Ph.D. Thesis Growing Trend of Drug Abuse and Misuse and Its Impact on Society: a Case Study of Hyderabad City

Ph.D. Thesis Growing Trend of Drug Abuse and Misuse and Its Impact on Society: A Case Study of Hyderabad City

THESIS IS SUBMITTED TO UNIVERSITY OF SINDH FOR FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY DEGREE IN PHARMACEUTICS (PHARMACY)

MUHAMMAD ALI Department of Pharmaceutics Faculty of Pharmacy

UNIVERSITY OF SINDH, JAMSHORO, PAKISTAN

2013

CERTIFICATE

I hereby certify that Mr. MUHAMMAD ALI S/O KHUDA BAKHSH GHOTO has carried out research on the topic “Growing trend of Drug Abuse and Misuse and its impact on society: A case study of Hyderabad city” under my supervision and his work is sufficient and distinct as per recognized standards. His dissertation is worthy of presentation to the university of Sindh for the award of degree of Doctor of Philosophy in Pharmaceutics.

Prof. Dr. Abdullah Dayo Supervisor & Dean, Department of Pharmaceutics, Faculty of pharmacy, University of Sindh Jamshoro, Sindh, Pakistan.

DEDICATIoN

To My Affectionate Supervisor, Beloved Parents Whose Prayers, Encouragements and Co-Operation Have Enabled Me to Achieve the Honour of the Highest State of Learning

Muhammad Ali

ACKNOWLEDGEMENT

I praise to the Almighty Allah (The Most Merciful, Gracious and The Most Compassionate), Who is the entire and only source of every knowledge, Who guides me in the obscurity and helps me out of difficulties, and Prophet Hazrat Mohammad Mustafa (Salallah-o-Alaihe Wasallim), whose teachings provide the spirit of learning the hidden and unconcealed facts of nature, for my spiritual guidance for me to carry this work. I am extremely grateful to Higher Education Commission (HEC) for their entire support and scholarship grant in this study. I also appreciate authorities of Higher education of Pakistan for their entire support and efforts to increase the manpower in the field of research in this country.

Muhammad Ali

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Abstract

Drug abuse is the consumption of drug apart from medical need or use, in unnecessary or in excessive quantities. Drug misuse is the use of drugs for the purpose or conditions for which they are not suitable choice or even if they are suitable choice but used in improper dosage. The menace of drug misuse and abuse is increasing globally day by day and Hyderabad being one of the largest cities of Pakistan is experiencing this practice widely. Psychoactive drugs, sedatives, hypnotics, antibiotics, multivitamins, laxatives, heavy tonics, steroids, antacids, cough syrups and analgesics etc, are commonly misused and abused in our society. Among these psychoactive agents and antibiotics are the most frequently misused and abused drugs. Psychoactive agents have great potential for physiological and psychological addiction; hence the users continuously use them to cope the situation of anxiety, insomnia, depression and pain. It has been observed that repeated use of such agents creates tolerance, which leads to frequent increase in dose of the drug. On other hand, misuse of antibiotics leads to microbial resistance ultimately leading to decreased efficiency of the drug in particular family or community. Self medication and over medication have become the norm. Self medication is risky and highly unsafe and at times dangerous too, it leads to misuse and abuse as well. Non-medically qualified people (Quacks / Store keepers) are not able to judge the correct use of medication or determine the dose, nor are they aware of the risks involved in drug misuse and abuse. It is because all the drugs which are available in market have great potential to be misused and abused. The initially observed causes of drug abuse and misuse are lack of patient’s awareness regarding side effects or complications of drugs, improper patients’ counseling, prescriber’s lust for heavy OPD (because of which incomplete message regarding proper usage of drug is transferred to patients), wrong prescription (generated by unqualified people), prescriptions error, drug advertisement, busy pharmacies, easy availability of controlled drugs, dispensing error, pharmacies or medical stores being run without professional person (without registered Pharmacist), Improper follow-up of patients, lack of concentration of drug regulating agencies and unethical promotions of pharmaceutical companies etc. Lack of patient counseling has a significant role in drug misuse and may result in drug abuse or addiction.

Prescription error is one the most important factor that leads to drug misuse and abuse. A prescribing error occurs as a result of a prescribing decision or during prescription writing process. Prescription writing skills / instructions should be according to the WHO guidelines which suggest giving the medicine to the patients in the proper manner by Pharmacist / dispenser / storing keeper. Many countries have adopted WHO guideline for the prescription in their health care system. The Pharmacist is the person professionally equipped with knowledge to understand all the drawbacks / complications of drug abuse and misuse and its harmful impacts on health of people. The objectives of this study are to explore the causes of drug misuse, abuse and their contributing factors in Hyderabad city. The survey study was conducted in different main targeted areas of Hyderabad city. A questionnaire and analysis sheets were designed with the study objectives. W.H.O parameters (World Health Organization Guidelines / Standards) for prescriptions writings , Drug information hand book (Lexi-comp) and BNF (British National formulary) were used for evaluation of proper dose of dosage form and drug-drug interaction. Ms-Office 2007 and Statistical tools such as Mean, Standard Deviation, Cumulative Frequencies, Relative Frequencies, Chi square test, Z test, ANOVA, Regression Analysis, and Graphical Representation of data have been applied through the Statistical package SPSS17.0.

Trend of sales at medical stores in Hyderabad city shows that sale with prescription is 41.6% and without prescription is 58.4%. It reflects easy availability of drugs on large scale without prescription whereas on other side 49.4% of patients/customers were even not asked about availability of doctors’ prescription by medical store keeper. Among the interviewed customers/patients male (62.4%) and female (37.6%) responded positively. It was observed that 29.1% patients/customers were between 31–45years ages. Maximum patients/customers without prescription (13.7%) were found in Pretabad, Hyderabad, on other hand maximum patients/customers with prescription (8.6%) were found in Saddar, Hyderabad, respectively. The available prescriptions (41.6%) were evaluated and categorized in four types. As Specialist prescriptions (56.4%), General practitioner prescriptions (19.8%), Hospital /Medical center prescriptions (15.7%) and prescriptions without name and

v address of doctor (8.1%); this includes non qualified persons/quacks as well. As the prescription error factor in drug misuse was considered the error was 30.6% in all prescriptions categories, whereas maximum errors were found in the prescriptions, which were without name and address of prescribers. Collectively 8.3% prescriptions were found very old and 11.8% were without date of generation of prescription. Trend of self medication is another factor of drug misuse identified on large scale in Hyderabad. According to data collected from patients/customers without prescription (58.4%), the decision of self medication, 55.8%, is influenced /suggested by self judgment, chemist, drug advertisement, friends, relatives, neighbors etc. and about 44.2% patients/customers were influenced by doctor. Majority of these customers/patients, 43.6%, were not clear regarding dose, frequency and duration of therapy. In 7.4% cases medicines were sold to < 15 years age children. Major therapeutic classes of drugs which are sold without prescription includes analgesic/painkiller (15.9%), sedative/hypnotics (12.1%), antibiotics (8.6%), antacid (9.2%), cough suppressant (5.3%), sexual vitality inducer (1%), psychoactive (9.2%) and others groups (38.6%). As age of patient is considered, it was observed that > 46 years age customers are involved mostly in drug misuse and abuse. Furthermore, 500 Patients/Respondents were interviewed in Out Patient’s Department (OPD) of a government hospital in Hyderabad to analyze the contribution of improper patient counseling factor in drug misuse and abuse. Out of 500 patients, 159 (31.8%) were not counseled by any health professional, whereas 341 (68.2%) were counseled by the prescriber, store keeper/dispenser or both. Out of 159 un- counseled patients, the highest number of patients 76 (47.7%) were unaware regarding duration of therapy. On the other hand, among 341(68%) counseled patients, 218 (63.92%) were counseled by both prescriber and storekeeper/dispenser, 65(19.06%) by prescriber only and 58(17.0%) by store keeper / dispenser only. The underlying reasons for improper counseling may be lack of pharmacist in hospital settings, heavy OPDs and busy pharmacies. Since the calculated value Z = 9.7061 falls in the critical region, so we reject the null hypothesis, it shows P1 ≠ P2, at 0.05 level of significance and concludes on the basis of data, that the proportion of both gender (male and female) are different with respect to the drug misuse and abuse. Additionally a total of 286 antibiotic containing prescriptions were randomly sampled from a government hospital. These prescriptions were categorized according to the antibiotic classes and errors were identified according to various

vi standards; W.H.O (World Health Organization) guidelines/standards for prescription writing. The extent of errors were calculated and the highest proportion of the prescriptions (89.86%, n=257) failed to demonstrate the patient’s weight and the least number of prescriptions (2.44%, n=07) contained the dosage form errors. The mean error per prescription was observed as 6.35 with S.D 3.138 and 95% confidence interval for µ is (5.98, 6.71). The major reasons were heavy patients’ influx, insufficient knowledge regarding prescription writing guidelines to prescribers and the lack of pharmacists. Continuous educational training programs regarding prescription writing skills, introduction of computerized prescription order entry system and by recognizing and appreciating the role of pharmacist in evaluating the prescriptions can substantially reduce these widespread errors. On other side 150 related peoples of health care systems (Doctors, Retailers/Store keepers and Pharmaceutical marketing personals) were interviewed to assess the role of these peoples in the eradications of drug abuse and misuse in our society. It was largely observed that there is lack of concentration, especially doctors and store keepers/retailers in the process of counseling with patients/customers regarding harmful effects of drug abuse and misuse on the health of patients/customers. Our results also found that majority of medical stores / pharmacies have no any criteria for dispensing the all types of medicines, which is contributing to easy availability of drugs and lack of concentration of drug regulating agencies at pharmacies/medical stores. This study will recommend the proposals for eradication of this social evil, which has been affecting the health of considerable portion of population in Hyderabad. The findings of this study will help Government to realize the importance of pharmacist in health care system and formulate the long-lasting strategy/policy to deal with problem of drug abuse and misuse and their contributing factors.

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Summary of Contents Certificate i Dedication ii Acknowledgements iii Abstract iv Contents viii List of Tables xii List of Figures xv Contents

TITLE

Growing Trend of Drug Abuse and Misuse and Its Impact on Society: A Case Study of Hyderabad City

Contents Chapter-1 Introduction ...... Error! Bookmark not defined. 1.1 Drug ...... Error! Bookmark not defined. 1.2 Medicine ...... Error! Bookmark not defined. 1.3 Abuse ...... Error! Bookmark not defined. 1.4 Misuse ...... Error! Bookmark not defined. 1.5 Drug Abuse ...... Error! Bookmark not defined. 1.6 Drug Misuse ...... Error! Bookmark not defined. 1.7 Drug dependence / addiction ...... Error! Bookmark not defined. 1.8 Manual of Drug law ...... Error! Bookmark not defined. 1.9 Prescription drugs ...... Error! Bookmark not defined. 1.10 Over the counter drug (OTC) ...... Error! Bookmark not defined. 1.11 Prescription and its parts ...... Error! Bookmark not defined. 1.12 Prescription and dispensation ...... Error! Bookmark not defined. A. Receiving ...... Error! Bookmark not defined. B. Reading and Checking ...... Error! Bookmark not defined. C. Dating and Numbering ...... Error! Bookmark not defined. D. Labeling ...... Error! Bookmark not defined.

E. Taking out and preparing the prescribed medication ...... Error! Bookmark not defined. F. Packaging ...... Error! Bookmark not defined. G. Rechecking ...... Error! Bookmark not defined. H. Delivering and Patient Counseling ...... Error! Bookmark not defined. I. Filling and Recording ...... Error! Bookmark not defined. J. Pricing the Prescription ...... Error! Bookmark not defined. 1.13 Errors ...... Error! Bookmark not defined. 1.14 Medication error ...... Error! Bookmark not defined. 1.14.1 Types of medication error ...... Error! Bookmark not defined. 1.15 Prescription error ...... Error! Bookmark not defined. 1.15.1 Prescription errors types ...... Error! Bookmark not defined. 1.15.2 Reasons of errors...... Error! Bookmark not defined. 1.16 Dispensing error ...... Error! Bookmark not defined. 1.17 Guidelines for good dispensing of prescription ...... Error! Bookmark not defined. 1.18 Parameters/Standards for good prescription writing...... Error! Bookmark not defined. 1.19 Self medication ...... Error! Bookmark not defined. 1.20 Psychoactive drugs ...... Error! Bookmark not defined. 1.21 Patient counseling ...... Error! Bookmark not defined. 1.22 Antibiotic misuse ...... Error! Bookmark not defined. 1.22.1 Antibiotic’s prescription errors ...... Error! Bookmark not defined. 1.23 Role of pharmacist ...... Error! Bookmark not defined. 1.24 Hyderabad city ...... Error! Bookmark not defined. 1.25 World Health Organization (WHO) ...... Error! Bookmark not defined. 1.26 W.H.O Guidelines to good prescribing ...... Error! Bookmark not defined. 1.27 British National Formulary (BNF) ...... Error! Bookmark not defined. 1.28 Lexi-Comp’s Drug Information Handbook ...... Error! Bookmark not defined. 1.29 Case study ...... Error! Bookmark not defined. 1.30 Statement of problems ...... Error! Bookmark not defined. 1.31 Aims and objectives of study ...... Error! Bookmark not defined. 1.32 Scope of study ...... Error! Bookmark not defined. 1.33 Ethical clearances ...... Error! Bookmark not defined. Chapter-2

Literature Review...... Error! Bookmark not defined. Chapter-3 Research Methodology ...... Error! Bookmark not defined. 3.1 Collections of data: ...... Error! Bookmark not defined. 3.2 Analysis of data: ...... Error! Bookmark not defined. 3.2.1 Analysis of 2000 samples...... Error! Bookmark not defined. 3.2.2 Analysis of 500 samples...... Error! Bookmark not defined. 3.2.3 Analysis of 286 samples...... Error! Bookmark not defined. 3.2.4 Analysis of 50 samples (Doctors) ...... Error! Bookmark not defined. 3.2.5 Analysis of 50 samples (Drug promoting individuals) ... Error! Bookmark not defined. 3.2.6 Analysis of 50 samples (Retailers) ...... Error! Bookmark not defined. Table (i): Analysis sheet 01 ...... Error! Bookmark not defined. Table (ii): Analysis sheet 02 ...... Error! Bookmark not defined. Table (iii): Analysis sheet 03 ...... Error! Bookmark not defined. Table (iv): Analysis sheet 04 ...... Error! Bookmark not defined. Chapter-4 Results, Statistical analysis and Discussion ...... Error! Bookmark not defined. 4.1 Randomly collected 2000 patients/customers ...... Error! Bookmark not defined. 4.2 With prescription (Samples 832) ...... Error! Bookmark not defined. 4.3 Prescription error ...... Error! Bookmark not defined. 4.4 Without prescription (Samples 1168) ...... Error! Bookmark not defined. 4.5 Misuse and Abuse and Error contributing factor (2000 samples) . Error! Bookmark not defined. 4.6 Patient counseling factor ...... Error! Bookmark not defined. 4.7 Prescription errors (All antibiotic containing prescriptions) ... Error! Bookmark not defined. 4.7.1 Distribution of antibiotic prescriptions according to specific drug classes ...... Error! Bookmark not defined. 4.7.2 Errors containing antibiotic prescriptions (Penicillin) .... Error! Bookmark not defined. 4.7.3 Errors containing antibiotic prescriptions (Cephalosporin) .. Error! Bookmark not defined. 4.7.4 Errors containing antibiotic prescriptions (Tetracycline)Error! Bookmark not defined. 4.7.5 Errors containing antibiotic prescriptions (Quinolone) .. Error! Bookmark not defined.

4.7.6 Errors containing antibiotic prescriptions (Macrolide) ... Error! Bookmark not defined. 4.7.7 Errors containing antibiotic prescriptions (Amino glycoside) ...... Error! Bookmark not defined. 4.7.8 Errors containing antibiotic prescriptions (Total prescriptions) ...... Error! Bookmark not defined. 4.7.9 Errors containing all antibiotic prescriptions ... Error! Bookmark not defined. 4.8 Role of Doctor, Field Manager / Medical representative and Retailer in the eradication of misuse and abuse of drugs ...... Error! Bookmark not defined. 4.9 Statistical testing / analysis ...... Error! Bookmark not defined. 4.9.1 Regression modal ...... Error! Bookmark not defined. 4.9.2 Testing hypothesis of proportion of gender with respect to drug misuse and abuse ...... Error! Bookmark not defined. 4.9.3 Analysis of 286 prescriptions and 95% confidence interval for µ ...... Error! Bookmark not defined. 4.9.4 Analysis of variance ...... Error! Bookmark not defined. 4.9.5 Chi-square tests ...... Error! Bookmark not defined. 4.10 Discussion ...... Error! Bookmark not defined. 4.11 Impact on society ...... Error! Bookmark not defined. Chapter-5 5.1 Conclusion ...... Error! Bookmark not defined. 5.2 Recommendations ...... Error! Bookmark not defined. References ...... 214

List of Tables

Table 1: Trend of sales of drug ‘with prescription and without prescription’ ...... Error! Bookmark not defined. Table 2: Sex of the customers / patients ...... Error! Bookmark not defined. Table 3: Number of male & female (customers/patients) with and without prescription ...... Error! Bookmark not defined. Table 4: Age of the customers/patients ...... Error! Bookmark not defined. Table 5: Age of the customers/patients with prescription ...... Error! Bookmark not defined. Table 6: Age of the customers/patients without prescription ...... Error! Bookmark not defined. Table 7: Area of customers/patients interviewed ...... Error! Bookmark not defined. Table 8: Area wise prescription and without prescription ...... Error! Bookmark not defined. Table 9: Trend of store keeper inquiry about prescription ...... Error! Bookmark not defined. Table 10: Customers’/Patients' prescription analyzed .. Error! Bookmark not defined. Table 11: Evaluation of prescription that how much it is old on the basis of issued date ...... Error! Bookmark not defined. Table 12: Distribution of prescription categories/types area wise ..... Error! Bookmark not defined. Table 13: Category/Type 01 prescriptions (469 samples) ...... Error! Bookmark not defined. Table 14: Category/Type 02 prescriptions (165 samples) ...... Error! Bookmark not defined. Table 15: Category / Type 03 prescriptions (131 samples) ...... Error! Bookmark not defined. Table 16: Category/Type 04 prescriptions (67 samples) ...... Error! Bookmark not defined. Table 17: Total prescription errors in all categories/types (832 samples) ...... Error! Bookmark not defined. Table 18: Area wise errors in all 04 type of prescription (832 samples) ...... Error! Bookmark not defined. Table 19: Age of customers/patients and errors in all 04 categories/types of prescriptions (832 samples) ...... Error! Bookmark not defined. Table 20: Age of the customers/patients ...... Error! Bookmark not defined. Table 21: Patients/Customers area wise ...... Error! Bookmark not defined. Table 22: Trend of purchased dosage form (1168 samples) ...... Error! Bookmark not defined. Table 23: The trend of nature (form) of dosage ...... Error! Bookmark not defined. Table 24: Self medication trend (1186 samples) ...... Error! Bookmark not defined. Table 25: Dose per time (1168 samples) ...... Error! Bookmark not defined. Table 26: Per day dose/frequency (without prescription) ...... Error! Bookmark not defined. Table 27: Duration of therapy (without prescription) ... Error! Bookmark not defined. Table 28: More than 01 standards/parameters together (without prescription) ..... Error! Bookmark not defined. Table 29: Trend of consultation time ...... Error! Bookmark not defined.

Table 30: Trend of medication record / previous drug history communication from patient to doctor ...... Error! Bookmark not defined. Table 31 Trend of follow-up of patients in our community ...... Error! Bookmark not defined. Table 32: Age wise misuse and abuse (without prescription, 1168 samples) ...... Error! Bookmark not defined. Table 33: Area wise misuse and abuse (without prescription, 1168 samples) ...... Error! Bookmark not defined. Table 34: Age wise misuse and abuse/prescription error (Total with and without prescriptions) ...... Error! Bookmark not defined. Table 35: Area wise misuse and abuse (Total with and without prescriptions) .... Error! Bookmark not defined. Table 36: Misuse and abuse and prescription error factor (with prescription v/s without prescriptions) ...... Error! Bookmark not defined. Table 37: Age wise (with prescription v/s without prescription) Error! Bookmark not defined. Table 38: Age wise prescription error (Contributing factor) ...... Error! Bookmark not defined. Table 39: Cost of medications (with and without prescription) .. Error! Bookmark not defined. Table 40: Socio-Demographic data of total interviewed persons...... Error! Bookmark not defined. Table 41: Age of counseled patients ...... Error! Bookmark not defined. Table 42: Age of un-counseled patients ...... Error! Bookmark not defined. Table 43 Education profile of total interviewed (500 samples) ... Error! Bookmark not defined. Table 44: if counseled, to whom they were counseled . Error! Bookmark not defined. Table 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient ...... Error! Bookmark not defined. Table 46: Trend of prescribed antibiotic in society ...... Error! Bookmark not defined. Table 47: No of errors containing antibiotic prescriptions (Penicillin) ...... Error! Bookmark not defined. Table 48: No of errors containing antibiotic prescriptions (Cephalosporin) ...... Error! Bookmark not defined. Table 49: No of errors containing antibiotic prescriptions (Tetracycline) ...... Error! Bookmark not defined. Table 50: No of errors containing antibiotic prescriptions (Quinolone) ...... Error! Bookmark not defined. Table 51: No of errors containing antibiotic prescriptions (Macrolide) ...... Error! Bookmark not defined. Table 52: No of errors containing antibiotic prescriptions (Amino glycoside) ..... Error! Bookmark not defined. Table 53: No of errors containing antibiotic prescriptions (Total prescriptions) .. Error! Bookmark not defined. Table 54: No of errors containing all antibiotic prescriptions ..... Error! Bookmark not defined. Table 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse...... Error! Bookmark not defined.

Table 56: Role of Medical Representative / Field Manager ...... Error! Bookmark not defined. Table 57: Sales promotions approaches of companies for Prescriptions generation ...... Error! Bookmark not defined. Table 58: Inspection of medical stores / pharmacies .... Error! Bookmark not defined. Table 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... Error! Bookmark not defined. Table 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy) ...... Error! Bookmark not defined. Table 61: Role of retailer / store keeper (Reasons of change of prescriptions) ..... Error! Bookmark not defined. Table 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy) ...... Error! Bookmark not defined. Table 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies) ...... Error! Bookmark not defined. Table 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies) ...... Error! Bookmark not defined. Table 65: Role of retailer / store keeper (Knowledge of medicines) . Error! Bookmark not defined. Table 66: Descriptive statistics; Number of parameter missed and consultation time given to patient ...... Error! Bookmark not defined. Table 67: SPSS output for correlation between number of parameter missed and Consultation time given to patient ...... Error! Bookmark not defined. Table 68: SPSS output for input of data for regression modal .... Error! Bookmark not defined. Table 69: SPSS output for modal summary of number of parameter missed and Consultation time given to patient ...... Error! Bookmark not defined. Table 70: SPSS output for significance of F (ANOVA) number of parameter missed and Consultation time given to patient ...... Error! Bookmark not defined. Table 71: SPSS output for explanatory and explained variable .. Error! Bookmark not defined. Table 72: SPSS output for C.I (95%) ...... Error! Bookmark not defined. Table 73: Residual Statistics (Number of parameter(s) missed) . Error! Bookmark not defined. Table 74: Descriptive measure on errors in antibiotic containing prescription .... Error! Bookmark not defined. Table 75: Standard deviation and mean of errors ...... Error! Bookmark not defined. Table 76: Case processing output of SPSS for validating and missing observation for C.I...... Error! Bookmark not defined. Table 77: 95% confidence interval for mean and other statistical tools for numbers of error ...... Error! Bookmark not defined. Table 78: SPSS output for ANOVA ...... Error! Bookmark not defined. Table 79: SPSS output for homogeneity of variance for numbers of errors ...... Error! Bookmark not defined. Table 80: SPSS output for ANOVA (numbers of errors in antibiotic containing prescription) ...... Error! Bookmark not defined. Table 81: Output of SPSS for role of doctors for improper usage of drugs and their complications especially drug misuse and abuse ...... Error! Bookmark not defined. Table 82: Chi-square test results for table 81 ...... Error! Bookmark not defined.

Table 83: Output of SPSS for role of Medical Representative / Field Manager ... Error! Bookmark not defined. Table 84: Chi-square test results for table 83 ...... Error! Bookmark not defined. Table 85: Output of SPSS for role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... Error! Bookmark not defined. Table 86: Chi-square test results for table 85 ...... Error! Bookmark not defined. Table 87: SPSS output for role of retailer / store keeper ...... Error! Bookmark not defined. Table 88: Chi-square test results for table 87 ...... Error! Bookmark not defined. Table 89: SPSS output for role of retailer / store keeper (Trend of re dispensing approaches at medical stores / Pharmacy) ...... Error! Bookmark not defined. Table 90: Chi-square test results for table no 89 ...... Error! Bookmark not defined. Table 91: SPSS output for role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / Pharmacies) ...... Error! Bookmark not defined. Table 92: Chi-square test results for table no 91 ...... Error! Bookmark not defined. Table 93: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies ...... Error! Bookmark not defined. Table 94: Chi-square test results for table no 93 ...... Error! Bookmark not defined. Table 95: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies) ...... Error! Bookmark not defined. Table 96: Chi-square test results for table no 95 ...... Error! Bookmark not defined. Table 97: SPSS output for trend of sales of drug ‘with prescription and without prescription’ ...... Error! Bookmark not defined. Table 98: Chi-square test results for table no 97 ...... Error! Bookmark not defined. Table 99: SPSS output for trend of store keeper inquiry about prescription ...... Error! Bookmark not defined. Table 100: Chi-square test results for table no 99 ...... Error! Bookmark not defined. Table 101: SPSS output for trend of counseling for proper medication usage at government hospital ...... Error! Bookmark not defined. Table 102 Chi-square test results for table no 101 ...... Error! Bookmark not defined.

