Analgesics misuse and the community pharmacists’ possible interventions
Abstract
Analgesics possess the capacity to induce substantial negative consequences. Given that potent analgesics are not subject to medical oversight and can be acquired by the general public without a prescription, it is imperative to concentrate all precautions and disciplines to modify consumer conduct concerning these medications through interventions targeted at pharmacists. This study aims to evaluate the main recorded adverse events coming from analgesic misuse and assess the role of community pharmacists in reducing them through possible interventions. A cross-sectional study design was carried out on selected patients on analgesics with different categories, and by applying Non-Medical Opioids (NMO) and Drug-Related Problems (DRPs) categories, the reduction in their side effects was obtained and statistically analysed. Applying the PTF program showed a reduction in all Non-Medical Opioids (NMO) categories from safety, necessity, and effectiveness, with a significant impact. The association between NMO categories and the polypharmacy for interactions showed a significant difference between analgesics when combined with other drugs and alone (p=0.0001). Regarding safety, quantitative unsafety decreased from 16.7 to 12.1 (p=0.02). The unsafely demonstrated a higher improvement, from 22.1 to 7.6 (p=0.03). Similarly, necessity improved with unnecessary polypharmacy reduced from 31.4 to 11.4 (p=0.001). Moreover, effectiveness improved with quantitative non-effectiveness reduced from 101.2 to 81.4 (p=0.001), meanwhile, the non-quantitative non-effectiveness showed better improvement, reduced from 99.3 to 71.6 (p=0.03). The community and clinical pharmacy disciplines can contribute effectively to decreasing the occurrence of adverse effects and side effects for most critically dispensed drugs, such as analgesics.
Keywords: Analgesics misuse, Adverse drug events, Community pharmacists, Non-medical opioids
Introduction
Chronic pain represents a considerable health challenge, specifically in elderly people, impacting individuals and imposing significant social and economic burdens on communities. It is characterized as pain that persists for over three months, having effects on physical, psychological, and social productivity [1, 2]. Epidemiological studies show significant variation in the prevalence of chronic pain, primarily due to differences in the study populations, methodologies, and diagnostic criteria used. Globally, it is estimated that about 20% to 30% of adults suffer from chronic pain, with reported figures varying from 10% to over 50% in different contexts [3, 4]. In developed countries, such as the United States and Europe, the prevalence of persistent pain remains notably high. Approximately 25% of adults report experiencing chronic pain, with 6% to 9% suffering high-impact chronic pain that significantly disrupts their daily activities [5, 6]. Research on Middle Eastern and Asian communities has reported prevalence rates ranging from 19% to more than 50%, with particularly high rates observed among elderly people [7-9]. These studies underscore chronic pain as a widespread condition that significantly impacts healthcare systems, social well-being, and overall quality of life.
Chronic pain could be managed by using both pharmacological and non-pharmacological approaches. Nonsteroidal anti-inflammatory drugs, opioids, antidepressants, and anticonvulsants are common pharmacological treatments used for pain treatment. Non-pharmacological interventions generally include physical therapy, psychological therapies, and complementary medicine [10, 11]. While pharmacological treatments can offer symptomatic relief, they often come with considerable limitations and adverse effects. For instance, prolonged use of NSAIDs raises the risk of gastrointestinal bleeding, kidney damage, and causes cardiovascular issues [12]. Opioids can be effective in some situations; however, it has negative consequences such as misuse and tolerance [13]. Antidepressants and anticonvulsants can also lead to sedation, dizziness, or cognitive impairment; however, physicians do not describe these medications in the treatment of chronic pain [14]. Non-pharmacological approaches are generally safer but are often underutilized because of limited access or patient noncompliance [15]. These challenges highlight the urgent necessity for strategies that are safer, more effective, and more accessible for managing patients with chronic pain within the community [16-21].
Community pharmacists are essential in managing chronic pain within primary care. As easily accessible healthcare professionals, they frequently serve as the initial point of contact for people seeking pain relief. Pharmacists can offer consultation about the safe and effective utilization of analgesics, also identifying instances of inappropriate use of these medications [22, 23]. They are also proficient in educating patients on non-pharmacological therapies, encouraging adherence to prescribed dosages and therapy duration, and referring individuals to specialized medical care in complex cases [24, 25].
