A quick search on the Telegram messaging app for words like Fentanyl, Percocet or OxyContin – three of the most powerful opioid painkillers – will yield a dizzying number of channels and groups where these drugs can be bought. These are highly addictive, prescription-only drugs, the use of which can be extremely dangerous. Despite the known dangers, however, a Shomrim investigation reveals that these drugs, once only available through a pharmacist, have now found their way into the hands of drug dealers on the black market, where there is plenty of demand. All you have to do is tell the dealer which drug you want, and the courier will be on his way.

“The doctor’s gone nuts and you're reaping the benefits: 100 Fenta patches, 100 mg, including delivery, just 280 shekels.” (Post in a Telegram group)

“Fenta” is the street name for Fentanyl, a synthetic opioid which is 100 times stronger than morphine, thanks to its heightened ability to penetrate the central nervous system and attach itself to the pain receptors. Fenta patches are usually given to cancer patients or others suffering terminal diseases to ease their pain, or in case of acute pain when the patient is not responding to other drugs. The patches are attached to the skin for 72 hours and they start to work relatively quickly.

Fentanyl is currently the strongest painkiller on the market. In certain respects, Fentanyl, along with other opioids, has replaced heroin as the most popular street drug in the United States – causing a public health plague that has led to the deaths of an estimated 850,000 Americans. Using a Fentanyl patch is incredibly simple. Rather than sticking it to their skin, users place it on aluminum foil, which is heated and the smoke is inhaled. The intoxicating effect is much stronger than any other drug, but Fentanyl can also be lethal. According to health authorities in the United States, around 100,000 people die every year as a result of using Fentanyl, making it the number one drug involved in cases of accidental overdoses.

There is no data on the consumption of Fentanyl in Israel, but looking through groups on Telegram – the messaging app of choice for the illegal drug trade – it is clear that the dealers have a massive supply of these drugs and other strong painkillers; needless to say, they operate without any supervision or control and the wide range of prices shows that there is much competition in the market. Alongside opioids, the dealers offer a wide range of other psychoactive drugs, from anti-anxiety drugs like Benzodiazepine and sleeping pills to drugs usually prescribed for attention deficit disorders.

“Mister Fenta is back – big time. The courier is out and about, the owner’s gone crazy. We’ve got all the patches – 100, 75, 50, 25. We guarantee the best prices on the market. Quick delivery across Gush Dan, the Center, the Lowlands, the South. Pay cash to the courier. Freebies for new customers and anyone ordering more than three patches.”

“The Drug Queen is here. Everything you need, freshly packed and unblemished. Specific drugs available on request.”

Alongside photographs of the prescription drugs on sale in these groups, there are short explanations regarding their original usage, the active ingredients they contain and the officially approved method of consumption. Under bottles of Attent, for example, the following appears: “Designed for the treatment of attention deficiency disorders and narcolepsy. Mechanism of action: Works on the central nervous system and increases the quantity of dopamine in the brain, which helps improve concentration and focus, and reduces symptoms of anxiety and impulsiveness.” Similar explanations appear for Leviance, Razin, Oxycod, Rivotril, Subutex, Zodorm, Stilnox, Bondormin and countless other drugs.

“Central Israel, are you ready? Large stock of all kinds of drugs: Percocet 5, 10; Oxy 20, 40, 80; Bondormin, Clonex, Ritalin, Cipralex, Fenta and an unlimited supply of other drugs. The courier is in Tel Aviv with a full supply. Hurry up and order.”

Shomrim contacted one of the dealers on Telegram to ask which drugs were available. “I’ve got Ritalin 10. 400 shekels, including delivery. Send the following confirmation: your ID card, your Facebook page and a video of you saying time and date. We’ll move on from there,” was the response. Other dealers were happy with just a selfie including the prospective buyer’s ID card, which supposedly ensures that the purchaser is not a police officer attempting to entrap the dealer. It is far from clear how this verification process works, but what is certain is that the Telegram drug dealers have a massive database of Israelis’ personal information.

“I cannot refuse when someone comes to me and dictates exactly what he wants – antibiotics, a referral to the emergency room, a summary of his health for the National Insurance Institute. I am not protected," says a doctor who lives in East Jerusalem

The market is flooded

This lawless situation when it comes to prescription drugs is possible, in part, because fake or real prescriptions, issued by a bona fide physician, have leaked out from the legal medical sphere – and health establishment instructions are being ignored, along with the recommended usage. “We’ve lost control of the situation,” said the head of the enforcement division in the Health Ministry, Dr. Ronny Berkovitz, at a meeting of the Knesset’s Health Committee in February 2023. “Over the past six years, there has been an increase by a factor of 1.5 in the number of [opioid] prescriptions issued, even though there has not been a concomitant increase in the number of patients. We have heard about physicians who were threatened into writing prescriptions… The market has been inundated with astronomical quantities of fake prescriptions.”