List of Figures

Figure 1: Trend of sales of drug ‘with prescription and without prescription’ ...... Error! Bookmark not defined. Figure 2: Sex of the customers / patients ...... Error! Bookmark not defined. Figure 3: Number of male & female (customers/patients) with and without prescription ...... Error! Bookmark not defined. Figure 4: Age of the customers/patients ...... Error! Bookmark not defined. Figure 5: Age of the customers/patients with prescription ...... Error! Bookmark not defined. Figure 6: Age of the customers/patients without prescription ..... Error! Bookmark not defined. Figure 7: Area of the customers/patients ...... Error! Bookmark not defined. Figure 8: Area wise prescription and without prescription ...... Error! Bookmark not defined. Figure 9: Trend of store keeper inquiry about prescription ...... Error! Bookmark not defined. Figure 10; Customers’/Patients' prescription (Samples 832) analyzed ...... Error! Bookmark not defined. Figure 11: Evaluation of prescription that how much it is old on the basis of issued date ...... Error! Bookmark not defined. Figure 12: Distribution of prescription categories/types area wise ... Error! Bookmark not defined. Figure 13: Category/Type 01 prescription (469 samples) ...... Error! Bookmark not defined. Figure 14: Category/Type 02 prescriptions (165 samples) ...... Error! Bookmark not defined. Figure 15: Category/Type 03 prescriptions (131 samples) ...... Error! Bookmark not defined. Figure 16: Category/Type 04 prescriptions (67 samples) ...... Error! Bookmark not defined. Figure 17: Total prescription errors in all categories / types (832 samples) ...... Error! Bookmark not defined. Figure 18: Area wise errors in all 04 categories / type of prescription (832 samples) ...... Error! Bookmark not defined. Figure 19: Age of customers/patients and errors in all 04 categories/types of prescriptions (832 samples) ...... Error! Bookmark not defined. Figure 20: Age of the customers/patients ...... Error! Bookmark not defined. Figure 21: Patients/customers area wise ...... Error! Bookmark not defined. Figure 22: Trend of purchased dosage form (1168 without prescription customers/patients) ...... Error! Bookmark not defined. Figure 23: the trend of nature (form) of dosage ...... Error! Bookmark not defined. Figure 24: self medication trend (1186 samples) ...... Error! Bookmark not defined. Figure 25: Dose per time (1168 samples) ...... Error! Bookmark not defined. Figure 26: Per day frequency (without prescription) .... Error! Bookmark not defined. Figure 27: Duration of therapy (without prescription) . Error! Bookmark not defined. Figure 28 More than 01 parameters together (without prescription) . Error! Bookmark not defined. Figure 29: Trend of consultation time ...... Error! Bookmark not defined.

Figure 30: Trend of medication record / previous drug history communication from patient to doctor ...... Error! Bookmark not defined. Figure 31: Trend of follow-up of patients in our community ...... Error! Bookmark not defined. Figure 32: Age wise misuse and abuse (without prescription, 1168 samples) ...... Error! Bookmark not defined. Figure 33: Area wise misuse and abuse (without prescription, 1168 samples) ..... Error! Bookmark not defined. Figure 34: Age wise misuse and abuse (Total with and without prescriptions) .... Error! Bookmark not defined. Figure 35: Area wise misuse and abuse (Total with and without prescriptions) ... Error! Bookmark not defined. Figure 36 Misuse and abuse and error (with prescription v/s without prescriptions) ...... Error! Bookmark not defined. Figure 37: Age wise (with prescription v/s without prescription) ..... Error! Bookmark not defined. Figure 38: Age wise prescription error (Contributing factor) ...... Error! Bookmark not defined. Figure 39: Cost of medications (with and without prescription) . Error! Bookmark not defined. Figure 40: Socio-demographic data of total interviewed persons. .... Error! Bookmark not defined. Figure 41: Age of counseled patients ...... Error! Bookmark not defined. Figure 42: Age of un-counseled patients ...... Error! Bookmark not defined. Figure 43: Education profile of total interviewed ...... Error! Bookmark not defined. Figure 44: if counseled, to whom they were counseled Error! Bookmark not defined. Figure 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient ...... Error! Bookmark not defined. Figure 46: Trend of prescribed antibiotic in society ..... Error! Bookmark not defined. Figure 47: No of errors containing antibiotic prescriptions (Penicillin) ...... Error! Bookmark not defined. Figure 48: No of errors containing antibiotic prescriptions (Cephalosporin) ...... Error! Bookmark not defined. Figure 49: No of errors containing antibiotic prescriptions (Tetracycline) ...... Error! Bookmark not defined. Figure 50: No of errors containing antibiotic prescriptions (Quinolone) ...... Error! Bookmark not defined. Figure 51: No of errors containing antibiotic prescriptions (Macrolide) ...... Error! Bookmark not defined. Figure 52: No of errors containing antibiotic prescriptions (Amino glycoside) .... Error! Bookmark not defined. Figure 53: No of errors containing antibiotic prescriptions (Total prescriptions) . Error! Bookmark not defined. Figure 54: No of errors containing all antibiotic prescriptions .... Error! Bookmark not defined. Figure 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse...... Error! Bookmark not defined. Figure 56: Roles of Medical representative / Field Manager ...... Error! Bookmark not defined.

Figure 57: Sales promotions approaches of companies for Prescriptions generation ...... Error! Bookmark not defined. Figure 58: Inspection of medical stores / pharmacies ... Error! Bookmark not defined. Figure 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... Error! Bookmark not defined. Figure 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy) ...... Error! Bookmark not defined. Figure 61: Role of retailer / store keeper (Reasons of change of prescriptions) .... Error! Bookmark not defined. Figure 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy) ...... Error! Bookmark not defined. Figure 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies) ...... Error! Bookmark not defined. Figure 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies) ...... Error! Bookmark not defined. Figure 65: Role of retailer / store keeper (Knowledge of medicines) Error! Bookmark not defined. Figure 66: Probability, Probability plot for regression (Number of parameter missed and Consultation time given to patient) ...... Error! Bookmark not defined. Figure 67: Graph the regression equation and the data points. .... Error! Bookmark not defined. Figure 68: Errors in prescriptions ...... Error! Bookmark not defined.

CHAPTER # 01

Introduction 1.1 Drug

Drug is chemical substance which is used for the diagnosis, Prevention, Mitigation and Treatment of disease after heaving biological response1. A drug, is any substance that, when absorbed into the body of a living organism, alters 2 normal bodily functions . A drug is a chemical substances used in the treatment, cure, prevention or diagnosis of disease or used otherwise enhances physical or mental well being3. In United States, the Federal food, drug and cosmetic Act definition of drug includes. “Articles indented for use in diagnosis, cure, mitigation, treatment or prevention of disease in men or other animals. Articles (other than food) intended to affect the structure or any function of the body of man on other animal4.

1.2 Medicine

A medicine is a drug taken to cure or ameliorate any symptoms of an illness on medical condition or may be used as preventive medicine that has future benefit but 5 does not treat any existing or pre existing diseases or symptoms .

1.3 Abuse

The word abuse means to use wrongly, mistreatment, corrupt practices and insulting 6 language .

1.4 Misuse

6 The word misuse means to use improperly, treat badly and incorrect or improper use .

1.5 Drug Abuse

Drug abuse is the consumption of drug apart from medical need or use in unnecessary 7-8 quantities or in excessive quantity, or repeated use of drug in way without prescribed .

1.6 Drug Misuse

Drug misuse is the use of drug for purposes or conditions for which they are unsuited or even appropriate use but in improper dose, or inappropriate use of prescribed drug 7-8 or without prescribed or non medical purpose (Not for pleasure) .

1.7 Drug dependence / addiction

Drug dependence / addiction is the repeated use of psychoactive drug in order to avoid physical and psychological withdrawal effects. Drug abuse may lead to drug 7-8 dependence or addiction, anti social behavior and traffic accidents . The menace of drug misuse and abuse is increasing globally day by day and Hyderabad being one of the large cities of Pakistan is experiencing this practice widely. Psychoactive drugs, sedatives, hypnotics, antibiotics, multivitamins, laxatives, heavy tonics, steroids, antacids, cough syrups and analgesics etc, are commonly misused and abused in our society. Among these, psychoactive agents and antibiotics are the most frequently misused and abused drugs. Psychoactive agents have great potential for physiological and psychological addiction; hence the users continuously use them to coup the situation of anxiety, insomnia, depression and pain. It has been observed that repeated use of such agents creates tolerance, which leads to frequent increase in dose of the drug. On other hand, misuse of antibiotics leads to microbial resistance ultimately leading to decreased efficiency of the drug in particular family or community. Self medication and over medication have become the norm; self medication is risky and highly unsafe and at times dangerous too leading to misuse and abuse as well. Non-medically qualified people (Quacks / Store keepers) are not able to judge the correct use of medication or determine the dose, nor are they aware of the risks involved in drug misuse and abuse. It is because all the drugs which are available in market have great potential to be misused and abused. Pakistan comprises of majority of Quasi literate people who easily establish trust on here-say and find no hurdles in purchasing psychoactive agent or other drugs from medical shop. A growing trend is of drug misuse and abuse (non medical use) of prescription medicines also, such as narcotic analgesics or pain reliever, muscle relaxant and benzodiazepines and other routine medicines. Non medical use of prescription drug is defined as, medicine not suggested/ prescribed by physician but the individual uses

medicine only for the experience or feeling caused by medicine. Psychotherapeutic prescription medicines include tranquilizer, painkiller, sedative and stimulant. (Jane Carlisle PhD, www.utexas.edu/research/prescription_trendweb.pdf) Over the counter drug abuse / misuse was identified as an internationally recognized problem, like codeine based analgesics, cough suppressant medicines specially dextromethorphan, sedatives, antihistamines, decongestants, laxatives are associated with harms like psychological and physiological, drug addiction and complication from other medicines ie Ibuprofen causes gastric bleeding and related economical issues9. Drug abuse has become a serious problem in the many countries; the pattern of drug abuse globally differs from country to country, province to province and society to society10-11. Non-medical use / misuse and abuse of prescription drug and over the counter (OTC) drugs have become a public health issue throughout the world. On other side use of illegal substances e.g Methamphetamine, Heroin and Marijuana has declined over the past years while abuse of prescription and over the counter medicines has increased. According to the American annual tracking recent survey on “Partnership for a Drug free society”, that one in five adolescent stated having abused prescription drug, on other side one out of ten adults reported having abused OTC cough suppressant medicines. Further in California, teenager drug abuse of discussed products is either on same level or more than local national trend. In continuity to prescription drugs, seventeen percent of eleventh grade pupils reported painkiller prescription used at least single time in their life, on other side nineteen percent or one in four youngster people reported used or tried over the counter cold and cough suppressant medicines at least one time12-13. There are many medicines with anxiolytic, analgesic, sedative and stimulant properties having the potential to be misused and abused commonly. On other side these drugs have positive cure effects. The use of wrong medication is commonly defined on the basis of consumer characteristics like any non prescribed use like for the purpose of recreation, the incidence of clinically significant symptoms like meeting the diagnostic criteria from the abuse which may lead to dependence. In different cases where multiple standards are used to explore the misuse, there is often lack of separation among them, whereas studies that use more exact standards tend to eliminate definite

types of misuse from consideration in total. In adding, in some cases there are a number of possible ways that single operational criteria met and many of these may be connected with substantially different complications, risks and harms. There is availability of different classifications of medication used, misuse both within and between studies, it is presently difficult to understand the clinical meaning of existing findings or to find out the true magnitude of issues related with any specific form of misuse. In the present review study many of the problems and challenges for adequately defining prescription drug misuse will be overviewed14. The rational use of drugs, pharmaceutical care system and clinical related regulation are key parts of health care system. For example recently a baby passed away due to wrong medication in a city of Pakistan, and it is not a single death because of incorrect medication issues. Health system needs some more legal, principle restricted and professional manners in order to appropriate / correct planning for systems. The available legislations for clinical health, drug rules and health practices seriously require the notice / concentration of leadership, society and judiciary to make assurance of safety and quality of valued lives15.

1.8 Manual of Drug law

According to this law drug is a chemical substance which is prepared, preserved, soled and introduced for sale in the market either for external or internal utilization in the cure, prevention, diagnosis of any disease in human beings or animals and in accordance with such conditions as may be suggested16.

1.9 Prescription drugs

It can be defined as the dispensation of drug to public only with an order written or given by authorized (Physician) person. The list of medication as on availability on prescription is made by food and drug administration17.

1.10 Over the counter drug (OTC)

OTC drugs are those drugs which are effective and safe for the use by the community or public without authorized person’s prescription18. The prescription drug list provided by the united health care and affiliated companies in order to classify various therapeutic groups on the basis of patients need.

Prescription drug is list prepared to dispense medicines for outpatient and doesn’t include inpatients medication. Over the counter (OTC) medicine may be decided by the patient or consumer that an over the counter medication is the most appropriate treatment. According to United health care benefits design, OTC drugs are defined as medication that doesn’t require a prescription by federal or state law to be dispensed19. According to warning network of drug abuse, emergency room visit related to non medical use of OTC and prescription drug increased sixty percent between the years 2004 to 2007. Because OTC and prescription drugs are legal and can be used to lessen symptoms and treat diseases, our communities perceive them that these medications are less dangerous than illegal drugs. These drugs are safe if used as per direction. However the misuse of any medication whether the medication is taken in appropriate or incorrect or some other person used prescribed medicine, it may lead serious adverse health effects20.

1.11 Prescription and its parts

It is the order generated by a qualified medical practitioner, for the dispensing and administration of a medicine in order to confirm dosage and therapeutic schedule for the proper treatment21. Prescription is a document written by a registered prescriber (e.g. doctor) to a qualified person (e.g. Pharmacist) to dispense either a therapy or medication device to a particular patient for a detailed time period. Subsequently, prescription is an order for medication either hand written or direct face to face communication or by telephonic or other means of communication to a qualified pharmacist by a authorized person (doctor, dentist, veterinarian or other specialized practitioner)22-23. A Prescription is a specific assigned medicine with correct dosage to be administered to a patient at a right time24. A word prescription can be decomposed into “Pre” and “Script” and literally means to write before a drug can be prepared, this is often called scripts. It is a officially permitted document in order to follow all prescription parameters that are written accurately and clearly. It contains all the directions directed by the doctor for the pharmacist and any mistake at this stage can lead error in the whole process of dispensation25-26.

Prescription is of 2 types i.e. A Magisterial prescription is for an on official drug. Whereas the other type of prescription describes all the directions given the pharmacist to dispense the particular medicine27. A prescription includes complete doctor’s information, patient’s information and drug information including i.e. date, superscription, inscription, subscription, transcription, 28 signature and identity of prescriber containing legal registration number .

1.12 Prescription and dispensation

Among the other duties of pharmacist, correct interpretation is also a key responsibility of the pharmacist so as to improve credibility among doctor and patient. Remington book of pharmaceutical practices describes the good dispensation steps as follows. A. Receiving B. Reading and Checking C. Dating and Numbering D. Labeling E. Taking out and preparing the prescribed medicine F. Packaging G. Rechecking H. Delivering and Patient Counseling I. Recording and filing J. Pricing the prescription

A. Receiving It is the initial stages at which a prescription is received from the patient and no any un authorize person have any legal right to receive the prescription except Pharmacist.

B. Reading and Checking This is a second step at which the received prescription is completely viewed and read by the pharmacist in order to check the directions given by the doctor at the same time it is the key responsibility of pharmacist to check the drug_drug interaction, adverse drug reaction and other drug related problems so that the patient should be treated properly. However, there are few official abbreviations of Latin language that must be viewed and followed in the prescription writing. Errors in the abbreviations can lead to

the complication in the dispensing and interpretation process which may lead to dispensation error which is contributing factor to drug misuse and abuse as well. The detailed list of abbreviations is described in table** given below.

Table: ** Commonly used abbreviations in healthcare systems 28 The Pharmaceutical book of Remington “the science and practice of pharmacy” . Abbr: Meaning Abbr: Meaning Aa Of each Elix Elixir Abd Abdomen EtOH Ethanol Ac Before meal Ft Make, let it be made Ad To, up to G or gm Gram a.d. Right ear GERD Gastro esophageal reflux disease ad lib At pleasure, freely Gl Gastrointestinal AM Morning GU Genitourinary Amp Ampul of medication Gr Grain Aq Water gtt A drop a.s. left ear HA Headache ASA Aspirin HBP High blood pressure ATC Around the clock HCTZ Hydrochlorothiazide Au each ear HR Heart rate BCP Birth control pill HRT Hormone replacement therapy Bid Twice a day Hs At bed time BM Bowel movement HTN Hypertension BP Blood pressure Inj An injection BPH Benign prostatic hypertrophy IV Intravenous injection BS Blood sugar IM Intramuscular injection BSA Body surface area ID Intradermal injection C With IU International units Ca Calcium JRA Juvenile rheumatoid arthritis CAD Coronary artery disease KCL Potassium chloride Caps Capsule Kg Kilogram Cc Cubic centimeter(milliliter) L Liter CHF Congestive heart failure Mcg Microgram COPD Chronic obstructive pulmonary disease MD Doctor of medicine CP Chest pain mEq Milliequivalent CRNP Certified registered nurse practitioner Mg Milligram Dil Dilute mg/kg milligrams/ kilogram Dtd Let such doses be given mg/m2 Milligram/square meter DC Discontinue medication mL milliliter DDS Doctor of dental surgery mOsmol Milliosmole DMD Doctor of medical dentistry M or min Minimum Disp Dispense MOM Milk of Magnesia Div Divide MS Morphine sulfate DJD Degenerative joint disease MTX Methotrexate DM Diabetes mellitus MVI Multivitamin DO Doctor of osteopathy NS Normal saline DW Distilled water NTG Nitroglycerin Dx Diagnosis OA Osteoarthritis OCD Obsessive compulsive disorder Tab Tablet OJ Orange juice TB Tuberculosis O2 Oxygen TCN Tetracycline Ou Each eye TED Thrombo embolic disease Od Right eye SOB Shortness of breath Os Left eye Sol Solution

Abbr: Meaning Abbr: Meaning P Pulse SQ Subcutaneous injection Pc After eating Sq m,m2 Square meter PEFR Peak expiratory flow rate Stat Immediately Pm Evening Supp Suppository Po By mouth Susp Suspension Postop After surgery Sx Symptom Pr Rectally Syr Syrup Prn When necessary T Temperature Pulv A powder TIA Transient ischemic attack PVCs Premature ventricular contractions Tid Three times aday PVD Peripheral vascular disease Tiw Three times a week Q Every Tbsp Tablespoon Qd Every day TMP-SMX Trimethoprim-sulfamethoxazole Qid Four times daily Tsp Teaspoon Qod Every other day Top (use) topically Qs As much as is sufficient Tx Treatment qs ad A sufficient quantity to (prepare) U Unit Qh Every hour UA Uric acid,urinalysis RA Rheumatoid arthritis UC Ulcerative colitis RN Registered nurse Ud As directed Rect Use rectally Ung Ointment S Without URI Upper respiratory infection Ss One-half ut dict as directed SC Subcutaneous injection UTI Urinary Tract Infection Sig Write on label WA While awake SL Sublingual Wk Week SLE Systemic lupus erythematosus

C. Dating and Numbering The date on the prescription plays an important role in order to persuade the patient compliance. On the other hand the numbering over the prescription is a supporting factor for the dispensing process and shows a particular identity which is assigned to a particular patient.

D. Labeling Labeling is employed to have an elegant view to the prescription which contains information of prescriber, hospital or pharmacy containing address, contact details of either doctor or patient or in order to high light the important aspects of the medication like date of dispensing, strength, and other precautionary indications etc.

E. Taking out and preparing the prescribed medication It is the following step after reading and checking; at this stage the pharmacist after viewing the written medication on the prescription decides the procedure of dispensing or compounding. The pharmacist takes out all the required material from the particular location. This technique is useful to check the ingredients at label in order to reduce the risk.

F. Packaging It is a next step after taking out the prescribed medication at which the dispensing pharmacist decide the packaging components based on method, quantity and type of medication being dispensed.

G. Rechecking This is a most important step as it minimizes the dispensing error at pharmacy. It is the duty of the pharmacist to again check all the packed material according to the label before handing over it to the patient.

H. Delivering and Patient Counseling The pharmacist should personally deliver the prescription medication to patient and give the desired information about specific instructions, precautions and warning for safe and effective use of prescribed drug.

I. Filling and Recording It is very important to keep a complete record and to maintain it on computer and manually so as to be reviewed if necessary.

J. Pricing the Prescription At the last step the price is fixed as per legal, hospital and pharmacy policies according to profit and cost of input inventory (Steven A scott 2005) 28.

1.13 Errors

Error (Latin= errare, wander) means something is incorrect or wrong, mistake29. It is the deviation from accuracy or correctness30, or something deviates from standard, truth and right31.

1.14 Medication error

A medication error is defined as a dose of medication that deviate from the physician’s order as written in the patient file or from standard hospital policy and procedure. A wrong dose that is detected and corrected before taking is not a medication error.

1.14.1 Types of medication error 1. Omission error is the failure to administer an ordered dose except the dose that patient refuse to take and the dose not administered because of known contraindications. 2. Unauthorized drug error is the administration of medication to the patients that is not authorized for the patients e.g. a dose given to the wrong patient, duplicate doses, administration of an un ordered drug, and a dose given outside a stated set of clinical parameters. 3. Wrong dose error is the wrong number of performed units (e.g. tablets) or any dose above or below the ordered dose by a predetermined amount (e.g. 20%) 4. Wrong route error is the error of administration of drug by a route other than that ordered. Also include the doses given via the correct route at the wrong site. 5. Wrong rate error is the administration of drug at the wrong rate. 6. Wrong dosage form error is the administration of drug by the correct route but in different dosage form than that specified, e.g. use of ophthalmic ointment instead of solution, purpose full alteration (crushing of tablets) or substitution of liquid for tablets. 7. Wrong time error is the taking of medication other than specified time 8. Wrong preparation of dose include incorrect dilution of reconstitution, not shaking a suspension , using expired drug, not keeping a light sensitive drug protect from light and mixing drug that are physically / chemically incompatible. 9. Incorrect administration techniques e.g. are the incorrect administration of ophthalmic ointments, Above all the medications error issue leads to misuse and abuse of drugs, so individual will face lot of complication, side effects adverse effects. It is the event which may lead to improper usage of medication or supposed to give and hazardous effect on the patient even under the supervision of patient or any of the health professionals i.e. Doctor, Pharmacist, Nurse32.

World health organization have discussed these errors as any mistake by a responsible health care person at any stage in the process of health care system. Generally, the medication error is the deviation from the Prescribers’ medical order as specified in the patients’ file33-34.

1.15 Prescription error

It is a resultant component which is due to either error in prescription writing or improper drug selection unintentionally, leads to in effective treatment and enhances the risk factor. This is also described by the panel comprised of 30 experts that prescription error is of two types which is discussed below35. Prescription error flow chart

Prescription Error

Error in Error in

Decision Making Prescription writing

Inappropriate Pharmaceutical Prescription Issues

Error due to failure to Transcription Communicate Errors Essential Information

Error at the time of taking decision may result inappropriate prescription like, Contraindicated due to existing clinical condition. Allergy to prescribed medicines. All type of drug-drug interaction. Inappropriate dose for patient’s renal function. Under dose or over dose. long-term drug use even during ADRs. Wrong drugs. Or other pharmaceutical compatibility issues. Error in prescription writing due to prescriber fails to write basic information. Incorrect drug dose and route of administration. Poor writing. Improper abbreviations vague order. Missing drug administration route. In appropriate duration and intervention of drug. 35 Missing of doctor’s signature .

1.15.1 Prescription errors types There are two most common type of prescription error occur when prescriber failed to communicate proper information regarding receiving of right drugs to right patient at right time, this practice my lead to misuse and abuse of drugs. Omission: It is the error in prescription which is incompletely written by doctor or prescriber. It may also be called as error of planning. Commission: It is the error in prescription in which the prescription is wrongly written by the doctor or prescriber. It is also known as error of execution36.

1.15.2 Reasons of errors The root cause causes of errors (prescription, medication, dispensing) according to USP are: a) Lack of knowledge of prescriber, nurses, pharmacists and dispensers. b) Poor performance of responsible persons i.e. pharmacist as he fails to understand the doctor’s instructions and guidelines given in the prescription.

c) If the pharmacist do not understand the procedure of drug distribution system so ultimately he will not follow the standard operating procedures d) Improper patient counseling by the health professionals e) Poor hand writing f) Lack of communication and feedback between physician – patient, in order to monitor drug therapy and feedback. g) Failed Communication Hand Written and Oral Communication. h) Drug with similar names i) Missing or misplaced zero and decimal point. j) Use of non-standard abbreviation k) Poor drug distribution practices l) Asses to drugs by non-pharmacy personnel m) Work place environment problem that lead to increased job stress. n) Dose miscalculation. o) Lack or patient information p) Lack of patient understanding of their therapy37-38.

1.16 Dispensing error

Any errors reported or detected after the dispensation of medicines and consumer left the pharmacy, or any deviation or inconsistency from the doctor order / prescription such as wrong drug, wrong dosage form, wrong dose, incorrect quantity, lacking of labels, and improper direction for medicine use and others including storage issues earlier to use39-40. Dispensation process of medication is core part of Pharmaceutical care system and about nine hundred millions medications are dispensed every year by hospital and communities pharmacy across in Wales and United Kingdom. Errors can occur at any step during the medication dispensing process. Estimated about 134341 dispensation process errors arise in community pharmacies of United Kingdom41. The occurrence of dispensing error mostly recognized by hospital and community pharmacies e.g. Wrong medicines, strength of dosage form, dosage form, incorrect quantity or labeled medication with wrong directions etc are the common dispensation process errors. Key contributing factors are resemblances of drugs, shortage of staffs

or technicians and computer facilities, heavy work load, interruptions, distraction or others are basic/ route causes to increase the incidence of dispensation process42.

