The International Narcotics Control Board^{52, 53} has published the following figures for the consumption of narcotic drugs in Israel (2002): codeine 453 kg (down from 550 kg in 2000); morphine 42 kg (down from 89 kg in 1999); pethidine 36 kg (down from 128 kg in 1999).

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)⁵⁴ in Israel was 253.  This compares with other countries in the Middle East region as follows: Cyprus 46; Egypt 2; Jordan 11; Turkey 7. The Palestinian Authority reported no morphine consumption during 2000-2002 (Table 3).

A comprehensive range of opioids is available and accessible for prescription throughout Israel. This situation is reported as having radically and steadily improved from the early 1990s, largely as a result of concerted campaigning by pioneers of palliative care to change government policy and legislation around opioid availability.⁵⁵

Table 3 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: the six MECC member countries in the Middle East region.

Source: International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

The commonest generic opioid in use is morphine sulphate used as oral tablets, as injectable solution, or in IV infusions and subcutaneous ‘pumps’ (syringe drivers). There is widespread and increasing use of proprietary opioids such as Fentanyl (Durogesic), Oxycodone and Hydromorphone. Pethidine is used for palliation in some hospitals and nursing homes, but more physicians are now prescribing either generic or proprietary morphine salts.⁵⁷ Some physicians find that patients and pharmacists are happier to be prescribed proprietary opioids as the names do not suggest an obvious association with morphine.⁵⁸

Other synthetic drugs with opioid properties such as Tramadol are used extensively by some physicians in cases of moderate to severe pain, particularly as these analgesics are subject to fewer restrictions and can be used for people who are morphine intolerant. Non opioid sedatives such as Midazolam are widely used by specialist palliative care physicians.⁵⁹

The current law permits physicians to prescribe up to 10 days supply of opioids per prescription which can be increased up to 30 days supply if there is good justification. There is no upper limit set on opioid dosage per prescription. Dr Nathan Cherny, Director, Cancer Pain and Palliative Medicine, Sha’are Zedek describes the current legislative and access situation: 

‘We have excellent access to all analgesics and for patients with advanced cancer the analgesics are all free of charge and we don’t have dosing limitations.  The prescribing limitations; you can prescribe only one month at a time but that’s not insurmountable and so there is excellent availability of drugs.’⁶⁰

In spite of legislation permitting 30 days supply, the preference is a maximum10 day prescription; as Dr Amitai Oberman, medical director, Home Hospice of the Valleys explains:

‘There is a possibility that if you write on the prescription that the patient is bed bound, you can get it for 30 days. That’s more tricky and the pharmacies sometimes don’t like it, but if you give them a call it’s fine, but otherwise you would have to fill it for 10 days.’⁶¹

Unless, however, prescribing physicians are specifically trained in palliative care or pain management, it is still the case that not all physicians have the necessary confidence or training when prescribing opioids, Amitai Oberman continues:

‘You know, you have to learn how to write a prescription for opioids and people don’t know how to write such a prescription, they make mistakes and some of the pharmacies are a bit hesitant when they see, like, colossal doses of Fentanyl, but on the whole I think we’re doing OK.’

There continues to be a need for improvements in prescribing practices for palliative pain relief and symptom control.⁶² Most commentators emphasise the importance of ensuring adequate and sustained education and training for physicians (and pharmacists) at all levels. Dr Jim Shalom, medical director of the Nancy Caroline Hospice of the Upper Galilee (HUG) describes some issues in the current situation:

‘One of the [notes] that [hospice founder] Nancy [Caroline] had on her refrigerator was that ‘Pain is a medical emergency.’ In other words we encounter problems with two types of physicians. We encounter problems with what I would - and I’m generalising - with physicians who just back away from any involvement with cancer patients, including referring them to us. For a long time, and probably still in areas that are under-serviced, people just don’t get treated properly: they don’t get treated by the hospital and they don’t get treated by the family physicians properly - although hopefully there are less and less of them. So that’s one category. The other category is the sort of proud family physician; he knows his stuff and thinks that he can handle it, when today really palliative care is different than it was 15 years ago. It’s far more complex, you know, the drug regimens are more complex and the orientation is far more sophisticated than it was before.’⁶³

Aliza Yaffe, Head Nurse at the Israeli Cancer Association, echoes these concerns, particularly the ongoing need to teach the principles of pain management:

‘The other day, one of the nurses came and said she went to see a patient in our regular surgical department, ‘The doctor said that the patient that I was visiting, he’s not in pain but he is very restless.’
So we have to decide, do you treat that restlessness or not? Everybody must treat restlessness. But [the doctor] said, ‘No, that’s not pain so I’m not giving anything, bring the oxygen.’
You know, you have to teach all the time, all the time, all the time.’⁶⁴