The Other Opioid Crisis

Grace Kudzu has sickle cell disease, a genetic disorder that makes her red blood cells sickle-shaped and rigid, rather than the usual flexible doughnut form. They block her capillaries and cause excruciating vaso-occlusive crises that last for days at a time. Painkillers are the only thing that help. She gets by with tramadol, a weak synthetic opioid that is cheap and relatively safe when correctly used.

Fifteen year-old Ayao also takes tramadol. But in his case, because he is addicted to it. When swallowed in large, non-therapeutic doses, tramadol produces a euphoric high similar to heroin.

In Lomé, Togo, where Grace and Ayao live, tramadol capsules cost less than $1 on the streets. But they are not like the legitimate pills found in pharmacies, and come in dosages far higher than typically prescribed. Ayao takes between 450mg and 675mg almost every day. Medical guidelines state that the maximum daily dosage should not exceed 400mg.

Tramadol abuse is widespread across West Africa. Boko Haram fighters take it before raids. Labourers take it for strength and to suppress hunger pangs. Young men use it as an aphrodisiac, and sex workers take it to get through the night. There are pop songs about it, and even a dance that culminates in collapsing, addict-like, on the floor.

In 2018, Nigeria alone seized 6.4 billion tramadol tablets, a tiny slice of a counterfeit medication problem estimated to account for 30% of the pharmaceutical market in Africa.

There have been calls for tramadol to be placed under strict international regulation like stronger painkillers.

It is not that simple, however, because the other side of the tramadol problem is an acute and systemic shortage of strong opioid painkillers, such as morphine, and pain often goes untreated. There are fears that restricting access to tramadol would make the situation even worse for people who have a legitimate need for strong pain medication, but must make do with tramadol. People like Grace.