Although chronic pain is globally acknowledged as a significant public health issue, data from many regions, especially low- and middle-income countries, remain limited. In Iraq and several other Middle East countries, there has been limited population-based research on the true burden of chronic pain and its effects on daily life [15]. Studying this knowledge gap is crucial for shaping national health policies, enhancing pain management approaches, and improving the quality of life for people suffering from chronic pain. This study aims to evaluate the most frequently reported adverse events linked to the misuse of analgesics and to explore how community pharmacists can assist in mitigating these risks via appropriate interventions [26-30].
Materials and Methods
Study design and setting
An observational descriptive study was conducted from January to June 2025, using the pharmaceutical care follow-up (PTF) program in different pharmacies, with a cross-sectional design adapted to assess analgesic misuse and the role of pharmacy interventions. This study was conducted in several community pharmacies that serve patients who frequently visit for prescription services. This study was conducted in Kirkuk city at various community pharmacies that serve patients who frequently visit for their prescriptions. Raosoft program (http://www.raosoft.com/samplesize.html; accessed on 2 September 2025) was used for calculating the sample size considering the total population of Kirkuk city, which is 1.13 million individuals. A minimum representative sample size of 97 was established, based on a 95% confidence interval and a 10% margin of error [31-35].
Inclusion and exclusion criteria
Inclusion criteria comprised patients of both genders, aged 18 years and older, who were capable of communication and decision-making, and who were seeking analgesics with or without a valid prescription. Conversely, exclusion criteria included patients who declined to participate in the study and those with legitimate medical reasons for long-term analgesic use, such as rheumatoid arthritis and specific grades of lumbar disc disorders.
Institutional Review Board Statement: This study received approval from the Iraqi Ministry of Higher Education and Scientific Research, Ak-Kitab University, College of Pharmacy.
Ethical approval
Verbal consent was obtained from patients to participate in this study. Responses from all participants were compiled into an anonymous database, ensuring the confidentiality of all information.
Statistical analysis
All data were analysed using SPSS version 21.0 to measure frequencies, percentages, means, and standard deviations; the post hoc Mann-Whitney test, paired t-test results, and ANOVA were also used at a significance level of 0.01.
Results and Discussion
The patient enrolled in the present study is middle-aged to elderly, with the majority of patients in the range of 50-79 years, with the single largest group being those over 40 years (n=51) (Figure 1), with most of them being female (68%) (Figure 1).
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Figure 1. Demography of the enrolled subjects in the present study, with description of age and sex distribution. |
Most of the enrolled patients were diabetic and hypertensive (n=91 and 78, respectively) and had other cardiovascular diseases, thyroid disorders, or autoimmune disorders (Figure 2a). Regarding the analgesic distribution types, most of the tested patients are taking paracetamol (n=78) and NSAIDs (n=48) (Figure 2b).
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a) |
b) |
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Figure 2. a) The prevalence of chronic diseases among patients recorded in this study. b) The distribution of analgesic classes uses frequency and percentage in this study. |
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Applying the PTF program showed a reduction in all Non-Medical Opioids (NMO) categories from safety, necessity, and effectiveness, with a significant impact. The association between NMO categories and the polypharmacy for interactions showed a significant difference between analgesics when combined with other drugs and alone (p=0.0001) (Table 1).
Regarding safety, quantitative unsafety decreased from 16.7 to 12.1 ( 4.6% reduction, p=0.02). The non-quantitative unsafety demonstrated a higher improvement, from 22.1 to 7.6 (a 14.5% reduction, p=0.03). Similarly, necessity improved with unnecessary polypharmacy reduced from 31.4 to 11.4, with a 20% reduction (p=0.001). Moreover, effectiveness improved with quantitative non-effectiveness reduced from 101.2 to 81.4 (19.8% reduction, p=0.001), meanwhile, the non-quantitative non-effectiveness showed better improvement, reduced from 99.3 to 71.6 (27.7% reduction, p=0.03).
