Thoughts from the void: Cannabis and Mali

'The drug use survey in Nigeria reveals tramadol to be a more accessible opioid than heroin, although it is still relatively costly if used frequently. While use of tramadol appears to cost about one third the price of heroin ($3.60 versus $10 per day of use in the past 30 days), in a country where the minimum wage of a full-time worker is around $57 per month, regular tramadol use still poses a considerable financial burden on users and their families. There is no information on the prevalence of drug use in other West African countries, but treatment data reveal 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. This was particularly the case in Benin, Mali, the Niger, Nigeria, Sierra Leone and Togo.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_4.pdf

'The trafficking and availability of tramadol for its non-medical use is a public health concern, but limited distribution of tramadol for medical use would also pose a public health concern, in particular in Africa, where there is a chronic shortage of pain medications. There are no data on the availability and use of tramadol for medical purposes, but data on internationally controlled substances clearly highlight the gaps in the accessibility of pain medications. The general lack of access to opioid-related pain medications under international control is a specific problem for developing countries, which is even more pronounced in countries in West and Central Africa than in other parts of the world.

Against this background of a de facto non-availability of internationally controlled opioids for pain medication for large sections of the population in West and Central Africa, tramadol – even though it is under national control in some West African countries – is in fact a widely available opioid in those countries, used for both medical purposes (including outside prescription) and for non-medical purposes' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_4.pdf

'From what is known, it is possible to identify common threats and different dynamics in the two opioid crises, in Africa and in North America: • The ease of manufacturing, easy accessibility and low-cost production make the illicit markets for tramadol and fentanyls substantially more profitable for traffickers than are other opioids such as heroin. • The large-scale manufacture of tramadol and fentanyls for the illicit market started in a context of an absence of international regulations on tramadol and many fentanyl analogues or their precursors. • The interchangeability (or substitution) of fentanyl and tramadol within the pharmaceutical and illicit drug markets makes it more difficult to address their misuse. Their non-medical use is also seen in the context of self-medication, and thus carries less stigma or is countered by lesser legal sanctions than is the case with other controlled drugs.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_4.pdf

'In West, Central and North Africa and the Middle East, tramadol – a pharmaceutical opioid not under international control – has emerged as a major opioid of concern. The drug, in addition to being diverted from the legal market, is mainly trafficked into those subregions in dosages higher than what is prescribed for pain management, with an increasing number of people with tramadol use disorder entering treatment.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_4.pdf

'The non-medical use of pharmaceutical opioids is not a new phenomenon. It has been observed for decades as part of the polydrug use pattern among high-risk or regular opioid users. What characterizes the most recent opioid crisis is the emergence of non-medical use of pharmaceutical opioids as the main phenomenon, leading to alarming rates of dependence and overdose deaths at the national level. The subregions most affected by this crisis are North America and West, Central and North Africa, where different opioids and different dynamics are driving the threat. In North America, the introduction of fentanyl and its analogues (fentanyls) in the drug market has resulted in a syndemic of use of opioids characterized by an unprecedented increase in opioid overdose deaths' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_4.pdf

'Medicines for pain relief are unequally distributed across regions. More than 90 per cent of all pharmaceutical opioids available for medical consumption were in high-income countries in 2018. Some 50 per cent were in North America, 40 per cent in Europe, and a further 2 per cent in Oceania. Those countries are home to about 12 per cent of the global population. Low- and middleincome countries, which are home to 88 per cent of the global population, are estimated to consume less than 10 per cent of pharmaceutical opioids.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_1.pdf

'In West, Central and North Africa, the opioid crisis is fuelled by tramadol; in North America, by fentanyls. Although those subregions have little in common in terms of economics, demographics or general patterns of drug use, both are struggling with an opioid crisis fuelled by substances that are easy to access and cheap to produce.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_BOOKLET_1.pdf

'With the exception of Nigeria, where 4.6 million people were estimated to have used opioids – mainly tramadol – in 2017, population-level prevalence estimates of the use of opioids are not available for countries in West, Central and North Africa. However, many countries in those subregions report high levels of non-medical use of tramadol. For example, in Egypt, 2.5 per cent of male and 1.4 per cent of female students aged 15–17 had misused tramadol in the past year. Students in that country also reported the use, to a lesser degree, of heroin or opium/morphine in 2016. Furthermore, data on the provision of treatment suggest that the prevalence of the non-medical use of opioids is quite high in Egypt. Tramadol tablets available in some parts of Africa are reportedly intended for the illicit market and may be of a dosage higher than usually prescribed for medical purposes.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_Booklet_2.pdf

'In line with the dominance of the opium production in Afghanistan, quantities of heroin and morphine seized related to Afghan opiate production accounted for some 84 per cent of the global total in 2018, a slight decrease from 88 per cent in 2017, the year of the bumper harvest in the country. Most of the heroin found in Europe, Central Asia/ Transcaucasia and Africa is derived from opium of Afghan origin, accounting for 100 per cent of all mentions in the responses to the annual report questionnaire by countries in Central Asia/Transcaucasia, 96 per cent in Europe and 87 per cent in Africa over the period 2014–2018.' - United Nations Office on Drugs and Crime, World Drug Report 2020, https://wdr.unodc.org/wdr2020/field/WDR20_Booklet_3.pdf