Special Series: Through The Looking Glass
How Germany Took a Leap Into the Unknown to Tackle Its Heroin Problem
More than 400 people died last year from drug overdoses in New Hampshire and that number is expected to surpass 500 this year. But as our numbers increase, in many parts of Europe drug overdose deaths are declining.
During a three week fellowship in Germany earlier this summer, NHPR reporter Paige Sutherland decided to dig into Germany’s drug policies—to see what’s different, what’s worked and what New Hampshire might learn as it continues to tackle an opioid crisis.
In a series called “Through the Looking Glass,” every morning this week you’ll hear stories about Germany’s policies, from rooms where addicts can legally use to needle machines in prisons.
Explore the series:
In Germany, Harm Reduction Is Working
When I got off the train at Kottbusser Tor at noon one day in Berlin, the first thing I saw was a young woman stooped on the steps smoking heroin. She was out in the open, tinfoil on display and lighter in hand. And once I exited the platform, the second thing I saw were two police cruisers stationed there.
This is normal here.
A Disease, Not a Crime
“Sometimes there are up to 200 people at this corner. It’s a drug user and a lot of people in a crowd standing over there," says Astrid Leicht, who heads the non-profit Fixpunkt.
The group runs needle exchange programs in Berlin including a mobile one that stops by this area three times a week.
Leicht says when it comes to arresting drug users, it’s not the police department’s priority.
Berlin’s lead detective within the Narcotics department, Michael Wulfert, can vouch for this. He says the city’s officers are trained not to treat addicts as criminals.
“Addiction is not a crime it is a disease, you know. And we got to adapt ourselves and our work to this philosophy," Wulfurt says.
"But basically the mentality concerning dealers and organized crime groups, keep the same way – enforcement, enforcement, enforcement.”
And enforcement is centered on high-level dealers. Recently his department seized 80 kilograms of heroin – ten times the amount seized in 2015.
When dealers do get arrested, the jail time they face is significantly less than in the states. The highest sentence for dealing in Germany is up to 15 years – half what one could serve in New Hampshire.
And for anyone with a sentence less than two years, even low-level dealers, there’s the option of going to a drug treatment program rather than jail.
Berlin’s drug czar Christine Kohler-Azara says they believe locking people up doesn’t work.
“People are not deciding by their own free-will to take drugs but it’s the disease that forces them that they have to take the drugs," she says.
"They cannot control it by themselves. So you need time but you have to give them the chance to get medical and get sociological and psychiatric help.”
In Germany, treatment ranges widely. There’s residential care, medically assisted therapy, needle exchange programs and then, so-called "drug consumption rooms" where people can use drugs freely.
And statistics show this comprehensive, a la carte approach has worked for Germany.
By The Numbers...
Since the country’s first heroin outbreak in the 1970's, the number of heroin users and drug-related deaths have decreased significantly. At its peak there were 2,500 drug related deaths, now there are 900.
Last year in Berlin, a city with 3.4 million people, 154 people died from a drug overdose. That’s nearly three times fewer deaths than happened in all of New Hampshire, where the population is a third of the city's size.
Hepatitis C and HIV numbers have also dropped in Germany. In the 1990’s, roughly 40 percent of heroin users had HIV. Today that number is about four percent.
Hepatitis C hasn’t fallen as drastically – it’s down to 70 percent. Health experts say that’s because many current drug users contracted the virus prior to some of Germany’s harm reduction policies.
But this shift in policies did not happen overnight. It took decades, according to Ingo Michels, the right-hand man to Germany’s Drug Czar.
He says it wasn’t until HIV numbers spiked in the early 1990's that lawmakers agreed abstinence wasn’t working.
“More and more people involved in this field recognized that it was not enough, it wouldn’t help," Michels says. "We did have this kind of drug-free treatment system but only five percent of the users used it and at the beginning we had very high drop-out rates so slowly at the beginning but rapidly changed this policy.”
A model for success?
But keep in mind there are many factors that likely contribute to Germany’s success.
For one, Germany has had universal healthcare for decades, so treatment for addicts is fully covered.
Second, the country has been funding substance abuse programs for years.
In Berlin, the city alone sets aside roughly ten million Euros for prevention and treatment annually.
But could Germany’s system work here in the U.S., even if the funding were made available?
'A Mental Somersault'
Academics like Peter Reuter have looked into this question.
