Analgesic use among the Brazilian population: Results from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM)

Patterns of Opioid and Non-Opioid Analgesic Consumption in Patients with Post-COVID-19 Conditions

Pain is a major health issue for healthcare systems, and access to pain treatment is a fundamental human right. Pain is a common symptom experienced in the post-COVID phase by a significant percentage of patients. This study describes the prevalence and associated factors associated with the use of opioid and non-opioid analgesics in subjects with post-COVID-19 condition. Sociodemographic data, post-COVID symptoms, health profile, and opioid and non-opioid analgesic consumption were collected in 390 subjects with post-COVID-19 condition. We analyzed the independent effect of all variables on opioid/non-opioid analgesic consumption by using logistic multivariate regressions. The prevalence of opioid and non-opioid analgesic consumption was 24.1% and 82.3%, respectively. Tramadol (17.18%) and codeine (7.95%) were the most commonly used opioid analgesics, and Paracetamol (70%) and ibuprofen (45.4%) were the most commonly used non-opioid analgesics. Females were more likely to consume non-opioid analgesics (aOR2.20, 95%CI 1.15, 4.22) than males. Marital status of married/partner vs. single (aOR2.96; 95% CI 1.43, 6.12), monthly income < EUR 1000 VS. > EUR 2000 (aOR3.81; 95% CI 1.37, 10.61), number of post-COVID symptoms < 5 (aOR2.64, 95%CI 1.18, 5.87), and anxiolytics consumption (aOR 1.85, 95%CI 1.05, 3.25) were associated with a greater likelihood of opioid analgesic consumption. Age > 55 years (aOR3.30, 95%CI 1.34, 8.09) and anxiolytics consumption (aOR2.61, 95%CI 1.36, 4.98) were associated with a greater likelihood of non-opioid analgesic consumption. Opioid analgesic consumption was highly associated (aOR 3.41, 95%CI 1.27, 6.11) with non-opioid analgesic consumption. The prevalence of opioid analgesic and non-opioid analgesic consumption in individuals with post-COVID-19 condition was 24.1% and 82.3%. Females with post-COVID-19 condition showed higher non-opioid analgesic consumption than men. Predictors of opioid consumption were marital status, lower monthly income, number of post-COVID symptoms, and anxiolytic consumption. Older age and anxiolytic consumption were predictors of non-opioid consumption.

Dental Pain Medication Prescriptions in Minas Gerais, Brazil (2011-2021): A Time-Series Analysis

To describe trends of dentist-prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, from January 2011 to December 2021, as well as to examine the relationship between these trends and characteristics of public oral health services in Minas Gerais, Brazil. In this time-series analysis, all drugs were classified according to the Anatomical Therapeutic Chemical classification system. Drugs categorized as NSAIDs (M01A), and other analgesics and antipyretics (N02B) were included for analysis. The outcome was the number of Defined Daily Doses (DDDs)/1000 inhabitants/year for NSAIDs and analgesics in each town. Covariates referred to characteristics of public oral health services, such as coverage, estimates of dental procedures, and frequency of toothache. Linear time-series regression models were used to determine the influence of covariates on the outcome. Overall, there were 58,482 prescriptions of NSAIDs recorded in thirty-eight towns, while 47,499 prescriptions of analgesics in forty-three towns. For each year, there was a 0.38 (p < 0.001), and 0.28 (p < 0.001) increase in the average log of DDD/1000 inhabitants/year for NSAIDs and analgesics, respectively. A positive association was detected between toothache (p < 0.001) and the prescription of NSAIDs. Over the eleven years, there was a general rising trend in the prescriptions. Toothache was the only characteristic of public oral health services associated with the prescription rates of NSAIDs, implying that as the frequency of toothaches increase, so do the prescriptions of NSAIDs in the studied towns.

Prevalence of pain and use of prescription opioids among older adults: results from the Brazilian Longitudinal Study of Aging (ELSI-Brazil)

Background

Pain has a significant impact on people's quality of life. The use of prescription opioids to treat pain is associated with an increased risk of opioid use disorders and overdose death. We measured the prevalence of recurrent pain, prescription opioid use, and associations between chronic conditions and prescription opioid use among Brazilian older adults.

Methods

We used data from the first population-based longitudinal study of aging in Brazil (ELSI-Brazil), 2019-2020 (mean age = 63.3; 54.4% female). Outcomes were: (1) experience of recurrent pain and (2) use of opioid analgesics in the past three months among those who experience pain. Exposures included selected health conditions, history of falls, and hospitalizations.

