Factors promoting self-medication and irrational use of opioids in chronic non-malignant pain management in Pakistan: A qualitative in-depth investigation
Authors: Iqbal A , Toh L S , Knaggs R D , Anderson C 
Published: March 2021

Abstract

Introduction
In many Lower and Middle-Income Countries (LMICs) people self-medicate, with non-prescription and prescription drugs both of which are easily available over the counter (1). One of the most common causes for self-medication is chronic pain (2). The role of community pharmacists becomes critical especially in LMICs where medicines are freely available and pharmacists are directly involved in supply of opioid medicines. Unresolved, prolonged chronic non-malignant pain (CNMP) may lead to self-medication with opioid analgesics and can cause irrational use of opioids. The complications of self-medication with opioids are vast in terms of both scarce resources and adverse clinical consequences such as adverse drug reactions, drug interactions and mortality associated with the diversion from intended use of opioid medicines. Self- medication with opioid analgesics in LMICs have not been explored before.

Aim
This study was designed to explore the factors that might contribute in promoting self-medication and irrational opioid medicine use in CNMP management and exploring potential roles of community pharmacists in stopping/avoiding self-medication with opioids in one LMIC, Pakistan.

Method
Qualitative interviews involving various stakeholders such as pharmacy policy makers (n=10) and people suffering from CNMP (n=12) were conducted. Additionally, focus groups were conducted with community pharmacists (n=38) and doctors (n=30). A semi-structured interview guide was drafted after an extensive literature review and was used for individual interviews and focus groups for each stakeholder respectively. The study duration was from December 2019 to July 2020. Critical case sampling, a type of purposive sampling, was done in order to promote applicability to other cases. Data was analysed using a CAQDAS software N-vivo 12, using thematic analysis. Ethical approval was obtained.

Results
Non-availability of community pharmacists in all pharmacies and lack of medication review services are amongst the major factors that are contributing towards self-medication of opioid medicines. Additionally, lack of awareness of people about opioid medicines and absence of strict laws regarding sale of opioid medicines under a valid prescription allows easy availability and promotes aberrant drug seeking behaviour. These factors contribute towards people not seeking professional health care services for the management of CNMP and continue self-medicating with opioid medicines. As a result, they do not get effective analgesic relief and waste limited financial resources. The major themes and sub-themes are presented in Table 1.

Conclusion
Self-medication with opioid medicines can cause irrational, inappropriate, and ineffective use of medicines and can additionally burden the limited financial resources available for health care needs. This in-depth exploratory study identifies many barriers that can promote self-medication with opioids and recognises a need for a multi-faceted intervention involving community pharmacists to promote rational opioid medicine use. However, major limitations of the proposed intervention identified from this study are the absence of integrated health systems and under-utilisation of community pharmacy workforce. The government needs to invest in infrastructure development, develop new health policies regarding medicine sale and build the role and capacity of pharmacy workforce to perform specialised roles in public safety especially in opioid medicines.

References
1. Bennadi D. Self-medication: A current challenge. Journal of basic and clinical pharmacy. 2013;5(1):19.
2. Kaushal J, Gupta MC, Jindal P, Verma S. Self-medication patterns and drug use behavior in housewives belonging to the middle income group in a city in northern India. Indian journal of community medicine: official publication of Indian association of preventive & social medicine. 2012;37(1):16.