Self-Medication with Painkillers in the Municipality of Bačka Topola A

Introduction: In Serbia, analgesics are available without a doctor’s prescription and using painkillers without previous consultation with a family physician has been ever more common among patients. Aim: The aim of this study was to investigate the attitudes about self-medication for pain relief and and characteristics of self-medication among patients in the municipality of Bačka Topola. Subjects and Methods: The study was conducted betweeen September 20, 2017 and September 29, 2017 in three General practice medical centres of the municipality of Bačka Topola. 136 adult patients, who agreed to fi ll in an anonymous questionnaire participated in the survey. Results: 75% of the study subjects used painkillers during the last year. The most common indications were headache 52%, joint pain 33% and back pain. 41% of the subjects said they used painkillers once a month. The most commonly used pain reliever was ibuprofen 47% followed by diclofenac 28% and aspirin 21%. 48% of our subjects did not seek advice from their family physician (self-medication) because the pain was not too strong and did not not last too long. while 32% of the subjects referred to earlier experience. 77% of subjects said they knew side eff ects of analgesics, but only 40% of them named it. 42% of subjects did not contact a family physician due to mild pain, 29% because of saving the time. 77% of subjects said that they are familiar with the side eff ects of analgesics, but only 40% could name them. Conclusions: The results of our study point out that the patients’ knowledge about painkillers plays a very important role in their rational consumption. Therefore, educational campaigns about the behaviour of patients towards painkillers are the key elements to ensure quality and knowledge based use of these drugs among patients.


INTRODUCTION
Pain is one of the most common medical symptoms and non-steroidal anti-infl ammatory drugs (NSAIDs) are among the most commonly used medications [1]. Th e objective of pain elimination is to enable normal functioning of the patients in working and daily activities. Painkillers are the most eff ective way to eliminate and relieve pain. Pain, which is an unconfortable feeling, may occur suddenly and for that reason we usually need to eliminate it quickly. In most cases we decide to take painkillers for pain relief without consulting a physician or pharmacist about the type of analgesic and its side eff ects. Th ere are numerous reasons for self-medication [2]. Self-medication has many advantages -we can save time by avoiding making appointments and waiting for examinations at the doctor's offi ce, we can avoid paying for examination and last but not least the pharmacies are more available than doctors. NSAIDs are the most commonly used painkillers [3]. In SerbiaNSAIDs can be purchased without a prescription, and are widely used because of their anti-infl ammatory, analgesic and antipyretic eff ects. However, nephrotoxicity remains a major concern with these drugs; other systems such as gastrointestinal, cardiovascular, hematologic, respiratory, and hepatic are also aff ected [4]. Responsibility remains with all healthcare professionals to establish the balance between the benefi ts and risks associated with these drugs. Th e patients who uses the drugs and the policy-framing bodies are others who could intervene in promoting the rational use of NSAIDs [5,6].

AIM
According to the above mentioned data, the aim of this study was to assess the attitudes about self-medication for pain relief and and characteristics of self-medication among patients in the municipality of Bačka Topola.

SUBJECTS AND METHODS
Th e study was conducted in Bačka Topola municipality (which includes 23 local communities), with 33.321 inhabitants (according to the 2011 Census). Th e study sample included adult subjects who consulted general practitioners at any of three general practice medical centers in Bačka Topola (in local communities Bačka Topola, Bajsa and Panonija) between September 20, 2017 andSeptember 29, 2017. and agreed to participate in the study. Aft er giving their written informed consent, they were instructed by the researchers on how to complete the questionnaire. Patients who visited these clinics several times fi lled in the questionnaire only once. Th e study was approved by the Ethics Committee of the Faculty of Medicine in Novi Sad (approval number 01-39/64/1) and the Ethics Committee of the Health Center "Dr Hadži Janoš" in Bačka Topola (approval number 01-2051-2).
Th e total number of questionnaires which were distributed among the patients in the three health centers of the above mentioned institute was 160. Th e questionnaire used in the research was based on the questionnaire by Brlić and his colleagues which had been used in the earlier study [7].
Th e content, comprehensibility, readability and appearance of the questionnaire were previously tested on 30 adult subjects in Bačka Topola. According to the test samples we made some necessary changes in the questionnaires.
Th e subjects needed fi ve or at least ten minutes to complete the questionnaire.
Th e questionnaire consisted of three separate parts. Firstly, it contained questions providing information about the patients' socio-demographic characteristics. Secondly, our goal was to collect data about: the leading health problems for which painkillers were used, which drugs were most commonly used and how frequently, the level of patients' knowledge about drug side eff ects, the intensity of pain for which analgesics is used and whether they read drug package inserts at all. Finally, we would also have found out whether the patients use alternative methods for pain relief.
Th e collected data from the questionnaires was statistically processed in Microsoft Excel 2007.