Findings

Prevalence of pain (n = 9234) was 36.9% (95% CI: 32.6-41.1). Pain was reported more frequently by female participants, low-income individuals, and those with a previous diagnosis of arthritis, chronic back pain, depressive symptoms, history of falls, and hospitalizations. Prevalence of opioid use among those reporting pain (n = 3350) was 30% (95% CI: 23.1-38.0). Prevalence of opioid use was higher among female and single individuals. In adjusted models, arthritis, chronic back pain, and presence of depressive symptoms were associated with prescription opioid use.

Interpretation

Prescription opioid use was reported by a sizable portion of the older adults who suffer from pain in Brazil. In a context of growing consumption of prescription opioids, opioid misuse has the potential to increase in the future. Surveillance of prescription opioid use is critical to prevent their harmful consequences.

Funding

ELSI-Brazil was funded by the Brazilian Ministry of Health.

Self-Medication Profile of Adult Patients with Temporomandibular Disorders in Southeast Brazil

BACKGROUND

Patients with temporomandibular disorder (TMD) often have orofacial pain and may use medication without professional prescription. Self-medication and inappropriate drug intake may cause serious health problems. This cross-sectional study evaluated the self-medication profile of TMD patients, the most used medications and their effect, and the relation between self-medication and socioeconomic factors.

METHODS

A non-representative sample (n=358) consisted of consecutive adult patients seeking TMD treatment in specialized referral centers for orofacial pain of two universities in São Paulo city, Brazil. A standardized questionnaire was used to collect the study variables before the TMD treatment: self-medication history, TMD pain intensity, sex, age, ethnicity, marital status, schooling and socioeconomic levels. Data were analyzed by descriptive statistics, chi-square test, and logistic regression models at the 0.05 significance level.

RESULTS

Almost 60% of 358 TMD patients reported self-medication. Patients with severe TMD were 4.7 times more likely to self-medicate when compared to patients with low TMD intensity (O=5.7; 95% CI=2.4; 13.3; P=0.043), as well as female patients were 30% more likely to self-medicate compared to male patients (OR=2.3; 95% CI=1.1; 5.1; P<0.001). The other independent variables were not associated with self-medication. The frequencies of moderate and severe TMD in women were larger than in those in men (P<0.001). Analgesics and anti-inflammatory drugs were the most used medications. Regarding medication efficacy, 82% of patients reported some improvement after use, but 9% reported side-effect sickness.

CONCLUSION

Self-medication is common among TMD patients attending specialized clinics, and this inappropriate practice is more likely to occur in women and in patients with severe signs and symptoms of TMD.

Real world evidence of the use of metamizole (dipyrone) by the Brazilian population. A retrospective cohort with over 380,000 patients

Objective

To determine under which health conditions metamizole (dipyrone) is used as a single drug or as fixed-dose combination.

Methods

Two retrospective cohorts of Brazilian patients treated with metamizole between January 2015 and December 2017 were analyzed: a metamizole-based cohort (Cohort 1) and a symptoms-based cohort (Cohort 2). Anonymized patient data was obtained from Amil Clinical Data Warehouse. The number of patients with symptoms was described by age and sex.

Results

The sample size of the two cohorts consisted of 384,668 patients. In patients using metamizole (Cohort 1), the most common reason for medication was the treatment of some form of pain (81%), followed by fever (19%). Headache was the most common (19%) specified pain class, followed by sore throat (8%), muscular pain (6%), and abdominal pain (5%). In adult patients (n=276,279; 71.8%), metamizole was used as a monotherapy or associated with another drug, for any sort of pain, in over 88% of the patients. General pain was the main reason for metamizole use in children (61%).

Conclusion

Real world evidence to evaluate Brazilian patients’ therapeutic options is unusual and yet to be more explored using digital tools enabling better data registration. The present study confirmed that metamizole is widely used as a non-anti-inflammatory drug, and also showed the management of pain and fever as the most frequent indications in all age groups studied.

Registry in Clinical Trials Database: REBEC Database: 10507

Comparison between metamizole and triptans for migraine treatment: a systematic review and network meta-analysis

Objective The aim of this systematic review was to evaluate the efficacy of metamizole and triptans for the treatment of migraine. MethodsRandomized controlled trials including people who received metamizole or triptan by multiple routes of administration and at all doses as treatment compared to subjects who received another treatment or placebo were included in the systematic review. The primary outcomes were freedom from pain at 2 hours; pain relief at 2 hours; sustained headache response at 24 hours; sustained freedom from pain at 24 hours. The statistical analysis of all interventions of interest were based on random effect models compared through a network meta-analysis. Results 209 studies meeting the inclusion and exclusion criteria were analyzed. Of these, 130 had data that could be analyzed statistically. Only 3.0% provided enough information and were judged to have a low overall risk of bias for all categories evaluated; approximately 50% of the studies presented a low risk of selection bias. More than 75% of the studies presented a low risk of performance bias, and around 75% showed a low risk of detection and attrition bias. ConclusionThere is no evidence of a difference between dipyrone and any triptan for pain freedom after 2 hours of medication. Our study suggests that metamizole may be equally effective as triptans in acute migraine treatment.

