Environmental Science and Pollution Research

https://doi.org/10.1007/s11356-020-08040-8

RENEWABLE ENERGY AND WATER SUSTAINABILITY

Tramadol abuse among workers in an industrial city in mid-Nile Delta

region, Egypt
Mahmoud Rabee Abd-Elkader 1 & Ibrahim Ali Kabbash 2 & Rania M. El-Sallamy 3 & Hossam El-Sawy 4 &
El-Sayyed Abdel-Hameed Gad 4

Received: 7 May 2019 / Accepted: 10 February 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Tramadol abuse is an increasingly alarming phenomenon among Egyptian Community especially among workers and drivers.
Study profile and factors affecting tramadol abuse among industrial workers in Mid-Nile Delta Region. A cross sectional study
among minibus drivers, construction and textile industries workers. From each target group 300 males were chosen randomly.
The total sample size was 900 persons. Interview questionnaire was used for data collection. Diagnosis of tramadol abuse was
according DSM-5 Criteria. Intake of tramadol was high among construction workers (92.3%) followed by bus drivers (53.0%)
and lastly textile workers (25.3%). The main source of tramadol was friends (45.4%) followed by drug dealers (16.6%). The main
reason of abuse was to improve mood (54.3%) followed by relief of pain and help to continue work (37.3%). Tramadol is
prevalent among industrial workers due to different reasons related to the work load and stressful events. Ever intake of tramadol
was high among construction workers followed by bus drivers and lastly textile workers. Drug testing for workers in workplace is
a must to ensure community safety.

Keywords Tramadol . Abuse . Workers . Drivers

Introduction Tramadol abuse is an increasingly alarming phenomenon

Tramadol is centrally acting opioid analgesics used for the
management of mild to severe pain. It is a commonly pre-
scribed painkiller. The analgesic actions of tramadol arise
from dual mechanism of action by agonist actions of the drug
at the μ-opioid receptor causing analgesia and sedation by
inhibiting serotonin and norepinephrine reuptake reducing
pain perception (El-Hadidy and Helaly 2015; Grond and
Sablotzki 2004).
Responsible editor: Philippe Garrigues
* Ibrahim Ali Kabbash
iafkabbash@gmail.com; Ibrahim.kabbash@med.tanta.edu.eg
1
Ministry of Health and Population, Cairo, Egypt
2
Public Health and Community Medicine, Faculty of Medicine Tanta
University, Tanta, Egypt
3
Occupational Medicine at Public Health and Community Medicine,
Faculty of Medicine Tanta University, Tanta, Egypt
4
Department of Neuro Psychiatry - Faculty of Medicine, Tanta
University, Tanta, Egypt
and widely spread among the Egyptian Community especially
among workers and drivers. In an Egyptian study, tramadol
was found to be second most common substance abused after
cannabis (El-Hadidy and Helaly 2015). Recently noticeable
and very obvious increase in all forms of violence, rape, ag-
gression, and traffic accidents were closely related to drug
abuse (Fawzi 2011).
Tramadol low price and availability without prescription
make it very popular. It is used by workers as a remedy for
premature ejaculation, increase sexual desire and for extended
orgasm. Its unintentional promotion by media, chemical
sellers/pharmacies, friends, and relatives helped in increasing
their usage until becoming abused (Caroline et al. 2017).
Construction workers by the nature of their occupation en-
gaged in strenuous hard work. Some construction workers are
engaged in other additional manual jobs aside construction
work which make them prone to muscle and joint pains, gen-
eralized body aches, and headache. So, they use tramadol for
pain relief and to cope with the exigencies of the job (Fawzi
2011).
Bus drivers usually drive for long distance and spend long
hours in a single posture without breaks especially in rural

