|Year : 2015 | Volume
| Issue : 2 | Page : 87-94
Non-medical use of prescription drugs in Bangalore, India
Prasanthi Nattala1, Pratima Murthy2, Thennarasu Kandavel3, Linda B Cottler4
1 Associate Professor, Department of Nursing, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
2 Professor, Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
3 Professor, Biostatistics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
4 Professor, Psychiatry, Center for Addiction Medicine, College of Public Health and Health Professions and College of Medicine, University of Florida, Florida, USA
|Date of Web Publication||25-May-2015|
Dr. Prasanthi Nattala
Associate Professor, Department of Nursing, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka
Source of Support: The study is funded by Fogarty International Center,
USA (Advanced In-Country Research Grant No. TW05811-08; PI: Linda
B. Cottler)., Conflict of Interest: All the authors declare that they have no
confl icts of interest.
| Abstract|| |
Background: Non-medical prescription drug use is an ongoing problem in India; however, there is paucity of literature in the Indian population. Objective: The objective of the present study is to explore the non-medical use of prescription medicines in urban Bangalore, South India (N = 717). Materials and Methods: Participants were recruited using a mall-intercept approach, wherein they were intercepted in 5 randomly selected shopping malls, and interviewed on their use of prescription medicines. Results: The mean age of the participants was 28 years (S.D. 5). The non-medical use of different prescription medicine classes over the past 12 months was as follows: anti-inflammatories and analgesics (26%), opioids (17%), antibiotics (13%), and sedatives (12%). The majority reported "use without prescription," while "use in ways other than as prescribed" was also reported. In all cases, chemist shops were the main source of obtaining the drugs non-medically. In multivariate logistic regression analyses, non-medical use was found to be significantly associated with participants' baseline characteristics like gender, education, current employment status, and marital status. Sixty-five percent stated that although "doctor's prescription is not required for common complaints, we can decide ourselves," while 60% stated, "it's okay to deviate from a prescription as needed." One hundred percent said that "using prescription medicines is more socially acceptable, and safer, compared to alcohol or illicit drugs." Conclusion: These findings underscore the need for considering various contextual factors in tailoring preventive interventions for reducing non-medical use of prescription drugs.
Keywords: Antibiotic misuse, drug use, non-medical prescription, non-medical prescription drug use, painkiller misuse, prescription drug abuse, prescription drug misuse, sedative misuse
|How to cite this article:|
Nattala P, Murthy P, Kandavel T, Cottler LB. Non-medical use of prescription drugs in Bangalore, India. Indian J Public Health 2015;59:87-94
|How to cite this URL:|
Nattala P, Murthy P, Kandavel T, Cottler LB. Non-medical use of prescription drugs in Bangalore, India. Indian J Public Health [serial online] 2015 [cited 2020 Feb 18];59:87-94. Available from: http://www.ijph.in/text.asp?2015/59/2/87/157500
| Introduction|| |
Non-medical use of prescription medicines (operationalized as use "in ways other than prescribed" or "when not prescribed") , is an ongoing problem in the developing world. In India, prescription drugs are regulated by the Drugs and Cosmetics Act, 1940, and the Drugs and Cosmetics Rules, 1945. Prescription drugs come under Schedules H and X of the Drugs and Cosmetics Act. However, despite legislative regulation, easy availability of a wide range of drugs has resulted in increased proportions of drugs used without prescription. While non-medical use of pharmaceutical drugs has been steadily rising across South Asia in the last decade, documented literature has been scarce, with prescription drugs being traditionally excluded from national drug use surveys.  A non-data based report was released recently by the United Nations Office on Drugs and Crime (UNODC) (2011),  which reiterated the magnitude of the problem, despite the absence of related baseline data.
In India, literature concerning non-medical prescription drug use has been sporadic, with a decade or so difference between studies. Two nationwide surveys on drug use conducted in the early 2000s , included benzodiazepines - apart from this, there is no national data on prescription drug use. Information has been largely anecdotal, available as newspaper or internet reports. ,, While previous studies have considered such factors as rural-urban differences, education, and economic status, , given the paucity of such studies, further research is warranted to examine the patterns of prescription drug use.
