[Epidemiology of substance use and substance use disorders in Germany]. / Epidemiologie des Substanzkonsums und der Suchterkrankungen in Deutschland.

AIM: The objective of this literature review was to investigate the epidemiological basis in public health and clinical treatment for four psychotropic substance groups (i.e., alcohol, tobacco, illegal drugs, and pharmaceuticals) in Germany. The following issues were addressed: (1) what impact does the consumption of these psychoactive substances have on the overall burden of diseases to the general public compared to other disorders? (2) What are the prevalences of these four substance groups regarding consumption, substance use disorders, and sequelae in Germany? (3) How many people with a substance-related diagnosis have been treated within the addiction help system? (4) What are the costs of substance-related disorders and problems? METHODS: Epidemiological data, mainly representative samples in Germany about use and abuse of legal and illegal drugs, were analyzed. For cost-benefit analyses, only the most recent studies were used. RESULTS: Alcohol-related disorders are among the ten most common diseases with the strongest impact on the overall burden of disease. The prevalence rates of substance-related diagnoses in 2006 (based on the last 12 months for 18-64 year olds) were 7.3% for nicotine dependence, followed by alcohol dependence (2.4%), alcohol misuse (3.8%), and illegal substances (0.6%). Alcohol consumption in Germany, defined as the per capita consumption of pure alcohol, declined between 1980 and 2007. However, extreme alcohol abuse in adolescents has increased. Inpatient admissions due to acute alcohol disorders increased more in adolescents than in the general population. Particularly critical is the increasing number of 10- to 15-year-old girls. The availability of treatment to patients with pharmaceutical-related disorders and with nicotine disorders is very low. Cost-benefit studies for the consequences of consuming various substances show that netto costs regarding alcohol taxes were 316 Euro per capita of the German population between 18 and 65 years for alcohol disorders and 133 Euro for nicotine dependence. CONCLUSIONS: The availability of nicotine and pharmaceutical dependence assistance to patients should be improved in the primary and secondary care systems. The alcohol abuse of adolescents requires specific observation and intervention. In order to adequately plan treatment systems for addiction, an estimation of the need for help and the acceptance of the help should be explored and analyzed in scientific studies.

[Efficiency of outpatient and inpatient alcohol treatment - predictors of outcome]. / Effizienz der ambulanten und stationären Alkoholentwöhnung - Prädiktoren des Behandlungserfolgs.

AIM: To study the prediction potential of demographic and psychopathological variables in the patient allocation context. METHOD: This was a follow-up study of alcohol-dependent patients (n = 242) who were treated in an outpatient (n = 75), inpatient short-term (n = 88), or inpatient long-term (n = 79) setting between 2003 and 2004. Demographic and psychopathological variables were measured by psychiatric basic documentation and the European Addiction Severity Index (EuropASI) . Abstinence two years after discharge from treatment was the primary outcome criterion. RESULTS: Significant predictors of outcome were a higher secondary school qualification, a finished professional training, later onset of alcohol dependence, less number of treatments for physical illness as well as no history of suicide attempts. Both satisfaction with the family background and being employed were predictors with allocation potential.

[Monitoring of the misuse of prescription drugs by clients of outpatient addiction treatment centres (PHAR-MON, formerly: Ebis-med). Monitoring of medication misuse]. / Monitoring des Arzneimittelmissbrauchs bei Klienten ambulanter Suchtberatungsstellen (PHAR-MON, ehemals: ebis-med). Monitoring des Arzneimittelmissbrauchs.

OBJECTIVES: The monitoring system PHAR-MON (formerly: ebis-med) documents the misuse of pharmaceuticals in addiction counseling centres as an early warning system. It is described as a diagnostic instrument according to its aims and tasks, implementation and assessing procedures and is evaluated according to the main quality criteria of diagnostic instruments. In addition, selected results are reported about the misuse of medicaments in the year 2004. METHODS: In analogy to diagnostic instruments, the main quality criteria objectivity, reliability and validity are applied to evaluate PHAR-MON, they are extended, however, by the validity of the sample of reference outpatient centers. Statistical methods for proving results are applied and discussed concerning their appropriateness for cross-sectional and longitudinal analyses of PHAR-MON data. The selected results are based on the survey data for 2004 of 32 counseling centers with 629 medicaments abused by 500 clients. The representativity was checked by comparison with the outpatient addiction statistics. RESULTS: The sample of counseling centers is representative for all addiction counseling centers in Germany. The dominant influence factor on the abuse of medicaments is the main diagnosis of the clients. Therefore, the analysis is separated for the main diagnoses as to alcohol, illegal drugs and medicaments. The statistical methods of confidence intervals and other statistical procedures are useful in proving data for cross-sectional and longitudinal analyses. In 2004 there was an increase of abused buprenorphine by 5.7% compared to the previous year. The rate of misuse of hypnotics, which is the largest group of abused medicaments, only slightly increased by 2.4%. CONCLUSIONS: The monitoring system PHAR-MON is a sensitive and valid monitoring system for the abuse of medicaments in addiction counseling centres. By documenting individual criteria of abuse in the new version of the documentation sheet, the results of medicament abuse can be analyzed in a more valid way. To improve the PHAR-MON system a study about reliability is planned. Because of the health risks associated with the abuse of medicaments, continuous information for physicians about the risks of medicament abuse is helpful to prevent negative consequences.