1.17 Guidelines for good dispensing of prescription

These guidelines have been developed by the Pharmacy Board of Australia (the board) under section 39 of the National Law. The guideline provides guidance to those registered in the profession in relation to a matter of professional practice, and many countries have adopted these guidelines in their local legislation43. Step No 01. Dispensing Safety, Precaution of Prescriptions A pharmacist must take reasonable steps to ensure that the dispensing of a medicine in accordance with a prescription or order is consistent with the safety of the person named in that prescription or order. During dispensing of prescription The pharmacist must ensure that the medications are safe, adequate or appropriate for the patients and same time he must check all the basic requirement or parameters of prescriptions and confirms doctor’s requirement, if any lacking or doubt is found, the doctor must be contacted. And he principally checks the per time dose, frequency, route administration, duration of treatment, present or missing other medicines, patient profile and other drug related issue like drug-drug interaction to be taken into account43. Step No 02. Dispensing multiple repeat prescriptions at one time The simultaneous supply of multiple quantities of a particular medicine (i.e. the supply of multiple repeats at once) may not be in accordance with the prescriber’s intention and is contrary to good pharmaceutical practice. The supply of different quantities of particular medications at a single time dispensing or supply of different quantities of medication to a patient so dispensing of different quantities of any prescription must only occur at the detailed direction of the doctor on each time. Unless special situation occurs to the satisfaction of the pharmacist and as adequate notation is made to that effect on the prescription and the dispensation record43. Step No 03. Facsimile and scanned prescriptions A pharmacist may dispense a prescription transmitted by facsimile or scanned copy in accordance with the guidelines.

The Pharmacist must take reasonable step to satisfy that the prescription is according to basic requirement of area; state legislation may dispense a prescription transmitted by copy of Scand through receiving of advance original prescription. If in the case poison, the original prescription must still b obtained and retained in accordance with the legislation of poison43. Step No 04. Internet, mail-order dispensing and other indirect supply of medicines The Board views the indirect supply of medicines, such as internet and mail-order dispensing, as less than the optimal way of delivering a pharmacy service because communication may be compromised. The Board recognizes, however, that there are circumstances where these forms of communication are necessary in, or appropriate to, the patient’s circumstances (e.g. in remote areas). The Pharmacist must supply medication as per local legislation and under the SOP practice and adopted quality system43. Step No 05. Extemporaneous dispensing (compounding) The Board recognizes that pharmacists are required to compound and dispense medicines extemporaneously. An extemporaneous preparation should be used only in circumstances where a commercial product is unavailable or unsuitable. The Pharmacist is bound to ensure that in the unavailability of any formulation printed in standard references, there must be good pharmaceutical and clinical evidence to support the safety, quality, efficacy and rational use of every extemporaneous formulation. Proof data is best obtained from journals (Peer reviewed) rather than only based on documents and impression43. Step No 06. Incident records Dispensing errors, significant other errors, omissions, incidents, or other noncompliance, including complaints of a noncommercial nature arising both within and external to the pharmacy, may be the subject of investigation. Pharmacists should therefore follow a risk management procedure, including appropriate record keeping. The record to show when the incident was recorded, when it occurred, who was involved (Both actual and alleged), the nature of the incident or complaint, what action were taken and any conclusion, If contact was made with third party , such as government department prescriber, lawyer of professional indemnity insurance company , detail of conversation should be recorded.

Regardless of how serious the incident may appear, comprehensive detailed records need to be kept. The record should be kept for three years43. Step No 07. Labeling of dispensed medicines Pharmacists are to label dispensed medicines in accordance with any statutory provisions and these guidelines with a view to: 1. Maximizing the benefits of the therapy 2. Improving the patient’s understanding of the treatment 3. Enhancing compliance 4. Minimizing adverse effects. Relevant legislation in force in the jurisdiction in which the pharmacist is practicing should be followed43. 7.1 Label The placement of dispensing label on the products largely determined by the design of the medicine package and the manufacturer’s label, the dispensing label is to be firmly attached to the immediate container (including each component of multiple therapy pack. The dispensing labels must be clearly and legibly printed in understandable 43 language . 7.2 Label contents These labels include brand and generic name of the medication and total information included dose frequency, direction, storage parameters, issued date, expiry and others. 7.3 Ancillary Label These labels are compulsory and these are listed in local legislation for pharmaceutical formulary43. Step No 08. Counseling patients about prescribed medicines Patients have the right to expect that the pharmacist will counsel them privately about their medicines, but the patient reserves the right not to be counseled. The pharmacist should make every effort to counsel, or to offer to counsel the patient whenever a medicine is supplied. Patient counseling is the final checking process to ensure the correct medicine is supplied to the correct patient. Lack of counseling can be a significant contributor in dispensing errors and their detection. In this regard, the Board endorses the current patient counseling guidelines produced by PSA and The SHPA, including the use of ‘Consumer Medicines Information’ (CMI) leaflets43.

The pharmacist is bound to council the patient regarding rational use of medicines, because different dosage form have different directions i.e. long term therapy , short term therapy, changes of dose or other parameters included. Irrational use of drug may contribute drug misuse and abuse. Step No 09. Privacy and confidentiality Commonwealth, State and Territory privacy laws set out the privacy principles applicable to health providers. Pharmacists should ensure that all pharmacy services are provided in a manner that respects the patient’s privacy requirements, and is in accordance with relevant professional and quality assurance standards. Information of patients that a pharmacist se to obtained in professional practices is must b confidentially; pharmacist may be exposed information with permission of person, authorized person, court order and as the best interest of patients43 Step No 10. Dispensing errors and near misses All reasonable steps need to be taken to minimize the occurrence of errors. Good pharmaceutical practices indicate that there must be scientific or systemic approach to deal or counter act the dispensing errors43. Step No 11. Pharmacists’ workloads Pharmacists should ensure that the individual workloads under which they operate are at reasonable and manageable levels to ensure the safety of the patient, provide an appropriate pharmaceutical service in an accurate, professional and timely manner and cope with fluctuations in workflow. Patients’ unrealistic expectations in relation to time taken to dispense the prescription, or the need to meet imposed maximum prescription waiting times are considered not conducive to the provision of such a service. Pharmacy owners and managers are to have in place suitable quality-assurance systems and procedures for the management of pharmacist workload. The board recommended that if dispensing orders are in the range of 150 – 200 per day with the help of an assistant, if work load exceeds more than 200, the owner must hire other pharmacist43. Step No 12. Dispensary assistants/dispensary technicians and hospital pharmacy technicians Pharmacists may be assisted in the dispensing of medicines in the dispensing area of a pharmacy business or pharmacy department, in accordance with the guidelines, by

suitably trained persons. The descriptions, ‘dispensary assistant’, ‘dispensary technician’ or ‘hospital pharmacy technician’ do not apply to a pharmacist, a provisionally registered intern pharmacist or a registered pharmacy student. For the purposes of these guidelines, ‘dispensary assistant’ and ‘dispensary technician’ have the same meaning. In different industrial relations circumstances, both terms are used43. The pharmacist is like owner of pharmacy business or department and he is responsible to ensure that they have no requirement of dispensing assistant or dispensary technician. Step No 13. Return of unwanted medicines Pharmacy owners or managers are encouraged to arrange and to accept for safe disposal of unwanted medicines from the public through their pharmacy’s participation in available programs, such as the Return of Unwanted Medicines (RUM) project. When pharmacist collects unwanted return medications from patients or others or unwanted are to be placed in a suitable interim container before being transfer to pharmacy for disposal43.

1.18 Parameters/Standards for good prescription writing.

All prescriptions must include / contain the following information: 1 Prescriber Name, with contact detail (perhaps incorporated as header/footer of prescription) 2 Date of prescription; 3 Patient Name and/or registration number (R/N),Date of Birth and/or Age, especially for children under 12 yrs and elderly over 75 yrs; 4 Approved medicine name (avoid abbreviations, prefer generic name) 5 Dosage strength (with appropriate units) 6 Route of administration or dosage form e.g. tablet; 7 Frequency of administration or dosing interval e.g. three times a day or every 6 hours; 8 Duration of therapy or duration of supply 25 9 Signature and initials of prescriber .

1.19 Self medication

Self medication is defined as an individual’s selection and use of medicines as self care just cure of self diagnosed disease and symptoms44. Self medication is recommended by W.H.O for rapid and effective relief of sign and symptoms of minor disease without professional medical consultation in order to reduce heavy load on health care system, most especially in short-staffed ,difficult to reach backward, rural and remote areas45. Spanish study showed that self medication is more common among females, individual who live in big cities and who reside alone. Further among individuals with report of severe disorder, the occurrence of self medication was high with highly educated individuals46. The trend of self medication has increased with non prescription drug (OTC) in recent years; these drugs are easily available at retails and pharmacy outlets. In the parallel, many products have deregulate for purchasing without a prescription47.The deregulations process have been champion by the pharmaceutical companies, the government policy maker and support in the light of patient wishes to have a greater role in their cure options48. There are many advantages have with self medication for health support system, it may support for utilization of clinical expertise of Pharmacist, increase accesses to medicines which may contribute to minimize prescription medicines cost associated with publicly sponsored health program49. Increasing easy availability of non prescriptions medicine may support to patient in order to believe that the medication for all therapies of diseases. The use of such type products may overcome or delay the diagnosis of serious diseases4. Further the possibility of high misuse and abuse of such products50-51.

1.20 Psychoactive drugs

Psychoactive drugs are defined that the medication which will affect people/individual psychology. They are mostly supportive agents for the treatment of anxiety, depression, pain, insomnia and other use. Majority of society feels unhappy/ depressed at different times; however when it prolongs and starts interfering routine life in that cases psychoactive drugs may be used. Anxiety may be defined that constant nervousness, panic or tension caused by psychological and stresses. They often known as minor

tranquilizer are used to support relaxation. On other hand insomnia have many route causes including depression and anxiety, if causes are known can be cure easily and sleeping pattern usually come back to normal. While insomnia is constant, in that cases sleeping medication may be useful/appropriate. Analgesics painkillers sexually vitality inducer ,tranquilizer , sedative , hypnotics heavy tonic, antacid , antibiotic , multivitamin, cough suppressant , psychoactive or other drugs are available in our market / society may be possible to be misused and abused. Now a day the prescription drug for an anxiety has increased significantly. The person with the issue of anxiety disorder is at risk due to non medical use of these drugs. But the information about whether the risk issue is high among the individuals/ patients with a prescription for such medicines are lacking, while anxiety medicines have clinical effectiveness, need highly clinical consideration must be given to the potential for their use, abuse addiction among the persons who are particularly on risk52.

1.21 Patient counseling

Patient Communication / counseling skills are playing very important role in health care system for doctors, pharmacists, patients or other health related peoples, for rational drug use and minimize the health related issues. Lack of communication / counseling may lead negative consequences or impact on the individual health and society. All the health related peoples must realize the importance of patient counseling in order minimize the drug misuse and abuse of prescription and non prescription drugs. On other hand the pharmacist (community) can play an important role in the process of patient counseling, an d must be able to communicate proper medication information in terms of rational use of drugs i.e. per time dose, per day frequency, administration, duration, storage, side effects, drug and food related interaction53. throughout pharmacist role, he gained a direct dealing or communicating with patients, this role generate best opinion and decision or view for both pharmacist or patients. These views and opinions may lead to improve the current services and expose need to have new services and increase the expectation and proper communication between two sides54.

Patient counseling is the provision of information to patients regarding proper use of medicines, medical devices and advice for their disease conditions. It is considered as the most important factor in designing and providing pharmaceutical care plan55-56. Patient counseling is the communication between health professionals and patients or their representatives either orally or in written regarding conveys of meaningful information of prescribed medications i.e. dose, frequency, duration, side effects, storage conditions and advice on diet plan and life style modifications57-58. Pharmacists, doctors and other health care professionals are key responsible persons to convey message regarding proper use of medication to the patients in health care system. It is their responsibility to possess a complete knowledge and communication 59-60 skills for patient counseling, and will be helpful to ensure the rational use of drugs . Many guidelines have been printed in order to highlight key points of effective counseling to be covered during communication with the patients. The Omnibus Budget Reconciliation Act (OBRA) 1990 guidelines emphasize that the pharmacist should discuss minimum key points i.e. name of dosage form, route of administration, per time dose, per day frequency, duration of treatment, direction and precautions of dosage form, adverse complications, side effects, contraindications, treatment monitoring, proper storage parameters, refill instructions for prescription and other necessary information, during counseling of the patient60. The prescribers should also keep in mind that it is their duty to help patients to obtain desired therapeutic outcomes and make it possible to improve the patient’s health by rationalizing the use of medications. Further, the relations and trust of patients with the health professionals can be improved by effective communication skills. Lack of patient counseling has a significant role in drug misuse, and may result in drug abuse or addiction in a society. Drug misuse is the use of drug for the purpose or conditions for which they are unsuited or even in appropriate use but in improper dosage. Drug abuse is the consumption of drug apart from medical need or use in unnecessary and/or in excessive quantity10. According to National Institute on Drug Abuse drugs such as depressants, opioids and morphine derivatives, and stimulants are commonly abused prescription drugs. Pain reliever drugs such as opioids and morphine derivatives were most commonly abused 61.

1.22 Antibiotic misuse

All the Antibiotics are considered as medication which is only sold on the availability of prescription. Although the maximum percentages of antibiotics worldwide are used without prescription in the communities, further use of inappropriate antibiotics is major health issue in the communities62. Antibiotics are most common sold drugs class in the many developed countries63. The misuse or irrational use of antibiotics s not only the appearance of bacterial resistant strains but it may lead issue of economical burden and adverse reactions on health care systems64. The some contributing factors in irrational use of drugs are economical, health policies, lack of doctors’ concentration about prolong resistance and outcome verses treating present symptoms, pharmaceutical marketing and important issue that is the sale of antibiotics without prescription in some countries65-66. Exception of narcotic based painkiller and heavy tranquilizers, patient or people can by any type medicine including antibiotics, without prescription67. Irrational use of antibiotics is contributing major route cause for the increase of antibiotics resistances. There are many factors which may contribute the irrational use of antibiotics i-e doctors’ knowledge and exposure68, diagnostic doubts, lack of patient and health related professionals, expectation of patients, pharmaceutical marketing, sale of antibiotics without prescriptions as well as political and economic reasons62,69. The antibiotics misuse has deeply negative impacts on patients and public/communities. The misuse therapy of antibiotics like failure to duration of therapy, missing of doses, again uses of left over antibiotics and sub optimal dose of already exposed patients etc. such types of antibiotics taking behavior may be the result of insufficient antibiotics exposure to the eradicate microbial infections and the maximum chances to arise the antibiotic resistant environment in the body. The misuse therapies of antibiotic have negative consequences, on failure of treatment, health recovery cost, resistant issue with antibiotics, duration of hospitalization time, maximum return visit to the doctor and wasted of medicines70-72. The excessive use of antibiotics drugs exposes the communities to unwarranted medicines and contributes that the increase of antibiotics resistances73. The contributing factor to misuse of antibiotics is the availability of antimicrobial drugs to the patients without the enquiry of prescription or direction from professional person. The use of unnecessary antibiotics are seriously dangers to the patients who

may be used antibiotics for the proper indication for which it will not be eradicate the infection or not effective. Some antimicrobials like Rifamcin (Tuberculosis), HIV, Zidovudin may used single or with other conditions, create high risk of resistant strain for the patient and communities74. There are many antibiotics dispensed according / under the strict local regulations and unavailable at the over the counter, but there are many reasons for out-patients may retain left over antibiotic to follow the course of treatment. Further these leftover support self cure either with inadequate short course of therapy or for wrong indications. With the leftover usage for later infections in the same persons may carry twice risks, like chance of resistances and loss of potency due to inappropriate and longer storage which may create sub therapeutic dose environments. Similarly other risk includes sharing antimicrobial agents with others, with additionally unexpected allergic reactions. Therefore most other drugs that are used incorrectly, may just pose of higher risk to the patients, misused antibiotics add the global risk of increased resistances. Leftover has involved public attention in just some current years75.

1.22.1 Antibiotic’s prescription errors Prescription is an order written by a physician, dentist or any other registered medical practitioner to a pharmacist to compound and dispense a specific medication for the patient76. In other words a prescription is an instruction from a prescriber to a dispenser77. A prescription order contains the directions for both the pharmacist and patient. Beside compounding and dispensing the medications, it is the responsibility of a pharmacist to make sure that the patient has comprehended proper method and timing of drug administration76. Another major responsibility of pharmacist is to evaluate the prescriptions thoroughly, finding out the problems and correcting them after having discussed with prescriber78. The standards for prescription writing vary from country to country. Generally the prescription must contain the information such as; (a) Name, address, contact number and signature of the prescriber (b) Name, address, contact number, age and gender of the patient (c) Date of prescribing the medicine, name, quantity and dosage form of the drug (d) Directions, instructions and warnings for patient76-77. The prescriber should follow the proper guidelines for writing a prescription in order to minimize errors. An error may be defined as; A wrong action attributable to bad

judgment or ignorance or inattention (www.wordnetweb.princeton.edu/perl/webwn). The term prescription error has a broad meaning as it includes the errors made by prescriber during prescribing medicines, the errors made by a pharmacist during dispensing and taking the drugs incorrectly by the patient are also included in 35,79 prescription error . defined the prescribing error as; “A prescribing error occurs when as a result of a prescribing decision or prescription writing process, there is an unintentional significant reduction in the probability of treatment being timely and effective and increase in the risk of harm”. Several numbers of studies have been performed on the prescriptions containing antibiotics and others for identifying the errors, one surveyed studied the prescribing errors in a tertiary care hospital. In this study 5.6 errors per 1000 orders were identified, representing the common error types of inappropriate antibiotic dosing and prescribing those medicines to which the patient had previous allergies80. Antibiotics and non-formulary medicines were found to be the most common agents implicated. Another study stated that in hospitalized patients medication errors are the most important problems. They performed a prospective cohort study in two academic institutions on 1120 pediatric inpatients. A total of 10778 medication orders were analyzed and 5.7% (616) medication errors were identified. Out of these 28% of errors were found in the prescriptions containing anti infective agents81. A survey report in province of Sindh, Pakistan reported the lack of pharmacy structure in large government hospitals. Furthermore, it included a report on a private hospital that saved approximately 15% of the patients from prescription errors by collaborating with pharmacy department82.

1.23 Role of pharmacist

Pharmacists must possess specific knowledge, attitudes, skills and behaviors in support of their roles. Although these roles go beyond those previously described in official WHO publications and policies, they should be considered essential, minimum, common expectations of national health care systems worldwide. The consultancy summarized these roles in "the seven star pharmacist83.

Care-giver The pharmacist provides caring services. Whether these services are Clinical, analytical, technological or regulatory, the pharmacist must be comfortable interacting with individuals and populations. The pharmacist must view his or her practice as integrated and continuous with those of the health care system and other Pharmacists. Services must be of the highest quality in our society. Decision-maker The appropriate, efficacious and cost effective use of resources (e.g., personnel, medicines, chemicals, equipment, procedures, practices specially in prescription review) should be at the foundation of the pharmacist's work. Achieving this goal requires the ability to evaluate, synthesize and decide upon the most appropriate course of action. Communicator The pharmacist is in an ideal position between physician and patient. As such, he or she must be knowledgeable and confident while interacting with other health professionals and the public. Communication (Counseling) involves verbal, non- verbal, listening and writing skills. Leader Whether the pharmacist finds him/herself in multidisciplinary (e.g., team) caring situations or in areas where other health care providers are in short supply or non-existent, he/she is obligated to assume a leadership position in the overall welfare of the community. Leadership involves compassion and empathy as well as the ability to make decisions, communicate, and manage effectively. Manager The pharmacist must effectively, manage resources (human, physical and fiscal) and information; he or she must also be comfortable being managed by others, whether an employer or the manager/leader of a health care team. More and more, information and its related technology will provide challenges to the pharmacist as he/she assumes greater responsibility for sharing information about medicines and related products. Life-long-learner It is no longer possible to learn all one must learn in school in order to practice a career as a pharmacist. The concepts, principles and commitment tolife-long learning must begin while attending pharmacy school and must be supported

throughout the pharmacist's career. Pharmacists should learn how to learn. Teacher The pharmacist has a responsibility to assist with the education and training of future generations of pharmacists. Participating as a teacher not only imparts knowledge to others, it offers an opportunity for the practitioner to gain new knowledge and to fine- 83 tune existing skills . The additional duties of the pharmacist to ensure the correct and safe medication process in order to manage and reduce all the risk factors that may lead to the serious health problems. Develop the pharmacy management structure and environment to ensure the safety of the medication and support the culture of rational use of drug and best therapy for all type of patients84.

1.24 Hyderabad city

Hyderabad is a city, district and division in the Sindh province. The city is an administrative headquarters lying on the most northern hill of the Ganjo Takkar ridge just east of the River Indus. Being one of the largest city of Pakistan, Hyderabad is a communication center, connected by rail with Peshawar and Karachi. Founded in 1768 on the site of the ancient town of Nirun-Kot by Ghulam Shah Kalhora, the saintly ruler of Sindh, it was named after the prophet Mohammed's son-in-law, Ali, also known as Haidar. It remained the capital of sindh under the Talpur rulers who succeeded the Kalhoras till 1843 when, after the nearby battles of Miani and Dabo, it surrendered to the British, the capital was then transferred to Karachi. It's also a second largest city of Sindh Province. It has over 6 millions populations. The city has one of the most interesting bazaar of the country, which is known to be the longest bazaar in Asia. There are two very well arranged ethnological museums in the city One the Sindh Museum. Both museums present an excellent portrait of cultural and tribal life of Sindh. The city is transit point for the tours from Karachi to the Interior of Sindh A visit to Kalhora Monuments close to the city gate is worth a visit, Mausoleums are beautifully decorated with glazed tiles and frescos. There are also two forts from 18th & 19th Century to see here85.

1.25 World Health Organization (WHO)

Public-health agency of the UN, established in Geneva in 1948 to succeed two earlier agencies. Its mandate is to promote "the highest possible level of health" in all peoples. Its work falls into three categories. It provides a clearinghouse for information on the latest developments in disease and health care and establishes international sanitary standards and quarantine measures. It sponsors measures for the control of epidemic and endemic disease (including immunization campaigns and assistance in providing sources of pure water). Finally, it encourages the strengthening of public-health programs in member nations. Its greatest success to date has been the worldwide eradication of smallpox86. An agency of the United Nations concerned with worldwide and regional health problems. Its functions include furnishing technical assistance, stimulating and advancing epidemiologic investigation of diseases, recommending health regulations, promoting cooperation among scientific and professional health 87 groups, and providing information and counsel relating to health matters . The World Health Organization (WHO) was created in 1948 by member states of the United Nations (UN) as a specialized agency with a broad mandate for health. The WHO is the world's leading health organization. Its policies and programs have a far-reaching impact on the status of international public health. Defined by its constitution as "the directing and coordinating authority on international health work," WHO aims at "the attainment by all peoples of the highest possible standard of health." Its mission is to improve people's lives, to reduce the burdens of disease and poverty, and to provide access to responsive health care for all people88.

1.26 W.H.O Guidelines to good prescribing

A core component of health care program resides in safe prescribing skills and an excellent consciousness of medication errors. Ineffective and unsafe treatment, aggravation or protraction of illness, distress and harm to the patient, and higher costs are the consequences of prescribing errors. WHOs Guide to good prescribing is a practical manual that helps in maintaining the both of the above components. In most of the clinical settings, medical students and practicing physicians do not have a clear idea of writing a prescription for a specific health problem. The WHOs manual offers medical practitioners with a standardized model for clinical prescription writing in the form of six deeds. The first one focuses on the correct diagnosis of patient problems so

that a clear indication for treatment can be obtained. Making the right diagnosis is an important step to start an effective treatment and this may be based on sign and symptoms, medication and clinical history, laboratory and radiological examinations. This manual do not focuses on diagnosis but on good and rationale prescribing. The second one is based on specifying a therapeutic goal for underlying cause of the disease so as to avoid needless prophylactic prescribing. The third step is to select a standard treatment plan identified in the manual as drugs. The verification of suitability of Drugs includes; Active substances and dosage forms available, Dosing schedules, Duration of drug treatment, Effectiveness and safety for patients. The fourth stage is to instruct the patient by writing a prescription order with the mandatory seven main components of prescription writing. These components also known as parts of prescription underlined by WHO are; Name and address of the prescriber, with telephone number, Date of the prescription, Name and strength of the drug, Dosage form and total amount, Information for the package label, Prescriber's initials or signature, Name and address of the patient; age (for children and elderly). Non adherence to treatment is the major cause of failure of therapeutic goal, therefore WHOs fifth deed is to give information, instructions and warnings to the patient so that he/ she may fulfill therapeutic plan effectively. Weather treatment options are effective or ineffective is the sixth step which is described in the book. The Manual also describes the ways of keeping up to date knowledge about drugs and new research items by enlisting many standard reference books and compendia because maximum information and awareness is the key which leads to optimal benefits and safety during prescribing. The manual ends with four annexes, from them annex one provides information about the pharmacodynamics and pharmacokinetic parameters in practice, while Annex two gives some important references from journals, articles and books, whereas Annex three focuses on the use of dosage forms, and Annex four provides information on the use and handling of parenteral preparations25,89.