areas with very bad roads. Thus, bus drivers are at a higher risk
to develop low back pain (LBP), inter vertebral disc prolepses,
and degenerative changes compared to other people (Jadhav
2016). World Health Organization (WHO) reported that 37%
of LBP is attributed to occupational risk factors (WHO 2009).
Bus drivers are required to be alert while driving without
taking sufficient periods of rest and sleep. So, they use stim-
ulant drugs particularly tramadol. Drug abuse among drivers
is a serious health problem as driving a motor vehicle under
influence of these elicited drugs may cause injuries not only to
a drugged driver but also to other drivers, passengers, and
pedestrians (Kaznga et al. 2012).
Tramadol is also used for alleviating symptoms of depres-
sion, anxiety, and nervousness caused by work stress, and
stress of life; by its action on noradrenergic system increasing
level of serotonin. WHO has highlighted the dangers of tram-
adol abuse and dependence (Fawzi 2011; Jadhav 2016).
Numerous studies involving dead or injured drivers of road
traffic accidents, confirmed that they were under the effect of
drugs and these drugs as tramadol significantly reduce driving
ability, lead to reduced perception, and attention (i.e., the abil-
ity to keep focused on a particular task over the time).
Tramadol-related fatalities are growing especially among
abusers. Tramadol-related deaths in 2008 were 32.5 times
more frequent than in 2005 (Hogado et al. 2018; Fawzi
2011; Carfora et al. 2018).
The European Union report of driving under the influence
of drugs stated that the relative risk is 2–10 times of being
seriously injured or killed in an accident while being positive
for opioids which impair tasks related to driving ability
(Herrera-Gomez et al. 2018). However, the legal framework
establishing the regulations varies according to the social, le-
gal, and economic characteristics of each country (EMCDDA
2018; WHO 2016). In Italy, driving under the influence of
alcohol and/or drugs has been forbidden since 1992 (Road
Traffic Law — RTL n. 282/92) (Carfora et al. 2018).
Drug testing in the workplace is a must to ensure safety for
the community (Kaznga et al. 2012). There is great conflict
between beneficial effects of reducing pain perception and
improved physical performance among workers and its long
term negative effects on cognitive function. This study is
needed to investigate the pattern of tramadol abuse among
workers and the different motives for abuse to help policy
makers develop intervention programs.
Methods
This cross sectional study was conducted among minibus
drivers, workers in construction industry and workers in tex-
tile industry in Mahalla El Kubra City which is the second
biggest city in Gharbia governorate. Mahalla El Kubra City
accommodates 1,026,832 populations. It is characterized by
Environ Sci Pollut Res
being an industrial city and most residents are workers in
spinning and weaving industry, traders, and governmental
employees.
The target population of this study was male workers ag-
ing 18–50 years old from different social and economic
background. In Egypt, construction workers and bus drivers
are almost all males and rarely females are encountered in
these occupations. The number of females in the selected
textile factory was low to be used for comparison with male
workers. The target population was stratified into: minibus
drivers, construction manual workers, and workers in textile
industry. From each target group a sample of 300 males were
chosen randomly using time location technique; in areas of
gathering of bus drivers, construction workers. One place
from each group was randomly chosen and visited on a ran-
domly chosen day and all subjects present on the chosen time
and location were interviewed. The process was repeated till
recruiting the target number of 300 subjects from each group.
For textile workers the list of factories in Mahalla EL-Kubra
was obtained from occupational health and safety depart-
ment. One factory was randomly chosen and sample was
taken by systematic sample. The total sample size was 900
persons.
A predesigned questionnaire was used for data collection
which included: socio-demographic data, and data about tram-
adol use. The questionnaire included 21 questions concerning
tramadol use with multiple choice questions. When more than
one answer was needed it was indicated in the question. The
diagnosis of tramadol use disorder was according DSM-5
criteria. The questionnaire was validated by a number of 7
experts and tested for its reliability in a pilot study of 50
persons. Cronbach’s alpha test was found to be 0.784 indicat-
ing good reliability. The questionnaire was filled by direct
interview and persons who cannot read or write were assisted
by the researchers.
Ethical consideration
Informed verbal consent was taken from each study partici-
pant after informing him about the aim of study and its bene-
fits. Confidentiality was guaranteed during the whole study
period and the data were collected anonymously. The collect-
ed data used only for purpose of the study. Access to collected
data was limited to the researcher and supervisors till comple-
tion of the work.
Statistical analysis
The collected data were organized, tabulated, and statistically
analyzed using statistical package for social studies (SPSS)
version 19 created by IBM, Chicago, Illinois, USA. Abuse
of tramadol was considered as the outcome variables while
socio-demographic factors and other personal factors were
Environ Sci Pollut Res

