Opioid misuse and related mortality have become emerging public health challenges in West and Central Africa. Although the global discourse on the opioid epidemic has focused on North America, evidence from the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO) reveals that Africa has developed a growing problem centered on the use of tramadol and codeine. Between 2017 and 2020, large-scale seizures, increasing hospital admissions, and policy restrictions illustrated both the magnitude and complexity of the crisis. Weak regulatory frameworks, widespread poverty, and inadequate access to pain relief have created a dual crisis excess access for non-medical use and limited access for legitimate medical purposes. This review synthesizes regional literature published between 2017 and 2020 to describe epidemiological trends, determinants, policy responses, and ethical challenges associated with opioid misuse in West and Central Africa. The findings highlight the urgent need for balanced opioid governance that integrates surveillance, prevention, and equitable pain management across the region.