– In 2016, 10 times as many Americans as Germans died as a result of drug overdoses. Three times as many Americans as Germans experienced opioid addiction.

Even as the rates of addiction in the U.S. have risen dramatically in the past decade, Germany’s rates have been flat.

That contrast, experts say, highlights a divergence in how the two countries view pain as well as distinct policy approaches to health care and substance abuse treatment.

Unlike in the U.S., where these pills are commonly dispensed after surgeries and medical procedures, opioids have never emerged as a front-line treatment in Germany.

“Among the most important reasons we do not face a similar opioid crisis seems to be a more responsible and restrained practice of prescription,” said Dr. Peter Raiser, the deputy managing director at the German Center for Addiction Issues.

Doctors must first try alternative treatments, which the universal health insurance system typically covers. Before prescribing opioids, physicians must get permission and screen patients.

“Here in Germany, they prescribe opiates if all the other drugs don’t work,” said Dr. Dieter Naber, a psychiatrist and researcher at the University of Hamburg.

Research shows that the number of Germans addicted to opioids has changed only slightly in the past 20 years.

In 2016, 166,300 Germans experienced opioid addiction — about 0.2% of the population. In the U.S., about 2.1 million Americans — 0.6% of the population — experienced opioid addiction in 2016.

Because of Germany’s health system — which emphasizes primary care and keeps cost sharing low — people who are prescribed opioids are more likely to keep up with their doctors’ visits. If they exhibit warning signs of addiction, physicians have a better chance of noticing.

Illicit drug use also occurs in Germany, and opioids are the main killer in drug-induced deaths. Still, the drug-induced mortality rate has gone down, according to the most recent European figures.

Even when people here get addicted, they are far less likely to die as a result. In 2016, 21 per million Germans died from drug-induced overdoses (of which most were opioid-induced). That same year, 198 per million Americans died from the same cause.

In Germany, drug addiction is treated with medication and “harm reduction” approaches, including so-called safe-injection sites — people experiencing addiction take drugs under medical supervision.

Such strategies are controversial in the U.S. A federal judge ruled in October against a Trump administration effort to block a safe-injection program in Philadelphia. The administration argued that such efforts enable and encourage addiction, and pledged to continue efforts to block safe-injection sites.

But “harm reduction” and supervised injection have been cited as best practices by the Organization for Economic Co-Operation and Development, a coalition of mostly Western nations.

“We know harm reduction works in terms of dealing with the problem of mortality,” said Dr. Andres Roman-Urrestarazu, a researcher at the University of Cambridge.

He added that Germany’s success with its multipronged approach illustrates that addiction is “a more complex problem” than the current U.S. response has acknowledged.