Ntcc 3rd Year.docx

AMITY INSTITUTE OF PHARMACY

SELF MEDICATION – RISK ASSOCIATED AND ITS PREVENTION

Submitted by:TANUJA CHAUDHARY B.PHARM (2015-2019) A4513315070

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SELF-MEDICATION–A CURRENT CHALLENGE

Self-medication is practised in the form of self-care of our health. During early times, selfmedication was regarded as unnecessary and potentially even unhealthy practice. Traditionally, self-medication was known as “taking drugs, home remedies or herbs by one’s own or advised by another person without consulting a doctor. Some of the common sources of self-medications are family, friends, neighbours, pharmacist, previous prescribed drugs or advertisements. Now-a-days people/patients desire to play intelligent, independent and informed role and not just in terms of decision making but also in the management of preventive, diagnostic and therapeutic activities which concern them. The most widely selfmedicated substances are over the counter drugs used to treat common health issues at home and dietary supplements as they are available without prescriptions and even at supermarkets. Patients wish to take a greater role in the maintenance of their health and to manage chronic and recurrent illnesses, e.g. topical corticosteroid, antifungal and oral contraceptive. An urge of self-care, feeling of sympathy toward family members in sickness, lack of time, lack of health services, financial constraint, ignorance, misbelieves, extensive advertisement and availability of drugs in other than drug shops are growing cause of self-medication. Selfmedication is becoming an increasingly important area within healthcare. It moves patients towards greater independence in making decisions about management of minor illnesses, thereby promoting empowerment. Self-care includes actions taken by individuals to promote or ensure their health, to recover from diseases or injuries, or to manage their effects. Selfmedication is thought to reduce the load on the medical services, decrease the time spent in waiting to see the physician, and saves cost especially in economically deprived countries with limited health resources. However, responsible self-medication is not free of risk which can increase the burden and out- of- pocket expenses since it may result in adverse health effects that require medical intervention.

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BRIEF OVERVIEW TO SELF MEDICATION

Common illnesses where patients self-medicate:1. Common infections 2. Chronic non communicable diseases 3. Mental illnesses

Factors leading to self-medication:1. Social 2. Fragmented health care system 3. Waiting time 4. Health care cost 5. Lack of awareness

Sources of medicine:1. Pharmacies 2. Drug stores 3. Medicines stored at home 4. Friends and relatives 5. Street vendors

Categories of medicines used for self-medication:1. Anti-biotics 2. Anti-histamines 3. Analgesics 4. Weight gain and weight reducing agents 5. Multi vitamins 6. Skin bleaching steroids

The use of medications without prior medical consultation regarding indication, dosage, and duration of treatment is referred to as self-medication. In most illness episodes; selfmedication is the first option which makes it a common practice worldwide. Common illnesses in which people self-medicate are common infection such as common cold, cough etc. chronic non communicable diseases such as diabetes, and mental illnesses such as depression or anxiety. Factors that lead to self-medication are social factors such as lifestyle, fragmented health care system i.e. when there are many different health “subsystems” that coexist, providing care for different parts of a country’s population. Each of these subsystems has their own way of financing and delivering healthcare, and each provides healthcare to different types of people. The problem is that when these subsystems operate independently from one another, they create major gaps in the provision of health services, often leaving out the poorest patients; waiting time; health care cost and lack of awareness are also responsible for selfmedication. Some categories of medicines that are often used for self-medication are antibiotics (amoxicillin/azithromycin); analgesics (ibuprofen/aspirin); weight gain or weight reducing tablets; multi vitamins; etc.

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HYPOTHESIS REGARDING SELF-MEDICATION

