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Introduction: The misuse or abuse and dependence of medications containing codeine continue to be a major global public health concern. This study aimed to investigate the role of community pharmacists in preventing the abuse or misuse and dependence of codeine-containing analgesic drugs in Saudi Arabia. Methods: A cross-sectional study involving community pharmacists from various community pharmacies across multiple cities of Saudi Arabia was conducted from 09 May to 09 October Study data were collected and managed using Research Electronic Data Capture tool. Fourteen trained data collectors visited randomly selected community pharmacies in different cities, provided pharmacists with an electronic questionnaire link, and collected their responses electronically. The dataset was downloaded in SPSS format, and analyzed for both descriptive and inferential purposes. Results: The primary indicators that community pharmacists considered when suspecting cases of abuse or misuse and dependence included customers who requested a larger quantity of the medication Pharmacists have been instrumental in preventing abuse or misuse and dependence by ensuring that medicines with abuse potential are not easily accessible to consumers It was also suggested that community pharmacists should receive specialized training in substance abuse or misuse, as Discussion: Community pharmacists, being frequently the initial point of contact easily reachable, possess the capability to greatly assist in identifying the patients and averting abuse or misuse and dependence during the dispensing of medication. Further, they can provide valuable guidance to those involved in efforts to reduce drug abuse or misuse and dependence. A persistent global public health issue related to the medications containing codeine is their misuse or abuse and dependence associated with them. This is especially concerning as codeine is found in both prescription and over-the-counter pain relievers, as well as cough suppressants Van Hout and Norman, Despite being considered a mild opiate, codeine still poses risks of dependence, abuse, and misuse due to the rapid development of tolerance with frequent or excessive usage. Prolonged use of codeine-containing medications can result in the development of physical tolerance, leading to unpleasant withdrawal symptoms upon discontinuation of the medication, along with side effects such as drowsiness, euphoria, and constipation Cooper, ; Nielsen and Van Hout, Codeine is often abused or misused in combination products, with consumers mistakenly believing they are taking lower dosages of the medication. However, over time, these combination products have been linked to serious clinical complications like gastrointestinal bleeding and severe hypokalemia Mill et al. As a result, there is a growing need for increased surveillance, better detection of misuse in clinical setting, and public health awareness initiatives Casati et al. Although the pattern of misuse or abuse of codeine-containing analgesics vary from country to county, This highlights the concerning trend of codeine misuse. Similarly, studies conducted in the Middle East have shown a widespread abuse and misuse of codeine-containing medicines, often through self-medication Casati et al. A study by Syed et al. Another study by Yasmeen et al. A substantial usage of analgesics among medical students was also noted in a study by Ibrahim et al. Ibrahim et al. However, it is worth noting that there is a lack of research on the role of community pharmacists in preventing codeine-containing analgesic medicine abuse or misuse and dependence. According to a survey conducted in the Eastern Region of Saudi Arabia, community pharmacists consider medication abuse and misuse to be a concerning issue Alshayban et al. Community pharmacists in Al-Baha region of Saudi Arabia also believe that over-the-counter OTC medications that include codeine are among the most frequently abused and misused Alqarni et al. Likewise, a multicenter study conducted among the community pharmacists in Saudi Arabia also raised the concern about the improper use of drugs, particularly opioids Yasmeen et al. Additionally, a comprehensive review conducted in the Middle East region also brought attention to the misuse of drugs containing codeine, especially when self-medication is employed Khalifeh et al. As per an additional research, community pharmacists think that patient counseling on opioid-containing medicines in particular is lacking in community pharmacy settings Ali et al. Given the presence of various medications containing codeine in the Kingdom of Saudi Arabia Syed et al. Additionally, they may be unaware of the addictive nature of such medications. The easy accessibility and prevalence, coupled with the covert nature of codeine-based medication abuse or misuse and dependence, pose challenges for their assessment and control Van Hout and Norman, ; Wells et al. Since community pharmacies are the most convenient source for individuals to purchase medications for personal use, they can be extremely helpful in promoting responsible use of medicines, which includes alleviating the abuse or misuse and dependence of drugs containing codeine. Thus, this study was designed and conducted with the purpose to ascertain the role of community pharmacists in preventing the misuse or abuse and drug dependence associated with codeine-based analgesic medications in Saudi Arabia. This was a cross-sectional study involving community pharmacists from multiple centers. This study was conducted across community pharmacy outlets located in various cities of Saudi Arabia from 09 Ma y to 09 October Three hundred seventy seven community pharmacists participated in the study, however only of them completed all domains of the questionnaire. The reason for the preference was due to their substantial experiences conducting community researches and are well-versed in topics relating to community researches. This was done based on the