The prescription plague: One in 10 Israelis in danger of opioid addiction

Three years ago, the Health Ministry set up a special committee to regulate the prescription of opioids. That was an understated response to a deadly plague that has shattered American society, seen otherwise normative people become addicted to painkillers prescribed by their family doctor – and half a million deaths. According to official figures, one in every 10 Israelis takes some form of opioid – but that does not take into account what is happening on the black market. Shomrim reveals the protocols of the Health Ministry’s Opioid Committee. Part 1 in a series.

Three years ago, the Health Ministry set up a special committee to regulate the prescription of opioids. That was an understated response to a deadly plague that has shattered American society, seen otherwise normative people become addicted to painkillers prescribed by their family doctor – and half a million deaths. According to official figures, one in every 10 Israelis takes some form of opioid – but that does not take into account what is happening on the black market. Shomrim reveals the protocols of the Health Ministry’s Opioid Committee. Part 1 in a series.

Three years ago, the Health Ministry set up a special committee to regulate the prescription of opioids. That was an understated response to a deadly plague that has shattered American society, seen otherwise normative people become addicted to painkillers prescribed by their family doctor – and half a million deaths. According to official figures, one in every 10 Israelis takes some form of opioid – but that does not take into account what is happening on the black market. Shomrim reveals the protocols of the Health Ministry’s Opioid Committee. Part 1 in a series.

Daniel Dolev

Illustration: Moran Barak

December 12, 2021

Summary

To

an outside observer, Dr. Udi Margalit appeared to be living a wonderful life. Despite being injured during his military service in the 1970s and developing a dependency on painkillers during his rehabilitation, he managed to pull himself together and kick the habit. He studied accountancy, opened a successful business and raised four children. Five years ago, in his mid-60s, everything changed.

“I was involved in a minor road accident, which caused me serious issues with my back. Some of the discs were knocked out of place and the nerves were damaged. I was diagnosed as suffering from chronic pain. Since then, I have had many encounters with the health system, and that’s what I want to talk about.” This is what, two years ago, Margalit told the special committee established by the Health Ministry to formulate its policy on tackling the painkiller and opioid epidemic. The United States, which has been rocked by the plague of opioid use, reports hundreds of thousands of deaths a year and, according to the Centers for Disease Control and Prevention, lost half a million lives between 1999 and 2019.

“I went to my doctor with one complaint: I’m in pain,” Margalit told members of the committee. “So much pain that I wasn’t able to live a normal life – day or night. In response, the health system inundated me with painkillers, without explanation, without knowing, without investigating, without listening to me or hearing my history of addiction from 1973 to 1979. The doctors listened but didn’t hear what I was saying. Their ears were sealed. I was prescribed OxyContin or some other painkiller without a second thought. From OxyContin, I went on to fentanyl patches and no one explained the dangers.”

The physicians treating Margalit swapped out the drugs occasionally and increased the dosage, but he had not yet recognized that he was again addicted. “I found myself completely enslaved,” he said, “and the dosages kept getting bigger and bigger – because I was still in pain. And when the pain still didn’t subside, they decided on even higher dosages – which is something they do a lot. I was walking around doped up; I didn’t know day from night. I was losing my cognitive abilities and a lot of other things. I lost my sense of taste and my mouth was always dry – but I craved sweet food. I needed nine teaspoons of sweetener to make my tea sweet enough. And I still didn’t realize I had a problem.”

The realization dawned on Margalit during a family vacation. “My wife and I took the grandchildren to Italy and I forgot my pills at home. That was the first time in my life it happened to me,” he said. “I was supposed to switch my fentanyl patch that day. Two days later, I found myself in a hospital near Lake Garda. I was going through severe withdrawal symptoms. It was only then that I understood I was addicted.”

When he returned to Israel, Margalit says, “I was given a prescription for methadone, but discovered that I could only get it filled in Tiveria. I drove there and I stood at what they call Methadone Junction. I was in line with street junkies, who had fresh needle marks from injecting heroin, who had come to get their methadone fix. Them and me in the same line. Why? What did I do wrong? My only crime was to be innocently driving one day when a stupid driver put his car into reverse and hit mine.”

