The illicit trade in this prescription pain killer has become the stuff of ballads and dance halls but its abuse is threatening to condemn those in real need to a life of chronic pain. Laura Salm-Reifferscheidt takes a look at the global sensation that’s topping the charts in Africa’s effort to curb drug abuse.
Ayao* is a tall and well-built 15-year-old, and like many his age, he is very particular about his appearance. He wears a white T-shirt, white trousers and Kappa slip-on sandals. He likes to put a lot of effort into grooming his stylishly cut hair. When I meet him at his family’s simple one-storey brick house in Lomé, Togo’s capital, he stands in his room looking into a tiny mirror, wincing as the comb gets stuck. Ayao works for a company that sells drinking water. He gets up at 5am to load carts with heavy bags of water sachets and deliver them to local shops. Before starting this morning, he took two white tramadol pills.
For four years now, Ayao has been taking between 450 and 675 mg of tramadol almost every day. The maximum daily dose recommended by doctors is 400 mg.
“When I take it, I feel like I can do anything”, Ayao says. “If I do not take it, I am not strong.” When he has taken the drug, he speaks so quickly that he stammers and trips over his words.
Tramadol is a synthetic opioid used to treat moderate to moderately severe pain. It’s relatively safe, cheap and widely available compared to other opioid painkillers, and is given to patients with after surgery or in cases of chronic pain. It’s not on the World Health Organisation’s (WHO) list of essential medicines — recommended drugs that healthcare services should have available, but it is on national lists in countries such as Togo, Ghana and South Africa.
Tramadol can also be a sedative, but if taken orally at high enough doses, it can produce a stimulating euphoric effect similar to heroin.
Those displaced by Boko Haram in northern Nigeria reportedly use the tablets to deal with post-traumatic stress. In Gabon it has infiltrated schools under the name kobolo, leading to kids having seizures in class, while in Ghana the ‘tramadol dance’ is trending, basing its zombie-like moves on the way people behave when they’re high on the painkiller.
Musicians from Sierra Leone, Togo and Nigeria have written songs about it.
But because it’s only about one-tenth the strength of morphine, tramadol is deemed to have a low abuse potential, a WHO 2014 report argues. It’s therefore not internationally controlled — or “scheduled” — by the United Nations. Instead, each country has to set up its own rules and regulations for tramadol production, import, export, distribution and use.
The efficacy of these is mixed. Across North Africa, West Africa and the Middle East, tramadol abuse is rife.
When Ayao started tramadol, he was still at school. He remembers being constantly tired while some of his classmates were always in good form. “I saw my mates and I wondered, why do they react so fast-fast?” One of them took Ayao to an old lady selling sweets, biscuits and medicines in a tiny shop not far away. They bought some green tramadol capsules, and Ayao’s habit began. He enjoyed how the drug made him feel. “I felt light and easy in my skin,” he says.
The reality, however, was not that simple. Ayao’s behaviour changed.
“In class, I was being too hot,” he says. He became disrespectful towards his teachers, and eventually, this led to his expulsion from school. No other public school will take him, and he doesn’t have the money for a private one.
Since he can longer go to school (despite it being compulsory at his age), Ayao works most days. He delivers water during the week, and on Saturdays assists his father, a mason. On Sundays, he goes running, and some afternoons he plays football with others from the neighbourhood. For all of these activities, he now needs to take tramadol.
The pills non-medical users of the drug buy from market women or roadside vendors are typically between 120 and 250 mg, though some speak of strengths of up to 500 mg. They usually cost between 250 and 500 francs (R6 and R12), depending on the dosage. The minimum wage in Togo is 35 000 francs (R840) per month.
Ayao’s father also works as a night watchman. For this, he buys blue Ibucap capsules — labelled as being manufactured in India and containing ibuprofen, paracetamol and caffeine — from one of the city’s countless medicine peddlers. He takes them to help him overcome the aches and pains he feels after a day of physical labour.
Tramadol, Ibucap — to Ayao’s parents they are both medicines. And because medicines are not seen as drugs — like cannabis or cocaine — they don’t carry the same stigma.
Ayao is far from the only one using tramadol for non-medical purposes.
There is a burly man with an empty look in his eyes who hangs out on the steps of a shop at the central market, a few hundred metres from Lomé’s palm-studded beach. He speaks of an inhuman energy rushing through his body when taking tramadol, pointing to a truck driving along the crowded street. “When a car comes towards you, you think it is a toy and you can just pick it up.” The man says he has had nearly a dozen tramadol-induced seizures.
Around the region, the few formal options that do exist for people who use drugs and want to stop are often embedded in psychiatric hospitals. But the stigma around checking into such an institution is strong.
In Togo, and most other countries, tramadol is officially a prescription-only drug but in sub-Saharan Africa, many people buy their medicines in the informal sector. Often neither vendor nor customer really understands what’s being bought and sold, especially given that pills frequently don’t contain what is stated on the packet.
