Discrepancies in Reports on Tramadol Abuse in Sierra Leone

Introduction

The Pharmacy Board of Sierra Leone on January 15, 2021 released a news article stating that narcotic drugs such as Tramadol and Diazepam are not easy to see currently. It states that when it noticed that youths were rampantly abusing them, it had immediately issued directives to all the licensed drug sellers to dispense the drugs on prescription basis and also to control the import quantity of the drugs. It claims that the abuse of Tramadol has since then drastically reduced in Sierra Leone (The Pharmacy Board of Sierra Leone , 2021). This situation is different from what the World Health Organisation reported in 2020 that several West African countries, including Sierra Leone reported widespread non-medical use of tramadol by young people. Sierra Leone shows that almost 90 per cent of drug users use a combination of tramadol and diazepam in alcohol (United Nations Office on Drugs and Crime, 2020). UNODC reported in 2019 that Sierra Leone is one of the main destinations countries in West and Central Africa of illegal tramadol shipments (United Nations Office on Drugs and Crime, 2019). The World Health Organisation also reported in 2018 that Sierra Leone is amongst the major transit or destination countries for tramadol trafficking (World Health Organisation, 2018).

The reports of the international agencies show a grievous social, political and legal issue facing Sierra Leone. The abuse of the concerned drugs raise many questions as to easy illegal accessibility of the drugs, the role of government in addressing this social issue, effectiveness of medicines regulations and policy measures and international policies and measures. Further, the claim of the Pharmacy Board of Sierra Leone of current reduction of abuse of Tramadol raises the question of either a gap in evidence between this claim and the reports or measures by the government are effective in tackling the problem. This essay will explore the questions raised here by examining policy and regulation in place and assessing the public health response approach to abuse of Tramadol and Diazepam.

Misuse of diazepam and tramadol and causes

The unlawful use of and illicit trade of prescription drugs in Sierra Leone are linked with the civil unrest that occurred in the country. The civil unrest and the simultaneous deterioration of the law enforcement capability enabled in 1994 the increased in number of transhipments of heroin origination from Asia and cocaine from South America to Europe and North America.

(United States. Bureau for International Narcotics and Law Enforcement Affairs, United States. Department of State. Bureau of International Narcotics Matters, 1995). The government showed no willingness in tackling this problem. There were no measures to counter the transit of the drugs and local production of cannabis. The government even after ratifying did not implement the 1988 UN Convention. The government did not take any real effort in addressing the problem (United States. Bureau for International Narcotics and Law Enforcement Affairs, United States. Department of State. Bureau of International Narcotics Matters, 1995). The UNODC report of 2019 and the World Health Organisation of 2018 are evidence of the failure of the government to take any concrete steps to deal with the problem enabling easy access to illicit drugs, including tramadol and diazepam.

The United Nations Office on Drugs and Crime (2019) identified similar reason for the easy accessibility to opioids such as diazepam and tramadol. Tramadol is, however, not under international control. The Single Convention on Narcotic Drugs of 1961 controls most pharmaceutical opioids, but not Tramadol. Its non-medical use has become a public health concern in particularly West, Central and North Africa. It is a justified concerned given that a record 125 tons of tramadol was seized globally in 2017. The West, where Sierra Leone is, and Central Africa high prevalence of non-medical use of opioids. This comprises 1.9% or over an estimated 5 million opioid users dominated by the non-medical use, particularly that of tramadol. UNODC did not find much data on the prevalence of drug use in Africa. As a result, it could not quantify the trends and level of the non-use of tramadol (United Nations Office on Drugs and Crime, 2019). This data corresponds to the 1994 condition reported by Bureau of International Narcotics Matters (1995) where there was an increase in illicit trade of prescription drugs in Sierra Leone and there was a complete government failure to address the problem.

