The reported increase in the non-medical use of opioid prescription medication in West Africa and Middle East coinciding with the ongoing problems in North America has moved the International Narcotic Control Board and the United Nations Office on Drugs and Crime to talk about a global opioid crisis requiring global solutions. The measures proposed include the strengthening of the global control system by adding the opioid analgesic tramadol to the list of internationally scheduled substances. Yet North America and West Africa have profoundly different health care systems as well as different access pathways to opioid medications and consumer motivation for non-medical use. Further, the substances driving the US opioid crisis are exponentially more powerful and dangerous than the falsified tramadol circulating in West Africa. Across West Africa patients are suffering from untreated pain, whereas one of the main drivers behind the different problems that has come to be known as the North American opioid crisis has been the overprescribing of opioid analgesics. Far from constituting a global opioid crisis, the two regions are facing fundamentally different challenges that need to be treated with specifically tailored policy responses. In particular, the urgent call for reducing opioid prescription levels in North America should not discourage medical professionals and public health agencies from rapidly improving pain management and opioid prescribing in Africa and other low and middle income countries.