1.27 British National Formulary (BNF) National war formulary was formulated in 1939 by the British government during World War II in order to meet the therapeutic knowledge demands during the war. After the war ended, the royal pharmaceutical society and British medical association decided to continue the publications for normal and routine use. It was the time when British National Formulary became for the first time as a reference book. The first

edition was published in 1949, and the new editions came into market after every 3 years. But soon it was realized that the gap between the editions is huge enough that it do not competes the emerging demands of the health society as it was the era of new developments in the field of medical and pharmaceutical sciences. Therefore since 1981 BNF was published twice a year and with the emergence of every new edition there were about 3000-4000 changes regarding new drugs, old drugs which were called off from the market due to serious adverse reactions, or a change in dosage regimen. Up to date, there are 64 editions of BNF available in the market with the latest reforms. The BNF covers a wide range of material and guidance on prescribing and pharmacology, along with clear facts and details in relation to all medicines including indications, contraindications, side effects, doses, legal classification, names and prices of available proprietary and generic formulations. This book also includes complete directions on prescribing that how and when drugs should be prescribed along with information on prescription writing in both ways that is hand written prescriptions and computer generated prescription orders with samples. Chapters on Emergency supply of medicines, control drugs and drug dependence, adverse drug reactions, prescribing for children, prescribing for palliative care, prescribing for elderly, prescribing in dental practice, drugs and sports, and emergency treatment of poisoning provides extensive information to be used as standard reference. The pharmacological detail of different drugs is provided in the form of their actions on various systems of the body. This classification in given in the form of drugs acting on gastrointestinal system, cardiovascular system, central nervous system, respiratory system, endocrine system, drugs used to treat infections, drugs used in obstetrics, gynecology and urinary tract disorders, drugs used in malignant diseases and immunosuppressant drugs used in nutritional deficiencies and blood disorders, drugs used in musculoskeletal and joint diseases, drugs used in ophthalmology, drugs used in ear, nose and or pharynx, drugs used in dermatology, immunological products and vaccines, and anesthetic drugs. After the information on drugs, at the end the formulary contains Appendixes. Appendix 1 provides information about drug interactions, Appendix 2 gives notes on the use of drugs in liver disorders, Appendix 3 in renal impairment, Appendix 4 on drug usage and risks in pregnancy, Appendix 5 covers information on drug usage during breast feeding, Appendix 6 contains guidelines on intravenous additives, Appendix 7 gives details about Borderline

substances, Appendix 8 includes substance on wound management products and elastic hosiery, and Appendix 9 is associated with instructive labels for dispensed medicines. At the end dental practitioners’ formulary, nurse prescribers’ formulary, non-medical prescribing and index of manufacturers along with special order manufacturer is given. BNF also provides information on yellow cards, cardiovascular risk prediction charts, adult advanced life support algorithm, medical emergencies in the community, conversions, and abbreviations and symbols used in prescribing. Thus BNF is an essential reference which reflects current best exercise as well as legal and professional guidelines relating to the uses of medicines90.

1.28 Lexi-Comp’s Drug Information Handbook It is a comprehensive resource for all clinicians and healthcare professionals, the Drug Information Handbook, 21st Edition, continues Lexicomp's tradition of delivering trusted, pharma-free pharmacotherapy knowledge to healthcare professionals. This resource follows a user-friendly, dictionary-like format, providing clinicians with fast access to Lexicomp's clear, concise drug information. Endorsed by the American Pharmacists Association (APhA), Lexicomp's Drug Information Handbook is relied on daily by clinicians everywhere to improve medication safety and enhance patient care. Lexicomp's Drug Information Handbook covers over 5,500 medications and features 43 new monographs and hundreds of updates to existing content. Each monograph encompasses up to 37 fields of information, including detailed content on dosage, drug interactions and adverse reactions. Supplementing Lexicomp's drug information is a comprehensive Appendix offering charts, tables, treatment guidelines and therapy recommendations and a Pharmacologic Category Index listing all drugs within their unique pharmacologic class. The Drug Information Handbook comprises of four sections. The first section is a compilation of introductory text pertinent to the use of this book. The drug information section of the handbook, n which all drugs are listed alphabetically, detail information pertinent to each drug. Extensive cross sectioning is provided by U.S. brand names, Canadian brand names, and index items. Many combination monographs have been added to this edition; however, they have been condensed with only brand names and forms available. The 3rd section is an individual appendix which offers a compilation of tables, guidelines, monograms, algorithms, and conversion information which can be helpful

when considering patient care. The last section of this handbook contains a Pharmacologic Category Index which list all drugs in this handbook in their unique pharmacologic class. The Drug Information Handbook follows an easy-to-use dictionary like format. All generic drug names and cross references are highlighted in red and listed alphabetically, eliminating the needs for an alphabetical index. Headings at the top of each page help expedite search. A brand name is identified with a diamond like symbol and cross referenced by page number to the generic drug monograph. Information in this book, A drug monograph is a collection of key fields of information specific to a particular mediation. The Drug Information Handbook provides up to 35 fields of information per monograph, including use, medication, safety, issues, ADR, mechanism of action. Pharmaco-dynamics / kinetics and more… Reliability of information and contents. Since 1978, lexi-comp has developed industry leading point of care clinical information. A unique publishing model ensures that information is reviewed by the dedicated editors and advisory panel, In house clinical team and thousands of professionals across the countries who utilize databases through custom formulary solutions. This multilayer review process allows, to provide the most accurate, clinically relevant and unbiased drug information to readers91.

1.29 Case study

A detailed analysis of a person or group, especially as a model of medical, psychiatric, psychological, or social phenomena. Case study refers to the collection and presentation of detailed information about a particular participant, or small group, frequently including the accounts of subjects themselves .A form of qualitative descriptive research92.

1.30 Statement of problems

The Drug misuse and abuse is growing fast particularly in the major cities of Pakistan including Hyderabad, where almost all types of pharmaceutical products are used / consumed. The users or consumers / are patients are generally unaware regarding side effects or complication of drugs misuse and abuse. All the pharmaceutical products must be consumed under the special instruction and direction of professional peoples or as per prescriptions directions. Tranquilizes, psychoactive drugs, sedatives, hypnotics, antibiotics, multivitamins, laxatives, heavy tonics, steroids, antacids, cough syrups and analgesics or other pharmaceutical products like codeine based syrups , narcotics analgesic and anxiolytics are being consumed excessively or commonly misuse and abuse in societies by the people around the world including Hyderabad, Pakistan, on other hand the lacking or unavailability of professional people including Pharmacist specially retail side is major drawback in our community. Drug misuse or abuse have many consequences including fatal results and may lead drug side effects and complication on health or addiction, drug tolerance etc.

1.31 Aims and objectives of study

1. To identify the causes of drug misuse and abuse in Hyderabad city. 2. To identify the sale of medicines at pharmacy / medical store with prescription and without prescription. 3. To evaluate the degree of prescription categories dispensed at medical stores / pharmacies and prescription errors at the targeted areas of Hyderabad. 4. To evaluate frequently prescribed antibiotics and degree of errors in the antibiotic containing prescriptions in our society. 5. To evaluate the impact/consequences of improper patient counseling. 6. To analyze the doctor consultation time, follow-up of patients and self medication practices in Hyderabad. 7. To analyze the role of Doctors, Field managers/Medical representatives, Retailer of stores and drug controllers in the eradication of widespread drug abuse and misuse. 8. To identify the unethical approaches of Pharmaceutical companies.

1.32 Scope of study

The study will recommend the proposals for eradication of this social evil, which has been affecting the health of considerable portion of population in our society, Hyderabad. The findings of this study will help Government to formulate long-lasting strategy / policy to deal with problems of drug abuse and misuse and lacking of world Health Organization’s (WHO) policies / standard for health care systems and to increase the betterment and quality of lives of peoples in our society.

1.33 Ethical clearances

This study protocols were approved by the B.A.S.R University of Sindh. In few areas, where from the data has been collected, there is no any committee for observational studies. However, during the survey verbal consent was taken from those who were involved.

CHAPTER # 02

Literature Review

Barrett et al. (2008): They elucidated a wide variety of characteristics and behaviors that can be considered insufficient drug utilization as well as the ever rising collection of psychoactive agents that were considered more aptly for misuse, according to their study it might be hard to attain either absolute coverage and specificity or both, for all potentially clinically relevant forms of misuse within the same assessment instrument. Their study clicks that there are many ways to misuse the medicinal agents. Every mixture of substance varies in the user characteristics as well as the routes of administration (e.g. Non-prescribed users & prescribed users) and in the purpose for use (e.g. to increase intoxication v/s medication of unpleasant side-effects). Therefore it might not be feasible for all time to thoroughly scrutinize all likely combinations of drug agents, user characteristics, administration techniques and motives for use in the same investigation. Therefore, it is important irrespective of the approach used, all operational definitions are clearly stated, the precise meaning of the terms used in the study are specified that the limits to the general ability and specificity of findings be clearly and directly acknowledged.6 Hadidi et al. (2009): Studied for the first time the drug abuse in Jordan. This study was designed to provide a close image of the toxicological data, manner, cause of death and other associated findings in such cases. Postmortem forensic pathology reports for all autopsies in the National Institute of Forensic Medicine were reviewed over a five years period and drug abuse associated deaths were selected. This study also confirmed the variation in the incidence and type of abused substances in Jordan as compare to other different countries. The low incidence of drug abuse deaths in Jordan could be due to the community attitude towards the drug addict control studies. 93 Payne-James et al. (1994): They surveyed Metropolitan Police Service stations (London, UK) within the area covered by Group IV Forensic Medical Examiners. He came across very amazing results that one hundred fifty consecutive drug addicts were assessed. Approximately, Eleven percent of individuals reported by forensic medical reports were drug misusers. This prospective survey by using an anonymous structured

questionnaire was attempted to define some of the characteristics of the selected group of drug misusers and it was therefore observed that drug misusers seen in police custody were likely to be recidivists. 94 Griffiths et al. (2008): Studied the misuse of the drugs being fatal among the inhabitant of England and Wales Mortality. Their analysis confirmed geographical variations in casualties related to drug misuse that demand further consideration. Furthermore, thorough analyses of death variation by gender, age group, as well as paucity of awareness within region that could enlighten this important matter of mortality data to plan successful strategies in order to decrease the rate of mortality related to drug misuse, it also depends on understanding the volume of the drug using population and the risk of lethal poisoning among drug users. So, it was finally concluded that studies of life threatening risk amongst the drug-using inhabitants were required to prevent arising. 95 Kouyanou et al. (1997): They reported the frequency of drug normal use, misuse, abuse and reliance in one hundred twenty five chronic pain patients they were attending specialist of pain clinics in South London. A total of one hundred ten patients (80%) were taking medication for analgesia (pain relief). Information was also offered on the misuse and abuse of non psychoactive drugs, it was also discussed that how patients utilize drugs. Therefore, they suggested it is a responsibility of the doctor to counsel the patient properly regarding to the harmful effects of the self administered analgesic medication. 96 Matheson et al. (1999): They studied on the increased trend of alternate for the prescribed medication in Britain. According to them, Pharmacist and Physician were equally responsible for the growing incidents of drug misuse. However, subjective statistics showed significant variation in prescription and dispensing. It was noticed that Methadone was the mainly prescribed drug to be addicted throughout the Scotland, but there was a significant difference among health board areas regarding prescription management. Finally, it was suggested that it is the responsibility of the Pharmacist to prevent such happenings and ensure primary health care.97 Velleman et al. (2005): Their study shows that a family performs a key part equally in intervention and prevention with substance utilize and abuse both during stir up risk, along with encouraging and promoting protection. This evaluation examines a figure of family process and structures that have been linked with young people engaged to

utilize such stuff and later abuse. So, it was concluded that family plays a vital role to prevents youth from misused agents. Hence it was recommended that family should take part in controlling such life hazard issues. 98 Tantum et al. (1993): They put their studies in North-West England and in other regions of Great Britain on drug misuse. For this reason, self designed forms were circulated among Physicians, non-medical health workers and all those who were in touch with misusers. These forms were collected post-free to a centre where the statistics was designed. For a 15-month phase 2127 reports were received from the north west of England in which 1792 persons involved. 99 Taha Nazir et al. (2011): A case was studied in which a 3 years girl died due to improper use of drug. She was brought to the hospital just because of minor burn (caused by the hot water). The girl was given a dose of Dormicum twice with brief gap, later a dose of Pavulon by the doctor, she became unconscious and died, but the inquiry board did not concern to explore the reason at which this injection was given to her, as it was not rational. This case was not only the death case due to the improper and irrational drug use but it highlighted the other death cases too. Hence, from this survey, it was suggested that the medical practioners must take care in prescribing the medication and also it is the responsibility of the drug regulating authorities to ensure the proper and rational therapy. 7 Michael Gossop et al. (2002): To assess the prohibited drug use and problem associated during its treatment at UK, a study was designed by National Treatment Outcome Research Study (NTORS). For that reason, throughout England drug treatment program customers from 54 residential and community were recruited. For study purpose four types of investigation methods were selected. These were  inpatient drug dependence units,  residential/rehabilitation programmes,  methadone maintenance,  Methadone reduction programmes. Through interview from 1-2 years follow up, patients' information about behavior, physical and psychological health by using drug substance was composed. Facts were obtained from 549 patients, which showed that mostly patient were under treatment at these treatment centers. Problems associated during treatment were mostly covered in first year and maintained during second year. At the individual level stability was

found in these patients. Self-discipline from prohibited drugs use significantly increased among patients from both residential and community programmes; there was reduction in the use of heroin, methadone, benzodiazepines, and crack cocaine. However, uses of injecting equipments were also reduced. Heavy drinking was not reduced which was known during follow-up. Psychological and physical health harms were condensed on both groups at follow-up. These changes stood for clinical settlements in individual patients, their families and society.100 Gbiri et al. (2011): The effects of a twelve week exercise on gait-speed, balance performance and quality of Life (QoL) of individuals diagnosed for substance abuse disorders were studied. For the purpose of study 87 inpatients were selected, from which 45 experimental (EG) and 42 controls (CG) groups were diagnosed for substance abuse disorder in a tertiary mental health institution in Nigeria. A twelve week exercise schedule was designed, which included free active exercise, aerobic, bicycle ergo meter and tread-mill exercise were done by EG participants. Body mass was considered from weight/height relation. One-leg stand balance was also assessed. In meter/minutes Gait-speed was calculated, while QoL was done by WHO-BREF. These tests were performed for six and twelve weeks. Figures were analyzed by independent t-test, Kruskal-Wallis, Analysis of Variance and McNemars test. The average age of the patients was 31.04±6.30 years. Gait, balance and QoL had negative impact with age. . EG were improved in gait-speed, balance performance and QoL at 6 and 12 weeks. Gait-speed, balance and QoL of EG were low at baseline and enhanced i.e. p<0.05 among 6 weeks and 12 weeks. It was observed that balance performance, gait-speed and quality of life with substance abuse disorder were laid down. Well, planned exercise programme proved to be successful in decreasing physical problems that improve functional performance and quality of life. Therefore, it was observed that these daily routine activities among individuals of substance abuse disorder brought to mark decrease in their dependency towards drug substance. 101 Fakeye et al. (2012): Studied the views and ideas of Nigerian community pharmacists on self medication use related to the definition, its advantages, drawbacks, treatment allowed for the self medication and the level of self medication practices. During December 2009 and July 2010 questions sheet of pretested structure was administered to community pharmacists practicing in Southwestern Nigeria. For summarizing the data descriptive statistics was used. Some tests were used to estimate the ideas of the

respondents in numerical variable with p < 0.05 considered statistically significant. It was believed by the respondents having postgraduate qualification p < 0.05 that without proper guide lines by healthcare professionals can lead to mismanagement or sub-therapeutic management of the diseases i.e. 66; 91.66%, medication errors or chances of disease problems 68;93.15%. After the years of practice which had a significant effect on community pharmacists’ ideas of self medication. Meticulous monitor of drug ad in the media can be helpful in the monitoring the practice of self medication i.e 63, 86.30%. Respondents think that keeping the specification of the medications i.e 29; 39.73% and diagnosis details i.e 19; 27.14% unknown to patients is immoral.Self medication may be suitable for fever i.e 53; 74.65%, diarrhea i.e 46; 67.65% and cough i.e 39; 53.62%, but for limited time , for patients on chronic medication who have constant clinical situation, as well as asthma i.e 46; 66.67%, hypertension i.e 36; 51.43% and diabetes i.e 37; 52.86%. It was believed that Community Pharmacists in Southwestern Nigeria possess a good understanding of the concept of self medication. They believed the practice should not be dejected in entirety but must be practiced under proscribed conditions, and at the end public clarification may help to ensure safe self -medication practices.102 Hughes et al. (2001): Found that Self-medication was frequently performed in the world, especially in economically divested communities. Self-medication has a positive permit on individual and health care system if it practiced correctly. This self medication permits patient to take responsibility and build confidence in order to manage his own health, in doing so, encourage self-empowerment. In addition, it helps to save the time used in waiting to see a physician, economical, and also over saving for medical schemes and the national healthcare system.49 Adolfo Figueiras et al. (2000): A cross-sectional approach was done by using a sample (n =20,311) representing adult population of 16 years age and older in Spain. This study was to identify the socio-demographic associated to self medication and undesirable medication. During the two weeks interviews the prevalence of self medication in the sample was 12.7%. It was more common in women, lonely people, and those were living in large cities. Acute disorders had been reported with the persons, who had higher occurrence of self-medication among those who were highly educated. Two weeks prior to the interview the prevalence of undesirable self- medication in the sample was 2.5%. It was more common in older people of 40 years

as compared to the population of 27 years. As compared to those who lived with their partner the occurrence of undesirable self-medication was 53% superior and 36% higher among students as compared to workers (95% CI: 1.9-83.5). The priority targeted populations for public health education programs (aimed at improving the quality of self-medication behavior) should be people over 40 years, people who lived alone and students.46 Mohamed Azmi et al. (2011): The objective of this study was to assess the frequency of self-medication among adults of urban origin and to spot any factors contributing to self-medication. The setting of the study was done in Kuala Lumpur, the capital of Malaysia. For that purpose a cross-sectional study method was employed in which a self administered opinion poll including adults of 21 years as an exit study was conducted. The main outcome measures were source of medication for the treatment of minor illnesses among participants, common illness chosen for self-medication by participants, number of medications taken in a day by participants and the informational sources of participants. At least one medication in the past week without prescription results were 62.7% who believed that OTC medicines were just as effective as those of prescribed by the doctors. While, 69.4% searched for a healthcare professional’s advice before they brought any medication and 8695 consulted a Pharmacist before they purchased any medication from pharmacy. Only 86% were those , who checked the expiry dates and 54.5% reported leftover medication. The conclusion of this survey of 314 participants showed that self-medication practice was prevalent in Kuala Lumpur with some practices being harmful. In order to ensure quality use of medicines, education on appropriate use of self-medication needed to be emphasized.103 Havens et al. (2011): This study was on the data of national survey on drug use and health. Nonmedical use of prescription drugs (pain reliever, tranquilizers, sedative and stimulants), were found more likely than urban adolescents. Factors associated with nonmedical drug use included decreased health status, major depressive episodes were found in adolescents of rural areas. 104 Fenton et al. (2010): They carried out a face to face survey of 34,653 adults in National Epidemiology Survey on Alcohol related conditions. The risk of nonmedical use computed for individuals, who had or had not received a prescribed anxiety medication and associated drugs. Characters associated with nonmedical use were

analyzed. These types of prescriptions had been used for lifetime or past years nonmedical use (odds ratio, 1.6 and 1.9 respectively) and lifetime DSM-IV abuse (odds ratio, 2.6). Those who had responded were young white male and had history of use of illicit drugs with history of illegal behaviors. Though, the direction of casualties cannot be determined in this study. Greater clinical attention must be given to anxiety medication because they had greater clinical utility and attention should be given to emphasize the potential risks.52 Cotto et al. (2010): Gender differences have been studied to assess the rate of substance misuse and drug user dependence. Two age groups were focused. One group had youths of age 12 to 17 years and the other had age of 18 to 25 years. For gender comparison, a combined annual data from National Survey on Drug Use and Health (NSDUH) was used. Taken as a whole, rates of substance use were notably higher for males than for females (P<0.01for everything except sedatives and tranquilizers). However, youth patterns differed from overall population and from youth adults. The use of alcohol (P<0.01) and nonmedical use of psychotherapeutics (P<0.0) were mostly noticed in girls. Marijuana dependence (P<0.01) was found more in boys. Youth adults female users reported to be dependent on cocaine or psychotherapeutics was notably higher than for males users (P<0.01). Males generally exceeded females in meeting abuse criteria (P<0.01 for marijuana among 12-17 years old- and for alcohol and marijuana and psychotherapeutics among 18 to 25 years old). It was noticed from the above findings that age, gender and substance of abuse played a major role in the observed pattern of drug use, abuse and dependence. Understanding the reasons and differences of the evaluated patterns over time could help in more effective prevention and treatment intervention.105 Marquez et al. (2012): The aim of their study was to spot practices of self-medication in the treatment of ocular conditions and to identify a profile of patients who self- medicated. A cross-sectional expressive survey of patients was conducted by Argentina, in which over the age of 17 years seen in ophthalmology practice in Cordoba. Self-medication was distinct as the use of ophthalmic medicines which had not been prescribed by a health care specialist in the previous years. The sample incorporated 379 subjects, 162 males (43%) and 217 females (57%); mean age was 46.8 years. Before looking for medical attention in these institutions; 97 patients (25.6%) reported as self-medicating. The most often employed products involved non-

steroidal anti-inflammatory drops in combination with a vesso-constrictive agent (32%) followed by a combination of antibiotics and steroids (9%), however, 14% of patients did not mention the name or type of medication applied into their account. A total of 31% of patients used drugs suggested by a pharmacist; 25% used drugs of their own choice and 24% followed suggestions from a friend or family associate. Only 12% of patients knew the drug's ingredients and only 3% were aware of any probable side effects. There was no difference in behavior patterns connected to educational level or age, however, there was an important difference related to gender, with males misusing ophthalmic drops more frequently than women (P = 0.004).Patients usually attempted to treat conditions that require ophthalmologic care by self-medicating with over-the-counter eye drops. So, it was suggested that educational efforts must notify the patients for the consequences of self-medication. 106 Radat et al. (2007): The purpose of this study was to evaluate behavioral dependence on migraine abortive drugs in medication-overuse headache (MOH) patients and identify the predisposing factors. According to this study, it was ordinary occurence that MOH patients declined after medication withdrawal. Behavioral determinants of medication overuse should therefore be acknowledged in MOH patients. This was a cross-sectional, multicenter study that incorporated 247 MOH patients (according to International Classification of Headache Disorders, 2nd edition criteria) consulted in French headache specialty centers. Face-to-face interviews were done by senior neurologists using a planned questionnaire including the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for the assessment of dependence, hospital anxiety and depression level for the estimation of anxiety as well as depression, 6-item short-form Headache Impact Test scale for the determination of functional impact. Most MOH patients had pre-existing primary migraine (87.4%) and current migraine-type headaches (83.0%). Treatment overused included triptans (45.8%), opioid analgesics unaccompanied or in combination (43.3% of patients), and analgesics (27.9). Two-thirds of MOH patients (66.8%) were measured dependent on acute treatments of headaches according to the DSM-IV criteria. Most dependent MOH patients had migraine as pre-existing primary headache (85.7%) and current migraine-type headaches (87.9%). However, the majority of them overused opioid analgesics. Mostly dependent patients than non-dependent MOH patients were reliant on psychoactive substances (17.6% v/s 6.1%). Multivariate logistic analysis indicated

that risk factors of dependence on acute treatments of headaches pertained both to the fundamental disease (history of migraine, unilateral headaches) and to drug addiction. Affective symptoms did not emerge among the predictive factors of dependence. In a few cases, MOH thus appeared to fit in to the spectrum of addictive behaviors. It was therefore suggested that in clinical practice, behavioral administration of MOH should be undertaken, moreover, pharmacological management.107 Thomas et al. (1976): For the purpose of study, 2500 patients were specified who suffered from drug overdose. For the most frequently abused drugs, including diazepam blood samples were quantitatively examined. In about one of every four of these, 61 % had positive findings, including diazepam. For the concurrent- analysis of diazepam and sedatives (in two instruments). A quick, easy and quantitative gas- chromatographic method was explained. To prove methods via ultraviolet spectrophotometery and thin-layer chromatography, a single extraction at low pH was exercised and preserved the balance of the sample to be used. List of the occurrence of other positive findings was also entitled and findings for diazepam were sort out by epoch.108 Yasmin Mumtaz et al. (2011): The frequency of self medication in the university students of Karachi Pakistan was found. Between July and August 2008 a cross sectional study was conducted. For this purpose two hundred and seven students through non-probability expediency sampling from two universities of Karachi, one medical and one non-medical were chosen. Information containing data was collected through self administered survey, examined by using SPSS v 10. Out of 207 contributors, 104 were studying at Dow University, while 103 were students of Karachi University. Male: female ratio was 1:4, while mean age was 22 years and rate of self medication came out to be 80.4%. Commonly the reason for not discuss with the doctor was that the non serious problem and the most frequent indications when self medication used were included as headache i.e. 62.3% and fever i.e 49.8%. About 62% contributors were familiar that Self medication could be harmful for them. It was found that the rate of self medication was high in educated youth although the fact that majority of the students were aware of its dangerous effects. In the local setting there seemed to be a need to review the definition and relative connotation of ‘self- medication’.109

