Bramness et al. 2023 [1] describe addiction training and related issues in 24 European countries. They report that France has far more university departments and full professorships in addiction medicine (23) than any other country in Europe. This striking difference in the infrastructure for training and education merits attention. It is also an example why the European Federation of Addiction Societies (EUFAS.net) undertakes benchmarking processes, which might inform developments in its member countries and beyond.

In our commentary, we want to offer more detail about these differences in training modalities and research infrastructure by comparing two European countries (France and Germany). They are similar in terms of consumption of psychoactive substances and the resulting health and social problems [2]. So despite the lack of comparative data between the two countries and the use of heterogeneous criteria for characterizing addictive behaviors, prevalence data for risky consumption of alcohol, alcohol dependence, problematic use of illegal drugs (including Cannabis), regular smokers, and DALYs for alcohol use disorders per 100,000 would ultimately be quite similar between Germany and France (respectively, 7.9 vs. 5 million, 1.6 vs. 1.8 million, 1.6 vs. 2.5 million, and 550 vs. 575, for a population of 83 million in Germany and 68 million in France) [3‒5].

In France, since 1958, 32 regional university hospital centers (CHU) managed by the Regional Health Agencies (ARS) are attached to medical faculties managed by the National Ministry of Higher Teaching and Research. University hospitals and medical faculties support training, research, and teaching. Training in addictology has historically been an integral part of specialized medical training in these establishments. University teaching and research in this field began in the late 1970s, when a handful of medical professors developed a specific approach to the management of patients who, at the time, were mainly alcohol-dependent. Gradually, a university movement took an interest in “alcohology,” teaching courses as part of medical studies and conducting research on the subject. The need for university teachers of addictology from a variety of specialties gradually became apparent. The emergence of this multidisciplinary teaching coincided with the emergence of the concept of addiction encompassing all substances and behaviors and integrating all approaches and currents.

One of the turning points in this global approach was the creation of the National University College of Addictology Teachers (CUNEA) in 1999. It brought together the pioneers to make addictology a university discipline. In the early 2000s, the French Ministry of Higher Education and Research opened up the possibility of appointing addictology academics from seven medical specialties: pharmacology, therapeutics, adult and child psychiatry, pneumology, gastroenterology, and internal medicine. In addition to developing addictology courses during medical studies, perfectly integrated into the national medical curriculum, these academics are responsible for research and regional coordination of the care system. After the 6th year of medical school, additional courses deepen the knowledge within a one-year accredited curse during specialty training (internship in an addictology center and local and national teaching). For practicing doctors, recognition of the addictology diploma is achieved through a two-year training course at a faculty, with 150 h of teaching and an internship (80 compulsory half-days). Addictology academics are also involved in other university training courses and coordinate university addictology diplomas for paramedics in particular (100 h of teaching, including internships). Training in addictology for psychologists varies from one university to another and most often consists of additional hours of teaching on addictions that do not lead to an additional diploma.

Additionally, addictology academics are responsible for addictology units in university hospitals, which are regional reference centers. At present, the vast majority of medical faculties and university hospitals have a university addictology department (currently 28 university professors or 5 associates).

The second crucial step in developing addictology in France was the organization of the “Health and Medical/Social Response” by the French Ministry of Health in 2007 [6]. It clarified the treatment channels and their funding possibilities and was the result of the work of a group of 5 experts from the French Federation of Addictology [7]. The hospital component is a care system organized on three levels: local response, a specifically addictology referral level, and a regional addictology university center located in a university hospital that supports teaching and research. The hospital system interfaces with the social outpatient system, which is generally in charge of specialized opiate treatment programs and prevention or harm reduction centers.

After the second world war, Germany adopted a federal constitution, which delegates power in many areas of internal politics and administration to the 16 Bundesländer (federal states). They are independent in all decisions concerning culture and education as well as in their health care systems. The national government only provides a general framework within which each Bundesland or even the city decides on the organization of its inpatient and outpatient facilities. While university hospitals cover the mainstream of medical disciplines in departments or divisions, this does not hold true for addiction medicine and thus for teaching and treating addictions. The situation is similar in most departments of psychology in German universities. As a result, medical and psychology students receive very little teaching in addiction and almost no exposure to afflicted patients.

The treatment system for addicted patients is divided into two domains. One is the medical sector, responsible for acute detoxification treatment, with a limited number of days covered by medical insurance companies. The second domain is organized by rehabilitation hospitals programs principally privately owned. Psychiatric hospitals can treat patients with drug or alcohol dependence for longer periods if there is a psychiatric comorbidity.

While psychiatrists are considered addiction specialists by their genuine training in psychiatry, other MDs must undergo roughly 50 h of specialized training in order to treat ambulatory patients with addiction problems. This includes practical skills in opioid-assisted treatment. In summary, neither of the domains where addiction patients are being seen is really linked to education and training at medical schools or psychology departments. In recent years, the focus of treatment for addiction problems has shifted more and more to outpatient facilities. In Germany, the two churches as well as organizations for public welfare provide nationwide counseling offices, which in general collaborate with local self-help groups. Again, they are not involved in training and education at medical schools or psychology departments. However, they organize master classes for psychologists, social workers, and nurses who then qualify as addiction counselors.

