Will Egypt’s law bend to its rising tide
The real revolution is yet to come when it relates to the country’s opioid epidemic
Athin, frail man slumps in an oversized chair, his body fading into the fabric. Deep creases line his face. “You can call me Amgad,” he says. It is not his real name. His voice is brittle in the soundless recording studio, but not uncomfortably so. For Amgad, this is a calm bolt hole: the padded walls block the incessant hooting of Cairo’s taxi drivers rising from the street below. He can come here because this is where his brother works, a man to whom Amgad believes he owes his life.
For nearly 20 of his 35 years, he has been dependent on drugs.
It was to drown out the mayhem in his family that Amgad first took a prescription painkiller as a 17-yearold, he says, thus becoming one of the statistics of an opioid wave ripping through Egypt at about the same time the drug epidemic was hurtling into a health crisis in the United States.
The teenager had already been smoking hashish, a concentrated cannabis-derived resin, for two years when a friend gave him a small white pain pill. It was tramadol, a synthetic opioid analgesic that is used to relieve moderate to severe pain, such as after an operation. On the streets of Cairo, however, the painkiller was being used as a recreational drug and was fast gaining a reputation for improving men’s confidence and sexual prowess, as well as “chilling” the user.
The pills were cheap and easy to get: if not from a friend or a dealer, many pharmacists were willing to sell them under the counter. They made Amgad feel alert and boosted his energy. The effect was mild enough to convince him the pills were harmless, but the euphoria made him go back for more.
“Life is not easy in Egypt,” he explains. “I had financial problems, and I felt I wasn’t meeting the family’s expectations. I managed to forget those problems only when I was high. I would regain my confidence, performing better in the family and at work.”
By the time the popular uprisings known as the Arab Spring swept through Egypt in 2011, removing former president Hosni Mubarak after almost 30 years, Amgad was topping up his hashish with daily sheets of 10 tramadol pills (often at less than $1 a pill) and heroin, he says. “I must have used everything on the market.”
Historically, Egypt is considered a transit point for heroin and opium moving from Asia to Europe, Africa and the US, according to a country profile by the United Nations Office on Drugs and Crime (UNODC). Its location, between the Mediterranean and Red seas, linked by the Suez Canal, places it in the middle of the world’s main drug trafficking routes.
In the years of instability following the Egyptian Revolution, tramadol flooded into the country from India and China and became as popular — if not more so — than heroin and cannabis, writes The Economist magazine.
The World Health Organisation (WHO) reported that Egyptian authorities seized about 120-million tablets containing tramadol in 2011 and about 320-million pills in the first quarter of 2012 alone.
So ubiquitous did the drug become that Egyptian authorities passed a 2015 law allowing anyone in possession of tramadol without a prescription to be fined or imprisoned. Police raided pharmacies selling tramadol illegally to crack down on the distribution chain, according to the Egyptian newspaper Mada Masr. But some pharmacists still find a way to deal the pills, explains Olfat Allam, a clinical psychologist who has been working with people who use drugs for 30 years.
“Some pharmacists will go to the extent of fabricating prescriptions to justify the sales,” she says. “It is a serious problem in the country and continues despite the fact that tramadol’s price rose significantly in recent months.”
At the end of 2017, the UNODC warned in a statement of a rise in the use and trafficking of tramadol across West Africa and its links with organised crime and terrorism as “tramadol is regularly found in the pockets of suspects arrested for terrorism in the Sahel, or who have committed suicide attacks”.
“The rise of tramadol consumption and trafficking in the region is serious, worrying, and needs to be addressed as soon as possible,” warns Pierre Lapague, UNODC’s regional representative in West and Central Africa.
Since 2013, seizures of tramadol have skyrocketed from 300kg to over three tonnes a year, the latest UNODC World Drug Report shows. Last September more than three million tablets were seized in Niger, packed in boxes bearing the UN logo.
One month earlier, Cameroonian customs on the Nigerian border recovered more than 600 000 tramadol tablets intended for the militant group Boko Haram, according to a statement by the UN’s drug body.
In Egypt, drug use should be seen in a religious context, says Mostafa Hussein Omar, a specialist psychiatrist at Cairo’s private Behman Hospital. The facility is the oldest and largest private psychiatric hospital in the Middle East.
“Unlike alcohol, which is legal yet clearly religiously forbidden, cannabis is not … Some people say that, if it is not clearly written in the religious text, it is fine to use cannabis,” Omar explains.
Similarly, tramadol is seen as a medicine and not as a drug. Nearly one in 10 Egyptian teenagers surveyed were found to be using the opioid, a 2015 study conducted among about 200 students revealed in The American Journal of Drug and Alcohol Abuse.
Overall, the prescription painkiller is the most abused drug in the country, social solidarity minister Ghada Wali has been quoted as saying by the online news service, Egypt Independent.
She cited figures from an antiaddiction hotline that showed more than 40% of callers reported using tramadol.
Ironically, the drug has long been considered to be a relatively safe painkiller that is less likely to be abused than morphine, found a 2014 WHO report.
Tramadol also has less dependence potential than other opioids. Since tramadol was introduced on the American market in 1994, it has gained popularity worldwide and is used to treat a broad range of pain such as that caused by cancer, osteoarthritis and fibromyalgia — a disorder characterised by widespread, chronic pain.
Like heroin and other opioids, tramadol prevents nerves from sending out signals that tell us we’re in pain, according to research published online by the American government’s National Institute on Drug Abuse.
But tramadol is also unique. The drug inhibits the absorption of serotonin — commonly believed to be the body’s “feel-good” chemical — as well as that of a substance often linked with humans’ “fight or flight” emergency response, noradrenaline. Because tramadol blocks the body’s ability to take up these chemicals, levels of the substances increase in the brain, the US research organisa-