Self-medication: from European regulatory directives to therapeutic strategy

Definition of self-medication: a scoping review

Self-medication (SM) is a global and growing phenomenon. It represents a public health problem due to antibiotic resistance, risk of adverse drug reactions, drug–drug interactions, disease masking, and increased morbidity. There is not a consensus on the definition of SM. The definitions found in different studies make it difficult to address this problem from a theoretical perspective and therefore find an adequate solution to this public health problem. The aim of this article is to search the medical literature to characterize the current understanding of SM in the medical community. We conducted a scoping review of definitions of SM by searching on PubMed – Medline, Embase, and LILACS using the following combination of keywords: ‘self-prescription’ or ‘self prescription’, ‘self-medication’ or ‘self medication’, or ‘automedication’ and ‘definition’ or ‘explanation’. The search was limited to articles containing the definition of SM, with no limit on language or year. Duplicate studies and those that did not mention the definition of SM were excluded from the final review. A total of 65 studies were included in the final selection. We found a vast heterogeneity in the definition of SM. Most articles based their definition of SM on the process of obtaining the drug, the nonparticipation of a specific health professional, the source of the medication, and the reason for SM. Other interesting concepts such as self-care, nonadherence to a prescription, reuse of stored drugs, and sharing and lending medicines were also considered forms of SM by other authors, however. This study highlights the need to reach a consensus regarding the definition of SM to adequately propose strategies to address this global health problem. This study shows the diverse concepts that need to be included in a future definition of SM.

Uses and perceptions of medications among French older adults: results from the 2020 French Health Barometer survey

BACKGROUND

There are few studies reporting on self-medication, perceptions or difficulties older adults have with their medications. This study aimed to describe the uses and the perceptions of medications among older adults in France and to identify patient groups based on that information.

METHODS

We used data from the 2020 'French Health Barometer' - a nationally-representative cross-sectional survey. We assessed polypharmacy (five or more medications), self-medication, and patient perceptions of medications. Robust Poisson regression was used to investigate socio-demographic and health-related factors associated with the outcomes. Latent class analysis was used to identify patient groups classified by the use and the perceptions of medications. Factors associated with group assignment were investigated by multinomial logistic regression. All analyses were weighted.

RESULTS

The study sample comprised 1,623 respondents aged 70-85 years. Polypharmacy and self-medication were reported in 23.5 and 48.7% of the older population, respectively. Polypharmacy was associated with increasing age, low education, and impaired health status. Self-medication was associated with female sex and high education. Among individuals taking at least 1 medication, 8.2% reported not to understand all their medications, and 9.7% having difficulty taking medications as prescribed. Among individuals taking at least 2 medications, 23.2% thought that they took too many medications. Three patient groups were identified: 'Non-polypharmacy, positive perceptions' (62.5%), 'Polypharmacy, positive perceptions' (28.0%), and 'Negative perceptions' (9.5%).

CONCLUSIONS

Polypharmacy and self-medication are common in French older adults. One segment of people reported negative perceptions of their medications regardless of their polypharmacy status. This underlines the difference between the objective and perceived measures of polypharmacy.

Knowledge, Attitudes, and Families Practices in Selecting, Obtaining, Using, Storing, and Disposing of Medicines on Self-Medication Behavior in Indonesia