Non-medical use of prescription drugs is a problem in the developed world as well. Studies from advanced nations such as the United States, for example, reveal that there were around 7,000 people initiating prescription drug misuse per day in 2006-2007.  However, in developing countries, the problem needs to be viewed keeping various other contextual factors in mind, such as lack of access to quality health care and poor legislation, all of which impact non-medical prescription drug use, which is already rampant.
Against this background, an urban community study on non-medical use of prescription drugs was carried out using a mall-intercept approach in Bangalore. This information, reported for the past 12 months, thus provides recent data on the problem. This preliminary information can help to renew a discussion on the continuing problem of non-medical prescription drug use, aid in developing preventive strategies, and raise public awareness about the potential risks associated with such use.
| Materials and Methods|| |
Prescription medicines were operationalized as:
- Medicines listed under Schedules H and X of the Drugs and Cosmetics Act, 1940 and the Drugs and Cosmetics Rules, 1945; and
- Drugs listed under Schedule G, which do not need prescription but require mandatory text on the label.
"Caution: It is dangerous to take this preparation except under medical supervision." Accordingly, the categories of prescription drugs assessed include analgesics/anti-inflammatories, sedatives, opioids, and antibiotics.
The Institutional Ethics Committee approved all protocols. Participants were recruited usingb a mall-intercept approach, , wherein they were intercepted in 5 randomly selected shopping malls in Bangalore (one each from the east, west, north, south, and central zones), explained that a research study on prescription drug use is being conducted, and asked if they might consider participating. For those who responded positively, initial screening was done to ascertain if they were between 18-40 years of age and currently residing in Bangalore. If found eligible, demographics were recorded, following which the nature of the study was explained in more detail. Those who agreed to participate further were administered written informed consent. After the interview, respondents were offered a gift coupon for Rs. 200 for redemption in the mall where data was collected, as compensation for their time. The gift coupons were purchased from the respective malls before commencement of data collection, and were valid for 6 months from the date of purchase. The respondents were also given a booklet (in English/regional language[s]) at the end of the interview, containing information about harmful effects involved with using prescription medicines non-medically.
Interviews were carried out by two project staff with graduate education and trained on the study protocol. Due to the crowding in malls and length of the interview, interviews were conducted between 11:00 a.m.-4:00 p.m., 4 days a week (Monday through Thursday). The first author observed at least 10% of the interviews every month, and provided regular feedback to ensure consistency and quality of the data obtained.
The standard formula was used for calculating sample size for a pre-defined proportion with a given confidence interval:
Based on anecdotal information,  with an expected percentage of prevalence of about 20% of prescription drugs use (e.g., painkillers) in the study population, the sample size was estimated to be 683, with 95% confidence interval of 6% target width.  Accordingly, the sample size was fixed at 700.
Non-medical use in the past 12 months
Non-medical prescription medicine use was operationalized as use "in ways other than as prescribed" or "when not prescribed." , Non-medical use during the past 12 months was assessed by asking respondents: a) in the last 365 days, did you use (the specific class of medicines) in ways other than as prescribed (e.g., using more tablets, or for longer duration, than indicated in the prescription) and b) in the last 365 days, did you use (the specific class of medicines) that were NOT prescribed for you? The names of various medicines were read out to respondents, along with popular brand names. Respondents were also shown medicine samples to enable recall of prescription drugs used in the last 12 months. Accordingly, two mutually exclusive categories of non-medical use were identified: Use "in ways other than prescribed" and use "when not prescribed."
Data were obtained using an instrument adapted from the Washington University Risk Behavior Assessment for Prescription Drugs (WU-RBA-RxDrug)  and the substance use module (SAM).  The WU-RBA-RxDrug and SAM have been shown to have good test-retest reliability among diverse cultures in the United States, , and have also been used in prior Indian literature. , The tool used in the present study was adapted from the WU-RBA-RxDrug and SAM. Content validation of the adapted instrument was established by faculty members experienced in treating patients with substance use disorders at the institute where the present study was undertaken, as well as by general physicians. The instrument was also translated into the regional language(s) and back-translated into English using standard procedures. The instrument was then pretested on 15 individuals shopping in a local supermarket (not included in the main study) before being used for the main study.