This is because the bulk of tramadol used for non-medical purposes in West Africa is not derived from legitimate pharmaceutical sources, argues a 2019 study published in the Journal of Illicit Economies and Development.
Rather, it’s made up of unlicensed, counterfeit or substandard pills manufactured primarily in India and China, which are then trafficked to North and West Africa.
“We have seen an increase in seizures of tramadol in various countries, especially those with sea [ports] where tramadol usually enters the region – Benin, Ghana, Côte d’Ivoire and Nigeria,” says Jeffery Bawa, drug control and crime prevention officer for the United Nations Office on Drugs and Crime (UNODC) Sahel programme.
According to the 2018 UNODC World Drug Report, North, Central and West Africa accounted for 87% of pharmaceutical opioids seized worldwide, a development due almost entirely to tramadol trafficking.
In Togo, raids on market and street vendors selling illicit medication have, however, increased, pushing tramadol underground.
“Now that we have started to strike, to repress, to seize the illicit products the bonnes dames [market women] sell, it’s begun to enter the clandestine,” says Mawouéna Bohm, deputy permanent secretary of the National Anti-Drug Committee. “That’s to say, the bonnes dames sell it to clients they know very well, and who also come with secret codes.”
As a result of the crackdown, prices have risen sharply in the past few months. Whereas a 120 mg capsule cost 50 francs (R1.20) before, it now costs up to six times that francs. The 225 or 250 mg pills sell for up to 500 francs (R12).
Neighbouring Ghana has also taken steps to combat tramadol abuse and there, the medication is now a controlled substance. Ghanaian authorities are also teaching people that this is a substance with health implications.
Facing similar challenges, in recent years Egypt has also put the painkiller under strict national control.
But seizures of unlicensed tramadol have remained significant. In 2017, more than 60% of those treated in a state-run addiction facility still named tramadol as their main substance of abuse.
So, in response, Egypt called for tramadol to be internationally controlled.
However, in March 2019 the UN Commission on Narcotic Drugs declined to add tramadol to its list of scheduled substances. Its concern was that international controls might make access harder for those in low-income countries who genuinely need the painkillers.
Grace Kudzu looks at her watch. It is time for her injection. She grabs a light brown vinyl purse and steps out of her parents’ large house, crossing the veranda and stepping onto a sandy road in one of Lomé’s quiet neighbourhoods.
Two streets on, she enters a courtyard, where she is greeted by Kodjo Touré*. The nurse, dressed in a white coat, runs a little neighbourhood clinic from his house.
Grace has sickle-cell disease, a genetic disorder of the red blood cells. While normally these cells are shaped like doughnuts, making them flexible so they can squeeze through even the smallest blood vessels, with sickle-cell they are shaped like a crescent moon, making them rigid. They get stuck in capillaries, blocking the blood flow to parts of the body. This can cause damage to bones, muscles and organs, and episodes of excruciating pain. The disease is commonest in sub-Saharan Africa, India, Saudi Arabia and Mediterranean countries, and in Togo an estimated 4% of the population suffer from it.
“It is a sickness I would not wish upon my worst enemy,” Grace says. For five days now she has been having one of her painful episodes. On average she has two of them a month, each lasting a week or more.
“If the pain wants to be kind to me, it comes slowly, but most of the time it just suddenly pops up in my body,” Grace says. The day before, a combination of fever and pain made her vomit. “The pain felt like something was squashing my lungs.”
Only regular injections of painkillers bring Grace some relief. She has come to Touré’s clinic so often that he no longer charges her.
And anyway, she carries everything she needs in her purse, including syringes, disinfectant, cotton wool, and five capsules each containing 100 mg of tramadol.
The problem is that for Grace, tramadol often isn’t enough to ease her pain. But in Togo, stronger pain medications, like morphine, are rarely available.
Touré breaks open one of the tramadol capsules, draws the liquid into a syringe and injects it into Grace’s arm. For just an instant Grace’s self-control cracks. She looks exhausted.
Grace spends most of her time advancing the cause of her “sickle-cell brothers and sisters”. She is the founder of the association Drépano Solidaires (United Against Sickle Cell) and is trying to set up an NGO to provide psychosocial support to people with the disease. She also volunteers at the National Sickle Cell Research and Care Centre, preparing files for the doctors and counselling patients and their relatives.
On a scale of 0 to 5, her pain can sometimes reach 4.3, she says. At that point, tramadol is just not enough. The painkiller is ranked at step 2 of the WHO pain ladder, a guideline for the use of drugs to manage pain.
“Sometimes when you are having the pain like this,” Grace says, “they can inject you those things, but it will not ease it.”