RESULTS
Out of 160 patients who received the questionnaire, 136 patients completed the entire questionnaire. Th e average age of patients was 50.06±16.56 years.
75% of the patients reported taking www.hophonline.org analgesics during the last year. 85% of female and 73% of male subjects took medication to pain relief (Table 1.). Th e study subjects were asked to assess the intensity of pain subjectively on a 1-7 scale according to the limit when they need to takea painkiller (Table 2.). On the scale 1 denotes the mild pain and 7 a very severe pain.

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Among the study subjects, the average pain threshold was 5.27. Most of them, 41% took medication only in the case of very severe pain, and 1.5% of the respondents would never take the painkiller. 47% of female patients would take a painkiller in case of a very strong pain and 22% of the men would use medication for mild pain. 64% of the patients visited doctors when feeling acute pain. It was enough to feel the pain for a few days. 29% of the patients asked for help from their physician aft er two weeks (Table 3.). Female patients turned to a doctor at least aft er a month, while 14% of male patients asked for help aft er a two weeks or a month.
In the study 34% of the subjects used a painkiller once a month. 29% used it once a year, 18% used it once a week, 10% used it every day and 9% had never used a painkiller (Table 4.). 45% of female subjectsused an analgesic once a year and 35% used it once a week, while this ratio was lower among themale patients. Th e most common indication for self-medication with analgesics was a headache (52%), even 56% of female respondents marked the headache as an indication. Our male subjects took painkillers mostly because of headache and articular pain (50%). Diff erences in the indications of menstrual discomforts were recorded, present exclusively in female population. Migrane as indicators for self-medication was also recorded more oft en in female population. Sex diff erences in the indications for pain self-medication are shown in Table 5.
47% of the study subjects used ibuprofen most oft en for pain relief, 43.1% of the female and 37.58% of the male subjects (Table  6.). Among the male respondents the next most commonly used painkiller was diclofe-nac (29% of them), while it came third among our female subjects (20% of them uses it). Female respondents used paracetamol more oft en than male respondents (20% and 8%, respectively). 64% of patients who practised selfmedication did not ask their physician for advice, because they had heard about the medicine from their physician earlier, while 21% claimed that they had used the painkillers for pain relief for years (Table 7.). Male respondents relied more on the advice of a friend or family member (22%) and previous experiences (27%), while most of the female respondents heard about the medicine from their doctors (68%) or pharmacist (13%).
For 38% of the study subjects these analgesics always help in pain relief, for 33% 9.). 77.2% of respondents said they knew about the side eff ects of drugs, but only 40% could describe those side eff ects. Most of our  66% of our subjects asked their physician/pharmacist for advice for pain relief. However, 48% did not ask for advice because the pain does not last for a long time and 32% refers to previous experiences. 42% of our patients chooses self-medication because of weak pain, 29% in order to save time and 26% to reduce the pain as fast as possible. 50% of the male subjects claimed that they use self medication to save time, 27% of them said that they want to avoid crowd and waiting in a raw. 45% of the subjects was against self-medication due to the risks of side eff ects. 17% thought it was dangerous to use self-medication because in that way you could take inappropriate medicine, 13% was afraid oft he risk of taking the medicine inadequately,1 1%was afraid of the danger of addiction, while 10% was against self-medication because of setting up the risk of inadequate diagnosis (Table 10.).
17% of patients thought that buying drugs without a medical prescription was not safe at all. 35% of them thought it was partly safe,while 25% considered buying drugs without prescriptions to be safe (Table 11.).
Th e study subjects also claimed that they use other non-pharmacological options to relieve pain (Table 12.). Taking rest was the most preferred option for 73%of the patients. It was followed by drinking herb tea (46.9%), massage (43.8%) and applying dressing over the aff ected part of the body (39.3%). Th e sex diff erence was recorded in the questions of massage, applying dressing over the aff ected part of the body, choosing physical activity and drinking tea for pain relief since these methods were preferred by female subjects.

