Evil spirits from the pillbox
July 10, 2020 — In West Africa, many people are illegally intoxicated on painkillers, which are part of the medical standard. Tighter controls can have serious consequences for the sick.
After Ayao has chosen a t-shirt with colorful prints, white pants, and fake kappa sandals, he pulls a comb through his short curls, distorting his face in pain. Quickly, the 16-year-old fishes two white Tramadol tablets out of his trouser pocket and put them in his mouth. “If I take this, I can do anything,” he says. “Nothing seems impossible.” Then Ayao, who has a different name, leaves his parents’ simple house on the outskirts of Lomé, Togo’s capital, to go to work. With a motorbike rickshaw, he delivers drinking water to shops.
Tramadol, a synthetic opioid, was developed by the German company Grünenthal GmbH and came onto the market in 1977 under the name Tramal. It is administered after operations, for cancer or chronic pain. It is cheap and easy to get, today generics, but also counterfeits are mostly produced in India. The painkiller has a rather calming effect but taken in high doses, it can cause strong euphoria, similar to heroin. Thus, in Togo and also in other countries of West and North Africa and the Middle East, it has become a drug of choice alongside cannabis. In Gabon, the pills hit the headlines in 2018 after schoolchildren suffered seizures in class. Refugees in northern Nigeria use them to relieve their post-traumatic stress disorder. In Ghana, the Tramadol dance has become a sad trend, where young people imitate the trance-like movements of those who are high on the painkiller. And it is said to give the fighters of the terrorist group Boko Haram in Nigeria a feeling of invincibility.
Ayao has been taking up to 675 milligrams of it almost every day since he was eleven years old. The maximum dose recommended by doctors for an adult is 400 milligrams a day. The teenager, who always talks too fast on Tramadol and stumbles over his words, says: “If I don’t take it, I’m not strong. It doesn’t feel good.” Typical withdrawal symptoms include stomach cramps, anxiety attacks, depression, and muscle pain. When Ayao started taking Tramadol, he was still in school. At that time he wondered why some of his classmates were so fit and awake. One of the boys took him to an old lady who was praising sweets, cookies, and medicine in front of her hut. The two of them bought some green capsules with Tramadol from her, they inspired Ayao: “I felt so light and comfortable in my skin.” That was the beginning of his addiction. Soon his behavior changed. “I became hot-headed.” Finally, he was expelled from school. He’s been working ever since. During the week he works as a water delivery man. On Saturdays, he helps his father, who’s a construction worker. He only has time to play football on Sundays. For all this, for any physical effort, he needs Tramadol. His parents don’t have a problem with it, as the pills help their son to earn money. For them, it is a drug, not a drug like cannabis, which has a stigma in West Africa.
“If I take this, I can do anything,” he says. “Nothing seems impossible.”
In Togo, it is mainly those who do heavy physical labor for a pittance who take Tramadol, including construction workers, porters, sex workers, truck and motorcycle taxi drivers. But also students and pupils consume it. The painkiller not only gives inhuman strength but also satisfies hunger. Men mix it with energy drinks in the hope of increasing their potency. But the side effects are devastating.
A young man tells me that he has already lost three acquaintances. One of them had just been riding his motorbike and had started shaking all over his body. A short time later he was dead. Many try to stop but do not know where to turn. In Togo and other African countries, evil spirits or hex are often suspected to be behind mental illness as well as alcohol and drug problems. Because of this belief, but also because of the lack of alternatives, sick people can be exorcised by healers or Christian priests. In Togo, there is only one state psychiatric hospital and too few clinics with psychiatric departments for more than seven million inhabitants. The stigma of seeking treatment is great. Those affected say they may be addicted, but not crazy.
The tramadol pills that people there misuse usually have a dosage of 120 and up to 500 milligrams. In the pharmacy, you can get — and officially only against a prescription — tablets with 50 or 100 milligrams, but Ayao and other addicts find their tramadol on the big market of Lomé, at street vendors who advertise all kinds of fake and inferior drugs, or at tea and coffee stand for the equivalent of 40 to 80 cents apiece.
These high-dose tablets are probably not derived from the legal pharmaceutical market, but produced specifically for amateur personal use, mostly in India. They reach West Africa via the ports in the Gulf of Guinea. Transnational smuggling and drug networks distribute them throughout the region. “We have porous borders. People can simply drive from Togo or Burkina Faso to Ghana with Tramadol, hidden in their clothes or on their motorbikes,” says Olivia Boateng of the Food and Drug Administration in Accra, Ghana. The United Nations Office on Drugs and Crime already issued a warning at the end of 2017: The increasing trade and consumption of tramadol is a security risk for the Sahel and North Africa. Since then, the painkiller has received increasing attention in the annual United Nations World Drug Report. The problem is now called “the other opioid crisis”, the one that does not affect the United States but poor regions of the world.
“We have porous borders. People can simply drive from Togo or Burkina Faso to Ghana with Tramadol, hidden in their clothes or on their motorcycles.”