According to the ladder, if weak opioids such as tramadol or codeine become insufficient, they should be replaced by a stronger step 3 drug such as morphine, fentanyl or oxycodone. But these are not readily available in Togo. The reasons are numerous and often compound each other.
Unlike tramadol, step 3 substances such as morphine are internationally scheduled, and countries must put forward annual estimates of their needs. “This is often a problem,” explains UNODC expert Thomas Pietschmann, from Vienna.
“Although it is a simple calculation — how many sick there are and therefore how much pain medication is needed — many governments do not want to taint their image,” Pietschmann says.
“So they do not declare the actual amount of controlled substances needed by their population, leading to a catastrophic shortage of controlled opiates such as morphine, especially in many African and Asian countries.”
The WHO estimates that, as of 2013, 83% of the world’s population – live in countries with low to non-existent access to controlled medicines and inadequate access to treatment for moderate to severe pain.
The 2019 estimates put forward for Togo, with its population of approximately 8-million, reflect what Pietschmann says.
A total of six scheduled substances are on its list, with only three being of any significant amount: 16 grams of fentanyl, 2 000 grams of morphine and 4 000 grams of pethidine. In Switzerland — which has a similar population size — access is far better to controlled substances is far better and the estimated need for quantities of these same drugs run from the tens of thousands to millions of grams.
When strong opioid painkillers do arrive in lower-income countries, they can usually only be prescribed and administered by doctors.
And there are not enough of them.
But if tramadol were internationally scheduled, would it fix the abuse problem in the region?
Olivia Boateng from Ghana’s Food and Drugs Authority thinks it would help.
“If we sit in Ghana and do our own laws in isolation and Nigeria does not do the same thing, we will have a spillover,” she says. “But if it were internationally scheduled, it would cut across and bring about a safe, legitimate supply chain. We have had [scheduled] morphine over the years, but have not had this sort of global abuse we have with tramadol.”
While a worldwide law isn’t on the horizon, interregional cooperation on tramadol is growing.
Last year, India introduced measures to control the drug under its narcotics law, giving its authorities the power to deal with illicit manufacturing and smuggling. And in May, the UNODC and the International Narcotics Control Board organised a trilateral meeting between India, Ghana and Nigeria to look at how to counter tramadol trafficking.
However, Ane Loglo is less sanguine about international control. In her view, advocacy, education and interagency cooperation — rather than repression, which pushes the drug underground — can be effective.
But where an international perspective is needed, she says, is in recognising that tramadol is just one small part of the region’s much bigger problem of counterfeit medication, much of which is substandard.
Fake pharmaceuticals in Africa account for up to 30% of the market. The worldwide market is estimated to be worth up to US$200-billion (about R3-trillion). Even if tramadol were controlled internationally and the flow of it were stemmed, as long as the counterfeit market continues to flourish, something else will simply take tramadol’s place.
Indeed, back in Lomé, Ayao is hanging out with a friend in his neighbourhood. They’re talking about a little white pill that’s new on the streets, nicknamed écouteurs (headphones) after the motif on its face. They don’t know exactly what it is, only that it is much stronger than tramadol, and cheaper, too, now that the price of tramadol has gone up.
But neither seems keen to dabble with it. They recount stories they’ve heard about its mind-muddling effects. Ayao says he already regrets the impact tramadol has had on his life. He feels left out when his former classmates talk about things that are happening at school.
NGOs and civil rights groups such as ANCE-Togo have extended their school- and community-based programmes on alcohol and tobacco to include tramadol, hoping to prevent kids from experimenting with it in the first place.
There are also measures being put in place to address the lack of strong painkillers for people like Grace. The Ministry of Health has an action plan for integrating palliative care into all levels of the Togolese health system. This has already included sending a small cohort of health workers to Uganda to learn from the pioneering approach to sustainable palliative care there, one aspect of which is that nurses and clinical officers can prescribe oral liquid morphine. But these measures are likely to take a long time to show any real effect.
In the meantime, Grace remains unwilling to give in to her pain. She’s promised herself that she will continue to transform her suffering into strength, and is working towards going to the USA to study public health. That way, she says, she can participate in the conception and implementation of policies that will help people with sickle-cell in her own country.
“I want to live a good life,” she says, “and not regret anything.”
*Some names have been changed.
This is an edited version of an article first published by Wellcome on Mosaic and is republished here under a Creative Commons licence. Sign up to the newsletter at https://mosaicscience.com/newsletter
Laura Salm-Reifferscheidt is an author and radio and print journalist whose work focuses primarily on public health and women’s and children’s issues. Among other things, she has been inspired by the resilience of women who survived acid attacks in Uganda and Pakistan, navigated a Delhi landfill with three young girls living and working there, visited the owner of the first sex shop in Soweto, and spent two months in rural Liberia during the Ebola outbreak. When she is not travelling, she is based in Berlin, Germany.