Mohamed El-Fayoumy and his father Kerim didn't think there was much of a problem with their daily tramadol use.

That was until Kerim spent two months in jail on charges of drug dealing.

Mohamed, 41, and Kerim, 67, work as donkey and horse barbers in the working class Cairo district of El Malek El Salah.

In late 2017 the men were working on the edge of the neighbourhood, an area renowned for drug dealers. Undercover police officers searched their pockets and turned out a "few pills" but certainly not enough to go to jail, Mohamed thought at the time.

Mohamed and Kerim at work. ( ABC News: Hamada Elrasam )

What is tramadol? Prescription opioid in capsule form

Prescription opioid in capsule form Prescribed in many countries, including Australia

Prescribed in many countries, including Australia Highly addictive

Highly addictive Milder than heroin

"They started to fight with us and asked us where a certain dealer was but we told them we didn't know," Mohamed says.

"So then they accused my father of being a dealer, saying he had 40 pills in his pocket ready to sell and that's what they wrote on the report."

"They put him in jail for two months and we had to pay 3000 Egyptian pounds (AUD$220) to get him out," Mohamed says.

Mohamed up close and personal with one of his "clients". ( ABC News: Hamada Elrasam )

Tramadol, drug of the poor

Tramadol is widely used by manual laborers in Egypt.

"I take tramadol to minimise the pain of animal bites and to be able to work long hours at a time," Mohamed says.

Living with his extended family in a cramped one-room apartment, Mohamed says he must work long hours to provide for them — his mother recently died from breast cancer and he has three children under the age of 10.

With the cost of living in Egypt having drastically increased in the past few years due to the flotation of the Egyptian pound and the government's cutting of welfare for the poor, drugs like tramadol offer relief to people doing gruelling work.

Mohamed lives in a cramped apartment with his extended family ( ABC News: Hamada Elrasam )

Arab Spring to addiction crisis

Addiction rates in Egypt most likely increased since the 2011 revolution as tramadol became more widely available.

The Egyptian Revolution may have contributed to the rise of tramadol. ( Reuters: Suhaib Salem )

The end of dictator Hosni Mubarak's nearly three-decade rule following mass street protests brought with it the collapse of the police force and general security.

This made it virtually impossible for Egyptian security forces to effectively patrol sea ports and the 1150-kilometre border with Libya, making it easier for drugs and weapons to be smuggled into Egypt.

This was coupled with a worsening economy and increased unemployment, leading to an environment ripe for drug abuse.

Opioids sweep the globe

But it is certainly not just an Egyptian problem.

In October last year, US President Donald Trump declared the opioid crisis a public health emergency, claiming more than 59,000 lives in 2016 in America alone.

Australia also has an increasing problem, with the National Drug and Alcohol Research Centre finding that prescription opioids now kill more Australians than heroin.

The report found that between 1990 and 2014, there had been a fourfold increase in the prescribing of opioids such as tramadol, OxyContin and fentanyl, which is up to 50 times more powerful than heroin.

In 2013, 597 Australians were estimated to have died from accidental overdose of opioids, according to the Australian Bureau of Statistics.

'Life would be very hard'

Like many who use tramadol regularly, Mohamed claims he is not addicted and will continue taking it in spite of the risks.

"I take one in the morning and another two later in the day — I'm not addicted but because it now costs 20 Egyptian pounds [$AUD 1.50] I need to reconsider taking it.

"It would be very easy to quit. But then life would be very hard."

Mohamed takes a break from his work as an animal barber. ( ABC News: Hamada Elrasam )

Others, such as 30-year-old bank teller Mahmoud, say they use tramadol for recreational purposes.

"I take a few pills a week and mostly on the weekends, it's something that makes me feel relaxed but also powerful," he says.

In a smoky PlayStation cafe in the wealthy suburb Maadi, Mahmoud is sweating heavily and speaking quickly after taking a tramadol pill.

"Life is hard and stressful in Cairo and tramadol makes me feel like I can deal with it."

Most abused drug

The widespread abuse of tramadol has become an alarming public health concern for the Egyptian government in recent years.

