Loading ...

More than 55,000 individuals are currently incarcerated in correctional facilities across Germany. Estimates suggest that between 50% and 75% of them have at least one mental health disorder. Among these, substance use disorders are particularly prevalent: International research indicates that at least 40% of prisoners have a substance-related condition that requires clinical treatment.

Germany’s first nationwide survey on addiction in prisons found that 44% of inmates have a substance use disorder. The majority are young men, while women represent only about 5% of affected individuals.

Whether a person with a drug problem is sentenced to prison or placed in a forensic psychiatric hospital under court-mandated treatment (known in Germany as Maßregelvollzug, or MRV) depends on whether the crime is linked to the addiction and whether the addiction impaired the person’s ability to control their behavior.

Addiction Treatment Not a Luxury

“Prison sentences are often seen as an opportunity for individuals to learn from their punishment,” said Elisabeth Dallüge, a psychological psychotherapist specializing in behavioral therapy. Dallüge spent 6 years working with individuals with addiction in correctional facilities and serves on the national board of the German Psychotherapists Association.

The problem, she explained, is that the conditions required for meaningful rehabilitation are often lacking. “A person whose life circumstances led to incarceration likely faces multiple challenges — yet these are rarely addressed.”

Germany has no standardized national framework defining what addiction therapy in prison should include. While some prisons have social therapy units, these are generally designed for inmates with severe personality disorders, not those with substance use disorders.

“There is no consistent protocol nor a unified model for ensuring psychosocial care in prisons,” said Dallüge. “Addiction is a medical condition — not a failure of willpower. Without access to proper treatment, we not only prolong individual suffering but also increase the risk to public safety through relapse. Treatment is not a luxury; it is both a protective measure and an opportunity for change.”

The easy availability of illicit substances inside prisons adds to the challenge. “Inmates use the same drugs available on the outside — cannabis, amphetamines, meth, cocaine, heroin,” Dallüge said. “These substances are much more accessible in prison than in forensic psychiatric hospitals, though even there, occasional cases of drug access still occur.”

Inadequate Care in Prisons

A survey conducted in late 2024 by the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) found that mental health care in German prisons remains severely under-resourced. Of 130 correctional facilities surveyed, 112 rated their mental health services as problematic. More than half reported that resources for outpatient psychiatric care were insufficient.

The situation was even more concerning for inpatient and partial inpatient treatment. Only 11% of inmates had seen a psychiatrist within the previous 4 weeks, and just 1% had received any form of psychotherapy. Among an estimated 1500 inmates clinically assessed as needing full inpatient psychiatric care, only half were transferred to suitable facilities.

“There is much more demand for psychotherapy in prisons than we can meet, simply because funding is lacking,” said Dallüge. In many prisons, a single psychologist or therapist may be responsible for up to 120 inmates. “Even in a full-time role, that leaves very limited capacity for each individual,” she noted.

“If meaningful therapy is defined as at least 50 minutes per week, then we are nowhere near meeting that standard,” Dallüge added. “The level of psychiatric care in correctional facilities is clearly inadequate, and the need continues to grow.”

Problems in Forensic Psychiatric Facilities

The DGPPN has also highlighted shortcomings in Germany’s forensic psychiatric system. Unlike standard prisons, MRV facilities are intended for individuals whose offenses were linked to mental illness, intellectual disability, or substance use disorders. These individuals are placed in treatment settings by court order.

“We’re seeing increasing difficulty in recruiting medical staff for these clinics, even as the number of patients, particularly those with schizophrenia in provisional placements, continues to rise,” said Jürgen Müller, MD, head of the DGPPN’s Department of Forensic Psychiatry.

Müller called for the formation of an interdisciplinary commission to develop sustainable reforms for the MRV system. A six-point policy paper titled Prison Health Is Public Health outlines proposed improvements.

Breaking the Addiction-Crime Cycle

In cases where a drug-related crime is clearly connected to a substance use disorder, courts may mandate treatment in a rehabilitation facility under Section 64 of the German Criminal Code. This pathway is designed to address both addiction and criminal behavior simultaneously.

However, use of this provision has increased significantly. In 2021, German courts issued over 3500 orders under Section 64 — nearly twice the number recorded in 2007 — placing pressure on the availability of specialized facilities.