Pathogenesis of COVID-19 described through the lens of an undersulfated and degraded epithelial and endothelial glycocalyx

The glycocalyx surrounds every eukaryotic cell and is a complex mesh of proteins and carbohydrates. It consists of proteoglycans with glycosaminoglycan side chains, which are highly sulfated under normal physiological conditions. The degree of sulfation and the position of the sulfate groups mainly determine biological function. The intact highly sulfated glycocalyx of the epithelium may repel severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) through electrostatic forces. However, if the glycocalyx is undersulfated and 3-O-sulfotransferase 3B (3OST-3B) is overexpressed, as is the case during chronic inflammatory conditions, SARS-CoV-2 entry may be facilitated by the glycocalyx. The degree of sulfation and position of the sulfate groups will also affect functions such as immune modulation, the inflammatory response, vascular permeability and tone, coagulation, mediation of sheer stress, and protection against oxidative stress. The rate-limiting factor to sulfation is the availability of inorganic sulfate. Various genetic and epigenetic factors will affect sulfur metabolism and inorganic sulfate availability, such as various dietary factors, and exposure to drugs, environmental toxins, and biotoxins, which will deplete inorganic sulfate. The role that undersulfation plays in the various comorbid conditions that predispose to coronavirus disease 2019 (COVID-19), is also considered. The undersulfated glycocalyx may not only increase susceptibility to SARS-CoV-2 infection, but would also result in a hyperinflammatory response, vascular permeability, and shedding of the glycocalyx components, giving rise to a procoagulant and antifibrinolytic state and eventual multiple organ failure. These symptoms relate to a diagnosis of systemic septic shock seen in almost all COVID-19 deaths. The focus of prevention and treatment protocols proposed is the preservation of epithelial and endothelial glycocalyx integrity.

Opioid use, regulation, and harms in Brazil: a comprehensive narrative overview of available data and indicators

BACKGROUND

Global opioid consumption increased multifold post-2000, disproportionately in high-income countries, with severe mortality/morbidity consequences. Latin America features comparatively low opioid availability; Brazil, the region's most populous country, makes an interesting case study concerning opioid use/harms. In this comprehensive overview, we aimed to identify and summarize medical and non-medical data and indicators of opioid availability and use, regulation/control, and harm outcomes in Brazil since 2000.

METHODS

We searched multiple scientific databases to identify relevant publications and conducted additional 'grey' literature searches to identify other pertinent information.

RESULTS

Despite some essential indicators, opioid-related data are limited for Brazil. Data indicate that population-level availability of prescription opioids represents only a small fraction of use in comparison to high-income countries. However, within Latin America, Brazil ranks mid-level for opioid consumption, indicating relatively moderate consumption compared to neighboring jurisdictions. Brazil has implemented restrictive regulations to opioid prescribing and is considered 'highly restricted' for opioid access. Codeine remains the major opioid analgesic utilized, but stronger opioids such as oxycodone are becoming more common. Professional knowledge regarding medical opioid use and effects appears limited. National surveys indicate increases in non-medical use of prescription opioids, albeit lower than observed in North America, while illicit opioids (e.g., heroin) are highly uncommon.

CONCLUSIONS

Overall population-level opioid availability and corresponding levels of opioid-related harms in Brazil remain substantially lower than rates reported for North America. However, the available surveillance and analytical data on opioid use, policy/practice, and harms in Brazil are limited and insufficient. Since existing and acute (e.g., pain-related) needs for improved opioid utilization and practice appear to be substantiated, improved indicators for and understanding of opioid use, practice, and harms in Brazil are required.

Over-the-counter analgesics during pregnancy: a comprehensive review of global prevalence and offspring safety

BACKGROUND

Analgesia during pregnancy is often necessary. Due to their widespread availability, many mothers opt to use over-the-counter (OTC) analgesics. Those analgesic compounds and their metabolites can readily cross the placenta and reach the developing foetus. Evidence for safety or associations with adverse health outcomes is conflicting, limiting definitive decision-making for healthcare professionals.

OBJECTIVE AND RATIONALE

This review provides a detailed and objective overview of research in this field. We consider the global prevalence of OTC analgesia during pregnancy, explain the current mechanistic understanding of how analgesic compounds cross the placenta and reach the foetus, and review current research on exposure associations with offspring health outcomes.

