Ayao combing his hair in his bedroom in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain.

When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.

Grace Kudzu (right) and her friend Ismael M-Tanko (second from left) visiting Selasse de Souza and her mother Grace Domety at their home in Lomé, Togo on 30 March 2019. Selasse, who like Grace Kudzu suffers from sickle cell disease, has difficulty speaking and is partially paralysed as a result of a stroke that is one of the risks of the disease. Grace Kudzu volunteers full-time in the care and counselling of her fellow sufferers. Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises.

A tramadol capsule with a stated dosage of 120mg and of a type commonly found on the streets, in the hands of a roadside coffee seller in Lomé, Togo on 22 March 2019. Some such vendors sell the opioid painkiller in addition to beverages, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.

Ayao (right) chatting with an acquaintance while roaming around his neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. Aggression and an excess of nervous energy are amongst the effects of the drug when users are 'high'.

Grace Kudzu, 35, with a young patient and her parents at the National Sickle Cell Research and Care Centre in Lomé, Togo on 8 April 2019. Kudzu, who volunteers at the centre full-time and suffers from sickle cell disease herself, was in the midst of a vaso-occlusive crisis at the time.

Students playing football in the schoolyard at the Blaise Pascal school complex in Lomé, Togo on 21 March 2019. A drug education session was held at the school, during which a former tramadol addict addressed the students with the aim of keeping them away from the drug.

17 year-old Jennifer Dossouvi as nurses struggle to find a viable vein for an intravenous tramadol infusion as they treat the pain caused by a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. It took seven painful attempts to find a vein that did not collapse, with the needle finally ending up at the base of her thumb.

A roadside tea and coffee stall in Lomé, Togo on 21 March 2019. Vendors at such stalls sometimes also sell the opioid painkiller tramadol, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.

A nurse administering a dose of the opioid painkiller tramadol to Grace Kudzu at his infirmary in Lomé, Togo on 29 March 2019. Grace suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped, rather than maintaining the typical doughnut-like form. They block capillaries and impede blood flow, causing excruciating vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.

Ayao outside a bar while his friend goes inside to buy alcohol as they roam around their neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. At 15 years old Ayao is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. His friend also struggles with addiction but has been able to reduce the amount he consumes.