Despite considerable investment in infrastructure, the demand for such placements exceeds capacity. In addition, the DGPPN reported in 2021 that about 50% of these treatment programs were terminated early due to poor prognoses. A legislative reform, implemented in October 2023, aimed to significantly reduce the number of court-ordered placements by tightening eligibility criteria.

“The reform was necessary,” said Johannes Fuss, MD, director and professor at the Institute of Forensic Psychiatry and Sex Research at the University of Duisburg-Essen, located in Essen, Germany. Still, he emphasized that Section 64 remains a highly effective tool. He cited a longitudinal study conducted in Essen, comparing outcomes between patients treated in MRV facilities and those who served traditional prison sentences. Over a 4-year follow-up, MRV patients, including those with suboptimal treatment engagement, showed significantly better outcomes.

Men with substance use disorders who were treated in forensic psychiatric settings had a substantially lower risk of reoffending compared with those with similar conditions who were incarcerated without receiving structured treatment.

Why Mostly Men?

Both prisons and MRV facilities in Germany are male-dominated, with approximately 95% of individuals in custody identifying as men. “As in the general prison system, women are rarely seen in MRV,” said Dallüge.

This imbalance reflects not only higher crime rates among men but also gender-related differences in substance use. Women are more likely to misuse legal substances or prescription medications with sedative effects, while men tend to use stimulants such as cocaine or amphetamines — substances more often associated with aggressive behavior and violence.

“Although women make up a small proportion of the prison population, they tend to have higher rates of mental illness than men,” said Fuss. “Women offenders often present with a complex combination of trauma, severe psychiatric illness, and co-occurring substance use disorders. This makes rehabilitation especially challenging.”

Most Prisons Offer Substitution Therapy

Under the German penal code, inmates are entitled to medical care equivalent in scope and quality to that provided under the country’s statutory health insurance system. This means prisoners must have access to evidence-based, up-to-date medical treatments — including for addiction.

The German Medical Association’s national guideline for opioid substitution therapy (OST) applies universally, including in correctional settings. “Research shows that substitution therapy can help reduce recidivism. Even in prison, OST is an essential part of addiction treatment,” said Heino Stöver, PhD, director of the Institute for Addiction Research at Frankfurt University of Applied Sciences in Frankfurt, Germany.

Legal rulings in two German cities — Dortmund and Hamburg — have helped strengthen consistent access to OST. In both cases, individuals who had been receiving methadone prior to incarceration successfully petitioned for continued treatment during their imprisonment.

Substitution therapy aims to reduce mortality, decrease the use of illicit opioids, stabilize patients medically and socially, and address co-occurring health conditions. Methadone is the most commonly used agent, followed by buprenorphine and diamorphine. All three significantly reduce the risk for HIV transmission by lowering the prevalence of injection drug use while also improving overall health and quality of life.

Historically, substitution therapy in prisons was subject to time limits. However, policy changes have shifted toward allowing indefinite treatment, aligning with clinical best practices.

OST Access Remains Uneven

Despite these advances, access to OST still varies significantly across Germany — not only by federal state but also between urban and rural areas and even from one facility to another. Inmates held in prisons that do not offer substitution therapy can apply for a transfer to a facility that does.

On average, about 24% of opioid-dependent inmates in Germany receive OST, according to Stöver. However, it’s estimated that approximately 70% of substitution therapies initiated before incarceration are discontinued during imprisonment — often in violation of national medical guidelines.

“The situation is highly inconsistent,” Stöver said. In some states, prison physicians provide OST only after being compelled by legal action. Northern states generally pursue more liberal drug treatment policies, while southern states remain more restrictive. For example, Berlin has long offered OST in prisons, whereas Bavaria is only recently implementing such programs.

Addiction Treatment Outcomes Vary

Under Section 64, offenders with substance use disorders can be placed in addiction rehabilitation clinics instead of prison. A critical requirement is a reasonable “prospect of success.” If clinicians assess that a patient’s likelihood of benefiting from treatment is low, the court-ordered measure can be terminated, and the individual returned to prison.

Recent data suggest that treatment outcomes depend not only on patient factors but also heavily on the facility itself. “The strongest predictor of early termination is the clinic,” said Fuss. “Some clinics work hard to treat difficult patients and have low dropout rates. Others end treatment in more than 50% of cases.”

“There is clearly room for improvement,” Fuss added. He noted that recent reforms to Section 64 are expected to reduce the number of people placed in forensic psychiatric care. As a result, more individuals with addiction disorders are likely to serve sentences in standard prisons, where addiction treatment options are significantly more limited.