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Table 1. The PTF significance on the reduction of NMOs occurrence and frequency |
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Category of NMO |
Frequency at PTF baseline |
Frequency of PTF after starting |
Reduction % |
p-value |
|
|
Safety |
Quantitative unsafety |
16.7 |
12.1 |
4.6 |
0.02 |
|
Non-quantitative unsafety |
22.1 |
7.6 |
14.5 |
0.03 |
|
|
Necessity |
Medications (no need) |
31.4 |
11.4 |
20 |
0.001 |
|
Effectiveness |
Quantitative non-effectiveness |
101.2 |
81.4 |
19.8 |
0.001 |
|
Non-quantitative non-effectiveness |
99.3 |
71.6 |
27.7 |
0.03 |
|
|
NMO=Non-Medical Opioids, PTF=pharmaceutical care follow-up |
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The table demonstrated the associations between NMO frequency and drugs used in polypharmacy combined with analgesics, with overall significant differences (p=0.0001) (Table 2). The results revealed lower or equal NMO frequency regardless of combination with analgesics. Most medications demonstrated that NMO frequency was 2 or more times when combined with analgesics, including muscle relaxants, anti-depressants, sulfonylureas, and anti-psychotics. Antihistamines and beta blockers demonstrated the most notable differences. Sulfonylureas revealed modest improvement, with NMO frequency decreasing from 3 to 2 when combined with analgesics. Thyroxin remained neutrally unchanged at a frequency of 3 regardless of analgesic combination.
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Table 2. Associations between the frequency of NMO and medications administered as polypharmacy with analgesics |
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Other medications |
NMO frequency mean |
p-value |
|
|
Combined use with analgesics |
Non-combined use with analgesics |
||
|
Muscle relaxants |
2 |
2 |
0.0001 |
|
Anti-depressants |
2 |
2 |
|
|
Sulfonylureas |
2 |
3 |
|
|
Anti-psychotics |
2 |
2 |
|
|
Thyroxin |
3 |
3 |
|
|
Antihistamines |
1 |
2 |
|
|
Beta Blockers |
1 |
3 |
|
Regarding DRPs, the reduction in side effects showed significance in all DRP categories (p< 0.05), except for personal characters (p=0.05) (Table 3). The association between DRP categories and the polypharmacy for interactions showed a significant difference between analgesics when combined with other drugs and alone (p=0.001). Also, it has been tnoted that the NMOs and DRPs increase in their occurrence with a significant relationship (p < 0.05) (Table 4).
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Table 3. The PTF's significance in the reduction of DRP occurrence and frequency |
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|
Category of DRPs |
Frequency at the DRP's baseline |
Frequency of DRPs after starting |
Reduction % |
p-value |
|
Interactions |
71.4 |
41.7 |
29.7 |
0.001 |
|
Personal characters |
31.6 |
21.2 |
10.4 |
0.05 |
|
Non-compliance |
51.8 |
19.8 |
32 |
0.04 |
|
Adverse drug events |
91.2 |
22.5 |
68.7 |
0.03 |
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Table 4. Associations between the frequency of DRPs and medications administered as polypharmacy with analgesics |
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|
Other medications |
DRP frequency mean |
p-value |
|
|
Combined use with analgesics |
Non-combined use with analgesics |
||
|
Muscle relaxants |
1 |
3 |
0.001 |
|
Anti-depressants |
2 |
3 |
|
|
Sulfonylureas |
2 |
1 |
|
|
Anti-psychotics |
2 |
1 |
|
|
Thyroxin |
3 |
3 |
|
|
Anti-histamines |
3 |
3 |
|
|
Beta Blockers |
2 |
2 |
|
Analysis of results demonstrated that mental confusion was the unique adverse effect, showing significant differences between both DRPs and NMO frequency. However, other adverse effects examined, such as fatigue, drowsiness, nausea, diarrhea, dry mouth, headache, dizziness, vertigo, constipation, and palpitations, have shown non-significant differences in DRP or NMO frequencies between studied groups (Table 5).
