In 2020, Israel led the world in consumption of opioids per capita. If the health authorities don't act soon, young Israelis will die in droves, says Dr. Itai Bavli of the University of British Columbia ■ 'Drugmakers will always find ways to influence things'
Please introduce yourself.
I’m originally from Kibbutz Magen near Gaza and now live in Vancouver, where I did my doctorate and postdoc – I’m a lecturer on ethics and public health at the University of British Columbia. I’ve also spent two years at Harvard as a guest researcher. My specialty is public health errors.
What does that mean?
Public health errors is a new field of research on wrong decisions that could affect the health of the entire population or parts of it; for example, the approval of the drug thalidomide, which was given to pregnant women in the ’60s and caused many babies to be born with birth defects. Or, back in the day, the health authorities didn’t take sufficient action against companies selling tobacco products – they didn’t act in time and the result has been millions of deaths.
The aim of the research into public health errors isn’t to find the people who are guilty but to identify the structural factors that could lead to similar mistakes.
'The substance is very similar to heroin. Users report a 'feel-good' sensation. Euphoria. Purdue worked systematically; they realized that their key was the doctors. They funded tens of thousands of 'workshops' for treating pain and invited doctors from all over the United States.'
You’ve studied things like the opioid crisis in North America. This is relevant because there is increasing evidence that Israel is on the brink of such a crisis. Some say the opioid crisis has already begun here.
I’m following the situation in Israel with concern and anxiety. Undeniably there has been a steep rise in the number of opioid prescriptions in Israel, and given what I know about the crisis – the way it developed and its consequences in North America – I’m very worried. I’m looking at what’s happening in Israel and feel like I’m watching an accident in slow motion. I can see the approaching catastrophe.
Let’s start with some general background.
Opioids are a family of medications for pain relief – painkillers, some of them produced from poppies and some synthetic. Opioids have been widely used in the medical community for many years. Opioids were used mainly in hospitals, mainly for the terminally ill. Though they relieve pain, they weren’t used for patients suffering from chronic pain because it was known that these drugs were addictive.
Then the Sackler family came along.
In 1995 a medication called OxyContin was approved for use. This drug is based on an opioid called oxycodone. The Sackler family, owners of the company Purdue Pharma, developed this drug based on an old medication of theirs. The alleged innovation was that they had convinced the Food and Drug Administration that this drug had a slow-release mechanism and therefore wasn’t addictive. The moment the FDA approved the drug, [Purdue] embarked on an aggressive and unprecedented marketing campaign.
'In one ad, people using the drug described how their lives had changed for the better. Researchers eventually located the people who took part in the ad and found, of course, that some had died.'
For a product that’s basically heroin.
Indeed. The substance is very similar to heroin. Users report a “feel-good” sensation. Euphoria. Purdue worked systematically; they realized that their key was the doctors. They funded tens of thousands of “workshops” for treating pain and invited doctors from all over the United States. They employed a huge number of sales reps, who worked tirelessly. They invited doctors to prestigious conferences at vacation sites around the world. They had a system for monitoring doctors; they homed in on those who prescribed a lot of opioids and latched the sales reps on them.
They identified the loopholes in the system and exploited them.
They found people in the medical community who were willing to cooperate with them and turned them into opinion-makers. When you’re sitting at a conference and listening to an eminent doctor praising OxyContin, it influences you. In that way they influenced entire generations of doctors. They funded research that showed, of course, that the drug was excellent. They even managed to get a textbook used at the University of Toronto’s medical school, a respected faculty, and taught the students about this new and effective pain treatment. They sent thousands of sales reps, who stuck close to the doctors and gave them gifts. What can you do? Doctors are people like everybody else.
'Fentanyl is intended for pain in the terminally ill or, let’s assume, for use after difficult surgery. Why did they approve fentanyl for chronic pain? I don’t know and I can’t understand it.'
There are many studies about doctors’ decision-making that support this conclusion. It’s not marketing, it’s psychological warfare. They simply gaslighted the medical community. They managed to convince everybody that the chances of getting addicted to OxyContin was less than 1 percent.
Their aim, which they achieved, was to change the narrative. Since many doctors were familiar with the problems of opiates, Purdue wanted to create a new narrative – that their drug was safe, that it wasn’t addictive, that it was the solution everybody had been waiting for. You have to realize that doctors were just waiting for the moment they’d be told that a treatment for chronic pain had been found, because it’s a complex medical situation that a good solution hadn’t been found for.