Reuter is a Professor at the University of Maryland’s School of Public Policy and Department of Criminology, but his focus in 2009 was on whether Baltimore specifically should look into heroin assisted therapy, something Germany began doing that same year.
Related: Read Reuter's paper Can Heroin Maintenance Help Baltimore?
The idea is this: heroin users who’ve unsuccessfully tried other kinds of treatment, including methadone, are prescribed heroin by licensed doctors. His conclusion was that it’s helped and is something worth exploring. So far Baltimore has yet to do so.
“For professionals that have dedicated their lives to reducing heroin use – the notion that part of the solution is to actually provide it is a mental somersault,” says Reuter.
Christian Hennis, who runs a drug consumption room in Berlin, challenges other countries wary of adopting harm reduction methods to just take the leap.
“If a thing has worked for years and years in places which are quite comparable to your Boston arc – then why don’t you do it, why don’t you give it a try," Hennis asks.
"There are many, many people, social workers, healthcare workers who are just dying to do that because they’ve learned it is necessary and it is possible.”
A Place to Get High...Legally
Outside Birkenstr Station in Berlin, it looks like your typical urban neighborhood. There are people eating in cafes, shopping at local convenience stores and on the corner what looks like a high rise apartment complex.
But this building isn’t a residential building, it’s one of the two places in Berlin where users can bring their own illicit drugs and legally use them – right there and then.
There’s no sign out front or even on the door. And if you did happen to walk past this place – you’d never guess people were shooting up heroin and smoking crack behind those walls.
Once inside there’s a common room with a handful of tables and reclining chairs and a spot where you can get coffee or something to eat.
But two doors down on the left you hear this kind of interaction, “I am giving you short needle, thank you,” said one of the nurses after he greets the incoming patient in German.
And then after that, you’ll hear a crinkling sound as that same man unwraps that very syringe, cooks up his heroin and injects it into his stomach. The guy next to him is doing the same thing – except he injects it into his arm. And the one next to him – his leg.
From an outsider’s perspective this seems odd, but to people like Ulrich, who’s been a nurse at one of Berlin’s drug consumption rooms for years, this is normal.
“They come here they do their drug, they don’t have to do any explanations, they are here. I take care of them, if they have an overdose – I bring them back,” Ulrich says.
Ulrich, who asked us not to use his last name, says besides keeping people alive – he’s also in charge of making sure addicts are injecting safely. Most, he says, don’t know how to shoot up so they often hurt themselves.
That’s why cautionary signs like these hang on the walls:
“Be careful with your blood because there are viruses, bacteria’s and fungus. Put it in the right direction. Take care of your veins. Throw your syringe away with the cap,” Ulrich reads off the walls.
These so-called drug consumption rooms have been up and running since 2000. Currently there are 25 facilities operating in six of the 16 federal states of Germany – all of which are government funded.
On average these rooms cost around 250,000 Euro a year to run.
People who come here are given clean syringes, alcohol wipes and most importantly medical attention.
Christian Hennis, who runs this particular consumption room in Berlin, says the idea is that drug addicts will use no matter what so we might as well make sure they are using hygienically and under the care of medical professionals.
“If people inject someone is sitting here and taking care. If someone falls off the chair we do this [rings bell] and then we know what to do if someone has an overdose,” Hennis says.
And so far not a single person has died at any of the consumption rooms throughout Germany.
But more importantly Hennis says are the social workers on site who talk with addicts and connect them to resources.
“You don’t have to be ashamed here of being poor, having no teeth, having been to jail for years and years,” Hennis says. “You don’t have to be ashamed to be an addict here because everyone is. And that is valuable because if you are poor and unwashed, who is going to welcome you?”
A Community of Addicts...and Support
This social structure is why 46-year-old Andreeas Hauser keeps coming back to the consumption room even though he stopped using drugs more than a month ago.
“I come here now five years in that room and I know the people who work here – It’s like I have a relationship to people I would say like therapists. For me it’s like a family because I know all of these guys.”
These drug consumption rooms are designed for people like Hauser – long-time addict, not working, typically homeless or in a shelter.
And these rooms are a prime example of Germany’s treatment philosophy: meet people where they’re at then gradually work to get them sober.
Hauser’s now using Substinol, which is a medicated morphine. He’s also tried methadone and suboxone as well as several inpatient treatment options.
“You can’t just stop using drugs – it’s not only your body which has a hunger for drugs it also depends on the situation you are in – your life, what is your perspective,” Hauser says.
