The opioid crisis, “the misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids,” is a global phenomenon. While it has increasingly been described in North America, it is becoming evident throughout the world.The reasons for this are manifold. In “Physician’s role in prescribing opioids in developing countries,” Roa et al describe what can happen when a patient is inappropriately started and inappropriately continued on opioid therapy. They describe a patient with refractory migraine headaches who was given 100 mg of tramadol intramuscularly at a walk-in clinic. He experienced immediate relief. He then began to pursue this drug more frequently.

“His visits to such medical units became increasingly frequent and he always received the ‘magical injection’ which gradually became ‘the only medicine on earth capable of alleviating my pain.’ Since his strenuous job did not allow him to attend walk-in clinics every time another… episode occurred, he managed to obtain written prescriptions from a physician which allowed him to acquire the medicine from any local pharmacy. Later the opioid was acquired from irregular sources which the patient did not want to disclose.”

Soon after, the patient began administering the drug intravenously. He reported episodes of generalized seizures after administration of the drug. He also expressed suicidal ideation due to his dependence on the drug and misuse of finances in order to acquire the drug.

Opioid misuse, in particular tramadol, is on the rise around the globe. ii This is particularly concerning due to tramadol’s marketing and perception as a drug with “low abuse/dependence potential.” Many harm reduction strategies have been described but research on access to these treatments in the developing world is lacking. Methadone is on WHO’s list of essential medicines, and buprenorphine has also been a recommended addition. Physicians are culpable for the initiation of opioids in this patient. They are also liable for his continued dependence.  As the authors say, “Current approaches to deal with the opioid epidemic focus on newer strategies to manage chronic pain; however the role of the physician as a primary barrier to possible addiction remains underestimated, poorly discussed and most of the times, simply ignored.”

The authors continue, “The responsibility for the opioid crisis resides with governments, health authorities, pharmaceutical companies, pharmacies, physicians, healthcare providers and lastly with [patients].”