Changing society, changing research: integrating gender to better understand physical and psychological treatments use in chronic pain management

ABSTRACT

Treatment of chronic pain should be multimodal and include pharmacological, physical, and psychological treatments. However, because various barriers to physical and psychological treatments (PPTs) exist, a better understanding of biopsychosocial factors leading to their use is relevant. This study aimed to explore the association between gender identity, gender-stereotyped personality traits, and the use of PPTs in chronic pain management. The ChrOnic Pain trEatment cohort, a self-reported data infrastructure resulting from a web-based recruitment of 1935 people living with chronic pain (Quebec, Canada) was analyzed. Gender identity was operationalized as women, men, and nonbinary. Gender-stereotyped personality traits were measured using the Bem Sex-Role Inventory (feminine, masculine, androgynous, undifferentiated). A checklist of 31 types of PPTs that can be used for chronic pain management was presented to participants (yes/no). From the 1433 participants, 85.5% reported using at least one PPT. Hot-cold therapies (43.4%), exercise (41.9%), and meditation (35.2%) were the most frequently used PPTs, but most popular PPTs were not the same among women and men. Women reported a significantly higher use of PPTs in general (87.2% vs 77.2%; P < 0.001). Multivariable and interaction analyses showed that identifying as a man decreased the odds of reporting the use of PPTs (odds ratio: 0.32, 95% confidence interval: 0.11-0.92) but only among participants who scored high on both masculine and feminine personality traits (those classified as androgynous). The high prevalence of PPTs use found in our study is positive. Our results are relevant for a more personalized promotion of PPTs for chronic pain management.

User experience with the Ask Your Pharmacist teleconsultation platform

Background:

An increasing number of pharmacists use technology and social media to connect with patients. However, such means may pose confidentiality issues and legal problems. To correct this situation, a platform of teleconsultation services provided by pharmacists, titled “Ask Your Pharmacist,” was created in Quebec, Canada.

Methods:

A web-based satisfaction survey was carried out among patients and pharmacists who have used the Ask Your Pharmacist platform to describe their experience and satisfaction with the platform and explore the perceived usefulness of this service in the province of Quebec.

Results:

A total of 53 patients and 27 pharmacists completed the survey. Most patients were satisfied or very satisfied with their experience with Ask Your Pharmacist (96.2%), said that it met their need (88.7%), and agreed they would not have to consult again about the matter discussed with the pharmacist (75.5%). The main motivation of pharmacists for volunteering on Ask Your Pharmacist was to meet the needs of patients (85.1%), promote their profession (55.6%), improve drug utilization in the population (55.6%) and increase accessibility to a pharmacist (51.9%). Most (81.5%) felt that providing written consultation (rather than oral) required more research on their part.

Discussion:

Most patients judged they would not have to have another consultation about the matter discussed with the pharmacist, suggesting that Ask Your Pharmacist may avoid the need for physician and emergency department visits.

Conclusion:

Most patients and pharmacists were satisfied with their experience with Ask Your Pharmacist and perceived this service as useful. Further studies should assess the impact of this platform on the utilization of other health care services. Can Pharm J (Ott) 2021;154:xx-xx.

Exposure to guideline-recommended drugs after a first acute myocardial infarction in older adults: does deprivation matter?

BACKGROUND

Inequities between guideline-recommended drugs (GRD) exposure and socioeconomic status might exist. The objective was to assess the association between a material and a social deprivation index and GRD exposure following a first acute myocardial infarction (AMI) in older adults in the province of Quebec.

METHODS

We conducted a retrospective cohort study using the Quebec Integrated Chronic Disease Surveillance System. Elderly ≥66 years, hospitalized for a first AMI between January 1, 2006, and December 31, 2011 and covered by the public drug plan were identified. Exposure to GRD (i.e. simultaneous use of 1) antiplatelet, 2) beta-blocker, 3) lipid-lowering and 4) angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker drugs) was assessed 30 and 365 days following hospital discharge. Associations between deprivation index and GRD exposure were estimated with log-binomial regressions adjusting for potential confounders.