WHO Geneva (2000): In a health care system self medication is a part of self care and is believed as primary public health source. Self medication also included the exercise of the medicines by the users for self recognized health problems or the ongoing use of medications properly prescribed previously. Additionally widening the definition comprises the treatment of family members particularly to child and elderly.110 Henry James et al. (2006): It was studied that headache after an exhausting day for an otherwise in a single dose healthy person could use up to one gram of acetaminophen. Hence self medication is not all time dangerous, if it is recognized that which medicine is to be used and for what purpose. Yet it is essential to instruct public for situations where they may self-medicate and when they must visit a physician yet for apparently unimportant condition. Headache, fever, flu and general ache, were the most reported complaints in this study for which drugs were taken. While, other illnesses comprise diarrhea, allergy and sleep problems. For us the last problems are naturally need specialists opinions and should not to be self medicated. The self medication for similar outline of disorders was experienced by the learners in earlier reported published literature. From the earlier findings it was found that mostly the drug used were pain killers also antibiotics and fever relieving medicines in this chain. In comparison with the earlier study. It was observed that this study also had a factor that pointed towards the danger and peril insight aptitude of the learners. In spite of unavailable of self medication practices about half of the apprentices considered these problems as less serious.111 Lars Bjerrum et al. (2003): This study explored the drug drug interactions in the prescriptions and also identified the patient who are more suspected to have these drug drug interactions, for that reason a data based study was done according to which In 1999, the individuals who were exposed to poly-pharmacy practice were observed to be more prone towards drug interactions. It was also noticed that among the inhabitants of the County of Funen (n_/471 732) there were occurrence of possible drug interactions. 33% of the people were exposed to poly-pharmacy and out of these 15% were exposed to drugs carrying a risk of harmful interaction. 25% of age 60 to 79 years receiving poly-pharmacy and 36% over 80 years were those who took the drugs with possible interactions. Out of those who showed the potential drug interaction, 62% were those who were exposed only to one drug interaction and 38% were those

who had two or more different drug interactions. Diuretics, NSAIDs, ACE inhibitors, digoxin, oral anti diabetics, calcium channel blockers, anticoagulants and beta- blockers were among the drugs accounting for the highest number of potential interactions. Potassium-sparing diuretics and oral anticoagulants were the most frequently observed drugs, focusing only on the key drug interactions. So, it was recommended that old patients who were exposed to poly-pharmacy should be deeply monitored as they are at greater risk of clinically induced drug interactions.112 Tamblyn et al. (1996): This study provides a quite precise depiction of drug interactions in the country as a group. It was concluded from this study that a significant amount of unsuitable drug interactions due to parallel prescribing by different doctors at the same time and the existence of a single prescriber appeared to lesser the risk of inapt drug interactions.113 Dukes et al. (1993): This study shows that inhabitants respond in unlike ways and hence the different potential interactions are showed that may generate no poor effects in some patients, whereas minute interactions could lead to adverse effects in others. It was noticed that the drugs with a quick dose response were more vulnerable to initiation or inhibition were most likely to result in clinically large interactions. It was expected that the occurrence of potential interactions from the number of persons with extend beyond prescriptions. The time of treatment was considered by assuming a daily intake of one defined daily dose. For almost all drugs a defined daily dose is defined as the typical quantity of the drug per day used for its main sign in adults. It does not unavoidably show the suggested or used dose for all individuals or for all diseases. The DDD is proposed to be as close as possible to the prescribing actuality, and it is familiar in view of the journalism, the manufacturer’s advice on the information sheet and the practice gained in the order with the product involved.114 Shehadeh et al. (2012): In their literature causes related with antibiotic use, resistance and safety have been well distinguished. However, only a few studies have been performed in Jordan on that topic. Objective of this survey was to measure knowledge, behavior and feelings toward antibiotics used in the adult Jordanians. The study denotes a cross sectional assessment by using an interviewer administered feedback. Information collected from a haphazard sample of 1141 adult Jordanians, enlisted at different situations, regarding their knowledge about the efficiency of, resistance toward, and self medications with antibiotics against bacterial, viral and parasitic

diseases. 67.1% people believed that antibiotics cure common cold and cough, while 28.1% people used antibiotics as analgesic. During pregnancy and nursing about 11.9% of females showed insufficient knowledge about the safe use of antibiotics. It was also observed that 28.5% people kept antibiotics at house for emergency use and 55.6% people use them as prophylaxis against infections. 49.0% use left-over antibiotics without doctors’ consultation. Some 51.8% used antibiotics based on a relative opinion. Out of all, 22.9% of physicians prescribe antibiotics on the phone and more than 50.0% habitually recommended antibiotics to cure common cold indications.115 Gyssens et al. (2001): Worked on the consequences of the absurd overuse of antibiotics in which its was focused that the misuse of antibiotics does not only create a drug related resistance but also increase adverse reactions as well as economical burden on national health system.64 Shankar et al. (2002): It was observed that in Jordan, patients visit a community pharmacy to buy a pharmaceutical product much like they would at a supermarket. Like most other developing countries, which have a authentic prescription is not always imposed for receiving prescription-only medicines(POM). It was common in practice that except narcotics and major tranquilizers, patients can buy any medication including antibiotics, without any prescription.67 McKee et al. (1999): In this study the knowledge of antibiotics that when antibiotics should be used, their effectiveness and the hazards of antibiotic resistance in Jordan were discussed. According to the study 47.3% contributors demonstrated less than 50% correct retort, among these adults regarding the mystery, whether antibiotics effectiveness against bacteria and viruses was obvious. In reality, it was argued that many patients do not understand the differences between bacteria and viruses and believed that antibiotics were effective against them equally.116 Hawkey et al. (1998): The information related to these concerns is outstanding. Considerably, respondents data considering antibiotic use was related with age (P = 0.042). 18–25 years old younger respondents were more probably using antibiotics earlier (P = 0.001). In the Jordanian the undue use of antibiotics must be deduced by giving main concern to knowledge-based learning programs for younger generations. Though, it is not this easy. 44.8% respondents who deviated from the statement that ‘Antibiotics are effective in the treatment of common cold, cough and nasal

congestion’ were expectedly prescribed by antibiotics in the previous year with those who did allowed. The mystification concerning antibiotics resistance was enduring. It was a well known reality that the unrestrained treatment of antibiotics could guide to considerable and severe troubles with the appearance and occurrence of resistant microbial strains, which is a worldwide dilemma.117 Sawair et al. (2009): In this study it was shown that a high proportion of antibiotics were being used without physician’s order, 35.0% directly from pharmacies as OTC, 53.4% self-medication using related antibiotics and 49.0% as left-over antibiotics. Generally, these percentages were likely to those stated later on i.e. 40.7% and 46.0% for a sample of Jordanians attended a department of dentistry and a sample of successive customers arrived at community pharmacy stores in Amman seeking antibiotics to treat systemic infections, respectively.118 Hammerlein et al. (2007): In patients’ guiding community pharmacist can play an important role and should be able to give basic drug information in terms of suitable drug usage, administration, dosage, side effects, storage and drug–drug and drug–food interactions.53 Bawazir et al. (2004): Their analysis that improved enhancement of the patients’ observation was found, where 38.5% gave positive reaction compared to only 17.9% in the previous study. Though, there were several obstructions who avoided Saudi Arabian community pharmacists to play a more dynamic role in consumer recommending, which may be due to no privacy, not enough quantity of competent pharmacists and participation of pharmacists in the business management of the pharmacy, and lack of suitable trainings.119 Iqbal et al. (2008): In this study the conclusion and conversation here are based on the facts gathered from a research on patients’ assessment, idea and satisfaction with pharmacist’s role in community pharmacy services. The study was conducted by using survey developed from instrument used in previous study.120 Anderson et al. (2004): Their main focus was the pharmacists’ role as health care provider, to improve the professional image of the pharmacy and to improve the patient satisfaction; it must be recommended to appoint at least one pharmacist in each community pharmacy for consultations. Furthermore, because of the majority of community pharmacists were emigrants, it is proposed that the Saudi Commission for Health Specialties (SCHS) to enhance the community pharmacists for studying an

extra course in pharmaceutical care. Besides, revising the pharmacy program and making more accents on patient centered care courses is another loom. There is also a necessity to give drug information in a patient-centered mode. According to the experience from European countries, the chance to receive private medication directing is a major part in ascertaining conviction between pharmacists and customers.121 Sawalha et al. (2010): In Nablus governorate, Palestine the prescription quality and prescribing trends of private clinicians was investigated. Over a study period of 288 working hours a total of 363 prescriptions were collected from a random sample of 36 community pharmacies. Information concerning rudiments in the prescription and the types of drugs prescribed were examined. Variables due to doctor were mostly prominent, though, patients address and weight were missing in all prescriptions and less than half included age and sex. In over 70% of prescriptions data concerning potency of the medications prescribed was missing. While other drug-related variables like frequency and instruction of use were present in over 80% of prescriptions. Antimicrobial agents were the most commonly prescribed and then the NSAIDs/analgesics. Amoxicillin alone or in combination was the most commonly prescribed antimicrobial agents followed by cefuroxime. Prescription writing characteristic in Nablus is poor in several aspects and perfection is required.122 De Vries et al. (1995): In Palestine it was the first survey to inspect the value of prescription writing and the prescribing styles in community pharmacies. It was clearly showed that there are some deficiencies in the quality of prescription writing. No one of the prescriptions contained the address of the patients and less than half included the patients’ age or sex. But these elements should be included according to World Health Organization (WHO).25 Huang et al. (2006): It is found that nonmedical use of some agents represents a growing and important public health problem. An improved understanding of nonmedical use of prescription anxiety medication is necessary for developing an effective prevention and treatment interventions, including risk factors. Earlier studies show that individuals with anxiety disorders have a high risk of nonmedical use of prescription anxiety medications.123 McCabe (2005): This study is based on the individuals with a prescription, behavioral characteristics associated with nonmedical use included illicit drug use, driving while

intoxicated and substance-related criminal activity. Our conclusions related to the characteristics associated with college nonmedical prescription anxiety medication users.124 Skaer TL et al. (2000): There are several limitations in this study. First of all, every survey question may have been focus to recall, self-report, and communal interest prejudice. Secondly, as only information on lifetime prescription was available, the prescription anxiety medication used non-medically may not have been the anxiety medication for which respondents had received a prescription; future studies should include questions particular sufficient to find out this information. Third, to expand statistical power, the definition of nonmedical use was wide, which include one-time nonmedical use. Yet, excluding respondents who connected in nonmedical anxiety medication use only once within any single year did not change the significance or strength of the association between a prescription and lifetime nonmedical use. It shows that our result did not come from these respondents only. Moreover, the survey questions on nonmedical use did not cover dangerous nonmedical use behaviors like intranasal administration and co-administration with other psychoactive substances, on using prescription anxiety medication for the suitable medical cause. Also, anxiety illnesses are rarely dealing with medications other than anxiolytic drugs.125 Lynette James et al. (2009): Electronic databases were searched from 1966 to February 2008 in order to identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy. It was added by hand-searching the bibliographies of salvaged critiques. Investigation of the results discovered the research methods, operational definitions, occurrence, type and causes of dispensing mistakes. In the UK, US, Australia, Spain and Brazil, sixty papers were identified investigating dispensing errors. Generally, the frequency of dispensing errors speckled depending on the study setting, dispensing system, research method and operational definitions. Dispensing the wrong drug, strength, form or quantity, or labeling medication with the incorrect directions were the most common dispensing errors identified by community and hospital pharmacies. issues instinctively reported as causative to dispensing errors were look-alike, sound-alike drugs, low staffing and computer software.High workload, disruptions, disturbances and not enough lighting were objectively shown to enhance the incidence of dispensing errors. Assessment of the reviewed studies was confused by differences in

study setting; investigate technique and operational definitions for dispensing errors, error rate and classification of error types. WHO is currently introducing global patient safety taxonomy(classification).Such a standardized taxonomy for dispensing errors would assist consistent statistics compilation and help the progress of error-reduction policies.42 Jennifer et al. (2011): They used to compare the occurrence of nonmedical prescription drug use among young people residing in urban, suburban, and rural areas of the United States and to conclude factors separately connected with rural nonmedical prescription drug utilize among youngsters aged 12 to 17 years. Contributors incorporated adolescents aged 12 to 17 years i.e. N=17,872, most of whom were residing in urban areas about 53.2%, male were 51%, and white were 59%. The nonmedical use of prescription drugs like pain relievers, tranquilizers, sedatives, and stimulants. Data was collected from the 2008 National Survey on Drug Use and Health. 26% were countryside adolescents more likely than urban adolescents to have used prescription drugs non-medically (adjusted odds ratio, 1.26; 95% confidence interval, 1.01-1.57) even after modification for race, health, and other drug and alcohol use. Health status, major depressive episode(s), and other drug (marijuana, cocaine, hallucinogens, and inhalants) and alcohol use were the factors associated with nonmedical use of prescription drugs on investigating the rural adolescents in particular. School enrollment and living in a 2-parent household were the Protective factors for nonmedical prescription drug use among rural adolescents. Urban adolescents were significantly less likely than rural adolescents to report nonmedical prescription drug use. Though, it was suggested from the results that there are numerous probable points of intrusion to avoid beginning or succession of use among rural adolescents including preventing school dropout, increased parental involvement, and increased access to health, mental health, and substance abuse management.126 Dew B et al. (2007): Among urban adolescents numerous studies have examined substance abuse; assumptions drawn from research conducted in urban settings may not be generalizable to those living in country areas due to a distinctive set of related impacts. As reviewed by Dew and colleagues, the susceptibility of country communities to the growing load of drug use can be ascribed to a number of unique financial, societal, and structural features. The annihilation of rural economies, caused by fall off the farming, manufacturing, and mining industries and proofed by high

rates of joblessness, has influenced communities’ responsiveness to drug use. Because of growth in internet contact and the increase of transportation systems, rural communities are decreasingly remote and have become another border line for illegal drug production and distribution. The writers also cite the decline of conventional relative structures and the weakening of parental links as causative to the growing crisis of rural drug use.127 Levine et al. (2009): The prevalence of drug is not only affected by the intellectual, structural, and social realities of rural life but also aggravate its results. The isolation and independence of rustic societies can pessimistically affect care seeking actions, mostly concerning psychological wellbeing and material misuse services. Obstructions to care seeking in rural areas are both attitudinal and structural. features such as comprehend disgrace and suspect in declarations of discretion plus barriers to shipping, lack of insurance reporting, and engaged of regional detoxification and psychiatric services can all restrain rural residents’ enthusiasm and capability to seek care. In light of the distinguishing factors that stimulus vulnerability to substance use in rural communities, epidemiologic investigate providing proportional investigations of rural and urban drug use and examining rurality as an sovereign hazard factor is deserved. The growing burden of NMPDU and the lack of information on NMPDU between rural youngsters in particular, are areas that want more awareness. One study performed in rural Vermont accounted elevated rates of nonmedical prescription pain reliever use among high school students but cannot compare these rates to those of urban youngsters.128 Yafang Tsai et al. (2012): In order to survive community pharmacies are seeking new strategies and developing new services due to facing changes in the medical environment. Certain aspects of service development in community pharmacies were explored in this two-phase study. First phase involved collection of qualitative data through interviews. While in the second phase, using a feedback form. A quantitative study was designed on the basis of the results of interviews conducted in the first phase, and sampling was conducted. In the results it was shown that development of community pharmacies could develop public health services and the pharmacy profession and facilitate a redesign of the service environment. In the quantitative study, more than 64% of the respondents agreed that improvement of community pharmacies would enhance the pharmacy professional environment and provide

flexible and diversified services. The concept of self-care management systems is accepted by another 95% of the respondents that are based on public health services provided by community pharmacies. Concerning the redesign of the service environment of community pharmacies, 42% of the respondents stated it IMPORTANT, and 53% stated it as Very Important.129 Bell Ja (2009): Found that the members of the community pharmacy to be a suitable setting and experience that pharmacist must provide public health services away from dispensing medicine. Some were largely satisfied with their experience with these services those that had experienced public health services (like self-management interventions) in a community pharmacy mostly relaxed with their skill with these examines.130 Alsultan et al. (2012): In the Kingdom of Saudi Arabia, the purpose of this survey was to draw pharmacy services in hospitals on a local level. A modified-American Society of Health-System Pharmacists (ASHP) investigation opinion poll as relevant to Saudi Arabia was used to carry out a national survey. In the Riyadh region after conferring with the pharmacy directors of forty eight hospitals, over the phone on the survey’s object, the survey were individually transported and gathered upon conclusion. The list of the hospital was drawn from the Ministry of Health hospital record. In the survey, 29 hospitals were participated giving a response rate of 60.4%. About sixty percent of the hospitals which participated in the survey demanded preceding endorsement for the use of non-formulary medications. Approximately 83.3% of hospitals evaluated obedience with clinical practice guidelines and 72.7% hospitals reported that pharmacists were also actively involved in these activities. In more than 95% of hospitals the Pharmacists provided discussions on drug information staff pharmacist, regularly answering questions were the most frequently mentioned (74.1%) method by which objective drug information was given to prescribers. In 77.7% of hospitals, electronic drug information resources were available, though internet service is not widely available to hospital pharmacists, with only 58.6% of hospitals providing pharmacist approach to the internet. Nearly, 34.5% of hospitals had computerized prescriber order entry (CPOE) systems with clinical decision support systems (CDSSs) and 51.9% of the hospitals had electronic medical record (EMR) system. In Saudi Arabia the hospital pharmacists have gradually been trained

by using electronic technologies to get better prescribing and recording of medications.131 EAHP survey (2010): In this survey, the features, span, and breadth of hospital pharmacy practice were assessed. The investigation results point out that the practice of hospital pharmacy varies from country to country and many nations face comparable challenges, apart from of their population, place, or wealth. Additionally, at the beginning of 2010 the European Association of Hospital Pharmacists (EAHP) reviewed its members on the position of the interest in hospital pharmacy in their country.132 Pedersen et al. (2011): According to this study, the United States of America is the country with the biggest custom of tracking and trending hospital pharmacy services. In more than 40 years there were over 20 surveys. Presently, national surveys of pharmacy by the American Society of Health-System Pharmacists (ASHP) in hospital settings focuses on the role pharmacists play in organizing and humanizing the medication use. This survey is planned in keeping with 6 steps in the medication-use system: i.e. Prescribing, transcribing, dispensing, administration, monitoring, and patient education. Every year, in the medication-use system, the survey directs on 2 steps. On combining, the latest four surveys signify a composite picture of the current role that pharmacists play in managing and improving the medication. Now, patient safety is a main concern for medication management and pharmacists are also retorting to changes in the healthcare system to find suitable ways to make better medication use at the steps of the medication use system prescribing and transcribing.133 Al-Dhawailie (2011): Worked on prescribing errors phenomena are very common within health care practice. These errors could result in adverse events and harm to patients. Pharmacist has an identified role in minimizing and preventing such errors. To detect the incidence of prescribing errors for hospitalized patient, to evaluate the clinical impact of pharmacist intervention on the detection of these errors and to propose a program to overcome this problem in a teaching hospital. For one month period starting November till December 2009, the inpatient medication charts and orders were identified and rectified by ward and practicing pharmacists within inpatient pharmacy services in a teaching hospital at King Khalid University Hospital (KKUH) at King Saud University, Riyadh, and Kingdom of Saudi Arabia on routine

daily activities. Data was collected and evaluated. The causes of this problem were identified. Approximately 113 (7.1%) prescribing errors were detected during the study period out of 1580 medication orders. Wrong strength and wrong administration frequency of the prescribed drug were the most errors encountered in the study, which were 35%, and 23%, respectively. Other errors such as wrong patient, wrong drug, and wrong dose were also encountered. Lack of knowledge of prescribing skill was the main cause of such errors.134 Eman Abahussain et al. (2012): In many countries the removal of surplus medications have been a problem, as pharmaceutical waste enters the ecosystem, which have an ultimate an effect on human health and environment. In Kuwait in earlier studies it was found that the method of disposal by the public was by disposing in the garbage or by cleansing down the drain. For the patient preference and environment safety, it would be suitable to use regional government pharmacies as collection points for appropriate disposal. For determining the practice of pharmacists, working in government healthcare sectors, with regard to disposal of returned unwanted medications by the public. This study also aims to assess pharmacists’ awareness toward the impact of improper disposal on the environment and to investigate whether pharmacists agree to have their pharmacies as collection points for future take-back programs. A random sample of 144 pharmacists from the six main governmental hospitals and 12 specialized polyclinics in Kuwait completed a self- administered questionnaire about their practice of disposal, awareness and opinion on using pharmacies as collection points for proper disposal of UMs. Data was analyzed using descriptive statistics. A total of 144 pharmacists completed the survey. Throwing UMs in the trash was the main method of disposal by majority of the respondents (73%). Only 23 pharmacists disposed UMs according to the guidelines of Ministry of Health, Kuwait (MOH). However, about 82% noticed to be aware that improper disposal caused damage to the environment and 97% agreed that it was their responsibility to protect the environment. About 86–88% of the pharmacists agreed to have government hospital pharmacies and polyclinics as collection points for future take-back programs. According to them, even though the current practice of disposal by majority of pharmacists was inappropriate, they were aware of the damage and acknowledge their responsibilities toward environment protection. Concerned authorities should monitor and implement proper disposal guidelines in all pharmacies.

Majority of pharmacists support the idea of having the government pharmacies as collection points for safe disposal of UMs in Kuwait.135 Subish Palaian et al. (2006): They studied that the drug therapy and modifications in life style are important to manage the chronic illness. patient counseling is one of the major element that patient should be aware about his/her illness, so that he/she can make necessary modifications and drug treatment by the physician in a better way leads to the patient compliance. Pharmacist has to play a significant role in patient counseling. This could be done through effective communication using verbal/non- verbal communication skills.136 Saira Azhar et al. (2011): They explored the clinical role of hospital pharmacist in three major cities of Punjab stated, Islamabad, Faisalabad and Lahore, Pakistan. In this cross-sectional study was done for which 116 hospital pharmacists were randomly selected as sample from public and private hospitals. It was found that 42.2% pharmacist were involved in patient counseling regarding drug.24.5% were focused on pharmacy record keeping. Only 57.8% indicated that they were involved in compiling and updating their drug formulary. From the above result they were suggested that there was great need to enhance their present professional role and involvement with the collaboration of other health care members in the medical services.137 Frank J. Ascione et al. (1985): This survey determined the pharmacist responding to the consumer query of prescription drug. 400 community pharmacies were randomly selected in Michigan in which 234 (58.5%) usable responses were studied the result indicated that pharmacist do not verbally communicate with the patient about what they dispense. Only written information was available on label of prescription container. However pharmacist provided an advice in response to patient request. These results suggested that patient has to more aggressive in seeking about their prescription and pharmacist should build a good communication to spend more time counseling them.138 Tim Covington et al. (1979): This study explored that the prescriptions were incomplete and inadequate that sufficient information was not provide while prescription writing so that patient were unable to understand the nature of illness and the importance of drug therapy to raise the issue of non compliance. In this study 19972 prescriptions were analyzed. On average 7.7 % had “as directed” were the only

instruction while 14.7 % had “PRN” (as needed) only. So they suggested that inadequate instructions would more probably confuse the patient.139 Godeliver et al. (2011): In this study the data were collected from the government hospital of Duress Salaam ,Tanzania, on HIV& non-HIV hypertensive patients and the role of pharmacist in their pharmaceutical care. Data were collected from patient through interview using a structured questioner and from the pharmacist by using self administered questioner and also by observation. A very few patients knew the names of antihypertensive medicines they were taking. Doctor provided information regarding the use of antihypertensive and antiretroviral (ARV) medicine. Adverse drug reaction was found higher by using both anti retroviral and antihypertensive than using only antihypertensive. Only 20 % of the patient of hypertensive HIV informed then pharmacist dispensed, antihypertensive that they were used ARV and only 19% pharmacist knew about drug-drug interaction between ARVS AND antihypertensive. Only 2% of patients were asked about another drug being used. So it was decided that dispensing and providing up to date information to the pharmacist must council the patient about hypertension –HIV-co –morbidity. HIV and hypertension clinics should work with proper coordination with each other to improve the patient safety.140 Sule Apikoglu et al. (2011): The role of the community pharmacy staff is to supply the emergency contraceptive pills without the doctor’s prescription to reduce the unwanted pregnancies and induced abortion. This survey has been carried out in Turkish pharmacy to observe the pharmacy technicians’ counseling practices and attitudes regarding these pills. Data were collected by structured questionnaire, demography, professional experience, counseling practice and attitudes regarding emergency contraceptive pills should be applied at the end of the “pharmacy technician certificate program”. The complete questionnaire (n=145) were analyzed. Mean (SME) age of the technician was 25.3 (0.4) years and majority (89%) of them practicing in a community pharmacy. Most of them have positive response towards these pills and despite this they also provided it to the client with proper counseling. They suggested to organization that to provide further education facilities to pharmacy technician about reproductive and sexual health and emergencycontraception that will help to increase the quality of emergency contraception.141 Stephanie et al. (2005): Studied a medical error by developing a model. They analyzed 25 different categories of doctors, paramedical staff and hospital

administration authorities by atlas software to record their visits by audio recording. They found four major factors which affected these disclosures provided issues, patient factor, error factor and institutional factor.142 John sanders et al. (2003): They studied the variation in rates and nature of medical errors. They found that 5 to 80 times one lack error occurred in diagnosis and disease management, 11% doctor’s mistakes to give correct dose. So it was suggested that is a needs to mange such hazards to ensure patients safety.143 Irshad et al. (2005): They disclosed the prescription error for 12 months period and assessed that 83% prescriptions had doctors name while 82 % had their signature. They also found that 94.6 % had patients name 77.3 % had their age and 51.3 % had their gender, 100 % prescriptions had lack of address and weight of patient. Some of them were filled correctly, 94 % had dose interval. So corrective measures must be taken to avoid drug abuse and misuse as early as possible.144 Rawan et al. (2005): Studied prescription from private sector at Galle in Srilanka. They collected data theory questionnaire and found that 812 prescription contained 2336 therapeutic drug included in this study. Out of these 208 had suffered from illegible hand writing 85 % followed to the standard prescription writing guidelines while 37 % of medication even by their generic names so that it was concluded that further practices must be done to reduce this type of error.145 Patrick Cornor et al.(2005): They explored medical error in outpatient diabetic care unit. They identified the medical error related to diabetes and then categorized them.th data were collected from pathology lab and pharmacy. They also surveyed 5729 hyperglycemic patient taking medication for one year .they tabulated the errors as diabetes control, lipid control and pharmacy error. They found that diabetic patient 22.1 % error ,27 % error were found in prescription of CHF patient it is suggested that immediate action should be taken to avoid such condition.146 Jill M Baren (2006): Researched on prescription writing errors for children and also proved that computerized physician order entry reduced the error rate. For this purpose 120 children were taken as a sample. They also studied potential errors occurred to overdose and under dose of the patient. For this reason they took 1933 prescription out of which 15 % with potential errors, 8% of high dose, 7 % with low doses then recommended dose. One analgesic Oxycodone was prescribed in overdose. They compared children prescription age 4-12 yrs with adult 13-16 years 1.7 and 1.1 times

