Side event: Opioid crisis: Tramadol in West Africa and other regions

Organized by the United Nations Office on Drugs and Crime, Research and Trend Analysis Branch.

Chairman:  Justice Tetteh-Chief Laboratory and scientific section, UNODCT: This afternoon we are all gathered to discuss a very important topic that is of interest to many in this room Tramadol, which is a very useful medicine for pain management, however research findings have shown non-medical use of it across a number of countries. This discussion is to understand the issues and how we can tackle the problem together.

Studies have shown that over 75% of people across the world have no access to pain management. If we look at the International convention, it calls for the availability of access to medicines, whilst avoiding their abuse. In this discussion we want to discuss the medical use, non-medical use, what we can do to address these challenges of non-medical use and also ensuring that there is availability for medical use.

Chloe Carpentier, Chief Drug Research Section, UNODC: Trafficking of tramadol has been reported in many parts especially across Africa. In terms of seisures, over 200 tons have been seized in 2015. Most of the seizures were recorded in Western Africa, North and Middle East.  A number of the seizures were heading to western and central Africa. Some of the shipments came by boat from the illegal market.  Products in the market were used orally and most of the preparations from the illegal market came in higher doses, tablets such as 250mg, 120mg, 225mg etc.

We have also had instances where non-medical use has been reported in North America. In Egypt, there have been 2/3 of users who have been thrown into treatment for tramadol use addiction.

A number of issues have also been identified as being causes of the influx of high doses of tramadol in the criminal markets, these are as a result of poorly regulated medical settings, porous borders and lack of proper structures to monitor the importation of tramadol into countries.

Antonin Tisseron, Consultant Research and awareness Section ROSEN, UNODC: This study is a leading on a EU- funded research project to conduct an in-depth assessment of tramadol (and other synthetic opioids) trafficking and get an understanding of traffickers and a knowledge of criminal networks.

The team draws on open sources and field missions to meetings with stakeholders and cross information. They include Guinea, Cote d’Ivoire, Ghana, Togo, Benin and Nigeria along the coast, and Niger and Burkina in the interior. In this study, there were challenges to harmonizing the data, for instance, seizure data was not always comparable. It can be recorded in weight or by the number of pills / capsules, and some countries have no data example, Burkina Faso. Nigeria only since 2018

Most tramadol was coming from India by sea or air. The main entry points were Nigeria, Benin and Guinea, there is a West to East axis from Guinea to Nigeria and a North-South axis, from the coast to the interior. Different methods are used to move tramadol, taxi, bus, truck there are no rules. The study found that, there was vulnerability at the borders because of corruption and threatening of law enforcement units that are doing important seizures.

About the products, it appears from World Drug Report that. most tramadol is above the medically approved dosage. So we speak about tramadol that is illegally trafficked to West Africa and not what is diverted from the supply chain. There are samples that have been analyzed in the labs, so we know that some are under dosed and others have other components, some psychotropic and other adulterants.

The criminal network, has a wide range of actors – not necessarily linked and mainly driven by opportunism and a transnational activity (Regional and transcontinental levels. There is the need to distinguish manufacturers, International traders, forwarders, wholesalers, conveyors, distributors / retailors, sellers (in street markets or not). There are suspicions of clandestine labs in West Africa, however, there has not been no dismantlement of tramadol lab yet. The difficulty is that there are many seizures but few investigations, and only little sellers, small fish, not the big men. It is also a question of penalties; they are very modest in nature.

To address most of the issues, we need International cooperation of law enforcement within West Africa, but not yet between Southeast Asian and West African countries.

Current developments are in faked medicines. We have pills that are sold as tramadol with green capsules but they are not tramadol.  We are also seeing increases in the legal supply chain. There may also be the entry of new pain killers like hydrocodone, oxycodone, fentanyl.

Gilles Forte, Coordinator, WHO: Gilles explained that, the work done by the Expert committee on Drug Dependence by the WHO was basically an exploratory study conducted on medical use of tramadol.

He reminded everyone about the recommendations of the expert committee on drug dependence that tramadol should not be scheduled but placed under surveillance especially because of its medical use.

The medical use of tramadol is not limited to low and middle income countries but also commonly used in Europe and Australia. Tramadol is the first line emergency analgesic especially in crisis situation. This is commonly used by Aids organization such as the International Red Cross, Medicin San frontiers and others.

He further explained that the epidemiological studies in the past have reported a lower tendency for tramadol misuse compared to other opioids but more recent information indicates a growing number of people abusing tramadol, particularly in a number of Middle Eastern and African countries. The sources of tramadol included illicitly trafficked drug, falsifies medicines and diverted medicines

He went on to present the medical usefulness of tramadol and emphasized the impact in terms of access in case that tramadol become a controlled medicine. In terms of therapeutic usefulness, it is used for both acute and chronic pain, e.g. trauma, post-surgery, chronic pain like cancer, palliative care, HIV, neurological diseases.  It is also provided in emergency care; tramadol is used mainly for post-operative pain. It is also one of the most widely used opioids worldwide and is included in many country essential Medicines lists. It is considered an essential medicine in most mid and low income countries. Because it is not scheduled, it is easy to access, prescribe by doctors without fear than other controlled opioids such as morphine. Tramadol also has a perception of being safe, without the usual negative perceptions that goes with other opioids. It is also the analgesic that is available in low and middle income countries.

There have been divergent views as regarding the findings on the impact of scheduling tramadol. There are those who are concerned that such effort will limit access to pain medication and will further widen the access gap. And there are those who believed the widely usage is the reason for the abuse. In all, many experts believe scheduling will create more barriers in settings where there already exists limited access to pain medicines.

Questions and contributions

Mr. Pierre Lapaque, Regional Representative UNODC: Thank you for these wonderful presentations, For the past years we have seen the regular abuse of tramadol widely, being a recreational drug for many non-medical users which is less costly, what we see also is that, there is a huge black market of tramadol, what is becoming clear also is that a lot of criminal markets, where tramadol has been seen in the pockets of terrorist groups. It is important that some steps are taken to address these concerns, there is need for international control of tramadol as well as cooperation from member states

Contribution from Axel Klein: What we have fail to understand is that, talking about international control will have a serious impact on patients who are currently left with nothing to rely on for their pain. What we also need to understand is that, the leakages of tramadol as per many of the speakers are mainly falsified tramadol and not from the medical sector. Our concern need to be on the falsified medicines such as anti-malarial, antibiotics flooding our markets and causing deaths. Scheduling it will have serious consequences on patients. Pain is a health issue and deliberately allowing people to suffer in pain without making available medicines for pain management is a gross violation of their fundamental human rights to adequate health service

Contribution from Cheick, UNODC: It is important that we all understand the social anthropology of opioid use in West Africa. One must know that, access to pain medicines has been a key challenge. The main problem has been that; the coverage of distribution is limited. For the past years, governments have given the license to business persons who are distributors

Ambassador Okeke, Nigeria: My question is to WHO, what does it mean to have tramadol under surveillance? Secondly, how did the WHO arrive at that decision not to schedule tramadol internationally?

Gille Forte, WHO: When we say a substance is under surveillance, it means that we are still monitoring tramadol and we need more data, the decision needs to be reliable data, At the moment what we have is largely anecdotal which is not evidenced-based. It is important we work closely. We also need to know more on its effect on health and not just seizures of tramadol. We must understand that, it is an opioid analgesic, and it is not a secondary class medicine. Scheduling it will create an important barrier to access for patients who need it for pain management.

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