The Other, Other Opioid Crisis: Tramadol in West Africa

Editor’s Note: Today’s post comes from contributing editor Dr. David A. Guba, Jr., of Bard Early College in Baltimore. 

For the past twenty years, a steady rise in opioid addiction and overdose rates across the U.S. has led to a “public health emergency,” declared by Donald Trump in October of 2017.[1] In 2017 alone, over 70,000 Americans died as a result of drug overdose, and 47,600, or 68%, of those fatal overdoses involved illicit and prescription opioids.[2] This means that opioids, whether in the form of illegal heroin or prescription pills such as OxyContin, killed more people in 2017 than car accidents (40,100) and gun violence (39,773). According to data compiled by the Kaiser Family Foundation, 37,113 of the 47,600 opioid-related deaths that year, or 78%, were of “White, non-Hispanic” people.[3] Particularly hard hit by the epidemic were the Rust Belt of the Ohio River Valley and mostly-white suburbs of Florida, New York, Pennsylvania, North Carolina, Michigan, and Massachusetts.

While the label “public health emergency” is apt given these statistics, the current media obsession with the “white prescription opioid cum heroin user”—epitomized in Chris Christies oft-repeated anecdote about his college buddy who was a “great looking guy, well-educated, great career, plenty of money, beautiful, loving wife, beautiful children, great house, and had everything” but then tragically succumbed to prescription opioid addiction after a back injury—is both unhealthy and unethical.[4] As Solomon Jones, a journalist with the Philadelphia Inquirer, recently argued, perceptions of drug addiction in America have become so “gentrified,” that what once “was primarily a black and brown problem” of morals “has been rebranded by whiter and richer” Americans as a public health crisis affecting good, white citizens deemed victims.[5]

This gentrified concept of opioid addiction creates and maintains yet another racialized double-standard in local and federal governments’ responses to drug addiction across the country. As Julie Netherland and Helena B. Hansen argued in a recent peer-review article, “Media coverage of the suburban and rural opioid ‘epidemic’ of the 2000s helped draw a symbolic, and then legal, distinction between (urban) heroin addiction and (suburban and rural) prescription opioid addiction that is reminiscent of the legal distinction between crack cocaine and powder cocaine of the 1980s and 1990s.”[6] By emplotting opioid addiction among white Americans within a rhetoric of tragedy and victimization, they argue, the media, local and federal governments, and even addiction treatment programs together reify the idea that opioid use among brown and black citizens represents a crisis apart, demanding an alternative and often severe juridical response rather than compassionate public health initiatives.

Recent articles published in the Washington Post, New York Times, and Vox have attempted to shed light on this tragic repetition of history in the unfolding story of racialized drug control in the U.S.[7] In an article published just two days ago on Vox, senior correspondent German Lopez drew much-needed attention to the other “forgotten” opioid epidemic tearing apart black communities in urban America, and particularly in Baltimore City. Lopez pointed out that while White Americans statistically continue to make up the bulk of opioid users and overdoses in the country, numerous cities with high populations of black citizens, such as Baltimore and Washington D.C., have witnessed a startling increase in opioid and especially fentanyl overdoses at rates higher than national averages. In 2017 opioid overdose rates in Baltimore City, where the population is currently 64% black, rose to 85.2 per 100,000, or roughly .1% of the city’s total population. This means that residents of Baltimore city were 35% more likely to overdose on opioids than citizens of the state of West Virginia, who are often viewed as the hardest hit by this epidemic.[8] As Abdullah Shihipar argued in a recent opinion piece in the New York Times, “the opioid crisis isn’t white” and to think so is to “risk overlooking the very real damage experienced by black, Latino, and Native American communities.”[9]

But the ongoing opioid crisis is not only not only white, but also not only confined to the political and moral economies and territorial borders of the U.S.[10] Put simply, the current opioid epidemic increasingly appears to be a fundamentally human and global crisis that also reifies the racial and (post)colonial dynamics of the West’s historical “wars on drugs.” The other, other opioid crisis raging in West Africa, and particularly in Ghana, Nigeria, Cameroon, Senegal, Benin and the Ivory Coast, offers a crucial case in point.

