Tag Archives: tramadol trafficking

12/15/20

Tramadol Is not a Safe Opioid

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The 2020 World Drug Report said the non-medical use of opioids has always been associated with the most serious health consequences among the various types of drugs. But in the last few years new threats have emerged with regard to the non-medical use of pharmaceutical opioids, leading to alarming rates of dependence and overdose deaths. The problems in North America with fentanyl and its analogues have led to an unprecedented increase in opioid overdose deaths. But in West, Central and North Africa, the Middle East and Asia, another opioid has emerged as a major concern—tramadol.

Tramadol’s potency was said to be comparable to codeine, about 10% the potency of morphine. This led to initial belief that it had a low risk of abuse when it was brought to market in the 1960s by the German pharmaceutical company Grunenthal. However, researchers later found that tramadol releases a far more powerful dose because of how it is metabolized by the liver. An article in The British Medical Journal, “Chronic use of tramadol after acute pain episode” said tramadol undergoes demethylation in the liver to the active metabolite desmatramadol, giving it an opioid effect comparable to morphine.

The BMJ article reported a study by researchers at the Mayo clinic that found patients who received tramadol for the acute treatment of pain had slightly higher rates of long-term opioid use after surgery. The senior author of the study said their finding did not support the idea that tramadol is less habit forming than other opioids. The lead author of the study said: “And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids.” Tramadol use has been increasing and was the third most prescribed opioid in the study at 4%, after hydrocodone (51%) and oxycodone (38%). “Although all factors related to the safety of a drug must be considered, from the standpoint of opioid dependence, the Drug Enforcement Administration and FDA should consider rescheduling tramadol to a level that better reflects its risks of prolonged use.”

While many countries in West, Central and North Africa report the non-medical use of tramadol as one of the main threats in drug use, quantitative information on the actual size of the population using tramadol non-medically was not available in most countries, according to the 2020 World Drug Report. However, treatment data in West African countries revealed tramadol to be the main drug of concern for people with drug use disorders. “Tramadol ranks highly among the substances for which people were treated in West Africa in the period 2014–2017.” In North Africa, Egypt reported tramadol is the main opioid used non-medically. In drug treatment, tramadol was also the primary drug, accounting for 68% of all people treated for drug use disorders in 2017. In the Sudan, the increasing non-medical use of pharmaceutical drugs among young people includes: tramadol, benzodiazepines, cough syrups and antihistamines, trihexyphenidyl (an antiparkinsonian agent), anticonvulsants, pregabalin and gabapentin.

In Iran, a recent study estimated that or 200,000 people aged 15-49 in urban centers had misused tramadol, most of whom were young people. The past 12-month of non-medical use of tramadol in the general population was 4.9 percent among men and .5 percent among women. In recent years, tramadol intoxication and fatal overdose, especially among young people with a history of substance use disorder and psychiatric comorbidity, has been a major cause of emergency department admissions. Among these cases, tramadol has been misused with other substances, especially benzodiazepines. “Tramadol was also found to be the cause of death in around 6 per cent of the total drug overdose death cases in the Islamic Republic of Iran reported in different studies from 2006 to 2017.”

AP News reported in “How tramadol, touted as safer opioid, became 3rd world peril,” that mass abuse of tramadol spans continents from India to Africa and the Middle East, creating international havoc. Some experts blame a loophole in narcotics regulation and a miscalculation of the drug’s danger. It was touted as a way to relieve pain with little risk of abuse. Unburdened by international controls that track most dangerous drugs, tramadol flows freely around the world. “But abuse is now so rampant, that some countries are asking international authorities to intervene.”

Grunenthal is campaigning to keep the status quo with tramadol regulation, arguing that typically it is illicit counterfeit pills causing problems. International regulations make narcotics difficult to get in countries with disorganized health systems. Adding tramadol to the list, the company said, would deprive suffering patients access to any opioid at all. The secretary of the World Health Organization’s committee recommending how drugs should be regulated said this is a huge public health dilemma. “It’s a really very complicated balance to strike.” Tramadol is available in war zones and impoverished nations because it is unregulated—the same exact reason it is widely abused.

