Reports came with increasing urgency – pills seized by the truck, pills swallowed by school children, pills in the pockets of dead terrorists.
These pills, they told the world, are safer than the OxyContins, the Vicodins, the fentanyls that caused so much devastation. But now they are at the root of what the United Nations called "the other opioid crisis" – an epidemic featured in fewer headlines than the US, while raging at the world's most vulnerable countries.
The mass abuse of opioid tramadol spans continents, from India to Africa to the Middle East, causing international havoc that some experts attribute to a breach in narcotics regulation and a miscalculation of the drug's danger. Synthetic opioid has been touted as a way to relieve pain with little risk of abuse. Unlike other opioids, tramadol flowed freely around the world, free from international controls that track down the most dangerous drugs.
But the abuse is now so rampant that some countries are asking international authorities to intervene.
Amandeep Kaur, a former tramadol addict, at a rehab center in Kapurthala, Punjab. "If I didn't have it, I felt lifeless; my body hurt like I was going to die," she said.
(Channi Anand / Associated Press)
Grunenthal, the German company that originally produced the drug, is campaigning for the status quo, arguing that largely illicit counterfeit pills are causing problems. International regulations make it difficult for narcotics to enter countries with disorganized health systems, the company says, and adding tramadol to the list would deprive patients suffering from access to any opioids.
"This is a huge public health dilemma," said Dr. Gilles Forte, secretary of the World Health Organization committee that recommends how medicines should be regulated. Tramadol is available in war zones and impoverished nations because it is unregulated. But it is widely abused for the same exact reason. "It's really a very complicated balance to find."
Tramadol has not been as deadly as other opioids., and the crisis is not killing off with the ferocity of the American drug struggle. Still, individual US governments from Egypt to Ukraine realized that the dangers of the drug were greater than previously thought and worked to control the tramadol trade. The North Indian state of Punjab, the center of India's opioid epidemic, was the latest to end. The pills were everywhere, like legitimate drugs sold in drugstores, but also illicit counterfeits sold by street vendors.
This year, authorities seized hundreds of thousands of pills, banned most pharmacy sales and shut down pill factories, raising the price from 35 cents for a package from 10 to 14 dollars. The government opened a network of treatment centers, fearing that those who had become opioid addicts would resort to heroin out of desperation. Hordes of people rushed in, seeking help in managing the excruciating retreat.
For some, tramadol has become as essential as food.
"As if you don't eat, you start to feel hungry. Similar is the case if you don't take it," said Deepak Arora, a car shop welder, a skinny 30-year-old man who took 15 pills a day, so much so that he had than steal your family to pay for the pills. "You're like a dead person."
Jeffery Bawa, an official at the United Nations Office on Drugs and Crime, realized what was happening in 2016 when he traveled to Mali, West Africa, one of the world's poorest countries ruled by civil war and terrorism. They asked people for their most pressing concerns. Most did not say hunger or violence. They said tramadol.
A drug user on a roadside in Kapurthala, Punjab. The center of India's opioid epidemic, Punjab, was one of the latest areas to crack down on the tramadol trade.
(Channi Anand / Associated Press)
One woman said that children stumble through the streets on top of the opioid; parents add it to tea to ease the pain of hunger. Nigerian officials said at a United Nations meeting on tramadol trafficking that the number of people living with dependence is now much higher than the number of AIDS or HIV.
Tramadol is so widespread in Cameroon that scientists a few years ago believed they had discovered a natural version in tree roots. But it was unnatural: farmers bought pills and fed them with cattle to ward off the effects of the debilitating heat. Their trash contaminated the soil and the chemical seeped into the trees.
Police have begun to find terrorist pills that travel to fund their networks and take them to bolster their capacity for violence, Bawa said.
Most came from India. The country's vast pharmaceutical industry is fueled by cheap generics. Tablet factories produce imitations and ship them in bulk around the world at doses that exceed medical limits.