In 1980, an article was published in The New England Journal of Medicine. … It had been found that less than 1 percent of cancer patients who had been treated with opiates in hospitals became addicted.
'Rafa, a company that's marketing OxyContin and fentanyl in Israel and was under the control of the Sackler family until the end of 2020, has donated money to nearly every hospital in Israel, to research foundations and even to the Israel Medical Association. This increase in the use of fentanyl has to be examined.'
This was just an observation, not based on data from a proper study – and it’s impossible to compare supervised treatment with opiates in the hospital to going home with a prescription. This marginal paragraph [in the article] was enough for Purdue Pharma to frame the whole story differently and declare that a study had been published stating that the medication wasn’t addictive. Within a few years, this conclusion was cited in hundreds of articles. I’ve also encountered that claim in articles published in Hebrew: less than a 1-percent chance of addiction.
They called OxyContin “the one to start with and the one to stay with.” What cynicism. Dependency on OxyContin occurs within days.
They said: We have a new trick that makes the opioids nonaddictive. Therefore, you can use this medication all your life. You can function with it.
'I live in Vancouver, a very beautiful city. Progressive. But when you go to the Downtown Eastside neighborhood, it's a completely different city. I don’t know if I can describe those sights in words.'
In one ad, people using the drug described how their lives had changed for the better. Researchers eventually located the people who took part in the ad and found, of course, that some had died. The slogan is a shocking one, because people stayed with the drug simply because it’s addictive.
The rest of the story is better known. In the United States, patients who developed a dependency on the medication and could no longer obtain it – one reason because their health insurance had lapsed – turned to the street: to heroin, to fentanyl, which is 100 times stronger than heroin. Nearly 1 million people have died from overdoses in the past decade in the United States.
More than 100,000 died of an overdose in 2021 alone. This figure includes both people who died of an opioid overdose and those who started out on a prescription drug and moved on to deadly street drugs.
'The important lesson we must learn from the opioid epidemic is that the drugmakers will always find ways to influence things – funding for research, conferences, a lobby, payments to patients’ organizations, sales reps.'
And that, of course, is an underestimate. Incredible. The Sackler family in effect has wiped out a small state.
Absolutely. Between 2015 and 2017, life expectancy in the United States dropped for two years straight. Before the coronavirus pandemic, that last happened during World War I. Purdue Pharma developed the market, or created a market. And more and more drug companies joined that celebration. They all wanted a piece of that very lucrative market. So we reached a situation where dealers waited outside pain clinics with heroin from Mexico, because they knew that addicted people weren’t getting what they needed.
Really an ecosystem.
When demand is great, a black market behaves like any other market. Supply expands to meet demand. Other substances came in – heroin and fentanyl from Mexico and China, and then carfentanil, and more and more, substances where only a small amount is enough for death by overdose.
I live in Vancouver, a very beautiful city. Progressive. But when you go to the Downtown Eastside neighborhood, it’s a completely different city. I don’t know if I can describe those sights in words. It’s a city of zombies. Entire streets of zombies. People collapsing in the street of an overdose and the rescue teams giving them [the antidote] naloxone. The situation isn’t improving, it’s only getting worse and worse. It’s so hard to see. It’s just horrific. I wish I could do something about it.
'The overprescribing only started the epidemic. Most addicts today are no longer addicted to prescription drugs but to street drugs.'
I don’t understand how they managed to fool the medical establishment; why the FDA acted the way it did. In fact, the intervention by the regulator here only exacerbated the damage. The FDA became a partner in crime.
It’s really hard to understand. I wrote a whole chapter about that in my doctoral thesis. What’s even more astounding is that at the time the drug was approved, in December 1995, there wasn’t even any evidence that the drug was effective for chronic pain and not addictive.
There’s a lot of anger at the drug companies, and rightly so, but the focus on them misses the really big problem – the failure by the gatekeeper, or gatekeepers, because the Drug Enforcement Administration also failed to prevent the distribution of opioids to places where it was clear there was too much consumption. It’s clear that Purdue deserves every condemnation and that the Sackler family should go to prison, but all this wouldn’t have happened if the regulators had done their job and protected the public interest.
This raises a lot of ethical questions – why did they approve the drug with the erroneous information? Had Purdue been in contact with Curtis Wright, who was responsible for approving the drug at the FDA and immediately thereafter went to work at Purdue? Was the FDA taken captive by the industry? It’s a black box; we don’t know what happened there.
