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Perception of the risk of adverse reactions to analgesics: differences between medical students and residents Sandra Castillo-Guzman
1 , Omar González-Santiago 2 , Ismael A. Delgado-Leal 1 , Gerardo E. Lozano-Luévano 1 , Misael J. Reyes-Rodríguez1 , César V. Elizondo-Solis1 , Teresa A. Nava-Obregón 1 , Dionicio Palacios-Ríos1
Published July 28, 2016 PubMed 27547561
Background. Medications are not exempt from adverse drug reactions (ADR) and how the physician perceives the risk of prescription drugs could influence their availability to report ADR and their prescription behavior. Methods. We assess the perception of risk and the perception of ADR associated with COX2-Inbitors, paracetamol, NSAIDs, and morphine in medical students and residents of northeast of Mexico. Results. The analgesic with the highest risk perception in both group of students was morphine, while the drug with the least risk perceived was paracetamol. Addiction and gastrointestinal bleeding were the ADR with the highest score for morphine and NSAIDs respectively. Discussion. Our findings show that medical students give higher risk scores than residents toward risk due to analgesics. Continuing training and informing physicians about ADRs is necessary since the lack of training is known to induce inadequate use of drugs.
Introduction Analgesics are the cornerstone of pain management and their availability is critical for to alleviate unnecessary chronic and acute pain, especially in developing countries (Lohman, Schleifer & Amon, 2010). However, these medications are not exempt from adverse reactions (ADR). The use of opioids is associated with various ADRs ranging from nausea and vomiting to urinary retention and respiratory depression. Paracetamol is relatively safe when taken in a therapeutic dose (≤4 g/day for adults). However, overdosage leads to hepatotoxicity and nephrototoxicity (Chun et al., 2009; Waring, Jamie & Leggett, 2010; Hodgman & Garrard, 2012). Non-Steroidal Anti-inflammatory-drugs (NSAIDs) can result in gastrointestinal (GI) complications, ranging from dyspepsia to peptic ulcer and GI bleeding (Castellsague et al., 2012). On the other hand, COX2 inhibitors could create an ulcerogenic dual-COX inhibitor when administered with low-dose aspirin. Moreover, by inhibiting COX2, they could delay ulcer healing. Similar to traditional NSAIDs, COX2 inhibitors compromise the glomerular filtration rate in patients at increased risk, and may cause peripheral edema and hypertension. In combination with an oral anticoagulant they increase the international normalized ratio (Mattia & Coluzzi, 2005). On the other hand, how the physician perceives the risk of prescription drugs could influence their availability to report ADR and their prescription behavior. With opioids, an apprehensive attitude when using morphine as an analgesic could lead to resistance to administer morphine to patients suffering from severe pain. Such reluctance can have a negative impact on pain management as well as quality of life (Joranson et al., 2000; Bandieri et al., 2009). With this in mind, the aims of this study was (1) to assess the risk perception of medical students (MS) and residents (Rs) towards the normal use of opioid and non-opioid analgesics, and (2) to assess the perception of common ADR caused by morphine and NSAIDs.
Methods This study was conducted in the Faculty of Medicine of the Autonomous University of Nuevo León (UANL) and the Dr José E. Gonzalez University Hospital, both located in the Metropolitan area of Monterrey, Mexico. The sample of MS was conformed by those who had already taken a pharmacology course and were surveyed in the faculty of medicine (halls, study areas, library). The sample of Rs include those of any specialty and year of residence and were surveyed in the hospital. After informing the aim of the study and obtaining verbal consent of the participants, the survey was applied. Participants were informed that the first section was optional. The questionnaire was self-administered with supervision.
Instrument The instrument was composed of three sections: the first section is general questions about gender, age and year of study or year of residence, as appropriate. This section was optional; the second section evaluated risk perception to analgesics when normal dosing was used; it included COX2-inhibitors, paracetamol, morphine and NSAIDs. This was performed as previously reported by Durrieu et al. (2007) and Durrieu et al. (2010). A visual analogue scale of 10 cm ranging from 0 (drug without risk) to 10 (highly risky drug) was used to assess perceived risk to each one of the analgesics previously mentioned. The value was obtained by measuring the distance between the left side of the scale (equal to zero) and the mark made by the participant. Since each scale measured 10 cm, risk perception could be considered a quantitative score ranging from 0 to 10. The third section evaluated risk perception to specific ADR when normal use of morphine and NSAIDs were used. The ADR evaluated were gastrointestinal (GI) bleeding, kidney damage, liver damage, sedation, bronchospasm, and addiction. Each adverse effect was assessed as a risk perception; that is, a visual analogue scale of 10 cm ranging from 0 (absent effect) to 10 (effect very frequent). Morphine was chosen due to the fact that it is a better-known opioid; therefore, it is a good representative of opioid analgesics. NSAIDs were chosen due to the fact that they are very familiar drugs to all students and they are a good representation of non-opioid analgesics. Statistical analysis Normality of data was tested with the Kolmogorov–Smirnov test. Data are reported as median and 25th–75th percentiles. The Mann–Whitney U-test was used for comparison between two groups of students and between males and females. The statistical package SPSS V20 and NCSS-10 were used for all analyses. Ethical approval and consent The Ethics committee of the Faculty of Medicine of the Autonomous University of Nuevo León approved this study and exempted from written informed consent. The reference number is AN15-011.
