334 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 334–339 Original Prevalence of Over-the-Counter Drug Abuse among Adults in Jeddah, Saudi Arabia Osama Yousif Safdar1*, Ghaidaa Faisal Albaz2, Sara Mohammed Mannan2, Wejdan Ali Alshehri2, Razan Mohammed Altumaihi2, Walaa Jamal Bakhashwain2, Shahad Tariq Khayyat2, Wasayf Mohammed Almehmadi2 1Professor of Pediatrics, Faculty of Medicine, Pediatric Nephrology Center of Excellence, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. 2Medical intern, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. *Correspondence to: Osama Yousif Safdar (E-mail: safderosama@hotmail.com) Abstract Objectives: Self-medication, also known as the use of over-the-counter drugs, can be defined as the economical choice of using treatments that have not been prescribed, recommended, or controlled by a certified healthcare professional, which can be found in pharmacies or convenience stores to treat self-recognized illnesses or symptoms. Previous studies on self-medication in Saudi Arabia are limited; thus, this study aimed to evaluate the prevalence of over-the-counter drug abuse among an adult population in Jeddah, Saudi Arabia. Methods: This was a cross-sectional study, and a validated electronic self-administered questionnaire was administered to the general population in Jeddah, Saudi Arabia, from June to August, 2020. Results: Overall, 400 participants were included in this study. The majority (94%) reported the use of over-the-counter drugs, of which 15.2% reported drug-related problems following over-the-counter drug use. The most frequently preferred over-the-counter drug group was analgesics/antipyretics (90.4%). More than three-quarters of our study participants stated that they read the instructions provided in the leaflet accompanying their medications carefully before use (76.3%). Conclusion: We found a highly significant prevalence of over-the-counter medication use, which exceeded 50%, without any significant association between over-the-counter use and other factors, except for the presence of chronic diseases. We recommend that, the Ministry of Health, Kingdom of Saudi Arabia should play a major role in monitoring the practice of self-medication by implementing policies and creating surveillance committees to that effect. Keywords: Prevalence, over-the-counter, drug, abuse, adults, Jeddah ISSN 2413-0516 Introduction Self-medication, also known as the use of over-the-counter (OTC) drugs, refers to the cost-effective use of treatments not prescribed or recommended by a certified healthcare profes- sional to treat self-identified illnesses or symptoms.1,2 Because of their existing benefits, over-the-counter drugs are becoming more popular among the general population and the health- care system.3 First, the availability of over-the-counter medications allows patients to treat many common health conditions without the assistance of a health care professional. Second, it saves time for both patients with minor illnesses and medical staff, allowing them to focus on more complex cases. It also improves public health at a low cost by reducing the frequency of clinical visits. Third, it has a positive impact on the health- care system, particularly by reducing reliance on scarce and valuable health resources.3 OTCs are classified into different categories by the World Health Organization’s Anatomical Therapeutic Chemical classification, such as analgesics, laxa- tives, and sedatives. cough and cold medications, antihista- mines, dermatologicals, and antidiarrheals.4 A previous study found that 57.7 percent of OTC drugs purchased from community pharmacies in Aden, Yemen, were used. 5 Furthermore, 285 medications were purchased without a prescription in a study conducted among adults in Riyadh. Of these, 49 percent should have been dispensed only by prescription, while 51 percent were OTC medications.5 Inadequate supervision can result in a variety of side effects due to drug-drug interactions, drug-food interactions, and allergic reactions.6 A drug-drug interaction is a change in the effect of a drug when two or more medications are used at the same time; this can increase the risk of side effects depending on the medication used.6 When ibuprofen is com- bined with a prescribed anti-inflammatory medication, they will react together and produce more anti-inflammatory activity or pain relief than the body requires, which can be harmful to the kidneys and liver.7 A drug-food interaction is a change in the effect of a drug when it is combined with certain foods. It can cause a drug’s absorption to be delayed, reduced, or increased, which can have negative consequences. Allergic reactions occur when the immune system recog- nizes the drug as an allergen and produces antibodies known as immunoglobulin E (IgE) that are specific to the drug. This reaction causes skin rashes, itching, wheezing, breathing diffi- culties, and anaphylactic shock, which can be fatal.9 Recently, there has been an increase in concern about the effects of OTC drug misuse on various populations. Locally, a study was conducted on the frequency of using non-prescribed medications in a population sample of 306 people in Al Madina city, as well as its impact on Saudi Arabia’s quality of care. 72.5 percent reported using non-prescribed medication, and 24.3 percent reported experiencing side effects from using non- prescribed medications, with no significant difference between men and women. Analgesics were the most commonly used type of medication. 