Harvey Milstein’s introduction to chronic pain, and to opioids, began in 2006 when he attempted to wrestle a shotgun cartridge filled with shot out of the barrel of his gun. The gun accidentally fired, shattering his left kneecap and filling it with shrapnel. At the hospital, Milstein was given OxyContin and Percocet, opioids, to ease the pain.
“The first few years they gave me medication whenever I needed it,” he recalls. “In later years they began putting limits on how much I could get.”
As his walk became affected by his injured knee, Milstein developed spinal stenosis, which places pressure on the spinal cord and nerve roots, and disc problems that caused him yet more pain. And as he developed increased tolerance to the medications, he needed larger doses to manage his pain.
“There were days I could only get five pills a day, but I needed a sixth,” he says. “The days I ran out were the most hideous days of my life. I lived for Percocet. My mind was only Percocet. There was no life except for Percocet. My life revolved around ‘Where can I get that pill,’ and as soon as I got the pill, somehow, I was consumed by where I would get the next one.”
Life events such as his own wedding and his daughter’s wedding are just foggy memories because of his addiction, Milstein says.
He is far from alone in his battle.
A research team at the Taub Center for Social Policy Studies in Israel compared rates of opioid use disorder (OUD) in Israel and in the United States. The study subjects included both inpatient and outpatient users of opioids.
Dr. Nadav Davidovitch, Dr. Yannai Kranzler and doctoral researcher Oren Miron found that in 2020, Israel’s consumption of prescription opioids appeared to exceed that of the US.
Strong opioids (defined as morphine or stronger) such as oxycodone (the main ingredient in both OxyContin and Percocet) and fentanyl weren’t used much before 2011. At the time, Israel relied on opioid alternatives and on weaker opioids such as propoxyphene and codeine. In 2011, Israel’s Health Ministry banned the use of propoxyphene due to unusual cardiological side effects, and in 2014, it limited the use of codeine. At the same time, there was an increase in the administration of oxycodone and the use of fentanyl continued to rise.
“We knew from the USA about the misuse of opioids,” explains Davidovitch, the principal researcher on the study. “Unfortunately, there was less awareness here and pharmaceutical companies were misleading physicians. Israel is turning into an even worse situation. Of course, pain is a very important issue and when we talk about chronic pain it is something that was neglected for many years. The solution should not be [taking] the easy way.”
Miron, a researcher at Ben-Gurion University of the Negev in Beersheva, spent years as a Harvard Medical School researcher, tracking the opioid epidemic in the U.S.
“In the past it was harder to get opioids; in fact they were under-prescribed even for people who needed it,” he says. “Then pharmaceutical companies created slow-release mechanisms like OxyContin, which is a slow-release formula of oxycodone and fentanyl patches, which deliver the medication slowly. Doctors didn’t realize how potent it was. Just one dose could cause addiction.”
Israeli culture is different
How do opioids manage to slip by the Israeli electronic medical records system when simple medications for everyday illnesses can be challenging to obtain?
Dr. Stacy Shoshan, an internal medicine doctor and addiction medicine specialist, says that unlike in America, it is very easy to get opioids from primary care doctors in Israel.
“The culture here is different,” she notes. “Patients are insistent, and they can even be violent. Doctors prefer to get the patient out of the office and will frequently do what the patient asks.”
While, according to Davidovitch, the Health Ministry has cracked down on opioid consumption during the last year and a half, just one fentanyl patch can start the addiction, and if the prescription runs out, if their own doctors won’t ante up more, addicts will doctor-shop to replenish their supply, or find the drugs illegally.
The study looked at specific populations within Clalit Health Services, Israel’s largest healthcare system, to determine the spread of the phenomenon, particularly in people under age 65 and non-cancer patients. The researchers found that the usage of opioids was more prevalent in people who lived in poorer neighborhoods.
According to the Taub Center study, there was a significant increase in the prescription of strong opioids for Clalit members between 2008 and 2018. This increase was most notable among persons under the age of 65 who did not have cancer.
The possible reasons for this rise include the recall of the weak opioid propoxyphene in 2012; the 2011 and 2012 World Health Organization guidelines recommending the use of strong opioids for non-cancer pain, even in children, which were later retracted in 2020; and the introduction of a generic fentanyl patch in Israel. The fentanyl patch has been widely misused, including in a recent series of overdoses among Israeli young adults.
The researchers’ analysis of opioid-related deaths in Israel during the 2015-2019 period revealed an increase in cases of poisoning caused by the use of opioids such as fentanyl (but not opium or heroin). The findings align with reports from law enforcement indicating a rise in fentanyl abuse and fatalities. However, it is hard to find statistics, as testing is spotty at best.
A 2018 Clalit study revealed that of the healthcare system’s 4.5 million members, 10% had at least one opioid prescription filled that year.
Shoshan says that emergency rooms cannot routinely test for opioids, as they do not stock urine testing sticks, so there is no true picture of opioid consumption.
Swept under the rug
Ron and Eila Lev lost their 26-year-old son Omer to a fentanyl overdose in 2019.
“He was in between rehabilitation programs, and he bought fentanyl patches from another patient outside a facility,” recalls the bereft father. “He ingested a time-release patch and his cousin found him stretched out on the bathroom floor. The medics placed him on life support and brought him to the hospital.
