Awareness of analgesics complications in Saudi Arabia: a cross-sectional study

All over the world, analgesics are considered one of the most widely used and abused medications. Painkillers such as paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin currently represent the principal means of pain management. Unfortunately, paracetamol and NSAIDs have dangerous side effects primarily when they are used improperly and without respect to safety rules. This study aims to assess the awareness of the indications, complications, and contraindications of commonly used analgesics. A total of 1554 participants responded to the survey, and the findings indicated that the main analgesic used is paracetamol. A proportion of 68.1% of the total number of respondents received their information about analgesic medications from a physician or pharmacist; 95.7% used analgesics when needed, and 70.9% mentioned that they would consult a physician or pharmacist if the pain was not relieved after the use of over-the-counter medications. Nearly 29% were not aware of the possibility of adverse effects of analgesic use. The most commonly used analgesic is paracetamol, and most of the participants had a poor level of awareness regarding the complications and side effects of analgesics in general. Our recommendation is to conduct a continuous health education campaign about the use of analgesics.


Background
Painkillers are considered globally as one of the most abused medications. Pain is defined as an actual or potential tissue damage associated with an unpleasant emotional and sensory experience. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin currently represent the principal means of pain management [1].
NSAIDs are medications with anti-inflammatory, analgesic, and antipyretic actions, and some inhibit the platelet aggregation [2,3], while paracetamol has antipyretic and analgesic effects [4]. Inflammatory conditions comprise the most prevalent indications for NSAID use. However, for fever and pain disorders, paracetamol and NSAIDs are considered as the first-line treatment [5].
Unfortunately, paracetamol and NSAIDs have dangerous side effects, especially when they are used with no respect to safety rules and in improper ways, such as without consulting a physician or pharmacist or being taken repeatedly without a prescription. They are not only associated with gastrointestinal tract, liver, nervous system, hematological, and kidney complications, but they can have adverse effects on almost every organ [6][7][8][9]. A cohort survey analysis conducted among people who are NSAID abusers showed a higher risk of ulcers compared to non-users of NSAIDs. Hence, the increased use of NSAIDs increases the risk of ulcers and, therefore, of bleeding, which can threaten the patient's life [10][11][12][13].
NSAIDs are contraindicated in patients who have an allergy to NSAIDs, severe kidney and liver insufficiency, an active peptic ulcer, and hemorrhagic diathesis, as well as those who are pregnant or breastfeeding [14]. Moreover, paracetamol is contraindicated in patients with severe renal or hepatic failure, methemoglobin reductase, or glucose-6phosphate dehydrogenase deficiencies and in patients with allergies to any ingredients of the drug formula [15].
An assessment through a survey study of Taif University students' knowledge, attitudes, and practices regarding medication use is essential for identifying gaps in these domains. The gaps can be the starting point of future educational programs to raise public awareness around the identified misconceptions. Therefore, this study was designed to identify the most common analgesics used by Taif University students. It was conducted mainly to assess the knowledge and awareness of Taif University students regarding the indications, complications, and contraindications of the most frequently used analgesics.

Methods
A cross-sectional study was designed using an electronic questionnaire that was distributed to students at Taif University to assess their knowledge, attitude, and practice regarding analgesic use and their awareness about analgesic complications. The questionnaire was distributed over 6 months starting in January 2018. In this study, we included male and female students from Taif University, regardless of their colleges or departments, as a randomized sample.

Questionnaire design
We designed the questionnaire based on many previous studies [16,17]. We then tested its validation by distributing it to a small sample of the target group to ensure they understood the questionnaire. They understood all the questions, indicating that the questionnaire was clear and understandable. The questionnaire was divided into five sections: (I) the participants' demographic data, which included age, gender, residence, and university level; (II) the participants' knowledge, attitude, and practice regarding analgesics; (III) the participants' knowledge and awareness about paracetamol; (IV) the participants' knowledge and awareness about aspirin; and (V) the participants' knowledge and awareness about ibuprofen.

Statistical analysis
The data were analyzed using the Statistical Package for the Social Sciences software (SPSS version 25). Descriptive data were presented in frequencies and percentages.

