The Use of Psychoactive Substances in Germany: Findings from the Epidemiological Survey of Substance Abuse 2021

Findings from the Epidemiological Survey of Substance Abuse 2021

Background: Monitoring the use of psychoactive substances and substance-related problems in the population allows for the assessment of prevalence and associated health and social consequences.

Methods: The data are derived from the Epidemiological Survey of Substance Abuse (ESA) 2021 (n = 9046, 18–64 years). We estimated prevalence rates of the use of tobacco, alcohol, illegal drugs, and psychoactive medications, as well as the prevalence rates of their problematic use (indicating dependence) using screening instruments, and extrapolated the results to the resident population (N = 51 139 451).

Results: Alcohol was the most frequently used substance, with a 30-day prevalence of 70.5% (36.1 million people), followed by non-opioid analgesic drugs (47.4%; 24.2 million) and conventional tobacco products (22.7%; 11.6 million). E-cigarettes were used by 4.3% (2.2 million) and heat-not-burn products by 1.3% (665 000). Among illegal drugs (12-month prevalence), cannabis was the most frequently used (8.8%; 4.5 million), followed by cocaine/crack (1.6%; 818 000) and amphetamine (1.4%; 716 000). Rates of problematic use among the study participants were 17.6% for alcohol (9.0 million), 7.8% for tobacco (4.0 million), 5.7% for psychoactive medications (2.9 million), and 2.5% for cannabis (1.3 million).

Conclusion: The consumption of psychoactive substances continues to be widespread in Germany. In view of the imminent legal changes, the high prevalence of cannabis use and its problematic use need to be taken into consideration.

The use of psychoactive substances is one of the main risk factors for the global burden of disease and premature mortality (1). In 2019, worldwide tobacco use was responsible for approximately 229 million disability-adjusted life years (DALY) and 8.71 million deaths. A total of 2.44 million deaths were attributable to the consumption of alcohol and 494,000 to the use of illegal drugs (2, 3). Thus, based on the total number of annual deaths (56.53 million), a fifth (11.64 million) are accounted for by the use of psychoactive substances (3). Despite an observed decline in the consumption of alcohol since the 1990s, Germany is among the 10 countries worldwide with the highest per capita consumption rates (4, 5). The proportion of smokers in 2019 was also above the West European average (6).

In addition to the high burden of morbidity and mortality, the use of psychoactive substances is associated with significant economic costs, which cannot be compensated for through tax revenue from the sale of legal substances (alcohol, tobacco). According to estimates, the consumption of alcohol in Germany generates annual costs to the economy of approximately 57.04 billion euros (7). The total direct and indirect costs to the economy of tobacco use in 2018 were estimated at 97.42 billion euro (7). The annual expenditure for illicit drug use in Germany in 2010 was put at 5.2–6.1 billion euros (8), while the costs resulting from the harmful use of cannabis were estimated in 2016 to be approximately 975 million euros per year (9).

Monitoring the use of psychoactive substances is an indispensable precondition of health policy decision-making and enables, among other things, an estimation of future costs and the evidence-based development of effective prevention and intervention measures. As a population-representative study, the German Epidemiological Survey of Substance Abuse (ESA) provides data on the use of both legal and illegal substances as well as on hazardous forms of use in the German adult population. The aim of this paper is to provide prevalence estimates of the use of tobacco, alcohol, illicit drugs, and psychoactive medications and of negative consequences of substance use in the German adult population.

Methods

Study design and sample

The target group of the ESA 2021 comprises German-speaking individuals aged 18–64 years and living in private households. Sampling was performed using a two-stage selection process. In a first step, 217 municipalities were randomly selected. A random selection of addresses was then made from the respective population registers. In order to make up for the low proportion of young adults in the total population, disproportionate sampling according to age cohorts was carried out. The survey was conducted in writing, via the internet, or by telephone. The adjusted sample comprised 9046 individuals, the response rate was 35.0%. The survey period ran from May to September 2021 in the second year of the COVID-19 pandemic. For further information on the methodology used for the ESA 2021, the procedure of the survey, the response rate by study arm, as well as prevalence rates according to survey mode, see eMethods, eFigure, and eTables 1–3.

eTable 1

Type of response by study arm, n (%)

eTable 2

Substance use prevalence estimates by survey mode, n (weighted %)

eTable 3

Substance use prevalence estimates by willingness to participate, n (%)

eFigure

Flowchart of the study design and response rates

Instruments

Conventional tobacco products, e-products, and heat-not-burn products

The use of conventional tobacco products (cigarettes, cigars, cigarillos, and pipes), waterpipes (hookahs), e-cigarettes, e-waterpipes, e-pipes, e-cigars, and heat-not-burn products was surveyed for the preceding 30 days (10). Daily cigarette consumption was defined as the use of at least one cigarette per day, while heavy cigarette consumption was defined as the use of at least 20 cigarettes per day. To survey dependence on conventional tobacco products and heat-not-burn products over the preceding 12 months, the Fagerström test for nicotine dependence (FTND) (e1) was used, while the Penn State Electronic Cigarette Dependence Index (PS-ECDI) was used for e-products (e2).