considered as exposure variables determining the pattern of Table 1 Socio-demographic characteristics of the studied workers
abuse. For numerical variables the mean and standard devia- Variables Number (n = 900) %
tion were calculated. For categorical variable, the number and
percentage calculated and chi square test of significance was Age in Years:
used for data analysis. When chi square was not appropriate, <20 41 4.6
Monte Carlo exact test was used. The odds ratio was calculat- 20- 348 38.7
ed as the risk estimate for each exposure to lead to tramadol 30- 376 41.8
use and the 95% confidence interval was calculated for each 40- 135 15.0
odds ratio. Multivariate logistic regression was performed for Range 18–53
exposure significantly affecting tramadol use to identify the Means 30.93 + 7.38
independent risk factors. The level of significance adopted at Residence:
p < 0.05. Urban 643 71.4
Rural 257 28.6
Marital status:
Results Single 141 15.7
Engaged 157 17.4
Table 1 shows that the total sample size was 900 workers Married 549 61.0
whose mean age was 30.93 + 7.38. The majority of studied Divorced 53 5.9
subjects was of urban residence (71.4%) and married Family size:
961.0%). The family size ranged from 3 to 18 persons with 3- 89 9.9
a mean of 6.75 + 1.99. Among studied workers, 73.6% had 5- 355 39.4
primary or secondary education, 56.1% had regular work sta- 7- 317 35.3
tus, and 44.6% reported not enough monthly income. Current 9- 87 9.6
smokers represented 74.6% of the studied workers. 11- 46 5.2
Ever intake of tramadol was high among construction 13–18 6 99.4
workers as reported by 92.3% followed by bus drivers
Range 3–18
(53.0%) and lastly textile workers (25.3%). These difference
Means 6.75 + 1.99
were statistically significant (p = 0.001). Age of first intake of
Educational level:
the drug was <30 years as reported by 84.9% of participants
Illiterate 209 23.2
without significant differences between different types of
Primary 376 41.8
workers. The main source of tramadol was friends (45.4%)
Secondary 286 31.8
followed by drug dealers (16.6%). Pharmacist as source was
University 29 3.2
significantly higher among textile workers (11.8%) as com-
Current Job status:
pared to 6.3% for drivers and 0.7% for construction workers
Regular 505 56.1
(p = 0.001). Concerning the number of pills on first intake, the
Interrupted 395 43.9
majority (73.8) reported intake of one pill daily which was
Monthly income:
significantly higher among construction workers (85.9%) as
Enough and saving 70 7.8
compared to drivers (68.0%) and textile workers (42.1%) (p =
Enough 429 47.7
0.001).
Not enough 401 44.6
Table 2 demonstrate that the main reason of abuse was to
improve mood as reported by 54.3% followed by relief of Smoking status:
pain and help to continue work as reported by 37.3%. Current smoker 671 74.6
Among textile workers, 7.9% reported using tramadol as a Ex-smoker 22 2.4
treatment and 69.7% to help continue work which was sig- Non smoker 207 23.0
nificantly higher than other studied workers (p = 0.004, and
0.001, respectively). Current intake of tramadol was 2–4
pills as reported by 54.3% and 25% reported intake of five other works while bhang was significantly higher among
pills or more daily. Intake of two pills or more was signifi- construction workers (p = 0.001). Tramadol abuse associated
cantly higher among construction workers as compared to problems were mainly family related as reported by 77.3%
other workers (p = 0.001). Abuse of other drugs was reported followed by work related problems (73.8%). These problems
by 77.7% of tramadol abusers. Hashish was the main abused were significantly higher among construction workers com-
drug (58.8%) followed by Bhang (45.2%). Textile workers pared to other groups of workers (95.3% and 91.3%, respec-
consumed hashish in significantly higher percentage than tively) (p = 0.001).
 Environ Sci Pollut Res

Table 2 Tramadol use characteristics of studied workers

Variables Textile workers Construction workers Bus drivers Total X2 p

(n = 300) (n = 300) (n = 300) (n = 900)