Different drugs show different effects and therefore are used for different reasons. According to the self-medication hypothesis, an individuals' choice of particular drug is not accidental or coincidental, but is a result of that individuals' psychological condition, since the drug of choice provides relief to the user according to his or her specific condition. Specifically, addiction is assumed to function as a compensatory means to modulate effects and treat distressful psychological states, in which individuals choose the drug that will most effectively manage their psychiatric distress and thereby help them achieve emotional stability. The self-medication hypotheses (SMH) were formerly given in papers by Edward Khantzian, Mack and Schatzberg, David F. Duncan. Initially it focused on heroin use, but follow-up paper added cocaine and was later expanded to include alcohol, and finally all drugs

of addiction. [9] According to Khantzian's view of addiction, drug users compensate for deficient ego function by using a drug as an "ego solvent", which acts on parts of the self that are cut off from consciousness by defence mechanisms. According to Khantzian, drug dependent individuals generally experience more psychiatric distress than non-drug dependent individuals, and the development of drug dependence involves the gradual incorporation of the drug effects and the need to sustain these effects into the defensive structure-building activity of the ego itself. The addict's choice of drug is a result of the interaction between the psychopharmacologic properties of the drug and the affective states from which the addict was seeking relief. The drug's effects substitute for defective or non-existent ego mechanisms of defence. The addict's drug of choice, therefore, is not random. While Khantzian takes a psychodynamic approach to self-medication, Duncan's model focuses on behavioural factors. Duncan described the nature of positive reinforcement (e.g., the "high feeling", approval from peers), negative reinforcement (e.g. reduction of negative affect) and avoidance of withdrawal symptoms, all of which are seen in those who develop problematic drug use, but are not all found in all recreational drug users. Duncan applied a public health model to drug dependence, where the agent (the drug of choice) infects the host (the drug user) through a vector (e.g., peers), while the environment supports the disease process, through stressors and lack of support. [8]

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CHARACTERISTICS OF SELF-MEDICATION

Self-medication is becoming an increasingly important area within healthcare. It moves patients towards greater independence in making decisions about management of minor illnesses, thereby promoting empowerment. Self-medication also has advantages for healthcare systems as it facilitates better use of clinical skills, increases access to medication and may contribute to reducing prescribed drug costs associated with publicly funded health programmes. [2] Monitoring systems, a partnership between patients, physicians and pharmacists and the provision of education and information to all concerned on safe selfmedication, are proposed strategies for maximising benefit and minimising risk. It is widely accepted that self-medication has an important role to play in health care and, with the continued improvement in people's education, general knowledge and socio-economic status; self-medication has been successfully integrated into many health care systems throughout the world. Self-medication products are those not requiring a medical prescription and which are produced, distributed and sold to consumers for use on their own initiative. Responsible selfmedication can be used to prevent and treat symptoms and ailments that do not need medical consultation or oversight. This reduces pressure on medical services, especially when these are limited. For those populations living in rural or remote areas where access to medical services may be difficult, patients are able to control their own conditions to a greater extent. Only if the condition fails to respond, persists, or becomes more severe will the patient need to seek professional medical care. [3] Self-medication is useful as it:

Help to prevent and treat symptoms and ailments that do not require a doctor.

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Reduce the pressure on medical services where health care personnel are insufficient.

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Increase the awareness of health care to populations living in rural or remote areas.

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Enable patients to control their own chronic conditions.

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Hay fever, headache, indigestion, mouth ulcer, nausea, cough, acne, allergic conjunctivitis can be treated by self-medication.

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For healthcare systems as it facilitates better use of clinical skills, increases access to medication and may contribute to reduce prescribed drug costs associated with publicly funded health programs. 5

POTENTIAL BENEFITS OF SELF MEDICATION

The social and economic benefits of self-medication reflect the fact that it is voluntarily chosen by consumers for conditions where it seems preferable to them. It will usually be selected for use in symptoms and conditions which the user regards as sufficiently troublesome to need medicinal treatment but not to justify consulting a physician. Only if the condition fails to respond, persists or becomes more severe will professional medical help be sought. Accordingly, good self-medication should offer the individual consumer:  Efficacy: i.e. the product does what it is claimed to do;  Reliability and safety: the individual will often choose a product which experience has shown to be suitable. The scope and duration of self-medication can be kept within safe limits by appropriate selection of approved indications, labelling texts, dosage strengths and forms, and package sizes;  Product safety when used as recommended in the instructions;  Acceptable risk, even when used for a longer duration, at a higher dose, or somewhat differently than recommended in the instructions;  Wider availability of medicines;  Greater choice of treatment;  Direct, rapid access to treatment;  An active role in his or her own health care;  Self-reliance in preventing or relieving minor symptoms or conditions;  Educational opportunities on specific health issues (i.e. stop-smoking aids and products to treat heartburn);  Convenience; Economy, particularly since medical consultations will be reduced or avoided; At the community level, good self-medication can also provide benefits such as saving scarce medical resources from being wasted on minor conditions, lowering the costs of communityfunded health care programmes (including prescription reimbursement systems), and reducing absenteeism from work due to minor symptoms. [3]

