Tramadol: Three cheers for the Expert Committee on Drug Dependence

In November 2018, the Expert Committee on Drug Dependence (ECDD) held its 41st meeting in Geneva. The ECDD is a committee that operates under the auspices of the World Health Organisation (WHO), and it is tasked with examining substances proposed for control under the United Nations international drug control treaties. It conducts a process of scientific review, and based on the evidence available to it, WHO makes a recommendation to the Commission on Narcotic Drugs (CND) in Vienna, which is the political decision-making body of the UN drug control system. It is one of the few ways in which the imperatives of public health can have an impact on the system.

This may all sound rather technical and dry. Nonetheless, it is rather important: Without a recommendation from the WHO, the international drug control system cannot add a drug to its hierarchy of ‘schedules’, or the various levels of control that the drug control system imposes. WHO can recommend no scheduling under the international drug control treaties, or any one of four schedules, ascending in their severity.

Tramadol is a synthetic opioid used as a painkiller, and at present it is not under international control. Importantly, tramadol is often the only analgesic available for those suffering ‘moderate to moderately severe’ pain, particularly in the developing world. It is used for treating serious injury, post-operative pain, persistent moderate to severe pain that is not affected by painkillers like paracetamol. Tramadol is widely thought to carry low potential for dependence when compared to morphine, and withdrawal symptoms are comparatively mild. Fatal overdose is rare and is usually the result of combining tramadol with other drugs, particularly alcohol.

The important thing in the case of tramadol is that it is frequently the only painkiller available for dealing with moderate to severe pain in parts of the developing world, which is largely because it is not scheduled under the international drug control system. So, it is a key component of a public health response in Africa and Latin America. Scheduling tramadol would likely have a severe impact on availability of and access to the medication, just as it has on morphine, which is of course scheduled under the control system and unavailable in many developing countries. Indeed, the WHO estimates that 5.5 billion people live in countries without access to pain relief.

Perhaps, then, this is the real ‘world drug problem’. And maybe the ECDD took a small step toward solving it in November 2018.

At the Expert Committee’s 41st meeting, a number of civil society representatives attended what is termed an ‘open session’, where NGO analysts, academics and medical professionals can put their views to the committee. When we arrived, there was a widespread feeling of gloom caused by the perception that the ECDD would decide to recommend the scheduling of tramadol. A few countries had been pushing hard for this outcome, backed by the International Narcotics Control Board (INCB), the body that monitors compliance with the drug control conventions. They argue that the drug’s illicit or non-medical use represents a threat to public health.

Nonetheless, the civil society delegates made their case, passionately and powerfully; if tramadol was subjected to controls under the international drug treaties, people would suffer: countless people, and they would suffer greatly, enduring the type of pain which people in the rich countries of the world are lucky enough to have controlled by a doctor. And, in the event – despite our early, gloomy prognosis – the Expert Committee recommended against scheduling tramadol, as it has on five previous occasions, suggesting that the international community continues to monitor the substance and its illicit use.

The ECDD has a mandate to conduct scientific reviews that are not influenced by politics and ideology. On this occasion, despite the pressure from some Members States and the INCB, it came to a decision based on public health. So, a big Hats Off is due to the Committee.