Alcohol

Alcohol consumption was measured for the preceding 30-day time period using a beverage-specific frequency–quantity index separately for beer, wine/sparkling wine, spirits, and mixed alcoholic beverages. Episodic heavy drinking was defined as the consumption of five or more glasses of alcohol (approximately 70 g pure alcohol) on at least one day in the preceding 30 days. The daily consumption of more than 12 g (women) and 24 g (men) of pure alcohol was defined as the threshold for hazardous alcohol consumption (11, 12). The Alcohol Use Disorder Identification Test (AUDIT) was used as an indicator for problematic alcohol consumption (indicating dependence) in the preceding 12 months (e3).

Illegal drugs

The use of cannabis (hashish, marijuana), amphetamine and methamphetamine, ecstasy, LSD, heroin, other opiates (for example, codeine, methadone, opium, and morphine), cocaine/crack cocaine, hallucinogenic mushrooms, and new psychoactive substances (NPS) was recorded for the preceding 12-month period. Problematic use of cannabis, cocaine, and amphetamine/methamphetamine within the preceding 12 months was measured using the Severity of Dependence Scale (SDS) (e4).

Medications

The use of analgesics, hypnotics and sedatives, analeptics, anorectics, antidepressants, and neuroleptic drugs was surveyed for the preceding 30-day period. Medications taken on a daily basis were also recorded. Problematic use within the preceding 12 months was recorded using the Short Questionnaire on Medication Use (Kurzfragebogen zum Medikamentengebrauch, KFM) (e5).

Statistical analysis

Descriptive data on substance use and problematic use are reported as prevalence estimates with 95% confidence intervals separately for men and women as well as for the total population. Statistically significant differences in prevalence estimates were measured using confidence intervals. Projections to the total resident population in Germany aged 18–64 years were performed based on a population of 51 139 451 individuals (25 940 597 men; 25 198 854 women) as of 31 December 2020 (e6). Post-stratification weights were used to adjust the data to the distribution of the target population in the German adult population in terms of the characteristics age, sex, school education, federal state, and community size class. Due to the complex sample design, the Taylor series linearization method was used to estimate standard errors (e7).

Results

Conventional tobacco products, e-products, heat-not-burn products

The 30-day prevalence of conventional tobacco product use was 22.7% (11.6 million individuals) and, for daily tobacco use, 13.7% (7.0 million individuals) (Table 1). Of the tobacco users, 21.0% (2.4 million) reported smoking at least 20 cigarettes a day. Waterpipe use was reported by 4.1 % (2.1 million individuals), e-cigarette use by 4.3% (2.2 million individuals), and heat-not-burn product use by 1.3% (665 000 individuals) (in the preceding 30 days). Men showed higher prevalence rates across all product categories compared to women. Evidence of dependence on tobacco products was seen in 7.8% (4.0 million individuals), on heat-not-burn products in 0.2% (102 000 individuals), and on e-cigarettes in 2.0% (1.0 million individuals) (Table 2).

Table 1

30-Day prevalence of the use of conventional tobacco products, electronic inhalation products, and tobacco heaters, as well as the use of waterpipes (hookahs); extrapolation to the 18- to 64-year-old population

Table 2

The 12-month prevalence of substance-related problems based on screening instruments: extrapolation to the 18- to 64-year-old population

Alcohol

A total of 70.5% of respondents (36.1 million individuals) reported having consumed alcohol in the preceding 30 days (Table 3). Of these, 33.3% reported at least one episode of heavy drinking—with a higher prevalence seen among men (41.9%) compared to women (23.3%). Among alcohol consumers, 21.9% (7.9 million individuals) reported consuming hazardous quantities of alcohol. Differences between prevalence rates among men (21.1%) and women (22.9%) were not statistically significant. Overall, 17.6% of respondents (9 million individuals) exhibited problematic alcohol use (Table 2).