Margalit is furious. Not with the surgeons who operated on his back, but with the physicians who, he claims, did not inform him about the highly addictive nature of the painkillers they prescribed him. “You read the leaflet and they sound very innocent. ‘Can cause dependency in some cases,’ it says. And the doctors? Not a word about addiction. They just said that they would have to consider changing the drug after one year. So perhaps the starting point should be to recognize that there’s a problem. That doctors are giving out prescriptions for drugs willy-nilly … I’m not talking about mistakes made by doctors or what if the surgeon had been more cautious. That’s not the issue. The problem is the deception, the lack of information. They took away my control over my life and gave it to someone else. Now I’m fighting to get my life back.”

Dr. Udi Margalit. Photo: Shlomi Yosef
Margalit is furious. Not with the surgeons who operated on his back, but with the physicians who, he claims, did not inform him about the highly addictive nature of the painkillers they prescribed him. “You read the leaflet and they sound very innocent. ‘Can cause dependency in some cases,’ it says. And the doctors? Not a word about addiction."

The epidemic that crushed America

Margalit delivered his harrowing testimony to the special task force established to tackle the over-prescription and overuse of opioids. The committee was established three years ago by the then director-general of the Health Ministry, Moshe Bar Siman-Tov, to regulate the use of these painkillers. The committee convened just eight times in over two years – the first time in March 2019 and the last in May 2021. It has yet to submit any recommendations. What is discussed behind closed doors remained far from the gaze of the public.

Until now. For the first time, Shomrim can reveal, via documents and first-hand testimony, the workings of the committee – which paint a picture that should be of grave concern for every Israeli. After all, just Margalit was injured in a traffic accident, no one is immune from the possibility that he or she will need treatment involving highly addictive painkillers. This is especially true when one looks at the recent history of opioids in the United States, where physicians prescribed the drug in large quantities to anyone who wanted it – turning millions of Americans into addicts and killing hundreds of thousands.

Some background: The opioid epidemic hit the United States long before anyone had ever heard of COVID-19. The start of the crisis can be traced back to the mid-1990s. Up until that point, opioid painkillers – which includes morphine and the street drug heroin – were almost exclusively used for extreme pain in emergency situations and for terminal cancer patients.

The rules of the game were changed by a drug developed by Purdue Pharma by the name of Oxycontin – the same drug that Margalit was prescribed. OxyContin is a slow-release opioid painkiller that can only be taken twice a day. The company, which was owned by the Sackler family, engaged in aggressive marketing of its new product, by financing studies that downplayed the addictiveness of the drug, funding medical conferences and NGOs which declared that their goal was to help ease the suffering of chronic pain patients, disseminating medical propaganda, and rewarding physicians for prescribing their product.

The U.S. Food and Drug Administration approved the drug, including a note in the leaflet stating that the risk of addiction was low, and permitted Purdue to send out marketing material with misleading information. The payback wasn’t long coming and was catastrophic: other companies started developing similar drugs and physicians prescribed them in huge quantities. One statistic that shocked the American people found that, between 2015 and 2017, for the first time since World War I, the average lifespan of Americans fell – a decline blamed on opioids.

At the height of the epidemic, thousands of suits were filed against companies manufacturing opioids. Last year, Purdue Pharma was convicted as part of a plea bargain on several counts relating to the marketing of its drugs and was fined some $8 billion. Meanwhile, many states are still engaged in compensation talks with the company, which has since filed for bankruptcy. In September, it was reported that a $26-billion deal had been agreed upon with four other companies that produced opioids, including Johnson & Johnson.

Now, the United States has recognized that it is in the grips of an opioid epidemic and is doing something about it. The former head of the FDA described the opioid epidemic as one of the “great mistakes of modern medicine,” and, in 2017, President Donald Trump declared a national emergency. But the spread of the drugs did not stop at the borders of the United States. In Israel, too, opioids have become increasingly prevalent in recent years.

Rally Against Purdue Pharma Bankruptcy Ruling. Photo: Reuters
At one committee meeting, Tal Morgenstern, a senior official from the Health Ministry, revealed that in 2018, more than 9 percent of the Israeli population had been prescribed long- and short-term opioid painkillers. That adds up to about 800,000 people – up from 700,000 in 2014.

Heated exchanges at the committee

The special opioid task force was headed by Dr. Hadar Elad from the Health Ministry’s Medical Division. It also included representatives from Israel’s four health maintenance organizations, the Pharmaceutical Society of Israel and several well-known public health experts (among them Dr. Paola Rosca, the director of the Health Ministry’s Department for the Treatment of Substance Abuse; Dr. Ronny Berkovitz, head of the ministry’s enforcement unit; Hagai Brosh, who heads the treatment and rehabilitation division in the Israeli Anti-Drug Authority, and Prof. Pesach Schwartzman, a family doctor who specialized in pain treatment and heads the Organization of National Palliative Care Services). The committee member who came out most strongly against the use of opioids was Evyatar Smolsky, the chairman of Le’Altar – the Foundation for Supporting Narcotic Patients.

