Israel has a serious opioid problem, according to a recent report published by the Taub Center for Social Policy Studies in Israel. The report warns that Israel is on the verge of an opioid epidemic, based on several peer-reviewed studies indicating that in 2020, Israel led the world per capita in prescriptions for the potent and addictive drugs.
Initially lagging behind the United States and other countries that have struggled with opioid epidemics since the late 1990s, Israel has unfortunately caught up in the past decade. Abuse of the drug fentanyl — 50 times stronger than heroin and highly addictive — plays a large role in the public health predicament in which Israel now finds itself.
“The watershed was about 10 years ago, because before that doctors prescribed alternatives and there was less access to opioids. It wasn’t as easy for patients to get them as is it today,” said Prof. Nadav Davidovitch, co-author of the report and the Taub Center’s principal researcher and health policy program chair, as well as head of Ben-Gurion University of the Negev’s School of Public Health.
The Taub Center report suggests that although the situation is dire, it is not insurmountable. Public health and addiction experts are working with the Health Ministry on a three-year plan that takes into consideration the report’s recommendation for a coordinated and integrated national program. The multiple stakeholders include government, physicians, drug companies, HMOs, patients’ organizations, law enforcement, and mental health and social welfare providers.
The report suggests that Israel, with its nationalized health system and fully electronic patient health records, is positioned for a relative advantage in tackling the problem compared to other countries.
Davidovitch told The Times of Israel that the Health Ministry and other governmental bodies were aware of the increase in opioid use, but until about two years ago did not realize the urgency with which it must be addressed.
As in other countries, drug companies began to heavily market opioids (also called opiates) in Israel, and many physicians were quick to see them as a magic bullet for treating pain without knowing enough about the potential for abuse, dependency and addiction.
Davidovitch noted that a delicate balance must be achieved. The opioid crisis must be dealt with while not ignoring the need for legitimate pain management.
“The solution is not that there will be no opioids at all, and all pain management is horrible. On the contrary. We need to treat those with chronic pain, especially cancer. But we need to do it the right way,” he said.
Overdoses may be flying under the radar
The data provided in the Taub Center report is alarming. In the first half of the last decade, the use of oxycodone and fentanyl (both stronger than morphine) increased. There was an especially sharp rise in the use of fentanyl beginning in 2014 after propoxyphene was banned and limits were placed on the use of codeine. It was subsequently determined that between 2012 and 2015, the rate of consumption of opioids in Israel was the highest in the OECD.
With fentanyl use skyrocketing beyond the equivalent of 140 milligrams of morphine per capita by the end of the last decade, data from the International Narcotics Control Board pointed to Israel surpassing the United States by having the highest prescription narcotics consumption in the world in 2020.
According to medical sources, among the most commonly prescribed opioid brand names in Israel are Percocet, Targin, ACTIQ, Oxycod and OxyContin — all of which contain either fentanyl or oxycodone as the active ingredient.
The studies upon which the Taub Center Report relies also indicate that Israel’s fentanyl use is mostly among young people of lower socioeconomic status who are not suffering from cancer.
This increased use of opioids — especially fentanyl — has led to increased abuse and dependency, with dependency often developing in just a few weeks. The number of opioid poisonings has also increased, but because fewer autopsies are performed in Israel than in other countries (due to religious restrictions), the true extent of opioid overdose is unknown.
“In the States, one of the things that characterized the opioid epidemic most of all is the disastrous number of overdoses that reached over 100,000 in 2022. We are missing that part of the equation in Israel,” said Prof. Shauli Lev-Ran, an addiction psychiatrist and co-founder of the Israel Center on Addiction.
“I did a joint study with the Health Ministry on the number of overdose-related deaths as per death certificates in Israel. It was surprisingly low,” he said.
According to Lev-Ran, the reasons for this are likely that overdoses are not diagnosed in Israel as they are in the US, and that Israeli pathologists register deaths as due to respiratory depression or cardiac arrest rather than a drug overdose.
“A lot of overdoses may be flying under the radar,” he said.
The view from the emergency room
Dr. Samer Hayek is an emergency medicine specialist at Rambam Medical Center in Haifa. He told The Times of Israel that he has personally never seen any unintentional opiate overdose come into the emergency room. Rather, he has seen suicide attempts with patients brought in unconscious and unable to say what they have taken.
“It is generally a combination of pills, but we always assume that one of the drugs the person has taken is an opiate, and we have a [temporary] antidote [called Naloxone] we give,” he said.
When asked why he assumes that the person has taken opioids, Hayek answered that it’s because in his experience, “80% of the people that come into the emergency room are in pain and they are discharged with a prescription for an opioid.”
“So we can assume that every second or third person in Israel has opiates in the house. If it’s not you personally, then a family member or friend probably has them,” Hayek said.
“They have pills dispensed by prescription. I haven’t seen people coming into the ER having used opioids intravenously or by sniffing like you see in the US,” he added.
Without enough pain specialists among Israel’s physicians, many people end up in the ER after having tried first- or second-line pain medications and asking for something stronger. Other patients are initially prescribed opioids after surgery or by a specialist to deal with an acute injury or condition. It is not uncommon for patients to have their family doctor or internist renew the prescription.