All comparisons were made between "users" of the specific class of drugs and "non-users." Non-users were those who did not report non-medical use of any prescription drug in the past 12 months. For categorical data, Chi-square analyses were used to assess associations between selected variables and non-medical prescription medicine use over the past 12 months. Separate multivariate logistic regression models were used to identify predictors of past 12-month non-medical use of each class of prescription drugs. For each drug class, all explanatory variables that showed a significant level of P < 0.10 in univariate logistic regression analysis were included in the multivariate model, along with other relevant variables. These variables were selected based on prior literature suggesting their association with non-medical use of prescription medications. , Analyses were conducted using SAS version 9.2 (USA).
| Results|| |
Description of the sample
Mean age of the participants (N = 717) was 28.0 years (S.D. 5.0). Thirty percent were between 18-25 years, 54% were between 26-33, and 16% were between 34-40 years of age. Forty-nine percent of the sample was female, 70% had graduate-level education or above, 62% were married, and they reported a mean monthly income of Rs. 42,306 (S.D. 35,604). One percent had a medical degree (MBBS/BDS). Two percent reported having suffered an accident/injury in the past. However, none had received treatment for any medical problem in the past year; prescriptions received for any complaints were issued prior to the last 12 months.
Past 12-month non-medical use of prescription medicines
Non-medical use of any prescription drug (sedatives/opioids/analgesics/antibiotics) was reported by 68% of the sample. Past 12-month non-medical use of specific medicine categories are presented in [Table 1].
|Table 1: Past 12-month non-medical use of different prescription medicine classes (N = 717)|
Click here to view
Source of obtaining prescription medicines for non-medical use
For all categories of prescription medicines, chemist shops were the main source of obtaining the medicines non-medically. Further details are reported in [Table 2].
Sociodemographics and past-12 month non-medical use of prescription medicines
Bivariate associations between past 12-month non-medical prescription drug use and sociodemographic variables are presented in [Table 3].
|Table 3: Comparison of nonmedical users with those who did not report use, by demographics|
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Correlates of past 12-month non-medical prescription drug use
Results of multivariate logistic regression analyses showing associations between past 12-month non-medical prescription drug use and selected baseline variables are reported in [Table 4].
|Table 4: Multivariate logistic regression predicting past 12-month non-medical use of prescription medicines|
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Fifty-two percent reported having seen advertisements of various products on television, to overcome drug addictions, relieve pain, increase height, increase weight, andstay slim and fit, among others (data not shown).
Six percent reported that they had used medicines for "body building" in the last 12 months. None of them could recall the name of the medicine, and claimed that friends had suggested the medicine "to build personality/body, muscles" (data not shown).
Sixty-five percent stated that "you don't need a doctor's prescription for getting most of the medicines we need, we can decide on our own," while 60% stated that "it's okay to deviate from a prescription as needed." One hundred percent said that "using prescription medicines is more socially acceptable, and safer, compared to alcohol, or illegal drugs like heroin."
| Discussion|| |
The present study provides recent data regarding non-medical use of prescription medicines in an Indian sample. The findings indicated that anti-inflammatories/analgesics were the most frequently reported class of prescription medicines used non-medically in the past 12 months (26%). It appears that anti-inflammatories/analgesics and opioids were loosely bought over the counter, as the majority reported that they had used them "without prescription." These findings point to the unregulated availability of medicines which may have resulted in their non-medical use. However, with regard to sedatives and antibiotics, participants seem to have relied on a prescription for initial use (referred to as "floating prescriptions"),  although they later deviated from it and used them "in ways other than as prescribed." This suggests that having a medical prescription might increase availability and opportunity to procure the medicines over-the-counter. With regard to sedatives, the present findings are similar to a prior report from an urban community in St. Louis, USA,  which had shown that heavy users of sedatives were more likely to report "using in ways other than as prescribed," compared to "non-prescribed use." Other studies have also emphasized the misuse of prescribed sedatives. , With regard to antibiotics, however, the present findings are at odds with a prior report that has documented use of antibiotics without prescription. 
Furthermore, in terms of specific drug categories, a few points deserve special mention. Among non-medical analgesic users, Nimesulide was the most frequently reported. Among antibiotic users, the most frequently reported pattern was erratic use, which poses a serious danger as it can contribute to antimicrobial resistance, a concern well highlighted by previous authors. , Sedative users, all "non-prescribed users," and some of those who had used them "in ways other than prescribed," reported "erratic use" [Table 1], which can increase the risk of harmful effects such as withdrawal seizures.
