association of impulsivity with quality of life and well-being after alcohol withdrawal treatment

OBJECTIVES

Impulsivity is related to a higher risk of relapse in alcohol use disorders. However, besides drinking behavior, other recovery outcomes like physical and mental health-related quality of life are at least as important. The present study aimed to fill a research gap regarding the association of different impulsivity facets with health-related quality of life and well-being in alcohol use disorder.

METHODS

Individuals with a primary alcohol use disorder diagnosis (n = 167) were interviewed with standardized self-report measures at the progressed stage of their withdrawal treatment and 6 weeks thereafter. Multiple regression models were calculated to examine the association of impulsivity, craving, and drinking patterns with health-related quality of life and well-being 6 weeks after withdrawal treatment, as well as the predictive role of impulsivity assessed during withdrawal for these two outcomes.

RESULTS

Craving was associated with health-related quality of life and well-being 6 weeks after withdrawal. Likewise, non-planning and attentional impulsivity were associated with well-being 6 weeks after withdrawal. Motor impulsivity during withdrawal treatment predicted health-related quality of life 6 weeks thereafter.

CONCLUSION

Impulsivity seems to be negatively related to health-related quality of life and well-being in the first weeks after alcohol withdrawal treatment, probably to a higher extent than drinking patterns, but differentiating between its facets seems to be important. These findings emphasize the importance of treatment approaches aiming at reduced impulsivity in the early recovery process.

Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study

BACKGROUND

Screening, brief intervention and referral to treatment (SBIRT) is a programme to reduce alcohol consumption for drinkers with high alcohol consumption levels. Only 2.9% of patients in primary health care (PHC) are screened for their alcohol use in Germany, despite high levels of alcohol consumption and attributable harm. We developed an open-access simulation model to estimate the impact of higher SBIRT delivery rates in German PHC settings on population-level alcohol consumption.

METHODS AND FINDINGS

A hypothetical population of drinkers and non-drinkers was simulated by sex, age, and educational status for the year 2009 based on survey and sales data. Risky drinking persons receiving BI or RT were sampled from this population based on screening coverage and other parameters. Running the simulation model for a ten-year period, drinking levels and heavy episodic drinking (HED) status were changed based on effect sizes from meta-analyses. In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German population received a subsequent intervention between 2009 and 2018. If every second PHC patient would have been screened for alcohol use, 21% of adult residents in Germany would have received BI or RT by the end of the ten-year simulation period. In this scenario, population-level alcohol consumption would be 11% lower than it was in 2018, without any impact on HED prevalence. Screening coverage rates below 10% were not found to have a measurable effect on drinking levels.

CONCLUSIONS

Large-scale implementation of SBIRT in PHC settings can yield substantial reductions of alcohol consumption in Germany. As high screening coverage rates may only be achievable in the long run, other effective alcohol policies are required to achieve short-term reduction of alcohol use and attributable harm in Germany. There is large potential to apply this open-access simulation model to other settings and for other alcohol interventions.

[Trends in dental and oral health status in Germany between 1997 and 2014]

Hintergrund

Zur Veränderung der oralen Krankheitslast in der deutschen Allgemeinbevölkerung über die letzten 20 Jahre gibt es bisher keine umfassende Darstellung.

Fragestellung

Wie haben sich die Prävalenzen der Karies, der Parodontitis und des Zahnverlustes und deren Determinanten von 1997 bis 2014 in Deutschland verändert?

Material und Methoden

Ausgewertet wurden Daten von 35- bis 44- und 65- bis 74-Jährigen der Deutschen Mundgesundheitsstudien (DMS) III, IV und V sowie von 25- bis 74-Jährigen der Studies of Health in Pomerania (SHIP‑0 und SHIP-Trend-0). Der Decayed, Missing, Filled Teeth Index (DMFT), die Anzahl füllungsfreier Zähne, der Community Periodontal Index (CPI) als auch Daten zur Zahnzahl und Zahnlosigkeit wurden herangezogen.

