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Knowledge and Attitudes Regarding the Self-Use of Pain Medications in Saudi Arabia: A Cross-Sectional Study

Objective: The objective of the study was to examine the knowledge and attitudes of the population in the Kingdom of Saudi Arabia regarding the use of over-the-counter (OTC) analgesics. Methods: A prospective cross-sectional study used an electronic survey questionnaire comprising 18 questions. An electronic survey was distributed through social networking sites during the period from November 1 to November 15, 2014, followed by data analysis. Results: Data from 1808 questionnaires were collected and analyzed. The results showed that 61% of the participants used analgesics without prescription; 67% used analgesics only for severe pain; 72% stated that analgesics could be administered with other medications; 68% reported that analgesics had an antipyretic effect; and only 1% reported that they had an anti-inflammatory effect. Further, 80% of the participants had the habit of reading drug product information and 77% were careful about the expiry date. Conclusions: The general population showed inadequate knowledge and attitudes toward OTC analgesics. Therefore, more programs to increase awareness and health education among patients are needed.


Study design
This cross-sectional study was conducted to assess the knowledge and attitudes of a sample of the general population in Saudi Arabia regarding the use of OTC analgesics from November 1 to November 15, 2014. The study protocol was approved by the King Abdul-Aziz University's Hospital Ethics Committee.

Population
The sample size was calculated based on the prevalence of OTC analgesic used as mentioned by Aljadhey et al., [11] using an error margin of 5%, a confidence interval of 99%, and Saudi population size of 33,582,116. Participants included males and females in Saudi Arabia aged between 18 and 60 years. Participants were invited to take part by sending each of them a link to the electronic survey questionnaire through several social networking sites.

Questionnaire
The study used an electronic questionnaire comprising 18 questions. The questionnaire was written in two versions (English and Arabic) and reviewed by a bilingual expert. The Arabic version was distributed to ten randomly selected undergraduate medical students as a pilot survey to assess the questionnaire's reliability. In addition, the questionnaire was reviewed by two pharmacologists to evaluate its reliability. The aim of the study and confidentiality were clarified in a statement at the beginning of the questionnaire, including a statement that the questionnaire is considered being a participation agreement. The participants did not receive any reward or payment for participation. The link to the questionnaire was accessible from November 1 to 15, 2014. Only completed questionnaires were included in the study. The questionnaire was composed of three parts, as shown in Table 1.

Statistical analysis
Statistical analysis of the data was performed using Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) for Windows 23.0 software package. Data were presented as frequencies and percentages for each answer.

Demographic characteristics of participants
A total of 1808 questionnaires were collected and analyzed. As shown in Table 2, most patients were females (72%). More than a third of the participants (37%) were aged between 26 and 35 years, and 72% of the participants were married. University graduates accounted for 68% of the population, whereas only four participants were noneducated. Occupations of the respondents were represented approximately equally by students, government workers, and others such as businessmen and retired workers. About 36% of the participants had an average monthly income of >10,000 Saudi Riyals, whereas only 13% had an average monthly income of <3000 Saudi Riyals.

Participants' knowledge regarding the use of analgesics
As shown in Table 3, analgesics without prescriptions were used by 71% of the participants. The top three most frequently used OTC analgesics in the study population were Adol (hydrocodone-acetaminophen), fevadol (paracetamol), and ibuprofen, with a frequency of 35%, 28%, and 10%, respectively. The majority of the participants (80%) agreed that analgesics are harmful to pregnancy. When participants Participants were asked about their (1) age, (2) sex, (3) marital status, (4) level of education, (5) field of work, and (6) monthly income. Participants were also asked if they had any chronic medical condition Part II: knowledge regarding analgesics Participants were asked about (1) sources of painkiller prescriptions, (2) frequently used painkillers, (3) whether painkillers harm pregnancy, (4) indications for painkiller use, (5) their adverse effects, (6) knowledge of the correct dose of painkillers, (7) appropriate age to use aspirin, and (8)  Participants were asked about (1) symptoms requiring painkiller use without consultation, (2) severity of pain forcing painkiller use, (3) reading product information before using painkillers, and (4) knowing the expiration date of painkillers were asked if they were aware of other indications of analgesics (other than pain), 68% were aware that analgesics could be used as antipyretics, and 27% were aware of the effective use of analgesics to relieve flu symptoms. Still, only 1% acknowledged the anti-inflammatory effects of analgesics. Forty-three percent of the participants knew that analgesics might cause peptic ulcers as an adverse effect. Ninety percent of the participants believed that analgesics must not be given to children aged <12 years. Only 9% of the participants believed that analgesics could be taken on an empty stomach, whereas the majority of participants (90%) were aware that analgesics must be taken with meals.

