Cairo, Egypt - As the sun rose on the first day of the Eid holiday, Youssef, an apprentice in a Cairo butcher shop, sat, knife in hand, covered in blood, nodding off. He had been awake for more than 24 hours, chopping up cows, goats and sheep in preparation for the holiday feast.

From the rowdy crowd of customers and bleating animals, another blood-covered butcher appeared with a packet of medication in hand. He popped a small red pill into Youssef's palm, and the apprentice took it immediately.

In minutes, Youssef - who declined to give his last name - was up, energised and back to work.

Lots of people take tramadol because they have two jobs and they can hardly sleep. - Ahmed Tourk, resident of Shubra neighborhood in Cairo

The pill was tramadol, an opiate that increases brain serotonin levels and relieves pain. This prescription-only painkiller is not as strong as heroin, but it shares many of the same effects. Although it is an opiate, it also has some anti-depressant properties, which make users feel more energetic.

Egyptians are using the pill as a recreational drug and also, reportedly, as an aphrodisiac. But most commonly, it serves as a cheap energy boost. At $3 for a sheet of ten pills, tramadol is generally affordable even in Egypt's dismal economy, and for many working-class people it has become a solution for the long, arduous workdays. A small-time Cairo drug dealer, who asked to be identified by the pseudonym Mohamed Farafiro, claimed that Egyptians like using the drug because it makes them productive.

Tramadol was first introduced to Egypt as a medication for cancer patients, and was produced in Germany and local pharmaceutical plants. Egyptians started experimenting with the pill roughly ten years ago, according to drug dealers, casual users, and the United Nations Office on Drugs and Crime.

Soon it caught on, and those who were taking tramadol to relax began to use it during work. Its popularity grew when the floundering job market forced many educated Egyptians into trade work and manual labour. "Lots of people take tramadol because they have two jobs and they can hardly sleep," said Ahmed Tourk, from the working-class Cairo neighborhood of Shubra.

Addictive, like heroin

Those using the drug as a practical work aid are not aware of its dangers, according to Dr Emad Hamdi, a psychologist and head researcher in Egypt's National Research Addiction Programme (NRAP). He said tramadol creates an extreme dependency with users, "more so than heroin".

NRAP research found that 60 percent of patients admitted to Cairo's rehab clinics were entering for tramadol addiction. Recently, Egypt's authorities have begun respond to the growing black market for the prescription pills. "People take it for work or recreationally, and they get addicted," said Hamdi. "It only takes a few days of consecutive use for the user to get hooked."

Faisal Hegazy is a programme officer at the United Nations Office on Drugs and Crime (UNODC) in Cairo. "Police began to realise tramadol was becoming a problem and started to crack down on pharmacies," he said, adding that anybody found with more than a couple sheets of tablets could face the death penalty or life imprisonment.

Nevertheless, the Egyptian market has begun to demand a higher quantity of tramadol, and with local pharmaceutical plants under watch, dealers have turned abroad. Importers have reportedly begun reaching out to traffickers, working with Indian and Chinese factories, which can produce tramadol in mass quantities, and at a higher dosage than the legal medication.

[Tramadol] carries less of a stigma than any of the other drugs in the country. - Dr Emad Hamdi, Egypt's National Research Addiction Programme

Reported rampant corruption among customs officials and the high volume of cargo containers that pass through Egypt's Suez Canal allow for the pills to enter the country with relative ease. Traffickers are understood to hide pallets of pills in cargo containers among furniture, home appliances, and industrial chemicals.

According to estimates given by the UNODC, some five billion pills circulated in the country in 2012. "There are 30 million containers circulating in the world, and only two percent are searched thoroughly," Hegazy said. "Shipments slip through borders easily."

'Less of a stigma'

The Quran explicitly bans alcohol, and although hashish - a cannabis product - has reportedly been used in Egypt since the 12th century, Muslim leaders often rail against the use of the drug.

But Hamdi claims that Egyptians have a more ambiguous relationship with tramadol. People who would never smoke a joint, he explained, may have fewer qualms about taking the painkiller. "It carries less of a stigma than any of the other drugs in the country," he said.

Farafiro, the Cairo-based dealer, said he knew of religious figures who would not touch alcohol, but do use tramadol. "A neighbourhood sheikh takes tramadol on Thursday nights to have sex with his wife," Farafiro claimed. "He goes to Gomaa [Friday] prayer still high."

While there is no clear data stating how many Egyptians consume tramadol, its economic importance to Egypt has grown in recent years. Trading in the hundreds of millions of dollars, it is one of Egypt's largest exports to both Libya and Gaza, according to the UNODC. Ten years ago, few people had heard of the pill. But now, Farafiro says, "tramadol is more popular than bread".

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