Evyatar Smolsky, the chairman of Le’Altar

In the first meeting of the task force, Rosca confirmed that Smolsky was the first person to alert the Health Ministry about the phenomenon and that he did so around a decade ago. At the same meeting, Prof. Shaul Lev-Ran, head of the Israel Center on Addiction at Lev Hasharon Medical Center, presented a study that found that one in six patients on long-term treatment of opioids would become addicted. Smolsky interrupted Lev-Ran’s presentation and asked to focus on the development of physical dependency, which the report found had an even higher incidence than the addiction levels. According to Smolsky, every single person given opioids over a long period of time would develop a physical dependency on them, leading to painful withdrawal symptoms, just as Margalit experienced in Italy.

“The important thing is what happens after,” explained Smolsky, who has been studying people who developed a dependency on these drugs for many years. He even managed to tackle his own addiction to opioids after 13 years of use. “When patients become chemical prisoners of this drug, and they plead with us to help them, we tell them that they’ve just got an addictive personality. It simply isn’t true.”

In a conversation with Shomrim, Smolsky said: “I was appointed to that committee which was, in fact, an advisory committee to the director-general of the Health Ministry, with the goal of scaling back the opioid epidemic. I was there as a representative of the public and the victims of these narcotics. There’s no disagreement on the panel that I was the person who brought the growing scale of the problem to the attention of the authorities, so I’m amazed that I have encountered very clear and transparent efforts to insist that there is no problem and to deny that the whole issue will blow up in our faces.

“Since I was on the committee to represent the public, patients and victims – and as chairman of Le’Altar – I sent a whole series of recommendations independent of the committee. After all, I did not have high hopes or expectations of that task force.”

Among the recommendations that Smolsky submitted was a total ban on the use of opioids, other than in emergency situations, as well as new regulations that would rescind the driver’s license of people taking opioids and have a legal guardian appointed for them. He does not like the term “addiction,” since he claims it has mental health overtones and insists that the problem is the development of physical dependency on opioids and the resultant side effects.

When Smolsky talks about efforts to continue as if there were no problem, he is referring mainly to the loud and angry arguments that he and Schwartzman had during discussions. It seems that Schwartzman is a skeptic and even disputes the use of the phrase ‘opioid epidemic.’ According to Schwartzman, Israel is in a far better place than the United States and warns against “throwing out the baby with the bathwater.” In other words, he opposes any restrictions on the use of opioid painkillers.

In a conversation with Shomrim, Schwartzman espoused the same view. “We’re a long way off what the Americans are experiencing,” he says. “We are in exactly the same situation as the Europeans. There’s no crisis here, in my opinion. At the same time, one of the things that we often do is copy-paste from the Americans, for better or for worse. So, we just have to remember not to get into the mess the Americans got themselves into. And that entails rational use. That’s the bottom line.”

The disagreements between the sides will soon move on to a new forum – the courts. Along with Physicians for Human Rights, Smolsky has petitioned the Supreme Court to force companies to place much clearer warnings on their painkillers, like the health warnings on cigarettes. In a separate case, Schwartzman wrote a medical opinion two months ago for two companies that market opioids in Israel, which are seeking to dismiss a class-action suit filed against them.

Rally Against Purdue Pharma Bankruptcy Ruling. Photo: Reuters
“The alarm bells have been ringing in the Health Ministry and with the public,” said David Papo, chairman of the Israel Pharmacists Association, at one of the meetings. “The figures we’re being given sound, okay, but there’s no doubt that, given what’s going on in the world, we are on the brink of an epidemic here. We’re in a war, so we need to take drastic measures.”

‘I saw it was a whitewash’

The main problem that the committee encountered was the absence of complete data. As far back as 2017, the Knesset Research and Information Center published a report on addiction to prescription drugs, in which it pointed out that Israel does not have a national database documenting the extent of the phenomenon. The report also stated that the Health Ministry asked the HMOs for data, but was given only partial information, and that, since each HMO had different definitions of addiction, it was impossible to unify the data.