Participants' attitude regarding the use of analgesics
Data on participants' attitudes regarding the use of OTC analgesics are summarized in Table 4. When participants were asked about the symptoms for which they could take OTC analgesics without medical consultation, 50% of them stated headaches, followed by 32% who stated menstrual pain as a symptom. Sixty-seven percent of the participants used analgesics only for severe pain. Seventy-two percent of the participants stated that analgesics could be administered with other medications. Eighty percent of the participants had the habit of reading the drug product information, whereas 77% were careful about the expiry date.

dIscussIon
Our study results revealed a widespread self-medication with OTC analgesics among this population, with users exhibiting inadequate knowledge and attitudes regarding OTC analgesics.
The present study showed that females used OTC pain medications more frequently than males and were more knowledgeable than males, which is consistent with other studies conducted on different populations such as Norwegian [12] and American. [10] This general observation may be because pain perception in females differs from that in males, indicating that females comparatively need more painkillers. [13] Further, most OTC analgesic users were between 26 and 35 years of age, with 30% being students. Almalak et al. [14] reported that 48.1% of university students used OTC analgesics and found that 76% of the respondents reported receiving therapeutic doses. On the contrary, Wongrakpanich et al. [15] showed that OTC analgesics were used more commonly among >60-year-old individuals. However, the direct comparison between studies is difficult due to the differences in methodologies.
Thirty-eight percent of the respondents used fevadol without a prescription, 28% used Adol, 10% used ibuprofen, and a negligible number used aspirin as an OTC analgesic. Paracetamol was the most common OTC analgesic used in the Norwegian [12] and the USA [16] studies. However, these results differ from those reported by Wolf et al., [17] who surveyed athletes and found that 80% of them self-administered ibuprofen, whereas paracetamol and aspirin were used by 29% and 71%, respectively. The differences in results are more likely because Wolf et al. conducted their research on athletes who were commonly suffering from muscle/joint pain, whereas in our study, headache was the most common cause for the use of OTC analgesics.
Seventy-one percent of our study participants used OTC analgesics without prescriptions. This prevalence is comparable to that observed in an earlier study which reported that 87.2% of medical students use analgesics without prescriptions. [18] An alarming finding was that three-quarters of the respondents in this study reported taking analgesics concomitant with other drugs, putting them at risk of analgesic drug-drug interactions. [19] Therefore, physicians should be encouraged to inquire their patients about the use of OTC analgesics routinely. Individuals self-medicate by obtaining OTC medicines from pharmacies. [20] However, this may be harmful because of inaccurate or insufficient knowledge about the use, indications, adverse effects, and contraindications of some OTC drugs. [21] conclusIons We conclude that inadequate knowledge and attitude regarding the use of OTC analgesics are prevalent among individuals in Saudi Arabia. The US Food and Drug Administration has established an awareness program regarding the safe use of OTC analgesics. [22] The need for local awareness programs is emphasized for increasing knowledge among the public about taking analgesics based on prescriptions and discontinuing the habits of self-prescription. Thus, we believe that the findings of our study are valuable in recognizing the target audience and the health education program.

Study limitations
The main limitation in the present study was the use of an online questionnaire, which enabled a selective sample of the population to use it and excluded those who do not use computers.