Over the last five years, media reports in West African countries have suggested a tramadol abuse 'crisis' characterised by a precipitous rise in use by youth in the region. This discourse is connected to evidence of an emerging global opioid crisis. While the reported increase in tramadol abuse in West Africa is likely true, few studies have critically interrogated structural explanations for tramadol use by youth. Nascent academic literature has sought to explain the rise in drug use as a function of moral weakness among youth. This Ghanaian case study draws on primary and secondary data sources to explore the pain that precedes tramadol abuse. Through a discourse analysis of 295 media articles and 15 interviews (11 with youth who currently use tramadol and 4 with health system stakeholders), this study draws on structural violence and moral panic theories to contribute to the emerging literature on tramadol (ab)use in West Africa. The evidence parsed from multiple sources reveals that government responses to tramadol abuse among Ghanaian youth have focused on arrests and victim blaming often informed by a moralising discourse. Interviews with those who use tramadol on their lived experiences reveal however that although some youth use the opioid for pleasure, many use tramadol for reasons related to work and feelings of dislocation. A more complex way to understand tramadol use among young people in Ghana is to explore the pain that leads to consumption. Two kinds of pain; physical (related to strenuous work) and non-physical (related to anxiety and the condition of youth itself) explain tramadol use requiring a harm reduction and social determinants of health approach rather than the moralising 'war on drugs' approach that has been favoured by policy makers.