results of a comprehensive qualitative study carried out by Alqarni et al. The insightful remarks these experts made were taken into consideration for modifying the study tool. Following a pilot test of the questionnaire among 20 community pharmacists, a second amendment was made. The revised version of the questionnaire contained questions about how pharmacists suspected consumers of abusing or misusing codeine-containing analgesic medications CCAMs , what strategies they used to combat consumers from abusing, misusing or becoming dependent on CCAMs, and what recommendations they could provid to prevent consumers from abusing, misusing or becoming dependent on CCAMs. Since the participants of the study were community pharmacists with at least a diploma in pharmacy qualification, the English version of the questionnaire was adopted without the need for translation into Arabic language. The questionnaire included the data collector number, demographic characteristics of community pharmacists, community pharmacy-related information, questions on utilization of codeine-containing analgesic medication, and questions focusing on the role and recommendations of community pharmacists in preventing abuse or misuse and dependence of codeine-containing analgesic medications. REDCap is a safe, web-based software platform that facilitates the collection of data for research studies. In addition to the feature of audit trails for tracking data tampering and export procedures, it has a user-friendly interface for validated data collection. Twenty data collectors initially agreed to participate and were trained to use the REDCap electronic data capture tool data collection. However, only 14 of them were well-prepared and participated in the data collection process. Indeed, the session or training focused specifically on ethical aspects and data accuracy. Each data collector was given the REDCap questionnaire link to be distributed to the community pharmacies in different cities, particularly major cities of the Kingdom to collect the data. Each data collector was assigned a unique code number together with name of city or area from where they were responsible to collect the data. The study included all community pharmacies and pharmacists who were willing to participate, regardless of gender or nationality. However, non-pharmacist personnel, such as support staff, and those who declined to participate were excluded from the study. The community pharmacies in major cities i. Data collectors physically visited the pharmacy and briefly described the objective of the study. After the pharmacists agreed to participate, they were provided with the electronic link of the questionnaire prepared and managed by the REDCap electronic data capture tools. The data collectors were directed to wait until the pharmacists were free and willing to entertain, rather than approaching them while they were busy serving customers. Additionally, they were instructed not to become angry or agitated with the pharmacists if they refuse to continue answering the questionnaire or to force them to stop in the middle of the survey if they become preoccupied with entertaining customers. The majority Saudi pharmacists who graduated from Saudi Universities comprised over half About one-third Although the majority Additionally, nearly half It was found that the majority According to the community pharmacists, Despite this, if CCAM users missed a dose, Although Community pharmacists adopted various strategies to identify consumers misusing or abusing CCAMs. Likewise, they brought in practice various approaches, and put forward multiple recommendations towards preventing misuse or abuse and dependence of CCAMs Table 2. Table 2. There is a growing concern regarding the abuse or misuse and dependence on codeine-containing drugs on a global scale. These issues have the potential to impact quality of life, associated costs, and morbidities Casati et al. This necessitates implementation of best practices to ascertain that these medications are used safely and for their intended purpose only. As community pharmacies are among the highly accessible and first point of contact for individuals seeking medical advice and obtaining medications for minor ailments, their role in preventing abuse or misuse and dependence is crucial. This quantitative study, probably the first of its kind in Saudi Arabia, focuses on the role of community pharmacists in preventing the abuse or misuse and dependence of CCAMs. The reason for choosing CCAM lies in the fact that codeine is frequently sold over-the-counter as combination with paracetamol and caffeine. Our study found that consumers purchased CCAMs to enhance mood or sleep, even though the primary reason for consumption was pain relief. As it is evident that prolonged use of CCAMs can lead to addiction, it is imperative to know whether consumers are aware about their addictive nature. The community pharmacists reported that Conversely, this suggests that a noticeable proportion of customers are still ignorant that using CCAMs may result in addiction. More over half of the consumers developed a craving for it if they missed a dose, which the community pharmacists saw as an indication of addiction based on their interactions and experiences with the consumers. This alarming situation emphasizes the need for collective efforts to raise awareness among consumers. Several studies have reported that codeine-containing preparations are among the most frequently abused or misused over-the-counter medications, particularly among younger individuals Wright et al. The accessibility of codeine-based medicines is one of the factors contributing to their increased misuse in countries where they are available over-the-counter further exacerbating their addictive nature Robinson et al. Furthermore, each Solpadeine soluble effervescent tablet contains paracetamol mg, codeine 8 mg, and caffeine 30 mg. The community pharmacists were asked a set of diverse questions related to the role they play in preventing CCAMs