Chemist shops were the main source of obtaining prescription drugs non-medically, which reiterates what is already well known: The advice of chemist shop attendants in most countries of South Asia is highly valued by customers, and chemist shop attendants often suggest/dispense prescription medicines. 
The findings have several implications for the field. First, doctors need to provide sound medical advice when issuing prescriptions. For instance, when a prescription for sedatives is given, the dangers of overdosing (e.g., respiratory depression) and erratic use (e.g., seizures) should be explained clearly, as well as the dangers of continuing to use for reasons such as to sleep, relax, and stress relief [Table 2].
Second, sensitization of chemist shop attendants is equally important, coupled with strict enforcement of laws in case of irresponsible dispensing. The role of chemist shop attendants in prescription drug misuse has been mooted in literature for decades, and it is important to note from this analysis that these trends continue, and steps need to be taken to curb the same.
Third, from a public health stance, an important measure is raising health awareness in the population. In the present sample, the majority were educated and relatively affluent, considering that they were mall-goers. However, 60% had opined that "doctor's prescription is not required for common complaints, or that it is alright to deviate even if you had one." While this may not necessarily imply that they would use prescription drugs in an irrational manner, it would still be worthwhile if they were made aware of adverse effects and drug interactions of common medicines available in the market.
In this regard, a pragmatic measure would be to incorporate this awareness as part of the public health information provided about ill effects of addictive drugs. These days, the television and other media in the developing world are attempting to convey health warnings about the harmful effects of alcohol and tobacco. However, there is practically almost no message provided about the dangers of using pharmaceutical products indiscriminately. Hence, these integrated messages can help individuals to make informed choices.
More importantly, health care professionals have the potential to impact the problem of non-medical prescription drug use in terms of both prevention and active interventions. For instance, at mental health care centers, professionals need to incorporate information about the dangers of non-medical prescription drug use into the psycho-education provided to those who have an alcohol or illicit drug use problem. At the community level, a practical measure can be done to sensitize doctors serving at peripheral health centers about providing information to patients and families regarding the dangers of using prescription drugs non-medically.
Another important implication of the present findings is that they indicate the need for health professionals to address the reasons cited by the respondents for using prescription drugs non-medically (e.g., "to sleep/relax/for stress relief" for using sedatives in the present sample). Similar findings were reported in St. Louis, USA, where motives such as "stress relief, for sleep, to change mood, to get high," were reported by more than 60% of the sample of non-medical sedative users.  It thus appears that despite the vast differences in culture, the findings point to some commonalities in terms of non-medical sedative use, notably the presence of a prescription, and specific reasons cited for using non-medically.
The present findings have also indicated that past 12-month non-medical prescription medication use was associated with several socio-demographic variables, and preventive measures should take into consideration such factors that may have a bearing on prescription drug use.
The present findings also raise issues such as why should 12% of a young, healthy sample feel the need for sedatives? Similarly, why should 26% of young, apparently healthy individuals that comprised the present sample feel the need for pain medication? The data thus provide information to health professionals who can use this knowledge to help patients/general public to cope with life circumstances without resorting to non-medical prescription drug use. Building a positive self-image would be an important component of this education, especially for young people, which will prevent use of drugs for purposes such as "bodybuilding" (reported by 6% of the current sample).
The findings should however be treated with caution, given the small, convenient sample, restricted to mall goers who were primarily between 18-33 years, educated, and relatively affluent, which limits generalizability.
The study also attempted to obtain the data using a mall-intercept approach, , which has not so far been reported for recruiting community samples in India, to enquire about their use of drugs. Despite some inconveniences (e.g. obtaining permission from malls, lack of space for conducting the interview), it is felt that this approach is worth exploring for obtaining health related information from the general public.
| Conclusion|| |
The present study provides some recent empirical information regarding non-medical use of prescription medicines among a young, healthy, and urban community sample. There is a pressing need to explore non-medical use of prescription medicines in this part of the world, and the present data can be a preliminary step for a larger epidemiologic study exploring non-medical prescription drug use. The present report can also provide some insights into developing preventive efforts and interventions to reduce non-medical use of prescription drugs.
| References|| |
McCabe SE, Boyd CJ, Teter CJ. Subtypes of nonmedical prescription drug misuse. Drug Alcohol Depend 2009;102: 63-70.
McCabe SE. Screening for drug abuse among medical and nonmedical users of prescription drugs in a probability sample of college students. Arch Pediatr Adolesc Med 2008;162: 225-31.