Tramadol has not been as deadly as other opioids, and the crisis isn’t killing with the ferocity of America’s struggle with the drugs. Still, individual governments from the U.S. to Egypt to Ukraine have realized the drug’s dangers are greater than was believed and have worked to rein in the tramadol trade. The north Indian state of Punjab, the center of India’s opioid epidemic, was the latest to crack down. The pills were everywhere, as legitimate medication sold in pharmacies, but also illicit counterfeits hawked by street vendors.

Authorities in Punjab seized hundreds of thousands of tablets, banned most pharmacy sales and shut down pill factories, pushing the price from 35 cents for a 10-pack to $14. When the government opened a network of treatment centers, fearful those who had become addicted would resort to heroin out of desperation, hordes of people rushed in seeking help. Tramadol had become as essential as food. A 30-year-old auto shop welder said, “Like if you don’t eat, you start to feel hungry. Similar is the case with not taking it.”

In 2016, Jeffery Bawa, an officer with the UN Office on Drugs and Crime, traveled to Mali in West Africa, one of the world’s poorest countries, which also struggles with civil war and terrorism. When he asked people what their most pressing concern was most said tramadol, not hunger or violence. At a United Nations meeting on tramadol trafficking, Nigerian officials said the number of people living with addiction is far higher now then the number with AIDS or HIV. In Cameroon, scientists thought they had discovered a natural version of tramadol in tree roots. “But it was not natural at all: Farmers bought pills and fed them to their cattle to ward off the effects of debilitating heat. Their waste contaminated the soil, and the chemical seeped into the trees.”

Police began finding tramadol pills on terrorists. It seems they now traffic tramadol to fund their networks and use it to bolster their own violent behavior. Most of the supply was coming from India, where pill factories produced counterfeits and shipped them in bulk around the world, “in doses far exceeding medical limits.” In 2017, law enforcement reported confiscating $75 million worth of tramadol from India on route to the Islamic State. Another 600,000 tablets headed for Boko Haram were intercepted. Three million more tramadol tablets were found in a pickup truck in Niger, in boxes disguised with U.N. logos.

Grunenthal has persisted with its campaign to keep tramadol unregulated. It funded surveys that found regulation would impede pain treatment and even paid consultants to travel to the WHO to make their case that tramadol is safer than other opioids. But that could change. Referring to the above-described Mayo Clinic study, AP News noted the researchers were surprised when they found their data indicated patients prescribed tramadol were just as likely to move on to long-term use as other opioids. The lead researcher of the Mayo study said: “There is no safe opioid. Tramadol is not a safe alternative. It’s a mistake that we didn’t figure it out sooner. It’s unfortunate that it took us this long.”

08/27/19

Global Troubles with Tramadol

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In the US, we see synthetic opioids like fentanyl grabbing headlines, and rightly so. The CDC reported the number of drug overdose deaths involving fentanyl increased from 1,663 in 2011 to 18,335 in 2016. The death rate more than doubled between 2013 and 2014, nearly doubled from 2014 to 2015 and more than doubled again from 2015 to 2016. Yet the World Drug Report 2019 said the non-medical use of tramadol required equally urgent attention, particularly in Africa. Global seizures of tramadol increased from 9 tons in 2013 to a record high of 125 tons in 2017. The largest quantity of tramadol seized from 2013 to 2017 was 96 tons by Nigeria, followed by Egypt with 12 tons. The main destinations were countries in West and Central Africa.

The fact that tramadol has been intercepted in areas close to where the Islamic State and some of its associated groups have been active has led to speculation that tramadol trafficking may be used to finance terrorist activities and used non-medically by their fighters to suppress pain and increase endurance. The largest tramadol seizures in Europe in recent years concerned shipments ultimately bound for North Africa, but they were modest in comparison to those intercepted by some countries in North Africa and the Middle East. “There have also been reports of non-medical use of tramadol in North America, Europe, East and South-East Asia, and Oceania, where diversion from licit sources has been reported in a number of countries.” See the following map.

Dr. Mahmoud Elhabiby reported the 2015 National Drug Survey in Egypt found that tramadol dependence (2.4%) ranked just behind cannabis (2.5%). “Moreover, the study show that Tramadol is the most prevalent opioid that causes dependence;” higher than heroin (.3%).

