Unlike in the United States, where these pills are commonly dispensed after surgeries and medical procedures, opioids have never emerged as a front-line medical 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 nation’s universal health insurance system typically covers. Before prescribing opioids, physicians must get special permission and screen patients to make sure they aren’t at risk for addiction.

“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. “It’s much, much, much more difficult.”