N % n % n % n %

Ever take tramadol 76 25.3 277 92.3 159 53.0 512 56.9 152.60 0.001*
Age at first intake:** MCET 0.568
<20 20 26.3 100 36.1 47 29.6 167 32.6
20- 41 54.0 140 50.5 87 54.7 268 52.3
30- 13 17.1 33 12.0 23 14.5 69 13.5
40+ 2 2.6 4 1.4 2 1.2 8 1.6
Source of tramadol:**
Friend 54 71.1 224 80.9 131 82.4 409 45.4 4.476 0.107
Physician 3 3.9 3 1.1 1 0.6 7 1.4 MCET 0.106
Pharmacist 9 11.8 2 0.7 10 6.3 21 4.1 21.555 0.001*
Drug dealer 15 19.7 47 17.0 23 14.5 85 16.6 1.090 0.580
Others 1 1.3 4 1.4 2 1.3 7 1.4 MCET 1.000
Number of pills on first intake:** 74.670 0.001*
<1 42 55.3 28 10.1 46 28.9 116 22.7
1 32 42.1 238 85.9 108 68.0 378 73.8
>1 2 2.6 11 4.0 5 3.1 18 3.5
Reasons for tramadol abuse:**
Improve mood 40 52.6 148 53.4 90 56.6 278 54.3 0.510 0.775
Treatment 6 7.9 2 0.7 5 3.1 13 2.5 MCET 0.004*
Improve sexual function 15 19.7 60 21.7 28 17.6 103 20.1 1.039 0.595
Help to work 53 69.7 78 28.2 60 37.7 191 37.3 44.09 0.001*
Current No. of tramadol pills intake: MCET 0.001*
None 5 6.6 2 0.7 1 0.6 8 1.6
<1 16 21.0 2 0.7 13 8.2 31 6.1
1- 28 36.9 9 3.2 30 18.9 67 13.1
2–4 20 26.3 175 63.2 83 52.2 278 54.3
5+ 7 9.2 89 32.2 32 20.1 128 25.0
Abuse of other drugs:** 37 48.7 244 88.1 117 73.6 398 77.7 55.790 0.001*
Bhang 6 16.2 122 50.0 52 44.4 180 45.2 14.844 0.001*
Hashish 34 91.9 130 53.3 70 59.8 234 58.8 19.846 0.001*
Beer 5 13.5 9 3.7 4 3.4 18 4.5 7.650 0.022*
Heroin 0 0.0 0 0.0 1 0.9 1 0.3 – –
Troubles with tramadol abuse: **
Family problems 22 28.9 264 95.3 110 69.2 396 77.3 158.64 0.001*
Work problems 15 19.7 258 91.3 105 66.0 378 73.8 173.55 0.001*
Police or criminal problems 1 1.3 33 11.9 13 8.2 47 9.2 8.312 0.016*

*Significant
**Percentage calculated form total abuse of other drug (more than one answer was reported)
MCET = Monte Carlo Exact Test

Table 3 shows that among studied workers, 30.6% reported
abuse of tramadol by a family member; 82.9% by one and
17.1% aby more than family member with statistically signif-
icant differences between studied groups (p = 0.001).
Regarding abuse by friends, 44.4% reported having 10–19
friends abusing tramadol while 18.8% had 20 friends or more
abusing it. Construction workers had significantly more
friends abusing the drug compared to other two groups (p =
0.001).
Table 4 demonstrate that knowing of health hazards of
tramadol abuse was reported by only 23.2% with textile
workers reporting significantly the highest percentage of
Environ Sci Pollut Res

Table 3 Tramadol abuse by family members and friends

Variables Textile workers Construction workers Bus drivers Total X2 p

(n = 300) (n = 300) (n = 300) (n = 900)

n % n % n % n %

Intake of Tramadol by a family member: 23.291 0.001*

None 239 79.7 187 62.3 199 66.3 625 69.4
Yes 61 20.3 113 37.6 101 33.7 275 30.6
Number of family members taking tramadol: 20.598 0.001*
One 41 13.6 106 35.3 81 27.0 228 82.9
More than one 20 6.7 7 2.3 20 6.7 47 17.1
Number of friends taking tramadol:
None 171 57.0 24 8.0 113 37.7 308 34.2 199.85 0.001*
1–4 27 9.0 15 5.0 14 4.6 56 9.5
5–9 46 15.4 60 20.0 56 18.7 162 27.4
10–19 37 12.3 144 48.0 82 27.3 263 44.4
>20 19 6.3 57 19.0 35 11.7 111 18.8