BACKGROUND: The irrational use of medicine in the family is a serious problem. Advances in education, economy, availability of medicines, regulations, and technology have encouraged people to self-medicate in overcoming their illness. Self-medication behavior is not only carried out by adults but also by the elderly, students, and even children. Self-medication can provide positive health benefits if done correctly starting from selecting, obtaining, using, storing, and disposing medicines. On the other hand, if self-medication measures are carried out inappropriately, they can lead to various drug-related risks. AIM: Therefore, this study aimed to describe the knowledge, attitudes, and families practice in selecting, obtaining, using, storing, and disposing medicine and to identify the factors influence of this construct. METHOD: The study was conducted using an analytical method with a cross-sectional approach using a questionnaire for families in Padang Pariaman Regency, West Sumatera, Indonesia, namely, in 2x11 Enam Lingkung and Sungai Garingging Districts. The total sample size obtained was 500 families. Bivariate analysis was determined using Chi-squared test and multivariate analysis was determined using linear logistic regression. RESULTS: Data from current study found that the percentage of the average score of family knowledge of selecting, obtaining, using, storing, and disposing medicines was in a low category (57.53%), family attitudes were in the negative category (59.38%) and family actions were in the negative category (55.27%). The results of multivariate analysis using linear logistic regression showed that the sub-variables that influenced the knowledge, attitudes, and actions of families about medicines were pharmacists/doctors as the main source of information about drugs (p = 0.006), education in the category of secondary education (p = 0.002) and mothers as family members who had a major role in managing medicines (p = 0.000). CONCLUSION: The results show that knowledge, attitudes, and practice of families about medicines are still low and very limited. Factors that influence knowledge, attitudes, and practice of families selecting, obtaining, using, storing, and disposing medicine are pharmacists/doctors as the main source of information about medicine, education, and mothers as family members who have a major role in managing medicines. The lack of knowledge, attitudes, and practice related to medicines and the important role of the family is the reason for the very importance of family-based medicines education.

Public Perception of the Range of Roles Played by Professional Pharmacists

Background: Professional pharmacists should be directly involved in patient healthcare as members of therapeutic teams are not the only dispensers of medication. Public perceptions of the professional role of pharmacists is expressed through patients’ attitudes, trust, and expectations as health and illness consultants, or qualified retailers of medicines. This perception is influenced by numerous determinants, both health-related and social. Objective: This research intends to describe the range of social roles pharmacists play from the perspective of potential pharmacy customers/patients. Methods: The data presented in the article comes from cross-sectional survey-based research, undertaken in 2018, on a representative sample of 600 Polish adults. Results: Over-the-counter medication is purchased by almost all Polish adults, but they do not tend to ask for advice at pharmacies. Most respondents consider a pharmacist to be “a person qualified to sell medicines”, with some of the participants regarding pharmacists as “ordinary retailers”. A small number of respondents are interested in benefiting from pharmaceutical care, but the pharmacy is still perceived to be a point of purchase for medication. Conclusions: Respondents do not treat pharmacists as health advisors and reduce its role to that of dispensing medication. Sociodemographic variables have no significant effect on social perception of pharmacists.

Pharmacokinetic effects of simultaneous administration of single-dose gabapentin 500 mg and zolpidem tartrate 10 mg in healthy volunteers: a randomized, open-label, crossover trial

Objective

Gabapentin is being investigated as a potential treatment for occasional disturbed sleep. This study assessed the pharmacokinetics and tolerability of gabapentin 500 mg and the commonly prescribed sedative/hypnotic zolpidem tartrate 10 mg, administered separately and in combination.

Methods

Forty healthy participants (19 male, 21 female) were randomized into this three-period crossover study [mean (range) age 34.1 (18–45) years, weight 68.3 (51.4–92.7) kg; 60 % white]. Participants were dosed with gabapentin alone (n = 39), zolpidem tartrate alone (n = 38), and the combination (gabapentin + zolpidem) (n = 38) over three treatment periods, which were separated by ≥7 days. Blood samples were collected pre-dose and 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 18, 24 and 36 h post-dose. Plasma concentrations of each drug were assayed using validated methods. Pharmacokinetic parameters were estimated from plasma concentration–time data using standard non-compartmental methods.

Results

For gabapentin + zolpidem combination versus gabapentin alone, mean pharmacokinetic parameters were peak plasma concentration (C_max) 4.61 versus 4.72 µg/mL, time to C_max (t_max) 4.63 versus 3.64 h and the area under plasma concentration–time curve extrapolated to infinity (AUC_0–∞) 53.4 versus 51.0 µg h/mL. For the combination versus zolpidem alone, mean pharmacokinetic parameters were C_max 154 versus 138 ng/mL, t_max 1.45 versus 1.84 h and AUC_0–∞ 912 versus 854 ng h/mL. The 90 % confidence intervals for C_max (rate of absorption) and AUC_0–∞ (extent of absorption) comparing the combination versus single drug administration fell within the 80–125 % range accepted for bioequivalence. All treatments were well tolerated.

Conclusion

The pharmacokinetics of gabapentin 500 mg and zolpidem tartrate 10 mg are unaffected when both drugs are taken simultaneously, compared with each drug taken alone.

