The INCB visited Egypt between 11th and 14th June 2017.The previous visit was in May 2001, and was included in the INCB’s Annual Report 2001, when the Board congratulated the commitment of Egypt to international drug control. These congratulations were prompted by actions such as the country’s determination to eradicate cannabis and opium crops in the Sinai Peninsula. The INCB were more critical, however, of the availability without prescription of controlled substances.  

The purpose of the latest visit was to review the implementation of the three international drug control treaties, and to discuss drug control developments since the 2001 mission. Likewise, the INCB wished to review the country’s challenges in the availability of controlled drugs for medical purposes, an area of particular relevance given Egypt’s concerns with tramadol.

The INCB appear to have had a close relationship in recent years over the synthetic opioid tramadol. At the 60th CND, Egypt submitted a conference paper concerning the tightening of control over tramadol, in which it made extensive use of INCB documentation dealing with tramadol including the Annual Reports for 2012, 2013, 2014 and 2015. The Conference Paper then states that:

The Egyptian authorities believe that the negative consequences of tramadol abuse necessitate that its control be expanded beyond a national control mechanism to be included under international control. In 2013, the Egyptian government proposed to the CND during its 56th session, a draft decision to support the international cooperation to prevent non-medical use of tramadol.

Again, as it did in the case of ketamine, the INCB is arguably exceeding its mandate under the international drug control conventions by making a similar argument to the Egyptian government. Recommendation on the scheduling of substances lies within the mandate of the WHO’s Expert Committee on Drug Dependence (ECDD), which has repeatedly undertaken pre-reviews on tramadol in recent years. Most recently, the ECDD carried out an update, which was contained in its 36th Report from 2014. Its recommendation on tramadol was: ‘Based on the evidence available regarding dependence, abuse and risks to public health, the Committee recommended that a critical review of tramadol is not warranted at this time.’ A critical review is the next step in the ECDD review process, and without its being undertaken a substance cannot be scheduled.

Amongst those who contributed evidence and views into the 2014 update process were pain specialists and pharmaceutical manufacturers, who commented that:

International control of tramadol would unnecessarily adversely affect the availability of tramadol for medical purposes in many countries worldwide that are not in need of further controls. In addition it is important to stress that tramadol is in many countries the only available stronger analgesic for patients suffering from moderate to severe pain. Therefore, an unwarranted scheduling of tramadol would contribute to worsening of the existing under-treatment of pain and lead to needless suffering of pain patients, especially in developing countries.

It will necessary to maintain a watch on the INCB and countries such as Egypt and their conduct in relation to tramadol. The campaign that prevented the international scheduling of ketamine can be marshalled again, but we cannot be certain that it will be as successful.

Thumbnail: Flickr CC frankieleon

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