Grace has sickle cell disease, a genetic disorder that makes her red blood cells sickle-shaped and rigid, rather than the usual flexible doughnut form. They block her capillaries, causing excruciating pain. She gets by with tramadol, a weak synthetic opioid painkiller that is cheap and relatively safe when correctly used.
Fifteen year-old Ayao (not his real name) also takes tramadol. But in his case, because he is an addict. In large doses, tramadol produces a euphoric high similar to heroin.
While the US crisis dominates the news, another opioid crisis goes largely unseen. Though perhaps less dramatic, it is wider-reaching and arguably more complex. Tramadol abuse is widespread across West Africa. In 2018, Nigeria alone seized 6.4 billion tablets, a tiny slice of a counterfeit medication problem estimated to account for 30% of the pharmaceutical market in Africa. In Togo, where Grace and Ayao live, tramadol capsules cost less than $1 on the streets. But they are not like the pills found in pharmacies, and come in dosages far higher than typically prescribed.
There are calls for tramadol to be placed under strict international control like stronger painkillers. But it isn’t that simple because the other side of the problem is a systemic shortage of stronger opioid painkillers like morphine, and pain often goes untreated. While restricting tramadol could ameliorate the social costs of addiction, it could make things even worse for people with a legitimate need for strong pain medication, but who must make do with tramadol.
A zémidjan (motorcycle taxi) rider obsessively cleaning his motorcycle in Lomé, Togo on 21 March 2019. Riders have a reputation for taking the opioid painkiller tramadol, which is widely abused in West Africa. The drug leaves users with an abundance of nervous energy, and there are numerous anecdotes of it leading to accidents as riders speed or ride erratically, or even collapse or suffer seizures while at the controls.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, the drug appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A zémidjan (motorcycle taxi) rider obsessively cleaning his motorcycle in Lomé, Togo on 21 March 2019. Riders have a reputation for taking the opioid painkiller tramadol, which is widely abused in West Africa. The drug leaves users with an abundance of nervous energy, and there are numerous anecdotes of it leading to accidents as riders speed or ride erratically, or even collapse or suffer seizures while at the controls.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, the drug appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A tramadol capsule with a stated dosage of 120mg and of a type commonly found on the streets in the hands of a roadside coffee seller in Lomé, Togo on 22 March 2019. Some such vendors sell the opioid painkiller in addition to beverages, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, tramadol appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A tramadol capsule with a stated dosage of 120mg and of a type commonly found on the streets in the hands of a roadside coffee seller in Lomé, Togo on 22 March 2019. Some such vendors sell the opioid painkiller in addition to beverages, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, tramadol appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
An itinerant medicine peddler’s wares on display in a market in Lomé, Togo on 1 April 2019. A culture of self-medication in many West African countries lends itself to the proliferation of counterfeit and illicit medications in the streets and  marketplaces of the region. Often neither vendor nor customer adequately understands what is being bought and sold, nor its indications, dosage or risks.
An itinerant medicine peddler’s wares on display in a market in Lomé, Togo on 1 April 2019. A culture of self-medication in many West African countries lends itself to the proliferation of counterfeit and illicit medications in the streets and marketplaces of the region. Often neither vendor nor customer adequately understands what is being bought and sold, nor its indications, dosage or risks.
Ayao (not his real name) combing his hair in his bedroom in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) combing his hair in his bedroom in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
A former tramadol addict giving testimony during a drug education session presented by local NGO Alliance Nationale des Consommateurs et de l’Environnement (ANCE) at the Blaise Pascal school complex in Lomé, Togo on 21 March 2019. The opioid painkiller is widely abused in West Africa and has been found amongst school students.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, the drug appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A former tramadol addict giving testimony during a drug education session presented by local NGO Alliance Nationale des Consommateurs et de l’Environnement (ANCE) at the Blaise Pascal school complex in Lomé, Togo on 21 March 2019. The opioid painkiller is widely abused in West Africa and has been found amongst school students.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, the drug appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
Students playing football in the schoolyard at the Blaise Pascal school complex in Lomé, Togo on 21 March 2019.
Students playing football in the schoolyard at the Blaise Pascal school complex in Lomé, Togo on 21 March 2019.