RESULTS

Exposure to GRD was 52.2% and 48.0%, 30 and 365 days after hospital discharge, respectively. No statistically significant association was observed in multivariate analysis for both time points. Thirty days post hospital discharge, adjusted prevalence ratio of non-exposure to GRD was 0.98 (95% confidence interval [CI]: 0.95-1.02) for most materially deprived vs. least deprived and 1.04 (95% CI: 0.99-1.08) for most socially deprived vs. least deprived. Similar results were observed for 365 days.

CONCLUSION

Exposure to GRD after a first urgent AMI among older adults insured by the public drug plan in the province of Quebec is relatively low. Reasons and risk groups for this low exposure should be studied to improve secondary prevention. However, results suggest equitable access to GRD, regardless of deprivation.

Public Health Outcomes May Differ After Switching from Brand-Name to Generic Angiotensin II Receptor Blockers

Background

It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death.

Study Design

This was a retrospective cohort study.

Methods

This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified).

Results

In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76–78 years, 59–66% were female, 90–92% had hypertension, and 13–15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99–1.14) for ER consultation, 1.26 (1.14–1.39) for hospitalization, and 1.01 (0.61–1.67) for death. The corresponding rates for candesartan were 1.00 (0.95–1.05), 0.96 (0.89–1.03), and 0.57 (0.37–0.88), respectively.

Conclusions

We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings.

Electronic supplementary material

The online version of this article (10.1007/s40268-020-00307-2) contains supplementary material, which is available to authorized users.

Impact of prior authorization for asthma medications on the use of emergency health services: a retrospective cohort study among newly diagnosed patients with asthma

BACKGROUND

A prior authorization process to limit the nonoptimal use of medications combining inhaled corticosteroids and long-acting bronchodilators was introduced in the province of Québec, Canada, on October 1, 2003.

OBJECTIVE

We assessed the impact of this administrative measure on the rate of asthma-related emergency department (ED) visits and hospitalizations.

METHODS

A retrospective cohort study was conducted using Régie de l'assurance maladie du Québec administrative databases. We identified all persons aged 6 to 44 years with an incident asthma diagnosis in the 2-year periods preceding (October 1, 2001-September 30, 2003) and following (October 1, 2003-September 30, 2005) the introduction of the process. Children aged < or = 5 years at the time of the first encountered diagnosis were excluded because it is difficult to make an objective asthma diagnosis until 6 years of age. People aged > or = 45 years at the time of the first encountered diagnosis were also excluded to avoid the inclusion of persons who might also have had chronic obstructive pulmonary disease. Two groups were created based on their prescription drug insurance (private or public). Publicly insured persons were considered exposed to the process while privately insured persons were considered not exposed. Cox proportional hazards regression was used to assess, for each insurance group, the hazard ratio (HR) for an asthma-related first hospitalization or ED visit between the 2 periods. The use of medication, quality of life, and visits to physicians' offices were not considered in the analysis. The interaction between group and period was assessed to test whether the change in risk between the preprocess and postprocess periods differed by insurance group; statistical models were adjusted for sex, age, region, presence of a comorbidity other than asthma, and discipline of diagnosing physician.

RESULTS

There were 47,579 publicly insured persons and 93,177 privately insured persons with incident asthma during the study period. The risk of an asthma-related first hospitalization or ED visit remained unchanged in the 2 periods evaluated among both the publicly insured (adjusted HR, 0.95 [95% CI, 0.88-1.03]) and the privately insured (adjusted HR, 1.03 [95% CI, 0.96-1.03]). The change in risk between the preprocess and postprocess periods was not significantly different between insurance groups.

CONCLUSIONS

The prior authorization process introduced to limit the nonoptimal use of combination products (formoterol/budesonide and salmeterol/fluticasone) had no apparent impact on first asthma-related hospitalization or ED visit in these patients newly diagnosed with asthma who were covered by Québec's public prescription drug insurance plan.

Trends in Prescription Chronic Pain Medication Use before and during the First Wave of the COVID-19 Pandemic in Québec, Canada: An Interrupted Time Series Analysis

BACKGROUND

In Canada, a state of health emergency was declared in May 2020 as a result of the COVID-19 pandemic. This study aimed to assess trends in the use of prescription medication for pain management by people living with chronic pain before and during the first wave of the pandemic.

METHODS

Participants (n = 177) were adults reporting chronic pain who had completed a web-based questionnaire in 2019 and for whom complete longitudinal private and public insurance prescription claims were available. The monthly prevalence of medication use for nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and prescribed cannabinoids was assessed. An interrupted time series analysis was then performed to evaluate if the COVID-19 pandemic had had an impact on trends in pain medication use.