At one committee meeting, Tal Morgenstern, a senior official from the Health Ministry, revealed that in 2018, more than 9 percent of the Israeli population had been prescribed long- and short-term opioid painkillers. That adds up to about 800,000 people – up from 700,000 in 2014. That’s a 16 percent increase over just five years. In addition, the average number of days of opioid treatment for each patient rose by around 20 percent during the same period – reaching an average of 99.5 days per patient.

The figures that Morgenstern provided the committee give only a partial picture, however, since, for example, they do not differentiate between cancer patients, for whom opioid treatment is more commonplace, and other patients. The committee decided to ask representatives of the four HMOs to provide more detailed statistics, especially on non-oncological patients who have been taking opioid painkillers for more than six months.

Members of the committee convened just eight times over the course of two years. They tried to get more detailed information from the HMOs, but at every meeting, encountered a new problem that prevented them from combining the data into an overall picture. On one occasion, for example, it turned out that two of the HMOs presented the total amount of opioids consumed in grams, while the other two presented it milligrams. There were also arguments over whether to include certain drugs in the calculations or not. The outcome was that, at the final meeting of the committee in May 2021, members still did not have complete data.

“I understood that this was a whitewash,” one committee member told Shomrim. “I knew that nothing concrete would come from it and that not a single patient would be saved. The HMOs, for example, could have admitted that there was a problem that they should have been aware of, that they didn’t do enough and that’s why the situation has reached such a critical stage here in Israel. Instead, they claim that it’s not such a big deal and that it’s not as bad as it seems. You know all the tricks. They inundate the committee with statistics, in an attempt to paint a certain picture.”

“I’m worried that we’ve had seven or eight meetings and we’re chasing the data the whole time,” said Yosi Lomnitski​ – the chief pharmacist at the Maccabi HMO – at one of the committee meetings. “They want us to do the research. These studies don’t lead to anything. We need to stop chasing after data and start doing things. We can see with our own eyes what’s going on.”

“The alarm bells have been ringing in the Health Ministry and with the public,” said David Papo, chairman of the Israel Pharmacists Association, at one of the meetings. “The figures we’re being given sound, okay, but there’s no doubt that, given what’s going on in the world, we are on the brink of an epidemic here. We’re in a war, so we need to take drastic measures.”

Indeed, testimony from senior physicians who were invited to speak to the committee highlight the problem better than confusing and occasionally contradictory statistics can. “I underwent training to study pain management,” Dr. Omri Lubovsky, deputy director of the Department of Orthopedic Surgery at Barzilai University Medical Center in Ashkelon, told committee members. “I heard a lecture by a surgeon from Sha’ari Tzedek Hospital who urged us not to be miserly with morphine and said that a good physician knows how to manage his patients’ pain. And that’s how I behaved for many years.

“The turning point came two years ago with the huge suits filed against Purdue Pharma in the United States, when it was revealed that doctors were behaving like the worst drug dealers, playing a very crucial role. I felt frustrated and cheated because I see my responsibility as a doctor toward my patients is to ensure that they are not in any pain. I was also taken in by the pharmaceutical salespeople with their long-acting opioids. I thought I understood pain, but, until 18 months ago, every patient I would release after surgery would automatically be given a prescription for OxyContin or Targin, as part of the pain-management approach. Because there’s no need for a patient to be in pain.”

Clalit medical Center. Photo: Shutterstock
Oren Miron, a doctoral researcher at Ben-Gurion University, began looking at opioids when he was a research associate at Harvard Medical School. Last year, he published a study based on figures from the Clalit HMO, which insures around half of the Israeli population. According to Miron’s findings, in 2018 one in every 10 Clalit members – that’s around 450,000 people – was given at least one prescription for opioids.

10 percent of Clalit patients

At its last meeting some six months ago, committee chairman Elad announced that, at long last, they had found a unified format according to which the HMOs would present their data to members. He also read out recommendations that had been raised during the committee’s discussions and said that members would soon be asked to rank them. At the end of that meeting, Schwartzman proposed that to allow committee members to make an informed decision, they should be sent the most up-to-date figures for the past four years and only then vote on the recommendations.

The Health Ministry claims that it has in its possession the most recent figures and that they were shown to the former director-general of the ministry, who left his position four months ago. What is certain is that those statistics never reached members of the committee, who did not then hold a vote or draw up agreed-upon conclusions. The Health Ministry rejected a request from Shomrim to see the figures it claims it presented to the director-general.

