Background

Tramadol is one of the most prescribed painkillers in the world [1]. It is a synthetic opioid used for moderate to severe pain and is an excellent alternative to morphine due to its consistent availability and low price [2].

Initially, it was assessed as having common addictive properties, so it has not been placed under international control, like fentanyl and methadone, which are responsible for the opioid crisis in other parts of the world. In addition, physicians prefer it to non-steroidal anti-inflammatory drugs, as it is more tolerable and has fewer side effects [2, 3]. Tramadol is widely used for neuropathic and nociceptive pain, back pain, and people with cancer and is often prescribed for the pain of sickle cell anemia [4, 5]. It is considered an essential medicine and is included in the essential and generic medicines (EGM) list of many African countries, such as Botswana, Niger, Ghana, Mali, Côte d’Ivoire, Ghana, and Nigeria [2].

Several articles have reported an increase in the non-medical use (NMU) of tramadol, with the presence of addiction symptoms similar to those of morphine, especially when taken regularly at doses above therapeutic levels; however, this is becoming increasingly common [6–12]. Thus, in a few years, tramadol has become a public health problem in Africa in the same way as fentanyl has been responsible for the opioid crisis in the United States [13, 14]. Moreover, the enormous amounts of illicit drugs seized by the authorities in African countries establish a growing interest in this product, especially among the younger populations. For example, in 2014, 17 tonnes of smuggling were seized across West African countries, 121 tonnes in 2015 and 170 tonnes in 2017 [2]. The NMU of tramadol is all the more harmful as the illicit doses sold on the pavements and markets are 2 to 5 times higher than the usual doses (100 to 250 mg against 50 mg usually), thus increasing its addictive power [10, 11]. There are several reasons for the sudden increase in the popularity of tramadol among African youth. For example, the tablet is available everywhere in West Africa, in every "pharmacy on the floor.”

Unlike other products, it is sold in full view of health and political authorities. In addition, tramadol is sold for between 0.20 and 1 USD per 10-tablet pack, which is far less than other drugs [2]. This explains why it is described as the ’cocaine of the poor’ by some authors [11]. Conversely, compared to other drugs, marijuana is easier to transport and conceal, and the punishments incurred by sellers and possessors are less severe, leading to the population perceiving it as a medicine [15]. In most African countries, it is easy to obtain in pharmacies without a medical prescription [2]. In North African countries, a literature review showed that tramadol is the second most commonly used drug by students in Egypt due to its psychoactive properties [16] and more generally in countries in the Eastern Mediterranean region, including Libya, Morocco, Somalia and Tunisia [17]. In Central Africa, especially Cameroon, tramadol is used illicitly for its psychoactive properties and to increase work efficiency [18].

Tramadol is usually taken with tea, coffee, or alcohol, with other pharmaceutical drugs, such as benzodiazepines, in several African countries [9, 10]. It is consumed collectively during weddings, baptisms, during community work, for euphoric sensation seeking, which is one of the main reasons for its consumption [15]. It is also taken individually to combat fatigue by manual workers or in the search for physical or sexual performance [14, 15]. Its use is often associated with public disorder and traffic accidents due to potential side effects like dizziness, euphoria, and changes in fear and pain [15]. Due to the increased NMU of tramadol in many African countries, some authors describe the situation as an opioid crisis due to tramadol [13].

Despite the warning signs and numerous press articles on the health and social consequences of the NMU of tramadol [19–22], more scientific studies are needed to circumscribe the extent and understand the health consequences of the phenomenon, as has been done in many parts of the world [23, 24]. Therefore, our scoping study aims to understand the nature and extent of tramadol NMU use and its health consequences in Africa to guide future research.

Methods

Protocol design

The study will be conducted according to the five methodological steps defined by Arksey and O’Malley (2005) and modified by Joanna Briggs Institute guidelines for conducting a scoping review to ensure systematic and repeatable studies [25]. The five steps are: 1) formulate the research question; 2) identify relevant studies; 3) select studies according to inclusion and exclusion criteria; 4) extract and map the results; 5) report the results [26] (Fig 1). The PRIMA-SCR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews) checklist will be used to report, filter and communicate our results [27].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Scoping review research methodology inspired by Arksey and O’Malley (2005).

https://doi.org/10.1371/journal.pone.0285809.g001

Stage 2: Identifying relevant studies

This scoping review will be conducted using the PCC (Population, Concept, Context) framework recommended by JBI [28]. Our search strategy will be based on the PCC framework described in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. PCC framework.

https://doi.org/10.1371/journal.pone.0285809.t001

The literature search will be done in several databases such as Medline, Embase, Scopus databases, the Web of Science, the African Journal online database, and for grey literature Google Scholar. Given the supposed weakness of the African literature on the subject, the keyword "tramadol," without any time restriction, will be used to query the selected databases. To this word will be added Medical Subject Heading (MeSH) as "Drug abuse," "illicit drugs," or "Prescription Drug Misuse," and "Africa." These keywords combined with the Boolean operators (and, or, not) will result in search equations that will form the basis of our search strategy.