These gaps in knowledge and the professionals who apply it became evident with the sharp rise in drug-related deaths in Germany in the 1990s. The federal government organized an initiative with money earmarked for addiction research. The major aim was to create centers of excellence, which would develop and/or adopt research methodologies and would train young scientists promoting research and dissemination of knowledge. Within a decade, these centers should be able to provide education and training expertise and compete with all fields of research even beyond health and medicine. On that behalf, applying centers should create professorships, which were to become sustainable over time [8, 9]. Finally, out of 16 applications, 4 were selected and funded and 5 professorships were initiated (Dresden, Essen, Mannheim, Tübingen, Würzburg). Other universities followed these examples and organized well-structured teaching curricula including addiction issues. Currently, addiction research has achieved the only nationwide research consortium (“Sonderforschungsbereich”) within the field of psychiatry, having successfully competed with all fields of science and research nationwide. On the other hand, not all of the five professorships are still in existence to date.

In conclusion, it might make a difference whether political decisions are being taken in one place such as in France or in sixteen places such as in Germany. In the case of training and education in addiction medicine and psychology, the well-developed clinical infrastructure at universities in France seems to have advantages. Regular encounters between students and afflicted individuals are the norm and not the exception. Compared with Germany and many other countries in Europe, the political system in France seems to have facilitated the formation of so many addiction departments at university hospitals. In Germany, with the autonomy of the federal states and their universities, introducing changes is more complex. After acknowledging the dire need for better training and education in addiction, the German government chose another approach. Nationwide calls for addiction research centers were linked to the creation of professorships. Repeated funding over more than 20 years laid the foundation for improvements in teaching addiction as well. However, this approach seems more vulnerable to changes over time than the one in France.

Yet, no progress would have been made had dedicated individuals not taken an initiative. These pioneers’ ideas convinced decision-makers in both countries. They argued that better treatment, prevention, and education in addiction issues are necessary and will be successful if based on scientific research. Many colleagues contributed to this process. For Germany, Hans Heimann (nationwide research funding for addiction), Johannes Brengelmann (behavioural treatment), Markus Gastpar (introduction of methadone maintenance and harm reduction), and Fritz Henn (creating the first university chair in addiction) laid the foundation, and many others followed. In France, we can cite pioneers like Pierre Fouquet (founder of the Société Française d’Alcoologie), Raymond-Michel Haas, Jean-Louis Balmès, Pierre Deniker, Jean Tignol, Didier Touzeau, William Lowenstein, Bertrand Lebeau, Jean Pierre Daulouède and Jean Dugarin who enabled the boom in the 1960s–90s care for patients dependent on alcohol or illicit products. This mission was pursued in the 90s–2000s by CUNEA academics, led in particular by Michel Reynaud who especially was instrumental in convincing the French government to initiate a process, which today is offering an academic infrastructure for multidisciplinary training and education in addiction. It also serves as basis for continued education and international exchange in addiction with annual conferences of various addiction societies in France. With the staff of 23 university centers, the attendance of theses conferences is naturally higher in France than in Germany. Taken together, the situation in France is strikingly different from other countries in Europe. Finally, we propose to highlight the important characteristics of the French system which seem remarkable to us and which could perhaps serve as an inspiration to other countries: (1) research and treatment of addictions are an integral part of the academic world, (2) the proximity of the hospital and the university during addictology training, (3) the appointment of more than 20 addictology academics spread throughout the national territory, (4) the links between medical disciplines supporting the teachers grouped together in a single national college, (5) the integration of addictology knowledge items into the national medicine program.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Each of the authors (G.B., F.P., K.M.) contributed equally to the writing of this commentary in its elaboration and rereading.

1.
Bramness
JG
,
Leonhardt
M
,
Dom
G
,
Batalla
A
,
Flórez Menéndez
G
,
Mann
K
, et al
.
Education and training in addiction medicine and psychology across Europe. A EUFAS survey
.
Eur Addict Res
.
2023
;
9
:
1
11
.
2.
World Health Organization (WHO)
.
Global health observatory data resposity
.
2022
. Available from: https://apps.who.int/gho/data/node.main.A1039?lang=en.
3.
Deutsche Hauptstelle für Suchtfragen2023
. Available from: https://www.dhs.de/unsere-arbeit/dhs-jahrbuch-sucht.
4.
Observatoire français des drogues et des tendances addictives
.
Drogues et addictions, chiffres clés
.
Paris
:
OFDT
;
2022
. p.
8
. Available from: https://www.ofdt.fr/publications/collections/drogues-et- addictions-chiffres-cles/drogues-et-addictions-chiffres-cles- 9eme-edition-2022.
5.
Shield
K
,
Manthey
J
,
Rylett
M
,
Probst
C
,
Wettlaufer
A
,
Parry
CD
, et al
.
National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study
.
Lancet Public Health
.
2020
;
5
(
1
):
e51
61
.
6.
Circulaire DGS/6B/DHOS/O2 n°2007-203 du 16 mai 2007 relative à l'organisation du dispositif de prise en charge et de soins en addictologie
.
7.
Lépine
JP
,
Morel
A
,
Paille
F
,
Reynaud
M
,
Rigaud
A
.
Rapport Proposition pour une politique de prévention et de prise en charge des addictions ; Un enjeu majeur de santé Octobre 2006
.
8.
Mann
K
.
Addiction research centres and the nurturing of creativity
department of addictive behaviour and addiction medicine, central institute of Mental Health, Mannheim, University of Heidelberg
.
Addiction
.
2010
;
105
(
12
):
2057
61
.
9.
Camarini
R
.
Interview with a scientist
. Dr. Karl Mann. The International Society for Biomedical Research on Alcoholism Bulletin.
2023
;
5
:
7
8
.