The United Nations Office on Drugs and Crime (2019) pointed out that the affected countries faced difficulty in controlling access to medical purposes while curbing abuse. They have limited resources and health care systems. They are unable to handle organised crime and trafficking due to limited resource. There is easy availability of the drugs in pharmacies and illicit market. The illicit drugs are of low price in comparison with controlled drugs. Young users have the wrong perception tramadol is a medication and it does not have the same level of risk and stigma as the use of controlled drugs (United Nations Office on Drugs and Crime, 2019). The United Nations Office on Drugs and Crime (2019) reported scarcity of national-level prevalence estimates of the non-medical use of tramadol. It, however, pointed out that different studies and surveys suggest a widespread non-medical use of tramadol in the African regions, including Sierra Leone. Similar observation is made by Olurishe (2019), who also pointed out data from drug abuse studies in Sierra Leone were scanty. Olurishe pointed out that Sierra Leone also reported trends and patterns of drug abuse. Though Olurishe’s study did not show any use of diazepam and tramadol in Sierra Leone, the study gave a general sense of the prevaling drug abuse situation in Sierra Leone and West African at large. For example, Olurishe’s study found marijuana as the commonly used drug with use of cocaine to a some extent among the young population. The substance abuse was attributed to stress, post war stress, rural urban migration. The abuse was more likely in the Muslims, male and people living within traditional community settings (Olurishe, 2019). Olurishe’s study also found higher abuse of drugs amongst young men who were riders of tricycle taxis. The study emphasied on the severity of drug abuse in Sierra Leone as it accounts for a large number of psychiatric patients. Olurishe (2019) pointed out that drug use and abuse pose a health problem within the West Africa subregion and the existence of educational deficit and lack of adequate health facilities worsen the problem. This is supported by the data reported by United Nations Office of Drugs and Crime (2019) suggests that there is no developed health-care system, which could control or regulate dispensing opioids. This problem is aggravated by easy availability of the illicit drugs due to apparent transhipments of illicit drugs in Sierra Leone. Olurishe (2019), therefore, suggested substance abuse prevention programmes, family and school intervention, peer education, and involvement of non-governmental organisations to deal with the socio-economic problems arising out of drugs abuse cases.

Public health relevance

The abundant abuse of drugs in the region of Western Africa is a public health concern. The reports as discussed above in section 2 are the evidence. Section 2 findings show that the failure of the government to take any concrete steps is a major cause for substance abuse. It predominantly shows abuse of Tramadol, but in general there is high prevalence of non-medical use of opioids in the West and Central Africa. Information and data available reflects lesser information about diazepam abuse. Further, lack sufficient data and information has failed to quantify the trends and level of the non-use of tramadol. UNODC, although, reported widespread non-medical use of tramadol in the African regions, including Sierra Leone. There is a deep rooted problem, socially, economically, and politically, associated with the subject of research in question. This is supported by the finding of Olurishe (2019), where substance abuse has resulted to psychiatric patients; has link with problem of educational deficit, lack of adequate health facilities and lack of regulatory measures. However, Olurishe (2019) found more cases of abuse of other drugs such as marijuana and alcohol.

The findings in section 2 shows that abuse of drugs and other substances in West Africa is causing severe public health concerns. The United Nations Office on Drugs and Crime (2019) report provides a trend in the region of West Africa. Authorities reported non-medical use of tramadol across all ages, socioeconomic classes, and genders both in urban and rural areas. Tramadol is being misused by school children. Most tramadol tablets or capsules are easily bought in the informal market, through street markets, tea sellers, and itinerant sales people amongst others. They are packaged showing a dosage higher than that available in pharmacies (United Nations Office on Drugs and Crime, 2019). The extent at which the drug has been illicitly moved and sold exposes the vulnerability of the regulatory system as well as that of the affected population at large. The extent of abuse of tramadol is large to the extent that it semes to be a norm to use it for every purposes the users feel fit to use. The United Nations Office on Drugs and Crime (2019) reported findings of interviews with non-medical users of tramadol that tramadol us used for a variety of reasons. Some abuse it for calming, analgesic and anti-fatigue effects with the hope to improve their intellectual, physical and working performances. Some abuse it to decrease sleep and appetite. Some in farming communities abuse the drug and also fed to cattle in order to make the cattle work under extreme conditions. Some use it for recreational purposes or to improve sexual stamina. Some abuse it as an alternative to heroin. The problem also lies with the perception of user that it is a medicinal and it is not harmful. This is evident in the manner users use in coffee, cannabis, and alcohol; with taurine and caffeine; and with tramadol and codeine. Similar use is found with diazepam common among people using tramadol non-medically, together or an alternative of tramadol (United Nations Office on Drugs and Crime, 2019). There are private reports about the abuse of tramadol. Moses B. Williams, a Mental Health Nurse in Bo District highlighted the normalised abuse of diazepam and more of tramadol. Students are addicted to drugs, including Tramadol. Tramadol is easily used as medicine by students for normal sickness like headaches. Youth can easily buy them from drug peddlers (Medium, 2017).