*Significant

knowledge (40.8%) (p = 0.001). Among abusers 78.9% re-
ported their desire to stop abuse with the significant higher
percentage among construction workers reporting 89.9%
(p = 0.001). The need of help to stop abuse was reported by
73.8% which was significantly higher among construction
workers (88.8%) compared to other workers (p = 0.001)
among abusers, 73.2% represented their readiness to receive
help to stop abuse. Construction workers showed
significantly higher percentage of 88.1% for those how are
ready to receive help to stop abuse as compared to 65.4% and
35.5% among drivers and textile workers, respectively (p =
0.001).
Table 5 shows that urban residence, low educational level
and being current smokers showed a significantly higher risk
to abuse tramadol. Risk of abuse of tramadol among urban
residents was 3.073 while the risk was 5.005 for workers with

Table 4 Distribution of studied workers in relation to perception of need for treatment

Variables Textile workers Construction workers Bus drivers Total X2 P

(n = 300) (n = 300) (n = 300) (n = 900)

n % n % n % n %

Know hazards of tramadol abuse MCET 0.001*

Yes 31 40.8 46 16.6 42 26.4 119 23.2
Do not know 41 53.9 231 83.4 116 73.0 388 75.8
Does not have any hazards 4 5.3 0 0.0 1 0.6 5 1.0
Want to stop Tramadol abuse: 71.879 0.001*
Yes 36 47.4 249 89.9 119 74.8 404 78.9
No 26 34.2 11 4.0 24 15.1 61 11.9
Do not know 14 18.4 17 6.1 16 10.1 47 9.2
Need help to stop tramadol abuse: 114.96 0.001*
Yes 25 32.9 246 88.8 107 67.3 378 73.8
No 34 44.7 8 2.9 30 18.9 72 14.1
Do not know 17 22.4 23 8.3 22 13.8 62 12.1
Ready to receive help to quit abuse: 99.30 0.001*
Yes 27 35.5 244 88.1 104 65.4 375 73.2
No 27 35.5 8 2.9 26 16.4 61 11.9
Do not know 22 28.9 25 9.0 29 18.2 76 14.8

