Tramadol misuse in the Niger Delta; A review of cases presenting within a year

ABSTRACT

Objective: Tramadol is an opioid agent used for pain management with huge potentials of misuse. The misuse of Tramadol is associated with increased morbidity and mortality; and this is common among young adults in low-income settings. The aim of this study is to highlight cases of Tramadol misuse managed in a rural teaching hospital in the Niger Delta region of Nigeria.

Method: We used the case report design to highlight five cases of Tramadol misuse in our setting over a year period.

Results: Majority of the cases were males and young adults using Tramadol for non-medical purposes. They all presented with various clinical features including altered levels of consciousness.

Conclusion: Tramadol misuse among young male adults is common in our region. Further research and intervention programs are essential to understand the true burden and also prevent further misuse in the community.

KEYWORDS:

• Tramadol misuse
• Niger Delta
• young adults
• males

Introduction

Tramadol is an opioid analgesic used mainly for treatment of moderate to severe pain (Miotto et al., 2017; United Nations office on Drugs and Crime, 2013). It has high potentials for misuse (Kertesz, 2017; World Health Organization, 2014). According to the United Nations Office on Drugs and Crime (UNODC), there are about 35 million users of opioids globally (United Nations Office on Drugs and Crime, 2017). Although Cannabis remains the world’s most widely used illicit drug (135 million users), opioids (such as morphine, heroin, methadone, buprenorphine, codeine, tramadol, oxycodone, and hydrocodone) are known to cause the greatest negative health impact (United Nations Office on Drugs and Crime, 2017). Out of the 17 million disability adjust life years attributable to substance use disorders, opioids contribute up to 12 million (United Nations Office on Drugs and Crime, 2017). In addition to the economic toll, the World Health organization report that globally, the yearly mortality on account of opioid overdose was between 70000 and 100000 deaths (World Health Organization, 2014).

Global trends indicate an increased misuse of opioids with a 5% prevalence reported in Europe (United Nations Office on Drugs and Crime, 2017). An online survey of UK university students listed Tramadol as among the most commonly misused prescription drug (Holloway, Bennett, Parry, & Gorden, 2014). This trend was noted also in many parts of Asia and Africa. A study in Egypt indicated that Tramadol is the most abused opioid (Mohamed, El Hamrawy, Shalaby, El Bahy, & Allah, 2015); while a study in Iran reported a 4.8% (men7.6%, women 1.8%) lifetime prevalence of Tramadol misuse (Nazarzadeh, Bidel, & Carson, 2014). A recent Lancet world report highlights the opioid crisis in Africa and its use for non-medical purposes (Salm-Reifferscheidt, 2018).

Studies in Nigeria indicate the use of Tramadol cuts across all parts of the country. In Kano, Northern Nigeria, a cross sectional study amongst commercial bus drivers reported that 85.2% of respondents misuse Tramadol (Yunusa, Bello, Idris, Haddad, & Adamu, 2017). Another cross sectional study among ‘Almajiris’ (street children), in Borno Northern Nigeria, reported a 7% prevalence of Tramadol misuse (Abdulmalik, Omigbodun, Beida, & Adedokun, 2009). In Owerri, South East Nigeria, a survey of the use of psychoactive substances amongst university students indicated that 53.4% admitted the use of Tramadol (Duru, Oluoha, Okafor, Diwe, & Iwu, 2017). Studies report various reasons for the misuse of Tramadol.

The 2017 UNODC report indicate that Tramadol use was common among younger people and peaks in childhood before 15 years. There was also increased use among individuals with STI and HIV (United Nations Office on Drugs and Crime, 2017). However, prescription of pain reliever was associated with the use of an opioid eight times more than other factors (United Nations Office on Drugs and Crime, 2017). Reasons for use of Tramadol include the need to relax, increase strength and sleep (Salm-Reifferscheidt, 2018; Yunusa et al., 2017) and this was higher in individuals of lower educational status or engaged in manual or strenuous jobs. In the study among university students, the predictor of use of psychoactive substances includes gender (males 5 times more than females), living away from parents, parental marital status and staying in a hostel (Duru et al., 2017). Abdulmalik and colleagues identified poverty, unstable family structure and being born in a polygamous family as correlates of use of psychoactive substances (Abdulmalik et al., 2009).

