Myths and methadone: Will Egypt’s laws bend to the rising tide of drug abuse?

The real revolution is yet to come when it relates to the country’s opioid epidemic.

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A man takes a dose of methadone at Ar Rahman mosque in Kuala Lumpur, Malaysia. In Egypt, methadone remains illegal and so too does opioid substitution therapy. (Bazuki Muhammad, Reuters).

Published in Bhekisisa, Centre for Health Journalism, Mail & Guardian

A thin, 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 inces- sant 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-year- old, 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 con dence 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.”

Chasing the dragon, stalking a virus: Life, heroin and needle exchange

This programme is saving heroin users on the streets of Tshwane, one clean needle at a time.

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 rst quarter of 2012 alone.

So ubiquitous did the drug become that Egyptian authorities passed a 2015 law allowing anyone in posses- sion of tramadol without a prescription to be ned 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 nd 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 signi cantly 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 consump- tion 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.

A man purchases medicine at a pharmacy. Local and international organisations say that rogue pharmacists are playing a key role in keeping the illicit market in tramadol fed and flourishing(Mohamed Abd El Ghany, Reuters)

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 anti-addiction 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, osteoarthritisand 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’ “flight or fight” 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 organisation the Mayo Clinic explains.

Amgad says he has tried kicking his spiralling drug habit more times than he can remember. “I got married and thought it would motivate me, but the drugs were stronger. My wife would push me away, and I felt even more like a failure.”

In Egypt, the ministry of social solidarity’s Fund for Drug Control and Treatment of Addiction (FDCTA) runs government’s battle against drug dependence, says Tamer Hosni, a psychologist who has been with the drug body for years.

FDCTA has gathered data that show one in 10 people have used an illicit drug at least once in 2016 — a prevalence almost double the global average of 5%, UNODC’s 2015 World Drug Report reveals.

“We give lectures about dangers of addiction, including smoking and drugs, in universities, schools and community centres,” Hosni says.

If that seems rather inadequate, given the enormity of the problem, Hosni points to the celebrity power the FDCTA has harnessed in a massive awareness campaign launched in 2015.

Celebrities such as the footballer Mohamed Salah, singer Hisham Abbas and actor Mohamed Ramadan are the faces of the star-studded campaign.

Documentaries, including 10-minute mini features shown in schools, are part of the project. Separately, a fictionalised television series called Taht El-Saytara (Under Control)was screened, unveiling the world of drug addiction in 30 episodes. This was the first large-scale creative work aimed at shaking o the strong social and cultural stigma of drug addiction in Egypt.

“The series has been incredibly helpful in family education,” says Omar.

Meanwhile, the FDCTA’s 24-hour hotline now fields more than 500 calls a day. “The high demand on the FDCTA’s free support has naturally created a waiting list,” he says. “In 2016 the fund supported over 82 000 people. Our Facebook page has over 1.5-million likes and over 22-million active viewers.”

Harm reduction: Evidence versus myth?

But Omar is concerned that the country’s ban on opioid substitution therapy (OST) is hindering its drug response.

As part of OST, doctors prescribe legal replacement options such as the drugs methadone or buprenorphine for people who use opioids, which are often taken as pills or liquids under the direct supervision of health workers.

Although these therapies do not give people a “high”, they allow opioid users to avoid debilitating withdrawal symptoms.

OST programmes have been shown to reduce illegal drug use, criminal activity linked to drugs as well as overdose deaths and even new HIV infections among people who use drugs, according to a 2011 study published in the Bulletin of the World Health Organization.

In 2015, UNODC found that not only could OST be critical to managing opioid dependence in Egypt but it could also help to prevent rising HIV and hepatitis C infections, including those among injecting drug users who share needles.

Egypt has the world’s highest rates of hepatitis C, a bloodborne infection, a 2007 studypublished in The Journal of the Egyptian Public Health Association revealed.

Omar supports the UN’s recommendations but methadone remains illegal in Egypt and OST is still highly contentious in the country, because many health professionals are convinced that the drugs would be diverted to illicit markets.

In its absence, most government and university hospitals rely on cognitive behavioural therapy (CBT), according to a 2015 UNODC report.

As part of this kind of approach, patients work with psychologists to change the way they think about challenging situations such as sub- stance abuse.

Meanwhile, the 12-step Narcotics Anonymous (NA) programme, a peer support group similar to Alcoholics Anonymous, is active in the country.

But research into the effectiveness of these programmes has historically been mixed and contentious.

2009 review by the international Cochrane Collaboration found that, although available studies indicated people in 12-step programmes seemed to benefit from them, participants should be cautioned that there was still a lack of evidence on their overall effectiveness.

Some psychologists believe that the only way to curb drug use is to being reaching out to people who use drugs through community outreach services and needle exchanges, for instance.

Amgad’s brother and close friends have supported him through his battle against drugs, paying for to go to NA.

“I have been clean for seven months,” he says. “It’s been a long and slow process.”

But Omar stresses the real need: to improve outreach services for people who use drugs.

“The way you reach them is through syringe exchange programmes, health promotion, civil society work on the ground,” he says.

“Even if this [methadone misuse] happens, it will be less harmful than, for example, heroin.

“We need civil society to keep pressuring the government to legalise those drugs.”

Amgad does not know when — or if — he will find a job again. He is still on the NA programme, praying the guilt will go away.

“I harmed a lot of people around me, especially my family,” he says. “It is only now that I can start making up for the pain I caused.”

Additional reporting by Adri Kotze

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