had potential errors respectively. Kids were prescribed by 5 or more medicine at the same date 3.3 times overdosed than dose receiving one prescription. So, they concluded that more potential error rate was found in out patient then studied inpatient error rate previously. Physician must pay attention while writing the prescription for children.147 Nadeem et al. (2001): Studied the prescription error in general practice. Classified these errors and explored the frequency of these errors. Also found the difference in prescription of general practice surgeries and high error rate in hand writing prescription. They had selected 23 doctors from their general practice in 3 community pharmacies for 2 months of period. From them 37.821 prescribed items they found that 2816 errors occurred with an error rate of 7.46 /100 items (95% CL 7.2-7.8)the common errors found in direction ( n=56) gave an error rate of 28/100 items (95 % CL 26-3) each doctors from different surgeries had different error rate with median ( interquartile range) 9.1(1.86) 3.4 (1.9) and 1.9 (1.4), kruskal Wallis ,chi –square 11.6,df=2 (p=0.003). Out of 1373 hand written items error found on 140 items that was (10.2%) compared with 1,233 of 33772 computerized items (7.9%) (CHI –Square 15.65, df=1,p≤0.0001) hand written prescription had more errors. Doctors’ from different practices made different types of errors.37 Khawaja Rizwanaualh et al. (2005): Studied benzodiazepines prescription from different consultants at AKU Karachi and interviewed 280 subjects. The data collected was examined by SPSS 10. The point prevalence was 21.2 %, found higher in men than woman. Common indications found were re anesthetic and psychiatric symptoms. 84 % patients taken drug orally and mean value equivalent dosage is 4.86 mg/day. They suggested that clear guild lines should be issued to health care professionals for the prescribing pattern of benzodiazepines by the authorities.148 Nabeel Zafar et al. (2008): They assessed the prescribing pattern of the medical students of Karachi of the two universities. The data were collected from 600 prescription and the results evaluated by the aid of Chi –square method and logistic uni-variate regression analysis performed on SPSS 14 version. They taken 295 prescriptions of medical student out of which 163 (55.3%) prescribed medications 48.5 % practiced this 2-3 times annually. The result found was practiced before (68.7%), problem was irrelevant (34.4%) and known everything 31.3 % (33.6 % undergraduate medical students prescribed drugs separately and 78.3 % of students prescribed them

from others. They concluded that prescription given by the non medical professionals should be injurious to patients care should be taken in this regards.149 Kripalani et al. (2007): Revealed that the prescription writing guideline. Their research was first published online on 20 Aug 2007. They explored that 40% of the medicinal agents in scanned drug cards were given without allergic information. This showed the prescription writing guideline should followed by every health care professionals.150 Khalil Memon (2010): He studied irrational use of the medicinal agents in the Sindh province of Pakistan. He randomly selected 1320 subjects from 30 hospitals belonged to three districts of Sindh. From them 30320 patients, 900 patients were interviewed about patient counseling. The standard was taken as WHO recommendations. He concluded that the overall condition of rational use of medication was worse in Sindh. It was suggested that it needs a great concentration and improvements.151 Philip Sloane et al. (2002): They worked on prescription pattern in old aged patients of residential care/assisted living. They collected samples through stratified random sampling method in which a total of 2078 residents were taken as sample. All the prescription and non prescription items before 4-7 days of data collection was analyzed. It was found that patients took 5 medications, 16 % received inappropriately prescribed medication. This problem related to the number of medication received, smaller bed size, lack of licensed nurses, absence of dementia and absence of weekly doctor’s visits. Attention must be paid for this purpose.152 Fuh et al. (2005): They determined the patients who were substance dependence in diagnostic and statistical manual of mental disorder. Edition IV DSM-IV and to identify the variable of substance dependence in patients with daily headache. They analyzed that patient in clinic from November 1999 to June 2004. The presence of likely medicine daily use headache (PMOH) was defined on the basis of international classification of headache disorders, second edition 2004. Hence, they concluded that such happened due to severe headache.153 Bilenko et al. (2006): Discovered the reasons that anti-pyretic agents were given to the children suffered from pyrexia which was sometimes given with wrong dose and with incorrect frequency of dose so they concluded that serious attention should be given to administered the actual recommended dose to children to avoid fetal consequences.154

Nousheen Aslam et al. (2010): They disclosed the prescribing patterns of doctors in different hospitals of Karachi for the period of 5 months. They studied 1000 medicines and also designed a few charts to gather the data about patients’ demography, reason of hospitalization, medication and number of analgesics. Patients took medicines according to their gender and age group within prescribed frequency. Prescription errors were evaluated in terms of frequency and percentage. 1000 medicine charts were assessed. 5891 drugs were given, out of them 1084 were analgesics (18.4%), 821 (75.7%) were non opioids and 263 (24.26%) opioids. Females were more exposed to analgesics (n=564.56.4%) than males (n=436, 43.6%). Age group were 11-30 yrs (n=263,26.3%) and 31-70 yrs (n=200,20.00%). Paracetamol was given as (n=340,34%), opioids were (n=263,26.3%) acetic acid NSAIDS (N=198,19.8%) aspirin (n=175,17.5) propionic acid NSAIDS (n=56,5.6%) and Fenamic acid NSAIDS (n=52,5.2%).paracetamol and aspirin in combination were more prescribed. Omission of weight of patient were most common error found during this study (n=174,17.4%).strength of tablets (n=136,13.6%) wrong dosage form (n=116,11.6%) and absence of route of administration (n=104,10.4%).155 Arun Kumar Dubey et al. (2006): They discussed the selection of drug administration techniques. It may be sometimes the main reason of medication error. Manipal teaching hospital identified this error and worked out to reduce this type of error with the collaboration of managerial and educational means.156 Khurshid Khowaja et al. (2008): They worked to report the drug administration error in tertiary care hospital of Karachi Pakistan. They used two samples, 1000 medication dosage at 95% Cl for analyzed medication error, second was subject that used medication e.g. doctors, nurses, pharmacist and patients. They used methodological triangulation methods. They found 100 % results with CPOE system by doctor, nurses and pharmacist. Error rate found was 5.5 % out of which 2.6 % pharmacist involved, 1.1 % nurses and 1 % doctors. Dispensing and administration of drub from prescription should be designed electronically were suggested.157 Tamuno & Fadare (2012): In this study they analyzed 500 prescriptions from patient department of AKTH between April – June 2009. The average number of drug prescribed was 3.04.generic name prescription was low at 42.7%.antibiotic prescription was high at 34.4 %. 4% injections were prescribed, while 36.2, 19.1, 25.8, and 1% had analgesics, anti malarial, antihypertensive and anxiolytics respectively.

9.7% vitamins were prescribed. Much use of antibiotic prescriptions and very rarely prescribed by generic name were common in Nigeria. It require proper audit and need to design strategies to avoid the irrational prescription.158 Teferra et al. (2002): Morbidity and mortality rate had been greatly reduced by the appropriate utilization of drug globally. It was suggested that it will also give medical, social and economic benefit to the patient.159 Erah et al. (2003): Their study showed that health care delivery system all over the world mainly depended upon the prescribing pattern of doctors. According to them, inappropriate and irrational prescribing of medication is the major cause of problem around the world at present time.160 Zou Jun et al. (2011): They studied the daily prescription indicator. According to WHO criteria and by comparing their mean of 10 days. They collected data from 1180 prescription and analyzed that prescribed by their generic name was 69.2%, antibiotic prescription was 39.15%, injections prescribed were 22.63%. Average number of drug was 2.04, and average drug cost was 124.30($18.24). By comparing the trend of prescribing, the drug cost and generic name percent increased annually. Other indicators had been included in decreasing trends. Academic and administrative intervention made by Chinese medical management. In this study it was observed that some prescribing indicators were higher in other countries but trends became more rational now.161 Malangu and Nchabeleng (2012): In this study antiretroviral prescription were received to determine the type of prescription error and to study its impact on patients. Of these 12 (6.2%) errors found during dispensing, prescription errors occurred 181 (93.8%) prescription, incorrect dose regimen 33% found, omission error 50% majority of these errors were corrected by the pharmacist and no harmful results happened. The prevalence of prescription error was 27.1%. the most common error was incorrect dose regimen . Continues medical training / education is suggested to overcome this situation.162 Eiad A Al Faris and Ahmed Al Taweel (1999): They researched to explore the prescribing patterns of family health care physician in Riyadh city, Saudi Arabia. In this study prescriptions were collected during two week from 8 PHC centers and were analyzed. a total of 17067 prescriptions most frequently prescribed drug is antihistamine (25%), paracetamol (20.3%) and antibiotic (14.7%).almost more than

half of the prescription URTI is diagnostic label used. other disease also mention such as diabetes mellitus, hypertension. 26% antibiotic were prescribed, 28% anti histamine were prescribed with URTI .many patients with psychological or psychiatric disorder were seen there during study period. No diagnoses for these were made. Special emphasis was made for detection, identification and management of mental disorders. Education about prescription writing for doctors must be providing. There is a need to know for both patients and doctors the benefit of the treatment and control of the illness. Non medical personnel treat the patient with flawed remedies that will create the doubts of quality, cost contaminant and accountability.163 Classen and Metzer (2003): This study discloses the facts that prescribing medication associated with the high rates of unwanted errors and side effects but these are normally prescribed or administered to cure or prevent the patient to improve his/ her quality of life and leads to positive health related outcomes.164 Kardas et al. (2007): This survey of outpatients was done in order to determine the use of antibiotics as self medications during a period of last one year for detecting those factors which possess of leftover antibiotics in society. According to them in their country it was common practice that antibiotics were dispensed in fixed packs instead of exact numbers of dosages and also reuse of these leftover antibiotics was very common. This misuse of antibiotics was just because of unavailability of information’s which should be provided by doctors or pharmacist to the patients. Hence it was proposed that a complete guidance should be available for the patients regarding the safe doses of antibiotics and the proper treatment of antibiotics.165 Mitsi et al. (2005): Their study shared an influential opinion towards antibiotics in Greek urban community. They studied the factors that affected attitudes to antibiotic use in Greek urban society. By means of a self designed questionnaire, they met with three hundred twenty three citizens for the reason of interview, out of which one hundred seventy three were adults while one hundred fifty were child care takers. Their outcome showed that adults used their antibiotics without consulting their Physicians, while the parents were conscious for their children so that they consulted with the doctors and only used prescribed medication. In the adults, 74.6% admitted using non-prescribed antibiotics, while only 22.7% of parents had administered non- prescribed antibiotics to their children. Approximately 50% of adults discontinued treatment earlier, more than 10% did not follow the correct dosage directives and

about 55% admitted using leftover antibiotics. Of the parents, 18.7% discontinued therapy earlier and 7.3% admitted keeping leftover antibiotics. The results expressed that adults were likely to show substandard compliance and to use non-prescribed antibiotics, while parents were less likely to use non-prescribed antibiotics for their children and were more compliant.166 Avorn and Solomon (2000): It was found that for the use of antibiotics by inpatients and outpatients economic, cultural as well as microbiological considerations must be considered. It was also suggested that physicians and policy makers must not be among those non therapeutic causes which played their role by creating hostility against therapeutic agents and also affected economy because of the use of unconcerned things. 167 Schollenberg and Albritton (1980): The misuse of antibiotics in a pediatric training hospital was also highlighted. Although there were differences, but the rate of reoccurrence mistakes concerning the use of antibiotics was same as was previously reviewed. The consequences of these errors or mistakes were increased risk of bacterial resistance, a change in hospital flora and undue price.168 Al-Ghamdi et al. (2002): The increasing rate of antibiotic misuse and the frequency of Hospital acquired infections were highlighted. For it, a study survey on 174 bed hospital in Saudi Arabia for a period of six month was done. They concluded that there must be effective procedures for decreasing the increased number of infections and increased misuse of antibiotics. Further, they proposed that a commission should be established to curb such occurrence. 169 Pechere (2001): According to him, it is essential to aware the people regarding the use and adverse effects of antibiotics. Hence he declared that its responsibility of Pharmacist to discuss with people the issues of antibiotics use. For the summarization of patients using antibiotics, 5379 cases from 9 different countries were discussed. He considered that antibiotics those drugs which are very potent and used against many harmful infections. On the other hand they can weaken our body immune system. He found in these 9 countries that it was common practice to sell the antibiotics by pharmacist without any prescription. And also he found the patients force their physicians to prescribe antibiotics. Hence he suggested that, proper awareness must be given to patients regarding the use of antibiotics.170

Reynolds and McKee (2009): Conducted a qualitative study in a province of southern China that seeks to appraise knowledge, attitudes, and practices in relation to the use of antibiotics. The misuse of antibiotics posses considerable risks. Effective action will be required to design a versatile strategy including education, based on an understanding of existing way of life, the replacement of perverse incentives with those promoting best practice and investment in improved observation. They also suggested all of this required to practice at National level.171 Oyetunde et al. (2010): Prescriptions are required for the sale of antibiotics but according to a survey in the Nigeria, it was not in practice to sale the antibiotics on prescription. It was seen that about 38.79% people were those who purchased the medicines without prescription but 25.86% people brought the drugs just by their names. While among them, without prescription buyers 90% were those who had no awareness regarding the use and duration of therapy of antibiotics. About 120 questions were asked by the surveyors during the survey and it was found that about 10% of the people bought the antibiotics without any prescription. It was also found that among all antibiotics, Ampiclox antibiotic was the most frequently sold brand. And it was suggested that regulatory agencies must focus on this misuse of drugs.62 Przemyslaw et al. (2005): Proposed that misuse of antibiotics has a negative effect on the people and also the community. The reason for such attempt was just to estimate the patient non compliance to the use of antibiotics which produced resistance in body and ultimately resulting in the failure of treatment. It was because of the use of same antibiotics by the patients without the prescription of the physician which produced resistance in the body and hence failure of the therapy occurred. 172 Peter Richman et al. (2001): A clear estimation of the misuse of the antibiotics was came forward after the survey and study of the patients who were using antibiotics without the prescriptions of their physicians. According to the data, there were total one thousand and sixty three volunteer participants in which 80% were white, 54% were woman, 58% were students of college level. 85% were those who had their family physicians, 88% had their health insurance. About twenty two people claimed that their physicians prescribed antibiotics even during the visit of the cold problems. It was amazingly seen that there were seventeen percent such patients of common cold, sore throat and urinary tract infection who took left over antibiotics, without the permission of their physicians. They believed that such types of problems should be

treated by antibiotics. From this survey it was concluded that how the people had false ideas relating the use of antibiotics. This was therefore concluded that such misconceptions of the misuse of antibiotics without the permission of doctor or pharmacist would be harmful and life threatening.173 Maki et al. (1978): Studied in a teaching hospital, the misuse of antibiotics and also the factors affecting the misuse of antibiotics. It was studied that in two months out of 549 hospitalized patients, 144 were receiving the same course of antibiotics. Further, it was also studied that the main cause of these seventy percent prophylaxis dose was infection. Out of 59% courses 30% were receiving right therapy and 17% adverse drug infections were observed. It was hence suggested that a complete educational program must be introduced for the dose regimen and administration of antibiotics.174 Nizami et al. (1992): In Karachi the practice by private pediatric physicians were studied. For it, 65 general and 29 doctors of children were selected. In the list of privately practicing physicians it was seen that out of total 2433 subjects 996 children were suffering from diarrhea. And for 49% cases antibacterial were prescribed. 53% practitioners suggested ORS for infants suffering from diarrhea while remaining physicians prescribed anti diarrheal agents. It was noted that there was dissimilarity in the self–accounted and practical prescribing behavior.175 Nicole Werner et al. (2011): Their investigational study associated with unwarranted use of fluoroquinolones in a tertiary-care academic medical center. They observe the frequency of its use, reasons to use and kind of adverse effects after use. The randomly-selected patient for fluoroquinolone therapy on published guidelines or standard principles of infectious diseases whether, it was necessary or unnecessary. After completion of therapy a chart review of 6 weeks was obtained to observe it adverse effects. 690 (39%) days were unwarranted out of 1,773. The most common unwarranted therapy for non-infectious or non-bacterial syndromes included 292 days of therapy of antimicrobials drugs. The time period not be more than 234 days of therapy. For urinary tract infection 30% include unwanted therapy. 27% of out of 60/227 treatment containing adverse effect , GIT having 14%adverse effect of course of therapy, 8% due to immigration of resistant pathogens and CDI 4% of regimens. In their organization 39% unwanted fluoroquinolone therapy was observed. Overuse of fluoroquinolones should be reduced with current guidelines for duration of antimicrobial therapy and for management of urinary syndromes.176

Anita Kotwani et al. (2011): This Investigational study from December 2007- November 2008 based on antibiotic use in the community by using three types of facilities patient interviews. These were include 20 private retail pharmacies, 10 public sector facilities, 20 private clinics to observe a complete record of antibiotics used in a year. Anatomical Therapeutic Chemical (ATC) classification and the Defined Daily Dose (DDD) measurement units were assigned to the facts. Antibiotic utilize was calculated as DDD/1000 patients visiting the facility and also as percent of patients treating with an antibiotic. 17995 patients visiting private retail pharmacies out of which 39% prescribed at least one antibiotic, 9205 public facilities out of which 39%prescribed at least one antibiotic and 5922 private clinics out of which 43%prescribed at least one antibiotic in observational study . Utilization patterns of antibiotics were comparable at private retail pharmacies and private clinics where fluoroquinolones, cephalosporins and most commonly prescribed groups of antibiotics extended spectrum penicillins. During prescribing antibiotics new members from each class of antibiotics were preferred. It was observed that some antibiotics consumption was higher in winter and fluoroquinolones during the rainy season were observed. Broad spectrum and newer antibiotics most commonly used in public and private sector at high rate. Appropriate and sustainable interventions of antibiotics facilities the rational use of antibiotics it would be helpful to decrease hazard effect of antibiotic resistance.177 Sotiria Panagakou et al. (2011): Their investigational study based on the Greek parents who had children of age between 5-6 years. It included all parents from all geographic areas of Greece. It was observed that 80% Greek parents thought that UTRIs are self limited and 74 % of them received antibiotics. 45% antibiotics were used due to cure ear ache. 10% antibiotics used for their children without medical device and 88% considered as unnecessary antibiotics to drives antibiotic resistance. About 70% of parents used antibiotics combination therapy with other medicine for symptomatic treatment for a child with URTI. Greek parents had a strong relationship with pediatrician and seldom administered antibiotics without checkup. It decreased misuse of antibiotics due to parents’ corporations. Unwanted antibiotics used in URTIs were very dangerous. Physicians spend a lot of time to create awareness among the people on the possible advantage from reducing antibiotic prescribing for children with URTI.178

Amy Sapkota et al. (2010): In their investigational study on 706 female undergraduate and graduate students at four universities in Southwest Nigeria it was assessed that, these universities were preferred by convenience and the study samples were accidentally selected group samples. The survey included self medication of antibiotics and analgesic in menstrual symptoms in these females. Information was analyzed by means of expressive statistics and logistic deterioration. The reaction rate was 95.4%, 86% of participants out of (95% CI: 83-88%) experienced menstrual symptoms, and 39% (95% CI: 36-43%) were analyzed using analgesics to treat these conditions. To treat menstrual symptoms by self-medication was only 24% (95% CI: 21-27%). The menstrual symptoms include cramps, headaches, pimples/acne, moodiness, tender breasts, bloating, heavy bleeding, backache, joint and muscle pain. Factor connected with this practice were at inferior level of instruction OR (Odds Ratio) i.e. 2.8, 95% CI: 1.1-7.1, p-value: 0.03 , non science major that is OR: 1.58, 95% CI: 1.03-2.50, p-value: 0.04, practice of analgesics i.e. OR: 3.17, 95% CI: 2.07- 4.86, p-value:<0.001); easygoing to tremendous serious bleeding i.e. OR: 1.64, 95% CI: 1.01-2.67, p-value: 0.05 and pimples i.e. OR: 1.57, 95% CI: 0.98-2.54, p-value: 0.06. To treat these symptoms mostly Ampicillin, tetracycline, ciprofloxacin and metronidazole were used. The use of antibiotics for menstrual symptoms by Doctors or nurses i.e. 6%, 95% CI: 4-7%, friends i.e.6%, 95% CI: 4-7% and family members i.e.7%, 95% CI: 5-8%. These drugs were obtained from local pharmacists i.e.10.2%, 95% CI: 8-12%. To treat menstrual symptoms with self medication of antibiotics just about 1 out of 4 university women surveyed in Southwest Nigeria. This put into practice could offer monthly, low-dose exposures to antibiotics among users. Additionally it was therefore emphasized that studies should be done to estimate the impacts of self-medication on student physical condition.179 Aref Bin Abdulhak et al. (2011): Their study explained sources of antimicrobial mishandling, growing antibiotics sales, lacking of medical prescriptions that make worse overall load of antibiotic resistance. By simulation of diverse clinical scenarios in Riyadh, Saudi Arabia the percentage of pharmacies who sold antibiotics without medical prescriptions was estimated. For five regions of Riyadh a cross sectional study of a quasi-random sample of pharmacies was completed. Two investigators visited to each pharmacy with a definite clinical disease i.e., otitis media, acute sinusitis, sore throat, acute bronchitis, diarrhea, and urinary tract infection (UTI) in childbearing aged

women. 327 pharmacies were visited it was observed 244 (77.6%) of 327, of which 231 (95%) antibiotics were dispensed without patient demand. Sore throat and diarrhea resulted in an antibiotic being dispensed in 90% of encounters, followed by UTI i.e. 75%, acute bronchitis i.e. 73%, otitis media i.e. 51% and acute sinusitis i.e. 40%. For diarrhea and UTI Metronidazole i.e.89% and ciprofloxacin i.e.86% were commonly given in these cases whereas 51% Amoxicillin was dispensed for the other cases. Allergic reaction of antibiotics or drug interaction information was not asked by any pharmacists. For UTI cases only 23% provided information about pregnancy. Without a medical prescription antibiotic can be obtained in Riyadh, related with clinical risks.180 Ashraf AbuKaraky et al. (2011): According to their study antibiotics prescribing practice depends upon procedure, patient and clinician associated factors. There is no compromise on the most suitable treatment for antibiotics in oral implant logy. 250 Jordan Dental Implant Group members were observed to investigate this study. To assemble the data 41 questions were chosen on a five page opinion poll. Numerical analysis was performed by means of SPSS Windows 16.0 i.e. SPSS Inc., Chicago, IL, USA. Expressive information were generated which showed response rate i.e.70.4% 176/250. Average age was 37.2 yrs, 49.4% always prescribed antibiotics mostly oral amoxicillin and amoxicillin with clavulinic acid. Three reasons which included flap raising, multiple implants and sinus or bone augmentation increased the antibiotics prescribing level. For the prescription of antibiotics three clinical factor which included i.e. patient medical condition, periodontitis and oral hygiene. Non-clinical factors which include reading technical equipment, courses, lectures, information gained during training and earlier experience with the medicine. Variation among the antibiotics was found due to antibiotics types, routes, dose and duration of administration. Recommendations on antibiotic use are required to avoid antibiotic overprescribing and mistreatment.181 Ghadeer Suaifan et al. (2012): According to this study antibiotic resistance depends upon the irrational antibiotics use. The investigational study in Jordan showed that mostly irrational antibiotic used among the community. Their aim to access up to date information, opinion and behavior on the topic of antibiotic use. Also to investigate what kind of reasons behind the resistance expansion among university students in Jordan this cross-sectional survey was conducted regarding medical and non-medical

students at the University of Jordan. Mostly non-medical female students were included in this study which showed 85% response rate. Analysis exposed insufficient knowledge, high consumption rates and self-medication among students in spite of their specialty. Only 44% non-medical and 28.1% medical students were agreed that antibiotics cure common colds and viral infections. Their last course of antibiotic did not completed by 61% of students, 31.2% antibiotic prescriptions from clinicians and 37.5% were prescribed antibiotics over the phone. In end, gaps in terms of information, opinion and practice concerning antibiotics used among students were estimated. Knowledge about antibiotics utilization and its resistance provided by National education programs to fill up this awareness gap. By controlling OTC sale, self-medication and high rates of consumption of antibiotics at a national level to regulate antibiotics.182 Antón et al. (2011): Their investigational study was on the use of anabolic medicine between the Spanish, Portuguese and Italian students in the Physical Education and Sport Faculties. In these three countries a survey was conducted in 6 different faculties from February to march in 2011. From 1st & 2nd year 144 students were selected for the study purpose. The investigational data showed that 25.2% students addicted by different kind of drugs, 3.4% male students used anabolic steroids in past and 5.2% student reported to use them in future. This data showed that only anabolic steroids created problems among teenagers and young sportsman. Including this Govt. should keep in mind other types of drugs, which have high consumption rate. Students should aware about drugs use and misuse by educational programs and other sources of knowledge from teachers, trainer and parents.183 Neuhauser MM et al. (2003): According to their study the use of fluoroquinolones was increasing day by day due to increase rate of fluoroquinolone-resistance among gram-negative bacilli in ICU. By reducing the use of fluoroquinolones may be helpful to bind the propagation of these pathogens. 66% fall in the use of fluoroquinolones was related to restriction program. CDI linked with fluoroquinolone-resistant North American pulsed-field gel electrophoresis type 1 (NAP1) strains.184 Skliros et al. (2010): This study was completed after visiting the 6 rural Health centers of southern Greece, between November 2009 and January 2010 while included data from 1,139 randomly selected adults (545 men/594 women, mean age ± SD: 56.2 ± 19.8 years). The entitled participants were required on a one-to-one basis and asked

to answer an unidentified feedback form. Within the past 12 months the use of antibiotics was reported by 888 participants 77.9%. 508 folks 44.6% reported that they had received antibiotics without medical recommendation at least one time. The major cause of self-medication was the pharmacy without prescription 76.2%. Among the antibiotics most commonly used for self-medication were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the most recurrent indications for the use of self-medicated antibiotics. Hence in Greece, despite the open and quick entrée to primary care services, it came into notice that a high percentage of countryside adult population used antibiotics without medical prescription usually for fever and common cold.185 Johan Schoring et al. (1991): This study described antibiotics utilized markedly in many areas of the world. To better describe how often and why these drugs were used, their use among a cohort of 105 children less than five years of age in a poor area of the northeastern Brazilian city of Fortaleza was studied. Throughout a 16-week period, 65 children took 137 courses of antibiotics. Physicians recommended 54% of these, mothers or their connections 39% and pharmacy workers 7%. Mothers and pharmacy employees recommended drugs for shorter courses than physicians, and were more likely to recommend drugs unsuitable for children. Period of illness was not a risk factor for antibiotic use, but both deprived nutritional status and poor socioeconomic status were the problem. Health care hunt behavior was further studied in 58 diarrhea episodes. The nature of care sought was related to the duration of illness. Overall, antibiotic use was very common and often badly chosen among children in this poor urban area. So it was suggested that more controlled use might shrink the use of potentially dangerous drugs and their disadvantages.186 Branthwaite et al. (1996): This study was done to determine patient perceptions of respiratory tract infections and attitudes to taking antibiotics, thus serving doctors to have a better perceptive of their patients and their requirements. Telephone interviews were conducted in the UK, Belgium, France, Italy, Spain and Turkey using standardized survey directed at patients who had taken an antibiotic or given one to their child for respiratory tract infectivity within the previous 12 months. About 200 working adults (< or = 55 years), 200 mothers of children (< 12 years) and 200 elderly adults (> 55 years) from each country were contacted; in total, 3610 subjects. Stress on

