An

internal document written by the Health Ministry’s Medical Directorate which has been seen by Shomrim reveals that the ministry is trying to increase oversight on the prescription of opioid painkillers. In a draft of the circular, the ministry admits that it has failed in its efforts to date to reduce the use of addictive painkillers in Israel.

Opioids are chemically related to heroin and morphine, but some are stronger and much more addictive. The irresponsible and criminal marketing of these drugs in the United States has left more than 600,000 people dead from overdoses in the past two decades. As Shomrim revealed in its series of articles, Israel also failed to contain the phenomenon and there has been a steady rise in the use of these powerful painkillers. Until recently, the Health Ministry was unable to even get accurate figures on the extent of the problem. Now, the ministry itself has confirmed this.

“Over the past decade, there has been a constant and worrying rise in the prescription of opioid drugs,” says the draft of the circular – which was distributed last week to the healthcare professional and was signed by Dr. Hagar Mizrahi, the head of the Health Ministry’s Medical Directorate. Elsewhere in the circular, it states that, “a 2019 report by the OECD painted a very poor picture of Israel, compared to over member countries, in terms of the extent of and growth in prescriptions for opioids. There was an increase of over 90 percent.”

The circular also states that, “there has been an increase in the number of patients using these drugs for extended periods of time (six months or more) and the number of patients taking high daily doses of the drugs (…) There are various reasons for the constant increase in the prescription of opioids and at least some of them stem from a lack of knowledge and understanding among patients and the lack of effective and affordable alternatives treatments for pain. The various steps taken to deal with the problem have not yet succeeded.”

Now the Health Ministry is trying to change direction. The circular instructs every HMO and hospital to introduce programs to optimize the use of opioids and to oversee prescriptions. One of the proposed changes is that healthcare facilities will have to get approval in advance to prescribe stronger opioids, such as fentanyl and oxycodone, to non-oncological patients. The program will also include alternative treatments, which will reduce the reliance on drug-based treatments, warning physicians about the dangers of long-term opioid prescriptions, and track down patients who may need external intervention to reduce their daily doses of opioids.

Every healthcare facility would also establish a special committee, headed by a deputy CEO, which would include at least five representatives from various medical professions, including a physician, a mental health expert, an addiction expert, a welfare worker, a pharmacist and a social worker. This committee would be charged with establishing the infrastructure needed to gather data on opioid prescriptions and to “advance and make available alternative treatments to opioids.” The circular states that these committees would meet at least twice a year and that their sessions would be documented. In addition, the HMOs will set up regional committees, headed by that region’s CEO, to address specific and complex cases and implement the program.

The draft circular was sent last week to hospital directors, HMO department heads and to other interested parties within the Health Ministry and externally. Nonetheless, it is still only a draft and does not yet contain mandatory instructions. One expert who has seen the draft was surprised that the ministry did not set down its own guidelines but, rather, left it up to the discretion of each body. The only hard and fast instruction included in the draft is that every institution submits data on the extent of opioid usage to the Health Ministry in the same format.

The Health Ministry was at pains to stress that this is still just a draft and that it has asked for comments and corrections from interested professional parties. Asked when the official circular would be issued, the ministry said: “We see this as a very sensitive issue and collating all the responses will take longer than usual; at least a month. Depending on the responses we receive, we may make changes to the draft and these changes could obligate us to send out a second draft. It is likely, therefore, that the final circular will be issued in two or three months.”

As for the decision not to issue guidelines, the ministry responded: “The opioid use is a complex issue which demands professional knowledge in the field of pain management, combined with a profound understanding of alternative treatments, the background illness and other issues. This complex and detailed knowledge can be found in many professional articles and books. It is hard to create a treatment ‘shopping list’ in a circular that will provide a professional answer for every case. Creating hard and fast rules will create restrictions that will leave some patients without a solution. The HMOs are responsible for making suitable professional treatment available and they offer a wide range of treatment options, from pain management in the hands of a family doctor to experts in pain. We reiterate that the circular has been submitted for comments and corrections, and we are waiting to get feedback from the field. If needed, we will issue even clearer guidelines.”