The conflict of interests is built in. I wonder if we can expect drug companies not to exploit every loophole. The line that drug companies aren’t supposed to cross – what’s it based on? Morality? Ethics? Goodwill?
There’s no doubt that this is problematic, and we definitely can’t expect the public interest to be maintained without an intervention. The weak link in the regulation, by the FDA for example, is what happens after the drug is approved. No one is there to monitor use, to identify the undesired effects, to examine what the companies are doing at the marketing stage.
This is a known structural problem that they’re trying to fix, but the drug companies of course know how to exploit this very well. From my perspective, one of the main aims of my academic career is to strengthen the regulators’ independence and reduce drugmakers’ influence on the regulators and the overall scientific-medical community.
Yes, for the opioid victims it’s too late.
True, but that doesn’t mean it can’t happen again with a different drug. You have to understand that the overprescribing only started the epidemic. Most addicts today are no longer addicted to prescription drugs but to street drugs. Even if doctors stop prescribing opioids for chronic pain, it won’t help at this point.
That’s because the epidemic has entered a new phase. And a new location, it seems. Now it’s in the streets.
‘I don’t know what marketing moves are being made in Israel, but I assume it isn’t out of the blue that doctors are prescribing fentanyl patches.'
Yes. The epidemic now is with the addicts in the streets. It’s a plague of the black market, which more and more drugs are coming through. People are falling like flies. More than once I’ve seen people collapsing from an overdose in the streets. People in Vancouver are saying that everybody knows somebody who has died of an overdose – a friend, an acquaintance, a relative. And of course this isn’t happening only in Vancouver. Those painful sights also exist in many big cities in the United States.
In Israel we’re seeing a significant jump in opioid prescriptions. Organizations have already issued warnings; the Taub Center for Social Policy Studies in Israel, Physicians for Human Rights. In 2020, Israel led the world in the consumption of opioids per capita. We’ve overtaken the United States.
I’m following the data with great concern. It’s very disturbing. There has mainly been an increase in the use of strong opioids, like fentanyl patches.
How was fentanyl even approved as a chronic pain reliever in Israel after everything that’s known about it?
It’s dreadful. Fentanyl is intended for pain in the terminally ill or, let’s assume, for use after difficult surgery. Why did they approve fentanyl for chronic pain? I don’t know and I can’t understand it. Yesterday I spoke with Nadav Davidovitch [the head of the Department of Health Systems Management at Ben-Gurion University and an author of the Taub Center report], and he says that Israel is already deep into the epidemic.
I can’t cite the numbers and can’t say how many deaths there have been because there’s no clear register. I only know that in North America they woke up too late, and we’re seeing the results. I don’t know what marketing moves are being made in Israel, but I assume it isn’t out of the blue that doctors are prescribing fentanyl patches.
Something is happening. An investigation by the Shomrim Center for Media and Democracy has revealed that the laboratories of Rafa, a company that’s marketing OxyContin and fentanyl in Israel and was under the control of the Sackler family until the end of 2020, has donated money to nearly every hospital in Israel, to research foundations and even to the Israel Medical Association. This increase in the use of fentanyl has to be examined.
Israel’s starved health system is vulnerable to infiltration by opioids. There’s a tremendous burden and meager resources, so instead of physiotherapy and follow-up getting prescribed, it’s a painkiller.
The situation in Israel is grave. We have to wake up and understand this. The overprescribing can easily lead to the process that occurred in North America at the beginning of the epidemic there. I know there’s already seepage into the black market. I know they’re selling fentanyl and OxyContin in the streets, and I also know how quickly this can degenerate.
I don’t know how this is going to look in Israel, and the dynamics differ from country to country and depend on other factors, but I can tell you that if the increased prescribing of opioids, especially fentanyl, continues, we’ll see an increase in addictions among young people. And we’ll see cases of death from overdose. A nightmare. If they continue to prescribe opioids like this, I see no reason why that won’t happen.
There are doctors in Israel saying that this isn’t a trend – that if it were, we’d be seeing zombies in the streets.
In North America we’re now seeing the tragic end of a process that began at the end of the ’90s with overprescribing. The result has been the destruction of communities and families and hundreds of thousands of deaths. It’s not worth waiting till we get to that point to understand that we’re in the middle of an epidemic that’s difficult or impossible to stop. We have to stop it now.
In Israel at least there isn’t the lapse of health insurance as a trigger to transition from medication to street drugs.
At Stanford University a few years ago, I met with Keith Humphreys, maybe the top addiction researcher in the world. He told me: I understand what’s happening in the United States. There are drug companies that want to maximize profits and there’s a private health system vulnerable to incentives. But in Canada there’s a public health system, so why is it happening there?
