A look at how a man-made opioid – marketed as less dangerous than similar drugs that are more tightly regulated – has spread addiction in the world’s most vulnerable nations.
It was supposed to be the safer opioid, a way to fight pain with little risk of addiction.
That promise has meant much less regulation of tramadol than other opioids. And its relatively low cost has made tramadol the drug of choice in many developing countries, where it is touted as everything from a mood enhancer to an elixir that can improve sexual stamina.
National writer Claire Galofaro spent months researching the issue after this summer’s United Nations world drug report depicted tramadol as “the other opioid crisis.” She downloaded so many documents about tramadol that she ultimately ran out of space on her computer and had to buy an external hard drive.
But how to illustrate the story from a fresh perspective?
India offered the answer. As both a center for the manufacture of counterfeit tramadol pills and a place where addiction was skyrocketing, India began regulating the drug in 2018, but tramadol is still widely available. Galofaro turned to New Delhi-based correspondent Emily Schmall, who traveled to Punjab state with senior video journalist Rishi Lekhi and photographer Channi Anand. The team gained unprecedented access to officials trying to stem the crisis, visited a treatment center and talked to people struggling with addiction. One woman became a heroin addict when her 14-year-old son died. A doctor prescribed tramadol to help her kick the habit — instead, she formed a new one.
A recovering tramadol user waits for her medication at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. India has twice the global average of illicit opiate consumption. Researchers estimate about 4 million Indians use heroin or other opioids, and a quarter of them live in the Punjab, India’s agricultural heartland.
AP Photo / Channi Anand
Drugstores, where tramadol was once easily available, line a street in Amritsar, in the northern Indian state of Punjab, Oct. 30, 2019. Before India regulated the man-made opioid in April 2018 the pills were everywhere, as legitimate medication sold in pharmacies, but also illicit counterfeits hawked by itinerant peddlers and street vendors. Still, the drug is widely available.
AP Photo / Channi Anand
A recovering drug user shows his veins at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. Researchers estimate about 4 million Indians use heroin or other opioids, and a quarter of them live in the Punjab, India’s agricultural heartland bordering Pakistan.
AP Photo / Channi Anand
A medic works at a drug treatment center where many cases of tramadol are recorded, in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019.
AP Photo / Channi Anand
A medic administers medicine to a recovering drug user at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. Man-made tramadol was billed as a safer alternative to other opioids, but it is now at the root of what the United Nations named “the other opioid crisis” – featured in fewer headlines as the U.S. epidemic – as it rages through the most vulnerable places on the planet.
AP Photo / Channi Anand
Jyoti Rani, a recovering tramadol drug user, breaks down while telling her story at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. Depressed over the death of her 14-year-old son, she fell into depression and became addicted to heroin. “I wanted to kill myself, but I ended up becoming an addict,” she cried. A doctor prescribed tramadol to help kick the habit, but she formed a new one. She locked herself in her room, not eating or taking care of two children. Rani used tramadol until she ran out of money and entered treatment. Now in recovery, her family tells her she’s become herself again.
AP Photo / Channi Anand
A recovering tramadol user signs a register after taking her medication at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019.
AP Photo / Channi Anand
Recovering drug users eat a meal at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. India has twice the global average of illicit opiate consumption, and a quarter of those users live in the Punjab, India’s agricultural heartland bordering Pakistan, where some of the most vulnerable are driven to drugs out of desperation.
AP Photo / Channi Anand
A recovering drug user eats a meal at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019.
AP Photo / Channi Anand
Amandeep Kaur, a former tramadol user, covers her face at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019. Kaur was pregnant when her husband died of a heart attack; she turned to the sex trade to make ends meet. She wanted not to feel, and a fellow sex worker suggested tramadol, eventually needing three pills to get through the day. “If I didn’t have it I felt lifeless, my body ached as if I was going to die,” she said. Eventually she joined the line stretching from the addiction clinic’s doors.
AP Photo / Channi Anand
Recovering drug users perform yoga at a treatment center in Kapurthala, in the northern Indian state of Punjab, Oct. 31, 2019.
AP Photo / Channi Anand
The deeply reported story, produced with support from the Pulitzer Center on Crisis Reporting, also delved into the toll tramadol is taking in Africa. In some countries there are now more people dealing with tramadol addiction than living with AIDS or HIV. Hundreds of thousands of pills, many knock-offs made in India, have found their way into the hands of Islamic State and Boko Haram terrorists, who sell them to fund their activities.
The story was one of the top-read pieces on AP News, with nearly 50,000 page views. It was used widely by AP customers in the United States and India, and cited prominently by an influential global newsletter on health.
For their work exposing an aspect of the international opioid crisis that has received far less attention, Galofaro and Schmall win AP’s Best of the Week award.