Ergebnisse

In beiden Studien waren bzgl. der Determinanten eine Zunahme der Probanden mit hoher Schulbildung, eine geringfügige Abnahme der Raucher sowie eine Verbesserung der Mundhygiene zu beobachten. Bei den 35- bis 44-Jährigen stieg die Anzahl gesunder Zähne von 11,9 in DMS III auf 16,8 in DMS V, während bei den Senioren die Anzahl gesunder Zähne um 5,9 anstieg. In SHIP wurde ein ähnlicher Trend beobachtet. Die Prävalenz des höchsten CPI-Grades 4 fiel in den DMS bei den 35- bis 44-Jährigen von 9,3 % auf 3,5 %; bei den Senioren lag der Wert 2014 wieder auf dem Niveau von 1997 (10,5 % und 9,8 %). Parallel dazu hat sich der Anteil der zahnlosen Senioren in beiden Studien halbiert. Die Zahnzahl nahm über alle Altersklassen hinweg zu.

Diskussion

DMS und SHIP zeigten über die Jahre konsistent eine Zunahme gesunder, füllungsfreier Zähne, eine geringfügige Reduktion der Probanden mit CPI-Grad 4 sowie mehr Zahnerhalt und weniger Zahnlosigkeit. Bedingt durch den höheren Zahnerhalt und die Alterung der Gesellschaft ist in Zukunft mit einer erhöhten parodontalen Behandlungslast zu rechnen.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03345-6) enthalten.

[National efforts for alcohol prevention by the Federal Center for Health Education (BZgA)]

Alcohol consumption in Germany continues to be high relative to its European neighbors. A long-term reduction of alcohol consumption can result in a reduction of the morbidity and mortality associated with alcohol. For many years now, the Federal Centre for Health Education (BZgA) has directed its focus in the field of addiction prevention on alcohol prevention and implemented three national multilevel campaigns intended for this target group. "Null Alkohol - Voll Power" (No Alcohol - Full Power) addresses adolescents between the ages of 12 and 16 and the campaign "Alkohol? Kenn dein Limit." (Alcohol? Know Your Limit.) comprises two separate campaigns dedicated to adults and 16- to 20-year-olds, respectively. Further, the BZgA provides sports clubs with the opportunity to participate in a program entitled "Alkoholfrei Sport genießen" (Enjoying Sports Without Alcohol). In this contribution, these measures and their foundational concepts are presented.The campaigns are interconnected to form a prevention chain that serves to bundle the individual efforts. All are based on the principles of social marketing and are continually quality checked. At the center of these efforts lies internet communication, complemented by direct communication in the lives of the target groups as well as mass communication in the form of billboards, TV and radio spots, ads, and print media. The BZgA is able to implement these programs in schools, clubs, and at the municipal level because of the good cooperation and coordination it maintains with the individual federal states. For decades now, the BZgA has conducted monitoring in the form of regular representative surveys, among others, on the subject of alcohol consumption behavior among 12- to 25-year-olds in Germany. The results show that although overall alcohol consumption may be on the decline over the long term, it still remains high.

Decreasing Non-bladder-cancer Mortality After Radical Cystectomy

Life expectancy is increasing in many parts of the world. Using proportional hazard models for competing risks, we investigated whether this increase has changed outcomes after radical cystectomy in a sample of 1419 consecutive patients treated between 1993 and 2018. During the observation period, the mean age and the proportion of patients with American Society of Anesthesiologists physical status class 3 or 4 increased, whereas the proportion of patients with heart disease decreased. Competing mortality (causes other than bladder cancer) decreased in all subgroups (hazard ratios [HRs] per year ranged from 0.931 to 0.963) and after controlling for increasing age (HRs ranged from 1.018 to 1.081). In an optimal model resulting from an analysis including age (HR per year 1.048, 95% confidence interval [CI] 1.027–1.070; p < 0.0001), comorbidity, tumor-related variables, body mass index, (neoadjuvant and adjuvant) chemotherapy and smoking status, the HR per increment for year of surgery was 0.928 (95% CI 0.886–0.973; p = 0.0019). The effect of year of surgery was greater than the decrease in competing mortality that may be expected with increasing life expectancy (4 yr for females, 6 yr for males).

Patient summary

In a review of data for 1993–2018, we found that death from other causes after removal of the bladder (radical cystectomy) for bladder cancer decreased over time. This decreasing trend might increase the age limit at which bladder cancer patients can benefit from radical cystectomy in the future.

[Age-specific trends in risky drinking in Germany: collectivity or polarisation?]