(In)Effectiveness of legal and regulatory measures

It is rather surprising to see the prevalence of the abuse of drugs in general when Sierra Leone has national laws and international framework in place to regulate use of drugs. The National Drugs Act of 2008 was drafted with the help of the U.N. Office of Drug Control (Library of Congress, 2008). It was approved by the Sierra Leone Parliament as an urgent necessity. It came after the July 13, 2008 incident when a South American aircraft filled with cocaine landed in an airport in the country (Library of Congress, 2008). This Act imposes harsh penalties on drug-related crimes with mandatory imprisonment of not less than 5 years for possession and use of hard drugs and other serious penalties on illegal drug makers and traffickers. It imposes life for “importing, exporting, transshipping, or transmitting” drugs (Library of Congress, 2008). Even the possession of cocaine and heroin-making materials is imposed a mandatory sentence of life imprisonment. It also imposed punishments for money laundering and holding proceeds of drug-related dealings (Library of Congress, 2008). It is also not a recent event that the UNODC has recognised the public concern of the problem of drug trafficking and abuse in the country. Since the 2008 incident, the UN Police (UNPOL) also been involved in strengthening anti‐drug law enforcement capacities. It set up the Joint Drug Interdiction Task Force (JDITF), which is a collective of all competent law enforcement agencies. An UN led system is in place led by an Integrated Office (UNIPSIL) headed by a Special Representative of the UN Secretary General (UNODC, 2021).

The UN Human Rights Office of the High Commissioner (2020) observes that Sierra Leone has not decriminalise ‘acquisition, use or possession of illegal drugs for personal use’. It is an offence for a person who unlawfully ‘prepares, extracts, manufactures, produces, or cultivates a prohibited drug; collects, transports, imports, exports, tranships or transmits any prohibited drug; supplies, administers, sells, exposes or offers for sale or otherwise deals in or with any prohibited drug’ (The UN Human Rights Office of the High Commissioner , 2020). The First Schedule of the National Drugs Control Act provides a list of prohibited drug. It does not list diazepam and tramadol as Prohibited Drugs (SierraLII, 2008). Thus, if diazepam and tramadol are not prohibited drugs, even the existence of a legal regulatory framework will not be able to control or regulate the abuse of the drugs. Further, the Criminal Procedure Act, 1965 does not provide for a different criminal procedures governing committed drug related offences. This Act places every crime, including drug-related crimes, on the same footing. The same amnesties are applicable to other crimes and drug-related crimes (The UN Human Rights Office of the High Commissioner , 2020). The existing legal framework does not allow handling the abuse case of the two drugs in question. Further, the court chooses fine over incarceration (Bridge & Loglo, 2017). Bridge and Loglo (2017) seems to aptly observe that the prevailing drug laws and approaches are rooted in the prohibitionist interpretations of the international drug conventions. They have not been reformed or questions for decades.