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RISKS IN SELF MEDICATION PRACTICES

Self-medication has a number of potential risks. In particular, the ordinary user will usually have no specialized knowledge of the principles of pharmacology or therapy, or of the specific characteristics of the medicinal product used. This results in certain potential risks for the individual consumer:  Incorrect self-diagnosis which leads to incorrect choice of therapy  Failure to seek appropriate medical advice promptly  Failure to recognize special pharmacological risks which may lead to rare but severe adverse effects  Failure to recognize or self-diagnose contraindications, interactions, warnings and precautions  Failure to recognize that the same active substance is already being taken under a different name  Failure to report current self-medication to the prescribing physician  Failure to recognize or report adverse drug reactions  Incorrect route or manner of administration  Inadequate or excessive dosage  Excessively prolonged use  Food and drug interactions  Storage in incorrect conditions or beyond the recommended shelf-life At the community level, improper self-medication could result in an increase in druginduced disease and in wasteful public expenditure [3]

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Recognizing Forms of Self-Medication

Self-medication and depression Depression is classified as a mood disorder. It’s associated with feelings of sadness, loss, and anger. When someone is depressed, these symptoms can impact their everyday life. Treating depression is important. It usually involves counselling, medication, or both. However, not everyone seeks professional help to treat their depression. Some try coping with their symptoms on their own. One way this happens is through self-medication. This can be dangerous and it can cause even bigger problems than simply choosing not to get treatment from trained medical professionals.

Self-medicating with food Risks: Decreased self-esteem, worsened depression symptoms If you’re an emotional eater, you might self-medicate with food. “Emotional eating” is using food as a way to suppress or soothe negative emotions. This practice is also called “bingeing” or “comfort eating.” Emotional eating may temporarily reduce stress in those who aren’t clinically depressed, according to a 2015 study. However, bingeing is not a healthy way to treat depression. It can negatively affect self-esteem and make symptoms of mental illness worse. It may also have an impact on physical health through weight gain.

Self-medicating with alcohol Forms: Beer, wine, liquor Risks: Addiction, legal consequences In low doses, alcohol can temporarily relieve symptoms of depression and anxiety. It can make a person more jovial and social, give them a sense of everything being “alright,” and 8

alleviate anxiety. However, when used regularly, it can lead to alcoholism, which worsens depression and anxiety. Alcoholism may require a lengthy recovery process and can be extremely difficult to manage. Recovery can be a life-long process. Post-traumatic stress disorder (PTSD) is another condition that frequently results in self-medicating with alcohol. Research shows that trauma and alcohol abuse are often linked.

Self-medicating with psychostimulants Forms: Cocaine, amphetamines Risks: Heart failure, death, legal consequences People with mental health conditions may abuse psychostimulants such as cocaine and amphetamines. This is most likely due to the feelings of euphoria these drugs can cause. However, cocaine can be addictive and cause depression. Cocaine has a high potential for addiction. It can be fatal when used as a recreational drug. It does major damage to the body’s cardiovascular system. Cocaine-related deaths can occur as a result of sudden heart failure. Amphetamines speed up the function of the heart and carry the risk of a stroke. Using these substances may distract from depression, but the “crash” feeling after the drugs have worn off doesn’t make them an effective solution for depression. In fact, cocaine users often find that it worsens their symptoms.

Self-medicating with caffeine Forms: Coffee, tea, energy drinks Risks: Increased feelings of depression and anxiety Caffeine is a stimulant that’s found in many foods and in drinks such as coffee and tea. While coffee is popular for its ability to perk you up, the effects are only temporary. Once the high wears off, your insulin levels drop, causing feelings of confusion and depression. Caffeine can also heighten feelings of anxiety. Cut down to one cup of coffee or tea per day if you’re sensitive to the effects of caffeine. 9

Self-medicating with cannabis Forms: Marijuana Risks: Worsened symptoms of depression, legal consequences Compared to illicit substances (such as opioids, cocaine, and amphetamines), marijuana, or cannabis is, by far, the most widely used substance among those with depression. While there are some assertions among cannabis users that cannabis treats depression, more studies are needed to determine the benefits and possible disadvantages of marijuana as a potential treatment for depression. Studies show that too much marijuana can worsen symptoms of depression.