10 Furthermore, according to another study conducted in Poland among 386 adults, approximately 91 per- cent of participants declared that approximately 91% of partici- pants declared using OTC pain relievers.10 8 335J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 334–339 O. Y. Safdar et al. Original Prevalence of Over-the-Counter Drug Abuse among Adults in Jeddah, Saudi Arabia Previous studies on self-medication in Saudi Arabia are limited. Therefore, this study aimed to evaluate the prevalence of OTC drug abuse among the adult population in Jeddah, Saudi Arabia. Methods Study Design An observational cross-sectional study was conducted ran- domly among the general population in Jeddah, Saudi Arabia, from June to August, 2020. Sample Size The sample size was 400 participants, which was calculated based on the creative research systems website with a confi- dence level of 95%.11 The inclusion criteria were adults aged ≥18 years; all health care professionals were excluded from the study. All participants were invited to voluntarily participate in the study by advertisements through different social media platforms. A previously validated, reliable, and self-administered questionnaire was used. It was adopted from the Al Madina study.12 The questionnaire was designed using Google Forms (Mountain View, CA, USA), and it consisted of two sections: The first section contained demographic information (gender, age, marital status, level of education, and occupation), while the second section assessed participants’ patterns of OTC drug use. Additionally, the questionnaire is attached as supplemen- tary material. Ethical Considerations The study was approved by the biomedical ethics research committee at authors’ affiliated institution. Consent was obtained from all participants after they were notified around the study objectives and confidentiality of the responses in the introduction section of the electronic questionnaire. Statistical Analyses The data were analyzed using SPSS software (Statistical Package for Social Sciences, Version 21). Frequency tests were used to describe qualitative data, quantitative data were expressed as mean and standard deviation (mean ± SD), and the chi-square test was used to test the relationship between variables. A P-value <0.05 was considered statistically significant. Results Initially, 576 responses were received, and only 400 partici- pants were selected to be included in the study based on our inclusion criteria. Of these, there were 200 men (50%) and 200 women (50%), with a mean age of 36.93 (±14.4). More than half of the respondents (54.5%, n = 218) were married, 188 (47%) were workers, and 314 (78.5%) had a high education level (Table 1). Approximately 376 (94%) participants reported the use of OTC drugs. Among those, 209 (55.6%) remained healthy, and 57 (15.2%) reported drug-related side effects after the con- sumption of OTC drugs. Most participants stated that they read the instructions provided in the leaflet accompanying their medication carefully before use (76.3%). Diabetes was reported as the most common chronic disease among the participants (27.4%), followed by hypertension (26.6%) and high cholesterol (19.1%) (Table 2). A very high proportion of the participants (76.9%) used OTC drugs use in the past six months for less than five times. Participants mostly obtained their medications from private pharmacies (n = 337, 89.6%), followed by governmental hos- pital pharmacies (n = 21, 5.6%). Regarding the duration of OTC drug use, 239 respondents (63.6%) used medication for 1–3 days. In 280 (74.5%) participants, pharmacists had a major impact with regard to the correct dosage of OTC drugs, fol- lowed by their previous prescription (n = 144, 38.3%). More- over, 276 (73.4%) participants reported that pharmacists were the main source of information when deciding to use an OTC drug, followed by their previous prescription (n = 137, 36.4%). The most frequently preferred OTC drug group was analge- sics/antipyretics (n = 340, 90.4%), followed by vitamins and food supplements (n = 196, 52.1%) (Table 3). Our results showed no significant relationship between reading the package insert and experiencing the side effects of OTC drugs (P = 0.610) (Table 4). Table 1. Sociodemographic profile of participants (n = 400) Variables Frequency Percent Marital Status Single 167 41.8 Married 218 54.4 Divorced/widowed 15 3.8 Job Status Student 91 22.8 Non worker 121 30.2 Worker 188 47.0 Level of Education Elementary 1 0.3 High school/Technical 85 21.2 Bachelor’s degree and above 314 78.5 Table 2. Parameters related to non-prescribed medication Parameters Yes No n % n % N = 400 Have you ever used a non-prescribed medication? 