Shomrim did received updated and detailed statistics from the Meuhedet HMO, which insures around 13 percent of Israelis. The figures – which were obtained after the Movement for the Freedom of Information submitted a request – show that last year alone some 9,100 Meuhedet patients were prescribed opioid painkillers for six months or longer.

Oren Miron, a doctoral researcher at Ben-Gurion University, began looking at opioids when he was a research associate at Harvard Medical School. Last year, he published a study based on figures from the Clalit HMO, which insures around half of the Israeli population. According to Miron’s findings, in 2018 one in every 10 Clalit members – that’s around 450,000 people – was given at least one prescription for opioids.

Oren Miron, a doctoral researcher at Ben-Gurion University. Photo: Ronen Akerman

Miron’s study also found that, in the decade ending in 2018, the amount of opioids consumer by all the HMO’s members rose by a factor of 2.2. A deeper dive into the figures reveals even more worrying findings: It turns out that, while the use of weaker opioids dropped during that period by 45 percent, the use of stronger, more addictive drugs – especially fentanyl – increased threefold. He also found that the largest increase in opioid consumption was among non-oncological patients aged under 65.

“Our study,” Miron told Shomrim, “appears to show that the large number of patients being prescribed opioids are not being given a weak drug for a day or two. We see that fentanyl – which is 50 times stronger than heroin – makes up most of the increase in consumption. That’s not a drug that physicians prescribe for a day or two to help someone recover from an operation. It’s a drug that is usually prescribed for long-term courses. Once, it was given almost exclusively to terminal cancer patients, but now we’re seeing it prescribed to the general population. I spoke to one soldier who broke his arm during his military service and was prescribed very strong opioids. He got addicted and nearly paid with his life. That is the most worrying thing.

“Some people want to escape from reality, so they take drugs,” Miron adds. “But there are so many people – people just like you and me – who trusted the physician who prescribed them 30 oxycodone pills. So, they take the pills and they get addicted. It’s a tragedy. People who believed that painkillers were safe and fell into a very deep hole. That’s why it’s so important, from one side, to stop the initial prescription of opioids and, from the other, to offer rehabilitation programs to people who have become addicted. You can’t just stop giving them their prescriptions, because an addict will just move on to heroin. We have to also offer an alternative.”

One such person is Yossi (not his real name), who is now 62. In 2012, he was diagnosed with Hodgkin lymphoma. “After around six months,” he says, “the pain became unbearable. It’s well known that chemotherapy involves a substance that attacks the nervous system. I found myself suffering from neuropathy, as well as a very bad infection of the colon – which is still with me. The pain centered on the left lobe of my brain. Terrible, terrible pain – accompanied by fevers. It felt like a hundred spiders were crawling over my back and legs and that they were biting me. At first, I was prescribed Targin and OxyContin, but they didn’t help. Then they decided to start me on a fentanyl patch.”

Over time, the dosage of fentanyl was increased. From 12.5 microgram patches, Yossi has eventually prescribed 75 microgram patches. “When you’re taking fentanyl, all you want to do is sleep and be left alone,” says Yossi. “When it was at its worst, my family couldn’t stand me. People on fentanyl are cranky, tense, they need quiet. You’re like a junky. It’s hard to function. I would fall over a lot and lose my balance. I hurt my eye one time and my shoulder.”

Yossi says that, when he broke his shoulder, he was rushed to a hospital in the center of the country. The physician who treated him didn’t know that he was on fentanyl and prescribed him a different opioid painkiller – Percocet. I was sitting with the surgeon and he told me that he would prescribe me a painkiller. I told him, “You’re a doctor! Why don’t you tell me that it’s an opioid? What will happen if I take it for two months? What will happen after?’ He didn’t reply.”

‘Total anarchy’

These people are the faces of the opioid epidemic. They are not junkies asking for loose change to buy their next fix from a drug dealer. They are normative people who get their ‘fix’ regularly from their family doctor. Prescription after prescription, at ever-increasing dosages. Some of them don’t even know that they’re addicted until they try to stop.

“I look at the problem and I can tell you that I see it from every possible angle,” said Dr. Daniel Flusser, head of the Internal Medicine Department at Soroka hospital, at one meeting of the committee. “I know of one patient who gets more than 200 Percocet pills a month and has been for three years. It’s an automatically renewed prescription. She takes the drug, but it doesn’t really help her. But no one has ever asked that woman’s doctor what’s up … All I’m trying to say is that there is total anarchy.”