“When I discharge a patient, I give them a prescription for only a limited number of pills and explain to them what an opiate is and what the dangers of abuse and addiction are. People don’t know this. They think it’s just a painkiller,” he said.
Both Hayek and Davidovitch emphasized the need for physician education about opioid addiction and proper prescribing guidelines. Davidovitch mentioned that doctors need to be more aware of the “doctor shopping” that some patients do to get fentanyl so they can sell, share or abuse it another way.
“I think that now in the last year, there is more awareness. But I still think that there are unfortunately some physicians who are in a state of denial [about the opioid crisis],” Davidovitch said.
According to Lev-Ran, this is not going to change unless all doctors are educated about addiction and cautious prescribing practices.
“Addiction medicine is not regularly taught in medical school. Diagnosing and treating addiction are not part of the core curricula in the different medical subspecialties,” he said.
Dispersed responsibility and fractured care
Lev-Ran points to systemic problems within Israeli healthcare as playing a large part in the growth of the opioid problem. In 2015, addiction treatment was carved out of the general medical system and the mental health reform.
“What that means is that while the Health Maintenance Organizations in Israel have direct responsibility for all of our physical and mental health needs, addiction treatment was excluded, and that causes an abundance of problems,” he said.
The result has been that addiction is on a short list of disorders that fall directly under the responsibility of the Health Ministry, with treatment provided in specific clinics.
“A lot of them were established in the 1970s and 1980s and were known as methadone clinics. They were geared towards IV drug users, particularly heroin users. The addiction scene has changed immensely over the past three decades, but the services almost haven’t at all,” Lev-Ran said.
Furthermore, the way individuals struggling with addiction are treated does not take into account that the majority of them suffer from comorbid psychiatric disorders, according to Lev-Ran. The Welfare Ministry is responsible for their psychosocial treatment, a psychiatric clinic (through one of the HMOs) for their psychiatric treatment, and the Health Ministry for their addiction treatment.
“Very few individuals [have the ability] to run among three different service providers,” Lev-Ran remarked.
He told The Times of Israel that he was pleased that in late 2022, the Health Ministry, recognizing the problem of fragmented care, launched a pilot to fund the HMOs for three years to develop their own addiction treatment programs. Since every Israeli must be a member of one of Israel’s four HMOs, this would enable a person with addiction to receive coordinated care alongside any physical or mental disorders they have.
“We’re talking about an addiction that the medical system is partially responsible for. If HMOs are taking part in prescribing opioids, it just makes sense that they would be responsible for treating any adverse effect,” Lev-Ran said.
Reversing the upward trend
As Israel comes to terms with and deals with its opioid crisis, the focus must ultimately be on the toll of overprescription and subsequent opioid disorders.
The Taub Center report offers several recommendations. Most obviously, it calls for better physician education and safer prescription and monitoring practices — especially for patients in high-risk categories. This goes hand-in-hand with better patient and family education about opioid use.
“We need to do public education, as we do about the dangers of smoking. And the approach needs to be tailored to different segments of the population rather than a one-size-fits-all approach. We especially want to reach young people of lower socioeconomic status,” Davidovitch said.
An important step was taken in August 2022 when the Supreme Court heard a petition filed jointly by Physicians for Human Rights and Le’altar, a nongovernment organization that offers help to people addicted to narcotics. As a result, the Health Ministry agreed to change the wording of the labeling on opioids from “Long-term use can lead to addiction” to the more definitive “The long-term use of this drug causes physical addiction.”
The Taub Center report also recommends a more integrated treatment approach that provides the psychosocial and mental support often needed by those more vulnerable to opioid abuse, disorders, and overdose.
It emphasizes that the research community must step up its role in closely monitoring prescription trends and adverse outcomes to supply near real-time data to policymakers.
“There’s a lot of room for additional research — not just about the rates of use, but also the negative consequences of this use,” Lev-Ran said.
“We are paying an enormous price for the fact that the Israeli health system has carved out addiction treatment and left it as an orphan diagnosis. If you don’t have to treat something, you don’t have to diagnose it. And if you don’t have to diagnose it, you don’t have to study it,” he said.
Lev-Ran noted that in addition to the medical rationale for addressing Israel’s opioid crisis, there is also a financial one. He cited a controlled economic study his center did with Clalit Health Services, Israel’s largest HMO. It found that people with prescription opioid use disorder utilize treatment services at a cost six times higher than their non-use counterparts.
“The only reason I can see behind [not dealing more aggressively with opioid abuse and addiction] is long-lasting, negative attitudes and stigma. And that’s something that we’re working very hard to change,” he said.
Davidovitch said that the Taub Center report has done the job of spotlighting Israel’s opioid problem and is pleased that it has woken up policymakers and the public to the dangers of fentanyl and similar drugs. He is optimistic about the country’s ability to tackle the issue, but also realistic about the time it will take.
“[The epidemic] is already here. Following what we know from the US and other countries, it’s not going to be solved very quickly, unfortunately. So we need to be patient. We need to implement a plan that has short-term, medium-term, and long-term goals, measure outcomes continuously, and present them to the Knesset once a year,” Davidovitch said.
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