376 94 24 6 N = 376 History of side effects with non-prescribed medications 57 15.2 319 84.8 Reading insert leaflet 287 76.3 89 23.7 Having chronic disease 167 44.4 209 55.6 Chronic diseases Hypertension 100 26.6 276 73.4 Heart diseases 46 12.2 330 87.8 High cholesterol 72 19.1 304 80.9 Diabetes 103 27.4 273 72.6 Endocrine disorders 29 7.7 347 92.3 Nervous system disorders 23 6.1 353 93.9 Skeletal/rheumatic disorders 41 10.9 335 89.1 Others 24 6.4 352 93.6 336 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 334–339 Prevalence of Over-the-Counter Drug Abuse among Adults in Jeddah, Saudi Arabia Original O.Y. Safdar et al. Table 4. Participants who read package insert and reported complications Do you read the package insert? Total P-value No Yes Have you experi- enced drug related problems? no 74 245 319 yes 15 42 57 Total 89 287 376 0.610 Table 5. The association of the duration of using over- the-counter (OTC) drugs and drug side effects How often do you use OTC drugs? Total P-value 1–3 days 3–6 days 6–9 days >9 days Have you experienced drug related problems? no 209 81 13 16 319 yes 30 22 1 4 57 Total 239 103 14 20 376 0.144 Table 3. Parameters and pattern of administration of non-prescribed medication Variables Frequency Percent Frequency of use non-prescribed medication over the past 6 months <5 times 289 76.9 5–10 times 59 15.7 >10 times 28 7.4 From where do you usually have the medication Private pharmacy 337 89.6 Governmental hospital pharmacy 21 5.6 Private hospital pharmacy 15 4 Free medical samples 3 0.8 Duration of taking non-prescribed medication 1–3 days 239 63.6 3–6 days 103 27.4 6–9 days 14 3.7 >9 days 20 5.3 How can you define the dose of the medication Pharmacists 280 74.5 Previous prescription 144 38.3 According to severity of symptoms 66 17.6 Family and friends 54 14.4 Others 19 5.1 Source of informa- tion when deciding to take a non- prescribed medication Pharmacists 276 73.4 Previous prescriptions 137 36.4 Family and friends 123 32.7 Personal experience 127 33.8 Mass media 56 14.9 Others 2 0.5 Type of medication commonly used Analgesics/ antipyretics 340 90.4 Antacids, antispas- modics, digestives 146 38.8 Vitamins and food supplements 196 52.1 Antitussive/ anti-histaminic 177 47.1 Creams and topical agents 184 48.9 Chronic disease medications 12 3.2 Antibiotics 74 19.7 Others 3 0.8 The duration of OTC drug use was not significantly asso- ciated with drug side effects (P = 0.144) (Table 5). By contrast, our results revealed a significant relationship between the presence of chronic disease and the use of OTC drugs (P < 0.001) (Table 6). There was no significant association between the use of OTC drugs and marital status, job status, level of education, and age (Table 7). In (Figure 1) OTCs are classified into 8 categories, with analgesics being the most commonly used OTC and chronic Table 6. The association of chronic disease with over-the- counter (OTC) drug use Have you ever used OTC drug? Total P-value No Yes Chronic disease Healthy 2 209 211 Chronic disease 22 167 189 Total 24 376 400 0.000 Table 7. Association between Sociodemographic variables and over-the counter (OTC) drug use Have you ever used OTC drugs? Total P-value No Yes Marital status Single 12 155 167 0.480 Married 12 206 218 Divorced/ widowed 0 15 15 Total 24 376 400 Job status Student 5 86 91 0.726Non-worker 9 112 121 Worker 10 178 188 Total 24 376 400 Level of education Elementary 0 1 1 0.604 High school/ Technical 7 78 85 Bachelor’s degree and above 17 297 314 Total 24 376 400 Age of participants <65 23 370 393 0.352 >65 1 6 7 Total 24 376 400 337J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 334–339 O. Y. Safdar et al. Original Prevalence of Over-the-Counter Drug Abuse among Adults in Jeddah, Saudi Arabia Fig. 1 Type of medication commonly used. disease medications being the least commonly used. Analge- sics (90.4%) was the most preferred OTC drug group, followed by vitamins and food supplements (52.1%) (P = 0.841, Figure 1). Discussion This study determined the most commonly used OTC medi- cation, the sources of information for OTC medication use, and the relationship between OTC medication use and various parameters. Over-the-counter (OTC) medication administra- tion has been widely observed for several decades, particularly in developing countries.13 The main finding of our study was that 94 percent of study respondents used medications without a prescription, which is consistent with the findings of another study (93.1 percent) conducted in Majmaah, Saudi Arabia.14 In contrast to other studies on the use of OTC drugs in Serbia (57.0 percent), the United Kingdom (38.0 percent), and Northern Ireland (32.2 percent), the prevalence of OTC medication use in our study was higher.15-17 Furthermore, any significant OTC medication rate greater than 50% is more likely to pose a health risk.18 The difference among the rates could be owing to variations in socio-economic factors, such as cultural beliefs, low cost, ease of access, the saving of time, and the severity of illness based on an individual’s knowledge and previous experience.19 The most commonly used types of OTC medications among our respondents were analgesics (90.4 percent), fol- lowed by vitamins and food supplement drugs (52.1 percent). Analgesics were frequently used because they are available in a variety of brands, formulations, and doses and can be used to treat various types of pain.20 This finding is consistent with the findings of a Wazaify study, which found that analgesics (76.4 percent) were the most commonly used, followed by minerals and/or vitamins (43.4 percent).17 Antibiotics (22.3 percent) were the most common medication dispensed without pre- scriptions, contrary to the findings of a previous study in Saudi Arabia.3 We believe this reduction in