*Significant MCET = Monte Carlo Exact Test

 Environ Sci Pollut Res

illiterate or primary education. The risk among current Discussion

smokers was the highest among other socio-demographic pre-
dictors as it was 7.413. Having regular job was found statisti- Tramadol abuse is not a newly introduced problem to
cally significant to reduce the risk of tramadol abuse which Egyptian community. What is new is the increasing alarming
was calculated at 0.069. Age in years, marital status, family phenomenon of wide range usage in recent years especially
size, job status, and monthly income were not found to affect among youth and productive middle age workers during their
significantly the risk of tramadol abuse among studied best productivity period. This is not only an Egyptian prob-
workers. lem, but also a problem in neighboring countries as detected
Table 6 demonstrate multivariate analysis for predictors of by Fawzi (2011).
tramadol abuse showed that the highest independent variable Our study was conducted in EL Mahalla EL Kubra City
affecting tramadol abuse was irregular job status with adjust- due to its unique properties as an industrial city and being the
ed odds ratio of 10.292 followed by being current smoking biggest castle for textile industry in Egypt. The present study
with adjusted odds ratio of 6.089. Large family size in- clarified that the prevalence of tramadol abuse among study
creased risk of tramadol abuse by 4.417. Meanwhile, low workers was 56.9%. This high prevalence may be due to low
educational level and urban residence double increased risk price, availability of drug in Egyptian streets without need
of abuse (2.095 and 2.046, respectively). for prescription and misconception that tramadol increase
sexual performance which makes it very popular. The prev-
alence was high among construction workers (92.3%)
followed by bus drivers (53.0%) and lastly textile workers
(25.3%). Construction workers’ hard job makes them more
Table 5 Socio-demographic risk factors for Tramadol abuse
prone to muscle and joint pains. They also had low daily
Risk factors Tramadol abuse Odds ratio 95% CI income and used to search for a second afternoon shift work-
ing shift to increase their daily income. So, they take trama-
Yes No
dol for pain relief. Bus drivers owned their busses through
n % n % bank loans. They need to work for long hours to be able to
pay installment on time. They are required to be alert while
Residence: driving without taking sufficient periods of rest and sleep so,
Urban 416 64.7 227 35.3 3.073 2.277–4.149 they take stimulant drugs particularly tramadol. Low income
Rural 96 37.3 161 62.7 of textile workers compared to construction workers and
Age in years: drivers and that they must go to factory daily in early morn-
<30 215 55.3 174 44.7 0.890 0.682–1.162 ing may explain lower prevalence among them compared to
30+ 297 58.1 214 41.9 others. Winstock et al. 2014 in United Kingdom (UK) report-
Marital status: ed in their study lower prevalence (44%). This may be due to
Currently married 287 52.3 262 47.7 0.613 0.466–0.808 difficult access to drug in UK. In contrary Cicero et al. 2007
Non married 225 64.1 126 35.9 reported higher prevalence (97%) because his study cases
Family size: were individuals with history of poly substance abuse.
<7 186 41.9 258 58.1 0.287 0.218–0.379 The present study revealed significant impact of friends on
7+ 326 71.5 130 28.5 tramadol abuse (45.4%) compared to other drivers for use.
Educational level: Also, friends number (10–19) and strong peer pressures play
Illiterate/primary 411 70.3 174 29.7 5.005 3.724–6.726 a critical role which was more among construction workers
Secondary/university 101 32.1 214 67.9
Job status: Table 6 Binomial logistic regression for socio-demographic risk factors
Regular 166 32.9 339 67.1 0.069 0.049–0.099
Risk factor Wald p Adjusted odds ratio
Irregular/unemployed 346 87.6 49 12.4
Monthly income: Irregular job/unemployment 101.717 0.001* 10.292
Enough 237 47.5 262 52.5 0.414 0.315–0.545 Current tobacco smoking 63.662 0.001* 6.089
Not enough 275 68.6 126 31.4 Large family size 59.129 0.001* 4.417
Smoking tobacco: Low educational level 14.257 0.001* 2.095
Current smoker 471 70.2 200 29.8 10.799 7.413–15.73 Urban residence 13.047 0.001* 2.046
Ex/non smoker 41 17.9 188 82.1 Unmarried 1.880 0.170 1.305
Not enough monthly income 1.801 0.180 0.757
*Significant
95% CI = 95% Confidence Interval *Significant
Environ Sci Pollut Res
and drivers compared to textile workers. The impact of friends
in our study is more than that reported in a UK survey
(Winstock et al. 2014) with one third of cases only obtained
tramadol from friends. In contrary Caroline in 2017 examined
the use of analgesics among construction workers in Ghana
and found that the effect of advertisements on radio and tele-
vision on tramadol use (72.9%) was more than by friends and
relatives (64.3%). In Ghana, the media, especially radio and
television, play a huge role in marketing a wide range of over
counter drugs.
In our study improving mood was the most important rea-
son for tramadol abuse as reported by 54.3% of participants.
Tramadol improves bad mood caused by work stress and
stress of life by increasing level of serotonin. Our finding
coincides with the finding of Cicero et al. 2007 working on
individuals with a history of poly substance abuse. That study
reported that 97% of study subjects shifted to co-
administration of tramadol due to its mood elevating
properties. Our findings are in line with El-Hadidy and
Helaly (2015) who checked the psychiatric status of 79 pa-
tients during tramadol abuse and 3 months after complete
