Successful alcohol and cannabis counselling in Germany: What is the difference between medical and legal referrals?

Background

Population surveys indicate that the 12-month prevalence of cannabis use in the general population of Germany roughly doubled between 2012 and 2021. The data from outpatient treatment reflect this trend. In light of the planned legalization of cannabis and a rising recognition of cannabis problems by physicians, more people may be referred to outpatient addiction counselling for cannabis-related problems by primary health care providers. Currently, about one in four people with cannabis-related problems are referred by law enforcement agencies to outpatient addiction counselling care facilities. Comparing legal to medical referrals to counselling, we examined the role of referral source for counselling success.

Methods

Routine monitoring data from outpatient community drug services of the city of Hamburg (Germany) covering the years 2012 to 2021 were analyzed. Three groups were compared: clients who entered the facilities only because of cannabis-related problems (n=6,411), those who entered because of alcohol and cannabis (n=4,651) and those who entered only because of alcohol (n=21,813). Logistic regressions were employed and adjusted for age, gender and data year in order to shed light on the association of the role of the referral agency with counselling success (e.g. completing counselling in a regular manner; change in motivation to abstain) for each of the three groups separately. 

Results

Cannabis-related counselling comes about much more frequently through legal referral (29%; alcohol-related: 5%). Over the years 2012 to 2021, there has been an increase in the proportion of medical referrals for alcohol-related counselling (13% to 21%), but not for cannabis-related (8% to 9%). Medical referral to outpatient addiction care is not clearly associated with better counselling success. Compared to legal referral, there is a significantly lower probability of completing counselling in a regular manner (aOR: 0.28), i.e., there are higher rates of counselling dropouts for medical vs. legal referrals. However, medical referral is associated with a higher probability that the motivation to abstain will develop positively in the course of the counselling (aOR: 1.65). 

Conclusions

Legal referred clients may more likely end the counselling regularly, because they may fear that unsuccessful counseling could result in further judicial sanctions, such as withdrawal of a driver's license or restrictions on custody of children. The positive effect of the medical setting as a referral source on the rather intrinsically motivated success indicator motivation to abstain could be related to the psychotherapeutic work which was already carried out in the medical setting prior to the start of outpatient care. It can be assumed that the reform of the Narcotics Act will further increase the importance of the care provided by doctors and psychotherapists. Against this backdrop, it appears necessary to train health care staff and provide the necessary resources.