Over-prescribing opioids is unethical - opinion

Tel Aviv University’s recent decision to remove the Sackler name from its Faculty of Medicine – which follows similar recent decisions by Oxford University and by King’s College London – is another landmark step in the fight to hold the Sackler family accountable for their role in causing the North American opioid crisis.

Yet name changes are insufficient as a means of curbing the dramatic rise of opioid use in Israel.

Instead, the medical community as a whole must stand up against the over-prescribing of opioids, as many healthcare workers have done elsewhere around the globe. Drawing from the hard-earned lessons of the United States, Israel is now at a critical juncture where medical institutions and ethical gatekeepers must act decisively.

Unfortunately, the Israeli Medical Association’s official position on opioids encourages continued opioid over-prescribing and it has resisted efforts to bring it in line with updated scientific evidence.

Hard-earned lessons from the US are ignored

IMA’s statement is also at odds with guidance from the United States, where lessons about aggressive opioid prescribing were learned. The US Centers for Disease, the Veterans Affairs Administration the Department of Defense and the American Academy of Neurology are all now warning that the risks of long-term opioid use far outweigh their unproven and transient benefits.

The IMA’s official position is based on the assumption that a crisis similar to that in the US will not occur in Israel. However, Israel is already following in the US’ footsteps. Increased prescribing of opioids in Israel has led to rising rates of opioid addiction. The copy-paste tactics of pharmaceutical companies worldwide, including aggressive marketing disguised as education and advocacy combined with the insidious influence of drug representatives, are influencing the prescribing practices of healthcare workers.

This is the case globally. In Sweden, France, Norway, the Netherlands, the UK and Israel opioid prescribing and cases of opioid-related harm are rising.

As Physicians for Human Rights Israel has documented, unlike in the US, Israel has never conducted a comprehensive investigation into its opioid crisis, nor have pharmaceutical companies ever been held accountable for the harm they caused.

Moreover, the content of the IMA’s official position appears influenced by the perspective of pharmaceutical companies. The IMA calls concerns about opioid addiction “opiophobia” – a term promoted by pharmaceutical companies to downplay the reasonable worries of physicians. Other industry-favored jargon also appears in the IMA’s official position paper, such as labeling chronic pain as “a disease in itself”, which likewise echoes the deceptive narratives propagated by opioid manufacturers.

The influence of pharmaceutical companies is clear throughout the official paper. While the IMA’s states its official goal as “efficiency and safety” in long-term opioid use for chronic non-cancer pain, this position contradicts well-established scientific evidence that the risks of long-term daily opioid use far outweigh potential benefits. With long-term use, opioids can even make pain worse. The IMA position also minimizes the very real risk of addiction even when opioids are taken exactly as prescribed.

In fewer than five days of daily use, opioid dependence begins to set in. Scientific evidence reveals that 40% of patients who take an opioid every day for 30 days are still taking opioids more than one year later. This means that IMA recommendations to doctors to assess the ongoing need for opioid treatment after six to eight weeks, leave patients at risk.

The Israeli Health Ministry has already acknowledged the dangers of opioids. Following a Supreme Court petition by PHRI and Israeli nonprofit Lealtar: The Narcotic Patient Support and Assistance Foundation, the Health Ministry changed opioid labeling to warn that long-term use “leads to physical dependence and may lead to addiction.”

That pharmaceutical companies inform the positions of medical associations is clear – the IMA, like many medical associations, has accepted donations from pharmaceutical companies – receiving nearly NIS 3 million in the last decade from Rafa Laboratories and Teva, both of which manufacture opioids. Yet it doesn’t need to be this way.

Although PHRI has called on the IMA to revise its position on opioids, the IMA has refused to do so. Yet as patients in Israel are increasingly prescribed opioids, the IMA must take steps to align itself both with the Health Ministry’s position and scientific evidence. This should be a launching-off point for the IMA to reevaluate its position and initiate discussions on refusing donations from opioid companies specifically – and pharmaceutical firms in general.

The opioid crisis, both in the US and Israel, highlights the need to address the influence that the pharmaceutical industry has on professional and ethical considerations, patent laws, and the medicalization of care. This must end, so we can prioritize the well-being of patients over financial gain.

Dr. Andrew Kolodny is the medical director for opioid policy research at Brandeis University and president of Physicians for Responsible Opioid Prescribing. Hadas Ziv is head of activities and ethics at Physicians for Human Rights – Israel. Dana Moss is international advocacy coordinator at PHRI.