[Is the European Addiction Severity Index a useful tool in the diagnostic routines of alcohol dependence?]. / Ist der European Addiction Severity Index ein sinnvolles Diagnoseinstrument bei Alkoholabhängigkeit?

AIM: To study the validity of the EuropASI in the patient allocation context and to measure the alcohol severity changes with treatment. METHOD: The examination based on three groups of alcohol-dependent patients (n = 242): outpatients (n = 75), inpatients in a short-term treatment (n = 88), and inpatients in a long-term treatment (n = 79). Treatments took place in two clinics. The European Addiction Severity Index (EuropASI)-Composite Scores were calculated for severity assessment of alcohol dependence. These scores are qualified for change measurement and scientific utilization. Assessments took place on admission and at discharge from the treatment unit. Analyses included the outset values comparison and the examination of both time as well as group effects. RESULTS: Mean age of patients was 45.3 years (SD = 8.6) and 26,4 % of the participants were females (n = 64). The three groups differed significantly in their completion of professional training, employment status, marital status, onset of alcohol dependence, daily alcohol intake in the past half year, previous detoxifications, previous rehabilitations, and at least one attempted suicide. Adjusted for these variables, the 3 groups differed in the alcohol domain at t0, and t0-t1-improvements resulted for the whole sample in the alcohol domain and the domain 'employment satisfaction'. DISCUSSION: The severity ratings by means of EuropASI-Composite Scores illustrated the assumption that the severity level gives information about the treatment needs: the more severe disorder the larger the treatment needs. Furthermore, a t0-t1-decrease of the Composite Scores was shown for the whole sample in the domains 'alcohol use' and 'employment satisfaction'. This points to a reduction of the addiction severity level due to treatment. In spite of some limitations regarding the Composite Scores, the EuropASI seems to be useful for patient allocation.

[Where are the 1.9 million patients dependent on legal drugs hiding?]. / Wo verstecken sich 1.9 Millionen Medikamentenabhängige?

Although the number of patients dependent on legal drugs is estimated to be as high as 1.9 million, very few are in clinical treatment. Research deficits in this area are evident.

[The mortality rate of alcoholic patients 4 years after inpatient treatment]. / Mortalität bei Alkoholikern 4 Jahre nach stationärer Behandlung.

Data on mortality during a 48-month follow-up period in a group of 1410 alcoholics who had received inpatient treatment were evaluated. In 1266 patients known to be either living or deceased the death rate was 7.6%. The percentage of deceased subjects was highest in the group over 50 years of age. The mortality rate was higher for men (9.8%) than for women (4.8%); for those with more than one divorce (16.8%); for those who were not fit for work (18.1%) or were retired at the start of the treatment (43.3%); who were employed in the alcohol business (21.7%); who had reduced their alcohol consumption before treatment (13.4%); who were unemployed 6 months after discharge (12.4%). The mortality rate was higher for those with high scores on a scale assessing calmness in a personality inventory (7.9%) and low scores on a questionnaire assessing motivation (10.9%) and insight into the need of change (12.4%). Alcohol-related illness before the index treatment played an important role: the mortality rate was higher for those who had had Wernicke-Korsakoff-syndrome (40%), delirium tremens (15.3%), pancreatitis (13.9%) or cardiomyopathy (14.1%). The mortality rate was higher for treatment dropouts (12.9%) and for those who regularly or occasionally took sleeping pills (28.5%), psychoactive drugs (15.1%) or other drugs (11.5%) during treatment. In the follow-up periods substance use had a great effect on mortality. The mortality rate for those patients who still abstained from alcohol for after 6 months (4.4%) was only a third of that the patients who had relapsed (12.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality in alcoholic patients given inpatient treatment.