Demographic characteristics of respondents
The number of participants in this study was 1554 students from various university faculties. The age of most participants was between 19 and 22 years (53.47%). The percentage of female participants was 58.9% while that of male participants was 41.1%. A majority of 91.8% of the respondents lived in cities, while only 8.17% lived in villages. Third year university students were the main contributors to this study (20.3%), whereas only 8.9% of the participants were postgraduate students (see Table 1).

Participants' knowledge, attitude, and practice regarding analgesics
The most commonly used drug was paracetamol, used by 77.3% of the study participants. 95.7% of the participants mentioned that they use it only when necessary, while 4.3% use it regularly (Fig. 1). 70.9% of the students said if it did not subside after taking one dose of an analgesic, he will ask a physician or pharmacist, while a few mentioned increasing the dose or using another analgesic if their pain was not relieved (8.5% and 20.5%, respectively) (Fig. 2). A small percentage of participants (8.6%) thought that increasing the dose of the analgesic would have no side effects (Table 2).
In terms of knowledge about the use of paracetamol, a small proportion (2.3%) of the students answered that they believed they could use more than eight tablets within 24 h. Seventy-two percent realized that paracetamol could cause liver failure, whereas 28% did not. A significant proportion of those who participated lacked knowledge about the side effects and contraindications of paracetamol (52.8% and 34.9%, respectively) ( Table 3).
Regarding the knowledge about and attitudes towards aspirin, 3.2% of the participants used more than six tablets of aspirin per day, while a majority of 89.2% did not use it. There was a significant deficiency in the participants' knowledge about the side effects of aspirin. 56.7% of the participants did not know the possible side effects of aspirin, and 42.9% did not know that it can cause bleeding. Also, there was a considerable lack of knowledge about aspirin's contraindications, with 38.8% of the participants unaware of them (Table 4).
We also noted a lack of awareness about the side effects and complications of ibuprofen, with 58.3% and 53.9% of participants unaware of the side effects and contraindications, respectively. A significant percentage of the respondents did not use ibuprofen, but among those who did, 1.3% used more than four tablets per day. Note that the researchers depended on the National Health Service (NHS) guidelines about safe doses [18] ( Table 5).

Discussion
In this study, we identified paracetamol as the most common analgesic used. Most of the participants in this study were between 19 and 25 years old. It is crucial that this age group has adequate knowledge and awareness about medications because they are the most important link between those under the age of 18 and over 25. According to this ratio, these results are consistent with studies conducted in Saudi Arabia and Norway [16,19] and are not consistent with others in the USA [20]. The most commonly used type of analgesic in Saudi Arabia is paracetamol, which is consistent with the results of previous studies [16,19,21]. There is a Fig. 1 The percentage of gender by when to use analgesics prevalent idea among the population in Saudi Arabia that paracetamol is completely safe. However, the National Prescribing Service MedicineWise (NPS MedicineWise) [22] indicates that this information is wrong.
In terms of students' knowledge, attitude, and practice regarding the use of analgesics, we found that most participants committed to a safe dose of analgesics, whereas a few took higher than the recommended daily dosage. It is important to note that the degree of knowledge in this study respect is high, as all of the study's participants are students at the university and have good knowledge and awareness in this aspect. This is consistent with the results of a similar study conducted by Karami et al.

in Saudi
Arabia in 2018 [16]. We have observed from the results of our study that there is an adequate awareness about the maximum safe dose of analgesics among the university student population. This is compatible with the results of the study conducted by Fendrick et al. in 2008 [23].
The usual number of paracetamol tablets used daily by most of the respondents is one to two every 4 to 6 h. This dose is safe according to the NHS recommendations. The same is true for the aspirin and ibuprofen daily doses taken by participants. This indicates the participants' adequate knowledge and awareness about analgesic doses.   Unfortunately, we found that there was poor awareness of the side effects of analgesics. This gives us an indication of the poor education about medicines in society, as we were expecting that the sample group should be the class with the highest level of knowledge in the community and could pass it on to the rest of the population.

Limitations
The present study dealt only with students' knowledge and awareness about the use of analgesics. Future studies should address the same problem with a more diverse sample of multiple populations and more analgesic medication. In addition, we conducted this study in one educational facility. Future research should focus on all university education facilities in Saudi Arabia.

Conclusion
The most commonly used analgesic among Taif University students is paracetamol, and the majority of Taif University students use over-the-counter analgesic medications without being aware of their contraindications and side effects. Our recommendation is to conduct a health education campaign about the use of analgesics.