Tramadol in Africa - Scarcity and excess of pain medication in a poorly regulated market

By Axel Klein, Maria-Goretti Ane, Ann Ukachi Madukwe, Osasuyi Dirisu, Johnny Strijdom, Fifame Aubierge Kpatinvoh, Lorrette Goussanou; ACK Consultants

West Africa faces two opioid crises: an acute shortage of opioid analgesics in the health care system leading to a great burden of untreated pain; and a profusion of substandard and falsified tramadol medications producing dependence and unrecorded fatalities.

In West Africa the great bulk of tramadol consumed for non-medical purpose is not diverted from health care settings but enters through illicit importation routes and informal distribution channels.

There is no record of non-medical tramadol use in Botswana or Namibia. Neither country has an informal, unregulated market for medicines and pharma product but good networks of pharmacies.

Weak controls at points of entry and porous border allow for the importation of vast volumes of substandard and falsified medicines including tramadol.

Pharmarco-vigilance systems vary significantly between countries and have the potential to sharply reduce the circulation of nationally controlled medicines.

The availability of international controlled medications like morphine is severely restricted by the regulatory requirements imposed on African health care providers.

Tramadol fills a critical gap in treating pain across Africa. International scheduling will discourage pharmacies from stocking it and remove the last effective, stage 2 pain medication available.

Informal and poorly regulated distribution systems play a key role in providing medication to rural and urban poor – but at the risk of channelling substandard and falsified medicines. Attempts at engaging and formalising this sector seek to rectify this over the mid term.

Tramadol in high potency dosage is popular with physical labourers in urban and rural areas for its performance enhancing qualities. In many cases functional consumption slips into recreational usage and then becomes habitual.

In most countries there is little public information or health advice in media accessible to the rural and urban poor, but there is considerable experience and concern among affected population.

Repressive responses can succeed in creating temporary shortages without eliminating supply. They fall particularly hard on the poor who are often brutalised by law enforcement. They have also proved ineffective in eliminating availability of substances that are internationally controlled and easily detected, such as cannabis.