Tramadol misuse has several health consequences and also associated with mortality. In the Niger Delta region of Nigeria, we are unaware of any study on the non-medical use of Tramadol. Hence, we decided to report these cases to highlight the dangers associated with Tramadol misuse in our setting. This study is important to inform public health practice and the need for addiction management in health institutions in the country to address the health needs of affected individuals.

Case presentation

We used the case report method to explore five cases of Tramadol misuse that presented at the emergency room of the Niger Delta University Teaching Hospital (NDUTH) within a year period (2017). The NDUTH is a 150-bed tertiary institution located at Okolobiri, a suburban setting which is about 15 minutes drive from Yenagoa (Bayelsa State) in the Niger Delta of Nigeria. Available records indicate the hospital attends to about 200 to 280 patients monthly on the average with a slightly higher female patient attendance. The low patronage was attributed to the location of the hospital and the apparent high poverty level in the region. Patients often go to religious healers, traditional healers, and local chemists first when they are sick. They mostly come to NDUTH for severe illnesses. However, patient turnout has been on the rise in recent times with the newly introduced Health Insurance Scheme. Table 1 summarizes the demographic and clinical characteristics of the cases.

Table 1. Demographic and clinical characteristics of the cases.

Cases	Gender	Age	Marital status	Lives With	Family Structure	Level of Education	Occupation	Doses Taken (mg)	Reasons for using Tramadol	Clinical features	Other substances used	Past Psychiatric history	Treatment outcome
1	Male	24	Single	Parents and siblings	Monogamous; parents married	Secondary	Computer Operator	1000	Not stated	Insomnia, restless, incoherent speech, reduced consciousness.	codeine	Nil	Good
2	Male	28	Single	Alone	Polygamous; parents separated	Secondary	Footballer	1400	Pain relief	Fainting, restless, incoherent speech, reduced consciousness, seizure.	Nil	Nil	Good
3	Male	18	Single	Parents and siblings	Monogamous; parents married	Secondary	Student	800	Memory aid, to relax, confidence	Fainting, incoherent speech, reduced consciousness.	Cigarette, alcohol	Nil	Good
4	Male	20	Single	Mother	Polygamous; parents separated	Secondary	Unemployed	1200	To relax, confidence	Dizziness, fall, restless, reduced consciousness.	Alcohol	Nil	Good
5	Female	25	Married	Husband and children	Polygamous	Tertiary	Nurse	800	Pain relief	Dizziness, excessive sleep	Nil	Anxiety disorder	Good

Case 1

IE is a 24-year-old computer operator with a secondary level of education. He is single and resides with his parents and siblings. He presented with a week history of restlessness, irrational and incoherent speech, destructive behavior and insomnia. There were associated loss of appetite, visual and auditory hallucinations and hyperactivity. He had taken about 1000 mg of Tramadol daily (normal recommended adult daily dose is about 200–400 mg) for four days prior to onset of symptoms and was found to be in possession of several 200 mg tablets of Tramadol at presentation. He purchased the Tramadol over the counter without a doctor’s prescription. He did not give any reason for taking Tramadol when asked. He occasionally took codeine-containing cough syrup with the Tramadol but could not give more details. He denied the use of other psychoactive substances and had no past history of a mental illness. Examination revealed a young man who was restless and agitated. He was talkative and in an altered level of consciousness (Glasgow Coma Score (GCS) was about 12). The pulse (106/minute) and blood pressure (150/90 mmHg) were elevated at presentation He was given Intravenous (IV) fluids and sedated with parenteral Chlorpromazine and Diazepam. Laboratory investigations were normal. He was admitted and placed on Olanzapine tablets. Five days later he was calm and much improved in his mental state. He was discharged on request and was seen a week later at the outpatient clinic. He has remained stable so far and reports from patient and family indicate he has been abstinent from Tramadol and codeine.

Case 2

OP is a 28-year-old footballer with secondary level of education and lives alone in a single room apartment. He is from a polygamous home and parents are separated. He had been taking Tramadol prescribed by a pharmacist, at therapeutic doses, for body pains. He was brought to the accident and emergency (A&E) unit following the sudden collapse, convulsion and loss of consciousness after ingesting 1400 mg of Tramadol in a single dose. He was in obvious respiratory distress and had incoherent speech. No history of use of other psychoactive substances and he had no diagnosed mental illness or seizure disorder in the past. Glasgow coma Score was 9 at presentation. His pulse rate, blood pressure, and respiratory rate were all elevated. Body temperature was normal. He had another episode of generalized tonic-clonic seizure in the A&E unit. He was given IV Diazepam, IV fluids, Tegretol tablets and admitted. He was jointly managed with the neurology unit. The patient stayed two weeks in the hospital. He regained full consciousness and insight and was seizure-free. He admitted to using the large dose of Tramadol because he had severe backache that day. He also confessed that he loved taking Tramadol because it had a calming effect on him. He was discharged after counseling and given multivitamins alone. He has been seen on two follow up visits and is so far abstinent of Tramadol from self-reports.