Self-medicating with opiates and opioids Forms: Codeine, heroin, methadone Risks: Worsened depression symptoms, death, legal consequences Opiates, such as codeine and morphine, are drugs derived from the poppy plant. Any drug that mimics the effects of an opiate is called an opioid. Opioids include heroin, oxycodone, and methadone. The World Drug Report estimated that in 2013, 40.9 to 58 million people worldwide used opiates and opioids. Depression is common among users of these drugs. When depression and opiate use or abuse are combined, the results can be deadly.[10]

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SELF-MEDICATION WITH ANTIMICROBIAL DRUGS

Self-medication can be defined as the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms. It is usually selected by consumers for symptoms that they regard as troublesome to require drug therapy but not to justify the consultation of a prescriber. In developing countries, most illnesses are treated by self-medication. A major shortfall of selfmedication is the lack of clinical evaluation of the condition by a trained medical professional, which could result in missed diagnosis and delays in appropriate treatments. A major problem with self-medication with antimicrobials is the emergence of human pathogens resistance. Antimicrobials resistance is a current problem world-wide particularly in

developing

countries,

where

antibiotics

are

often

available

without

a

prescription. Resistance to antimalarials drugs has also been reported in many third world countries. Reasons for this resistance include the irrational use of antimalarials, including their indiscriminate non-prescription use. In Sudan there is suspicion that self-medication is high. A reason for this is the fact that in Sudan most drugs can be obtained from pharmacies and drug stores without the requirement of a prescription. As a result, minor ailments are often treated with antimicrobials. In addition, self-treatment of malaria is common following self-diagnosis mainly based on presumptive symptoms of malaria. Self-medication with antimicrobials has the potential to harm society at large as well as the individual patient. Policy makers should be concerned if the spectrum of drugs available without a prescription includes antibiotics. The increase in antibiotics resistance in developing countries is of current public and professional concern as it results in multiple resistant organisms difficult to treat. It is widely believed that human malpractices such as inadequate dosing, incomplete courses and indiscriminate drug use have contributed to the emergence and spread of antimicrobial resistance. The consequence of this is the loss of relatively cheap drugs that will require new drugs development, which will be more expensive and will further disadvantage patients in developing countries such as Sudan. The rational use of antibiotics is thus of utmost importance to limit the increase in bacterial resistance. [5]

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CASE STUDIES

Scenario 1 M. K., a 36 years old, truck driver working in the oil fields suffered from a cough productive of whitish sputum, for the past 10 weeks. He visited many pharmacies and used 18 different products during the past weeks, including cough products, common cold products, antihistamines, decongestant, nasal sprays, antibiotics and analgesics according to advice from relatives, friends, pharmacists and some doctors; but without relief. He also used various home remedies and herbs suggested by family and friends but without benefit. M. K. finds it difficult to work and takes time off during the job. The cough now is worse awakening him at night with chest discomfort. He had taken a medical leave and decided to see a doctor who referred him to a chest physician. The chest physician took an appropriate history, examined the patient, requested a chest X-ray which showed hyperinflation, the Peek Expiratory Flow Rate was 65% of the expected and the CBC (Complete Blood Count) was normal. A diagnosis of bronchial asthma was made and; severity was assessed. The patient was started on step 2 of asthma treatment; regular corticosteroid plus when required salbutamol Metered Dose Inhalers (MDI) was prescribed. Problems • In appropriate self-medication. • Delayed diagnosis for a serious health condition. • Economic burden on the patient and the health care system. • Home remedies and herbs are not free from adverse effects; they might have worsened the patient’s condition • The patient’s health suffered longer than necessary, and missed many work days. Solutions • Campaign of health education to the public highlighting the adverse effects of selfmedication.

