AMMAN: Khaled was standing in the doorway of his father’s cell phone store in north Homs three years ago when an artillery shell fell just meters away. It exploded on impact, scattering shrapnel in all directions. In an instant, Khaled sustained major nerve damage in his lower limbs and was paralyzed from the waist down.

After Khaled was injured in July 2015, the 23-year-old underwent treatment for the next 18 months at the field hospital in Rastan, the largest city in the encircled, opposition-held northern Homs countryside.

At the hospital, a doctor prescribed tramadol, an opioid painkiller, as part of Khaled’s treatment plan, in order to ease the pain caused by the nerve damage.

When Khaled’s treatment ended, the physician overseeing his case informed him that there was no need to continue taking tramadol, he says. But by then it was too late, he tells Syria Direct. He could not stop.

“The pain was gone,” Khaled tells Syria Direct from his home in Rastan. “But I kept on taking the medication because I couldn’t bear to go without it.” Khaled asked to not be referred to by his full name, fearing harm to his reputation and his family’s standing in the local community.

Khaled’s story is a textbook case of a broader public health crisis in opposition-held territories across Syria: the abuse of prescription medication in the wake of wartime injuries.

In the rebel-held countryside north of Homs city alone, at least 700 residents currently struggle with dependency on controlled medications, Majad Rajab, the head of a volunteer team there that works to raise awareness about addiction, tells Syria Direct.

Although prescription drug abuse existed in Syria before the outbreak of armed conflict, a combination of severe injuries caused by frequent bombardment and a lack of pharmaceutical regulation in rebel-held areas like north Homs is leaving medical personnel, civil society members and residents powerless to curb the spread of painkiller addiction.

Volunteers in north Homs post flyers on dangers of substance abuse in December 2017. Photo courtesy of VACT.

‘No alternatives’

Khaled lives his life along a set of routines. Every morning, he eats breakfast with his parents. At 10am, Khaled heads to the cell phone store with his father and works there until the early evening, then he returns home for dinner with his family. At night, the 23-year-old occasionally visits friends in Rastan or invites them to his home.

Khaled has another unchanging ritual: a daily dose of tramadol, typically one 50 mg pill in the morning and the other at night.

He’s been doing this for a year and a half.

Khaled says that he has tried to wean himself off the painkiller before, but his attempt was unsuccessful.

“I held on for two days,” he says. Without tramadol, “I can’t do anything, can’t work, nothing.”

Although the World Health Organization (WHO) categorizes tramadol as a “relatively safe analgesic,” the painkiller can induce mental and physical dependency “when used for prolonged periods of time,” more than several weeks or months, according to a June 2014 report by the WHO Expert Committee on Drug Dependence.

Abruptly stopping a regimen of tramadol commonly induces symptoms of withdrawal, including gastrointestinal pain, bone pain, insomnia, depression, excessive sweating and irritability.

“It’s as though there’s something unnatural happening in my body, a prickling sensation that something is missing,” says Khaled, describing a day without tramadol.

But the main reason Khaled continues to take painkillers, he says, is the impact on his mental and emotional state if he skips a dose.

“I break anything around me, scream at any any person who crosses my path,” the Rastan resident says.

“My parents are tired of these incidents and feel sorry for me,” says Khaled, adding that he claims to still to be in pain to excuse both his own behavior and his need for more tramadol.

Tramadol is one of a handful of painkillers and medications that commonly lead to dependency among residents of the the rebel-held northern Homs countryside, the head of psychology and neurology at Rastan’s field hospital tells Syria Direct.

Khaled’s packet of tramadol. Photo courtesy of Khaled.

Doctor Ahmad al-Beiruti, who also oversees all of the outpatient clinics in Rastan, says that he has noted an increase in non-medical use of painkillers such as tramadol and oxycodone, as well as muscle relaxers and psychiatric medications, since he began working in the northern Homs city six years ago.

Though trained as a pediatrician, al-Beiruti is one of just a few physicians with an interest and background in psychiatry and neurology in northern Homs, a besieged pocket of territory home to an estimated 240,000 residents. As such, he is “kept apprised of all cases of addiction” by medical personnel across the region, he says, as well as the staff of the Volunteer Addiction Control Team (VACT), an anti-drug initiative which began in north Homs in 2017.

The vast majority of the addiction cases in north Homs, the physician says, fall into three broad categories.

Some residents obtain antipsychotic drugs in an attempt to self-medicate. Without any medical supervision, they often ramp up their dosages or move onto stronger medications.

A portion of the population also struggles with addiction to illegal narcotics, drugs without any current medical use, a topic al-Beiruti says he is not well-versed in, seeing as it is not discussed “out in the open.”

But by far the largest portion of cases, the doctor says, concerns addiction to painkillers such as oxycodone and tramadol, which became a major issue after bombings on north Homs began in 2012, says the physician.

Rebel factions took control over north Homs, a collections of cities, towns villages and rural areas directly north of the provincial capital, in 2012 as protests against the government of Bashar al-Assad transformed into armed conflict.

The Syrian Arab Army (SAA) and allied forces encircled north Homs in stages over the next two years. Since then, pro-government forces have launched regular airstrikes and artillery shells on rebel military positions and residential areas in the pocket, routinely inflicting civilian casualties.

The Syrian government appears to be renewing its focus on wresting control of northern Homs from rebel forces this month. Pro-government forces have launched hundreds of airstrikes and artillery shells on north Homs in the past two weeks alongside a ground offensive aimed at breaking rebel defensive lines.