According to a 2016 study commissioned by the United Nations, 90% of all illicit opioids confiscated around the world were seized in North and Western Africa, and the vast majority of those opioids were tramadol tablets produced in India. These Royal-225 tablets (Figure 1) are made predominantly by small, family-owned firms in India, who then export the packaged drugs to Benin, where they are resold and transported to neighboring nations. Because of its relative narcotic weakness, lower abuse potential, and unique chemistry, tramadol is unregulated by the International Narcotics Control Board (INCB), which allows the relative free flow of the drug across many international borders.[11]

Screenshot 2019-04-04 at 8.13.30 AM

Figure 1: Indian-produced Royal-225 Tramadol tablets sold in West Africa

In a report published in The Lancet in May of 2018, Laura Salm-Reifferscheidt described the widespread use of tramadol in the city of Lomé in Togo, just to the west of Benin.[12] Street venders sell the tablets along with coffee and tea. “Motorbike-taxi drivers, truck drivers, students, sex workers, and even farmers,” Salm-Reifferschedit reports, “daily use tramadol for non-medical purposes,” and often at dosages that well exceed the recommended 400mg. In Cameroon to the east, tramadol use has risen to such heights that scientists recently discovered traces of the substance in the soil. “When questioned by the researchers, local farmers said they take large amounts of tramadol and also feed it to the cattle so they can keep ploughing the soil for longer.” Nigeria likewise is currently experiencing a tramadol and codeine crisis linked to the ongoing conflict between Boko Haram and vigilante forces, especially in the northern region of the country. According to a BBC report from June of 2018, both sides of this conflict routinely use tramadol as both an analgesic and narcotic motivator. Clearly, West Africa, much as the U.S., Canada, New Zealand, the Ukraine and Egypt, is experiencing a serious, if less-fatal, opioid epidemic.

The point here is that the tendency of Western governments and media outlets to conceive of the opioid crisis as a predominantly “white” and “American” problem not only runs the risk of ignoring the rise in addiction and overdose deaths among black and brown Americans, but it also acts as a barrier for international cooperation in the regulation of the global opioid trade.

NOTES:

  1. https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html
  2. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
  3. https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22White,%20Non-Hispanic%22,%22sort%22:%22desc%22%7D
  4. https://www.nbcnews.com/storyline/americas-heroin-epidemic/governor-christie-battle-against-opioid-addiction-personal-n740066
  5. https://www.philly.com/philly/columnists/solomon_jones/addiction-opioids-war-on-drugs-safe-injection-sites-race-20180404.html
  6. Julie Netherland and Helena B. Hansen, “The War on Drugs That Wasn’t: Wasted Whiteness, ‘Dirty Doctors,’ and Race in Media Coverage of Prescription Opioid Misuse,” Culture, Medicine, and Psychiatry 40 (2016): 664-686, 664.
  7. Notable examples include Peter Jamison, “Falling Out: A Generation of African American heroin users is dying in the opioid epidemic nobody talks about. The nation’s capital is ground zero,” Washington Post (18 December 2018); Abdullah Shihipar, “Opinion: The Opioid Crisis Isn’t White,” The New York Times (26 February 2019); German Lopez, “The opioid epidemic is increasingly killing black Americans. Baltimore is ground zero,” Vox.com (1 April 2019).
  8. German Lopez, “The opioid epidemic is increasingly killing black Americans.”
  9. Abdullah Shihipar, “Opinion: The Opioid Crisis Isn’t White.”
  10. Justin Scheck, “Tramadol: The Opioid Crisis for the Rest of the World,” Wall Street Journal (Online), Oct 19, 2016.
  11. On 18 August 2014 the DEA scheduled (IV) tramadol as a controlled substance.
  12. Laura Salm-Reifferscheidt, “Tramadol: Africa’s opioid crisis,” The Lancet 391:10134 (19-25 May 2018): 1982-1983.
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