21 May 2018

The scourge of tramadol abuse

Tramadol abuse is at the centre of a debate that weighs up health concerns against the global politics of pain treatment.

The use of tramadol as a recreational drug is on the rise across Central Africa. The illegal trade and non-medical abuse of this synthetic opioid poses alarming risks for health and security. Health practitioners are faced with the dilemma of restricting the availability of this normally legal medicine to curb the abuse; or jeopardising access to pain treatment for legitimate patients.

National governments around the world, from the United States to Morocco, have generally made tramadol a prescription-only medicine. The World Health Organisation (WHO), however, has decided not to ‘schedule’ the drug; a measure that would subject it to tighter international controls and better regulate production and supply.

The WHO defines tramadol is a ‘centrally acting analgesic used to treat both acute and chronic pain of moderate to (moderately) severe intensity’. Unlike morphine, for instance, it does not have a high dependency potency. However, when abused for non-medical purposes, it can pose various health risks. Ingested with other drugs or alcohol, tramadol use can lead to central nervous system depression, coma, tachycardia, cardiovascular collapse, seizures and respiratory arrest.

In Central Africa, the alarming spike in the abuse of this drug has received much media coverage in recent years. ‘Tramadol is a social malaise’ read one headline in Cameroon, while a another describes how ‘painkiller abuse sparks fear for Gabon’s young’. Similarly, in Congo, a media report covered ‘the dangerous consumption of tramadol as narcotics by Ouesso youths’.

Tramadol does not have a high dependency potency, but when abused, it can pose various health risksThe issue has also been linked to acts of violence and criminality in Gabon and Ghana for example, where cases of robbery, rape and stabbing have been attributed to misuse of tramadol. Primary users in Central Africa include schoolgoing teenagers, some as young as 12 or 13, but also street children and informal sector workers, such as truck drivers and motorbike taxi owners. In the case of the latter, tramadol has been described as easing conditions associated with driving for long hours on bad roads.

Tramadol has also been reported to be used by Boko Haram to send suicide bombers on terror missions. In  August 2017, customs officials in Cameroon reportedly seized 600 000 tramadol pills worth about XAF30 million (€46 000) destined for the terror group.

In December 2017, the United Nations Office on Drug and Crime (UNODC) issued a statement sounding the alarm on tramadol trafficking and consumption. But tramadol abuse and addiction aren’t limited to a specific class or gender. The ‘democratisation’ of tramadol can be attributed to its extremely low prices. On the black market, tablets cost between XAF50-500 (€0.07-0.76) apiece across Central Africa. Most recreational users acquire tramadol from small shops or roadside vendors.

Cases of corrupt pharmacists and health practitioners selling genuine tramadol without prescriptions have also been reported, but the rapid penetration and extensive availability of the drug in Central Africa can mostly  be attributed to illicit trafficking.

In Gabon and Ghana, cases of robbery, rape and stabbing have been linked to tramadol abuse

India is often cited as the main sourcing country. The often-counterfeited drug is then believed to be smuggled to Libya or Benin, and dispatched to West Africa through Nigeria, and to Central Africa through Cameroon and Chad. Traffickers use unpoliced borders to avoid controls, or resort to bribing customs officials. Not surprisingly, therefore, suppliers of small vendors and resellers are primarily found at border areas, such as the north-west and far north of Cameroon (along its Nigerian borders); at the Congo-Cameroon border; or in the Lake Chad region and Chad-Sudan border.

At its 39th Meeting of the Expert Committee on Drug Dependence in November 2017, the WHO reiterated its stance to keep tramadol unregulated. This seemingly intransigent position requires a balanced examination against the global politics of pain treatment.

Tramadol is used clinically worldwide to manage pain in a wide range of conditions. It is not on the WHO list of essential medicine, but is listed as such by Médecins Sans Frontières, the International Association of Hospice and Palliative Care, and the International Maritime Organisation’s medical chest for ocean-going merchant vessels without a doctor on board. The WHO Interagency Emergency Health Kit 2011 mentions tramadol as a practical alternative to morphine in situations where opioids are not available.

Opioid access and distribution are severely restricted worldwide. This is a contentious topic, as over-regulation and economic factors leave millions of people untreated for severe pain globally. This includes 5.5 million terminally ill cancer patients and a million HIV/AIDS patients. An estimated 5.3 billion people (76% of the world population) are said to live in countries with low to non-existent access to controlled opioid analgesics. Comparatively inexpensive, tramadol is a viable alternative.

Opioid distribution is severely restricted worldwide, and tramadol is seen as a viable alternative

The WHO’s position is also supported by pain management experts, who argue that stricter international controls would unjustly affect certain countries and sufferers.

Proponents of unregulated availability have recommended context-specific solutions to the abuse of tramadol in Central Africa, while keeping the drug available for medical purposes. But national governments’ responses to the issue remain lukewarm.

While practitioners in Gabon have complained about a lack of governmental response, in Cameroon – where tramadol is the second-most-used substance after cannabis among the youth – the government has set up an inter-ministerial committee against cannabis and other narcotics.

States should indeed adopt holistic approaches that include cooperation with international bodies such as the UNODC and INTERPOL, while engaging health professionals, educators and families to address the demand side of the trafficking. This would be in line with the UNODC position, which, since 2016, has been stressing the importance of demand reduction efforts as part of a balanced approach.

 Agnes Ebo’o – ENACT Regional organised crime observatory coordinator – Central Africa, ISS

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