Tramadol: From ‘safest painkiller’ to major health concern

Over the years, the potential for the abuse of tramadol has been demonstrated in human studies, with its placement on a scale of likelihood of abuse with the opioid drug, morphine.

The National Survey on Drug Use and Health, a recent survey that was released early this year presented the first-ever large-scale nationwide survey of the extent and pattern of drug use in Nigeria. It has been recognised as the first of its kind.

The survey was conducted by Nigeria’s National Bureau of Statistics (NBS) and the Centre for Research and Information on Substance Abuse (CRISA), with technical support from the United Nations Office on Drugs and Crime and funded by the European Union.

It provides extensive data on the issue that has plagued Nigeria. This survey being a landmark, it is important to explore the public health crisis that tramadol has ensued.

What is tramadol?

The German pharmaceutical company Grünenthal, which specialises in pain treatment, first synthesised Tramadol in 1962. Grünenthal was responsible in the last seven decades for its manufacture and promoting of the drug Thalidomide that would turn out to be teratogenic.

Tramadol started selling on the international market in 1977 under the trade name Tramal and most drug regulatory agencies around the world quickly adopted it as a relatively low addictive potential, moderate pain-relieving opioid drug.

On classification, it falls below morphine and codeine among the opioids, but with an effect that is on a scale as both drugs. NAFDAC first registered the drug in 1995 in Nigeria under its parent company.

Tramadol abuse

With tramadol’s usage over time, incidences of addiction and abuse have been growing, reported as incidents and in specific studies.

The UNODC 39th report states that in several of these studies, subject participants were able to identify the effects of tramadol similar to morphine. It is interesting to note that in these studies, volunteers were drawn from subjects with no history of substance abuse, non-dependent opioid users and recreational drug users (i.e persons worn off addiction).

Addiction was noted as dose-dependent dependence (i.e increased addiction with increased dosages), drug reinforcer, and drug liking effects respectively.

This has corresponded with increasing population reports of growing addiction and abuse with tramadol. In the U.S., the Drug Enforcement and Administration reported 3.2 million people using the drug for non-medical use in 2014. The first incidences of tramadol dependence and addiction were first reported in the early 1980s.

Tramadol in Nigeria is regulated as the 50 and 100mg dosage strengths but very high dosage forms of 200 and 225 mg have infiltrated the market.

This is significant as we have seen that tramadol has great abuse potential, evidence showing that addiction can occur even with a single exposure, with serious health consequences. In addition, it has been related to criminal activity and lawlessness across the country.

The national survey identified that 14.3 million Nigerians, equivalent to 14.4 per cent of the Nigerian population between the ages of 15 and 64 had abused drugs in the past year. This is twice the world’s average of 5.6 per cent and is equivalent to 1 in every 7 Nigerians.

This report identified that the “most common drugs injected in the past year were pharmaceutical opioids”.

These pharmaceutical opioids primarily included tramadol, codeine, or morphine of which the survey estimated 4.7 per cent of the Nigerian population as having engaged in their non-medical uses. This is approximately 4.6 million people, equivalent to the population of an average state in Nigeria.

Indeed evidence has pointed to the fact that Nigeria is one of the countries in the world with the highest use of Tramadol relative to its population.

Nigeria’s biggest drug supplier

Information from the Nigeria Customs Service tells us of the seized drugs at the Nigerian border. They provided us with a detailed report from the Enforcement, Investigation & Inspection Department on the surge of drugs seized from 2014 to 2018.

Data on illegal tramadol coming into the country seized shows that India, USA and China are the three major sources of illicit tramadol (according to volume in that order) coming into Nigeria.

The volume has been increasing tremendously over the last 5 years. In one single seizure this year, 42 containers (not to be mistaken with cartons) of tramadol was seized.

Further, the United Nations Office on Drugs and Crime (UNODC) has noted that non-medical use of tramadol is fast becoming a problem in Africa, with little attention being given to it, in the shadow of the opioid crisis in the US and elsewhere.

The UNODC’s 2019 world drug report has also shown the bulk of this tramadol “is being illicitly manufactured in South Asia and trafficked to the region, as well as to parts of the Middle East”, corroborating the data received from the Nigeria Customs Service.

Between the period 2014 -2018, illicit tramadol seizure was valued at N901,162,398 duty paid value (i.e this is the money the government lost on this drug items illicitly brought into the country. This means that the actual value of this drug seized was much more, perhaps 10 times more) suggesting the lucrative nature of the illicit trade.

Dangers, consequences of drug abuse

Accordingly, the UNODC Nigerian region representative, Oliver Stolpe, “by now, Nigerians living with a drug use disorder outnumbered, by far, people living with HIV and AIDS in the country”.

The consequence, in terms of adverse effects from drug use and especially drug dependence behaviours, are well-known to any society.

These effects can be health-related as well as social. The effects of drug abuse have on health are short and long-term. Effects of drug addiction include a person’s nutrition, sleep and susceptibility to communicable diseases.

People are also more prone to injury as a result. Further, pregnant women or breastfeeding mothers experience health impact to both them and the child. Pregnant women who abuse drugs have their babies experience withdrawal after birth; this is known as neonatal abstinence syndrome (NAS). Drug abuse also increases the risk of premature or low birth weight.

The social implication of drug abuse ranges from family conflicts, loss of unemployment and also legal issues resulting from criminality or arrest from drug abuse. Moreover, drug abuse is a well-recognised link to terrorist activity as it fuels violent behaviour and the drug trade. This, therefore, means that addressing the drug abuse problem and the surge of tramadol especially, would have benefits that transcend public health and wellbeing.

Is there a case for control?

For the other opioids such as fentanyl and morphine, international control is regulated by the WHO, in recognition of their abuse potential.

At its 2018 meeting, the World Health Organisation’s Expert Committee on Drug Dependence concluded that it was “not likely to be converted into a controlled substance.” This means that control can possibly be at a country level, but this might be less effective since there would still be much room for unregulated production and illicit trade.

The case made for non-regulation includes the fact that this is a cheaper analgesic for pain control from cancer and other chronic disease conditions.

As such, a strong regulation would mean difficult access to patients in low- and middle-income countries. But perhaps this has to be considered in the presence of strong data evidence. There are no precise available data showing the actual prescription of tramadol for medical use per year in Nigeria for instance.

Hence the first recommendation for future actions begins, with an actual medical use data gathering. Thenceforward, efforts to regulate the drug, with careful consideration for genuine medical uses should be made.