Potential measures

Recently, the government has started recognising the problem in questions as deep rooted. The year 2019 saw the government willingness to approach the issue by harmonising and reforming the existing drug laws. This is needed for effective and evidence-based drug control responses based in human rights, public health and sustainable development. The recent development such as the West Africa Drug Policy Network (WADPN)’s online programme titled ‘Roadmap to Sierra Leone’s Drug Law Reform’ is a positive sign with the aim to make public understand the current drug problem and take positive actions (International Drug Policy Consortium, 2020). Stewart and his collegaues conducted a Acceptance and Commitment Therapy training in 2016 in Sierra Leone is reported. The training involved psychological interventions in low and middle-income countries in order to reduce psychological inflexibility and wellbeing. The training showed positive result (Stewart, et al., 2016). Reading such kind of training programmes and government all round initiative of training, creating awareness and criminal law reforms may produce positive results. Lesson can also be learned and implement from the U.S. Department of State’s Bureau of International Narcotics and Law Enforcement Affairs (INL) that helped Sierra Leone from 2015 – 2020 through its training and institutional programmes to correct policing and judicial system (BUREAU OF INTERNATIONAL NARCOTICS AND LAW ENFORCEMENT AFFAIRS , 2020). It found corruption as a pervasive problem compromising citizen access to basic public services and institutions including health, education and the police. INL helped the country with its criminal justice system by training the police in managing public order, implementing stricter enforcement like the Transnational Organized Crime Unit making arrests, investigating serious criminal cases, seizing illicit drugs and contrabands and supporting successful prosecution, promoting judicial transparency, and correctional services’ institutional policies (BUREAU OF INTERNATIONAL NARCOTICS AND LAW ENFORCEMENT AFFAIRS , 2020).

Findings and Conclusion

This research so far has generally shown that West Africa is affected by the problem of drugs and other substance abuse. The research was aimed to focus on the misuse of prescription drugs, diazepam and tramadol, in Sierra leone. However, the research identified a larger problem of social, economic and political natures. Focusing on the problem in hand, it is found that the use of the drugs is normally seen medicinal. It is a norm in the country to use those drugs for all the purposes that the users feel fit, whether it be medicinal or non-medicinal. The aftermath of the civil unrest, the increase in transhipments of illicit drugs to and through the country and the weak legal and regulatory framework have all resulted to easy access to prescription drugs sold outside the system for medicinal and non-medicinal drugs. The fact that the public office is not regulated properly, the police and judicial system are weak and not transparent, and the society at large with economic problems all have led to the abuse of the drugs and other substance at large by the entire section of the public, whether old or young.

The UNODC report of 2019 and the World Health Organisation of 2018 have shown the failure of the government in tackling the problem. Tramadol seems to be more abuse and use than diazepam. In general, the West and Central Africa have high prevalence of non-medical use of opioid. The research have shown a variety of causes for this issue, including limited resources and health care systems, limited legal and enforcement resources and educational deficit to tackle the problem. The finding by the The United Nations Office on Drugs and Crime (2019) indicates that the abuse of tramadol has become a norm because of its use without any medical guidance. Diazepam, although reported abused is scanty, is also commonly used with tramadol non-medically. This creates a major public health concern as the lack of government action is pushing many into addiction. The scarcity of national-level prevalence of data as reported by the Uited Nations Office on Drugs and Crime (2019) also presents a challenge to formulate appropriate policy measure.

The suggestion for substance abuse prevention programmes, family and school intervention, peer education, and involvement of non-governmental organisations is an indication that the problem has penetrated deeply into the society. Such kind of intervention is multi-disciplinary, which indicates the seriousness of the issue. The real problem is the lack of appropriate legal framework including regulatory and enforcement mechanism to regulate, control and prevent further abuse of the drugs and mitigate risk of public health. The existing laws, the National Drugs Act of 2008, is not sufficient. The criminal justice system, as provided under the Criminal Procedure Act, 1965, does not have the edge to deal with the problem. The existing international conventions that do not have legal force in the country fall short of its objectives.

To conclude, until all the shortcomings are removed and address, the problem will continue. An all-round multi-level approach is needed. Firstly, correct the law or enact a specific law to deal with the issue. Secondly, empower the police, the judiciary and the entire criminal justice system to take corrective and preventive actions. Thirdly, involve agencies to create and implement awareness and education programmes at different educations and other social institutions. Fourthly, seek help from international bodies to strengthen preventive measures.

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Bibliography

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3.1. Existing regulatory and policy measures in place

3.2. What policies/approaches might be effective

Discussion/conclusion

Your discussion/conclusion section shouldn't just repeat what you have written in the main body of the essay - There is a clear summary of the main body of the assignment (5%) - Clear recommendations for practice, policy and/or further research are made and these follow logically from the findings of the main body (10%)