Israel's own opioid crisis

The opioid epidemic in America, also known as the opioid crisis, is sweeping through that nation, state by state, claiming thousands of lives in its wake. By 2015, annual overdose deaths from heroin alone surpassed deaths from both car accidents and guns. In 2016, 64,000 Americans died from opioid overdoses. Opioids include prescription drugs such as oxycodone, vicodin and percocet, as well as morphine and heroin. The term opioid is now used to refer to the entire family of opiates, including those that are natural, synthetic and semi-synthetic. The story of addiction usually goes something like this: Person A is injured in a way that requires a visit to a doctor, who prescribes any one of a plethora of painkillers. He or she becomes addicted them over a period of prolonged use and begins to seek them out through illegal means. On the street, the pills can be quite expensive, and before long, Person A feels the financial impact of the mounting addiction, learning that heroin is significantly cheaper and has essentially the same effects, only more acute. So Person A switches to heroin, which can be acquired fairly easily and for about the same amount of money as a pack of cigarettes. Before long, Person A is a full-blown heroin addict. Of course, this story has many variations. Person B may have begun by purchasing pills on the street and then chose heroin for the same reason. Person C may use both pills and heroin, depending on which is more readily available. Whatever the details of the individual stories, the opioid epidemic is a real and indiscriminate killer, affecting lower-class and affluent communities alike. How is this crisis manifesting itself in Israel? Americans often move to Israel to become closer to God, or to reconnect with their heritage, bringing their personal history and culture with them. Are they bringing their addictions with them as well? How do addiction patterns in Israel differ from those in America, and where does the Orthodox community fit into the equation? To answer these questions, I took a hard look at Israel's drug culture. “WHAT I see as the biggest problems in Jerusalem are fentanyl and oxycodone,” says Eric Levitz, executive director of the AZ House in Pisgat Ze'ev. “Some of it is actually coming from the border of Mea She'arim. I went with someone about a year ago who was a recovering fentanyl addict and he showed me where he used to get it.” Fentanyl is a particularly egregious kind of opioid, one that seems to be more prevalent in Israel than in America. Fentanyl initially became famous as the preferred sleep aid of singer Michael Jackson. It is ultimately what ended his life. Fentanyl is about 75 times stronger than morphine and can be taken either by injection, as a lozenge, or as a patch that adheres to the skin. In Israel, fentanyl patches are easy to come by for those who know where to look. “In America, heroin is usually cut with fentanyl at best, or maybe Similac or vitamin B,” Levitz continues. “Here, you can buy patches that are pure fentanyl. It's extremely potent and people don't have any experience with that amount of potency. Two kids who were in recovery in my house went out, smoked fentanyl, and died.” Levitz, a former addict himself, has been clean since 2012. He opened the AZ House in September of 2016 to model the facility in Cleveland where he first got clean. AZ House is an all-male residential therapeutic community that is completely free of charge. With a capacity of 15 residents, the average is around 10. AZ House currently has six residents, all of whom must detox before entering, since it is not a medical facility. AZ House's program is eight months long and consists of three segments. For the first two months, residents work through the 12 steps of Alcoholics Anonymous, which also serve as the framework for Narcotics Anonymous. They do not have access to cell phones or money. There is a house phone so that they can talk to their sponsors. Essentially, they do what the house does: eat, sleep, go to meetings and work through the steps. After two months have elapsed, they are encouraged to leave the house and get a job. The third segment is when they pay their first month's rent and they begin to have the freedoms of a clean house. In this phase, they can choose whether to attend group meetings and are drug tested frequently to ensure their new-found freedom is not too much for them. At this point, they are expected to give back to the house as well; being emotionally and physically available for new residents. “Out of the 35 guys who have come through the house since we opened, probably about 14 are clean right now,” Levitz says. “Out of the ones who didn't make it, they either left prematurely, were using the facility as a hotel with no intention of getting clean, stopped working through the program and weren't doing what they were told, or were kicked out because they were disruptive. I don't even know whether to include them because they never gave the house the opportunity to really help them. We have about an 80% retention rate of those who complete the program, which is really good. We had a guy who left for three weeks and then came back, not because he wasn't ready to live in the outside world, but because he missed the house and the feeling of family it gave him. He's considered a graduate. I closed his file, but he's still here.” The AZ House is rare among recovery facilities. The fact that it is entirely free, with no government support, is uncanny. It runs on donations, blood, sweat and tears. Levitz spoke of a point about eight months ago where all funding was pulled and there was no more money coming in. He and the assistant director, Brian Surasky, had to come up with NIS 20,000 to