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• Advice healthcare workers on recommending medication after appropriate a diagnoses has been made. • Advice healthcare workers to refer patients to the appropriate specialty in order to prevent prolonging patient's suffering, subjecting them to needless complications and to over burden them with an extra out of pocket expenditure. • Identify triggering factors and the role of occupation on bronchial asthma so as to avoid them.

Scenario 2 A 9 months old baby boy developed watery diarrhoea, six motions per day. The mother gave her baby metronidazole suspension which she already had at home. After using the drug for two days the diarrhoea didn't stop, she went to the pharmacy and was given co-trimaxozole suspension. Nevertheless the diarrhoea did not settle. Two days later, the child developed oral thrush, refused feeding and his general condition deteriorated. The mother stopped the medication and took him to a traditional healer, who cut the baby’s uvula. The baby’s condition got worse and was taken to the hospital. He was diagnosed as sepsis with malnutrition and was admitted for 15 days. The specialist instituted the appropriate management and counselled the mother and advised her on how to deal with such conditions if experienced in the future. Problems Inappropriate management of diarrhoea: • The mother didn’t seek medical advice from the start. • Inadvertent use of medicines stored at home; leftover antibiotics. • Resorting to the traditional healer. • Irrational dispensing of antibiotics by the pharmacist. • Failure of the pharmacist in counselling and providing proper advice. Consequently this led the mother to seek help from traditional healers.

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• The pharmacist did not provide the mother with ORS and Zinc Sulphate according to the national guidelines and Integrated Management of Childhood Illness– Federal Ministry of Health. • Inappropriate self-medication with metronidazole and irrational dispensing of co-trimexzole delayed the diagnosis and led to grave consequences. . • The cost of over-the-counter drugs and consequences of self-medication can be more expensive than seeking proper medical care. It can also delay the proper treatment. Solutions • Diarrhoea is a common childhood illness. The mainstay of management is oral rehydration solution and zinc supplement. However the use of antibiotics and metronidazole to treat diarrhoea in children is very common. • Pharmacists and other health care professionals should be trained and motivated to follow standard treatment guidelines when dealing with health problems. • Regulations to limit public access to antibiotics should be enforced. • The public awareness about self-medication and antibiotic use should be raised especially in regard to children. • Educational programmes using different forms of media should educate the public about the adverse impact of resorting to traditional healers.

Scenario 3 A24 old lady was brought in a bad condition to the Emergency Room in Khartoum teaching hospital. Upon arrival, she was hypoglycaemic, severely hypotensive with impaired consciousness. Two days prior to admission the patient, according to her family, has started to complain from myalgia, malaise, anorexia, diarrhoea, abdominal pain and vomiting. The history taken from a family member has shown that the patient, advised by a friend of hers, was using tablets known as ''annajma'' bought from a local market, for the last 6 months to gain weight, as she thought she was too skinny. The patient has stopped her medicine 3 days earlier, because she thought they were useless. The tablets were identified as dexamethasone 14

2 mg tablets. Laboratory investigations have revealed sodium blood level of 124 mEq/ml (normal 135 - 145mEq/ ml), blood sugar was 50 mg/ dl (normal 150 mg/ dl). Blood pressure measurement was 50/ 40 mm Hg (normal 120/ 80 mm Hg). The treatment for adrenal crisis was instituted. The patient was immediately cannulated for IV access, and given treatment in form of dextrose, normal saline, and hydrocortisone planned to continue the treatment for the following 48 hours. Unfortunately, the patient's condition deteriorated, and passed. Problems This case illustrates the risks associated with self-medication with systemic corticosteroids, which has become a common practice by many Sudanese ladies recently to gain weight and whiten skin. Corticosteroids are known to cause water and salt retention leading to weight gain. Glucocorticoids have high adverse effect profiles, and should be used only under close medical supervision when clearly indicated. Chronic use Fatal Outcomes of Street Sold Medications: "Annajma" Example Practice Issues of glucocorticoids is the most common cause of adrenal crisis which represents a true endocrine emergency, a life threatening condition if untreated. Systemic corticosteroids used for more than 3 weeks require dose tapering to allow for the hypothalamic pituitary adrenal axis recovery. Solutions The importance of raising awareness of the public about the risks involved with corticosteroids self-medications and the problems of obtaining medication items from sources other than pharmacies. More effort is required from the concerned authorities to prohibit medicines to be obtained from channels other than the official channels.

