Self-medication and Risk of Abuse with Benzodiazepines in Adults Patients Lima-Peru, 2019.
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Introduction: Benzodiazepines have the potential to generate abuse, so an indiscriminate consumption, through the sale without prescription and the practice of self-medication, would mean a high risk due to their abuse. Objective: To establish the relationship between self-medication with benzodiazepines and the risk of abuse that requires treatment in adult patients of Hospital San Juan de Lurigancho, 2019. Methodology: It was an observational, correlational descriptive, transversal and prospective study. The sample size was 874 participants (95.0% confidence level; 80% power). Sampling was performed non- randomly. A survey was used to determine demographics, benzodiazepine use, and questions of Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Results: Of the study population, the most prevalent demographic data were female sex (74.5%), the median age was 52 years (interquartile range:
40-62 years), the age range 50-59 years (26.43%), married marital status (31.6%), secondary education level (48.4%) and occupation as a housewife (47.3%). Of adults studied, 485 were considered as consumers of benzodiazepines with prescription and 389 consumers without a prescription. Prescription and non- prescription consumers needing treatment were 129 (26.60%) and 245 (62.98%), respectively (p <0.001). Conclusion: There is a higher prevalence of people who need treatment for abuse in consumers without a prescription than in the group of consumers with a prescription so there is a significant relationship between self-medication with benzodiazepines and the risk of abuse that requires treatment in study population.
Because they contain psychotropic substances and are used as therapy for mental or neurological diseases, Benzodiazepines are a group of substances that belongs to psychopharmaceuticals(1). They mainly act on the central nervous system (CNS), generating sedation, hypnosis, decreased anxiety, myorelaxation, anterograde amnesia, and anticonvulsant activity. The inherent possibility of habit forming, dependence, and abuse(2) is concerning. Abuse is a maladaptive behavior(3) that occurs when people make excessive, persistent and sporadic use of a medication, in such a way that it is not related to proper use and acceptable medical practice.(4)
Benzodiazepines are widely prescribed in clinical practice, however, due to their high addictive power and an unfavorable benefit/ risk ratio, it has been proved that measures should be taken to reduce the use of these drugs(5-7). According to the WHO, the use of benzodiazepines, with no medical prescription, is at the top of the list within this group of substances, and South America is one of the regions where it prevails; this is also confirmed by the Organization of American States (OAS) (8,9). In 2011, it was reported in Peru that 25% of psychotropic drugs, including benzodiazepines, were sold without a prescription. Despite the government´s attempt to control this situation, and several pharmacies and drugstores being periodically intervened for selling this product without a medical prescription, the problem continues.(10-12)
One of the problems that comes in hand with this situation is self-medication, which is defined as the act of medicating oneself without the advice of a physician(13,14). Therefore, the general objective of this research, is to establish the relationship between benzodiazepines use and self-medication, and the risk of abuse that would require treatment in adult patients at the San Juan de Lurigancho Hospital, 2019.
As specific objectives, this research aims to determine the sociodemographic factors, establish self-medication of benzodiazepines in the studied population, specify the risk of abuse in the group of those individuals who self- medicate and specify the risk of abuse in the group of those who use this drug with a medical prescription.
An analytical cross-sectional study was carried out in 874 adult patients. The inclusion criteria was: the use of benzodiazepines, being 18 years old or older and having received medical care at the San Juan de Lurigancho Hospital during the year 2019. There was less than a 10% exclusion, especially among those who did not respond the surveys adequately or completely.
The sample size was calculated using a pilot test as a reference, which was carried out at the same health facility where the study was conducted (with a confidence limit of 95% and a minimum power of 80%). A non- random sampling among people who attended medical services was performed. They were approached, prior authorization from the institution, in the waiting room (where they were asked if they wished to participate in the survey, explaining the purpose of it). Once the patient agreed, the interviewer proceeded with signing the informed consent form and with the completion of the survey. The study and the informed consent form were approved by the ethics committee of the Universidad San Martín de Porres (USMP), Official Letter No. 1037-2018 and No. 258-2019, correspondingly; and it was also authorized by the corresponding hospital authority - Memorandum No. 226-2019. The objective of the study was not to collect information for each type of benzodiazepine However. the interviewer did mention some examples to the participant, so they could become more familiar with the questions.