In 2018, 87 percent of all synthetic opioids seized worldwide were seized in North, Central, and West Africa, a development that is mainly due to smuggling of tramadol. In Nigeria alone, 6.4 billion tablets were seized in the same year. As tramadol is only about one-tenth of the strength of morphine, it was originally classified as a drug with low potential for abuse. Unlike stronger opioids such as morphine or fentanyl, it is also not on the United Nations list of internationally controlled narcotics. Each country decides for itself whether and how it controls tramadol. In Togo, raids on markets and middlemen have increased over the past year. This has sometimes led to an increase in the price of the tablets but has only pushed the trade underground. In neighboring Ghana, where a study showed that one in four minibus drivers in the Accra metropolitan area takes tramadol, the drug has been strictly controlled. Campaigns at markets, bus stations, and schools their information about the dangers. The police were trained to “treat fake drugs with the same urgency as weapons,” explains Olivia Boateng. For two years now, tramadol has been subject to the narcotics law even in India: Illegal production and smuggling can be punished more severely. The consequences are also being felt in West Africa. “As a result of this change in India, far fewer large container loads are now confiscated,” says Matthew Nice, head of the International Narcotics Control Council’s Global Opioids Project, which is combating the smuggling of non-medical synthetic opioids through the worldwide exchange of information. But changes in the laws of one country do not stop international smuggling altogether. “Rather, a shift will be seen. The smugglers will then find new ways, especially to places where there are many consumers,” says Nice.
In recent years, there have been increasing calls for Tramadol to be brought under international control because of increasing global abuse. Boateng is convinced that this would help: “If we here in Ghana make our laws and Nigeria does not do the same, then Tramadol will spill over to us. If the drug were regulated uniformly, it would protect all countries in the region and ensure a legal supply chain. “We’ve had regulated morphine for years, but we’ve never seen this global abuse like with tramadol,” Boateng says. In March 2019, even after another review, the UN Commission on Narcotic Drugs refused to internationally control the analgesic. However, such regulations could make access to tramadol more difficult for those who need it.
“We’ve had regulated morphine for years, but never experienced this global abuse like with tramadol.”
Like Jennifer Dossouvi. When we meet her, the 18-year-old is lying on a bed at the National Centre for Sickle Cell Anemia in Lomé. Her face is contorted in pain. Tears roll down her eyes and drip onto the plastic mattress cover. The young woman suffers from a hereditary disease. Her red blood cells are not round and elastic but sickle-shaped. They clump and clog narrow vessels, the blood flow is interrupted. This damages bones, muscles, and organs, and the acute vascular congestion causes severe pain. Jennifer’s had a sickle cell crisis for four days. Now she is given 200 milligrams of tramadol as an IV drip. “It helps a little, but then it gets worse,” she says. “I can’t sleep, I can’t go to school.” If the pain is too much, tramadol won’t help her. The student needs a more potent drug, but that is in short supply. “If you prescribe morphine, the patient has to go to all the pharmacies in Lomé and should be lucky to find it in one,” says Hèzouwè Magnang, Jennifer’s doctor and the director of the center.
In Togo, but also in many other countries in Africa and Asia, there is an undersupply of strong analgesics. According to the World Health Organization estimates, around three-quarters of the world’s population have no or only limited access to controlled analgesics. There are many reasons for this: International regulation of strong opioid analgesics requires each country to submit annual estimates to the International Narcotics Control Board of how much morphine and other narcotics it needs for its population. In most cases, countries report far too low figures out of concern about illegal trade and abuse. Also, narcotics are often only allowed to be prescribed by doctors — and in poorer countries, there are too few of them. In Togo, there is one doctor for every 20,500 inhabitants, whereas in Germany there are only around 240. There is also a certain “opioid phobia” in many countries, perhaps due to a lack of expertise.
“The number of doctors trained in palliative care is insufficient,” says Maria-Goretti Ane Logo, a lawyer from Ghana and advisor to the International Drug Policy Consortium. “The laws are strict and doctors are afraid to prescribe morphine if something goes wrong and they have to bear the consequences.” For pharmacists, there are bureaucratic hurdles and low-profit margins. Ane Loglo says it’s not worth the effort. “You order morphine, you don’t prescribe it, it stays on the shelf and expires.” In the eyes of the lawyer, tramadol is only part of a much bigger problem: that of counterfeit and substandard drugs. Up to thirty percent of drugs in Africa are counterfeits. The global market for them is estimated to be worth up to 200 billion dollars. In many cases, if at all, infringements of intellectual property are punished. This hardly deters smugglers.
“The number of doctors trained in palliative care is inadequate.”
Ayao also talks about a new pill nicknamed “écouteurs”, or headphones, which is circulating in Lomé. It is said to be much stronger than Tramadol — and also cheaper after the price of the painkiller has risen due to the raids. For him, the “écouteurs” are still not an option, he hasn’t heard anything good about them, and his fear of them is too great.