In 2017, police reported that $ 75 million in tramadol from India was confiscated en route to the Islamic State militant group. Authorities intercepted 600,000 pills directed at Boko Haram. Another 3 million were found in a pickup truck in Niger, in boxes disguised as UN logos. The agency warned that tramadol was playing "a direct role in destabilizing the region."
"We can't let the situation get out of hand any more," this warning said.
Grunenthal maintains that tramadol has a low risk of abuse; Most problem-causing pills are imitations, not legitimate pharmaceuticals, and American research has shown lower levels of abuse than other prescribed painkillers. The company sent a report to WHO in 2014 saying that abuse evident in "a limited number of countries" should be seen "in the context of political and social instability in the region."
But some wealthy countries concerned about rising abuse have also acted to contain the drug.
The United Kingdom and the United States regulated it in 2014. Tramadol was not controlled in Denmark until 2017, when journalists asked doctors to review studies submitted to regulators to support the claim that it has a low risk of addiction, the report said. Dr. Karsten Juhl Jorgensen, acting director of the Nordic Cochrane Center and one of the doctors who reviewed the materials. Everyone agreed that the documents did not prove to be safer.
"We know that opioids are some of the most addictive drugs on the planet, so the claim that you have developed one that is not addictive, which is an extraordinary claim, and extraordinary claims requires evidence. And it just wasn't there," he said. Jorgensen "We have all been fooled and people are angry about it."
Jorgensen compares allegations that tramadol is low-risk to those made by US companies now facing thousands of lawsuits, claiming that misleading campaigns spreading opioid safety have triggered the US addiction epidemic.
Stefano Berterame, head of the International Council on Narcotics Control, said there is a critical difference: The crisis is not as deadly as the American one, which began with prescribed opioids and turned to heroin and fentanyl. Tramadol does not routinely cause respiratory depression that leads to overdose death.
But it most often affects poor nations where overdose statistics are erratic, he said, so the true number of tramadol is unknown.
The United Nations established the International Narcotics Control Council in 1961 to spare the world the "serious evil" of addiction. Since then, he has tracked most opioids.
Tramadol exemption means that authorization is not required when the drug moves across borders. Its easy availability also leads to confusion about what tramadol is, experts say. In many countries, it is believed to be a mood enhancer or treatment for post-traumatic depression and stress. Some take it to improve sexual stamina or endure tiring work.
Grunenthal synthesized tramadol in the 1960s, when the company became involved in a scandal with the marketing of sedative thalidomide, which caused extreme birth defects in thousands of babies whose mothers took it. Tramadol was initially believed to be at low risk of abuse because initial studies have studied injecting tramadol, the most potent route for most opioids. But the researchers later found that tramadol releases a much more potent dose taken orally due to the way it is metabolized by the liver.
Tramadol's world market expanded rapidly in the 1990s. In 2000, WHO, which evaluates drugs and recommends scheduling, noted reports of addiction. A committee has reviewed the drug several times since then, recommended that it remain under surveillance, but declined to add international regulation.
There is no alternative to tramadol, said Forte, the committee secretary. It is the only opioid available in some of the most desperate places in the world; Relief organizations rely on him in war zones and natural disasters. It is not used extensively because it is a particularly good drug, he said. The most effective opioid is morphine, but morphine is tightly controlled and countries in crisis fear abuse. Tramadol has become the standard precisely because it is not controlled.
The WHO is considering whether any other drug could take its place, but so far has not found it. Meanwhile, Forte said, the agency is working with abused countries to uncover counterfeits.
Legitimate tramadol remains a lucrative business: market research estimates the global market will reach $ 1.4 billion, according to Grunenthal. The medication has long lost its patent protection. It is now manufactured by many companies and sold under about 500 brand names. Grunenthal markets it as Tramal and Zaldiar, tramadol combined with acetaminophen. In 2018, these products yielded $ 190 million, according to the company's annual report.
"Our goal at Grunenthal is to develop and deliver medicines and solutions that address the unmet needs of patients with the goal of improving their quality of life," the …