Table 3

30-Day prevalence of alcohol use; extrapolation to the 18- to 64-year-old population

Illegal drugs

With a 12-month prevalence of 8.8% (4.5 million individuals), cannabis was the most frequently used illegal drug, followed by cocaine/crack cocaine with 1.6% (818 000 individuals; Table 4). In total, 1.4% of participants (716 000 individuals) reported having used amphetamine, while 1.3% (665 000 individuals) reported NPS use. At 0.2% (102 000 individuals), the 12-month prevalence for the use of methamphetamine was the lowest. A statistically significantly higher prevalence was seen among men compared to women for cannabis, cocaine/crack cocaine, and the use of at least one illegal drug. With a prevalence of 2.5% (1.3 million individuals), problematic drug use according to SDS criteria can be seen particularly in relation to cannabis (Table 2). In this group, men were more frequently affected (with a prevalence of 3.4%) compared to women (1.6%). Prevalence rates for problematic use of cocaine and amphetamine/methamphetamine according to SDS criteria were both 0.4% (205,000 individuals). Sex differences in the 12-month prevalence of these substances were not statistically significant.

Table 4

12-Month prevalence of illegal drug use; extrapolation to the 18- to 64-year-old population

Medications

Non-opioid analgesics were the medications most commonly used, with a 30-day prevalence of 47.7% (24.2 million individuals) (Table 5). The second most commonly used medications were reported to be hypnotics or sedatives (5.4%; 2.8 million individuals), followed by antidepressants (5.3%; 2.7 million individuals) and opioid analgesics (2.1%; 1.1 million individuals). In total, 51.4% (26.2 million individuals) reported having used at least one medication in the preceding 30 days, with the percentage for women (60.6%) being statistically significantly higher than that for men (42.5%). Among the users of the respective medication group, antidepressants (90.4%; 2.5 million individuals) were those most frequently used daily, followed by neuroleptics (83.9%; 601,000 individuals) and anorectics (57.2%; 117,000 individuals). Non-opioid analgesics were the medications most rarely used daily (6.9%; 1.7 million individuals), with the percentage for men (9.8%) being statistically significantly higher than that for women (5.0%). In total, 18.9% of medication users (5.0 million individuals) reported using at least one of the abovementioned medications daily. Finally, 17.6% of respondents (2.9 million individuals) exhibited problematic alcohol use (Table 2).

Table 5

30-Day prevalence of medication use and daily use; extrapolations to the 18- to 64-year-old population

Discussion

Conventional tobacco products, e-products, and heat-not-burn products

With the proportion of smokers exceeding a fifth (22.7%; 11.6 million individuals), the use of conventional tobacco products among 18- to 64-year-olds is widespread in Germany. Thus in 2020, of the 27 EU Member States (plus Great Britain), Germany ranked 16th on a list in descending order of smoking prevalence (13). According to results of the German Study on Tobacco Use (DEBRA), a nationally representative survey, the prevalence of tobacco use in 2021, including adolescents and older individuals (≥ 14 years), was approximately 30% (14). Smoking is one of the largest preventable risk factors for a multitude of physiological diseases (including, cardiovascular and respiratory diseases as well as cancer) and is considered to be the cause of around 125 000 deaths each year in Germany (15). Studies show that only total abstinence from smoking can be considered as harmless to health (e8). In view of this, it is even more concerning that only one in five German smokers reports attempts to quit (16). The same study shows that e-cigarettes (both with and without nicotine) as an alternative to smoking are the most commonly used single form of aid during any attempt to quit smoking. According to recent evidence, e-cigarette vaporization is less harmful to health than smoking tobacco cigarettes (17), but it is not considered safe (18). In particular adolescents and young adults are at increased risk for taking up e-cigarette use—and thus also for the associated health risks—due to the multitude of flavors on offer (19). Overall, the percentage of e-cigarette users among the adult population is relatively low at 4.3%; the same applies to the percentage of heat-not-burn product users, which at 1.3%, is significantly lower than that of e-cigarette users. However, the prevalence rates among young adults of exclusive use of alternative products, such as heat-not-burn products, waterpipes (hookah), or e-cigarettes, are markedly higher compared to those among older age groups (20).

Alcohol

With a 30-day prevalence of 70.5%, alcohol is the most frequently used psychotropic substance in Germany. The consumption of large quantities of alcohol has been shown to be associated with an increased risk for a wide range of non-communicable diseases (e9). While the consumption of high-risk amounts of alcohol over a prolonged period of time is associated in particular with chronic diseases (for example, cardiovascular disease or cancer), episodic heavy drinking predominantly leads to acute diseases and injuries, including harm to others as a result of traffic accidents or alcohol use during pregnancy (21, 22). Studies also suggest that blackouts caused by binge drinking, particularly in adolescents, can increase the risk of an alcohol use disorder, in addition to massive brain and nervous system damage (23, 24). The available results show that 17.6% of alcohol consumers surveyed exhibit problematic alcohol consumption. Results of the DEBRA study point to a comparable prevalence (19.4%) (25).