Kumar MS. Rapid Assessment Survey of Drug Abuse in India. New Delhi: United Nations Office on Drugs and Crime (UNODC), Regional Office for South Asia (ROSA); 2001.
Srivastava A, Pal HR, Dwivedi SN, Pandey A. National Household Survey of Drug Abuse in India. Report submitted to the Ministry of Social Justice and Empowerment, Government of India, and the United Nations Office for Drugs and Crime; 2002.
Sharma R, Verma U, Sharma CL, Kapoor B. Self-medication among urban population of Jammu city. Indian J Pharmacol 2005;37:40-3.
Dineshkumar B, Raghuram TC, Radhaiah G, Krishnaswamy K. Profile of drug use in urban and rural India. Pharmacoeconomics 1995;7:332-46.
Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD: SAMHSA; 2008.
Remafedi G, Jurek AM, Oakes JM. Sexual identity and tobacco use in a venue-based sample of adolescents and young adults. Am J Prev Med 2008;35(Suppl):S463-70.
Muhib FB, Lin LS, Stueve A, Miller RL, Ford WL, Johnson WD, et al
.; Community Intervention Trial for Youth Study Team. A venue-based method for sampling hard-to-reach populations. Public Health Rep 2001;116 (Suppl 1):216-22.
Newcombe RG. Two-sided confidence intervals for the single proportion: Comparison of seven methods. Stat Med 1998;17:857-72.
Cottler LB, Ben Abdallah A, Striley CW. Computerized Risk Behavior Assessment for Prescription Drug Use. St. Louis: Washington University School of Medicine; 2007.
Cottler LB. Computerized Substance Abuse Module. St. Louis: Washington University School of Medicine; 2000.
Leung KS, Ben Abdallah A, Copeland J, Cottler LB. Modifiable risk factors of ecstasy use: Risk perception, current dependence, perceived control, and depression. Addict Behav 2010;35:201-8.
Shacham E, Cottler LB. Sexual behaviors among club drug users: Prevalence and reliability. Arch Sex Behav 2010;39:1331-41.
Satyanarayana VA, Chandra PS, Vaddiparti K, Benegal V, Cottler LB. Factors influencing consent to HIV testing among wives of heavy drinkers in an urban slum in India. AIDS Care 2009;21:615-21.
Cottler LB, Satyanarayana VA, O′Leary CC, Vaddiparti K, Benegal V, Chandra PS. Feasibility and effectiveness of HIV prevention among wives of heavy drinkers in Bangalore, India. AIDS Behav 2010;(Suppl 1):S168-76.
Ecks S. Tracing pharmaceuticals in South Asia [monograph on the internet]. Available from: https://www.csas.ed.ac.uk/__data/assets/pdf_file/0009/39483/Ecks_Treatment_gap_for_antidepressants_India_June2009.pdf. [Last accessed on 2014 Aug 30].
Nattala P, Leung KS, Abdallah AB, Cottler LB. Heavy use versus less heavy use of sedatives among non-medical sedative users: Characteristics and correlates. Addict Behav 2011;36:103-9.
Simon GE, Ludman EJ. Outcome of new benzodiazepine prescriptions to older adults in primary care. Gen Hosp Psychiatry 2006;28:374-8.
Kokkevi A, Fotiou A, Arapaki A, Richardson C. Prevalence, patterns, and correlates of tranquilizer and sedative use among European adolescents. J Adolesc Health 2008; 43:584-92.
Saradamma RD, Higginbotham N, Nichter M. Social factors influencing the acquisition of antibiotics without prescription in Kerala State, South India. Soc Sci Med 2000;50:891-903.
Sehgal R, Burke JP. Combating antimicrobial resistance in India. JAMA 1999;281:1081-2.
Ganguly NK, Arora NK, Chandy SJ, Fairoze MN, Gill JP, Gupta U, et al
.; Global Antibiotic Resistance Partnership (GARP) - India Working Group. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res 2011;134:281-94.
Cottler LB, Striley CW, Lasopa SO. Assessing prescription stimulant use, misuse, and diversion among youth 10-18 years of age. Curr Opin Psychiatry 2013;26:511-9.
Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect 2003;79:442-7.
[Table 1], [Table 2], [Table 3], [Table 4]