Einleitung

Nach der Collectivity-of-Drinking-Cultures-Theorie von Skog finden Veränderungen des Alkoholkonsums in allen Bevölkerungsgruppen und -schichten als parallele Verschiebungen statt. Ziele des vorliegenden Beitrags sind (1) die Darstellung zeitlicher Trends des riskanten Konsums und des episodischen Rauschtrinkens nach Altersgruppen und Geschlecht und (2) die Prüfung, ob die Trends in allen Altersgruppen parallel verlaufen („Kollektivität“) oder zwischen Altersgruppen divergieren („Polarisierung“).

Methoden

Datengrundlage sind 9 Erhebungen des Epidemiologischen Suchtsurveys (ESA) zwischen 1995 und 2018. Als Schwellenwert für riskanten Alkoholkonsum wurde ein täglicher Konsum von mehr als 12 g Reinalkohol bei Frauen beziehungsweise 24 g bei Männern herangezogen. Episodisches Rauschtrinken wurde als Konsum von 5 oder mehr Gläsern Alkohol (ca. 70 g Reinalkohol) an mindestens einem Tag in den letzten 30 Tagen definiert. Lineare Regressionen wurden für die Vorhersage des zeitlichen Effekts auf riskanten Konsum bzw. Rauschkonsum nach Altersgruppen (18–29, 30–39, 40–49 und 50–59 Jahre) und Geschlecht getrennt berechnet und auf Unterschiede geprüft.

Ergebnisse

Die Entwicklungen riskanten Alkoholkonsums nach Altersgruppen verlaufen bei Männern weitgehend parallel, bei Frauen gegenläufig. Die Trends des episodischen Rauschtrinken weisen bei beiden Geschlechtern keine parallele Entwicklung auf: Während in der jüngsten und ältesten Altersgruppe die Prävalenz im Zeitverlauf anstieg, sank sie in den übrigen Altersgruppen.

Diskussion

Vor dem Hintergrund einer generellen Abnahme spricht die Zunahme in den Trends risikoreichen Alkoholkonsums in bestimmten Gruppen für einen Ausbau verhaltenspräventiver Maßnahmen. Zur Fortsetzung der positiven Entwicklung und der Vermeidung einer Trendumkehr sollten zudem auf die Gesamtbevölkerung ausgerichtete Präventionsanstrengungen intensiviert werden, beispielsweise durch Erhöhung der Alkoholsteuer oder Reduktion der Verfügbarkeit von Alkohol.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03328-7) enthalten.

Escaping the past and living in the present: a qualitative exploration of substance use among Syrian male refugees in Germany

Background

Syrians have been the largest group of refugees in Germany since 2014. Little is known about Syrian refugees` perspectives on substance use. The aim of this study is to investigate the perspective of male refugees from Syria and to foster specific knowledge and understanding of substance use.

Methods

We applied a qualitative study design. Five semi-structured focus group discussions with a total of 19 refugees were conducted in 2019 among the difficult to reach population of Syrian refugees. Audio recordings were translated and transcribed. We used a hybrid approach by integrating inductive and deductive thematic frameworks.

Results

We identified common themes. Firstly, refugees perceived that substances are widely available and accepted in Germany. Secondly, refugees perceived that rules and norms in Germany differ from rules and norms in the home country and favor availability of substances. Thirdly, substance use is related to the intention to escape the past. Fourthly, substance use is related to living in the present through connecting with others and being part of the community. Finally, mental health professional treatment for substance use is associated with shame.

Conclusions

Findings support Syrian refugees` perspectives of substance use as a way of both escaping the past and coping with psychosocial difficulties in the present in a socio-ecological understanding. Understanding the explanatory model of Syrian refugees can inform future interventions to prevent substance abuse and design tailored interventions. Further studies with Syrian refugees in more countries are needed to better understand resettled refugees` perspectives on substance use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00352-x.

Trends in risky prescriptions of opioid analgesics from 2011 to 2015 in Northern Germany

INTRODUCTION

Due to their euphoric and sedative effects, opioid analgesics have high potential for abuse and dependence. In the last decade in the USA and many Western European Countries the prescription rates of opioid analgesics have steadily increased.

OBJECTIVE

This study describes 5-year trends in the prescription of opioid analgesics and risk indicators such as duration, dose and 'doctor shopping' in Northern Germany.