Flusser also says that there is a group of former addicts who injected drugs intravenously but who “got clean.” In practice, however, they merely switched drugs and now get their supply the legal and easy way – with a doctor’s prescription. “Most of the time they don’t inject,” he says. “Sometimes they do and sometimes they don’t. But their family doctor provides them with an alternative. In the absence of regulation, the solution lies with the family doctor. The doctors prescribe fentanyl patches for lower back pain, as well as Percocet, but nobody stops to ask them what their patients are suffering from. Because by law they can prescribe. We’re living in a country without regulations. Total anarchy.”

For their part, the pharmaceutical companies argue that, given the lack of data, there is no justification to place restrictions on the prescription of opioid painkillers. In a medical opinion written for these companies, Schwartzman points out that there is no central body in Israel that supervises the prescription of opioids in real-time and presents figures from the Clalit HMO.

In fact, according to the figures Schwartzman presented, there was an annual average increase of 4.5 percent in the prescription of opioids between 2011 and 2016 to non-oncological patients. However, he believes that “this increase almost certainly represents improved pain management policy in Israel and possibly rectifies the underuse of opioids in the preceding period.”

Even the mortality figures do not help to gage the exact extent of the phenomenon, since, according to members of the committee, they are not detailed enough. For example, even if the patient died of hypoventilation as a result of overdosing on opioids, the cause of death will be listed as hypoventilation. The committee was presented data collated by the National Center of Forensic Medicine, but those figures do not even claim to give a broad picture of the situation, since the center only performs autopsies if there is a suspicion of foul play.

Illustration: Moran Barak
“Our study,” Miron told Shomrim, “appears to show that the large number of patients being prescribed opioids are not being given a weak drug for a day or two. We see that fentanyl – which is 50 times stronger than heroin – makes up most of the increase in consumption. That’s not a drug that physicians prescribe for a day or two to help someone recover from an operation. It’s a drug that is usually prescribed for long-term courses.

The thriving black market

Data regarding the legal use of opioids is vague, but when it comes to the black market, the committee did not even hear any rough estimates as to the extent of the problem. Rather, members discussed the methods used by dealers and addicts to get the drugs – especially the fact that the Health Ministry is light years behind them.

A month ago, Dr. Israel Levin, a 73-year-physician from Omer, admitted to illegally exporting opioid painkillers. Levin treated foreigners who came to Israel for treatment – so-called medical tourism. He kept photocopies of their passports and, after they had left the country, issued fake prescriptions for drugs. He would collect the pills himself and sell them to overseas buyers on the internet. In four years, he sold 102 packs of fentanyl, 302 packs of Percocet and 154 packs of Ritalin (a non-opioid).

As part of a plea bargain, Levin was convicted by the Be’er Sheva District Court of exporting drugs, fraud and tax violations. The prosecution will ask the court to impose a one-year custodial sentence, in addition to a fine of 1.2 million shekels and back taxes.

Levin’s case came to the public’s attention when he was indicted and a plea deal was agreed, but he was also mentioned in a committee meeting back in November 2019. Most of the meeting was dedicated to what one could call the opioid “white market” – tens and perhaps hundreds of thousands of Israelis who have regular opioid prescriptions, often without real medical necessity and without taking into account the highly addictive nature of these drugs.

How does the seepage from the legal market to the black market work? Here’s one example: Until last year, Israeli physicians could only issue hand-written prescriptions for opioids, not digital ones. In August 2020, the Health Ministry changed the regulations, allowing for electronic prescriptions for these drugs as well as hand-written ones. The logic was to allow a doctor on a home visit to issue a prescription, without having to return to his office computer. However, this made it even easier to forge prescriptions; an unscrupulous patient could take the prescription, photocopy it and then go to any number of private pharmacies to have it filled several times.

“If someone has copies of a prescription and buys opioids at a private pharmacy, what’s to stop them going to another pharmacy, then to the HMO’s pharmacy and then to one of the big chains? No one would know,” says Ronny Berkovitz, from the Health Ministry’s enforcement unit. “Beyond the fact that there are countless forged prescriptions, there’s also the phenomenon of repeat buying with a single prescription.”