In order to investigate the source of these prescriptions, you have to dive deep into the data and the records that are kept by Israeli health maintenance organizations. This is because most of the opioid prescriptions are written by community doctors. In conversations that Shomrim conducted with several sources in the HMOs, the finger of blame was pointed on several occasions in the same direction: East Jerusalem.

“In East Jerusalem, we saw a lot of young people, aged between 18 and 20, who were given heaps of opioids and crazy doses over the years. It’s obvious that they are not consuming them themselves. We’re talking about quantities that would be enough to kill an elephant. It’s pretty obvious that it’s for resale,” says one senior official from the Clalit HMO, which, with around 300,000 members, is the largest HMO in East Jerusalem. According to the official, the proportion of East Jerusalem residents who regularly use opioids in the whole of the Jerusalem district is significantly higher than their proportion in the total population. “We’re talking here about around 4,000 patients who received a prescription for large quantities of opioids and for extended periods.”

One possible explanation for this highly worrying figure is the way that healthcare services are provided in East Jerusalem. Around 40 percent of the residents of Jerusalem – some 400,000 people – are Arabs who live in the east of the city. Most of them are not served directly by their HMO, instead using the services of dozens of franchisees who operate as subcontractors for the HMOs. Physicians working in the Arab neighborhood of East Jerusalem have described some of these franchisees as “dubious businessmen.”

“A franchisee is someone who gets money from the HMO in exchange for providing services to residents of East Jerusalem,” one doctor, who lives in East Jerusalem and who is a senior official at one of the HMOs, tells Shomrim.

Why do the HMOs not provide service directly? Why do they need to work with subcontractors?

“It started during the first intifada, when it was problematic for the HMOs to enter neighborhoods in East Jerusalem. So, they came up with this solution – providing services through a subcontractor, and at the same time they absolve themselves of responsibility for supervising what was happening there. Some of the franchisees are doctors who no longer behave like doctors; they are businesspeople in every respect. Others have no connection to the medical professional whatsoever. There’s one who is actually a truck driver. That’s the level we’re dealing with.”

What does that mean?

“The HMO pays the franchisee between 70 and 80 shekels a month for each patient. [This does not include medicine and payments to hospitals; for comparison, the state pays HMOs 4,000 shekels a year per patient. The HMO sets aside a measly sum of money for the franchisee. HR] The franchisee tries to save money wherever possible, so he employs unlicensed doctors from the West Bank. Instead of paying a doctor with an Israeli license, for, say, 300 shekels an hour, they bring Palestinian doctors and pay them 70 shekels an hour. That’s pure profit. There are also cases where they employ ‘doctors’ who have just finished their studies and have not passed the requisite exams.”

And how does it work? After all, does the physician who issues the prescription not have a license?

“That’s true. But a licensed Israeli physician has a password for the computer system and five unlicensed doctors use the same password.”

Does the licensed doctor know this is happening?

“He knows and he gets paid for it. He’s actually selling his passport.”

Is the Ministry of Health aware of this?

“Absolutely. I have spoken to the ministry about this personally. But it does not appear that the ministry wants to deal with it, for the time being at least.”

And how does this affect the industry that has sprung up around opioid prescriptions?

“I cannot refuse when someone comes to me and dictates exactly what he wants – antibiotics, a referral to the emergency room, a summary of his health for the National Insurance Institute. I am operating from a low status. I am not protected. He could be drugged up and attack me.”

There’s no protection?

“In some locations there is. Certainly, in places that are outside the [West Bank separation] fence, like the Shoafat refugee camp – where even the police won’t go. Even in Isawiyah there have been cases like that. You’re not working somewhere where you can press a button and the police will be there in an instant.”

So, when a patient comes along and says, “Give me a prescription for opioids,” the doctor cannot refuse?

“Exactly. In some cases, the physician was beaten and threatened at gunpoint. We’ve heard all kinds of horror stories. Everyone has heard about that – but no one is doing anything.”

“In East Jerusalem, we saw a lot of young people, aged between 18 and 20, who were given heaps of opioids and crazy doses over the years. It’s obvious that they are not consuming them themselves. We’re talking about quantities that would be enough to kill an elephant."