Survey data involving the level of risk of abuse, classified the participants as follows: No risk (no treatment required), mild risk (no treatment required), moderate risk (mild treatment required), and high risk (intensive treatment required). For the purposes of this study, based on this information, it was considered convenient to classify the patients into 2 groups: “Does not require treatment” and “Requires treatment”. In this way, the relationship between self- medication and the need for treatment as a result of benzodiazepine abuse, was assessed.
Additionally, the group of benzodiazepine users was classified into: people who do not practice self-medication and people who do practice self- medication. The first group included users with a current medical prescription. And the second group included users without a prescription and users with an expired one. Participants were also grouped by their demographic data: gender, age, marital status, education level and occupation.
Data, of the dependent and independent variables, were collected through a survey that included questions related to demographic data, and prescription use for benzodiazepines; as well as questions from the ASSIST questionnaire developed by WHO to assess the level of risk of abuse, which was used to group patients into 2 categories “Does not require treatment” or “Requires Treatment”. The data collected was then entered and analyzed on a personal computer, using the Stata program. During this step, the descriptive statistics of the research were carried out, the frequencies and percentages of the categorical variables were obtained, as well as the statistical crosses, throughout the chi-square test for each case. In all crosses, the value p<0.05 was considered as the cut-off point for statistical significance. Also, a report of the results and conclusions was sent to the corresponding hospital area, in order for them to seek improvements in their processes and in further control of this medication.
Of the 874 people who were studied, females were most prevalent (74.5%), the average age was
52 (interquartile range: 40-62 years), the most prevalent age range was 50-59 (26.43%); the most common marital status, married (31.6%); the most common educational level, high school (48.4%) and the most common occupation, housewife (47.3%).
Table 1. Demographic characteristics of adult patients consuming benzodiazepines at Hospital San Juan de Lurigancho, 2019.
Regarding the use of a medical prescriptions, 485 (55.5%) have used a medical prescription to consume benzodiazepines, 206 (23.6%) have used the medication without having been prescribed and 183 (20.94%) have used it with a non valid prescription.
Table 2. Relationship of demographic data and Abuse that requires treatment in adult patients who consume benzodiazepines at Hospital San Juan de Lurigancho, 2019.
Do not practice self-medication (Group 1)
(Users with prescription)
Do not practice self-medication (Group 2)
Users without a prescription
Users with a non valid prescription
Of the population studied, 485 were benzodiazepine users with a prescription and the other 389 users without a prescription. 129 (26.60%) from the first group and 245 (62.98%) of the second group, require treatment for abuse. The relationship between self-medication and the need for treatme had a p<0.001 using the Chi-square test.
Graph 1. Treatment requirements for adult patients consuming benzodiazepines at Hospital San Juan de Lurigancho, 2019.
The relationship between gender and the need for treatment was p=0.015 and the relationship between occupation and the need for treatment was p=0.022.
Table 3. Relationship of demographic data and Abuse that requires treatment in adult patients who consume benzodiazepines at Hospital San Juan de Lurigancho, 2019.