METHODS

The annual rates of opioid analgesic prescriptions have been analysed for patients with statutory health insurance processed by the North German Pharmacy Data Center for the years 2011-2015. A distinction was made between non-cancer patients and cancer patients, and different groups according to prescription duration and dose level.

RESULTS

Between 2011 and 2015, the annual number of patients with opioid analgesic prescriptions increased from 500,000 to 550,000. About half of non-cancer-patients (85% of the total sample) and cancer patients received opioid analgesics for 90 days or less. The rates for long-term prescriptions (⩾9 months) ranged between 6-7% for non-cancer patients and 7-8% for cancer patients. Between 1.2-1.8% received opioid analgesics in doses of more than two defined daily doses. The majority of non-cancer patients with opioid analgesic prescriptions were female. The average age of non-cancer patients was 66 years. About 80% of non-cancer patients with first opioid analgesic prescription received World Health Organization step II medication.

CONCLUSION

For the first time, this study provides comprehensive patient-related analyses of opioid analgesic prescriptions in Germany over a 5-year period. Despite a slight increase in the overall number of opioid analgesic prescriptions, an epidemic spread of opioid analgesics cannot be observed.

Controlled administration of cannabis to mitigate cannabis-attributable harm among recreational users: a quasi-experimental study in Germany

Background: New approaches are required to slow down or reverse increasing trends of levels of delta-9-tetrahydrocannabinol (THC) and cannabis-attributable hospitalizations in Germany. Legal access to cannabis may constitute one viable effective policy response; however, available evidence does not suffice to inform a regulation model for Germany. The proposed study aims to reduce harm for cannabis users through legal access to herbal cannabis through pharmacies.

Protocol: A quasi-experimental study comparing cannabis users with legal access to herbal cannabis (Berlin, intervention group) to those without legal access (Hamburg, control group) (total N=698). As the primary outcome, we hypothesize that: 1) illegal THC consumption will reduce by at least 50% in the intervention group and 2) total THC exposure in the intervention group will be reduced by at least 10% lower than that of the control group, taking into account baseline values. Secondary outcomes comprise measures of frequency of use, THC-impaired driving, and mode of administration. Paired t-tests and multilevel regression models will be performed for statistical analyses.

Discussion: This study proposal is currently being reviewed by the ‘Federal Institute for Drugs and Medical Devices’ – the body responsible for approving research studies on classified substances, including cannabis. Upon approval and prior to the start of the study, a full ethical review will be undertaken. Results may inform a regulation model for Germany and other jurisdictions and are expected to deepen the understanding of the effects of legal access to cannabis.

Pre-registration: German Clinical Trials Register (DRKS), DRKS00020829

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others-A Perspective of German Addiction Medicine Experts

Background: Over the past 15 years, comparative assessments of psychoactive substance harms to both users and others have been compiled by addiction experts. None of these rankings however have included synthetic cannabinoids or non-opioid prescription analgesics (NOAs, e.g., gabapentinoids) despite evidence of increasing recreational use. We present here an updated assessment by German addiction medicine experts, considering changing Western consumption trends-including those of NOAs. Methods: In an initial survey, 101 German addiction medicine physicians evaluated both physical and psychosocial harms (in 5 dimensions) of 33 psychoactive substances including opioids and NOAs, to both users and others. In a second survey, 36 addiction medicine physicians estimated the relative weight of each health and social harm dimension to determine the overall harm rank of an individual substance. We compared our ranking with the most recent European assessment from 2014. Results: Illicit drugs such as methamphetamine, heroin, cocaine and also alcohol were judged particularly harmful, and new psychoactive drugs (cathinones, synthetic cannabinoids) were ranked among the most harmful substances. Cannabis was ranked in the midrange, on par with benzodiazepines and ketamine-somewhat more favorable compared to the last European survey. Prescribed drugs including opioids (in contrast to the USA, Canada, and Australia) were judged less harmful. NOAs were at the bottom end of the ranking. Conclusion: In Germany, alcohol and illicit drugs (including new psychoactive substances) continue to rank among the most harmful addictive substances in contrast to prescribed agents including opioid analgesics and NOAs. Current laws are incongruent with these harm rankings. This study is the first of its kind to include comparative harm rankings of several novel abused substances, both licit/prescribed and illicit.