Illegal drugs

With a 12-month prevalence of 8.8%, cannabis is the most frequently used illegal substance. A rise in the prevalence of use in recent years has been reported both throughout Europe (26) and in Germany (5).

A comparison of the last ESA survey in 2018 also shows a further increase in the 12-month prevalence of cannabis use by 1.7 percentage points (27). Since 2017, medical cannabis has been available on prescription in Germany for certain indications. With approximately 30 000 to 40 000 users of medical cannabis in Germany (28), the majority of the estimated 4.5 million users obtain cannabis from illicit sources. In particular the regular use of cannabis has been shown to be associated with an increased risk for mental health disorders (for example, anxiety disorders, psychoses, depression) (29, 30). In view of the current political debate on legalization in Germany, one should not underestimate the risks and hazards of cannabis use especially to adolescents and young adults (31, 32). The results of the present study show that one in four cannabis users exhibits problematic use.

With the exception of cannabis, the use of other illegal drugs in Germany is much less widespread. Cocaine is the second most commonly used illegal substance; with a prevalence of 1.6%, the consumption of cocaine/crack cocaine exceeds the overall prevalence for Europe (1.2%) (33). At 1.4%, the prevalence of amphetamine use in Germany is twice that of Europe as a whole (0.7%). The use of NPS (1.3%) is far more widespread in Germany than the use of methamphetamine (0.2%) and, compared to results from 15 countries with available data, is significantly higher than the average value of 0.6% (33).

Medications

With around 24.2 million users, non-opioid analgesics are the most frequently used group of medications in Germany. These pain medications that are available over the counter from pharmacies are used primarily to treat mild to moderate pain, but can cause serious side effects if used improperly (34, 35).

The prevalence of non-opioid analgesic abuse among self-medicated users is estimated to be 6.4% (3.2 million individuals) in Germany (36). In contrast, the percentage of people using prescription opioid analgesics is, as expected, lower at 2.1%. Analyses of prescription data show a constant rise in the total number of opioid analgesic prescriptions over the last decade (37). An increase in long-term prescribing (≥ 3 months) for chronic non-cancer-related pain is also evident, despite the fact that there is little evidence of efficacy in this patient group (38, 39).

According to the results of this study, approximately 2.9 million individuals show problematic medication use. One can assume that—in addition to opioid analgesics— hypnotics and sedatives are particularly associated with problematic use, since these drugs have a high dependence potential by virtue of their pharmacological properties (39).

Limitations

Survey data on prevalence rates of use are subject to a number of limitations. For example, one can expect biases due to systematic non-participation by certain user groups (see eMethods Section for non-response analyses). Since all information on substance use is based on self-reporting, the full picture may be underestimated as a result of socially desirable response behavior. With regard to the representativeness of the present study, it is important to note that due to the study design, certain population groups are difficult or impossible to reach. This applies in particular to individuals aged over 64 years, homeless people, as well as people receiving inpatient treatment.

Conclusions

The use of illegal and legal psychoactive substances remains widespread in Germany. Alcohol is the most frequently used psychotropic substance, followed by non-opioid analgesics and tobacco. Cannabis is the most commonly used illegal substance. Against the backdrop of the planned legislative changes (40), the high prevalence rates of cannabis use as well as its problematic use are likely to spark discussion.

Funding

The 2021 German Epidemiological Addiction Survey (ESA) was funded by the Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) (Ref: ZMVI1–2520DSM203). Funding is not subject to conditions.

Conflict of interests statement
The authors declare that no conflict of interests exists.

Manuscript received on 1 April 2022, revised version accepted on 1 June 2022.

Translated from the original German by Christine Rye.

Corresponding author
Christian Rauschert, M. Sc.
IFT Institut für Therapieforschung
Leopoldstraße 175
80804 München, Germany

Cite this as:
Rauschert C, Möckl J, Seitz NN, Wilms N, Olderbak S, Kraus L: The use of psychoactive substances in Germany—findings from the Epidemiological Survey of Substance Abuse 2021. Dtsch Arztebl Int 2022; 119: 527–34. DOI: 10.3238/arztebl.m2022.0244

►Supplementary material

eReferences, eMethods, eTables, eFigure:
www.aerzteblatt-international.de/m2022.0244

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