Treatment Through Medication - Even Heroin Itself
Besides drug consumption rooms, the “gold standard” of care for addiction in Germany is medication-assisted therapy.
In Berlin roughly 5,000 opioid users are using substitution treatment – that’s nearly half.
That percentage is similar to Germany as a whole, with 80,000 of the country's opioid users using this therapy. There are even people on heroin-assisted treatment, which advocate Astrid Leicht says was approved federally in 2009 allowing doctors to legally prescribe heroin.
“It’s just to make the people feel normal and to help them to function in a normal way and not to make them feel high all day and night,” Leicht says.
Roughly 75 percent of people in Germany undergoing substitution treatment stay with it, which is drastically higher than those in inpatient programs.
Arthur Coffin does counseling for those on medication-assisted therapy. He says the reason this treatment has been successful is that everyone in it is required to undergo counseling.
“Addiction is not only connected to substance abuse – there is a whole social aspect that belongs to it and if you don’t try to fix it on a multilevel way then you will always go around in circles,” Coffin says.
For years Germany’s federal drug goals have been centered on this principle of options. The goal at the top is abstinence - the bottom pure survival.
Sadly though, Berlin drug czar Christine Koehler-Azara says, not everyone is going to get sober but that doesn’t mean you don’t still treat them.
“We are responsible to give them the chance to reach at least these goals. But when they are not able to reach abstinence it makes no sense to leave them alone with nothing,” Koehler-Azara says.
But adopting this framework took time, she says.
“It was a learning process to see that we cannot give them one answer like abstinence – we have to give them several answers and they have the opportunity to make a selection – a decision – what they want,” Koehler-Azara says.
German officials are realistic that the country can never fully eradicate opioid addiction but there’s one thing all in the drug field such as social worker Christian Hennis can agree on:
“Would be catastrophic if we wouldn’t have started 20 years ago for harm reduction stuff like giving out syringes and all this.”
Clean Needles Offer Safety - And Sometimes, A Bridge to Treatment
If you live in Berlin and are looking for clean needles – you don’t have to travel far to get them. Just look for a vending machine.
Astrid Lecht explained to me how the machines work. She runs the nonprofit Fixpunkt, which operates the 18 other needle vending machines in the city.
Basically you put in a Euro and out comes a box filled with a clean syringe, alcohol wipes, water and Vitamin C to mix the heroin with.
Berlin is not alone in offering these machines – 200 other German cities also offer the service.
They’re located in high drug use areas, generally near train stations but they’re almost unnoticeable, because they look exactly like cigarette machines and rather than displaying a photo of a syringe, there’s a red ribbon on the front to symbolize drug prevention.
Fixpunkt also manages mobile vans that travel around the city handing out similar supplies.
The van is not flashy, it could even be mistaken for a food truck. The setup is similar, too. Patients come to the window, ask for supplies and then leave – with or without talking to a social worker.
Sebastian Bayer works at one of these mobile syringe vans. He says at first it's common that people just want to grab their supplies and go, but the end goal is to eventually get people to talk to a social worker on site and explore treatment options. But that takes time.
“When they come one time, two times, three times and when people here five weeks then you can contact – you have to work on the relationship,” Bayer says.
Not Just Alive...But Safer
For Leicht, getting clean needles to users is key in ensuring the first and most important step: keeping these addicts alive. For her it’s personal.
“In former times, younger times, I had a lot of friends who were affected by HIV/AIDs and drug addiction and they nearly all died and that is the beginning of my motivation to prevent people from this situation,” Leicht says.
Keeping people alive and preventing diseases is one of the major pillars behind Germany’s approach to addiction, so much so that Germany also offers clean needles behind bars.
The philosophy behind this says Sandra Poenisch, a social worker at the women’s prison in Berlin, is rooted in this:
“You don’t have any prison in the world without drugs. And we just want to make sure they can use drugs in a healthy way," Poenisch says. "
We are always asked – do you give them drugs as well? No we don’t give them drugs. But they are always using drugs.”
At Lichtenberg Prison, 35 percent of the inmates have a drug problem. The prison offers substitution therapy, counseling as well as syringe vending machines.
To get to these machines you walk through several locked doors until you come to this small enclosed room with a small metal box attached to the wall.
These needles, however, aren’t the everyday ones you’ll find on the street. They do have some safeguards on them. Once the needle is used it immediately pops back into the tube of the syringe so it can not be used to hurt anyone, Poenisch explains.