A questionnaire to document self-medication history in adult patients visiting emergency departments

PURPOSE

To develop the first questionnaire to obtain a complete medication history by documenting self-medication history in adult patients admitted to a medical emergency department (ED).

METHODS

A Questionnaire to document Self-Medicating Behaviours (QSMB) was developed between January and September 2008 (reference period), tested and refined between October and December 2008, and used routinely between January and December 2009 (routine period) in a tertiary care medical ED. The rate of SMBs measured with QSMB during the routine period was compared to the SMB rate measured with a spontaneous reporting method during the reference period. As survey teams changed every trimester, we also analysed the evolution of SMB rate over time.

RESULTS

QSMB is divided into two parts. The first part consists of 20 closed-ended questions exploring all indications and dimensions of self-medication. The second part assesses the characteristics of each medication mentioned by the patient in the first 20 questions. The patients interviewed during reference and routine periods did not significantly differ. The routine period patients reported a third more SMBs (89.8% vs 57.6%, respectively; p < 0.0001) and twice more self-medication drugs than the reference period patients. SMB rate was significantly different between the survey teams during the reference period (p < 0.0001), but not during the routine period (p = 0.078).

CONCLUSIONS

This questionnaire complements the traditional tools that are already available to collect medication histories of prescribed drugs. It may improve the recognition of iatrogenic conditions related to self-medication, and provide support to public health efforts and research programs on self-medication.

Misuse of medicines in the European Union: a systematic review of the literature

BACKGROUND

Although awareness of the misuse of medicines is increasing, data on the extent of the problem in the European Union (EU) are lacking.

METHODS

In order to assess the magnitude and severity of the problem, a systematic review of the literature on the misuse of analgesics, opioid substitution medicines and sedatives/hypnotics (with the exception of benzodiazepines) was conducted using the PubMed and Web of Science databases. Relevant literature was identified between 2001 and 2011.

RESULTS

The main groups of misused medicines include opioid analgesics, methadone, buprenorphine and Z-drugs. Regional trends in medicine misuse indicate heterogeneity across the EU with respect to misused medicine types and research activities. Prevalence, high-risk populations and factors contributing to medicine misuse are discussed.

CONCLUSION

The implications of these findings for prevention, treatment, and policy in the EU are considered.

Public perception on the role of community pharmacists in self-medication and self-care in Hong Kong

BACKGROUND

The choices for self-medication in Hong Kong are much diversified, including western and Chinese medicines and food supplements. This study was to examine Hong Kong public knowledge, attitudes and behaviours regarding self-medication, self-care and the role of pharmacists in self-care.

METHODS

A cross-sectional phone survey was conducted, inviting people aged 18 or older to complete a 37-item questionnaire that was developed based on the Thematic Household surveys in Hong Kong, findings of the health prorfessional focus group discussions on pharmacist-led patient self management and literature. Telephone numbers were randomly selected from residential phone directories. Trained interviewers invited eligible persons to participate using the "last birthday method". Associations of demographic characteristics with knowledge, attitudes and beliefs on self-medication, self-care and role of pharmacists, and spending on over-the-counter (OTC) products were analysed statistically.

RESULTS

A total of 1, 560 phone calls were successfully made and 1, 104 respondents completed the survey which indicated a response rate of 70.8%. 63.1% had adequate knowledge on using OTC products. Those who had no formal education/had attended primary education (OR = 3.19, 95%CI 1.78-5.72; p < 0.001), had attended secondary education (OR = 1.50, 95%CI 1.03-2.19; p = 0.035), and aged ≥ 60 years (OR = 1.82, 95% CI 1.02-3.26; p = 0.042) were more likely to have inadequate knowledge on self-medication. People with chronic disease also tended to spend more than HKD100 on western (OR = 3.58, 95%CI 1.58-8.09; p = 0.002) and Chinese OTC products (OR = 2.94, 95%CI 1.08-7.95; p = 0.034). 94.6% believed that patients with chronic illnesses should self-manage their diseases. 68% agreed that they would consult a pharmacist before using OTC product but only 45% agreed that pharmacists could play a leading role in self-care. Most common reasons against pharmacist consultation on self-medication and self-care were uncertainty over the role of pharmacists and low acceptance level of pharmacists.

