Back in 2017, the Philadelphia Inquirer spoke with Chera Kowalski of the city's McPherson Square Park library, which had become something of a refuge for drug addicts with nowhere else to turn. In the previous two months alone, the then 33-year-old librarian had performed CPR and administered opioid-overdose spray Narcan on eight different overdose victims. Similar scenes have been playing out in towns across the U.S. in recent years, as an explosion of opioid addiction has turned into a veritable national public health emergency.

Part of a category of dopamine-releasing chemicals (with "opiate" used to specify natural opioids like morphine), opioid abuse traces its origins back through history, from the 19th-century Opium Wars in China to the 1970s spread of heroin abuse in the West. Today, the emergency is perhaps more insidious, as readily prescribed pharmaceutical painkillers start to lead to addiction and a gateway to heroin on the street. While in prior times, opioid abuse may have been concentrated in deprived communities, prescription opioids can now put almost anyone at risk.

And while much of the attention has been focused on the U.S., opioid addiction is leaving its tracks across Europe, Asia, and Africa. With this in mind, we take a look at how it is playing out in five different countries around the world:

1. France

In the mid-1990s, France was a success story for drug treatment, fighting off a heroin epidemic with the revolutionary decision to allow all doctors – not just addiction specialists – to prescribe the non-addictive opioid treatment drug buprenorphine. In four years, heroin addiction fell by 79%, supported by France's nationalised healthcare system.

Yet recent opioid abuse in France has been on the rise again, up 74% between 2004 and 2015, according to the French Observatory for Analgesic Medicine (OFMA). A 2018 investigation by the British Pharmaceutical Society linked an increase in oxycodone prescriptions in France to pharmaceutical marketing practices. The report found prescriptions of certain fentanyl variations rose as much as 263%.

A box full of benzodiazepines, the sleeping pills which Joseph Boudre was addicted to — Photo: Gotgot44

In 2016, Joseph Boudre died, aged 18, in his grandmother's home in Cannes, after consuming what he'd thought was morphine, reported French radio network Europe1. In middle school, he'd been prescribed benzodiazepines for his sleep, and in time, became addicted. Soon after, he turned to over-the-counter opiates for their high. His addiction engulfed him, and he turned to street drugs, where he met his death after accidentally consuming the opioid fentanyl.

"He wanted to stop, but it took over his body," describes his mother, Juliette. She detailed Joseph's story recently in book form, entitled Maman, ne me laisse pas m'endormir ("Mom, Don't Let Me Fall Asleep"). "Opioids made the situation worse because they're much stronger," she said. "They're the next step."

"There is a risk of an epidemic in France, but we're still in a situation where we can avoid it," says OFMA director Nicolas Authier. Currently, regulations in place are limiting another epidemic, with medical opiate use limited to 28 day programs, and direct-to-consumer drug marketing forbidden. The French National Agency for the Safety of Medicines and Health Products (ANSM) make sure to educate doctors about the risks of opioids, holding seminars on the topic and maintaining a number of observatories around the country monitoring opioid use.

2. Nigeria

In Nigeria, Islamic terror group Boko Haram is known to feed the prescription painkiller Tramadol to children. They push the pills into dates, then offer them to captive child soldiers, reported The Guardian in 2013. The drug makes them all but impervious to physical pain, as well as fatigue and hunger. Pushing young people to work beyond the limits of exhaustion, the opioid turns them into the perfect warriors. They tell the child it gives them courage and strength, that they will not feel their injuries during battle. The children are sent to their deaths in a trance, suicide bombers are sure they won't feel the heat of the blast.

But the painkillers are not just in the pockets of militants, but also everyday workers. A nation clasped by poverty, conflict, and unemployment means value in drugs that let you work longer, and diminish hunger. Out of 195 million people, almost 60% are in absolute poverty, with mass unemployment. This drives drug usage at a rate of almost three times the global average, according to Nigeria's Guardian. While cocaine and heroin are too expensive for most, Tramadol sells for $0.30 per strip of ten.

Last year, the UN called Tramadol and Codeine the most widely abused drugs in Nigeria. While the latter was banned following a BBC report, Tramadol remains ubiquitous. Nigeria's Daily Post reported over half a billion smuggled tablets of Tramadol seized at one of its ports last November. Without international regulation, importing it from India is fairly cheap.

UN reports suggest most of the drugs are trafficked to fund terror groups, including Boko Haram, raising the likelihood that the Islamist group buy the drugs for themselves, and sell on the surplus for profit. Legislative regulation alone won't work therefore, as seen in a recent random truck search in Owerri, which unveiled over 1,000 illegal packets of codeine alongside weaponry and ammunition, reported in Nigeria's Punch. By most accounts, prohibition simply drives the demand for illegal traffickers.

The Nigerian stigma around addiction means there is little Nigerian drug abuse data available, and a "dearth" of treatment centers, mostly funded by charities. WHO data shows abstinence-centered rehab programs, but no substitution therapy, which is more effective. It is therefore clear that tackling the issue requires strategies changing both the law and the stigma.

3. United States

Despite the heightened awareness, the opioid crisis in the U.S. is still full-blown. There are at least 115 daily opioid overdoses right now in the U.S., which could rise to 250 with the current spread of fentanyl and lack of resources in treatment centres, according to health magazine STAT. If so, the death toll for the decade would be comparable to that breast and prostate cancer.

