As the United States struggles to grapple with its escalating opioid epidemic, Israel’s Health Ministry is working to contain an opioid-fueled crisis of its own before it, too, reaches epidemic proportions.
Citing a 150% spike in addictions to opioids over the past five years, Paola Rosca, head of the ministry’s Department for the Treatment of Substance Abuse, said last week that she is working closer than ever with physicians and patients to curb prescriptions.
Noting that roughly 20% of approximately 250,000 Israeli patients annually prescribed opioids – primarily for chronic pain – become addicted, Rosca said on Wednesday the ministry is dealing with a “crisis.”
Like heroin, opioids are derivative of opium and are powerful and highly addictive pain relievers popularly prescribed to patients under the brand names Percocet, Fentanyl and Oxycodone.
In the late 1990s, opioids replaced another class of commonly prescribed pain relievers known as non-steroidal anti-inflammatory drugs (NSAIDs) after it was proven that NSAIDs, such as Voltaren, can cause serious side effects, including ulcers.
“Around 20 years ago, it was determined that opioids were safer and more efficacious than NSAIDs in treating chronic pain,” said Rosca. “So, doctors in Israel and around the world were able to prescribe opioids much more easily, and there weren’t many controls or monitoring of prescriptions at that time.”
Compounded by claims among pharmaceutical companies that opioids were not addictive in low dosages, Rosca said there was a groundswell in the number of patients being treated with the drug internationally for chronic pain of varying degrees.
“As the number of patients suffering from various levels of chronic pain increased, so did the number of opioid prescriptions and there was not enough monitoring,” she said.
“Another thing that happened when opioids were first prescribed in Israel is that a number of family physicians who were reluctant to give opiates got the message that they were safe from HMOs and the ministry itself.”
However, as tolerance to the drug heightened, resulting in increased dosages, followed by addiction and millions of overdoses – particularly in America, where opioids are liberally prescribed – Rosca said Israel began to reevaluate its own opioid policy.
To combat the crisis, the ministry this year launched a PR campaign to raise awareness among doctors, particularly family practitioners, who most commonly prescribe the drugs as a first line of defense against pain.
“In Israel, we have started to train doctors and addiction specialists to raise awareness about opioid addiction and to incorporate more physiological treatments instead of using opioids right away,” she said.
In Israel, however, the vast majority of opioid prescriptions are not written by pain specialists, but rather primary-care physicians with less understanding and training about the dangers of addiction.
“There are not that many pain doctors in Israel, so most people get prescriptions from general practitioners.
Therefore, this is the group of doctors we are focusing on to raise awareness and how to prescribe medicine in a safer way,” she said.
Rosca noted that the Israeli Association for Pain Medicine recently published a pamphlet for doctors on how to treat patients with chronic pain without relying exclusively on opioids.
“For example, before prescribing opioids for pain, we first ask them to speak with their patients to determine if they suffer from any other addictions or whether they suffer from mental problems,” she said.
“Then, if they still decide to prescribe it, they must verify that the patients do not become addicted.
Also, we are working with the HMOs to organize special services for patients with pain.”
Furthermore, Rosca said a national database is in the works to monitor opioid-dosage levels around the country to identify patients most at risk. In conjunction, the Health Ministry’s chief pharmacist is also promoting electronic prescriptions to reduce potential abuse.
HMOs are also now required by the ministry to include information to all patients about opioid addiction at the beginning of their treatment for pain, and to consider alternative treatments, including medicinal marijuana, as a substitute whenever possible.
Rosca conceded, however, that cannabis is generally considered a secondary or tertiary drug to treat pain, with few alternatives as effective as opioids themselves.
The ministry currently has 13 rehabilitation centers for opioid addiction throughout the country, with another seven planned to keep up with growing demand, she said.
“A lot of people addicted to opioids do not realize that they are addicted, so early detection and treatment is very important,” she said. “Right now, we are working with the HMO Maccabi to provide services to detect addiction and treat it quickly.”
According to Rosca, only some 3% of Israeli opioid addicts turn to heroine as a substitute after doctors cease writing prescriptions, making Israel’s battle against heroine far less pronounced than in America, where the narcotic is considerably more pervasive.
Another notable distinction between Israel and the US, in terms of opioid abuse, is the age of those most commonly afflicted. While people between the ages of 25 and 44 represent the majority of opioid addicts in the States, Rosca said that in Israel, people 50 and older are most at risk due to increasing pain management treatments.
“These are people who suffer from neuropathic pain and other physical injuries that get much worse with age,” she explained.
Indeed, according to data from the ministry, between 2010 and 2015, the number of Israelis aged 45-74 who were prescribed opioids tripled, while use among those 75 and older doubled.
“Here in Israel, we have fewer young people with this problem, which is very different from the States,” she said. “In the US, it is far more accessible for young people than here.”
To date, accessibility to Fentanyl, the most powerful synthetic opiate prescribed in Israel, has been dramatically restricted, while less potent alternatives, such as Oxycodone, are meted out more judiciously to non-cancer patients, she said.
Rosca said the ministry is also working with the Anti-Drug Authority and other national and regional drug and mental health agencies to promote pilot programs and cooperation in treatment plans.
“Between that, educational outreach and our computerized database tracking prescriptions, we hope to lower the number of those suffering,” she said.