Editorial

Frictions in drug control: prescription opioids, prohibition and consumption cultures in Africa

Introduction

There has been a growing concern about the misuse of pharmaceutical opioids in Africa, with some commentators describing it as part of a “global opioid crisis” (e.g. Kurth et al., 2018), ignoring the socio-historical peculiarities and contextually distinct materializations of these public health crises. Scholars have challenged this broad-brush approach through critical commentaries and original research (Klein et al., 2020; Klantschnig and Dele-Adedeji, 2021). Others have argued that conflating these distinct crises “blocks the path to rational regulatory reforms and public health strategies that could constructively address each crisis on its own terms” (Pettus and Radbruch, 2023, p. 2). A notable outcome of the global crisis narrative, according to Klantschnig and Dele-Adedeji (2021), and crucially for the purpose of this Special Issue, is the increased focus on the tramadol economy in Africa. The narrative has stirred political interests and enforcement-based responses across the continent and among international drug control agencies, who view the crisis as a “drugs” problem that should be addressed with law enforcement and bureaucratic controls (Klein et al., 2020). However, the wider social and structural drivers of opioids consumption on the continent are neglected, and the potential impacts of restrictive controls on health care remain poorly understood. This Special Issue aims to fill these knowledge gaps.

Opioids and essential medicines

Pharmaceutical opioids are essential medicines. They are also listed on the United Nations (UN) drug control conventions because of the risk of misuse and dependence. This creates frictions due to apparent contradictions between the intent of the two listings. While essential medicines are considered highly relevant to public health, the drugs listed in the UN conventions are subject to strict control. The UN drug control conventions assure the availability of drugs (including essential medicines) for medical and scientific purposes. However, the focus of implementation has been overwhelmingly on restrictions on opioids availability, especially in low- and middle-income countries (LMICs). In many LMICs, the availability of opioids falls significantly below what is required to meet the medical needs of the population. In 2016, the International Narcotics Control Board (INCB) estimated that 92% of morphine was consumed by people in high-income countries, who account for only 17% of the world’s population (INCB, 2016). In contrast, more than 20 million people living in LMICs die while suffering from severe pain due to low access to opioid analgesics (Knaul et al., 2017). In Africa, many people suffer pain needlessly due to poor access to opioid analgesics (INCB, 2019). While governments and health systems are partly accountable for this situation, the major impediments to the availability of opioids in the region arise from the international drug control system (Ooms et al., 2023).

Opioids consumption and control

In Africa, pharmaceutical opioids such as tramadol are used to manage moderate to severe pain. Non-medical use of tramadol has also been reported, much of which involves illicitly produced tramadol (Degenhardt et al., 2019). Research has begun to show how so-called non-medical uses are situated within the context of youth sociality, poverty, unemployment and low access to health services (Dumbili et al., 2021; Nelson and Alichie, 2022). However, the findings are often drowned in the crisis narratives of sensational media reports, which stoke moral panic and foster enforcement-based responses. Strict control has not reduced non-medical opioid use. Past year prevalence of opioids use in Africa is estimated to have increased fourfold between 2010 and 2019 (UNODC, 2021). Instead, the approach has fostered the expansion of illegal markets for falsified and substandard products (Klein et al., 2018). These dynamics illustrate the challenges associated with the criminalization of opioid consumption, indicating a need for critical interrogation of the tensions that arise from the intersections between drug policies and contextual realities.

Analysing frictions

The aim of this Special Issue is to explore frictions arising from the interface of opioids control and consumption practices and markets in Africa. “Friction” describes the creative tension that results when universalizing forces and local particularities collide and generate new social forms in the process (Tsing, 2005). In Africa, the global force of prohibition has generated both traction and resistance through its encounter with local realities. It has generated traction by fostering strict controls on essential medicines. Conversely, it has produced resistance by stimulating supply channels and consumption cultures that resist these very control measures. These dynamics invite critical analysis. The articles in this Special Issue analyse historical developments in opioids control policies, the impact of control measures on illegal markets and the availability of essential medicines. They also examine consumption practices among different populations, showing how these practices emerge within the interstices of control policies and unmet social and health-care needs.

Articles summary

Tinasti and Outleb analyse opioid regulation in Morocco, showing how recent restrictive regulations are influenced by international frameworks and how they affect access to opioid analgesics for pain management and palliative care, as well as opioid agonist therapy. Ane-Loglo examines tramadol regulation in Ghana and six other African countries, showing how they impact the medical use of tramadol. Although tramadol is essential for managing pain in these countries, existing regulatory frameworks hinder access to these medicines. Onyima documents how street-involved young men in a south-eastern Nigerian city obtain opioids from street drug dealers and pharmacies and consume them by sniffing, popping and mixing tramadol with other drugs. These practices emerged in response to the threat of formal control. Nwafor and colleagues show how manual labourers in two south-eastern Nigerian cities consume tramadol to improve energy for work, pain relief and sexual performance. These consumption practices are contextualized by difficult working conditions and low access to pain management. Nelson and colleagues show how strict measures imposed by the Nigerian state on opioid supply due to public concerns about non-medical use among youth did not mitigate this practice. Instead, it constrains access to opioids for medical purposes and fuel police corruption. Dele-Adedeji and colleagues show how social relationships facilitate the illegal tramadol market in Nigeria, enabling market actors to resolve frictions between illegality and the social acceptability of tramadol. Last, but not the least, Otu and colleagues describe how domestic and international politics shape opioid control in Nigeria, reproducing punitive approaches that hinder access to opioids for medical purposes.

Conclusion

Studies included in this Special Issue show that while some use opioids for medical purposes, what is regarded as non-medical or extra-medical use also persists (see also Sultan and Hupli, 2020). Because opioids are essential medicines for pain management and palliative care, we emphasize the need to resolve the frictions and tensions resulting from the control of opioids through enforcement-based measures. There exists a need to reform policies emanating from moral panic regarding the rise in non-medical use as well as from external influences, especially as they restrict supply of opioids for medical treatment, enable illegal markets in opioids and exacerbate health-care challenges in these countries. The focus should be on ensuring access to opioids for health care and mitigating diversion and illegal trade, including through addressing the social and structural drivers of non-medical consumption.