“Five days later they determined he was brain dead. The cause of death was listed as brain death, not as an overdose,” Ron Lev says.
There are no statistics or real numbers for the number of deaths by overdose, or even for hospital admissions for opioid-related problems, according to Lev, who has taken up a campaign to lobby for awareness on the dangers of drug addiction.
“Everything is swept under the rug,” Ron continues. “They claim that in Israel there are 50-60 deaths per year, but the real numbers are far higher. In my town of 2,000 alone, there were four deaths. But even parents don’t want to talk about it. They say, why should anyone remember our son as an addict? So, the stigma continues.”
The Levs created an advocacy group called Omer’s Light and are fighting for sweeping changes, including support for parents who are battling drug dependencies in their children who are past army service age.
“We met with a government committee that made recommendations to pass the rehabilitation programs from the Health Ministry to the individual healthcare systems,” he adds. “Its recommendations were adopted by the Cabinet, but set a three-year preparatory period before it passes to the health funds. We hope we helped them to reach this decision, which is in a positive direction, although it’s too slow.”
The ministry had suggested in 2003 that electronic databases be utilized to prevent the unnecessary prescription of opioids. However, this recommendation was not acted upon as it would be complex and costly. Similarly, in 2016, the Israel Medical Association put forth recommendations for the prevention of unwarranted opioid prescription and the treatment of opioid addiction, but these solutions were not implemented and were not incorporated into clinical practice.
Doctors were in a bind. They couldn’t leave their addicted patients in pain without medication. So they dispensed prescriptions when the patients came calling.
Kranzler says, “If we are dispensing opioids, we have to have guidelines as to what levels and what are the tapering-off plans. Given the crisis, we need to put the supports in place to help patients alleviate their pain and help the person find healthy support so they can get treatment and make it out OK. But there is a decided lack of continuity of care.”
“It’s important to look at the trends and the solutions,” says Miron. “The most important solution is to keep those who are addicted to opioids from transitioning to street drugs. They need to be weaned off gradually.
“The withdrawal is similar to [that from] heroin and needs to be a slow and gradual process,” he adds. “If we limit the prescriptions, we need to ramp up police efforts against the black-market problem. And there is a shortage of rehabilitation facilities, especially in the Negev. Rehab facilities are more geared towards heroin addiction. It’s very problematic.”
According to Miron, the Health Ministry recently issued a regulation to place warnings on opioid boxes.
“We suggested that the healthcare systems place a pop-up on the medical ‘Clicks’ screen to inform physicians of the addictive properties of the medication,” adds Davidovitch. “We should also be routinely testing dead people for opioid overdoses. We feel the number of overdoses is sadly underreported.”
A happy “ending/beginning”
Thankfully, for Milstein, now 64, there is a happy “ending/beginning” to his story.
After running out of medicine on a visit to the United States and a bicycle accident that caused yet more pain, he realized he couldn’t keep spiraling downward, using up two-week prescriptions in two days’ time.
“I walked into my family physician and begged him to help me,” he says. “He gave me OxyContin but the slow release didn’t give me the kick I needed. He suggested fentanyl, but I didn’t want to start it. Then he suggested an out-of-pocket rehabilitation program with the Health Ministry, mostly geared for heroin addicts. Desperate, I went.”
Milstein saw a doctor and then a social worker and had to detoxify from the opioids for two days.
“I had the sweats, I was shaking, I couldn’t sleep,” he describes. “I just lay on the couch moaning.”
And then he was put on Suboxone, a drug that relieves opioids cravings and withdrawal symptoms. It wasn’t an easy transition. There were side effects, and he points out that it affects each person differently.
“I was dizzy. I was exhausted. But since I was retired, I just rode it out,” he says. “For me it was a miracle drug. I lost my cravings for Percocet and I haven’t had the desire to touch anything recreationally.”
According to an article by Dr. Peter Grinspoon in Harvard Health, “Suboxone works by tightly binding to the same receptors in the brain as other opiates, such as heroin, morphine, and oxycodone. By doing so, it blunts intoxication with these other drugs, it prevents cravings, and it allows many people to transition back from a life of addiction to a life of normalcy and safety.”
After a year and a half, Milstein is still in the program, being carefully monitored and given prescriptions for Suboxone. And his advice for anyone addicted to opiates is, “Get your doctor to help you find a program.”
Meanwhile, the researchers on this study issued a call to action against opioid dependency. Suggestions include:
- Improved surveillance of opioid prescriptions and adverse outcomes, including the availability of publicly accessible, near-real time data on prescription drug use to enable monitoring of trends, evaluation of policies and programs, identification of vulnerabilities, partnership facilitation and recommendation making.
- Increased autopsies in suspected overdose deaths and the formation of a mortality review committee.
- Safer prescription practices such as utilizing prescription drug monitoring systems to inform healthcare providers in hospitals, clinics and pharmacies about high-risk patients and the appropriate use of fentanyl substitutes and alternatives for opiate-based medications.
- Patient and family education regarding the risks of addiction, treatment plans that include tapering off opioid use, and mandatory check-ins with medical providers throughout the consumption period to monitor medication use.
- Case management to address mental health and other needs such as food insecurity, family support and stable housing for recovery, with support from social workers.
- Trauma-informed health services and linkages to mental healthcare and other social supports for individuals who receive opioid prescriptions, especially those at increased risk.