Ayao (not his real name) roaming around his neighbourhood while high on tramadol and cannabis in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) roaming around his neighbourhood while high on tramadol and cannabis in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
A roadside tea and coffee stall in Lomé, Togo on 21 March 2019. Vendors at such stalls sometimes also sell the opioid painkiller tramadol, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, tramadol appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A roadside tea and coffee stall in Lomé, Togo on 21 March 2019. Vendors at such stalls sometimes also sell the opioid painkiller tramadol, emptying a capsule or two into a cup of coffee when a customer asks for “an egg” or “something extra” in their coffee. The drug is also sometimes mixed into energy drinks or sodabi, a local liquor distilled from palm wine.A prescription-only analgesic intended for the treatment of moderate to moderately severe pain, tramadol appears on many countries’ lists of essential medicines. However, there is a proliferation of cheap generics manufactured in high, non-therapeutic doses available outside the legitimate supply chain, purportedly from sources in India, China, Nigeria and elsewhere. When taken at such dosages, users say, the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to dependence when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment.
A view over the area of Kodjoviakopé in Lomé, Togo on 31 March 2019.
A view over the area of Kodjoviakopé in Lomé, Togo on 31 March 2019.
Yem-bla Pharmacy in Lomé, Togo on 9 April 2019.
Yem-bla Pharmacy in Lomé, Togo on 9 April 2019.
Market stalls in the neighbourhood of Atikoumé in Lomé, Togo on 21 March 2019. As in other similar locations, tramadol can readily be purchased by those who know where to seek it out.
Market stalls in the neighbourhood of Atikoumé in Lomé, Togo on 21 March 2019. As in other similar locations, tramadol can readily be purchased by those who know where to seek it out.
A market in the neighbourhood of Atikoumé in Lomé, Togo on 21 March 2019. As in other similar locations, tramadol can readily be purchased by those who know where to seek it out.
A market in the neighbourhood of Atikoumé in Lomé, Togo on 21 March 2019. As in other similar locations, tramadol can readily be purchased by those who know where to seek it out.
Grace Kudzu and her friend Ismael M-Tanko bringing a box of provisions to the home of a young woman who suffers from sickle cell disease in Lomé, Togo on 30 March 2019. Grace suffers from sickle cell disease herself, and volunteers full-time in the care and counselling of her fellow sufferers.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu and her friend Ismael M-Tanko bringing a box of provisions to the home of a young woman who suffers from sickle cell disease in Lomé, Togo on 30 March 2019. Grace suffers from sickle cell disease herself, and volunteers full-time in the care and counselling of her fellow sufferers.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu (right) and her friend Ismael M-Tanko (second from left) visiting Selasse de Souza and her mother Grace Domety at their home in Lomé, Togo on 30 March 2019. Selasse suffers from sickle cell disease and has difficulty speaking and is partially paralysed as a result of a stroke that is one of the risks of the disease.Grace suffers from sickle cell disease herself, and volunteers full-time in the care and counselling of her fellow sufferers.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu (right) and her friend Ismael M-Tanko (second from left) visiting Selasse de Souza and her mother Grace Domety at their home in Lomé, Togo on 30 March 2019. Selasse suffers from sickle cell disease and has difficulty speaking and is partially paralysed as a result of a stroke that is one of the risks of the disease.Grace suffers from sickle cell disease herself, and volunteers full-time in the care and counselling of her fellow sufferers.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu, 35, contemplating a crutch that she used to have to use due avascular necrosis of the hip resulting from the ischaemia that is typical of sickle cell disease. She explains that she was eventually able to forego the crutch by managing her weight.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu, 35, contemplating a crutch that she used to have to use due avascular necrosis of the hip resulting from the ischaemia that is typical of sickle cell disease. She explains that she was eventually able to forego the crutch by managing her weight.Sickle cell disease is a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Ayao (not his real name) at his part time job delivering bags of sachets of drinking water in Lomé, Togo on 9 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain, and says he takes it for endurance when playing sports. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) at his part time job delivering bags of sachets of drinking water in Lomé, Togo on 9 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain, and says he takes it for endurance when playing sports. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) outside a bar while his friend goes inside to buy alcohol as they roam around their neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. At 15 years old Ayao is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) outside a bar while his friend goes inside to buy alcohol as they roam around their neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. At 15 years old Ayao is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) chatting with an acquaintance while roaming around his neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) chatting with an acquaintance while roaming around his neighbourhood high on tramadol and cannabis in Lomé, Togo on 1 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) taking a break during an informal neighbourhood football tournament in Lomé, Togo on 7 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain, and says he takes it for endurance when playing sports. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Ayao (not his real name) taking a break during an informal neighbourhood football tournament in Lomé, Togo on 7 April 2019. The 15 year-old is addicted to tramadol, a prescription-only opioid analgesic intended for the treatment of moderate to moderately severe pain, and says he takes it for endurance when playing sports. In West Africa there is a proliferation of illicit and counterfeit versions of the drug that are manufactured in high, non-therapeutic dosages and sold outside the legitimate pharmaceutical supply chain. When taken at high dosages the drug boosts confidence, suppresses hunger, creates feelings of euphoria, provides the energy to do strenuous labour for long periods of time, and enhances sexual potency. However, it often leads to addiction when taken in such a manner, and brings with it risks of liver and kidney damage, seizures and cognitive impairment. Consideration is being given to scheduling tramadol internationally in the manner of other opioid analgesics such as morphine, but some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need for such painkillers while doing little to curb illicit use.
