Palliative care and pain relief are an important cause of world sufferings, and about 80% of these sufferings are thought to occur in low-income countries.^{Reference Bhadelia, De Lima and Arreola-Ornelas1} Opioids are very important in pain management, and, unfortunately, they are the second most abused psychoactive drugs and present the greatest harm to the health of users.² Tramadol and codeine are the most abused opioids in Africa.²

Only about 1% of the opioids used worldwide is distributed to low-income countries, hence the clamour for increased opioid use in Africa in recent years; however, these efforts may not be sustainable since these drugs are not readily available.^{Reference Bhadelia, De Lima and Arreola-Ornelas1,Reference O’Brien, Schwartz and Plattner3} If not properly managed, this well-intended effort could worsen the abuse of opioids in Africa and, resultantly, pharmaceuticals may see Africa as a new profit-making ground.

Tramadol and codeine are affordable, less expensive, highly available, and may be abused for their analgesic, perceived calming and anti-fatigue effects to improve physical, intellectual, and working performances in Africa.² In predominantly Muslim countries with a strong injunction against psychoactive substances and where public codes of morality tend to condemn “intoxication” as unacceptable, an opportunity opens up for moderately powerful substances such as opioids with a medical alibi.^{Reference Klein4}

African opioid crisis, evident mainly in the abuse of tramadol and codeine prescription opioids, is fueled by cheap prescriptions, drug racketeering, Medicrime, drug trafficking, and high-level involvement in drug-related offenses.^{2,Reference Klein4,5} Obstacles to controlling the crisis include absence of quality data, weak public health response, poorly motivated drug law enforcement agencies, and health care workers often crippled by a lack of skills, resources, and efficient coordination.^{Reference Klein4,5}

A cursory review of the fight against cannabis misuse has revealed that restrictive legislations tend to encourage adulterated drugs, increase drug trafficking, and drug misuse.^{Reference Klein4} Nonetheless, the continent should be cautious with the liberalization of opioid use to avoid the mistakes of the West.² There is thus a need for a balanced approach to solving the African opioid crisis without undermining the care of patients in need of these medications.

Quality evidence-based data from epidemiological and aetiological studies should be available for policy formation and interventions that suit the African peculiarities. Where there is drug use disorder, attention should be more on prevention and interventions. Authorities should ensure appropriate legislation to streamline the prescription process tracking system, to prevent people from collecting multiple prescriptions, and to ensure appropriate sanctions for violators. Drug law implementation by medicine standards authorities should ensure the availability of opioids by focusing more on other aspects of the fight against opioid misuse such as Medicrime.^{Reference Klein4} Authorities and non-governmental organizations should scale up oversights of institutions involved in implementing drug laws and relevant guidelines to reduce the social costs of well-intended measures.^{Reference Klein4} Also, China and India should be persuaded to increase crackdown on African-bound opioids using diplomacy, since most of the seized drug consignments originate from these countries.²

In conclusion, despite the current African opioid crisis on the continent, licit opioid use can be encouraged with caution and strong political will.