SEARCH METHODS

A comprehensive English language literature search was conducted using PubMed and Scopus databases. Different combinations of key search terms were used including 'over-the-counter/non-prescription analgesics', 'pregnancy', 'self-medication', 'paracetamol', 'acetaminophen', 'diclofenac', 'aspirin', 'ibuprofen', 'in utero exposure', 'placenta drug transport', 'placental transporters', 'placenta drug metabolism' and 'offspring outcomes'.

OUTCOMES

This article examines the evidence of foetal exposure to OTC analgesia, starting from different routes of exposure to evidence, or the lack thereof, linking maternal consumption to offspring ill health. There is a very high prevalence of maternal consumption of OTC analgesics globally, which is increasing sharply. The choice of analgesia selected by pregnant women differs across populations. Location was also observed to have an effect on prevalence of use, with more developed countries reporting the highest consumption rates. Some of the literature focuses on the association of in utero exposure at different pregnancy trimesters and the development of neurodevelopmental, cardiovascular, respiratory and reproductive defects. This is in contrast to other studies which report no associations.

WIDER IMPLICATIONS

The high prevalence and the challenges of reporting exact consumption rates make OTC analgesia during pregnancy a pressing reproductive health issue globally. Even though some healthcare policy-making authorities have declared the consumption of some OTC analgesics for most stages of pregnancy to be safe, such decisions are often based on partial review of literature. Our comprehensive review of current evidence highlights that important knowledge gaps still exist. Those areas require further research in order to provide pregnant mothers with clear guidance with regard to OTC analgesic use during pregnancy.

Evaluation of prescription pattern of analgesic use among ambulatory elderly in South-Western Nigeria

Background:

Inappropriate prescribing of analgesics has a global impact on the health of elderly patients and the society. Empirical evidence on the prescription of analgesics among elderly Nigerians is scarce.

Objectives:

The objective of the study was to evaluate the prescription pattern of analgesics and describe the co-prescribing of gastroprotective agents with non-steroidal anti-inflammatory drugs (NSAIDs) among elderly patients at the geriatric center, University College Hospital, Ibadan.

Methods:

A retrospective cross-sectional, hospital-based study was carried out among elderly patients (≥60 years) who were prescribed analgesics. Using a data extraction sheet, information on demographic characteristics, drug utilization pattern, and morbidities was obtained from patients’ case files via electronic health records.

Results:

A total of 337 patients case files were reviewed, the mean age was 72 ± 8.8 years, and 210 (62.3%) were females. There were a total of 2074 medications prescribed, with 733 (35.3%) being analgesics. Majority of the elderly patients (259, 76.9%) were on nonopioids, with 252 (74.8%) on NSAIDs. Paracetamol was the most commonly prescribed analgesics (181, 24.6%), followed by diclofenac/misoprostol (177, 24.1%), opioid analgesic prescribed was 88 (12.0%), with paracetamol/codeine 58 (65.9%), and tramadol 16 (18.2%) being the most prescribed opioid. A significant proportion of the hypertensive elderly patients (160, 78.8%; P < 0.036) were on NSAIDs. The oral route of administration (302, 89.6%) was the most common route of administration. Majority (310, 92%) of elderly patients taking NSAIDs had a co-prescription for gastroprotective agents.

Conclusions:

Majority of hypertensive patients were on NSAIDs. This calls for prompt awareness of rational analgesic use among the elderly to improve management and their survival.

Exploring the Impact of the Rational Antibiotic Use System on Hospital Performance: The Direct Effect and the Spillover Effect

Irrational antibiotic usage not only causes an increase in antibiotic-borne diseases, but also inflicts pain on patients, as a result of inappropriate treatment. In order to resolve the hazards caused by irrational antibiotic usage, a kind of e-health service, the Rational Antibiotic Use System (RAUS), has been incorporated into the hospital information system. The RAUS provides doctors and patients with the functions of antibiotic usage monitoring, antibiotic information consultation and antibiotic prescription support. Though existing literature has already proved the usefulness of the RAUS on monitoring doctors’ behavior, the effects on hospital performance from an organizational perspective has rarely been measured by empirical data. Therefore, our study has explored the effects of the RAUS on the performance of a large Chinese hospital, which has implemented the RAUS since March 2014. Through empirical research, we quantified the effects of the implementation of the RAUS on a hospital’s performance from both the direct effects on the “drug income” and the spillover effect on the “treatment income”. The results indicate a significant positive spillover effect on the treatment incomes of a hospital in its inpatient activities (seen as significant in the long term) and in its outpatient activities (seen as significant in both the short and long terms). In addition, this research provides certain theoretical and practical implications for the dilemma of e-health services application in irrational antibiotic usage.