RESULTS

The beginning of the first wave of the pandemic was associated with the onset of a downward trend in opioid use (p < 0.05); no such association was found regarding NSAIDs. However, point prevalence of opioid use at the beginning (Nov. 2019) and at the end (Mai 2020) of the study period remained somewhat stable (17.0% vs. 16.4%). Regarding prescribed cannabinoids, a gradual increase in use was observed over the entire study period independently from the impact of the first wave of the pandemic (15.3% vs. 22.6%, p < 0.05).

CONCLUSION

While the occurrence of the first wave did have an impact on opioid use among people living with chronic pain, access to and use of opioids appear to have returned to normal before the end of the first wave of COVID-19.

Educational needs and preferences of adult patients with acute or chronic pain: a mixed methods systematic review protocol

OBJECTIVES

This review will aim to synthesize the available quantitative and qualitative evidence on the educational needs and preferences of adult patients with acute or chronic pain.

INTRODUCTION

Acute and chronic pain are prevalent problems and are associated with significant individual and societal consequences. Education is a critical component of pain management. However, the impact of educational interventions on pain outcomes remains limited. The lack of patient input--what patients want to know and how they want to be informed--is one of the main issues underlying intervention design.

INCLUSION CRITERIA

We will include qualitative, quantitative, and mixed methods studies describing the educational needs and preferences of adult patients with acute or chronic pain.

METHODS

This review will follow the JBI guidelines for mixed methods systematic reviews. We will search MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ProQuest Dissertations and Theses. The search strategy will commence from the year 1990 onward and there will be no language restrictions. The retrieved titles, abstracts, and full-text reports will be screened by pairs of independent reviewers. These pairs of reviewers will also independently extract data using the JBI tools for mixed methods systematic reviews. Methodological quality will be assessed using the mixed methods appraisal tool. A convergent integrated approach to synthesis and integration of the quantitative and qualitative data will be used.

REVIEW REGISTRATION

PROSPERO CRD42022303834.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Relationship Between Diet Quality and Glucose-Lowering Medication Intensity Among Adults With Type 2 Diabetes: Results From the CARTaGENE Cohort

Background

In real-world settings, whether diet and medication are used as complements for glycemic management in type 2 diabetes (T2D) remains unclear. This study assessed the relationship between diet quality and intensity of glucose-lowering medication among adults with T2D.

Methods

This cross-sectional study included 352 adults with T2D from the CARTaGENE Québec population-based cohort. Diet quality was assessed using the Healthful Plant-Based Diet Index (hPDI). Glucose-lowering medication intensity was graded according to self-reported information on the type and number of drugs: no medication; oral monotherapy; oral polytherapy; and insulin with and without oral medication. In the subsample of 239 individuals who reported the medication dosages, intensity was also graded using the Medication Effect Score (MES).

Results

In multivariable-adjusted models, we found no evidence of a relationship between the hPDI and medication intensity, assessed using the categorical approach (Pbetween-group = 0.25) or the MES (P = 0.43). However, the hPDI was inversely associated with the MES among men < 50 years of age and women < 60 years (β1-point MES = -2.24 [95% confidence interval, -4.46, -0.02] hPDI points), but not among older individuals (β = -0.03 [-1.28, 1.21] hPDI points). Evidence of a nonsignificant inverse relationship between the hPDI and HbA1c was observed (β10-point hPDI = -0.23% [-0.63, 0.17]), whereas a positive and significant association between the MES and hemoglobin (Hb)A1c was found (β1-point MES = 0.30% [0.10, 0.51]).

Conclusions

In this cohort of adults with T2D, there was an overall lack of complementarity between diet quality and intensity of glucose-lowering medication. The issue was particularly important among younger adults for whom diet quality was inversely associated with intensity of medication.

Pilot randomized controlled trial of a program to enhance experience and adherence with adjuvant endocrine therapy among women with non-metastatic breast cancer: 12-month quantitative results

PURPOSE

Adjuvant endocrine therapy (AET) reduces recurrence risk after hormone receptor-positive breast cancer, but non-adherence is common. We pilot-tested SOIE, a program to enhance AET experience and adherence, to assess its acceptability, feasibility, and effects on psychosocial precursors of AET adherence.

