Trade-Offs in Managing Tramadol Abuse in Central Africa

By Agnes Ebo?o

Tramadol is increasingly being used as a recreational drug across Central Africa. The illegal trade and non-medical use of this synthetic opioid poses risks for health and security. Health practitioners are faced with the dilemma of restricting its availability to curb abuse, at the expense of patients who need it to relieve pain.

Many governments worldwide, including the United States and Morocco, have made tramadol a prescription 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 as a 'centrally acting analgesic used to treat both acute and chronic pain of moderate to (moderately) severe intensity'. Unlike morphine, for instance, it is not highly addictive. But when used for non-medical purposes and in combination with other drugs or alcohol, it can pose various health risks.

In December 2017, the United Nations Office on Drugs and Crime (UNODC) issued a statement sounding the alarm on tramadol trafficking and consumption. In Central Africa, the spike in the abuse of this drug has had wide media coverage in recent years.

'Tramadol is a social malaise' read one headline in Cameroon, while another described how 'Painkiller abuse sparks fear for Gabon's young'. Similarly, in the Republic of the Congo, a media report covered 'the dangerous consumption of tramadol as narcotics by Ouésso youths'.

The issue has also been linked to violence and crime in Gabon and Ghana, where cases of robbery, rape and stabbings have been attributed to tramadol misuse. Primary users in Central Africa are schoolchildren as young as 12 or 13. Other users include street children and informal sector workers, such as truck drivers and motorbike taxi owners. Tramadol has been described as easing conditions associated with driving for long hours on bad roads.

It is also reportedly 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.

But tramadol abuse and addiction aren't limited to a specific group, class or gender. It is very cheap - on the black market, tablets cost between XAF50-500 (€0.07-0.76) each across Central Africa. Most recreational users buy 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 availability of the drug in Central Africa can mostly be attributed to illicit trafficking.

India is regularly cited as the main sourcing country. The often-counterfeited drug is 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. These include the north-west and far north of Cameroon (along its Nigerian borders), at the Congo-Cameroon border, and in the Lake Chad region and along the Chad-Sudan border.

So why is the WHO so determined to keep tramadol unregulated? Tramadol is used clinically worldwide to manage various kinds of pain. It is not on the WHO list of essential medicine. But Médecins Sans Frontières and the International Maritime Organisation do list it as such. The WHO Interagency Emergency Health Kit 2011 mentions tramadol as a practical alternative to morphine where opioids aren't 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's population) are said to live in countries with low to non-existent access to controlled opioid analgesics. Comparatively inexpensive, tramadol is 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. Those who support unregulated availability recommend context-specific solutions to the abuse of tramadol in Central Africa, while keeping the drug available for medical purposes.

But the responses of governments in the region remain lukewarm. While health practitioners in Gabon have complained about a lack of government action, 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.

Since 2016, the UNODC has stressed the importance of reducing demand for tramadol trafficking as one of the ways to address the problem. States should adopt holistic approaches, including cooperating with global bodies like the International Criminal Police Organisation and UNODC - and also work with health professionals, educators and families to address demand.

Agnes Ebo'o, Regional Coordinator Central Africa, ENACT project, ISS

This article was first published by the ENACT project. ENACT is funded by the European Union (EU). The contents of this article are the sole responsibility of the author and can under no circumstances be regarded as reflecting the position of the EU.

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