Treating civilians who sustained severe injuries in bombings—who often require amputations—“requires strong analgesics to numb the pain,” says al-Beiruti.

“There are no alternatives,” he adds, saying that despite the risk of dependence after prolonged use, “we can’t ban a painkiller just because it is addictive.”

Unregulated pharmacies

Every few weeks, Khaled takes a trip to a local pharmacy in Rastan and purchases a box of tramadol. As a young, unmarried man living at home with his family, he has few financial responsibilities and the money he makes at his father’s cell phone store is enough to cover the cost of his habit.

Even after Khaled’s physician stopped writing him prescriptions at the end of his treatment in early 2017, the Rastan resident says he had no trouble replenishing his supply of tramadol.

“You can get these drugs in pharmacies, even without a prescription, because there is little regulation,” says al-Beiruti. “Herein lies the problem.”

The Homs Health Directorate, the opposition body overseeing medical facilities and pharmacies in the province’s northern countryside, released a statement in early January calling for the registration of all unlicensed pharmacies, reported the pro-opposition, Gaziantep-based news outlet SNP.

An airstrike on Rastan city in north Homs Wednesday. Photo courtesy of the Syrian Civil Defense in Homs Province.

An estimated “70 unregulated pharmacies” in rebel-held north Homs are selling medication without proper licensing and supervision, Rahab a-Radwan, the head of the directorate’s Pharmaceutical Control Division, told SNP in the same report.

Talal Mardoud, president of the opposition-run Homs Health Directorate, says that those pharmacies operating “outside our control” are one of the main drivers of the high addiction rates in the region.

The underlying issue, he says, is that medications often enter the rebel-held Homs countryside through channels outside the purview of the Homs Health Directorate and the opposition-run locals councils in the region.

Though Syrian government forces maintain a blockade of north Homs, foodstuffs, medicines and other goods regularly enter the rebel-held pockets through formal crossings or backroad trafficking routes.

Convoys of humanitarian assistance, including basic medical supplies such as painkillers, enter north Homs several times a year through rebel-government crossings. Opposition-run local councils and bodies like the health directorate then distribute the aid to residents.

Traders with ties to government authorities or those willing to pay off checkpoint personnel also reportedly transport goods through these crossing in order to capitalize on the opportunity for profit.

In addition to aid convoys and commercial deliveries through formal crossings, goods like food and medicine enter the pocket through a series of smuggling routes connecting nearby government-held territory to rebel-held north Homs.

Smuggled medications can then be sold to pop-up pharmacies that operate outside the purview of the health directorate.

Both Mardoud and Majd Rajab, the head of the VACT volunteer team that works to raise awareness about addiction in north Homs, told Syria Direct they see the ongoing smuggling of painkillers into the region as a major obstacle to curbing addiction.

The health directorate head acknowledges that cracking down on these unlicensed pharmacies is only part of the solution. A licensed establishment could also sell controlled substances to residents without a doctor’s prescription.

The only course of action at the time, says Mardoud, is “regular inspections and monitoring” of pharmaceutical warehouses and pharmacies to ensure that strong medications are distributed only to residents with a prescription.

Despite the health directorate’s efforts to crack down on unregulated pharmacies since the beginning of the year, Khaled tells Syria Direct this month that he still has no issues getting tramadol.

“It’s normal, no big deal,” says Khaled. “[The pharmacists] even put some medication aside for me.”

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The rebel-held northern countryside of Homs in February 2018. Photo courtesy of Saif al-Hilaoui/AFP/Getty Images.

‘A silent death’

“Addiction: A silent death,” read a November 2017 social media post by VACT.

The anti-addiction initiative has worked to shatter that silence since its launch nine months ago, the organization’s president, Majd Rahab, tells Syria Direct.

He and his fellow volunteers were motivated to create VACT after noticing a rise in painkiller abuse in north Homs, he says, adding that it was starting to “become normalized.”

The team of 15 volunteers works to raise awareness about the dangers of painkiller addiction and its harmful physiological effects through social media campaigns and flyering around the cities, towns and villages of north Homs.

The team’s ultimate goal, though, is to establish the first rehabilitation center for addiction in the rebel-held countryside of Homs. Specialized centers for substance abuse already exist in Syria’s opposition-held south and north.

VACT has identified a team of medical personnel willing to volunteer at the proposed center—two pharmacists, 10 nurses and seven doctors, including Dr. al-Beiruti—but the project is still in its early stages, Rajab says.

The organization receives no external financial support and all of VACT’s activities are funded by the individual donations of its members, he adds.

At a specialized center, treating addiction to a substance like tramadol would not be overly complicated, as al-Beiruti sees it. The patient would need to be quarantined for at least 10 days, he says, during which medical personnel would treat the symptoms of withdrawal.

But sitting at his home in Rastan, Khaled says he feels there is nowhere to turn to get the help he needs, and that he cannot see a way out of the vicious cycle in which he finds himself.

“To be honest, I’m frustrated by the situation I’m in,” Khaled tells Syria Direct, “but there is no treatment, no center for cases like mine. What can I do?”

Khaled has stopped trying to quit taking tramadol on his own.

“As long as I take the medicine, I’m fine,” says Khaled, adding the tramadol helps him maintain a “normal” relationship with his family and his friends.

“I tell them that I am still in pain.”