GPs to prescribe antibiotics was highlighted by over 50% of interviewees' believed that they should be prescribed for most respiratory tract infections. Though interviewees were optimistic about antibiotics, with over 75% judging them to be valuable and to swift recovery, some ambivalence was shown. Most patients waited 2- 3 days prior to consulting their doctor and over 80%respondents probable symptoms to improve after 3 days' treatment. This provided a natural division for compliance, with most defaulters stopping after 3 days because they felt better. Second only to lesser side-effects, patients ranked shorter and more suitable dosage alongside efficacy as the improvements most sought in antibiotic treatment. In wrapping up, patients regarded antibiotics as important in the treatment of respiratory tract infections, with concern shown in short-course, once-daily therapy. Doctors, however, need to restore patients confidence that short courses would eliminate infections and have minimal adverse effects on the immune system.187 Caig LF et al. (1995): According to this study at the National Ambulatory Medical Care inquiry a sample survey of office-based physicians in the United States held by the National Center for Health Statistics, Centers for Disease Control and hindrance. Physicians sampled for the 1980, 1985, 1989, and 1992 National Ambulatory Medical Care questionnaire, which included groups of 2959, 5032, 2540, and 3000 physicians, respectively. Model physicians responded in 1980, 1985, 1989, and 1992 reported data for 46,081, 71,594, 38,384, and 34,606 sample office visits respectively. Including information on antimicrobial drug prescribing from 1980 through 1992, rising prescribing measured by the annual drug prescription rate per 1000 population, was found for the more expensive, broad-spectrum antimicrobial drugs, such as the cephalosporins; declining rates were observed for less costly antimicrobial drugs with a narrower spectrum, such as the penicillins. No trend was set up for trimethoprim- sulfamethoxazole, the erythromycins, or the tetracyclines. During the decade, an increasing trend in the visit rate to office-based physicians for otitis media was practical, while the visit rate for sinusitis among adults was found to be superior in 1992 than in each of the further study years. The increased use of broader-spectrum and more expensive antimicrobial drugs have implications for all patients because of the impact on health care expenses and the possibility for the emergence of antimicrobial resistance. The data suggest that the incidence of otitis media and sinusitis is escalating.188

Chretien et al. (1975): Antibiotics self-treatment was evaluated among patients at a university health service in an 18-month period. Sixty-two students took antibiotics, usually or penicillin (21%), tetracycline (40%) for varying intervals before seeking medical care. Respiratory symptoms were the most general reason (40%). The most frequent drug foundation was residual medication obtained by prescription from a private physician for a previous illness (43%). Though self-therapy was of short duration, the negative bacteriologic cultures obtained on our evaluation in all but four patients challenged clear-cut diagnosis. The conclusions indicate that inappropriate use of antibiotics by patients would be shortened by prescribing only the precise amount needed for a given illness and by emphasizing the need for completion of the course of therapy.189 Calva et al. (1996): In developing countries, antibiotics are the most widespread drugs to be sold and some data suggested that they are recurrently misused. In order to portray the pattern of antibiotic use in a periurban community in Mexico City, 1659 randomly-selected households were visited and an interview with the housewives was carried out. Six local drug stores were also examined at random. A social worker made six visits to each pharmacy, noted the events during the purchase of the drug and applied a planned questionnaire to the customer instantly after the transaction. Of 8279 individuals, 425 (5%) said that they used minimum one antimicrobial in the earlier 2 weeks and antibiotics were the majority (29%) of the drug sales. The apparent reasons for drug use were acute respiratory tract ailments and gastroenteritis. The drugs most commonly reported were: erythromycin, cotrimoxazole, metronidazole, penicillin, neomycin and tetracyclines. While self-medication and drug purchases without medical prescription were common, the bulk of antibiotics were prescribed by a physician. About two thirds of individuals using an antibiotic said they had used it for less than 5 days and 72% of the purchases were for inadequate quantities of drugs. The data suggested that antibiotics were repeatedly misused and they hold up the need to assess the determinants of self-medication, health-seeking behavior and physician prescribing practices. So they concluded that there would be need for effective educational programs to advance prescribers' decisions.190 Reyes et al. (1997): A prospective cohort study was conducted to evaluate factors coupled with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study was conducted in four

primary health care clinics in Mexico City, two belonged to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty- two patients with ARI and 155 with AD were incorporated. Data about study variables and the evaluation of compliance were obtained through patient interviews and direct observation. Factors linked with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 55.5% for AD and 60% for ARI in both health care systems. Prescription of an antibiotic was observed only in 13.5% of cases. Related factors were: complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16- 3.26); increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an insufficient physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was elevated in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to alter physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.191 Ray K et al. (2003): A cross-sectional survey was conducted upon total of 500 respondents, 250 were adults and 250 children among them, who consumed antibiotics in the previous three months. Data were analyzed to conclude the patterns of compliance, utilization and awareness regarding antibiotic medication amongst the inhabitants at Kolkata. Antibiotic consumption without prescription was clear amongst 41.2% of adults in comparison to that of 8.4% in children (P < 0.01). Compliance to daily dosage was seen in 40.8% of adults in contrast to 82.8% in children (P < 0.01). Awareness pattern on the subject of antibiotics were reported to have been more in the children group (16.4%) while compared to the adults (8%). The awareness regarding antibiotic resistance remained more or less comparable in both the groups. The study concludes that elevated over the counter (OTC) sale and not enough compliance to antibiotic medication needs further intervention approach towards information, education and communication (IEC) to all concerned.192 Chen et al. (2011): The information on the basis of users v/s non users of Benzodiazepine and its misuse was collected by team work. This work was not only limited to these information but also include adverse effect of Benzodiazepine use and misuse among patients. In most of the cases anxiety was observed due to some fatal effect. This study also include control of Benzodiazepine misuse and abuse prescribed

by different prescriber to create effective treatment of anxiety so that patient should not become addicted.193 McCabe (2009): Their study was based on three characteristics i.e., purpose, route of administration, and co-ingestion with alcohol, other than OTC drugs misuse against four different types of disease i.e., pain, sedative/anxiety, sleeping, and stimulant medications to investigate drugs related problems. A net survey was done on three thousand three hundred thirty nine students who were attending four year study program of U.S university, self-medication subtypes and some prescription drugs mostly contained oral routes of administration and recreational subtypes were specified by recreational motives, oral or non-oral routes, and co-ingestion.194 Shenkman et al. (1995): Their study showed that syringe pumps were basically used to provide maximum drug concentration directly into the bloodstream. It was also used by addicted person and misusers to intravenously administer opoids like Morphine and Midazolam.195 Meltzer et al. (2011): Studied on the Current Opoid Misuse Measure(COMM) particularly in pain management patients by self-reporting assessment of medication- related behaviors. The activities of the COMM were evaluated in primary care (PC) patients with chronic pain. It was suggested that the COMM could identify the patients with prescription drug use disorder (PDD). English person in the case of chronic pain, receiving opoid analgesic prescription in the last year were administered to COMM. The Composite International Diagnostic Interview served as the ‘‘gold standard,’’ using DSM-IV criteria for PDD and (SUDs).196 Subramaniam et al. (2004): Their investigational study was to treat the psychiatric patients depends on different safe, quick and successful methods. They differentiate the healing process in three patients in ICU by polysubstance mistreatment in sedation with a benzodiazepine, lorazepam, and anaesthetic propofol. Only Lorazepam was not effective in mass high doses in these cases. Multiple agents were used to compensate withdrawal symptoms. It was noticed that Lorazepam was safe and successful in evaluating the symptoms of acute withdrawal syndrome associated with poly substance exploitation. To reduces vital dose and side effect in any individual drug by using Multimodal treatment with benzodiazepines, propofol, haloperidol, clonidine, and methadone. Further clinical studies were recommended with various combinations of drugs therapy to treat these patients require ICU admission.197

Bermas and Masooleh (2011): Their investigational study showed that family background is the major factor, which prevents the addiction from narcotic drugs at primary, secondary and tertiary stage. They explained how family contributes in prevention from addiction of narcotic agents.198 Elwood (2001): His observational study showed that the misuse of codeine cough syrup in two well known states of USA. According to his survey Codiene Syrup was continuously misused in USA as a result of increasing price upto 40 US Dollars. Deaths were reported due to codeine misuse and overdose in many cases.199 Longoria (2005): His study showed inhabitants demographic individuality of grandparents raised grandchildren across the United States and observe the neighborhood conditions, as compare to alcohol and drug (AOD) consumption as predictors of these surrogate parents. From the compound global diagnostic interviews were taken from grandparents on AOD utilization, only twelve mental components outline was used to evaluate expressive well being. A major investigational component was employed to assemble “apparent regional risk” to explain grandparent’s opinion of neighborhood environment. Multivariate statistical investigation was done to obtain inhabitant’s approximate.200 Kelly and Parsons (2007): Their study on the Non medical prescription drugs showed that it was gradually increasing day by day among youngsters of eighteen. For the purpose of this investigational study they interviewed few club going youngsters to investigate the misuse of drugs which was prescribed drugs at high rates. The misuse of Analgesics, Sedatives and CNS Stimulants at devastating level. A huge number of medications indicated as pain killer. Among those young addicts, bisexual women were more likely to involve in drug abuse and misuse. So they also suggested to control over these young spoiled groups through public health initiatives.201 Morasco and Dobscha (2008): Their study on the substance use disorder (SUD) and self medication in one hundred twenty seven patients who received opioid analgesics for management of chronic pain.202 Donald and Harwin (2006): Their investigational study explained the parental abuse of drugs or alcohol to rapidly issue for child trouble social workers. According to their two hundred ninety records in one year period in four London boroughs over on average. Parental substance misused (PSM) were most important feature of

community work caseloads. Their study also included misuse of alcohol and other addicted substance that create problem in social life.203 Sketris et al. (1985): Their study explained that sixty four maritime doctors prescribed benzodiazepine through compilation over 154 days. Diazepam, chlordiazepoxide and oxazepam most commonly prescribed anxiolytic benzodiazepine. These three agents covered almost 60% of all benzodiazepine prescriptions. Triazolam and flurazepam were prescribed eight times more, while the other two agents were also used frequently i.e. Nitrazepam and Temazepam. They therefore suggested that in order to control use of benzodiazepines few steps should be taken by Pharmaceutical industries, Pharmaceutical marketing and medical educators to create an awareness regarding to the dangerous effects of Benzodiazepines. Doses should be adjusted for the prophylactic treatment. Only 3.3% out of total 7,066 prescriptions were inappropriate.204 Berry et al. (2000): It was surveyed that in UK and Ireland, three hundred four departments of anesthesia were sent opinion to poll for alcohol and drug abuse in anesthetists above the previous 10-year period. Particulars were searched on the basis of the nature and degree of matter problems, their appearance and supervision. A high response rate of 71.7% was achieved and total of 130 cases were accounted, out of which 34.6% were consultants while 43.2% were trainees. More than half of respondents felt a lack of confidence in treating with alcohol or drug misuse amongst coworkers. The results of this survey demonstrated that in the UK and Ireland over the last 10 years more than one anesthetist per month had presented with important alcohol or drug misuse. It was suggested to be significant that those with management liabilities for departments of anesthesia were responsive that such difficulties existed and were likely to effect on the professional aptitude and health of the affected individual. Recently, public guidance in the management of these problems the Working Party on Substance Abuse at the Association of Anesthetists. A case was made for increasing responsiveness in this vulnerable issue to allow early gratitude and management of an anesthetist who misuse alcohol and drugs, since intrusion can be valuable.205 Gilbert Gee et al. (2007): The Objectives of this study was to examine the relationship among self-reported inequitable management and prescription medication use, illicit drug use, and alcohol dependence. For that purpose data from the Filipino

American Community Epidemiological Survey was used and a cross-sectional analysis engaged 2217 Filipino Americans for interviews in 1998–1999. The association between unfair treatment and the substance use categories were assessed on the basis of multinomial logistic and negative binomial regression analyses. Information of undue treatment were related with prescription drug use, illicit drug use, and alcohol dependence after managing age, gender, location of dwelling, service status, educational rank, racial characteristics, confinement, verbal communication spoken, matrimonial status, and a number of health situations. Undue cure may contribute to illness and succeeding exercise of prescription medications. In addition to, some persons may used illegal drugs and alcohol to deal with the anxiety allied with this treatment. Concentrating on the past history of unjust treatment may also be a possible way. They sought to expand prior investigation by scrutinizing the relationships of recognitions of iniquitous treatment with alcohol dependence, use of prescription and illegitimate drugs. Because unfair treatment may direct to illness and consequent use of medications, it was conjectured that wrong management would be associated with larger use of prescription medications. Furthermore, given that individuals may abuse substances to deal with stress helped in unfair treatment, it was hypothesized that unfair treatment would be associated with probable misuse of medications, use of illicit drugs, and alcohol dependence.206 Glanz et al. (1986): According to this study the role of general practitioner has become more prominent in recent spread of drug misused in the United Kingdom. Although general practitioners might be the first get in touch with, few data were offered on the extent of their contact with drug misusers. A postal survey was carried out in mid-1985 of a 5% national sample of general practitioners in England and Wales related to their role and views on the treatment of opiate misusers, including the degree of their contact with such patients during a four week period. Of the 1166 general practitioners surveyed, a response rate of 72%, 845 replied. The results illustrated that around one in five general practitioners in England and Wales attended an opiate misuser during this four week period, seeing an expected 6000 to 9000 patients, one third of who were "new" to the general practitioner. A cautious estimate of between 30,000 and 44,000 new cases of opiate misuse presented to general practitioners in a year was suggested, with some modification because of double counting. A wide variation in the commonness of consultations among regional health

authorities was set up, and several of the regions with a high prevalence are outside the London area. The scale of contact thus confirmed the importance of the general practitioner in the national response to drug misuse.207 Christine Barrowclough et al. (2010): This study was done in order to evaluation of efficiency incorporated motivational interviewing and cognitive behavior treatments in order to standards care for patient with psychosis and a co-morbid agent use problems. There are three hundred twenty seven patients with a clinical analysis of schizophrenia, or schizoaffective disorder, schizophreniform disorder and a diagnosis of dependence on alcohol or misuse of drugs, or both according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition were studied. The intrusion was integrated motivational interviewing and standard care and cognitive behavioral therapy, this was comparing with standard care only. In phase I of treatment which was on the motivation building instrument associated in engaging the patient, then exploring and resolving ambivalence for change in substance use. In phase II on the action instrument helps & make easy changes using cognitive approaches of behavior. There were setup of twenty six treatments in a year up. There were 327 samples were randomly allocated to either the intervention [n=164] or therapy as usual [n=163]. At twenty four months, 99.7% [326] were evaluated on the primary results and 75.2% [246] on the main outcomes. Therapy had no any positive effect on admissions in hospital or death during the follow-up, with 38/163 [23.3%] of the treatment group and 33/163 [20.2%] of controls deceased or admitted. Treatment had not showed the effect on frequency of drug use or the perceived negative consequence of drug misuse. The treatment had a significant association on readiness to change use at one year [2.05, 95% CI 1.26 to 3.31; P=0.004]. There had no effects of therapy on clinical experimental results such as psychotic symptoms, relapses, self damage and functioning. 208 Arpino C et al. (1995): Antidepressant prescribing patterns were studied, over a period of 30 months, in indiscriminate sample of 8743 residents of the area of Rome, Italy. Regional outpatient drug monitoring system’s data were used. The fraction of subjects received at least one prescription of antidepressant drugs was 5.4%; the female-to-male ratio was 2.1. Utilization prevalence increased with age. The most prescribed drug was fluoxetine followed by ademetionine and amitriptyline. For unexpectedly high proportion of subjects, the observed length of treatment was shorter

than expected on the basis of present knowledge in clinical pharmacology unsuitable diagnostic and therapeutic procedures likely explained.209 Barbui C et al. (2003): This current cross-sectional database analysis was intended to define what constitutes a typical population of patients receiving antidepressants. From a database covering a population of 1,057,053 residents in Piedmont, Italy, and counting all community (i.e. outside hospitals) prescriptions reimbursed by the NHS, all prescriptions of antidepressant drugs dispensed for the duration of the first six months of 2000 were extracted. Using the general practice patient code all minutes were attributed to a sample of patients receiving antidepressants. During the study period 22,135 patients were dispensed one or more prescriptions, yielding a prevalence of use of 27.6 (CI 27.1, 28.0) per 1,000 females and 13.7 (CI 13.4, 14.0) per 1,000 males (female/male ratio 2.01). The prevalence of use gradually increased with age, with the maximum rates in subjects over 75 years. The distribution of patients by number of antidepressant prescriptions showed that nearly 50% took only one or two prescriptions during the six months survey. Moreover, 18,676 subjects (84%) were prescribed antidepressants jointly with other medications. These data suggest moving the focus of antidepressant drug trials from chosen to non-selected populations of patients, including the elderly and patients with medical co morbidity, enrolled by using entrance criteria as close as possible to those adopted in everyday clinical practice. The high proportion of irregular antidepressant users suggested that clinical trials should go after all patients, without excluding those who failed to continue the study of medication.210 Simoni-Wastila L et al. (2006): They studied the substance-related disorders, drug- induced disorders, cocaine-related disorders, dependency, opioid-related disorders, abuse, stimulant-related disorders, marijuana-related disorders, and withdrawal syndrome. MEDLINE and Psych-Info were searched. Articles published in English between January 1, 1990, and May 31, 2006 was included in review. Despite a bulk of information on the epidemiology and treatment of alcohol abuse in elderly, few comparable data were obtained on drug abuse in this population. The evidence suggested that although illegal drug used was comparatively rare among older adults compared with adolescents and younger adults, there was a rising problem of the misuse and abuse of prescription drugs with abuse potential. It was therefore expected that up to 11% of older women misuse prescription drugs and that nonmedical use of

prescription drugs among all adults aged > or =50 years would add to 2.7 million by the year 2020. Factors associated with drug abuse in older adults included female sex, history of a substance-use or mental health disorder, social separation and medical exposure to prescription drugs with abuse potential. No validated screening or assessment equipments are accessible for identifying or diagnosing drug abuse in the older population. Special approaches may be essential when treating substance-use disorders in older adults with manifold co morbidities and/or functional impairment, and the least concentrated approaches should be considered first. Psychoactive medications with abuse possibility were used by at least 1 in 4 older adults and such use expected to develop as the population ages. The treatment of disorders of prescription drug used in older adults might engage family and caretakers, and should take into account the unique emotional, physical and cognitive factors of aging. Further, it was suggested that research on the epidemiologic, health services, and treatment aspects of drug abuse in older adults, as well as the expansion of appropriate screening and diagnostic tools.211 Holm et al.(1989): They carried out a general practice, in which a multicentre- questionnaire for investigation was designed, according to their survey prescription of psychotropic drugs to 3,756 patients was defined as per object; psychiatric diagnosis, treatment and addiction. Women and men were prescribed by psychotropic drugs twice but no difference of worth was noticed between the relative distributions of the variety of objects of prescription. 83% to 90% of the psychotropic drugs were prescribed as tranquilizers or hypnotics while 9% to 13% were prescribed for the management of psychosis. Two thirds of the psychotropic drugs were prescribed for patients who were measured mentally normal, as well as those suffering from environmental and psychosocial problems while only 1/3 of the patients had a real psychiatric diagnosis. Between 18% and 81% of the patients for whom psychotropic drugs were prescribed, depend upon the pharmacological assembly, did not have any real psychiatric problem. Whereas, for 50% of the patients, the psychotropic medication prescribed was the only figure of treatment, 17% had traditional interview of treatment from the general practitioner and 17% had received treatment from a specialist in psychiatry or had been admitted to a psychiatric department. More or less 20% of the patients for whom psychotropic drugs were prescribed were potential or true addicts.212

CHAPTER # 03

Research Methodology 3.1 Collections of data: The survey data used in study was collected through primary and secondary source. Pharmacies/clinics/hospitals of the following targeted areas of Hyderabad have been taken as population 1. Sadder 2. Latifabad 3. City 4. Qasimabad 5. Heerabad 6. Pretabad 7. Fort area 8. Hussainabad 9. Market.

3.2 Analysis of data: On one hand well-designed questionnaire according the nature of study has been used to collect information for analysis and on other hand analysis sheet was prepared as per authentic references material (See page # 85 and 86), such as British National Formulary, (Mar 2010)90, Drug Information Hand Book (Lacy Charles F et al., 2010) 91 and World health organization (WHO) Parameters / standards for Prescription Writing (De Vries TP et al., 1995)25. The study also focuses to explore the role and contribution of doctors, medical representative, field manager of drug promotion companies, retailers and drug regulating agencies. Ms-Office 2007 and Statistical tools such as Mean, Standard Deviation, Cumulative Frequencies, Relative Frequencies, Chi square test, Z test, ANOVA, Regression Analysis, and Graphical Representation of data have been applied through the Statistical package SPSS17.0

3.2.1 Analysis of 2000 samples. Using simple random sampling 2000 patients/customers were interviewed and the designed questionnaire and analysis sheets were filled to analyze the information contributing to drug misuse and abuse. Collected samples have been classified in to two categories, with prescription and without Prescription. Both categories have been classified separately and tested for further statistical treatment. Other characteristics of data have been evaluated are wrong prescriptions (generated by unqualified people /Quacks), prescriptions errors, drug advertisement, busy pharmacies, easy availability of controlled drugs, pharmacies or medical stores being run without professional without Pharmacist, enquiry of prescription by medical store keeper at pharmacy, improper time for consultation (Diagnosis, medicines decisions for prescriptions and counseling) during prescriber’s lust for heavy OPD, self medications, improper follow-up of patients, lack of concentration of drug regulating agencies and unethical promotions of pharmaceutical companies etc. Different tools of SPSS17.0 for classification and conclusion were used. These include Chi square test at alpha = 0.05, Regression Line for prediction, Frequency distribution etc. Out of 2000, 1168 Samples were found without prescription. These were further evaluated for various factors contributing in drug misuse and abuse in our society. The factors considered were self medication, trend of sales of medications, incorrect use of medication as per British National Formulary (Mar 2010)90 such as per time dose, per day frequency, duration and combination of improper usage of more than one parameters mentioned in analysis sheet/table no (i) see page # 85.

For 832 samples found with prescriptions, analysis sheets were filled to evaluate these for prescription errors as per authenticated references; British National Formulary (Mar 2010)90 and WHO Parameters for Prescription Writing (De Vries TP et al., 1995)25 mentioned in analysis sheet/table no (ii) see page # 85, the trend of types/classes of dispensed prescription at medical store, and date of generations of the prescriptions.

3.2.2 Analysis of 500 samples. The second main aspect of this study is to assess patient counseling. Using simple random sampling technique 500 samples (excluding first 2000 samples) were interviewed and questionnaires were filled after dispensation of medicines from the pharmacy or dispensary to know whether patients were counseled properly for drug use or not. Further the data have also been tested regarding proper medication usage as per British National Formulary (Mar 2010)90 references and other factors such as counseling by doctor during OPD, by pharmacist / store keeper / dispenser during dispensation of medications and literacy ratio of patients visited government hospitals OPDs. The study was conducted in one of the targeted government hospital in Hyderabad. SPSS 17.0 version has been used for systemic arrangement of data, Chi square test and Z test etc. 3.2.3 Analysis of 286 samples. A sample of 286 prescriptions (Excluding above said 2000 and 500 samples), containing at least one antibiotic, have been selected randomly, For further statistical treatment these 286 prescriptions were grouped according to specific classes of antibiotic, i.e., Penicillins, Cephalosporins, Tetracyclines, Quinolones, Macrolides, and Amino glycosides mentioned in analysis sheet/table no (iii) see page # 85. A prescription must contain 16 standards/parameters as per authenticated references; British National Formulary (Mar 2010)90, Drug Information Hand Book (Lacy Charles F et al., 2010) 91 and WHO Parameters for Prescription Writing (De Vries TP et al., 1995)25. Lack or deficiency of any of these parameters in prescription has been considered error(s) containing prescription mentioned in analysis sheet / table no (iv) see page # 86. This study was carried out after collecting the prescriptions from a one government hospital, three private hospitals and 10 outpatient clinical settings in various areas of Hyderabad, Sindh, Pakistan. Different Statistical parameters i.e. Mean, Standard deviation, Confidence interval for mean, ANOVA through the help of SPSS 17.0 have been calculated to reach at conclusion.