The huge overdose rates are a result of overprescription, due to marketing campaigns by the likes of Purdue, which initially promoted the drugs as safer and less addictive than they are. Patients needlessly taking high-strength opioids became addicted, and once prescriptions run out, a steady supply on the street meant easy access for new addicts. Fentanyl overprescription persists years later, partly still due to pharmaceutical marketing.

NOPE (Narcotic Overdose Prevention Education) vigil in Florida — Photo: Jim Damaske/Tampa Bay Times/ZUMA

According to a study by Dartmouth University, 1997 to 2016 saw a nearly $10 billion increase in pharmaceutical drug-marketing spending, mostly physician-directed. The results were phenomenal, with consumer drug-spending increasing $213 billion in the same time frame. One of the most-marketed areas was chronic pain, which most opioids treat. While names like OxyContin are no longer heavily marketed due to backlash, heavy advertising is still common.

FDA strategies towards drug companies remain vague, and DEA failure to investigate the causes behind large opioid shipments last year was enough to merit a 324-page congressional report admonishing the agency. In 2017, President Donald Trump declared the crisis a Public Health Emergency, and a year later, signed a bill to expand treatment and research; but it did not provide sustained funding, and it faced wide criticism.

For current addicts however, treatment remains limited. Medication Assisted Treatment (otherwise known as substitution therapy) is underfunded. Accreditation for treatment centers is time and resource consuming, and requires renewal every 1 or 3 years. To prescribe buprenorphine, a first-line treatment for opiate addiction, doctors must take a special, 8-hour class. For those doctors that can access buprenorphine, the Atlantic reported that many fear being overrun by addicts, unable to treat other patients. But limited insurance coverage means most addicts are priced out of the treatment anyway. It is estimated that of those eligible for addiction treatment, only around 10% receive it.

4. Germany

"Germany risks suffering an opioid epidemic similar to that seen in the USA," said Christoph Stein, director of the anaesthesiology department at Charite hospital in Berlin.

Interviewed last year by German daily Die Welt, Stein said: "The use of opioids per person in Germany is already shockingly high and is barely distinguishable from the U.S. Even for a relatively minor operation, patients are sent home with big packs of opioids because the doctor wants to be sure that the patient is satisfied."

Still, despite growing usage rates, opioid deaths in Germany are rare and treatment is more easily accessible than in the U.S. Speaking to the German edition of The Local, deputy CEO of the German Center for Addiction Peter Raiser claims that for some 200,000 opioid-dependent Germans, regulations keep them protected. The latest Country Drug Report shows that for the 150,943 high-risk opioid users in Germany, there are 78,500 on opioid substitution treatment, a rate of treatment roughly four times higher than the U.S.

5. Palestine

"It numbs the pain," says Mahmoud, 35, of the little red Tramadol pill resting in his palm. The family man and former business owner from Gaza City first turned to the opioid after a bullet fragment hit his spine. Now an addict, Mahmoud shared his story last June with the Abu Dhabi-based The National newspaper. In Gaza, where locals say conflict and economic hardship turn existence into an "open-air prison," drugs are a common way to escape — and more and more, that means opioids.

Isolated economically from the outside world by Israel and Egypt in 2006, the Palestinian Territories have veered towards economic ruin ever since. The blockade drove unemployment up to 44%, and poverty rates to 53%. As poverty rose, so did drug use, which after the 2009 Gaza War, spiked dramatically. Inexpensive and accessible because of lack of international regulation, Tramadol flowed in from the first year after the conflict. Local psychologist Mohammed Salah, 32, told Vice that many of the addicts are suffering some form of PTSD. The locals nicknamed it "cocaine of the poor," and ever since, its popularity has only grown. "I have seen the top elites taking it — university students, girls and respectful people," Dr. Fadel Ashour told the Associated Press in February.

Palestinian anti-drug police in Gaza City in 2017 — Photo: Ashraf Amra/APA Images/ZUMA

Addiction is taboo in Gaza, so treatment is difficult to access or promote. Most treatment centers are small, and most addicts are too embarrassed to go. According to a 2017 report by the UN and World Health Organization, 2% of men in the region are "high-risk" drug users, with Tramadol as Gaza's most abused drug. Yet Dr. Ashour believes the true figure is much higher, with most feeling too shameful to come forward.

The drugs are smuggled into Palestine through tunnels from Egypt. Cutting the area's legal imports and exports made the black market grew, and in turn, the drug trade. Hamas quickly began to fight the abuse with a hardline anti-drug campaign. In 2010, they burned nearly 2 million tablets of the painkiller in a hospital incinerator. When most of the tunnels were destroyed by the Egyptian government in 2014 and 2015, smuggling became more complex, often inside other goods like washing machines, or even catapulted over border fences. Tramadol prices rose, which police see as a step forward to end drug abuse while continuing to focus on cutting supply.

But drug use is only increasing, even though penalties for trafficking became harsher, with two death penalties issued for drug dealers in 2017. Yet with a lack of funding, training, and equipment for the police force, they remain ineffective at catching abusers. In 2018, Vice spoke with a Tramadol dealer named Ahmed, 20, who said business was good. "My clients are poor people who want to forget," he said. "It's a way to stop existing without having to kill yourself."


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