It is difficult to accurately gauge how many Egyptians use the drug, but the Drug Control Fund treatment centre estimated in 2015 that tramadol is the most abused substance in Egypt. Around half of Egypt's 100,000 opioid users are dependent on tramadol, the other half heroin, according to the Ministry of Health and United Nations Office on Drugs and Crime's 2015 estimates.

Calls to the Drug Control Fund hotline doubled in the first half of 2017, reaching 48,000 calls, according to Social Solidarity Minister Ghada Wali. And in early April, calls to the hotline increased 400 per cent following an anti-drug video starring the astronomically popular Egyptian soccer player Mohamed Salah, Ms Wali says.

Mohamed, a donkey and horse barber, drinks tea while waiting for clients. ( ABC News: Hamada Elrasam )

Government cracks down

Since President Abdel-Fattah al-Sisi came to power by leading a military coup in 2013 on the back of mass protests against his Islamist predecessor, the security state has returned in full force, tightening the previously lax control of borders and ports.

The government has attempted to crackdown on tramadol availability which in turn has made it more expensive.

Some drug-dealing suspects have faced harsh consequences — last year a British woman was jailed after being found with almost three hundred pills when she arrived at a Red Sea resort.

Laura Plummer, who was sentenced to three years in jail, claims she was unaware that the pills were illegal and that they were for her Egyptian husband who had back pain.

There are also accusations, however, that police are often complicit with drug dealers and that those convicted of trafficking are out of jail within months.

Mohamed cuts a dog's hair in Old Cairo. ( ABC News: Hamada Elrasam )

No substitutes

Yet there are limited options for drug addicts to recover.

"There is not enough money provided to the public sector and in the private sector doctors aren't given the authority to carry out what experts suggest," says Dr El Amrousy, a specialist who runs a private addiction clinic in Cairo and was the former head of addiction with the health ministry.

"There are no substitutes available in Egypt.

"Many people, when they want to quit tramadol, move onto heroin because there are no options for opiate substitutes," he adds.

Dr Mohamed Hamed, a UNODC programs officer, cites a lack of awareness on where and how people can access addiction treatment in the country.

"There is a lack of evidence-based treatment such as opioid substitution therapy — it's not legal in Egypt," he says.

He believes a pilot project to test opioid substitution that the government is considering could help up to 60 per cent of addicts, based on UNODC research.

Mohamed plays with a dog. Animal bites are one of the reasons he uses tramadol. ( ABC News: Hamada Elrasam )

Recovery

Farris, a 27-year-old freelance photographer, successfully quit tramadol.

He previously abused a range of substances, but says tramadol was his go-to drug.

"It ruined my life," he says, smoking a cigarette outside a photo exhibition in the prosperous Cairo suburb Heliopolis.

"Many people around me died because of drugs."

Through his late teens and early 20s, Farris was in hospital half a dozen times because of his drug use.

Now he's been clean for a little over three years.

Farris attends Narcotics Anonymous sessions a few times a week and says he was lucky because of his supportive middle-class family.

The entrance to Amr Ibn El Aas cemetery, in an Old Cairo neighbourhood famous for drug dealing. ( ABC News: Hamada Elrasam )

For Ahmed, 32, from an impoverished informal neighbourhood north of Cairo, it took having a daughter, big debts and the death of a family member after taking tramadol to consider quitting.

"I took it for 10 years, everyday and it was controlling my body completely," Ahmed says.

"During that time I had two jobs and was working so hard and the only way to continue was by taking the pill and in the end I was taking 12 a day."

One time, his wife said they urgently needed to take his daughter to the doctor. "I felt nothing and I didn't have the pills so I couldn't go anywhere. After I stopped doing pills I thought, "how could I leave my daughter?", she's sick and I'm not going to the doctor."

"When I didn't have pills I couldn't even go downstairs to get food for my family but once the dealer called I'd be out in a second and when I'd take the pill I felt like I could walk to Alexandria," Ahmed says.

Shedding shame

Farris says it's difficult for people to see themselves as addicted. When people first suggested he get help, he refused.

"I was hearing but not listening," he says.

"Here in the Middle East, being addicted is very shameful … but after some time, I realised that addiction is a sickness and disease."

Having reached step five in the Narcotics Anonymous program, Farris feels confident that he can stay away from tramadol.