Substitution: Judgment on take-home regulation

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substitution: Doctors are not to blame for take-home damage to their patients.

In principle, doctors in drug substitution therapy are only allowed to give the patient methadone, polamidone or another substitute drug at home in clearly defined exceptional cases. In such cases, the doctor must give sufficient reasons for his decision. The question of whether the take-home regulation supports the therapy progress of the patient concerned is of central importance for him. This is the case, for example, if it positively influences the taking up or maintenance of a job. According to the requirements of the German Medical Association, this is only permitted if the course of treatment has stabilized in every respect. In addition, the patient receives a constant dose of his replacement drug.

Only preparations of levomethadone, methadone, buprenorphine or a drug approved for substitution may be prescribed as a substitute. In justified exceptional cases, codeine or dihydrocodeine can also be prescribed. The Federal Government has regulated the legal requirements for substitution-based treatment of drug addicts in Sections 5 and 5a of the Narcotics Prescription Ordinance (BtMVV) and only those doctors who have undergone specific addiction medical training may prescribe substitution drugs.

If a patient dies during a "take-home" procedure, the doctor cannot be held responsible for this, the Federal Court of Justice (BGH) in Karlsruhe recently said. This confirmed a verdict by the Deggendorf district court against a doctor in Bavaria. He treated drug-dependent substitution patients from 2006 to 2011. As a rule, patients must take the prescribed substitute under supervision in practice to prevent abuse. In at least four patients, however, the doctor put out so-called "take-home prescriptions" for the replacement drugs methadone and levomethadone.

Patients who are prescribed such a prescription can pick up their replacement drug themselves in the pharmacy and then take it on their own without medical supervision. In the dispute, the doctor had issued one of his patients five "take-home prescriptions" in succession without having personal contact with him during this time. The patient later died of an overdose of methadone. The regional court in Deggendorf now accused the doctor of accepting that the addict and other patients would not take the methadone as intended. In addition, the doctor had not sufficiently controlled the possible "consumption" of other drugs. The district court then fined the doctor for "illicitly prescribing narcotics" and imposed a fine of 360 daily rates, which corresponds to a fine equivalent to an annual income.

In contrast, the district court cleared the doctor of accusation of negligent homicide. The patient was "responsible for himself, knowing the risk of an overdose," the judgment says. This decision-making process is certainly a tightrope walk because it is part of the medical oath to save human lives in every respect. But you have to be able to demand a certain amount of personal responsibility from the patient, according to the judges. After all, the goal of substitution treatment is to enable patients to return to “normal” everyday life. (fr)

Image: Sigrid Rossmann /

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