CONCLUSIONS

The majority of respondents supported patients with chronic illness to self-manage their diseases but less than half agreed to use a pharmacist-led approach in self-care. The government should consider developing doctors-pharmacists partnership programs in the community, enhancing the role of pharmacists in primary care and providing education to patients to improve their awareness on the role of pharmacists in self-medication and self-care.

Combined analgesics in (headache) pain therapy: shotgun approach or precise multi-target therapeutics?

BACKGROUND

Pain in general and headache in particular are characterized by a change in activity in brain areas involved in pain processing. The therapeutic challenge is to identify drugs with molecular targets that restore the healthy state, resulting in meaningful pain relief or even freedom from pain. Different aspects of pain perception, i.e. sensory and affective components, also explain why there is not just one single target structure for therapeutic approaches to pain. A network of brain areas ("pain matrix") are involved in pain perception and pain control. This diversification of the pain system explains why a wide range of molecularly different substances can be used in the treatment of different pain states and why in recent years more and more studies have described a superior efficacy of a precise multi-target combination therapy compared to therapy with monotherapeutics.

DISCUSSION

In this article, we discuss the available literature on the effects of several fixed-dose combinations in the treatment of headaches and discuss the evidence in support of the role of combination therapy in the pharmacotherapy of pain, particularly of headaches. The scientific rationale behind multi-target combinations is the therapeutic benefit that could not be achieved by the individual constituents and that the single substances of the combinations act together additively or even multiplicatively and cooperate to achieve a completeness of the desired therapeutic effect.As an example the fixed-dose combination of acetylsalicylic acid (ASA), paracetamol (acetaminophen) and caffeine is reviewed in detail. The major advantage of using such a fixed combination is that the active ingredients act on different but distinct molecular targets and thus are able to act on more signalling cascades involved in pain than most single analgesics without adding more side effects to the therapy.

SUMMARY

Multitarget therapeutics like combined analgesics broaden the array of therapeutic options, enable the completeness of the therapeutic effect, and allow doctors (and, in self-medication with OTC medications, the patients themselves) to customize treatment to the patient's specific needs. There is substantial clinical evidence that such a multi-component therapy is more effective than mono-component therapies.

Self-medication of migraine and tension-type headache: summary of the evidence-based recommendations of the Deutsche Migräne und Kopfschmerzgesellschaft (DMKG), the Deutsche Gesellschaft für Neurologie (DGN), the Österreichische Kopfschmerzgesellschaft (ÖKSG) and the Schweizerische Kopfwehgesellschaft (SKG)

The current evidence-based guideline on self-medication in migraine and tension-type headache of the German, Austrian and Swiss headache societies and the German Society of Neurology is addressed to physicians engaged in primary care as well as pharmacists and patients. The guideline is especially concerned with the description of the methodology used, the selection process of the literature used and which evidence the recommendations are based upon. The following recommendations about self-medication in migraine attacks can be made: The efficacy of the fixed-dose combination of acetaminophen, acetylsalicylic acid and caffeine and the monotherapies with ibuprofen or naratriptan or acetaminophen or phenazone are scientifically proven and recommended as first-line therapy. None of the substances used in self-medication in migraine prophylaxis can be seen as effective. Concerning the self-medication in tension-type headache, the following therapies can be recommended as first-line therapy: the fixed-dose combination of acetaminophen, acetylsalicylic acid and caffeine as well as the fixed combination of acetaminophen and caffeine as well as the monotherapies with ibuprofen or acetylsalicylic acid or diclofenac. The four scientific societies hope that this guideline will help to improve the treatment of headaches which largely is initiated by the patients themselves without any consultation with their physicians.

Assessment of self-medication practices in Assendabo town, Jimma zone, southwestern Ethiopia

BACKGROUND

The actions taken for the treatment of illness or symptom of an illness vary depending on the perceptions and experiences of individuals and other factors. A significant portion of all care in illness is self-care. In many cases, self-medication is an important initial response to illness. Although some health-care providers attach negative connotations to it, the World Health Organization acknowledges the existence of a valid role of self-medication.