DISCUSSION
Th e results of the study show that self-medication with painkillers is very common among patients in the Muncipality of Bačka Topola. Taking painkillers in the past year was confi rmed by 75% of the study subjects. by 85% of the women and 73% of the men. Similar results were reported in Great Britain, which show that 73% of the study subjects took painkillers in the past month [8]. Likewise, other studies also showed a higher rate of self-medication was present among female subjects [9,10,11]. Similarly, in the present study, 47% of female patients would take a painkiller for a very strong pain, while 22% of the men would use medication for mild pain. Almost 50% of the study subjects used ibuprofen most frequently, 28% of them used diclofenac and 21% of them used acetylsalicylic acid. Based on a recent study in Vojvodina, diclofenac and ibuprofen are the most commonly used painkillers [12]. Th is research shows that male subjects use diclofenac at a Volume 6 • Number 2 • August 2019 • HOPH [23]. Th us, patients will assume an active part in taking care of their health and upgrade their quality of life.
Th is study shows that 74.2% of the subjects (77.2% of female and 68.7% of male subjects) reads package inserts. Th ere were similar results in Croatia, where 76.6% of the participants in the research read the package inserts [7]. However, frequent and irregular use of drugs suggests that users are not properly informed, pointing to the need of improving the transfer of information to make selfmedication safer, more appropriate and based on good knowledge [24].
Th e study of patient preferences for pain self-medication conducted in the USA revealed the non-pharmacological methods of pain relief wase used by 68% of patients [25]. As many as 40% of them used exercise, 30% reported cooling/warming the body part involved, 22% used relaxation and 22% massage for pain relief. In the present study, the rate of subjects using massage for pain relief was similar (29%), whereas data on subjects using exercise and dressings over the aff ected parts of the body diff ered considerably (14% and 17%, respectively).
Despite analgesics being easily available to the people, they can have numerous side eff ects. Although 77.2% of the subjects answered "yes" to the question if they were aware of the side eff ects of painkillers, only 40% could describe their characteristics. Th erefore it should be suggested that selfmedication of painkillers cannot be considered completely safe. Th ese results are the key to disseminating health knowledge. At this point should be underlined that the need for advice about possible side eff ects of medicines should be the essential part of communication with the patients. In addition, when talking about self-medication, the pharmacist's advisory role is extremely important, as selfmedication is usually done without physician advice. Besides, since painkillers in Serbia can be purchased without a medical prescription, pharmacists are the last link to patients before analgesics use [25,26].

CONCLUSION
Based on the results, self-medication and the use of painkillers are present among patients in the Municipality of Bačka Topola. However, self-medication is not without risks, higher rate. Th e use of ibuprofen is the safest which is proved by the fact that it is the most commonly used NSAID in the European Union (Denmark, Norway, Finland) since ibuprofen is the least likely to cause gastrointestinal and cardiovascular side eff ects [13.14]. According to the results of this study, our male subjects used diclofenac more frequently, even though this NSAID has a detrimental eff ect on heart function. Th erefore, in some countries of the European Union (Slovakia, Czech Republic, Hungary, Poland) the use of diclofenac was reduced. Ibuprofen was recommended instead [15,13]. One of the possible causes of this routine diclofenac utilization can be the more aff ordable price of this medicine. In Serbia, diclofenac can also be found in delayed release form (Retard), which means that you can take it once a day, while ibuprofen has been on the market in retard form only recently. Th is more convenient solution can also cause the frequent use of diclofenac.
Paracetamol is used by 15% of patients in the study. Paracetamol is one of the main causes of drug poisoning, while its high doses can cause adverse eff ects on liver function. A preventive strategy was defi ned in Great Britain to control the rate of paracetamol induced poisoning. For this purpose, the legislation was modifi ed as to restrict the amount of tablets that can be bought withot prescription. With this measure. the mortality rate caused by paracetamol or acetylsalicylic acid overdose was reduced by 22%, while the rate of admissions to departments of nephrology and liver transplantation because of hepatotoxic lesions which was caused by paracetamol decreased by 30% [16].
Headache was the most common indication for self-medication with painkillers, as it was claimed by 52% of the study subjects. It was followed by back pain (41%) and articular pain (33%.). Headache has been identifi ed as the predominant indication for medicamentous treatment in many studies [8,[17][18][19][20]. A study conducted in Iran showed that 68% of patients who suff ered from headache had irregular sleeping habits, changing environment Led to a stressful life and in addition, another the predictive factor of headache was poor socio-economic status [21,22]. As self-medication for pain has also been encouraged by the WHO, an appropriate approach to the user will enable safer self-medication and making correct decisions on discomfort elimination largely due to inappropriate administration of medication.. Th e surveyed sample revealed many shortcomings regarding the attitudes and knowledge associated with analgesics use. Rising the level of medical knowledge and patients' awareness is an essential factor of proper self-medication. Pharmacists hold key position for monitoring the safe and eff ective use of painkillers through advice and counselling.