Data on mortality during a 48-month follow-up period in a group of 1410 alcoholics who had received inpatient treatment were evaluated. In 1266 patients known to be either living or deceased the death rate was 7.6%. The percentage of deceased subjects was highest in the group over 50 years of age. The mortality rate was higher for men (9.8%) than for women (4.8%); for those with more than one divorce (16.8%); for those who were not fit for work (18.1%) or were retired at the start of the treatment (43.3%); who were employed in the alcohol business (21.7%); who had reduced their alcohol consumption before treatment (13.4%); who were unemployed 6 months after discharge (12.4%). The mortality rate was higher for those with high scores on a scale assessing calmness in a personality inventory (7.9%) and low scores on a questionnaire assessing motivation (10.9%) and insight into the need of change (12.4%). Alcohol-related illness before the index treatment played an important role: the mortality rate was higher for those who had had Wernicke-Korsakoff syndrome (40%), delirium tremens (15.3%), pancreatitis (13.9%) or cardiomyopathy (14.1%). The mortality rate was higher for treatment dropouts (12.9%) and for those who regularly or occasionally took sleeping pills (28.5%), psychoactive drugs (15.1%) or other drugs (11.5%) during treatment. In the follow-up periods substance use had a great effect on mortality. The mortality rate for those patients who still abstained from alcohol after 6 months (4.4%) was only a third of that for the patients who had relapsed (12.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective multicentre study of in-patient treatment for alcoholics: 18- and 48-month follow-up (Munich Evaluation for Alcoholism Treatment, MEAT).

In a prospective multicentre study of 1410 alcoholics (73% men) data were collected at five different times: admission, discharge, 6, 18 and 48 months after discharge. The details from the 21 treatment centres involved were acquired from staff-members; follow-up data on patients were collected by personal interviews and/or mailed questionnaires. In all, 85%, 84% and 81% of the patients could be traced, respectively. Additionally, data of patients' sick leave days and in-patient treatment were provided by the health insurance and pension insurance institutions, respectively. Outcome criteria were drinking behaviour, working and partner situation, and subjective complaints. The drinking behaviour was divided into three rough categories: abstinent, improved and unimproved. For 18 months 53% of the patients remained abstinent, 8.5% improved and 38% did not improve. For 48 months 46% remained abstinent, 12% improved and 42% did not improve. During the last 6 months prior to the 48-month data collection 66% were abstinent, 4% improved and 30% did not improve. Only 3% of patients succeeded in maintaining controlled drinking. The percentage of days of sick leave was reduced by 64% and of in-patient treatment from 34.7% to 14.6% during the 18-month period after discharge (in comparison with the 18-month period prior to treatment). Only 21% of the patients regularly attended self-help groups. Out of the patients' variables, ten for men and five for women could be identified as prognostically relevant. In the 48-month follow-up these factors were reconsidered. In men almost all, in women only three of the five factors were confirmed. The treatment variables were evaluated according to the prognosis factors (positive vs negative group). In the 48-month follow-up the treatment variables relevant in the 18-month follow-up were also reassessed. In the positive prognosis group five variables were confirmed, in the negative prognosis group only one. In addition, differentiated indication variables for the three treatment lengths were developed and applied to a model. The following appeared to be clues regarding the length of desirable treatment. For an unfavourable prognosis in both men and women no short-term treatment should be given; medium- or long-term treatment is to be preferred. For a medium prognosis men do better with short-term treatment; for women medium-treatment is preferred. For a favourable prognosis for men medium-term treatment should be avoided; long-term is preferred; for women short-term treatment may also be preferred.

Diagnosis of alcoholism: the Munich Alcoholism Test (MALT).

The purpose of our project was to develop and empirically test a diagnostic instrument which would permit sufficiently reliable differentiation between alcoholics and healthy as well as sick persons and which would also be easy and economical to administer. For this purpose, roughly 250 diagnostically relevant items were selected from the extensive literature on alcoholism and, with a total of 1335 patients (661 of these were alcoholics), were evaluated in three separate phases for their ability to differentiate. The best items were selected on the basis of various statistical criteria and then cross-validated. The result is the Munich Alcoholism Test (MAT) which consists of two complementary parts: a 7-item physician's assessment part and a 24-item self-assessment part. In a cross-validation study on 675 unselected in- and outpatients a validity of r = 0.94 was obtained. The reliability of the self-assessment part was r = 0.84.

[Diagnosis of alcoholism. The Munich Alcoholism test (MALT) (author's transl)]. / Diagnose des Alkoholismus Der Münchner Alkoholismustest (MALT).

From the extensive literature on alcoholism 250 relevant diagnostic items were selected and tested for their selectivity in 3 independent inquiries among 1335 patients (661 of them alcoholic), both outpatients and inpatients. The outcome is a two-part test: a section of 7 questions answered by the doctor and a self-assessment section comprising 24 questions answered by the patient. Its validity (validity of the whole test r=0.85) and reliability (reliability of the self-assessment section r=0.94) are high. A diagnosis of alcoholism made according to the usual clinical aspects was confirmed in 90% of 675 unselected medical, surgical and psychiatric patients and alcoholism was suspected in a further 8%.