Limited Psychotherapy in Prison

While substitution is relatively common in German prisons, and many individuals receive treatment in MRV facilities under Section 63 of the German Criminal Code, access to structured addiction therapy within regular prison settings remains limited. “In my experience, very little psychotherapy is offered in prisons. Only a small number of selected inmates receive it,” said Fuss.

“Substitution therapy alone isn’t enough — effective addiction treatment requires a range of tools,” he added. In rehabilitation clinics, care is typically delivered by a multidisciplinary team that includes medical, psychological, and social work professionals. In prison, however, such integrated approaches are rare unless the inmate qualifies for treatment under Section 64 or is diverted under Section 35 of the German Narcotics Act — a provision known as the “therapy instead of punishment” model.

Birgitta Kraatz-Macek, from Condrobs, a Munich-based social services organization, oversees addiction counseling in five Bavarian prisons. She noted that Section 35 is being applied less frequently in Bavaria, partly due to a policy shift toward prioritizing punitive measures over rehabilitative interventions.

Dallüge confirmed that addiction therapy is neither mandated nor consistently available in prisons. “If an inmate is fortunate, there might be a treatment program in place — and they might secure a spot,” she said.

Three-Part Approach to Addiction Therapy

The clinical status of the individual plays a critical role in treatment planning: Are they currently intoxicated? When was their last use? “You have to meet people where they are,” said Dallüge. “Start by stabilizing them — for opioid users, that may involve initiating methadone or buprenorphine treatment to support detoxification. Simultaneously, if the treatment is done properly, you try to introduce them to psychotherapy.”

This process is challenging in both MRV and prison environments. “These individuals aren’t seeking help voluntarily. They’ve lost their freedom, and we’re saying to them: ‘You’ve used substances for years, and now we’re taking away one of your only coping mechanisms,” Dallüge explained.

The therapeutic task is to build trust and help the patient evaluate whether detox and a life free from substance use might be achievable and worthwhile. “Once a therapeutic relationship is established and motivation begins to grow, that’s when real progress can start,” she said. “Once trust and motivation develop, therapy can begin. Successful addiction treatment depends on three things: the therapy itself, the patient’s motivation, and social support. Support from the prison system also plays a role,” she added.

Dropouts and Relapses

In the German state of Hesse, approximately 70% of incarcerated individuals receiving substitution, whether in prison or in MRV, discontinue treatment before completion. “Dropouts and relapses are a normal part of the process,” said Dallüge. “The real issue is how we respond to them.”

Motivation and personal insight are crucial. “I would tell my patients: A relapse can happen. What matters is how you react,” she said. Do they give up and continue using, or do they view the relapse as a warning and an opportunity to adjust their approach?

“A stable therapeutic environment with professional support is essential — and that’s more often found in MRV than in prison,” Dallüge added. “The ideal conditions include no major psychiatric comorbidities and the presence of a realistic, forward-looking perspective.”

When no clear release date is available, therapy should help the individual identify personal goals. Relapse is particularly likely when the motivation for treatment is purely legal — such as seeking a shorter sentence. “Those cases rarely result in meaningful, long-term change,” Dallüge said.

Does a failed treatment attempt make it harder to access therapy again? It depends on the setting. In MRV, relapses are expected, although a poor prognosis may lead to the person being returned to prison. In prison, where resources are already limited, dropping out of therapy may mean returning to the waitlist.

Aftercare Also Inadequate

Resource limitations also affect post-release support. “Patients who recognize that they have a chronic condition can learn to manage it,” Dallüge said. “But achieving long-term recovery — that’s the real challenge. And aftercare is severely lacking.”

Some aftercare services are available to individuals released from MRV. However, those leaving prison due to sentence completion often depart with little more than a small amount of cash and a contact for probation services.

“There’s no standardized system to link released prisoners with addiction counseling or support,” said Dallüge. “It’s mostly up to the individual. There are no national aftercare programs to support people with substance use disorders after incarceration.”

Relapse rates remain low in MRV, at 6%-8%, but in regular prison settings, they can range from 30% to 40%.

“Clearly, incarceration alone doesn’t address the underlying problems,” Dallüge concluded. “If someone is addicted and receives no help, they remain ill — no matter how long they’re locked up.”

This story was translated from Medscape's German edition.