METHODS

We conducted a 12-month pilot randomized controlled trial among women who had a first AET prescription. Intervention group received SOIE while control group received usual care. Psychosocial factors from the Theory of Planned Behavior (TPB) (intention - primary outcome -, attitude, subjective norm, behavioral control), additional constructs (AET knowledge, social support, coping planning), impact of AET services received, and adherence were measured by questionnaires at baseline, 3-month, and 12-month endpoints. Group patterns were compared using repeated measures analyses with generalized estimating equations.

RESULTS

A total of 106 women were randomized (participation = 54.9%; intervention n = 52; control n = 54; retention = 93.8%). Among SOIE women, ≥ 90% received the program components and were satisfied. Both groups scored high on adherence intentions and group patterns over time were not statistically different. In the intervention group, AET knowledge and coping planning with side effects increased (group-by-time p-value = .002 and .016), a higher proportion reported that AET services received helped them take their AET (p < .05) and have a consistent daily intake (p = .01).

CONCLUSION

SOIE is feasible and acceptable for survivors with an AET. SOIE did not significantly impact adherence intentions but was beneficial for other program outcomes and daily intake.

IMPLICATIONS FOR CANCER SURVIVORS

SOIE may represent an encouraging avenue to enhance supportive care and empower survivors with managing AET.

Perspectives of Women with Breast Cancer and Healthcare Providers Participating in an Adherence-Enhancing Program for Adjuvant Endocrine Therapy: A Qualitative Study

BACKGROUND

Adjuvant endocrine therapy (AET) is prescribed for 5-10 years to women with hormone-sensitive breast cancer to prevent recurrence. However, a significant proportion of women do not adhere to AET. We developed SOIE, a one-year program designed to enhance the AET experience and adherence. SOIE was pilot-tested in a mixed-methods randomized controlled trial. This report presents the experience of women and healthcare providers (HCPs) with SOIE.

METHODS

A descriptive qualitative study using semi-structured interviews and thematic analysis was conducted with 20 women and 7 HCPs who participated in the program.

RESULTS

Most women and HCPs reported high satisfaction with the program. Women felt it addressed their need for information and strategies to manage side effects. They felt supported and developed a more positive attitude toward AET, which contributed to their intention to pursue AET. They perceived that the program helped them navigate the AET experience and reduced their stress or fear regarding AET. HCPs corroborated these benefits.

CONCLUSIONS

Findings suggest that SOIE can enhance the experience and motivation to pursue the AET treatment by meeting important needs for information, side-effects management, and psycho-emotional support. Programs like SOIE can have benefits beyond adherence by improving patients' well-being during this crucial long-term treatment.

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BACKGROUND

Older adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.

METHODS

The sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013-2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.

RESULTS

Opioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.

CONCLUSIONS

Potentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

Pain relief and associated factors: a cross-sectional observational web-based study in a Quebec cohort of persons living with chronic pain

Objectives

Randomized clinical trials are used to evaluate the efficacy of various pain treatments individually, while a limited number of observational studies have portrayed the overall relief experienced by persons living with chronic pain. This study aimed to describe pain relief in real-world clinical settings and to identify associated factors.

Methods

This exploratory web-based cross-sectional study used data from 1,419 persons recruited in the community. Overall pain relief brought by treatments used by participants was assessed using a 0%-100% scale (10-unit increments).

Results

A total of 18.2% of participants reported minimal pain relief (0%-20%), 60.0% moderate to substantial pain relief (30%-60%), and 21.8% extensive pain relief (70%-100%). Multivariable multinomial regression analysis revealed factors significantly associated with greater pain relief, including reporting a stressful event as circumstances surrounding the onset of pain, living with pain for ≥10 years, milder pain intensity, less catastrophic thinking, use of prescribed pain medications, use of nonpharmacological pain treatments, access to a trusted healthcare professional, higher general health scores, and polypharmacy. Factors associated with lower pain relief included surgery as circumstances surrounding pain onset, use of over-the-counter pain medications, and severe psychological distress.

Discussion

In this community sample of persons living with chronic pain, 8 out of 10 persons reported experiencing at least moderate relief with their treatment. The analysis has enabled us to explore potential modifiable factors as opportunities for improving the well-being of persons living with chronic pain.