The role of pharmacists in responding to symptoms and dispensing drugs without prescriptions fits well with the extended role of pharmacists in providing pharmaceutical care. It is substantial and requires a mix of good knowledge and skills; like how to differentiate between minor and serious symptoms, listening skills, questioning skills and good knowledge about evidence-based treatments for different ailments. [6]

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Recommendation to overcome irresponsible self–medication

• Regulatory authorities are required to continuously review and classify medicinal products on the basis of safety, efficacy, and contribute to enforcement and implementation of laws and regulations. • Adaptation of self-medication protocols by Ministry of Health and provision of reference materials and training activities for healthcare workers to meet local needs. • Continuing education for pharmacists should be undertaken and supported to ensure maintenance of pharmacist's capacity to respond to the changing health needs of the public • National pharmaceutical associations should develop certain performance standard, based on the concept of pharmaceutical care. • Pharmacies survive commercially through product sales, but these should never be their principal focus. Product selection must be appropriate to the need and circumstances of the patient, and based on informed judgment and whenever necessary and appropriate, the patient must be referred to physician. • Expansion of health insurance services to universal coverage can reduce the prevalence of self- medication practices.

Response to symptoms by Pharmacist Pharmacists are frequently used as an alternative and less expensive source of medical care, and the first place to call for advice about minor conditions and medications. • When pharmacists receive requests from the public for advice on a variety of symptoms thought to be related to mild self-limiting minor ailment, they may supply a medicine, if truly indicated with advice to consult a medical practitioner if the symptoms persist. • Pharmacists should hold fully the responsibility and accountability for dispensing drugs without prescriptions in pharmacy.

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• In responding to symptoms, pharmacists are required to follow a systematic approach according to a logical sequence. • This can be accomplished by first identifying the patient, establishing the profile of symptoms, establishing drug history, herbals or other traditional remedies, establishing possible existence of risk factors and finally differentiate between minor and serious symptoms, which is the most challenging step, before making a decision. • Symptoms like nausea, vomiting, indigestion and burning urination MAY or MAY NOT be due to mild diseases. When drug treatment is appropriately recommended, the patient is advised to come again for evaluation of treatment outcome if symptoms persist.

Figure 1 Flow chart of role of pharmacist in responding to symptoms

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CONCLUSION

Consumers need independent information to ensure the safe, effective and rational use of drugs in self-medication. Advice to the consumer/patient should include a description of how to use the product without medical supervision and the circumstances in which referral for medical advice is necessary. In many cases, self-medication products are also understood to mean alternative medicines, food supplements, vitamins, herbs or other substances contained in commercially available products. Many are also sold in pharmacies or health food stores and have not been clinically tested and do not have a scientific basis for their recommended medicinal use. Moreover, certain products can cause severe safety problems. In highly regulated markets, pharmacists and other health care providers that recommend alternative medicines expose themselves to malpractice and liability claims if a patient is either injured or has treatment inappropriately delayed as a result of recommending such products. In conclusion, self-medication can facilitate access to medicines and reduce health care costs. But more specific studies are needed to evaluate the impact and role of self-medication in the diversity of settings of different health care sectors. The combined efforts of industry and regulators must meet the expectations of consumers by providing products which are safe, effective, good value for money, and accompanied by complete and relevant information. High ethical standards should be applied to the provision of information, promotional practices and advertising. The content and quality of such information and its mode of communication remains a key element in educating consumers in responsible selfmedication. [3]

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REFERENCES

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012703/ 2. https://www.ncbi.nlm.nih.gov/pubmed/11735659 3. http://apps.who.int/medicinedocs/en/d/Jh1462e/1.html 4. https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2125.2003.01716.x 5. https://sites.ualberta.ca/~csps/JPPS8(2)/A.Awad/sudan.htm 6. http://apps.who.int/medicinedocs/documents/s22205en/s22205en.pdf 7. https://link.springer.com/article/10.2165/00002018-200124140-00002 8. https://www.addictioninfo.org/articles/258/1/The-Self-Medication-Hypothesis/Page1.html 9. https://en.wikipedia.org/wiki/Self-medication 10. https://www.healthline.com/health/depression/forms-self-medication

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