antibiotic use was owing to the implementation of a new rule by the Ministry of Health that warns against selling antibiotics without prescriptions and prohibiting pharmacists from dispensing any drug without a prescription issued by a licensed doctor to practice in the kingdom. Violation of this rule could result in imprison- ment for up to six months, withdrawal of the license, and a fine that could reach 100,000 SAR.21 In our study, the main source was found to have a major influence on participants’ choices of OTC drugs, which was the pharmacists’ recommendation and that correlated with the results of four previous studies in Northern Ireland, Eritrea, and Japan.17,22 Furthermore, pharmacists play a significant role in assisting with the safe and proper use of non-prescribed self-medication, as well as in resolving and avoiding drug- related problems in order to achieve ideal patient quality of life and the best outcomes. As a result, it is critical to consider this factor when accounting for both pharmacist practices and training. In contrast, media advertising was identified as the primary source of information in a study conducted in Pakistan (46.7 percent).23 A related study was conducted in 20 selected pharmacy outlets in Eritrea and reported that the percentage of respond- ents who read the package insert before using OTC drugs was very low, representing only one-third (35%) of the respond- ents. Additionally, a higher proportion of OTC drug users (81.8%) exhibited high risk practices.22 In contrast to this finding, we discovered that 76.3 percent of respondents said they read the package insert. Furthermore, they reported drug-related issues as a result of self-medication (23.7 per- cent). This suggests that our respondents were more cautious in order to avoid unfavorable outcomes. As a result, it is crit- ical to assist patients in making use of the information in package leaflets and to improve their understanding.24 According to the findings, respondents with a higher level of education (bachelor’s degree or higher) are more likely to use OTC, which is consistent with the findings of other studies because they can understand and read the descriptions on drug packages.15,25 In our study, there was no significant association between self-medication and educational level, which is in agreement with the finding of a study conducted in Al Majmaah city.14 However, a study conducted in Hail reported a significant relationship with 71.5% (n = 663) of the highly 338 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 334–339 Prevalence of Over-the-Counter Drug Abuse among Adults in Jeddah, Saudi Arabia Original O.Y. Safdar et al. educated responded affirmatively for receiving self-medica- tion.26 Similar trend was reported by a study conducted in Nepal.27 According to our findings, two-thirds (63.6 percent) of the participants used non-prescribed medication for 1–3 days, which is consistent with previous findings reported in Al Madina city.12 OTC drugs can expose patients to unantic- ipated drug-related problems; 15.2 percent of our partici- pants had a history of drug-related side effects, which was lower than the proportion reported in Al Madina city (24.3 percent).12 There was no significant association (P = 0.144) regarding the relationship between the duration of OTC drug use and the consequent complications. As shown in a previous study, patients with chronic disease using OTC medications had an increased risk of adverse drug reac- tions.28 In our study, there was a significant relationship between having a chronic disease and the use of OTC drugs (P = 0.000), which was similar to the results of a study con- ducted in Serbia (P = 0.019).15 There are some limitations to our research. It is a cross- sectional study with recall and selection biases. The majority of the included participants were highly educated and over the age of 65, which does not represent the entire Jeddah because the questionnaire was not available for a diverse range of participants, such as illiterates and people from dif- ferent socioeconomic backgrounds. Because our study only looked at the prevalence of OTC medication, more research is needed to determine the specific reasons that drive people to self-medicate. Conclusion This study evaluated the prevalence of self-medication among adults in Jeddah, Saudi Arabia. It was found that a highly signif- icant rate of OTC medication use was present among our par- ticipants, and this rate exceeded 50%; however, there was no significant association between OTC use and any other factors except for the presence of chronic diseases. Therefore, we advise the Ministry of Health, Kingdom of Saudi Arabia, to play a major role in monitoring the practice of self-medication by implementing policies and setting-up surveillance committees to that effect. Additionally, different platforms on social media should help raise awareness among society around the hazards of using non-prescribed medications, especially for long-term use. Moreover, our study suggests the importance of reassessing the list of medications that can be sold as OTC and providing a proper training program for community pharmacists. We also recommend that the Saudi Food and Drug Authority should carefully monitor drug companies and pharmacists. 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