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Commentary by Natalie Tecimer. Back to Issue 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 the most recent year with full data , Some expect these numbers to have tripled for , and six U. 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. In mid- October, two Chinese nationals were indicted for running a large illicit fentanyl distribution network and their three American accomplices were arrested. 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. 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 fentanyl variants and precursors on its list of controlled substances, 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 Convention against Drugs. 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. 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, 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. In the past year, U. 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. There have been several instances of seizures of tramadol from India destined for Islamic State territory. The group has been involved in both the trafficking and consumption of tramadol, 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. 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. For example, Egypt first scheduled tramadol in 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. One potential reason India does not regulate tramadol, or other opioids, is the lack of domestic concern about addiction. 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 report on corruption, Transparency International found that India had the highest bribery rates across the Asia Pacific region. The lack of international regulations also contributes to the problem. The WHO used the case of Egypt scheduling tramadol in and up-scheduling labeling it as a greater threat in , presented by a German pharmaceutical company, as evidence that when tramadol is scheduled, consumption for legitimate medical use declines. 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. The United States finally added tramadol to its drug schedule in , 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. The National Security Strategy advocated a stronger U. Tramadol is cheap, widely available, and extensively abused. 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. Natalie Tecimer is a program manager and research associate with the Wadhwani Chair in U. Commentary by Natalie Tecimer Published March 23, Full citations available in PDF.

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Misrata buying weed