‘Doctors are afraid of problems’

Similar incidents to those described by the doctor who lives and works in East Jerusalem have been reported by a large franchisee who works with the same HMO in East Jerusalem. “I can’t just pick up the phone and call the police. If I do, I will be tarred as a collaborator. So, patients shout and threaten,” he says. “There was one patient who picked up a computer and smashed it on the desk after he tried to throw it at a doctor. I have never called the police. The moment I do, I’m finished in that neighborhood. This needs to be dealt with in the internal framework [of local mediators], but the young person addicted to opioids doesn’t care about that. The doctors are afraid of problems and simply hand out the prescription.”

As mentioned, old records kept by Clalit show that there are thousands of young people in East Jerusalem who receive long-term prescriptions for high doses of opioids. One doctor in East Jerusalem who is not connected to Clalit is not surprised by these figures.

As you understand it, are the patients getting opioids for personal use or for resale?

“There are some cases when patients are given prescriptions because of justifiable complaints, but no one warns them that the drug can be dangerous. And so, they find themselves in a loop of consuming narcotics in ever-increasing quantities, and they become drug addicts. And when that happens, they would sell their mothers and wives; they would sell anything for another dose of the drug.

“The second type is drug dealers who obtain prescriptions from all kinds of places, buy the drugs at pharmacies and then sell them. If you go right now to Shoafat, the price of 20 10-mg Percocet pills is 500 shekels. As an insured patient, you can buy that for 17 shekels thanks to HMO subsidies. It’s a hell of a business.”

Where do the dealers get their prescriptions?

“One option is from the franchisees, who are the weak link in this whole story. Another option is through the HMOs themselves [legally obtained prescriptions which the patient then sells or gives the drugs to dealers without consuming them – HR]. It’s not just opioids. There’s also medical marijuana. Criminals use their prescriptions.”

Can the franchisees themselves ask you for these prescriptions?

"Yes, they also demand other things, other materials, so what's to stop them from asking for something as simple as a prescription?"

How many users and how many opioid prescriptions are there in East Jerusalem?

“A huge number.”

"If you go right now to Shoafat, the price of 20 10-mg Percocet pills is 500 shekels. As an insured patient, you can buy that for 17 shekels thanks to HMO subsidies. It’s a hell of a business.”

‘Like a hole in the bucket’

The Ministry of Health set up a special task force to deal with opioid addiction several years ago (Shomrim revealed the protocols of Committee in the past). The most significant thing that this unit has done is to set up a national database using information from all of the HMOs. According to this information, in 2023 some 90,000 Israelis were given a prescription of opioids of varying doses. The task force also found two encouraging figures: in 2023, there was a 5 percent drop in the number of opioid prescriptions issued compared to the previous year; and there was also an important and significant drop of 12 percent in the consumption of strong opioids.

The Ministry of Health ascribed these decreases to the new restrictions imposed by the HMOs on prescriptions for strong opioids, as well as more effective instruction for physicians. “If someone goes to the doctor and complains of back pains, they will no longer get a prescription for Fentanyl. The doctor can’t write one because the computer won’t let him. And no other body will give him the authority to do so. When it comes to other opioids, a prescription can only be refilled with approval from the authorities. As a result, we have seen a drop in some districts in the number of opioid prescriptions,” says Prof. Matan Cohen, who works for Clalit and who has conducted research into increased mortality from prescription opioid medication in the Israeli population.

An article based on Clalit data, which was published in the Journal of General Internal Medicine in November, shows that, some two months after the decision in mid-2022 to move authority for prescribing strong opioids (such as Fentanyl, Percocet and OxyContin) to within the HMO itself, there was a dramatic 80 percent drop some six months later in the number of new prescriptions for Fentanyl.

According to Cohen, significant work has also been done in East Jerusalem. “Studies from across the world, as well as surveys conducted in Israel, show that among people from a lower socio-economic background, the use of opioids is more prevalent. This is a worldwide phenomenon, so it’s not surprising to see the more widespread use of opioids in East Jerusalem. The moves that Clalit initiated are having an impact. The repeat prescriptions issued to thousands of patients are now undergoing inspection or have been halted entirely. There are also moves afoot to reduce the dosages.”

A senior Health Ministry official tells Shomrim, "The main issue now is leakage from private pharmacies and personal purchases. It’s like trying to plug a hole in a bucket. In the end, forging a prescription is extremely easy." The official adds that the ministry plans to propose a series of laws during the Knesset's winter session to address these issues. The proposed measures aim to reduce the use of handwritten prescriptions and strengthen the digital connection between private pharmacies and HMOs. These steps are intended to curb prescription misuse and improve oversight of the medications doctors prescribe.

