Just say no

Activists, researchers sound alarm as Israel’s opioid use reaches critical level, surpassing U.S.

Nonprofits working to get government to make it more difficult for doctors to prescribe powerful opiates as Israeli consumption levels surpass U.S.

For Eviatar Samoolsky, founder and director of the Israeli nonprofit Lealtar: The Narcotic Patient Support and Assistance Foundation, combating opioid addiction, which recently reached epidemic proportions in Israel, is a personal issue. Since he recovered from his 13-year dependency on opioids following a 1997 work accident that left him in a wheelchair, Samoolsky has been on a crusade not for better treatment for patients who have become dependent on the drugs, but to have better and tighter protocols for prescribing them to prevent the addiction in the first place.

Samoolsky does not mince his words when it comes to the direct correlation he sees between opioid prescriptions and opioid addiction: Simply put, he said, people prescribed opioids for pain management end up becoming “junkies.” While chemically related, some opioids, like fentanyl, are 50-100 times more potent than heroin and morphine and create a dependency that is a physical-chemical reaction to the drug, rather than a psychological addiction, said Samoolsky. He said this is why he believes the many rehabilitation facilities treating drug addiction in Israel that don’t focus on the physical aspect of the dependency are not the answer for opioid dependency.

“My main work is to prevent people [with chronic pain] from taking opioids in the first place; to show them the real picture. Because, you know, the devil never shows his real face because if he does nobody would go with him. So the best way [for companies] to push opioids is to play the angel, smuggling “heroin forte” into people’s minds, using the high level of trust in medicine and in doctors to simply smuggle in the strongest heroin,” Samoolsky told eJewishPhilanthropy. “The problem is that the real money [for pharmaceutical companies] is in chronic pain treatment, not in emergency treatment.”

Though it is not a regular feature on the nightly news in Israel, opioid addiction has rapidly become a major issue in the country. Last month, a study by the Taub Center for Social Policy Studies in Israel determined that the country had earned the ignoble superlative of having the highest level of per capita opioid consumption in the world in 2020 (the last year for which global data are available), surpassing the United States.

The study’s authors – Nadav Davidovitch, director of the Ben-Gurion University School of Public Health, Dr. Yannai Kranzler and Oren Miron – urged Israel to take immediate action to reduce unnecessary opioid prescriptions and excessive consumption of narcotics for pain management.

Until 2011 Israel had a relatively low rate of consumption of prescription opioids, said Davidovitch, due to its low use of strong opioids such as oxycodone and fentanyl, relying instead more on opioid alternatives or weaker opioids such as propoxyphene and codeine. But in 2011 Israel banned the use of propoxyphene because of a rare cardiological side effect and three years later also placed limits on the use of codeine.

Since 2014 the strong use of opioids began, especially with a sharp increase in the use of fentanyl, according to the study. The Taub Center researchers found that fentanyl consumption per capita– measured in “morphine milligram equivalent” — more than doubled from 2014 to 2018.

Since then, the situation has only worsened, the researchers said, with fentanyl consumption continuing to increase.

While Samoolsky and other activists say that far more work must be done, they have had some successes in changing the government’s opioid policies.

On Jan. 12, six months after a Supreme Court hearing of a petition submitted by Physicians for Human Rights Israel and Lealtar, the Israeli Ministry of Health agreed to change labels on opioid packaging to warn that their use always leads to physical dependence, replacing the current label which states opioids “can” lead to dependency. The new labels have yet to be put on the packaging as the decision works its way through the system.

PHRI and Lealtar maintain that the current warning labels on the drugs are insufficient and inaccurate, and should be in larger print and use more exact language for the warning. The ministry had previously focused their prevention efforts — which Hadas Ziv, PHRI policy and ethics director, deems “lacking and insufficient in themselves” — on practices among physicians and in the healthcare system rather than raising awareness among patients, noted PHRI. The ministry also argued that changing the labeling would discourage patients who do need the opioids, and that the packaging was too small for a bigger warning.

The turning point at the August hearing came when the ministry’s addictions department head, Dr. Paula Roshka, testified that opioids use will always lead to physical dependence, said Ziv.

The new policy follows a long battle to hold the Health Ministry and opioid manufacturers responsible, noted Ziv.

“We thought, OK, because [the Ministry of Health] moves slowly and is part of the administration, and is influenced by pharmaceutical companies, we would appeal to the patients’ right to know. We decided to start with a really small step like changing the package label warning and not to allow blurring of the reality behind a warning stating that in some cases opioid use can cause dependency,” said Ziv.

The Ministry of Health did not reply to a request to interview Roshka, but as early as 2018, in an interview with Israel’s Kann news broadcaster, Roshka warned there was a need to stop the misuse of opioids in Israel so “it does not become an epidemic.” At that time there were about 60 deaths from opioid overdose in Israel she said, but added that the decentralized reporting by health funds made it difficult to collate data. (The rarity of autopsies in Israel also make such data hard to come by.) She noted the ministry had begun to disseminate information about opioid use to physicians.