Figure 1: Risk perception toward different analgesic between medical students and residents. DOI: 10.7717/peerj.2255/fig-1
Results Five hundred and five students were interviewed. Women and men represented 39.7% and 60.3%, respectively. MS on the other hand, represented 58.9% and Rs 41.1%.
Risk perception to analgesics Overall, the analgesic with the highest risk perception was morphine, while the drug with the least risk perceived was paracetamol (Fig. 1). This pattern was observed in MS and Rs of all years of study (Table 1). In the case of MS, there was a significant difference among years of study and perception of risk to morphine and NSAIDs. For morphine, the higher risk score was observed in 3rd year medical students while the lowest score was in 6th year medical students. For NSAIDS, this was the opposite. With respect to Rs, there no was a significant difference between year of residence and risk perception score for each one analgesic.
Table 1: Risk perception to analgesics by year of study (median and interquartile range). Degree
Year
3 4 Medical students 5 6 P value 1 2 Residents 3 4 P value
Paracetamol COX2 inhibitors NSAIDs
Morphine
1 (0.3–2.5) 1.3 (0.5–2) 0.8 (0.4–2) 1 (0–2) 0.25 1 (0.3–1.7) 1 (0.3–1.8) 1.5 (0.7–2) 1.2 (0–1.8) 0.4
6 (3.5–8.5) 6 (4–7.5) 5.5 (2.7–8) 4 (2–6) 0.00 3.8 (2.5–5.3) 4 (1.8–6.5) 3 (2.2–5.4) 3.3 (1.8–5.2) 0.8
4 (2.5–5) 3 (2.5–5) 3.7 (2.5–5.3) 3 (1.5–5) 0.09 1.8 (0.9–3.1) 2 (1–3) 2 (1–3.4) 2 (1.1–2.5) 0.9
2.3 (1.5–4) 3 (2.2–5) 3.5 (2–5) 3 (1.7–5) 0.03 2.3 (1.2–3.7) 2.5 (1.3–3.8) 2.5 (1.7–3.5) 2 (1.4–3.5) 0.9
DOI: 10.7717/peerj.2255/table-1
MS had greater scores in risk perception than Rs (Table 2). This difference was significant for COX2 inhibitors, morphine and NSAIDs. These high scores were also observed in both genders of MS. Significant differences between females and males was observed only for paracetamol in MS (P = 0.04) (Table 2).
Table 2: Risk perception to Analgesics between medical students and residents a according their gender (median and interquartile range). COX2 inhibitors MS (n = 300) R (n = 209) Total (N = 509) Male (N = 307) Female (N = 202) P value
3.3 (3–3.7) 3.5 (3–4) 3 (2.7–3.8) 0.10
Paracetamol MS (n = 300) R (n = 209)
P
2.0 (1.7–2) 0.00 1.0 (1–1) 2.0 (1.7–2.5) 0.00 1.0 (1–1.3) 1.8 (1.2–2) 0.00 1.0 (0.5–1) 0.12 0.04
Morphine MS (n = 300) R (n = 209) P
P
1.0 (1–1.2) 0.70 5.0 (5–6) 1 (0.8–1.2) 0.29 5.26 (2.64) 1.0 (0.7–1.5) 0.52 5.0 (4.5–6.2) 0.57 >0.05
3.4 (3.1–4) 3.95 (2.31) 3.4 (2.9–4) 0.91
NSAIDs MS (n = 300) R (n = 209) P
0.00 3 (2.7–3.3) 0.00 3.0 (2.8–3.5) 0.00 2.8 (2.3–3.3) 0.19
2.3 (2–2.5) 2.5 (2–2.7) 2.2 (2–2.6) 0.50
0.00 0.00 0.02
DOI: 10.7717/peerj.2255/table-2
Notes: MS Medical students R Residents P