Gender differences in the association between adherence to healthy diet principles and adherence to cardiopreventive medication among adults from Québec (Canada)

Adherence to healthy diet principles and to cardiopreventive medication, both key behaviours in CVD prevention, is known to differ between women and men. Whether these adherence behaviours are differentially related among women and men has never been thoroughly assessed. The objective was to assess gender differences in the association between adherence to healthy diet principles and to cardiopreventive medication in adults free of CVD. This cross-sectional study included 268 women and 204 men from the CARTaGENE cohort (Québec, Canada) who were using antihypertensive and/or cholesterol-lowering medication. Adherence to healthy diet principles was assessed using the Alternate Healthy Eating Index (AHEI, %), calculated from a validated FFQ assessing diet in the 12-month preceding its completion. Medication adherence was assessed using the daily pharmacotherapy possession rate (DPPR, %), calculated from prescription claim data over the same 12-month period. In multivariable-adjusted analyses, an inverse association between AHEI and DPPR was observed among men (βAHEI for 10 % increment in DPPR = -0·65 %; 95 % CI -1·28 %, -0·03 %; P = 0·04), while it tended to be positive among women (β = 0·44 %; 95 % CI -0·11 %, 1·00 %; P = 0·12; Pgender×DPPR = 0·01). The negative association between AHEI and DPPR was stronger among men who never smoked or used cholesterol-lowering medication only. Among women, the positive association was stronger and statistically significant among those with obesity or using ≥ 3 medications simultaneously. Association between adherence to healthy diet principles and to cardiopreventive medication differs between women and men, with men potentially facing greater challenges in achieving optimal complementarity between these two behaviours.

Prevalence of cannabis use for pain management in Quebec: A post-legalization estimate among generations living with chronic pain

Background

Medical cannabis has been legal in Canada since 2001, and recreational cannabis was legalized in October 2018, which has led to a widespread increase in the accessibility of cannabis products.

Aims

This study aimed to estimate the prevalence of cannabis use among adults living with chronic pain (CP) and investigate the relationship between age and cannabis use for CP management.

Methods

A cross-sectional analysis of the COPE Cohort data set, a large Quebec sample of 1935 adults living with CP, was conducted. Participants completed a web-based questionnaire in 2019 that contained three yes/no questions about past-year use of cannabis (i.e., for pain management, management of other health-related conditions, recreational purposes).

Results

Among the 1344 participants who completed the cannabis use section of the questionnaire, the overall prevalence of cannabis use for pain management was 30.1% (95% confidence interval 27.7-32.7). Differences were found between age groups, with the highest prevalence among participants aged ≤26 years (36.5%) and lowest for those aged ≥74 years (8.8%). A multivariable logistic model revealed that age, region of residence, generalized pain, use of medications or nonpharmacological approaches for pain management, alcohol/drug consumption, and smoking were associated with the likelihood of using cannabis for pain management.

Conclusions

Cannabis is a common treatment for the management of CP, especially in younger generations. The high prevalence of use emphasizes the importance of better knowledge translation for people living with CP, rapidly generating evidence regarding the safety and efficacy of cannabis, and clinicians' involvement in supporting people who use cannabis for pain management.

[Use of Quebec Medico-Administrative Databases for Mental Health Studies: Opportunities, Methodological Challenges and Limitations - The Case of Depression among Diabetic Subjects]

The use of medico-administrative databases for studies on mental health issues is very common because of the large number of people in these databases and the possibility to carry out long-term studies. Several challenges, such as identifying people with a disease of interest or being exposed to a risk factor, have to be overcome through validation studies to ensure an optimal use of these resources. Moreover, limits (lack of certain relevant information) and the coverage of about 40% of Quebec's population by the public drug plan are to be considered in the interpretation and generalization of research results based on these data sources. In the specific case of depression, we used these databases to determine the incidence of depression among diabetic individuals in Quebec. This required the use of a previously validated algorithm (validated in another province) that we modified to define and identify the cases of depression in the RAMQ databases. We observed an incidence of depression of 9.47 persons years over a follow-up of 8 years. Finally, we assessed the impact of depression on adherence and persistence with antidiabetic drugs as well as the factors that affect patients' use of these drugs. Our results suggest that depression has a negative impact on the use of antidiabetic drugs and allow the identification of possible solutions.