Results

In January 2023, the search strategy used for this study identified 4030 studies in the selected databases. Two independent researchers will conduct the review process of the titles and abstracts of the articles on the COVIDENCE platform in the last week of April 2023. The identification and completion of the review of the different articles are expected to occur by the end of July 2023. Subsequently, the full review of the articles that have passed the initial selection will commence in August and September 2023, followed by the data extraction and analysis stage in October and November 2023. The study results are anticipated to be available and prepared for publication by December 2023 (Fig 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 2. Timeline of expected results.

https://doi.org/10.1371/journal.pone.0285809.g002

Discussion

The scoping review aims to investigate the prevalence, subpopulations affected, and health consequences of non-medical use of tramadol in African countries. To do this, two types of data will be gathered: quantitative data to show the phenomenon’s prevalence in different subpopulations and qualitative data to illustrate the health consequences of the NMU of tramadol. This study will not require approval from an ethics committee as the Scoping Review methodology involves reviewing and collecting data from publicly available materials. To disseminate the results, a thematic analysis will be conducted to better understand tramadol NMU’s health consequences. The results will be submitted for publication in a scientific journal and presented at relevant conferences such as the International Conference on Public Health in Africa (CPHA).

We anticipate certain limitations in our review. Firstly, it is possible that many locally conducted studies, which have not been published yet, may not be incorporated in this review. Secondly, since the phenomenon under study is hidden, the data collected through self-reporting or prevalence surveys may be prone to underreporting or social desirability bias. Furthermore, health is not only the absence of disease; thus, the consequences of the NMU of tramadol extend beyond health implications. The United Nations Office against Drugs and Crime (UNODC) has also highlighted tramadol NMU’s role in undermining the Sahel’s economies and security [14]. This link has been further confirmed by the Institute for Security Studies report, which focuses on the relationship between violent extremism and illicit activities in the so-called 3-border zone between Burkina Faso, Niger and Mali [31]. According to this report, two cases emerge from the attitude of armed groups regarding the nature or degree of their involvement in illicit activities: 1) they are sometimes beneficiaries of trafficking products such as tramadol, used as a stimulant for fighters of armed groups; 2) without being involved, they may derive income from illicit trafficking activities by levying taxes on convoys in their area of control, providing armed escorts, protection or transport of tramadol traffickers. Future research into the consequences of NMU of tramadol should include the social and economic impacts on the African population.

Study implications

By exploring the prevalence and public health consequences of the NMU of tramadol, this study can contribute to a better understanding of the scale of the issue and inform the development of evidence-based interventions and policies to address it. Additionally, the findings of this study can serve as a valuable resource for future research on the NMU of tramadol in Africa, providing insights into knowledge gaps and areas that require further investigation. Ultimately, the results of this study have the potential to positively impact public health outcomes and contribute to the overall well-being of individuals and communities affected by the NMU of tramadol in Africa.

Limitations

The present study may encounter potential limitations, including (1) language bias as only studies published in English and French will be included, which may constrain the scoping review and disregard relevant studies published in other languages; (2) publication bias, as only studies that have been published will be considered, thereby missing unpublished studies or studies in progress; (3) quality of studies, since the scoping review will not evaluate the quality of the included studies, the results may be impacted by the quality of the studies and the likelihood of bias in their design and methodology; (4) heterogeneity of studies, since the studies included in the review may exhibit variations in their definitions of NMU of tramadol and their data collection methods, making it challenging to make direct comparisons across studies. Lastly, it is noteworthy that this study does not include articles addressing the economic and social ramifications of NMU of tramadol, which may extend beyond health-related consequences.

Conclusion

This scoping review aims to identify and map the existing literature on the prevalence and public health consequences of the NMU of tramadol in Africa. It will focus on the prevalence, patterns, and risk factors of tramadol misuse and the public health consequences of its NMU. In this protocol, we identified a comprehensive search strategy and data extraction process to gather relevant studies for the review. However, we also highlighted potential limitations, including language bias, publication bias, heterogeneity of studies, and limited assessment of study quality. Despite these limitations, this scoping review has the potential to provide valuable insights into the NMU of tramadol in Africa and its public health implications.

Supporting information