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Table 5. Associations between frequency of DRPs and NMO and analgesic side effects |
||||||
|
Other medications |
DRP frequency mean |
p-value |
NMO frequency mean |
p-value |
||
|
Side effects |
No side effects |
Side effects |
No side effects |
|||
|
Mental confusion |
2 |
3 |
< 0.05 |
1 |
3 |
0.001 |
|
Fatigue |
3 |
3 |
2 |
3 |
||
|
Drowsiness |
2 |
2 |
2 |
3 |
||
|
Nausea |
2 |
3 |
2 |
3 |
||
|
Diarrhea |
2 |
3 |
2 |
3 |
||
|
Dry mouth |
2 |
3 |
2 |
3 |
||
|
Headache |
2 |
2 |
3 |
3 |
||
|
Dizziness |
2 |
3 |
2 |
3 |
||
|
Vertigo |
2 |
3 |
2 |
3 |
||
|
Constipation |
3 |
3 |
2 |
3 |
||
|
Palpitations |
2 |
3 |
2 |
3 |
||
|
NMO=Non-Medical Opioid, DRPs=Drug-Related Problems |
||||||
The application of the PTF system represents a transfer in the community pharmacists' plans for analgesic therapy management, mitigating the challenges associated with opioid drugs and polypharmacy [36-41]. The results revealed that the PTF system reduced NMO outcomes - safety, necessity, and effectiveness, mitigating pain by balancing safety and augmenting medication regimens. Perhaps helping polypharmacy application in patients requiring analgesic therapy with complex comorbidities requiring multiple medications. The reduction of DRPs reflects perhaps the role of PTF in saving polypharmacy-related issues; nevertheless, personal characteristics have shown resistance to PTF, demonstrating no changes. Reflecting that patient characteristics may impact the outcomes. Systematic review conducted by Viswanathan et al. (2015) indicated that the pharmacist intervention in analgesic dispensing resulted in improvements in medication adherence, clinical outcomes, and reductions in adverse events [42]. Moreover, the adverse effects were reduced by one-quarter by the application of the PTF strategy by a pharmacist [43].
The administration of high-risk medications (e.g., analgesics) represents an important safety checkpoint step by pharmacists before drug dispensing. The DRPs are a critical public health issue, affecting millions of people per annum, perhaps focusing on the analgesics as the commonly abused drugs carrying potential for abuse, and complex adverse effect profiles [44, 45]. Moreover, subclasses of analgesics require specialized pharmaceutical intervention. NSAIDs alone are precipitating 16,500 USA deaths per annum, probably due to GIT complications alone [46], while prescription opioids are precipitating 70,000 overdose deaths in 2019 [47]. Analgesic prescription is most often associated with polypharmacy, drug-drug interactions, inappropriate dosing, and inadequate patient monitoring. Adverse drug reactions account for about 6.5% of hospital admissions in the United Kingdom, reflecting the critical necessity for PTF at both community and clinical levels. These confirm that pharmacist care prevents adverse effects of dispensed drugs and enhances medication safety [48]. Patient education (proper administration techniques, recognition of adverse effects, appropriate use patterns, and strategies for minimizing risks) has consistently improved medication adherence and reduced adverse effects [49]. Chisholm-Burns et al. (2010) revealed that technical support by pharmacists mitigated medication errors and adverse events [50]. Rutkow et al. (2015) revealed that prescription drug monitoring programs utilization by pharmacists resulted in significant reductions in analgesic adverse events [51]. MacLaren et al. (2008) demonstrated that pharmacist participation in pain management resulted in improvements in analgesic efficacy while mitigating adverse effects [52].
Kaboli et al. (2006) revealed that pharmacist-provided patient care resulted in mitigation of adverse drug events and improved patient status [53]. Scarsi et al. (2011) revealed that pharmacist interventions targeting critical medications demonstrated mitigation in side effects and enhanced patient safety outcomes, perhaps via using risk stratification tools, implementation of monitoring approaches, and optimization of rapid response protocol for managing adverse events when they do occur. Mekonnen et al. (2016) revealed that application of pharmacist care resulted in mitigation of medication-related readmissions and adverse events [54]. Barry and Edgman-Levitan (2012) revealed that pharmacist-provided patient care resulted in improved patient satisfaction, adherence to medication intake, and mitigated adverse events [55]. Sultana et al. (2013) confirmed that the pharmacist care system resulted in more cost-effective therapy [56].
Conclusion
Patients who are under treatment of analgesics get a great benefit from the PTF as the community pharmacists interventions revealed a significant impact as this program decreases the frequencies of side effects, and other interactions to other medications at all categories of NMO and DRP to reveal that the pharmacies and community and clinical pharmacy disciplines can contribute effectively to decrease the occurrence of adverse and side effects for most critically dispensed drugs such as analgesics.
Acknowledgments: The authors are grateful to Al-Qalam University and Al-Kitab University for their provided facilities to accomplish this work.
Conflict of interest: None
Financial support: None
Ethics statement: The study approved by the department of Pharmacy (Alqalam University College, Iraq), Approval session number 01 on 10 Sep 2025.
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