According to Morgenstern, “we started looking into this after a strange case of a pharmacist who appointed himself as a kind of service provider for terminal patients at the clinic where he was employed. At first, decided arbitrarily to help some of the patients, and then he saw that it was quite a nice little side income, so he simply went to the doctors and told them that he needed a prescription for some patient or other. They gave him prescriptions for Fenta 100 [the strongest fentanyl patch available in Israel] and he sold them. He managed to get about 110 packs in five months before we caught him. He was a senior pharmacist, who was held in high esteem and was up for promotion.”

Dana Sonnenfeld, the head of the Israel Police’s drug lab, added that “of late, there’s a huge quantity of fentanyl patches on the streets. We have had reports of deaths resulting from people using these patches without any real medical need. We’ve also heard that, instead of adhering them to their skin, some users are chewing, sucking, or snorting them.”

‘Like buying a gun’

The solution raised at the committee meetings was to introduce a computerized record of all opioid prescriptions, which would be installed in every pharmacy and hospital. That would prevent people from photocopying prescriptions since the system would recognize pre-used prescriptions. It would also recognize forged prescriptions and, at the press of a button, would provide reliable data about the use of these drugs.

Simple enough. But it turns out that a similar proposal was brought to the Health Ministry back in August 2003 – but nothing was done. In committee meetings attended by representatives of the Health Ministry’s legal department, it became apparent that several pilot programs were started, but the Justice Ministry, citing patient privacy, opposed the idea.

Committee members expressed their frustration at the situation on several occasions. “There are some people who aren’t allowed to buy a gun, because it’s not legal, and there are people who can’t buy a drug for the same reason. So why, if we recognize that taking opioids is life-threatening, can’t we ask the relevant ministries to set up a database,” said the representative of one of the HMOs. “Obviously, there’s the issue of tracking an individual’s use of opioids. But we’re not talking about a pint of milk or some snacks. It’s like buying a gun. Or drugs. Why doesn’t the Justice Ministry understand that any harm to privacy would be to protect people?”

Some members of the committee also pointed out that, while the Justice Ministry opposes the establishment of a computerized system to track opioid consumption, there is an almost identical system in place to issue medical marijuana. Elad explained that the difference is that licenses for medical marijuana are issued by the state, so there is a legal justification to track their use.

Nitzan Horowitz, The Minister of Health. Photo: Noan Moshkovitz - The Knesset

Health Min.: ‘The committee’s work dragged on because of the Coronavirus pandemic’

At the last meeting of the committee, some six months ago, members discussed the various proposals that had been raised over the past two years. They will be asked to rank these proposals and then submit them to the health minister. Among the proposal were interim solutions that could resolve some of the problems, including a suggestion that every pharmacy is obligated to report to HMOs each time it provides opioids to one of its members. This would not close every loophole but would at least address the issue of photocopied prescriptions and would help to locate patients who misuse opioids.

When will the proposals be submitted, allowing for concrete steps to be taken? The Health Ministry is taking its time. This infuriates Hadas Ziv and Nadav Davidovich, from Physicians for Human Rights, who were not committee members but were invited to address the panel several times. Since then, they have been keeping tabs on its work. Last year, for example, the Health Ministry wanted to freeze the committee’s work because of the COVID-19 pandemic and only after PHR intervened did the ministry move the meetings to Zoom.

“The whole operation of the committee was bizarre,” Ziv told Shomrim. “There was, for example, another Health Ministry committee that examined racism in the health system. That committee held meetings, published reports and updated us all the time. Here? Since we appeared before them, we haven’t heard a word from the opioids committee. We feel the whole time that we’re forced into being the committee’s watchdog. You’re supposed to be preventing the opioid crisis. That’s not our job. Where are you?”

In response, the Health Ministry told Shomrim that, “the ministry advocated in recent years for legislative changes that would allow for the establishment of a computerized system, but the issue was stymied because of concerns over privacy. Tighter supervision of physicians issuing prescriptions is one of the ways of ensuring more regulated use of such drugs and stamping out abuse. The Health Ministry committee is looking at various recommendations to raise awareness regarding opioid prescriptions and encouraging doctors to keep closer tabs on their patients.”

The ministry also said that “the committee’s work dragged on because of the complexity of the issue, but mainly because of the outbreak of the Coronavirus pandemic, which forced us to put most of our resources into dealing with the outbreak. Updated consumption figures, interim conclusions, and possible recommendations were presented to the previous director-general of the Health Ministry and, once missing details are provided, will be sent to the new DG.”

This is a summary of shomrim's story published in Hebrew.
To read the full story click here.