Case 3

MF is an 18-year-old secondary school final year student who was writing his final examinations at presentation. He lived with his parents and siblings. He had been smoking cigarettes and taking alcohol occasionally for about two years. His friends were also doing the same but his parents were not aware of that. He was also introduced to Tramadol by friends. It made him feel confident and happy. He started with 100 to 300 mg daily but increased it gradually. He had been taking Tramadol for over three months before presentation. He presented with a history of sudden blackout and fall with the loss of consciousness while he was writing an examination in school. There was no associated seizure. He sustained an injury to the left eye on account of the falls. He took 800 mg of Tramadol that morning before going to school. He had never taken such a high dose before and took the present dose to aid his memory in the examination. He was subsequently brought to the A&E unit by the school authorities who also called his parents. Examination showed a young man who was unconscious (GCS 10), had incomprehensible speech and somewhat restless. He had a swollen left eye with bruises. Vital signs and routine laboratory investigations were essentially normal. He was sedated with IV diazepam, given IV fluids and routine vitals signs/input-output monitoring. The Ophthalmologists also co-managed this patient. He regained full consciousness and insight after two days on admission. He was discharged after counseling on request of his parents to enable him to continue with his examinations. However, he is yet to present for follow up since then.

Case 4

AE is a 20-year-old secondary school dropout from a polygamous family. Both parents are small-scale farmers and traders. He is the fifth of his mother’s six children. His parents are separated and he lives with his mother. He engages in menial jobs occasionally to meet some needs. He was introduced to Tramadol by his friends and also takes alcohol occasionally. He took 1200 mg of Tramadol mixed with a glass of alcohol (about 200 ml of beer) at once. This was to make him relaxed and bold enough to approach a lady he was interested in. Subsequently, he became very dizzy and fell a number of times. He was brought into the emergency room of the NDUTH by friends. At presentation, his speech was incoherent and irrational. He had an altered level of consciousness (GCS 11) and was restless. There was no respiratory distress but his pulse rate was elevated at 104 per min. Other vital signs were essentially normal. An assessment of acute intoxication with alcohol and Tramadol was made. He was admitted for observation and given IV fluids and Diazepam. Laboratory investigations were within normal limits. By the next day he was fully conscious and speech was rational. He was counseled with his mother and discharged on multivitamins. He has been seen on two follow up visits so far and has reported abstinence from alcohol and Tramadol.

Case 5

LC is a 25-year-old staff nurse, from a polygamous home but happily married with two children. She is a known peptic ulcer disease patient and was previously treated for an anxiety disorder by a private Psychiatrist a few years ago. She started using Tramadol intermittently about 3 years ago to help relieve the ulcer pain. Over time, she began using it almost on a daily basis and increased from 200 mg to 600 mg daily. At presentation she was taking up to 800 mg daily, usually in divided doses. She had difficulty stopping or controlling the use of Tramadol. She presented voluntarily with complaints of dizziness and excessive daytime sleepiness which was affecting her productivity at work. She also expressed a desire to stop taking the substance. Her mood was stable and no other obvious psychopathology was found on examination. An assessment of Tramadol dependence was made. She opted for outpatient care. We placed her on a reducing regiment of Diazepam starting from 40 mg in daily divided doses over a week period. She was counseled and told to come for follow up a week later. She was also given a certificate to exempt her from duty at her workplace for that period. She has been seen on three weekly follow up visits so far and has reported abstinence from Tramadol. She is also stable in her mental state.

Discussion

We have presented five cases of Tramadol misuse that presented within the period of one year in a tertiary teaching hospital in the Niger Delta. Our study reveals that most of the study participants were males and young adults; and presented with altered levels of consciousness. This observation is in line with the reports of past studies that showed higher rates of Tramadol misuse in males compared to females (Abdulmalik et al., 2009; Mageid, 2017). Studies and media reports in recent times have highlighted an increasing use of opioids especially among the youths globally (United Nations Office on Drugs and Crime, 2017). While the high rate of opioid misuse in the US and other developed nations have been emphasized, the rate in developing countries like Nigeria are also on the increase and may be largely unknown and under-reported (World Health Organization, 2014).

