Opioid poisoning is now a global public health crisis. According to the World Health Organization (WHO), more than 58 million people use opioids, with a growing proportion using them for non-medical purposes. Nearly 110,000 overdose deaths were recorded in 2019, mainly linked to fentanyl and tramadol [1]. The chemical formula for tramadol is C₁₆H₂₅NO₂, with a structure similar to that of morphine or codeine. Tramadol is a chiral molecule, with a racemic mixture whose enantiomers have a noradrenergic mechanism of action and opioid and serotonergic analgesic effects [2]. The effects of tramadol are stimulating and euphoric, which are often sought after by adolescents in their quest for improved performance at work, sexual performance, or relaxation [3]. As a result, the misuse of opiates is on the rise, particularly among adolescents and young adults, with serious consequences for mental and physical health and social life.

In Africa, the phenomenon is reaching alarming proportions. Tramadol, a relatively accessible opioid drug, is trafficked and used extensively in several West African countries, including Nigeria, Ghana, Niger, Côte d’Ivoire, and Togo [4][5]. It is often used as a performance-enhancing drug or anxiolytic and consumed in tablet form or dissolved in homemade drinks. Its sale on the informal market encourages the proliferation of illicit forms, with high concentrations or combined with other psychoactive substances (PAS, any substances capable of altering brain function [6]), thereby increasing the risk of acute intoxication [7].

In Côte d’Ivoire, although epidemiological data remain limited, there has been an increase in the consumption of tramadol among adolescents and young adults. The version known as “Kadhafi”, with a high dose of 225 mg or 250 mg, is commonly sold on the black market. Its use is frequently accompanied by psychiatric, neurological, and addictive complications, and, more rarely, by severe orofacial effects that are still poorly documented [7][8].

It was in this context that a case was reported on 24 June 2025 in Bingerville (population estimated at 204,656 in 2021) [9]. It is part of Greater Abidjan, the economic capital of Côte d’Ivoire. It was in this municipality that a 19-year-old boy presented with acute glossoptosis (an orofacial abnormality defined by a posterior fall of the tongue towards the oropharynx, which can lead to partial or complete obstruction of the upper airways) [10]-[12], macroglossia (abnormal enlargement of the tongue, which may be congenital) [13], with breathing difficulties, after consuming 250 mg of illicit Tramadol. It was these physiological and psychological reactions that sparked our interest in this study, the overall objective of which was to investigate opioid intoxication in this case.

This was a descriptive clinical case study conducted from 1 to 25 July 2025 at the Addiction and Mental Health Department of the National Institute of Public Health/Abidjan, with an investigation phase carried out from 1 to 3 March 2025 in the commune of Bingerville (Côte d’Ivoire).

The following was carried out to collect information:

1) an individual interview, using a structured questionnaire with closed and open questions, the aim being to collect as much data as possible.

2) direct observation of clinical manifestations.

3) Access to medical information and reports from other professionals involved in the care of the patient or from the patient’s family and friends.

4) Visits to health centres in the municipality of Bingerville and the surrounding area to search for cases.

The case investigated concerns a 19-year-old male, single, with higher education, unemployed, who frequently consumes adulterated tramadol with friends, often in combination with alcohol. This profile matches that most frequently observed in studies on problematic tramadol use among young people. Adolescents and young adults are a population particularly vulnerable to opioid abuse, whether consumed alone or in combination with other substances [9][14][15]. According to the study by N’Djambara et al., the age of first use is around 13 years [8]. Similarly, the work of Sarah Caupp et al. reported that 60.1% of opioid poisonings involved subjects aged 18 to 24, mostly male, often with co-use of benzodiazepines and alcohol [15]. Duke et al. highlighted the concept of co-ingestion among young tramadol users [16]. The main motivation in the case studied was the pursuit of sexual performance. N’Djambara et al. in Togo noted this motivation among tramadol users [8].

In this case, there was a history of addiction to psychoactive substances (Table 3). Psychomotor development was normal, and no congenital orofacial malformations such as Pierre Robin syndrome or other chronic comorbidities were reported. Acute toxicity appeared within 60 minutes of taking a 250 mg tablet of illicit tramadol and alcohol, with symptoms such as dizziness, headaches, and anxiety (Table 4). These clinical manifestations, consistent with tramadol intoxication, are corroborated by several studies [17]-[21].

Although convulsions are frequently reported in tramadol abuse [17][22], no signs of convulsive seizures were observed here. However, unusual but clinically serious signs were noted: glossoptosis, macroglossia, glossitis, and breathing difficulties (Table 4). These signs are rare in the literature on opioids and seem to suggest an atypical presentation, but one potentially linked to the consumption of the drug “Kadhafi”, a substance identified locally as a diverted or illicit form of tramadol overdosed at 225 mg or 250 mg. In his study, Kouadio A reported the tongue falling back into the throat (glossoptosis) after the use of psychoactive substances consisting of overdosed “Kadhafi” tramadol sold on the black market [7]. In our study, glossoptosis and macroglossia were only present in the case investigated, with no other similar cases reported in the municipality of Bingerville.

The two friends who consumed the drug “Kadhafi” did not present with glossoptosis, macroglossia, or other signs of acute intoxication. This could be explained by their acquired tolerance. This contrast illustrates both the inter-individual variability of pharmacological reactions, i.e., individual metabolic differences, and possible variations in the composition of the tablets consumed.

The toxicological examination of urine carried out on Day 1 confirmed the presence of opiates, supporting the hypothesis of acute tramadol intoxication. The test was negative on Day 7, in line with data in the literature indicating that tramadol is detectable for approximately three days after ingestion [17][23]. The presence of benzodiazepine in the urine on Day 7 was likely due to previous treatments (Table 5).

Complete resolution of symptoms after two weeks, multidisciplinary therapeutic intervention including supportive psychotherapy, administration of corticosteroids to manage inflammation and potential allergic reactions, antibiotics as prophylaxis against infection, muscle relaxants, and anticholinergics (trihexyphenidyl) to normalise tongue motility, benzodiazepines for anxiety, alimemazine to manage insomnia, and manual intervention to prevent respiratory obstruction by the tongue, contributed to a favourable outcome (Table 5). These measures helped to limit serious complications, particularly the risk of asphyxia.

The patient was part of a group of friends who used psychoactive substances, with a history of glossoptosis reported in one of them. Belonging to such a group, where psychoactive substance use is normalized, is a major risk factor for the initiation of risky behavior. Indeed, the influence of peer groups and friends increases, reaching a peak during adolescence [24].

This clinical case highlights acute opioid poisoning linked to the consumption of tramadol in an illicit form known locally as “Kadhafi” and co-ingested with alcohol. This case illustrates the diversity and severity of atypical clinical presentations associated with new forms of psychoactive substance use among adolescents. It highlights the need to raise awareness among young people, train health professionals to recognize the signs of poisoning, and establish a local epidemiological surveillance system to prevent or detect cases at an early stage.