Self-medication, therapeutic non-compliance and adverse reactions

Compliance is defined as the degree of follow-up that patients carry out with the recommendations made by healthcare personnel. Until relatively recent times, it was thought that these indications were accepted and followed by patients, and the possibility that they were not initiated or that they were abandoned was practically ignored.

However, this situation has clearly changed, and now both in the clinical research process and in routine healthcare practice an attempt is made to detect, quantify its frequency and avoid non-compliance. The studies that attempt to determine its magnitude are very different, since the methods of quantifying compliance, pathologies and treatment characteristics vary from one study to another.

However, in all of them high levels of non-compliance are usually indicated, which can reach 40-70%, which together with its negative effects means that this possibility must always be taken into account before any recommendation made to the patient, and that the analysis of the factors that influence it is of great interest.

Types of default

Non-compliance with the
treatment can be due to:

• abuse
• omission
• erratic use

As can be seen, omission is not the only form of non-compliance, since there may be erratic or inappropriate follow-up of the recommendations and also excessive use, since it is not uncommon for some patients to use higher doses of the prescribed medication or what is prescribed. use more often than recommended.

Factors influencing compliance

Two main types of factors that affect compliance can be differentiated, some depending on the patient and his disease, and others on the treatment.

Patient dependent factors.

Although there are contradictory data, the sex or socioeconomic status of the patient does not seem to markedly modify compliance. Regarding age, it is often suggested that children, adolescents and the elderly tend to perform worse.

Numerous sociological and psychological characteristics affect compliance. Thus, worse compliance is related to not living together with the family, hostile attitude, schizoid personalities and poor acceptance of the disease. Similarly, some aspects of the family environment clearly influence compliance.

In this sense, the following factors improve it:

• Support from other family members
• Supervision of taking medication by family or friends
• Existence of the same disease within the family

While others negatively influence:

• Communication problems between family members.
• Assistance to the patient’s consultations without any company.

It is also important to take into account the relationship of the patient with the health personnel, since when the relationship is good and satisfactory, compliance improves.

The information available on the relationship between the disease and compliance is not very extensive, but it seems logical to think that in serious situations compliance will be better than in banal ones.

Treatment-dependent factors.

The duration of treatment is negatively related to compliance, since in chronic treatments compliance is worse. Likewise, in general, hospital treatments have better compliance than outpatient ones.

The prescribed guideline also significantly affects compliance, as follows:

• The parenteral route ensures better compliance than the oral route
• The higher the number of drugs, the worse the compliance
• The greater the complexity of the prescription, the worse the compliance
• The lower the number of daily medication intakes, the better compliance
• Poor explanation of the pattern also reduces compliance

Consequences of non-compliance

When a patient develops undesirable effects, non-compliance can save him or her problems and is therefore called “smart non-compliance.” However, the consequences of non-compliance are usually negative, both from a clinical and economic perspective, the following being the most notable:

• Poor therapeutic response
• Increase in health spending (lengthening of sick leave, new prescriptions, etc.)
• Storage of medications in patients’ homes, facilitating self-medication and poisoning

Furthermore, when non-compliance occurs in patients included in clinical studies, their results may be biased.

Assessment of non-compliance

There are 2 types of methods, direct and indirect.

Direct

Direct companies always find a compliance rate lower than expected, since they detect non-compliance more objectively. They are very accurate, but they are more expensive and often require invasive techniques.

Indirect

The indirect ones are simpler and usually require the collaboration of the patient, so there is the possibility of deception.

They generally overestimate the level of compliance.

Self-medication

Self-medication, defined as the use of pharmacological products without the intervention of health personnel, is a problem of great importance and widely disseminated, which has made the WHO consider it a priority issue. Its importance varies from one community to another depending on the availability of medicines and the accessibility to professional health care.

However, its magnitude is high, calculating that 10-30% of the population self-medicate on a regular basis, and that in 50% of disease episodes self-medication is carried out, in fact most of the pharmacological groups are consumed as importantly by self-medication. The consequences of self-medication can be positive, and in fact there are numerous situations in which a correct, responsible and informed self-medication can improve the quality of life of patients, reducing health costs. For example, chronic pathologies and / or those with exacerbations (eg: Headache), or banal ones could be subsidiary to self-medication, as long as it was carried out in a logical way. Along with this criterion of correct self-medication (justified indication), It is necessary to remember that the medicine used must be in good condition, and that the dose must be adequate. However, and unfortunately, the information available indicates that the self-medication that is practiced cannot be classified as “responsible”, since the available studies suggest that in more than 70-80% of the cases it cannot be considered adequate.

On the other hand, self-medication often has negative effects for the patient, since it can develop adverse effects and / or interactions with medications prescribed by healthcare personnel. In addition, and as with antibiotics, self-medication can have negative consequences for other patients, since it favors the selection of resistant strains of microorganisms. The origin of the drugs used for self-medication is diverse. It can come from:

1. Leftover medication from previous prescriptions (home kits)
2. Over-the-Counter (OTC) Medications
3. Medications for which a prescription is required obtained without it
4. ‘Unorthodox’ medicines (herbs, ‘natural products’, etc.)

Home preservation of medicines

Drugs are usually molecules that have a more or less long stability depending on different factors. Usually a number of storage conditions should be met that are not met in a home medicine cabinet.

Storage at the wrong temperature, humidity, and light can cause changes in the molecule ranging from inactivation to the formation of toxic metabolites (as happened with tetracyclines in the 1960s). These problems are more frequent if the medication is available in containers that, once opened, do not guarantee its airtightness.

The storage conditions required for most drugs would be:

• Place with temperature not higher than 22ºC nor lower than 15ºC
• Humidity less than 85%
• No direct exposure to sunlight

These conditions are not usually met, since the most used place for storing medicines is the bathroom, so the use of these products can be risky. In addition, home medicine cabinets often contain drugs whose expiration date has been widely exceeded.

Dosage in self-medication

It is also important that the dose of the drug that is self-prescribed is correct, this is not always the case, and it is common for patients to take medications at insufficient or excessive doses,

The first so that the drug does not harm them, so they do not get relief from their symptoms, and the second to try to relieve them as soon as possible, sometimes causing toxicity pictures.

Indication in self-medication

Defining the clinical situations in which self-medication may be justified is a point where more problems arise, since a correct diagnosis is often necessary before using a drug, and sometimes a drug can mask a serious process. However, it is clear that there are situations in which self-medication does not pose conflicts.

Thus, it would be ridiculous to advocate that a headache in a person who suffers from them regularly and has already been studied, has to be seen by health personnel every time they have an episode.

The correct definition of these situations and the development of strategies to ensure that patients know them are essential to ensure that self-medication does not cause more problems than it avoids.

Rules to avoid the problems of self-medication

In a generic way, over-the-counter (non-prescription) products should only incorporate well-known drugs, and with an exceptionally low potential toxicity, and preferably be mono-drugs, that is, they should not include several active ingredients simultaneously. In addition, the supply of drugs for which a prescription is necessary without a prescription should disappear. Secondly, health education programs aimed at the population would be necessary in which they are taught the situations in which drugs can be used without direct health advice.

It would also be of great interest to prepare leaflets aimed at patients, in which they are informed in a pleasant and clear way about the characteristics of their disease and the medication they are going to use. Finally, it is essential to remember that routinely, and especially in the face of any change in the treatment of the patient, you should ask yourself specifically if you are using any other pharmacological product, mentioning other products that the patient does not consider medicines (homeopathic preparations, dietary supplements, herbs, etc.)