In Nigeria a cross sectional study where clients’ medical records were reviewed found the prevalence of tramadol abuse was 54.4% for the stipulated review period. In the original study, 67% of the subjects reported using multiple psychoactive substances, with benzodiazepines (44%) and cannabis (53%) being the most common. “Over 91% of the subjects obtained the drugs without a prescription and over 60% met at least three ICD-10 Diagnostic criteria of dependence.”

The CEO of Ghana’s FDA, Delese Mimi Darko, said “It is important we let people know that abusing medicines like Tramadol can have bad consequences, including death.” There have been reported cases of armed robbery, youth vandalism, car accidents, and in some cases, violence linked to the use of tramadol. The FDA in collaboration with the police seized over 500,000 capsules of tramadol in 2017. Given Ghana’s porous borders, tramadol abuse is a regional problem. Darko called for the development of a national tramadol abuse prevention strategy.

In December of 2017 the United Nations Office on Drugs and Crime (UNODC) warned the international community of the implications of the non-medical use of tramadol on the economies and security of West Africa. The UNODC Regional Representative, Pierre Lapaque, said “The rise of tramadol consumption and trafficking in the region is serious, worrying, and needs to be addressed as soon as possible. We cannot let the situation get any further out of control.” Reportedly tramadol is smuggled through the Gulf of Guinea by transnational organized crime networks, through areas partially controlled by armed groups and terrorist organizations.

By the end of September 2017, over 3 million tablets were seized in Niger, packed in boxes with the United Nations logo. In August of 2017, Cameroonian customs officials on the border of Nigeria seized 600,000 tablets intended for Boko Haram. In August of 2018, the UNODC organized a workshop to address the opioid problem in West Africa. “The event brought together senior representatives of law enforcement and health-care services, justice and law enforcement, as well as chiefs of the Inter-ministerial drug committees from Togo, Nigeria, Niger, Ghana, Benin and Côte d’Ivoire.”

The problem of abusive consumption and trafficking of tramadol plays a direct role in the destabilization of the region, as not only do groups smuggle tramadol across borders to generate revenues, they also use it for themselves. As stated by Mr. Lapaque, “Tramadol is regularly found in the pockets of suspects arrested for terrorism in the Sahel, or who have committed suicidal attacks. This raises the question of who provides the tablets to fighters from Boko Haram and Al Qaeda, including young boys and girls, preparing to commit suicide bombings”.

A study done of patients visiting pharmacies in northern Iran showed that 56% of patients who sought tramadol did not have a prescription. “More than 63% of patients reported a history of addiction or drug abuse.” The majority of people seeking tramadol were adolescents/young adults, under the age of 30. Fifty-five percent were under the age of 18. “More than 71% had been able to get access to tramadol without a prescription in the past.” And more than 71% had taken at least two courses of tramadol for more than a week in the past year.

Another study of Egyptian university students by Bassiony et al, “Opioid Use Disorders Attributed to Tramadol Among Egyptian University Students,” found the prevalence of tramadol use was 12.3% among university students. It was higher among males (20.2%) than females (2.4%). Only 15% were using tramadol alone. One-fifth of these students started with tramadol as their first drug. The average age at onset of tramadol use was 17.6 years of age. There was a considerable relationship between tramadol use and other substances. “Smoking, cannabis, and alcohol use predict tramadol use. About 60% of students who use tramadol had drug-related problems and 30% had dependence.”

A different study by Medhat Bassiony and others, “Adolescent tramadol use and abuse in Egypt,” stated tramadol abuse liability was underestimated and the evidence for abuse and dependence was emerging. Here the prevalence of tramadol use was 8.8% among school students, with the average age of onset of tramadol use was 16.5 years of age. Eighty-three percent reported using tramadol alone and the remaining 17% combined tramadol, alcohol and cannabis. Two-thirds of these students started with tramadol as their first drug after they started smoking tobacco. Over one-third of tramadol users had drug-related problems and 6% had drug dependency concerns. They recommended:

Large population-based longitudinal studies in adolescents and young adults are needed to estimate the prevalence, risk factors and consequences of tramadol use in Egypt. In addition, the possible role of tramadol as a gateway drug in the development of substance abuse and dependence in Egypt should be investigated.