We found no pattern in the living arrangement and occupation of the study participants. Two lived with both parents/siblings while others lived alone/with one parent/with husband and children. Duru and colleagues reported that Tramadol misuse was more common among young people who lived alone or apart from their parents (Duru et al., 2017). Such living arrangement may limit parental watch and control. Thus, the youths have a lot of freedom and may be easily negatively influenced by their peers. Other studies did not really investigate the relationship of living arrangements and Tramadol use. The small size of our cases could have blurred any association between living arrangement and Tramadol use. It may be possible that who an individual lives with could influence substance use behavior and this could be worth investigating further. Tramadol misuse has been reported more among those from polygamous, unstable homes; among the cases we presented, 60% are from polygamous homes and parents are separated among 40% of them. Similar trends have also been reported (Abdulmalik et al., 2009; United Nations Office on Drugs and Crime, 2017). Again, there may be poorer parental control in polygamous homes. Predictors of Tramadol misuse from previous studies generally include male sex, living apart from parents, living in a hostel, polygamous family setting, low socioeconomic status and parental marital status (Abdulmalik et al., 2009; Duru et al., 2017).

All cases presented used between 800 and 1400 mg of Tramadol. These were about 2–4 times higher than the recommended daily doses of 400 mg (Dayer, Desmeules, & Collart, 1997) and would naturally result in toxicity and adverse effects. The common trend of the dose used among all the cases was starting from a normal therapeutic dose and self-increasing to very high doses. Common clinical presentations were dizziness (100%), altered consciousness (80%), incoherent speech (80%), restlessness (60%) and falls/seizures (40%). These are in line with the pharmacological effects of Tramadol above therapeutic doses (Miotto et al., 2017).

Four out of five cases offered reasons for using Tramadol. These include pain relieve, to relax and relieve anxiety, to boost confidence and aid memory. Yunusa and colleagues reported that most of their study participants used Tramadol to enable them relax, boost their confidence and enhance sleep (Yunusa et al., 2017). We found that 3(60%) of the study participants used Tramadol in addition to other substances. Alcohol and codeine were other substances the patients use. Studies have previously documented multiple substance uses among individuals who misuse Tramadol (Abdulmalik et al., 2009; Mageid 2017).

Initial and short-term treatment outcomes for all the cases were satisfactory. This emphasizes the need for prompt and personalized management of such cases as early as possible. There is also a need for immediate and long term follow up management. Most (80%) of the cases presented for follow up while one was not seen again after satisfactory initial management. Above all, prevention of Tramadol misuse should be the priority.

Our study is not without limitation. We have reported only five cases that presented in our setting within a year period. This may not reflect the true prevalence of Tramadol misuse in our setting because these cases presented on account of life-threatening acute manifestations of Tramadol misuse. Those with few or tolerable effects may not have come to the hospital.

Conclusion

The misuse of Tramadol and other opioid drugs is on the increase and has attained epidemic proportions globally. In Nigeria and other African countries, the true prevalence may not be known and there is most likely a gross under-reporting as with misuse of other substances. There are increasing media reports (Ifijeh, Isiguzo, Babalola, & Addeh, 2017) and unofficial anecdotal reports of widespread Tramadol misuse in Nigeria in recent times. Young people are mostly involved in Tramadol misuse with the attendant negative effects on their health and socioeconomic wellbeing. The misuse of Tramadol and other opioids by young adults has huge economic implications for every nation. The time for action is now. All effort must be made to prevent inappropriate Tramadol use and provide help and rehabilitation to those affected. But first, we should be able to investigate the real extent of the problem. We have only presented five cases; there may be thousands more who did not present to us. There is a need for population-based studies to determine the true prevalence of Tramadol misuse in our setting and the country. It is essential that intervention programs target young adults using health education and information to address the myths and misconceptions about the usefulness of Tramadol misuse.

Disclosure of potential conflicts of interest

The authors report no conflict of interest. They authors received no funding for the study.

Ethical considerations

Clearance for case presentation was obtained from the Research and Ethics Committee of the Niger Delta University Teaching Hospital, Bayelsa State. Informed consent was also obtained from the patients and caregivers.

Acknowledgments

The authors express profound gratitude to the patients, caregivers and Medical Officers who were involved in the management of these patients. We also thank all those who made this presentation possible.