The Dangerous Opioid from India
This piece was originally published in The Diplomat.
The opioid crisis continues to claim thousands of lives every month across the United States, driven in part by use of fentanyl, a powerful opioid primarily manufactured in China. But it is another opioid, tramadol, that threatens to wreak global havoc, and another Asian giant that is pouring it into the world.
In 2015 (the most recent year with full data), 12.5 million people in the United States abused opioids, and it is estimated that 24,861 people died from overdoses of prescription and synthetic opioids.1 Some expect these numbers to have tripled for 2016,2 and six U.S. states have now declared public health emergencies to combat the opioid crisis.3 In October, President Trump declared the opioid crisis a public health emergency.
Fentanyl is at the center of the opioid crisis in the United States. It is used as a direct substitute for heroin, but it is 50 times more powerful than heroin. Fentanyl is a synthetic opioid, meaning it requires precursor chemicals to manufacture, and it is prescribed as a pain medication. In the past two years, however, illicit manufacturing and importing of fentanyl has skyrocketed. The death rate from synthetic drug use reflects this trend.
China is the number one supplier of fentanyl to the United States. China is also the main supplier to Canada and Mexico. Cartels in the latter usually then smuggle it into the United States. After years of persistent efforts, the U.S.-China bilateral crackdown on opioid trafficking has started to see recent success. In mid- October, two Chinese nationals were indicted for running a large illicit fentanyl distribution network and their three American accomplices were arrested.4
Fentanyl exported from China to the United States comes in several different forms: fentanyl, its precursor chemicals, fentanyl variants, and fentanyl-laced counterfeit prescription opioids.5 India exports many controlled and prescription drugs to the United States, including fentanyl. Indian fentanyl exports to the United States are a fraction of those from China, but India does export tramadol, which is a growing issue for the United States. However, unlike China, which has now designated over 100 fentanyl variants and precursors on its list of controlled substances,6 India has not placed fentanyl, or most other opioids, on its controlled substances list, easing production and export. India only regulates 17 of the 24 basic precursor chemicals for fentanyl (as listed by the UN 1988 Convention against Drugs).7
In the Middle East and Africa, the less potent opioid tramadol, not fentanyl, is responsible for the opioid crisis. India is the biggest supplier.
Tramadol is a less powerful opioid, though more potent if taken orally than injected due to its chemical makeup, and it is not regulated by international conventions nor in many countries. Tramadol is prescribed as a pain medication, but because of tramadol’s stimulant effects, it can allow people to feel high-functioning while taking dangerously high doses. This combination is dangerous: cities with high tramadol abuse have reported increasingly high rates of traffic accidents. In Garoua, Cameroon, hospitals can trace 80 percent of all traffic accidents resulting in hospital visits to tramadol,8 suggesting that at least half of adults in the city use tramadol. To make it even more apparent how dire tramadol addiction has become, hospital staff reported that people waiting for patients outside of the hospital gates would start convulsing, the sign of a tramadol overdose.9 In some countries, tramadol deaths outnumber heroin deaths.10
In the past year, U.S. law enforcement officials estimate that 1 billion tramadol tablets have been seized leaving India by the United States and its international partners in counter-narcotics, and actual exports could be exponentially greater.
In the past year, U.S. law enforcement officials estimate that 1 billion tramadol tablets have been seized leaving India by the United States and its international partners in counter- narcotics, and actual exports could be exponentially greater. Southeast Asian countries, which also do not regulate tramadol, are frequently used as transit countries, with tramadol repackaged in creative ways. Often, the tramadol is not seized until it reaches the Middle East.11 The former Drug Enforcement Administration (DEA) attaché for South Asia, the India Country Office, reported that “Libya has emerged as a significant hub for tramadol trafficking” and “the vast majority of these tramadol shipments originated from India via commercial shipping containers.”
Indian tramadol networks have even been linked to ISIS and Boko Haram, raising security concerns. There have been several instances of seizures of tramadol from India destined for Islamic State territory. In May, $75 million worth of tramadol, about 37 million pills, was seized in Italy en route to Misrata and Tobruk, Libya12; ISIS had purchased them for resale to ever-growing markets. The group has been involved in both the trafficking and consumption of tramadol,13 and the quantity of drugs being purchased by ISIS is so great that it can be assumed the group is selling a significant portion for profit.
The 37 million tramadol tablets purchased by ISIS had taken a familiar route from India through Southeast Asia. Neither India nor many Southeast Asian countries regulate tramadol, and since tramadol is not on the international drug schedule, it is only regulated if individual countries decide to classify it. But, if only one country classifies the drug and places it under regulation, it will not necessarily affect the supply. This was a problem for Egypt, which scheduled tramadol in hope of curbing abuse. Despite this, Indian tramadol exports to Egypt continued to rise and tramadol is the most abused drug in Egypt today.14
Tramadol is not on the international drug schedule, or a controlled substances list that mandates regulation, under the World Health Organization (WHO) and so individual countries’ attempts to regulate it often fail. For example, Egypt first scheduled tramadol in 2002 because of growing tramadol use, but since tramadol was not on the international drug schedule, India was not obligated to notify Egypt of an upcoming tramadol export. Thus, Indian exports to Egypt continued to rise and tramadol is the most abused drug in Egypt today. Egypt’s National Council on Fighting and Treating Addiction reported in 2013 that 30 percent of adults abused drugs.15
One potential reason India does not regulate tramadol, or other opioids, is the lack of domestic concern about addiction. However, India does have addiction problems, and India’s Home Minister Shri Rajnath Singh specifically acknowledged that tramadol addiction is a growing problem.16 Yet, the government acknowledgement has not been sufficient; government corruption plays a role with the pharmaceutical corporations, wholesale exporters, and internet companies responsible for the illicit flow of opioids out of India. In their 2017 report on corruption, Transparency International found that India had the highest bribery rates across the Asia Pacific region.17
The lack of international regulations also contributes to the problem. The WHO used the case of Egypt scheduling tramadol in 2002 and up-scheduling (labeling it as a greater threat) in 2009, presented by a German pharmaceutical company, as evidence that when tramadol is scheduled, consumption for legitimate medical use declines.18 Although the WHO acknowledges that tramadol is widely abused and that there have been huge seizures of the drug, it decided against critical review and international controls.19 The United States finally added tramadol to its drug schedule in 2013, as a Schedule IV drug, out of five classes, meaning it is regulated less than other drugs like heroin, fentanyl, methadone, or oxycodone.
Not only does the United States need to work closely with India to ensure tramadol misuse does not escalate at home, but more critically the U.S. needs to pay close attention to the networks and workarounds India has established in the tramadol trade, and prevent them from being used for fentanyl. The 2017 National Security Strategy advocated a stronger U.S.-India strategic partnership,20 and with the Trump administration’s prioritization of the opioid epidemic, this issue should be high on the U.S.-India partnership agenda.
Tramadol is cheap, widely available, and extensively abused. It is easily purchased by ISIS and anyone who does a google search for “tramadol from India.” Tramadol’s global networks raise significant security concerns and have great potential to be used for other drugs or illicit goods. As the world pays closer attention to fentanyl from China, there is room for another major supplier to the United States. India has been slow to regulate precursor chemicals and does not regulate fentanyl or tramadol. Indian traffickers have developed the worldwide networks. The drug threat from India requires a greater level of U.S.-India cooperation because it is too high to ignore.Natalie Tecimer is a program manager and research associate with the Wadhwani Chair in U.S.-India Policy Studies at CSIS.