Therapists who work with drug addicts say that, in addition to the above-mentioned measures, authorities should also open more rehabilitation centers. They come face-to-face with the addicts whose prescriptions have been or are about to be halted. There are currently 22 in-patient detox centers in Israel – 10 of them are public and 12 are private – to provide treatment to those addicted to drugs, alcohol and prescription drugs. But they have a total of just 500 spaces. In addition to these frameworks, there are 25 stations which provide ongoing drug treatment using Subutex and Methadone (which are used for substitution therapy) and around a dozen centers for prescription drug addicts.

“There is no intention of stopping patients’ prescriptions overnight. Instead, there will be a process whereby we can prevent or reduce the drug treatment to a bare minimum before ending it completely,” Prof. Cohen adds. “We will want to offer alternatives and rehab options to anyone who develops a dependency on these drugs, to improve the quality of their lives and in order to minimize the negative accompanying phenomena.”

When it comes to detoxification, Cohen says that there is an additional problem. “There are extremely strict regulations when it comes to operating clinics of this kind. A rehab clinic that wants to offer the option of substitution therapy must obtain a specific license to do so. And that’s despite the fact that a regular doctor can write a prescription for Fentanyl or Oxycodone,” he stresses. “One of the goals of the HMOs is to provide clinics for people who have developed addictions, but the regulatory challenges make it hard to do so. The medical system is not yet flexible enough when it comes to its rehabilitation section.”

According to Cohen, in order to ensure that there is supervision over the responsible consumption of opioids, there needs to be a change in how these drugs are prescribed in hospitals. “When we [community doctors] start out with prescriptions, the computer will send us an alert, saying, ‘In a month from now, you won’t be able to prescribe the same drug. Are you sure that this is the correct prescription? Did you get the patient to confirm that he is aware of the dangers?’ That doesn’t happen in hospitals. It just doesn’t exist. Patients are hospitalized in the emergency room and they leave with a prescription. But there is no mechanism that steps in and says when it's okay and when it’s not. So, we have a situation in which normative people develop an addiction to opioids. These are innocent cases, but that’s how it happens. It’s one possible route to addiction.”

Explanation, not propaganda

Throughout the discussions held by the Ministry of Health task force between 2019 and 2023, many senior doctors appeared before it, testifying to the “trigger-happy” policy when it comes to prescribing opioids in hospitals. “I know of many physicians, including orthopedic surgeons, who prescribe large quantities of opioids. In hospitals, they use opioids as soon as a patient arrives at urgent care,” the director of one department at Soroka Medical Center said at one of the discussions. At another discussion, a senior doctor from Rambam Hospital in Haifa spoke about another negative element: the financial motivation of pharmaceutical companies.

“There are drug propagandists who roam hospitals unsupervised,” she says. “As a result, interns use these drugs without medical supervision. I urge you to issue instructions or to determine regulations making it illegal for these propagandists to talk to doctors who are not fully informed of the facts. They must be forced to get permission from the department director and any meeting must be ‘insulated,’ with the director or a senior doctor from the department present, to oversee the medical framework for the drug and to make sure that the propagandist does not unduly influence a young doctor.”

Others who have first-hand experience from within the hospital healthcare system warned the task force about the dangers of ignoring the protocol, doctors who behave unprofessionally and the lack of knowledge and instruction about the dangers of the long-term use of opioids. Another possible loophole is the transition to the use of “lighter” opioids. “The harder we make it to get a prescription for strong opioids, the more we will see people start using drugs like Tramadol [a less potent opioid analgesic used for moderate pain], which has been exempted from dangerous drugs supervision and is prescribed like a simple painkiller by the HMOs and hospitals. But it’s still dangerous and addictive,” warns one senior physician from Clalit. Indeed, according Ministry of Health’s statistics, around 870,000 patients from all the HMOs were prescribed Tramadol or Codeine during the course of 2023.

Alongside the welcome – albeit somewhat tardy – measures that have already been taken, experts in the field of public health and drug addiction warn about the shockwaves from the prolonged, bloody and traumatic October 7 war, including the possibility that there will be a marked increase in the use of opioids and benzodiazepines in particular. There is no statistical analysis yet to confirm these concerns. Without proper educational explanations and increased awareness among both doctors and patients, they stress, Israel could quickly find itself in a dangerous situation – just like the United States.

The Ministry of Health submitted the following response: “The  Ministry of Health is working with the HMOs in order to gradually stop providing services in East Jerusalem through franchisees and to switch to providing direct service by the HMOs at accepted standards. At the same time, encouraging support tests have been published for HMOs which provide a budget for a transition to the model of direct operation.”