The decades-long opioid epidemic in the U.S. — caused by increased opioid consumption during the 2000s and which has seen 80,000 deaths just in 2021 — should serve as a warning for Israel, the authors of the Taub report said.

“In our study we saw a rise in the use of opioids in Israel over the last two decades — especially in the last decade when pharmaceutical companies started to bring opioids to Israel and patients started to demand them more because they became more aware of them,” Davidovitch told eJP. “We are getting signs from the field that there is a problem while many within the (health system in Israel) are in a state of denial or do not understand the magnitude of the problem.”

Chronic pain management is a serious issue, he said, but many people are not receiving proper treatment and there are long waiting periods for management clinics. Whereas before the issue of pain was not taken seriously by health professionals, the pendulum has now moved to the other extreme where opioid drugs are prescribed too freely by doctors, Davidovitch added.

Though they identified misuse and overuse in all socioeconomic levels of society, there is a higher risk among lower socioeconomic groups that are less aware of the risks, said Davidovitch.

“Especially physicians not specialized in pain management such as orthopedic surgeons started giving these painkillers without a deep understanding of the dangers involved. We see more young patients without cancer taking these drugs in recent years,” Davidovitch said. “We know this is the tip of the iceberg because [this data] is just from prescribed drugs. We know for sure there is a black market and that drug addicts replace their supply, understanding that they can take fentanyl, which is ‘legally’ available, instead of heroin.”

Better regulation of opioid use by health funds for pain management through electronic medical records already in use is critical for primary prevention so people do not get into the situation of dependency in the first place, he said.

A national program including issuing of a yearly report needs to also be created to deal with the growing crisis, he said. In 2019, the director general of the Health Ministry established an expert committee to advise on policies to reduce prescription opioid use and misuse.  However, with the onset of COVID-19 pandemic soon after the committee was created, and with the political instability that the country has seen in recent years – resulting in Israel having had five health ministers in the past four years – the committee has had little opportunity to convene.

Samoolsky is a member of the committee, representing the public. His work with Lealtar, which is done in partnership with his girlfriend, Ayala Bat Shaul, includes speaking one-on-one with people with Opioid Dependency Disorder as well as lectures at medical schools.

“It is very different when a doctor talks to a narcotic patient and when I talk to a narcotic patient. I talk ‘narcotic,’” said Samoolsky. “I have been working with patients voluntarily for the 13 years since Lealtar exists, and I haven’t taken a penny. My knowledge is not for sale and people’s problems are not for making money.”

He supports Lealtar’s work through some speaking engagements, which he would like to expand to the USA, sales of a Hebrew-language book he co-produced with Bat Shaul called “Pain Game,” and a play written by Bat Shaul portraying Samoolsky’s struggle and rehabilitation from opioid dependency. She is also currently working on a movie about his work as well.

“It is very important to say loud and clear that because of the [physical] mechanism of narcotics in the body, the people who take narcotics for pain very quickly become dependent and…become 1000 times (worse off) than the objective reason that they were taking it in the first place,” said Samoolsky.

Ziv said the current situation in Israel is similar to what the situation was like in the U.S. before Americans recognized that a crisis was underway. While PHRI accepts the usage of opioids in cases of oncological or acute pain, the drugs should be prescribed for a short time and by following proscribed procedures, and not used in pain management at all. Misuse of opioids in chronic pain management can cause terrible damage to the patient and their use should be avoided completely, PHRI maintains.

Their campaign to change the label warning was made possible due to their close collaboration with Lealtar, medical community colleagues who supported the appeal and researchers who collected data and drafted a new report exposing Israel’s dangerously unprepared health care system currently available only in Hebrew, PHRI says.

Journalist Daniel Dolev, who has been reporting on the opioid crisis in Israel for two years for the nonprofit online news organization Shomrim, and has produced several in-depth investigative reports about the issue. He feels that with all the other things happening in the country, misuse and overuse of opioids in pain management just does not seem to be very urgent to the government.

“All the time the opioid issue is getting pushed back and meanwhile you see the number of heavy users of opioids increasing. In Israel the situation reached this level really just because of bad behavior. Someone who is supposed to have taken action is not acting,” he said. “There are some drug rehab centers but not one that focuses on opioid use, probably because they don’t realize they have to focus on that.”

Though when the expert committee does meet and Samoolsky continues to put the urgency of the issue front and center, the other committee members don’t always want to hear what he has to say, said Dolev.

“He comes from another world,” said Dolev. “He speaks differently than the doctors sitting around the table because they have time and he doesn’t have time.”