OBJECTIVE

This study was aimed at assessing the magnitude, type, and factors of self-medication in Assendabo town, Jimma, southwestern Ethiopia.

METHODS

A community-based cross-sectional study was conducted in Assendabo town during February and March 2006. Open-ended questionnaire was used to collect data by interviewing heads of households in the study population. The data collected were properly screened before they were analyzed.

RESULTS

A total of 242 households with 1257 individuals were visited, of which 143 (11.4%) reported at least 1 episode of illness and of whom 56 (39%) used self-medication using both modern pharmaceuticals and traditional medicines. Low severity of illness was a major reason for practicing self-medication; 80.6% of self-medicating individuals had no information on potential drug adverse effect. About 55% of ill persons who treated themselves reported improvement in their condition.

CONCLUSIONS

There is high prevalence of self-medication in Assendabo town. Lack of drug information and accessibility to over-the-counter drugs without any health professional guide contributed to the high incidence of self-medication. Enforcement of regulations in drug distribution and provision of appropriate health education to the community at large is critical.

Muscle damage induced by black cohosh (Cimicifuga racemosa)

Extracts of black cohosh (Cimicifuga racemosa) are commonly used for the treatment of symptoms associated with menopause. Adverse events with black cohosh are rare, mild and reversible. A few number of serious adverse events, including hepatic and circulatory conditions, have been also reported, but without a clear causality relationship. We report the case of a woman with severe asthenia and very high blood levels of creatine phosphokinase and lactate dehydrogenase. The patient referred to take a dietary supplement derived from black cohosh for ameliorating menopause vasomotor symptoms. To exclude a possible involvement of this product, the patient was suggested to discontinue this therapy. After suspicion the patient showed a progressive normalization of biochemical parameters and improvement of clinical symptoms. We can hypothesise a causative role for black cohosh in the muscle damage observed in this patient. Factors suggesting an association between black cohosh and the observed myopathy included the temporal relationship between use of herbal product and asthenia and the absence of other identified causative factors. Rechallenge with the suspected agent was inadvisable for ethic reasons because of the risk of a serious relapse. This is the first time that asthenia associated with high muscle enzymes serum levels by black cohosh has been reported. In our opinion, this report is of interest because of the widespread diffusion of use of black cohosh as an alternative medicine for relief from menopausal symptoms.

The drug utilization patterns of Hong Kong Chinese adults

This paper reports the findings of a pilot study on the drug utilization patterns, including both Western and Chinese medications, of Hong Kong Chinese adults with an aim to plan quality community-based safe medication practice education. A tool for collecting the drug utilization patterns was developed for the purpose of the study. One hundred Chinese adults were invited to participate in this pilot study. Structured interviews were used in the study. Drug utilization patterns of the subjects in the preceding 2 weeks were investigated. It was found that 44 adults took Western medications such as cough and cold remedies or analgesics. Nineteen adults took Chinese medications such as tonics or prescriptions for relieving exterior syndrome. Adults who took Western medications understood the effects and side effects of the drugs better than those who took the Chinese medications although their knowledge was not sufficient to allow them to perform safe medication practice. It was concluded that the tool is useful in the future, in large-scale research studies to promote safe medication practice.

Selecting nonprescription analgesics

Worldwide, there has been an emerging patient demand for access to efficient drugs without consulting a doctor and obtaining a prescription. As a result, there has been an expanding movement of prescription-only drugs to over-the-counter (OTC) status. An increasing number of drugs are becoming available OTC, empowering patients to treat themselves. Where the principle of empowering individuals to treat themselves can fail is when consumers lack the knowledge to do so safely. This potentially applies to the self-selection of analgesic drugs by consumers. When used inappropriately, these drugs pose significant risks. The nonsteroidal antiinflammatory drugs (NSAIDs) are associated with many adverse reactions, interactions, and contraindications in a number of patient groups, even at OTC doses. In particular, in the elderly, the high incidence of cardiovascular and gastrointestinal disease, coupled with age-related decline in renal function and multiple medication use, all warrant extra caution with the use of NSAIDs and make paracetamol the simple analgesic drug of first choice. Despite the possibility of hepatotoxicity in overdose, paracetamol represents a better all-round option for most patients requiring OTC analgesic therapy.