U is for Ultram
The world’s most widespread problem drug?
Ultram is just one of the many brand-names of the drug Tramadol. As an synthetic opioid pain medication it is primarily used to treat moderate to moderately severe pain. The onset of such pain relief usually begins within an hour of being taken orally although it is also available by injection.
As is typical of opioids, common side effects include constipation, itchiness, and nausea. Serious side effects can include seizures, decreased alertness, and drug dependency. The risk of an overdose also an ever-present one. In 2017 there were 33 recorded fatalities in Northern Ireland that were connected to the drug. A research paper looking at the situation there suggested that around half of these fatalities were of people who were being prescribed tramadol at the time of their passing. Fatalities were considerably more likely to occur if tramadol was combined with alcohol, benzodiazepines or other opiates.
Tramadol itself was patented in 1963 and launched under the name "Tramal" in 1970’s by a West German pharmaceutical company By the mid-1990s, it had been approved in the U.K and the U.S and became available as a generic medication being marketed worldwide.
Synthetic opioids such as the more well-known Fentanyl have received considerable media attention in the United States. This has mainly centred on the role they play in overdose situations. The Centres for Disease Control (CDC) put this figure at some 36,000 fatal cases in 2019.
The role that synthetic opioids, especially tramadol, play in other areas of the world has however been much less comprehensively reported. While America wrestles with its opiate crisis, across much of Africa, the Middle East, and parts of Asia and Europe, tramadol pills are the drug of choice. The Wall Street Journal described it as epidemic that was: “fuelled by cut-rate Indian exports and inaction by world narcotics regulators.”
According to the United Nations (UN), West and Central Africa now account for 87% of all pharmaceutical opioids seized globally. Reasons for this explosion of use is primarily its low-cost. In Nigeria tramadol retails at around $0.05 for a 200mg pill (or $0.30 for a strip of ten tablets) as opposed to about $2.50 in the US. Secondly it has an ability to help people work long hours in physically demanding jobs. Religion may also have a part to play as well. Alcohol is usually forbidden in Muslim communities in the region but there is less of a taboo around prescription drugs.
The illicit use of the drug is thought to be a major factor in the success of the Boko Haram terrorist organisation based in North-eastern Nigeria, but also active in Chad, Niger and northern Cameroon.
One former member of the group was quoted as saying "Whenever we took tramadol, nothing mattered to us anymore except what we were sent to do because it made us very high and very bold, it was impossible to go on a mission without taking it." It appears that Boko Haram would often force-feed their often child-soldiers the drug before commencing an operation. It may also increase the sense of ruthlessness that soldiers would feel during an operation, leading to atrocities and war crimes.
Nigeria’s anti-drug agency routinely intercepts huge quantities of various tablets every year . For example, in November 2018 over half a billion tablets of tramadol were seized in the Port of Lagos among 33 flagged containers. Although it has prescribed medical uses, tramadol, unlike most opiates, isn’t regulated by the International Narcotics Control Board. This means that it can flows freely from factories in places like India and Egypt.
Some believe that although the seizures receive strong publicity at the time, the drugs may return the supply chain via a series of corrupt officials.
Countless millions of pills must also slip through the net, with aid workers in the region saying that tramadol dependency is usually first on the list of problems faced by people who once lived under the Islamist militants. To meaningfully reduce the illicit trade, Nigeria will need to work more closely with other governments, particularly those of its neighbours, to find ways of tracing and controlling the flow of drugs into the country. At home it will also need to significantly enhance regulation and enforcement. This would include ensuring that pharmacies receive prescriptions before selling the opioid.
Meanwhile in conservative Gaza, part of the disputed Palestinian territories, drug use is highly stigmatised. Despite that, widespread misuse of the synthetic opiates is now part of the coastal enclave’s many interconnected crises. Drug education classes are a recent development, and for now at least only for boys. They are funded as part of the Hamas-run government’s own “War on Drugs”. Some commentators note that Hamas has long been accused of profiting from the drug trade over the years.
Many of those who have become dependent on tramadol in Gaza were injured, often losing limbs, from the actions of the Israeli military in the continuing conflict. Trying to cope with both physical pain and bleak future prospects, it is not surprising that substantial numbers turn to using tramadol or similar products off-prescription.
Whilst Israeli checkpoints restrict the flow of many goods in the Palestinian territory it is believed by some that they purposely allow tramadol across the disputed border as a ploy to further weaken the densely-packed society of the 2 million people crammed into the 141 square miles of the strip.
Exact figures for tramadol abuse are difficult to determine because of the social stigma surrounding drug use in Gaza. No government body tracks rates, but a 2017 report by the UN’s Office on Drugs and Crime and the World Health Organization found that nearly 2% of males (aged 15+) in the West Bank and Gaza were high-risk drug users (with tramadol being Gaza’s most used drug in this category). Anecdotally, Palestinians in Gaza frequently cite tramadol use as an indication of how a decades of political and humanitarian crisis has upended life, particularly for young people. Deep-seated views mean that many report that they could never tell their family, for fear of a violent response or being socially excluded. Authorities usually say it’s only a male problem, but privately, women say females also use.
Whilst Tramadol appears to be prescribed for a wide range of ailments, an illegal trade also exists with the pills being smuggled in via the tunnels from Egyptian territory alongside all manner of products including fuel, food, weapons and consumer goods. The network reached perhaps some 1,500 tunnels a decade ago. Extensive efforts, including flooding them with sewage, were made to close down the trade in 2013. Since then, it’s thought that some have been re-opened.
It is also thought that it was among those who worked the tunnels that the use of tramadol first really took off in the area. Bosses freely handed out the pills to their workers in an attempt to take the edge off the stresses and dangers of the job, and keep the supply lines moving freely.
As more of Africa’s natural resources are exploited the modern world increasingly makes its impact on more physically remote areas and their indigenous peoples. The Baka people of Cameroon’s rainforest, for example, have only relatively recently become accustomed to the commercial sale of branded alcohol products, yet alone Tramadol. It’s negative impacts health, social cohesion and cultural resilience means that it’s use can be termed a ‘public health crisis’. The Baka people themselves have reported that alcohol and tramadol use has led to wide range of problems which include a dramatic increase in the number rapes recorded, especially of adolescents.
From millionaire’s homes in Beverley Hills to remote villages in the rainforest there is an argument to be had that next to alcohol this one largely unregulated product, tramadol, is causing more problems worldwide than any other.
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Western Region Drug and Alcohol Task Force,
Unit 6, Galway Technology Park, Parkmore, Galway H91 W30F
Tel: 091 48 00 44 Email: info@wrdatf.ie