These machines have been running for almost 20 years and so far prison officials say there have been no problems. No deaths, no attacks on staff and no increase in drug use or the spread of diseases.
There’s also an effort by advocates to get free drug screening passed in Germany. The Netherlands has it and the idea is this: bring your drugs into the lab and they’ll test to see what’s in them.
Those involved in Germany’s drug scene say most people don’t know what they’re taking. For example, the batch of heroin that’s currently being sold on the streets of Berlin contains around six percent heroin – meaning that other 94 percent is unknown.
No "Just Say No"
Besides preventive measures around public health – Germany also drastically changed its policies on what’s being taught in the classroom.
Rather than tell children "drugs are bad, don’t use them," Berlin’s Drug Czar Christine Kohler-Azara says the curriculum is focused on telling kids the risks and letting them make up their own minds.
“We cannot make the decision for other people they have to make their decisions by themselves but we can provide them the information they need to make a responsible decision,” she says.
This concept is known as 'risk assessment' and it’s taught in school as early as age ten.
“You have to look at yourself and make some sort of plan – I have these resources, I have these risk factors, I want to have this kind of fun – what is my decision,” Koehler Azara says.
But Arthur Coffin, who works with youth on drug prevention in Berlin, says words aren’t enough, especially for those who are already in the throes of addiction.
“I’ve seen people on heroin with rotting legs, and you ask yourself as a normal person how can you do that," Coffin says.
"Well, they got one of the best drugs in the world to help blend out a rotting leg. There’s only one thing that helps and that’s relationship building – nothing else helps,” he says.
Coffin’s group “Login” begins relationship building early by training parents on how to better deal with at-risk kids and the ones already using.
Teachers are also trained on how to better engage with students in order to foster open discussions around drugs and strengthen support networks.
But at the end of the day – advocates like Leicht say they are realistic when it comes to prevention.
“We can influence people but not in the way that we can convince them to stop or not to stop to use drugs," Leicht says.
"We can give them pause and we can give them ideas but they have to decide for themselves.”
Could Germany's Strategies Be Put to Work in New Hampshire?
Reporter Paige Sutherland spoke to Morning Edition's Rick Ganley about her series, and where New Hampshire stands when it comes to harm reduction policies like the ones adopted in Germany to deal with heroin addition.
Rick: Good morning Paige, thanks for being here.
Paige: My pleasure.
So it seems these strategies have been working for Germany. Heroin use is down, overdose deaths have declined as well HIV and Hepatitis C numbers. Have other countries tried using similar harm reduction methods?
Germany is definitely not the pioneer of these ideas. Switzerland began using heroin-assisted therapy, which is the concept where doctors can legally prescribe heroin, since 1994 – 15 years after Germany.
Switzerland opened up the first drug consumption room in 1986. Now there are nearly 90 worldwide in nine countries including the Netherlands, Spain, Denmark Luxembourg as well as Canada in 2003.
But none so far in the U.S. - however many states are looking into it as we speak such as lawmakers in New York, Maryland and California as well as individual cities like San Francisco and Seattle.
And how is that push going in the U.S.?
Well Rick – it’s moving slow. Allowing people to smoke crack or shoot up heroin in these designated rooms is a new concept for many people in the U.S. and to be honest something that’s hard for people to wrap their heads around.
But for advocates like Patricia Sully, who’s helping to lead the charge in Seattle, having these rooms available makes perfect sense and aren’t about enabling drug use.
"And I think we are seeing public opinion moving in a significant direction that may well even in the near future leave some openings, some freedom for trying some different solutions," said Dante Scala, a political science professor at UNH.
Audio: “It’s about recognizing that there are people who are currently addicted and those people are using drugs and if we ever want them to make it into treatment, if we ever want to change that behavior we have to keep them alive and healthy.”
There are also a lot of policy questions attached to opening these rooms – what’s the enforcement protocol on possessing and using these illegal drugs especially when it comes to transporting them to the room, would changing these individual state laws clash with federal drug policies, etc.?
Some of these ideas like heroin-assisted therapy and drug consumption rooms are a little out there for New Hampshire – what’s been some of the reaction you’ve received from policymakers here in the Granite State?
I think the best word to describe it would be puzzled. It’s not that many people are outright against these ideas – it’s just that there are a lot of questions. For drug consumption rooms – the questions are quite similar to what’s being asked in Seattle.