treatment. They found that patients during tramadol abuse
period were angry and aggressive. After treatment significant
increase in anxiety and depression happened, which prove
mood elevation effect of tramadol.
As regards tramadol use for improving sexual functions as
reported in the present study. The study workers in the pres-
ent study are hard workers for long hours daily which may be
reflected on the capacity to have successful sexual relations.
In the study of Xiong et al. 2011, positive effects of tramadol
were reported for prolonging the inter-vaginal ejaculation
time and improving partner intercourse satisfaction.
Improving sexual function was also reported by Safarinejad
and Hosseini 2006, who found that 50 mg tramadol have a
significant effect in delaying ejaculation in men with prema-
ture ejaculation. Salem et al. 2008 supported the fact that
tramadol is effective medication for premature ejaculatory
and for extended orgasm and to increase sexual pleasure.
Abdel-Hamid et al. 2016 studied the relationship between
tramadol abuse and sexual function. They reported that tram-
adol is a useful intervention for treating premature ejacula-
tion as supported by meta-analysis of eleven clinical trials
and evaluated by six systematic reviews. But it should be
used only when other therapies failed, due to the risk of
addiction. Their study also demonstrated that these patients
are liable to develop other sexual dysfunctions such as sec-
ondary hypogonadism, erectile dysfunction or desire
disorder. Thus the relationship between tramadol and sexual
function appears to be controversial. Which may be attribut-
ed to misuse/overdose of tramadol, as well as co-
administration with other drugs.
In the current study one reason for intake of tramadol
was to avoid physical fatigue and as pain killer. Fawzi
2011 and Hamdi et al. 2016 reported same findings espe-
cially among middle age groups of workers. Caroline et
al. 2017 reported higher percentage of construction
workers (66.4%) using analgesics mostly to relieve pain
and aches as they were unaware of health hazards of con-
tinuous use or misuse and did not read the labels on these
medications.
Concerning use of other drugs concomitantly with tram-
adol in the present study which was more among construc-
tion workers and drivers. Hashish was the main abused drug
followed by bhang. UNODC (2010) reported cannabis as the
commonest drug abused in Egypt. The percentage of canna-
bis (hashish) abuse in Egypt was reported also by Anti
Narcotic General administration of Egypt (2005) and Yassa
et al. (2009). The multidrug abuse increases the risks of ac-
cidents in the workplace of construction workers which are
usually highly fatal or accompanied by permanent disability
being working at higher levels from the ground. The problem
is more serious among drivers as accidents committed by
them not only have consequences on their health and quality
of life but also affects a large number of other people in-
volved in car accidents. The findings of the present study
are in accordance with Francisco et al., (2018) who proved
the presence of multiple drugs abused particularly cannabis
among Spanish drivers [10]. Our findings were higher than
Carfora et al. (2018) who found that multiple drugs (20%)
mainly cannabis (18%) are detected in blood samples from
drivers injured in road accidents in Italy. This lower percent-
age may be due to examining blood of injured drivers in road
traffic accidents attending emergency department only.
Kaznga et al. (2012) in Italy took urine samples from
43,535 workers’ with different duties. Cannabis was the
most frequently detected drug.
Regarding troubles associated with tramadol abuse in the
present study which was more among construction workers
and drivers. This is due to the bad effect of tramadol on social
and work relationship with its wrong judgment and aggressive
behavior. In agreement with our findings Crowly 1988 found
that drug addiction causes serious dysfunctions in relationship
and interaction in family, work, and community. El-Hadidy
and Helaly (2015) checked the psychiatric status of 79 patients
during tramadol dependence period over at least 5 years. They
reported that, patients during tramadol dependence period
were very angry and aggressive. The increased aggressiveness
could be a reason of increased risk taking and hence accidents
among bus drivers.
Our present study revealed that desire to stop tramadol
was present among the majority of study participants. The
main reason for that was their perception of health hazards,
social problems and work troubles associated with tramadol
abuse. Ongoing health education in workplace on health
hazards of these drugs can help tramadol abusers to start
quitting.

Conclusion
Tramadol abuse was high among construction workers
followed by bus drivers and lastly textile workers. There
are different reasons for uptake and the majority of perceive
its hazards on their work and family relation and need help to
quit it.
Recommendations
Egypt should have laws and legislation for workplace drug
testing (WDT) especially for drivers with the aim to ensure
public safety for the community. WDT should be performed
pre -employment, then randomly at least once a year and in
cases of suspicion of drug abuse and after work accidents.
Public health awareness in mass media is essential to educate
the general public about the risks of analgesic misuse as the
media is a credible source of information.
Compliance with ethical standards
Conflict of interest None to declare.
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