cover expenses. They prayed and threw themselves into marketing and fund-raising, with no prior experience. They did what they had to do, even relinquishing their salaries for six months. After working 100- hour weeks that found them shooting promotional videos, cold calling, fund-raising without a primary donor, doing all administrative work, buying everything for the house, as well as taking in new residents and ensuring that the current ones continued to work through the program, they were able to secure enough funding to get them by the next few months. “We gave our lives,” Levitz exclaims. “No clinician would ever do that. They can't do this job. We've treated another 15 people since then. I don't think that God is going to pull the plug on something that is saving lives. You just have to keep showing up to an impossible situation. It was crazy. The community needs to view this place as an asset. It's 100% free. “We do not take government money or insurance. I don't believe that you can have that because you have to weed out any possibility of a conflict of interest. As far as I understand, if you want to be maximally effective, you have to provide the service for free. This way the clients know you're not getting anything out of helping them. It allows them to let their guard down. It is also an environment that is gratitude-based instead of entitlement-based. When you're getting it for free, you're every day thanking God that you're not sleeping on the street. This place is for people who want to be here. It really makes for a very different environment.” AZ HOUSE accepts everyone, regardless of religion or ethnicity, but it caters mostly to Orthodox Jews. In fact, 90% of residents come from Orthodox homes. According to Levitz, there are two types of addicts who come to AZ House: ones who drank alcohol and smoked marijuana, and ones who did anything that came their way, mostly opioids. With the first group, the stigma is severe enough in Orthodox communities that they might as well have been doing heroin. “It's not a drug problem; it's a societal problem,” Levitz explains. “In recovery, we talk about how it's both a thinking problem and a spiritual one, and that the drugs are but a symptom. The underlying issue seems to be that they've gone 'off the derech.' What these kids have to deal with because of the religious indoctrination is terrible; it's so sad. They have so much inner conflict based on these religious ideas. “Usually these drug problems occur after they stop being religious. Once they stop, they figure they might as well go get high. It's a problem that I see starting way before they pick up. What I would say to the parents is that the whole system is broken. “They have forgotten their No. 1 job, which is to love their child. If you want the kid to be a swimmer and he wants to play hockey, go buy him skates. Just because you think you know what God's will is, doesn't mean you're right. God might have a different plan. These parents forget this and end up destroying their child. What we're talking about is a much bigger problem than drugs. A child needs to know that they are nurtured, that they are loved no matter what. To not give that to them is a form of emotional abuse. Most of what I've seen is that these things result in drug use.” The substances in Israel IN TERMS of the preferred substances in Israel, many are similar to America with opioids and amphetamines, like crystal meth, ranking high on the list. Israel also has a large problem with a substance known as Hagigat or cathinone. One of the ways that this drug can be made is by taking the plant and refining the chemicals to their purest state. You can also synthetically create an analog that has the same molecular structure. When you do this, you yield something called a research chemical, which is not illegal because it was just made. In its most benign form, the plant-based substance can be found in natural energy drinks at stands in Jerusalem's Mahaneh Yehuda market. The effects are similar to a heavy dose of caffeine, but when injected, the effects are similar to crystal meth. Addicts will inject themselves repeatedly and stay high for days on end. They may repeat this for months, sleeping only a handful of times. Cathinone, like other drugs such as opioids and crack cocaine, is readily accessible in Israel, particularly in south Tel Aviv. Unlike in America, where one may have to meet a drug dealer on the corner, in Tel Aviv the drugs can be purchased in grocery stores. “The lower you are, the greater your use, no matter which country you are in,” David Michaeli, founder of Eco Encounter Psychotherapy, states. “I've been in the field since 1996 and have been running this program since 2009. I also run a probation program with a professional team called the Trail Team. I think urban culture, along with its benefits of comfort, has pathologies that are increasing all the time. It includes having less meaning and more violence. The drug is not just a material, it's a culture. Technology is beautiful, but any bright side has also a dark side. My work deals with the dark side.” Michaeli's programming is similar to that of wilderness therapy in America, the most well-known of which is found in Utah. The idea is to take recovering addicts out into nature, so that they can confront themselves. “I just visited south Tel Aviv with someone who is an expert on drugs in Israel,” Michaeli continues. “He showed us where to get Nice Guy [synthetic marijuana], heroin and other substances. It's changing all the time in terms of preferences – whatever is the most available is the most popular in my experience.” According to Nir Oren, who runs the youth program (ages 14 to 19) in Givat Shemesh's Retorno, the largest Jewish