abuse, misuse and dependence. Community pharmacists assessed the patients through observation of their behavior and attitude. Although varied responses were observed from the pharmacists regarding each question or situation regarding identifying the users, behaviors such as requesting for larger quantity, frequently visiting the pharmacy, and requesting for the same brand of CCAM, visiting the pharmacy during busy time, refusing any alternative to CCAM, exploiting the crowd to avoid being asked by the pharmacist, and requesting for a specific size were indicative of identifying CCAM users. The study by Carney et al. However, the act of refusing to sell or denying the availability of CCAM was not as common in practice. This is particularly due to safety concerns, as users often argue and sometimes become violent when faced with denial or referral. However, they could just as easily get the medicine by going to another pharmacy. Consequently, the pharmacists may hesitate to refuse the sale out of fear of losing customers. This observation is supported by Sansgiry et al. Increasing public awareness about the risks of CCAMs was among the most common recommendations made by the pharmacists. Studies have also shown that increasing public awareness and proper counseling could assist in preventing CCAM abuse, misuse, and dependence Bergin et al. Mandatory basic training on addiction and harm reduction, monitoring of prescribed or over-the-counter CCAMs, and increasing the visibility of health warnings on the outside of packs were among the other recommendations made. Community pharmacists also highlighted the need of developing secure central database to monitor the purchase of CCAMs, prescribing CCAMs to be confined to prescribers who are trained in addiction, and implementing health warnings as pop-up alerts on online shopping platforms to prevent abuse, misuse, and dependence. The future of the country would ultimately gain a great deal from having young people free from addiction. The effects of substance abuse, misuse, and dependence on the general health, and future of the country should also be emphasized. The absence of comprehensive information regarding community pharmacies and community pharmacists prevented this study from selecting participants using a specified random sampling approach, rather than simple random. Although the approach was to recruit community pharmacists working in urban, semi-urban and rural areas of the country, we could not enroll the pharmacists from all the regions except the major cities. Additionally, we could succeed to enroll pharmacists from only some pharmacy chains despite our maximal efforts. Moreover, the response rate was also low. Hence, study findings may not be generalized. However, the exploratory nature of this study still offers key insights into understanding the role of community pharmacists in dealing with the public health issue of CCAMs abuse, misuse, and dependence despite these limitations. These limitations could be addressed in future research. While changing the behaviors of users is a challenging task, community pharmacists, as the first point of contact and being more accessible, could play an important role in preventing abuse or misuse and dependence on codeine-containing analgesic medications. Therefore, it is essential to reinforce their roles and mandate their training on substance use and abuse. This also draws attention to the need of a multifaceted collective approach in the manufacturing, advertising, prescribing, and dispensing of medications with abuse potential. Government regulatory agencies should develop comprehensive plans to raise awareness and enforce stricter regulatory controls on the safe and effective use of codeine-based drugs. This could potentially reduce codeine-associated morbidity and mortality, improve quality of life, and save national resources. The datasets presented in this study can be found in online repositories. However, the funder had no role in study design, data collection and analysis, preparation of the manuscript, and decision to publish. We also express our gratitude to community pharmacists for giving up their important time to participate in this study. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Algarni, M. Community pharmacists' views and experiences toward over-the-counter medicines misuse and abuse in Saudi Arabia: a qualitative study. Ali, M. Knowledge, attitude, and the practice of community pharmacists to dispense opioid-related and opioid-containing medication in eastern province, Saudi Arabia. Bioallied Sci. Alruthia, Y. The status of licensed pharmacy workforce in Saudi Arabia: a economic vision perspective. Health 16, Alshayban, D. Knowledge, perception, and practice of pharmacy professionals on drug misuse and abuse in eastern region of Saudi Arabia. Ashp ASHP Statement on the pharmacist's role in substance abuse prevention, education, and assistance. Health Syst. Bach, P. Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders. Bergin, M. Practice implications and recommendations for managing codeine misuse and dependence. Acta Pharm. Carney, T. Health Addict. Abuse Treat. Policy 13, Casati, A. Misuse of medicines in the European Union: a systematic review of the literature. Chan, W. Prescription medicine misuse in the Asia—Pacific region: an evolving issue? Cooper, R. Over-the-counter medicine abuse — a review of the literature. Use 18, 82— Harris, P. The REDCap consortium: building an international community of software platform partners. Research electronic data capture REDCap —a metadata-driven methodology and workflow process for providing translational research informatics support. Hill, D. Misuse of over the counter medicines in community pharmacies in Scotland. Use 23, 7— Ibrahim, N. Self-medication with analgesics among medical students and interns in king abdulaziz university, Jeddah, Saudi Arabia. Pak J. Khalifeh, M. Self-medication misuse in the Middle East: a systematic literature review. The challenge of complex drug use: associated use