There are studies on the prevalence of self- medication in Peru, showing high levels of this habit and several studies on the abuse of benzodiazepines(15-21), some used the ASSIST questionnaire applied in this study. However there are no studies that relate the habit of self- medication and the risk of benzodiazepine abuse, which was the reason for this research. In addition, abuse is classified into categories according to its severity and the need for treatment.(4-22)
According to the ages recorded in the questionnaires, people between 50-59 years old had a higher prevalence in the use of these medications. Age is not a well-defined factor in the consumption of benzodiazepines. A study carried out in Lima, in 2013, shows that people between 51-65 years old, are the largest consumer group, but only by a slight difference with other age groups A different study, shows that people between 42-49 years old are the main users of this medication with prescription, and those between
20-39 years old without a prescription, therefore, we could say that age is not a factor that can be extrapolated to all populations.(20,21,23)
Regarding demographic data, it is observed that the use of benzodiazepines is more prevalent in women. This result is consistent with sources that show that the females have a greater tendency to use this kind of medication, as mentioned in WHO and OAS reports. Local studies have corroborated this information. For example, one study showed that among the group of people who self-medicated with anxiolytics, 60% were women. Another study showed that it was 66%. Two epidemiological studies on drug use in Lima also showed a similar trend (conducted by DEVIDA in 2014 and 2016). (8,9,19,20,23,24)
Single and married people have been the most prevalent in the use of these drugs. This result is related to a study carried out in the United States, in a group of benzodiazepine users, where both single and married people were the most prevalent. In Peru there are no similar researches, but there is a study on the prevalence of self-medication, where it was found to be more frequent in single and married people. We must also consider the characteristics of the population in Lima , which according to a survey carried out by Devida, (to assess the consumption of tranquilizers), the population of Metropolitan Lima constituted mostly married and single people. This means that there is a greater probability of encountering people with this marital status in a study of this nature.(23,25,26)
Regarding their occupation, it was noted that most participants marked the box containing the“other” option. So, other occupations were added, resulting in housewives consuming benzodiazepines the most. This result is related to the fact that women were where the highest prevalent found. A study on self-medication prevalence in Peru showed that housewives fall into this practice more than other groups. In addition, a foreign study indicates that housewives are more likely to practice self- medication, compared to women who have a paid job.(25,27)
People with high school education were the most prevalent group found to use benzodiazepines. Very similar results were obtained in a study in Spain, and a study carried out in Peru.(19,28)
Regarding the use of medical prescriptions, it was found that the majority of the population in this research, have used one in order to consume benzodiazepines. Since the survey was conducted in a hospital, the previous information was expected, understanding that people who receive medical care are more likely to follow their doctor’s instructions. This does not mean that most of these people have not used benzodiazepines without a prescription, since surveys also found that 26.6% of this group required treatment, due to the risk of abuse. This means that there is a group that uses this medication with or without a prescription. The reasons why this can happen may vary. We could think that some people might not be satisfied with the dose administered by their physician, others who might have completed their visits would no longer want to take it again, etc. These reasons were not studied in the present research and would imply a separate analysis.
Focusing on the main objective of the study,
which was to find out if there was a relationship between the habit of self-medication and abuse
that requires treatment, we were able to find that
485 people out of cohort, have used a prescription, that is, people who have followed the instructions of their prescribing doctor and have attended their regular visits, which are important for the physician to be able to check the use of the medication(3). Of these 485 people, only 27% had a level of risk of abuse that required treatment, here we have, as we discussed, people who follow their prescription but still feel the need to use a higher dose to the point that they require treatment. 389 people have always used this medication without a prescription or have eventually abandoned their visits with their prescribing doctor, and have permanently self-medicated. Of these 389 people,
63% required treatment. Using the chi2 test, a p
<0.001 was obtained, being much lower than the level of significance of 0.05 that had been established. Therefore, this result showed that if there is a significant relationship between the self-medication of benzodiazepines and a level of risk of abuse requiring treatment. Although it is true that there is no similar study with which this information can be compared to, the result is closely related to the literature that mentions that the indiscriminate and uncontrolled use of benzodiazepines can lead to abuse and dependence, and therefore, it must be strictly supervised by the prescribing physician and it must only be sold with a valid prescription.(2,5-7)
The relationship of demographics with signs of abuse requiring treatment also provided information that should be further investigated. We can also conclude that gender and occupation have a significant relationship with the level of risk of abuse that requires treatment. This matches the prevalence studies that showed which of the demographic groups practice self-medication the most(8,25). This reinforces the fact that self- medication has a significant relationship with the level of risk of abuse that requires treatment.
Since the study was based on patients self - reporting, some questions could have an implicit memory bias, therefore, investigations that are generated longitudinally, following up on the patients, should be carried out. However, the results found are still important, since it is a first study in our environment, which can serve as a background for others who would like to address the same topic.
Based on all the findings, it is concluded that there is a significant relationship between self- medication with benzodiazepines and the risk of abuse that requires treatment in adult patients. Age and occupation also have a significant relationship with abuse that requires treatment.
Since this was a cross-sectional study, a prospective study is recommended to assess whether self- medication is the cause of this abuse, given that the present study has concluded that there is a significant relationship, but does not indicate self-medication as a cause. This recommended prospective study would include an evaluation along with the clinical history and follow-up of the patients, which will also allow us to know the reason for prescribing these medications and the true cause of abuse.
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