Lucas Kpogli administering a 100mg dose of tramadol, an opioid painkiller, to Grace Kudzu at his infirmary in Lomé, Togo on 29 March 2019. Grace suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped, rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Lucas Kpogli administering a 100mg dose of tramadol, an opioid painkiller, to Grace Kudzu at his infirmary in Lomé, Togo on 29 March 2019. Grace suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped, rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu, 35, with a young patient and her parents at the National Sickle Cell Research and Care Centre where she volunteers in Lomé, Togo on 8 April 2019. Grace suffers from sickle cell disease herself, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped, rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
Grace Kudzu, 35, with a young patient and her parents at the National Sickle Cell Research and Care Centre where she volunteers in Lomé, Togo on 8 April 2019. Grace suffers from sickle cell disease herself, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped, rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to exceedingly painful vaso-occlusive crises. During such crises, which in Grace’s case may occur twice a month and last a week or more, she is heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people like Grace, while doing little to curb illicit use.
13 year-old Nassibatou Alassani and her father Yaminou Alassani, 56, with Dr Hèzouwè Magnang during a consultation for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Nassibatou suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Nassibatou are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
13 year-old Nassibatou Alassani and her father Yaminou Alassani, 56, with Dr Hèzouwè Magnang during a consultation for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Nassibatou suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Nassibatou are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
17 year-old Jennifer Dossouvi as nurses struggle to find a viable vein for an intravenous drip as they treat her vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. It took seven painful attempts to find a vein that did not collapse, with the needle finally ending up at the base of her thumb. Jennifer suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Jennifer are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
17 year-old Jennifer Dossouvi as nurses struggle to find a viable vein for an intravenous drip as they treat her vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. It took seven painful attempts to find a vein that did not collapse, with the needle finally ending up at the base of her thumb. Jennifer suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Jennifer are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
Grace Kudzu, a full time volunteer, comforting 17 year-old Jennifer Dossouvi as she is treated for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Both suffer from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, people such as Jennifer and Grace are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
Grace Kudzu, a full time volunteer, comforting 17 year-old Jennifer Dossouvi as she is treated for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Both suffer from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, people such as Jennifer and Grace are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
17 year-old Jennifer Dossouvi with Dr Hèzouwè Magnang during a consultation for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Jennifer suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Jennifer are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.
17 year-old Jennifer Dossouvi with Dr Hèzouwè Magnang during a consultation for a vaso-occlusive crisis at the National Sickle Cell Research and Care Centre in Lomé, Togo on 10 April 2019. Jennifer suffers from sickle cell disease, a hereditary condition prevalent in West Africa that causes red blood cells to become sickle-shaped rather than maintaining the typical doughnut-like form. Such cells tend to block capillaries and thus impede blood flow, leading to excruciatingly painful episodes known as vaso-occlusive crises. During such crises, patients such as Jennifer are heavily dependent on the opioid painkiller tramadol. But because illicit and falsified tramadol is widely abused for non-medical purposes in the region, consideration is being given to scheduling it internationally in the manner of other opioid analgesics such as morphine. Some experts are of the opinion that this will further reduce the already limited pain management options for people with a legitimate need, while doing little to curb illicit use.

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