of codeine-containing medicines and new psychoactive substances in a European cross-sectional online population. Lo, M. Codeine consumption from over-the-counter anti-cough syrup in Taiwan: a useful indicator for opioid abuse. Acta Anaesthesiol. Taiwan 53, — Mill, D. Counting the cost of over-the-counter codeine containing analgesic misuse: a retrospective review of hospital admissions over a 5 year period. Drug alcohol Rev. Mody, S. Over-the-counter codeine: can community pharmacy staff nudge customers into its safe and appropriate use? Mubarak, N. Are pharmacists on the front lines of the opioid epidemic? A cross-sectional study of the practices and competencies of community and hospital pharmacists in Punjab, Pakistan. BMJ Open 13, e Nielsen, S. Over-the-Counter codeine-from therapeutic use to dependence, and the grey areas in between. Norman, I. Best practices and innovations for managing codeine misuse and dependence. Raosoft Sample size calculator. Google Scholar. Robinson, G. Misuse of over-the-counter codeine-containing analgesics: dependence and other adverse effects. PubMed Abstract Google Scholar. Roussin, A. Misuse and dependence on non-prescription codeine analgesics or sedative H1 antihistamines by adults: a cross-sectional investigation in France. RPS Sansgiry, S. Abuse of over-the-counter medicines: a pharmacist's perspective. SFDA Saudi food and drug authority. Syed, M. Physician perspectives on codeine accessibility, patterns of use, misuse, and dependence in Saudi Arabia. Van Hout, M. Misuse of non-prescription codeine containing products: recommendations for detection and reduction of risk in community pharmacies. Drug Policy 27, 17— Wells, J. Purchasing over the counter OTC medicinal products containing codeine - easy access, advertising, misuse and perceptions of medicinal risk. Wright, J. Changes in over-the-counter drug misuse over 20 years: perceptions from Scottish pharmacists. Public Health Oxf 38, — Yasmeen, A. Suspected inappropriate use of prescription and non-prescription drugs among requesting customers: a Saudi community pharmacists' perspective. Saudi Pharm. Drug-related problems and pharmacy interventions in non-prescription medication, with a focus on high-risk over-the-counter medications. Zaprutko, T. Misuse of OTC drugs in Poland. Health Policy , — Keywords: codeine analgesics, community pharmacists, dependence, misuse and abuse, role, Saudi Arabia. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Table 1. Figure 1. Health conditions prompting customers to purchase CCAMs. Figure 2. Figure 3.

Top 10 most used drugs in the Kingdom of Saudi Arabia 2010–2015

Ed-Dammam buying MDMA pills

But because of the demand and counterfeit drugs in the marketplace, buyers may not be getting what they bargained for. Although medical experts say 50 percent of the men over 45 years of age are believed to suffer some degree of sexual dysfunction, pharmacists say most of the customers asking for the blue pill are young men in the age group. Ahmad, a pharmacist, told Arab News. Another pharmacist said his shop gets customers of all ages, from 20 to 70 years old, asking for the blue pill. Magdi Mohsen, medical adviser at Pfizer Corp. Viagra, a product of Pfizer for ED erectile dysfunction , is the second best-selling pharmaceutical product in Saudi Arabia after Augmentin, an antibiotic. Although pharmacists are not supposed to sell Viagra without a prescription, like many other prescription medications they do. Another pharmacist said almost 90 percent of the Viagra sales are without prescription. The older the age group, the less likely they are to buy the drug, perhaps out of embarrassment. However, Dr. Ahmad said that when a middle-aged or an elderly gentleman asks for the drug he usually buys three or four boxes at once, especially if he is about to travel because it is easier, but not necessarily cheaper, to purchase it here. A box of Viagra contains four tablets and is sold for the standard price set by the Ministry of Health at SR According to an Egyptian pharmacist here, Viagra is cheaper in Egypt and other Asian countries, which is the reason some people might try to smuggle large quantities and sell it illegally. Another reason could be that the Ministry of Health does not permit the selling of mg tablets of Viagra, only the 25 mg and 50 mg, again enticing people to smuggle in the higher-dosage tablets and sell them for a profit. The danger for men buying the medication without a prescription is in not knowing their health condition or not informing the pharmacist. Back in March, newspapers reported on an old man from Turaif province who died on his wedding night after taking Viagra. There have been many reports of elderly men going to hospital emergency rooms suffering from a heart problem after taking the potency medications. Since Viagra was introduced in Saudi Arabia six years ago, it has become one of the top-selling medications. It remained the only male potency medication for three years before others types were developed, but it is still the most popular. The demand for male-potency medication also has increased the drug counterfeiting, which has cut into sales of Viagra. Even those medications carrying the same logo and packaging of Pfizer imported from other countries might not be authentic or approved by the Ministry of Health here. People in many Arab countries, including Saudi Arabia, where the sexual dysfunction problems were initially viewed as a psychological ailment, now are considered a medically treatable problem, and much of the stigma associated with these drugs is fading. According to pharmaceutical market experts, sales of potency medications ranged from SR million to SR1 billion in in Saudi Arabia, representing one-fifth of the total pharmaceutical market. Saudi Arabia is at the top of the list among GCC in terms of consumption, sources said. Publication Date:. Mon, Main category:. Old Categories:. Search form Search. Print Edition Read pdf version Subscribe now.

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