And when talking with people about heroin assisted therapy - I’ve been asked questions like, "Is it FDA approved?," "What license would doctors need to prescribe," "Is it injected or in pill form?"
Related: Infographic of opioid overdose deaths in New Hampshire as of December 12, 2016
It seems Seattle is making good strides in getting some of these harm reduction strategies up and running, but Seattle is across the country from New Hampshire – any efforts closer to home?
The closest thing I’ve seen is across the border in Massachusetts they have these so-called Safe Rooms where people can come and run off their high under the care of medical professionals but they are not allowed to bring in their drugs and use them.
But I think it’s fair to say drug consumption rooms are a little far off for New Hampshire as we are still hung up on trying to simply legalize needle exchange programs. Keep in mind – more than 30 states have needle exchange programs and we are the only one in New England without one.
So last legislative session lawmakers tried to create a pathway for a needle exchange program but that bill was turned into a study committee. What was the hold up?
The concerns were mainly centered on how the bill was written. The main sponsor, Republican Rep. Joe Hannon, sought to legalize heroin residue on used needles making it possible for organizations or non-profits to open up their own needle exchange programs. The hope was to try to get around the hurdle of putting funding on the bill, which in a Republican controlled House and Senate would have created some waves.
But many were worried that if the program wasn’t state run it wouldn’t be properly regulated.
Earlier this week the study committee met and hopes to get something passed this upcoming legislative session.
Click here for Paige's earlier reporting on an attempt to pass a needle exchange bill at the statehouse
Many critics would argue that sending a bill to a study commission more or less kills a bill. Should we expect to see actual progress on this topic?
That’s a fair criticism. When it came to just allowing people without a prescription to get up to ten clean syringes at a pharmacy that took a decade to pass. As well passing the state’s Prescription Drug Monitoring Program also took a decade – making us nearly the last state in the country to have one.
But last week the state’s new Drug Czar James Vara released his six recommendations for addressing the opioid crisis - getting a needle exchange program was third on the list.
Audio: “It’s a new process in this state – it’s a conversation to be had. But it’s really important to note that we are having the conversation. It is a conversation that is actually now occurring. Much like substance misuse disorders – it’s a conversation that wasn’t happening. But now not only have we had the conversation we are allocating money for these programs.”
So to backtrack a little bit – Germany seems to have decreased their overdose fatalities. Berlin alone had 154 drug related deaths last year – meanwhile New Hampshire, which is a third of the size, had more than 440 deaths and is on track to surpass 500 this year. How did we get here?
There are many factors that led us here. One: Over prescribing. Like I mentioned before it took ten years to get a Prescription Drug Monitoring Program passed – meaning doctors didn’t know who were getting opioids and how much of it?
As well nationally there was a lack of addiction training when it came to prescribing opioids. This is something Germany got a hold on early by educating doctors and adopting strict rules on when to prescribe and the overall quantity.
Two: Adopting the national “War on drugs” mentality. But this is something that is starting to change as more and more police stations have begun to direct addicts to treatment rather than jail cells. For instance, currently there are efforts in Laconia, Manchester and on the Seacoast.
Whereas in Germany, police departments began these efforts decades ago.
Three and probably most important: Funding. In Germany substance abuse has been funded for decades. Berlin alone sets aside 10 million Euros a year towards this issue. Meanwhile New Hampshire has been under-funding it for decades.
Here’s Tym Rourke who chairs the Governor’s Commission on Drug and Alcohol.
Audio: “Our system can currently treat between 4 and 6 percent of the addicted population but then what’s driving behind that is that we’ve also been second to last in the United States for per-capita expenditures and we are the lowest in New England.”
But recently the state has ramped up its funding.
Yes, just since January alone the state has put more than $30 million towards this issue. And besides increased funding, the state has also made strides by passing laws such as expanding access to the overdose reversal drug Narcan, increasing insurance coverage to changing the state’s prescribing rules.
So it seems we are making progress, but should I expect to see syringe vending machines in Concord anytime soon?
I wouldn’t hold my breath. I don’t think New Hampshire is socially or politically ready for those yet, but after talking with Dante Scala, who is a political scientist professor at UNH, it seems now is the time more than ever for the state’s drug policies to explore some unchartered waters.
“And I think we are seeing public opinion moving in a significant direction that may well even in the near future leave some openings, some freedom for trying some different solutions to the problem. So I think the door is open in a way that it hasn’t been for decades.”