I answered him that exactly the same manipulations worked in Canada with its public health system. I’m also not sure that the health-insurance issue explains the transition to street drugs. In Israel, too, there could be a situation where a patient who’s taking opioids and needs increasingly larger doses will be refused by the doctor because she realizes that this is dangerous, and since he’s already addicted and needs to obtain more, he’ll turn to the street and street drugs.
That’s exactly the thing about overprescribing. It creates an increase in demand for drugs that have the identical effect – and an increase in supply. When supply in the black market increases, so does demand. This is a snowball that begins with overprescribing, overflows into the streets and gets completely out of control.
In my research I show that in Canada they believed at the start of the 2000s that addiction to OxyContin was an American problem, so they didn’t take action. They didn’t update the information leaflet. They didn’t warn doctors of the danger. This was an error by the regulators in Canada, which led to an overprescription of opioids and the grim and grave results we’re seeing now.
So Israel’s public health system is no guarantee for avoiding the crisis.
The public health system won’t necessarily make the difference, though it’s clear that in a country like the United States, where health is a business in every respect, the opioid manufacturers have greater influence. A public health system can more effectively track the way doctors are prescribing, and doctors in the public system should have fewer incentives to maximize profits.
The important lesson we must learn from the opioid epidemic is that the drugmakers will always find ways to influence things – funding for research, conferences, a lobby, payments to patients’ organizations, sales reps. Therefore, strong regulations are needed to prevent them from obtaining this influence on the medical and scientific community.
This isn’t an easy mission. There are talented people in the drug industry who know how to manipulate – people who sit and think how they can get those doctors, who are overburdened and agitated, to prescribe a certain medication.
There’s a link between opioid use and socioeconomic status. When people don’t have means to treat themselves, they take medication. Barbara Ehrenreich wrote the book “Nickel and Dimed” on her attempt to live the blue-collar life in the United States for a year. She describes how she and her colleagues, with aching knees and backs, take a lot of painkillers simply to survive their shifts. This too is a cause for concern in Israel. I’m thinking about the truck drivers with backaches. It’s scary.
Opioids are associated with the lower middle class, and for good reason, because it really is a solution that lets people keep functioning, keep working and remain “productive individuals,” as they say in the United States.
If you were asked for recommendations on what should be done in Israel, what would you suggest?
I think things have to be examined in depth – not to panic but to realize that the decision not to act could lead to unnecessary suffering. A committee has to be formed to look into doctors’ prescription habits – it’s important to understand why there has been an increase in prescriptions.
We have to teach the Israeli medical community about the dangers in taking opioids. I once taught a bit about this at Hebrew University. We have to make sure that there are enough detox programs for addiction sufferers – as far as is possible, to separate the industry from the medical community, to simply reduce contact. It’s vital to learn from what has happened in North America so that we don’t make the same mistakes.
I can’t breathe. I don’t know why this is depressing me so much.
Because it’s a really depressing topic.
Yes, but I always write about depressing topics, and in this story there’s cynicism that I can’t bear. It’s not a natural disaster. It’s not the result of social or geopolitical processes. It’s a man-made disaster. In an article of yours, you wrote that the executives have taken the lawsuits, the potential damages, into account in their calculations. How can anybody stand this?
Yes, they calculated what’s called “the cost of doing business.” They said: It doesn’t matter how much they sue us, we’ll earn billions from this drug. And they were right. They made tens of billions. So what if they had to compensate anyone? So they paid out about $6 billion for lawsuits. Okay. The profit line is still ticking along beautifully.
Some of the profits, of course, wind up as donations. The Sacklers were famous philanthropists, whitewashing themselves to death.
In the past, the Sackler family marketed Valium. They’re champions at creating a good image with the help of donations to museums, research institutes, Tel Aviv University. Until very recently, Tel Aviv University’s medical school was still named after them.
They haven’t even been convicted of any crime. Only recently did it become clear that they won’t even have to apologize. This is appalling. Money conquers all.
I’m not a legal expert, but this really looks bad – a family that has caused so much suffering, that made millions on the backs of addicts. I don’t understand why they aren’t in prison. What they’ve done also has long-term effects that can’t be measured.
There’s a huge rift, a colossal crisis of confidence between the public and the medical community, and I don’t know if it will be possible to heal it. To maximize their profits, they were willing to destroy so many people. It’s impossible to comprehend this.