drug rehabilitation facility in the world, most of the young people coming through the doors are there for marijuana addiction and alcohol abuse. There is also nominal MDMA and opioid use, but it's not the major issue that he sees. Retorno currently has 48 young residents. Like AZ House, the food is kosher and it is a Shabbat- friendly environment. Unlike AZ House, Retorno is a medical rehabilitation center offering detox, recovery, outreach and prevention services. “I had someone recently who was addicted to fentanyl, but I don't see that a lot. I've been running the Retorno youth program for four years and I ran the adult program for six years before that. Our regular program is 18 months. We use the 12 steps in our therapy. About 80% of our residents come from religious backgrounds. Haredim have no less of a problem with addiction than other groups in society, but they need more resources to help. “People find solutions to their misery wherever they can. Drugs have become easier to access and your dealer could be a nice kid, not some criminal. On the other hand, one of the worst substances is the synthetic one, Nice Guy. It's highly addictive and very damaging. The youth now are using it less. I hear them saying more and more that they don't use it. Marijuana is being decriminalized here, so it makes it less frightening to use. I don't think the problem is becoming bigger, but I also don't think it's getting better either.” According to Levitz, it is cheaper in Israel to acquire an opioid pill prescription than in America. According to Rabbi Tani Prero, who runs the Yagilu wilderness therapy program, there is not the same quick fentanyl fix mentality in Israel that permeates the American medical and social systems that made overprescribing a problem in the first place. “I think that doctors in the US, along with parents, psychologists and the school systems, are more solution- oriented and diagnosis-oriented,” Prero explains. “We're going to medicate you and that's the solution. Israel may be moving in that direction, but not to the same extent. In the US, if you're poor, you need money; if you're sad, you need antidepressants; if you can't sit in school, you need ADD medication. At the end of the day, it's not about taking a pill. It's about working through your own feelings and experiences in life.” Yagilu is a wilderness program where individuals or groups can venture out in different areas of Israel's landscape, sometimes for a few days, sometimes longer. At the time of our interview, Prero was preparing for an upcoming trip with a group of young women who are recovering addicts. They finished rehab and are now deepening their connection to Judaism through a program called Jewessence. Prero will take them out into the wilderness for three days, where they will be responsible for hiking, getting along with others in the group, preparing the food that Yagilu provides and making fires at night. In the course of their journey, the integral part of the discussion centers around the breakthroughs and failures that happen along the way. “These are often expressed as interpersonal issues in the group,” Prero adds. “Then we work through those and the girls will hopefully discover their role in what happened, taking responsibility for their actions. They realize that their behavior affects others. When we're talking about substance abuse, people often have a lot of excuses as to why things aren't perfect. What we do is we use the same kind of approach to help them process the things that make them turn to those substances. “We tend to blame someone as a way of dealing with our own problems, or we'll turn to things that give us a different kind of a fix rather than dealing with our problems directly. It's hard to stare it in the face and say, 'This hurts, I have pain and I'm going to deal with it.' It's easier to pop a pill or smoke whatever it is as a temporary soothing fix. What we're trying to show them is that they can develop self-awareness. They're learning strategies of how to deal with it and also learning that they have control, which is a very powerful feeling, but control means you also have responsibility.” IN GENERAL, Israel is still in better shape than the US when it comes to the opioid epidemic, but the Health Ministry is worried about the widespread use of prescription painkillers, which has risen by 150% in the past five years. This doesn't take into account other substances, like cathinone. Only time will tell if Israel will find itself in a situation like that of the US, where a disturbing problem has become a full-blown crisis. For now, those suffering from addiction in Israel have a range of options for treatment that can be the doorway to a new life. The question remains how to stop potential addicts before they go too far. “In terms of kids from Orthodox communities, drugs make them feel better and help them deal with the pain that should be dealt with by their families,” Levitz says. “I don't think we can stop this. All we can do is to try to do better as a community. All of the Torah in one sentence is: Be a good person and love your neighbor as yourself. Start there and then go learn the rest. “Love your child exactly the way he or she is; it's God's child, not yours. God made them perfect. Now not everyone is going to do that, but it has to start somewhere. “I thought when I opened AZ House that I was going to be dealing solely with alcohol and drug addiction, but what I'm really dealing with is off-the-derech kids from Orthodox communities. It's really a community problem. We need to provide treatment places that understand this, with people who are willing to give their lives because that's what it takes.”

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