Returning to the global perspective, the World Drug Report 2019 estimated 53 million people used opioids at least once in the past year, of whom half were past-year users of opiates, heroin and opium. The highest prevalence of non-medical use of opioids was in North America, with 4% of the population between 15-66. This represented 25% of global opioid users. The major opioids of concern in North America were hydrocodone, oxycodone, codeine and tramadol. The use of opioids in Australia and New Zealand was much higher (3.3% of the adult population) than the global average (just over 1%), with the non-medical use of opioids also being the main opioids of concern. See the following chart:

While America struggles with its own opioid crisis, across much of Africa and the Middle East tramadol is the drug of choice; a choice “fueled by cut-rate Indian exports and inaction by world narcotics regulators.” Unlike other opiates, tramadol isn’t regulated by the International Narcotics Control Board. So, it flows freely from factories in India and Egypt into Gaza, where the tramadol crisis started in the tunnels. Working grueling 12-hour shifts in the underground tunnel network, tramadol was freely exchanged between tunnel workers. “Bosses handed out pills before shifts to keep people moving amid the stresses and dangers.”

Tramadol was cheap. One pill cost just two shekels (56 cents). One 17-year old working in the tunnels was soon taking 8 pills daily. During the wars with Israel, he kept working. The bosses paid extra if he did, “so he self-medicated with tramadol as the bombs fell.” But then Egypt and Israel began flooding and bombing the tunnels and it was too dangerous to do tunnel work anymore. Now 23, he found himself unemployed and addicted to tramadol. However, the tramadol wasn’t the same quality as when he had started using, so he he needed more.

Doctor Khaled al-Safadi, who has worked in Gaza’s Psychiatric Hospital for 15 years, said: “The percent [of tramadol users] is rising because of the severe situation, the siege that we are in, the generation that has no income. . . It’s an escape from the world they are living in.” Last year he opened the first inpatient ward for treating drug addiction. Of the 12 beds on the ward, just two were filled. “Drug abusers are afraid to seek help because of social stigma and lack of trust in dealing with government institutions—combined with the government’s own inattention to these pressing issues.”

But tramadol keeps coming. Instead of coming through the tunnels, it is smuggled in smaller quantities in washing machines and gas canisters. The collapse of the tunnel trade and high use has pushed prices up. Ten years ago, 20 shekels paid for 10 tramadol pills; today that buys just one. “Even the one escape left to them, getting high, is now increasingly unattainable.”

Don’t believe the myth that tramadol is a non-addictive, non-opioid alternative. It is an opiate agonist, meaning it binds to the mu receptor and activates the receptor to produce a biological response, the same as does heroin. It has a significant potential for overdose or poisoning. In excessive doses, whether alone or in combination with other CNS depressants such as alcohol, it can result in drug-related death.

Tramadol can cause withdrawal symptoms, particularly if it has been used regularly over a long time period or in high doses. Withdrawal symptoms, particularly if you stop using it suddenly, may include restlessness, watering eyes, runny nose, nausea, sweating and muscle aches. Seizures are more likely to occur at the high doses of tramadol abuse. According to drugs.com,

Serious side effects including seizures and serotonin syndrome may also occur due to drug interactions. Examples of drug classes where this might occur include the serotonin reuptake inhibitors (SSRIs, SNRIs), TCAs and MAO inhibitors (like phenelzine or linezolid) — all types of antidepressants. In fact, tramadol should never be used with an MAOI inhibitor or within 14 days of taking an MAOI. Taking tramadol with drugs that already have a seizure risk may worsen that risk.

Tramadol is a Schedule IV Controlled Substance, according to the DEA. It has an abuse potential and as an opiate agonist can cause fatal overdose and respiratory failure. Extended release tablets and capsules have been misused by splitting, breaking, crushing, chewing, snorting or injecting the dissolved products. This results in the uncontrolled delivery of the drug and can result in overdose and death.

A study published in the British Medical Journal sought to examine the risk of prolonged opiate use in patients receiving tramadol versus other short-acting opioids. Receiving tramadol was associated with a “6% increase in the risk of additional opioid use” relative to others receiving other short acting opioids. The researchers concluded people receiving tramadol after surgery had a somewhat higher risk of prolonged opioid use when compared to those receiving other short acting opioids. They suggested federal officials consider reclassifying tramadol and that providers use as much caution when prescribing tramadol as they do with other short acting opioids. For more information on tramadol, see “Trouble with Tramadol.”