3.2.4 Analysis of 50 samples (Doctors) Analysis of doctor’s role in eradication of drug misuse and abuse 50 doctors from different areas of Hyderabad were selected randomly and interviewed to know their role in the eradication of drug misuse and abuse. Simple statistics have been used through SPSS 17.0. 3.2.5 Analysis of 50 samples (Drug promoting individuals) Analysis of drug promoting individual’s role in eradication of drug misuse and abuse 50 drug promoting individuals (Medical Representatives and Field Managers) were randomly selected from the different drug promoting companies of Hyderabad to explore their role in the eradication of drug misuse and abuse. Descriptive statistics have been used through SPSS 17.0. 3.2.6 Analysis of 50 samples (Retailers) Analysis of role of dispenser or store keeper in eradication of drug misuse and abuse 50 retailers or store keepers or dispensers were selected randomly from different targeted areas of Hyderabad to explore their role in the eradication of drug misuse and abuse. Tabular and graphical representations have been used through SPSS 17.0.

Table (i): Analysis sheet 01 BNF Parameters / Incorrect use / Percentage Correct use / Percentage standards for proper Improper use Proper use dose of medications DRUG - - INFORMATION Dose Per time Per day frequency of dose Duration of therapy More than one parameter together

Table (ii): Analysis sheet 02 WHO Parameters / Not written / Percentage Written / Percentage standards for Not mentioned / Mentioned /Not prescription writing error error

DRUG - - INFORMATION Dose per time of medication Per day frequency of dose Duration of therapy More than one parameters together

Table (iii): Analysis sheet 03 Distribution of Antibiotic prescriptions according to specific drug classes Antibiotic Class Number of Prescription % age Penicillin Cephalosporin Tetracycline Quinolone Macrolide Amino glycoside Total Antibiotics

Table (iv): Analysis sheet 04 No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 02 Writing ambiguous medication order 03 Patient’s age not mentioned 04 Patient’s weight not mentioned 05 Patient’s gender not mentioned 06 Patient’s diagnosis not mentioned 07 Misspelling of medications 08 Missed directions of use 09 Dose omission or writing incorrect dose 10 Missed or incorrect dosage form 11 Missed or incorrect Strength of medicine 12 Missed or incorrect administration route 13 Missed or incorrect frequency 14 Prescribing without using metric system 15 Omission of prescriber’s signature 16 Presence of potential drug interaction

Errors have been evaluated at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards, using following formula. A C   100 AB C= Percentage of prescriptions containing errors A= Number of prescriptions having error AB= Total number of prescriptions.

CHAPTER # 04

Results, Statistical analysis and Discussion

2000 randomly selected samples have been classified for further statistical treatment to test different characteristics of samples. 4.1 Randomly collected 2000 patients/customers Randomly collected samples have been arranged according to their homogeneities

Table 1: Trend of sales of drug ‘with prescription and without prescription’ Trend Have you prescription of these Trend Without prescription medications? With prescription including OTC

No. customers/patients interviewed Yes =832 No=1168 2000 Interviewed during purchasing/after the 41.6% 58.4% dispensation from medical store/chemist

Figure 1: Trend of sales of drug ‘with prescription and without prescription’

Have you prescription of these medications?

Yes, 41.6% 42% Yes NO, 58.4% NO 58%

Table No 1; 41.6% respondent replied “No” and 58.4% replied “Yes” when inquired about the prescription during purchasing/after the dispensation from medical store/chemist. So the trend of sales of drugs at medical store/pharmacy in our society is with prescription and without prescription 41.6%, 58.4% (Table No. 01) including OTC respectively.

Table 2: Sex of the customers / patients

Sex of the customers / Patients

Valid Frequency Percent Cumulative Percent Percent

Male 1248 62.4 62.4 62.4

Valid Female 752 37.6 37.6 100.0

Total 2000 100.0 100.0

Figure 2: Sex of the customers / patients

Female, 37.6%

Male, 62.4%

Out of 2000 patients; 1248 and 752 were male and female respectively, mentioned in Table No. 02.

Table 3: Number of male & female (customers/patients) with and without prescription

Gender of customer/patient Frequency Percent C. Percent

Male with prescription 511 25.6 25.6

Female with prescription 321 16.1 41.6

Male without prescription 737 36.9 78.5

Female without prescription 431 21.6 100.0

Total 2000 100.0

Figure 3: Number of male & female (customers/patients) with and without prescription

Female without Male with prescription prescription 21.6% 25.6%

Female with Male without prescription prescription 16.1% 36.9%

Out of 1248 (Table No.03) male respondents 511 and 737 found with prescription and without prescription respectively. Out of 752 female 321 and 431 found with prescription and without prescription respectively.

Table 4: Age of the customers/patients

Cumulative Ages Frequency Percent Percent

< 15 years 149 7.5 7.5

16-30 years 521 26.1 33.5

31-45 years 581 29.1 62.6

46-60 years 505 25.3 87.8

> 61 years 244 12.2 100.0

Total 2000 100.0

Figure 4: Age of the customers/patients

700

600

500

400

300

200

100

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥61years Ages 149 521 581 505 244

2000 patients /customers (with prescription and without prescription) have been distributed in age groups to see frequent age group. It has been found that 149, 521, 581, 505, and 244 patient/ customer having ages 15 years or less than 15 years, 16 to 30 years inclusive, 31 to 45 years inclusive, 46 to 60 inclusive and 61 years or above respectively, mentioned in Table No.04

Table 5: Age of the customers/patients with prescription

Age Frequency Percent Cumulative Percent

< 15 years 62 7.5 7.5

16-30 years 226 27.2 34.6

31-45 years 240 28.8 63.5

46-60 years 211 25.4 88.8

> 61 years 93 11.2 100.0

Total 832 100.0

Figure 5: Age of the customers/patients with prescription

Age of the customers / patients with prescription 300

250

200

150

100

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥61 years

Furthermore, patients/customers with prescription (832) have been distributed in age group to check most frequent age group with prescription. It has been seen in the survey study that 62, 226, 240, 211, 93 (Table No 05) patients/customers having ages 15 years or less than 15 years, 16 to 30 years inclusive, 31 to 45 years inclusive, 46 to 60 inclusive and 61 years or above respectively.

Table 6: Age of the customers/patients without prescription

Age Frequency Percent Cumulative Percent

< 15 years 87 7.4 7.4

16-30 years 295 25.3 32.7

31-45 years 341 29.2 61.9

46-60 years 294 25.2 87.1

> 61 years 151 12.9 100.0

Total 1168 100.0

Figure 6: Age of the customers/patients without prescription

Age of the customers / patients without prescription 400

350

300

250

200

150

100

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥61 years

Table No. 06;1168 patients/customers without prescription have been distributed in age group to compare and check most frequent age group without prescription. It has been seen in the survey study that 87, 295, 341, 294, 151 patient/customer having ages 15 years or less than 15 years, 16 to 30 years inclusive, 31 to 45 years inclusive, 46 to 60 inclusive and 61 years or above respectively.

Table 7: Area of customers/patients interviewed

Area Frequency Percent Cumulative Percent

Sadder 291 14.6 14.6

Latifabad 242 12.1 26.7

City 241 12.1 38.7

Qasimabad 206 10.3 49.0

Heerabad 219 11.0 60.0

Pretabad 218 10.9 70.9

Fort area 211 10.6 81.4

Hussain abad 180 9.0 90.4

Market 192 9.6 100.0

Total 2000 100.0

Figure 7: Area of the customers/patients

Area of customers / patients interviewed 350

300

250

200

150

100

09 targeted areas of the Hyderabad have been surveyed; Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad, and Market, interviewed patients/customers are 291, 241, 241, 206, 219, 218, 211, 180, and 192 which is shown

in Table No. 07 respectively. These are the famous/potential and main areas of Hyderabad in the context of clinics and hospitals. Mostly in Hyderabad hospital and clinical setup of doctors are in the said areas.

Table 8: Area wise prescription and without prescription

Area With Pres. without Pres. Total

Sadder 172 119 291

Latifabad 126 116 242

City 98 143 241

Qasimabad 78 128 206

Heerabad 97 122 219

Pretabad 58 160 218

Fort area 72 139 211

Hussainabad 59 121 180

Market 72 120 192

Total 832 1168 2000

Figure 8: Area wise prescription and without prescription

200 180 160 140 120 100 Area wise with 80 prescription 60 Area wise without prescription 40 20 0

In table No. 08; it has been also focused in the study that the patients/ customers area wise without prescription and with prescription to compare and check in which area mostly patients/customers are without prescription and with prescription.

Out of 832; 172, 126, 98, 78, 97, 58, 72, 59, 72 patients/ Customers found with prescription in the area of Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad, Market respectively. Out of 1168; 119, 116, 143,128.122,160, 139, 121, 120 patients/customers found without prescription in the area of Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad, Market respectively in our society. Table 9: Trend of store keeper inquiry about prescription Does store keeper inquire you about prescription?

Response Frequency Percent Cumulative Percent

890 Yes 44.5 44.5

No 988 49.4 93.9

To Some extent 122 6.1 100.0

Total 2000 100.0

Figure 9: Trend of store keeper inquiry about prescription

Trend of Store keeper inquiry about prescription 1200

1000

800

600

400

200

0 Yes No To Some extent

2000 samples have been further classified according to trend of prescription enquiry at medical store/pharmacy in our society, mentioned in the table No. 09, when the question “Does Store keeper inquire you about prescription” was asked from the patients/customers, 890 patients/customers replied “Yes”. 988 replied “No” and 122 replied “to some extent”.

4.2 With prescription (Samples 832) Prescriptions errors analyzed as per WHO basic/essential parameters/standards of prescription for prescription writing The prescription of patients /customers have been analyzed according to the WHO prescription standard

Table 10: Customers’/Patients' prescription analyzed

Cumulative Categories / Types of prescription Frequency Percent Percent Specialty Prescription( Category / Type 01) 469 56.4 56.4 General Practitioner prescription (GP) 165 19.8 76.2 (Category / Type 02) Hospital / Center / clinics Printed Prescription 131 15.7 91.9 (Category / Type 03) Just name of drug on prescription, No any 67 8.1 100.0 information of prescriber (Category / Type 04) Total 832 100.0

Figure 10; Customers’/Patients' prescription (Samples 832) analyzed

(Type 04) Just name of drug on prescription, No any information of prescriber, 8.10% (Type 03) Hospital / Center / clinics Printed Prescription , ( Type 01) 15.70% Specialty Prescription, 56.40% ( Type 02) General Practitioner prescription (GP), 19.80%

The prescriptions of ‘832 customers/patients have been analyzed and arranged according in to four categories/types, mentioned in Table No. 10. Prescriptions have been analyzed classified in following 04 categories / types.

Category/Type 01, Doctor's specialty prescription; It has been seen in (469 prescription) that the Name, specialty degree, Address and other information of prescriber were clearly printed. Category/Type 02, General practitioner prescription (GP); it has been seen in this second Category (165 prescriptions) that doctors’ Name, simple graduation degree and address were written in prescription. Category/Type 03, Hospital/Center/Clinics printed prescription; it has been found third category / type (131 prescriptions’) Category/Type 04, Just name of drug on prescription, No any other information of prescriber; it has been considered fourth category/type (67 prescriptions) these are papers just contains the drugs name only, neither any other information of prescriber. nor address of clinics or hospitals. These prescription are may be generated by unqualified/quakes which are totally deviate from WHO prescription writing standards.

Table 11: Evaluation of prescription that how much it is old on the basis of issued date

Date Frequency Percent Cumulative Percent

< 15 days old 411 49.4 49.4

16-30 days old 109 13.1 62.5

31-45 days old 79 9.5 72.0

46-60 days old 66 7.9 79.9

> 61 days old 69 8.3 88.2

Date Not written 98 11.8 100.0

Total 832 100.0

Figure 11: Evaluation of prescription that how much it is old on the basis of issued date

Evaluation of prescription that how much it is old on the basis of 450 issued date

400

350

300

250

200

150

100

0 >15 days old 15-30 days 30-45 days 45-60 days > 60 days old Date Not old old old written

In the table No. 11, the Prescriptions have also been further evaluated on the basis of issuing date. Checking of issuing dates factor is important due to refilling of prescription, misuse or addiction of drugs. Date of generation of prescription is important part of prescription which is explained by WHO guidelines for prescription writings and during refilling of prescription it is necessary to check the date of prescription on top priority basis by Pharmacist/dispenser. A big number of prescriptions found 15 days or less than 15 days old i.e. 411 prescriptions and109, 97, 66, 69 Prescriptions found 16 to 30 days old inclusive, 31 to 45 days old inclusive, 46 to 60 days old inclusive, 61or above days old respectively, 98 prescription were seen without mentioning the date of issue/generation respectively.

Table 12: Distribution of prescription categories/types area wise

Area Type 01 Type 02 Type 03 Type 04 Sadder 30.06 10.3 7.63 5.97 Latifabad 15.35 15.15 16.03 11.94 City 12.15 10.9 12.21 10.44 Qasiabbad 9.38 9.09 9.92 8.95 Heerabad 11.08 10.9 13.74 13.43 Preatabad 3.62 13.93 6.1 14.92 Fortarea 6.6 13.33 7.63 13.43 Hussainabad 6.82 6.66 7.63 8.95 Market 4.9 9.69 19.08 11.94

Total 100 100 100 100

Figure 12: Distribution of prescription categories/types area wise

100% 90% 80% 70% 60% Type 04 50% Type 03 40% 30% Type 02 20% Type 01 10% 0%

In table No 12 show frequencies and percentage of generation of prescription types / categories area wise in Hyderabad. Maximum and minimum prescriptions type 01, 30.06% and 4.9% were found in sadder and market area respectively. The maximum type 02 prescriptions were found in Latifabad i.e. 15.15% and minimum were found in Hussainabad i.e. 6.66% respectively. Moreover prescriptions type 03 and type 04, maximum and minimum prescriptions i.e. 19.8%, 14.92% and 6.1%, 14.92%, 5.97% were found from Market, Preatabad and Preatabad, Sadder respectively.

4.3 Prescription error All categories/types of prescription have been analyzed according to drug information related WHO parameters / standards for prescription writing.

Table 13: Category/Type 01 prescriptions (469 samples)

Dose per time Per day Duration *More than one Dose per time frequency per day frequency of therapy parameter/standard not written & duration of not written not written together not written therapy written 1.49% 3.4% 18.12% 0.85% 76.5%

Figure 13: Category/Type 01 prescription (469 samples)

Dose not written , Freq. not written , 1.49% 3.40%

Duration not More than one written , 18.12% parametertes / Standards not written, 0.85% Dose, frequency and duration written, 76.50%

* More than one parameter/ standard together not written i.e. per time dose and per day frequency or per time dose and duration or frequency, duration and per time dose etc not written on prescription, these all standards / parameters together mentioned on one box of table. It has been demonstrated in table No 13 whether prescriptions (category / type 01) are followed by WHO parameters / standards of prescription writing or not (Prescription error considered as basic contributing factor in drug misuse and abuse). 469 specialties prescription of category / type 01 has been further classified according the homogeneities of parameters / standards and found 1.4, 3.4%, 18.12, 0.84, and 76.5% prescription; ‘Dose per time not written’, ‘Frequency per day not written’, ‘Duration of therapy not written’, ‘More than one parameters / standards together not written’,

100

and written all these i.e ‘Dose per time, frequency and duration written all contributing parameters’ respectively.

Table 14: Category/Type 02 prescriptions (165 samples) Dose per time Dose per Per day Duration of *More than one frequency per day time frequency therapy parameter/standard & duration of not written not written not written together not written therapy written

1.81% 4.24% 19.39% 1.81% 72.72%

Figure 14: Category/Type 02 prescriptions (165 samples)

Dose not Freq. not written , written , 1.81% 4.24%

Duration not written , 19.39% More than one parametertes / Dose, frequency Standards not and duration written, 1.81% written, 72.72%

* More than one parameter/ standard together not written i.e. per time dose and per day frequency or per time dose and duration or frequency, duration and per time dose etc not written on prescription, these all standards / parameters together mentioned on one box of table. It has been demonstrated in table No. 14 whether prescriptions (category / type 02) are followed by WHO parameters / standards of prescription writing or not (contributing Prescription error considered as basic contributing factor in drug misuse and abuse), 165 prescription of category / type 02 has been further classified according the homogeneities of parameters and found 1.81, 4.24, 19.39, 1.81, 72.72% prescriptions; ‘Per time dose not written’, per day ‘Frequency not written’, total therapy ‘Duration not written’, ‘More than one parameters Dose, or duration and frequency or others not

101

written’, ‘ Dose, frequency and duration written all contributing parameters ’ respectively.

Table 15: Category / Type 03 prescriptions (131 samples)

Dose per time Dose per Per day Duration of *More than one frequency per day time frequency therapy parameter/standard & duration of not written not written not written together not written therapy written 6.1% 7.63% 22.13% 2.29% 61.83%

Figure 15: Category/Type 03 prescriptions (131 samples) Dose not written , 6.1% Freq. not written , 7.63%

Duration not written , 22.13% Dose, frequency and duration written, 61.83%

More than one parametertes / Standards not written, 2.29%

* More than one parameter/ standard together not written i.e. per time dose and per day frequency or per time dose and duration or frequency, duration and per time dose etc not written on prescription, these all standards / parameters together mentioned on one box of table. It has been demonstrated in table No. 15 whether prescriptions (category / type 03) are followed by WHO parameters / standards of prescription writing or not (Prescription error considered as basic contributing factor in drug misuse and abuse), 131 prescription of category / type 03 has been further classified according the homogeneities of parameters and found 6.1, 7.63, 22.13, 2.29, 61.83% prescription; ‘‘Per time dose not written’, per day ‘Frequency not written’, total therapy ‘Duration not written’, ‘More than one parameters Dose, or duration and frequency or others not written’, ‘ Dose, frequency and duration written all contributing parameters ’ respectively.

102

Table 16: Category/Type 04 prescriptions (67 samples)

11.94% 14.92% 44.76% 2.98% 25.37%

Figure 16: Category/Type 04 prescriptions (67 samples)

Dose not written , 11.94% Dose, frequency and duration Freq. not written, 25.37% written , More than one 14.92% parametertes / Standards not written, 2.98%

Duration not written , 44.76%

* More than one parameter/ standard together not written i.e. per time dose and per day frequency or per time dose and duration or frequency, duration and per time dose etc not written on prescription, these all standards / parameters together mentioned on one box of table. It has been demonstrated in table No. 16 whether prescriptions (category / type 04) are followed by WHO parameters / standards of prescription writing or not (Prescription error considered as basic contributing factor in drug misuse and abuse), 67 prescription of category / type 04 has been further classified according the homogeneities of parameters and found 11.94, 14.92, 44.76, 2.98, 25.37% prescription; ‘‘Per time dose not written’, per day ‘Frequency not written’, total therapy ‘Duration not written’, ‘More than one parameters Dose, or duration and frequency or others not written’, ‘ Dose, frequency and duration written all contributing parameters ’ respectively

103

Table 17: Total prescription errors in all categories/types (832 samples)

Cumulative Prescription errors parameters/ standards Frequency Percent Percent

Dose per time not written’ 26 3.1 3.1

Per day frequency not written’ 43 5.2 8.3

Duration of therapy not written’ 176 21.2 29.4

*More than one parameters together not 10 1.2 30.6 written

Witten all above parameters/ standards 577 69.4 100.0

Total 832 100.0

Figure 17: Total prescription errors in all categories / types (832 samples) Dose not written , Freq. not written , 3.1% 5.2%

Duration not written , 21.2%

Dose, frequency and duration written, 69.4% More than one parametertes / Standards not written, 1.2%

104

written’, ‘(Written All standards / parameters) Dose, frequency and duration written’ respectively.

Table 18: Area wise errors in all 04 type of prescription (832 samples)

Dose More than one Frequency Duration Area Not parameters together Written all Total Not written not written written not written

Sadder 1 4 13 1 153 172

Latifabad 5 6 22 2 91 126

City 3 5 20 1 69 98

Qasimabad 3 4 17 1 53 78

Heerabad 4 5 23 1 64 97

Pretabad 2 5 19 1 31 58

Fort area 3 5 20 1 43 72

Hussainabad 2 4 19 1 33 59

Market 3 5 23 1 40 72

Total 26 43 176 10 577 832

Figure 18: Area wise errors in all 04 categories / type of prescription (832 samples)

100% 90% Written all 80% 70% 60% Moore than one parameters 50%

40% duration not 30% weitten 20% frequency not 10% weitten 0% Dose not written

105

Further prescriptions have been classified according to the area wise prescription errors in all category / type of prescriptions to check the area of frequent errors in table No.18. After classification and evaluation of data; out of 192 prescription from sadder; 1,2,13,1,153 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written , ‘Written all’ parameters respectively. Out of 126 prescriptions from Latifabad; 5,6,22,2,91 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written, ‘Written all’ parameters respectively. Out of 98 prescription from City; 3,5,20,1,69 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written’, ‘Written all’ parameters respectively. .Out of 78 prescription from Qasimabad; 3,4,17,1,53 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written , ‘Written all’ parameters / standards respectively. Out of 97 prescriptions from Heerabad; 4,5,23,1,64 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written, ‘Written all’ parameters / standards respectively. Out of 58 prescriptions from Pretabad; 2,5,19,1,31 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written, ‘Written all’ parameters / standards respectively. Out of 72 prescriptions from Fort area; 3,5,20,1,43 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written, ‘Written all’ standards respectively. Out of 59 prescriptions from Hussainabad; 2,4,19,1,33 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written, ‘Written all’ parameters / standards in respectively. Out of 72 prescription from Market; 3,5,23,1,40 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written , ‘Written all’ parameters / respectively.

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Table 19: Age of customers/patients and errors in all 04 categories/types of prescriptions (832 samples)

More than (All) Dose, Age wise one frequency Dose Frequency Duration not distribution parameters and Total Not written Not written written with pres together not duration written written

< 15 years 4 6 25 1 26 62

16-30 years 5 6 36 2 177 226

31-45 years 6 10 37 2 185 240

46-60 years 5 9 40 3 154 211

> 61 years 6 12 38 2 35 93

Total 26 43 176 10 577 832

Figure 19: Age of customers/patients and errors in all 04 categories/types of

prescriptions (832 samples)

300

250 (All) Dose, frequency and 200 duration written (All) Dose, 150 duration and frequency not written 100 duration not written

50 frequency not written 0 ≤15 years 15-30 years 30-45 years 45-60 years ≥60 years

In table No. 19; errors have been classified according to the age group of patients/customers. Out of 62 prescription (of 15 or less than 15 years age); 4,6,25,1,26 prescription have been found ‘Dose not written’, ‘Frequency not written’,

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‘Duration not written’, ‘More than one parameters / standards not written , ‘Written all’ respectively. Out of 226 prescriptions (of 16 to 30 years age inclusive); 5,6,36,2,177 prescription have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameter / standard not mentioned (All contributing factor) ‘written all’ respectively. Out of 240 prescriptions (of 31 to 45 years age inclusive); 6,10,37,2,185 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘(More than one contributing factor) Dose, duration and frequency not written’, ‘(Written All) Dose, frequency and duration written’ respectively. Out of 211 prescriptions (of 46 to 60 years age inclusive); 5,9,40,3,154 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘(More than one contributing factor in drug misuse and abuse) Dose, duration and frequency not written’, ‘(All written) Dose, frequency and duration’ respectively. Out of 93 prescriptions ( of 61 or above years age); 6,12,38,2,35 prescriptions have been found ‘Dose not written’, ‘Frequency not written’, ‘Duration not written’, ‘More than one parameters/standards not written’, ‘Written all’ respectively.

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4.4 Without prescription (Samples 1168)

1168 customers/ patients without prescription have also been characterized to test deferent variables

Table 20: Age of the customers/patients

Age of the customers Frequency Percent Cumulative Percent

< 15 years 87 7.4 7.4

16-30 years 295 25.3 32.7

31-45 years 341 29.2 61.9

46-60 years 294 25.2 87.1

> 61 years 151 12.9 100.0

Total samples 1168 100.0

Figure 20: Age of the customers/patients

Age of the customer without Prescription

8% 13%

≤15 years 25% 16-30 years

25% 31-45 years 46-60 years ≥61 years

29%

Patients/customers without prescriptions have also been studied and classified according their ages in table No.20. Out of total patients/customers 1168; 87, 295, 341,

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294, 151 having ages 15 or less than 15 years, 16 to 30 years inclusive, to 45 years inclusive, 46 to 60 year inclusive and 61 years or above respectively.

Table 21: Patients/Customers area wise Area Frequency Percent Cumulative Percent

Sadder 119 10.2 10.2

Latifabad 116 9.9 20.1

City 143 12.2 32.4

Qasimabad 128 11.0 43.3

Heerabad 122 10.4 53.8

Pretabad 160 13.7 67.5

Fort area 139 11.9 79.4

Hussainabad 121 10.4 89.7

Market 120 10.3 100.0

Total 1168 100.0

Figure 21: Patients/customers area wise

180

160

140

120

100

110

Table No. 21; without prescription customer / patients have been also arranged in the classes of homogeneities area wise in table No. 21. Out of 1168; 119, 116, 143,128.122,160, 139, 121, 120 patients/customers found without prescription in the main and potential area of Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad, Market respectively.

Table 22: Trend of purchased dosage form (1168 samples) Which drug you are taking/Purchasing? Drugs/Medicines Frequency Percent C. Percent

Analgesic / Painkiller 186 15.9 15.9

Sedative / Hypnotic 141 12.1 28.0

Antibiotic 101 8.6 36.6

Antacid 108 9.2 45.9

Cough suppressant 62 5.3 51.2

Sexual vitality inducer 12 1.0 52.2

Psychoactive 107 9.2 61.4

Others 451 38.6 100.0

Total 1168 100.0

Figure 22: Trend of purchased dosage form (1168 without prescription customers/patients) 500 450 400 350 300 250 200 150 100 50 0

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Table No.22 shows trend of sale of dosage form; When they were asked and checked “Which drug you are taking / Purchasing” most of them replied ‘Analgesic / pain killer class i.e. 184 patients/customers. 141, 101, 108, 62, 12, 107,451 respondent replied Sedative / Hypnotic, Antibiotic, Antacid, Cough suppressant, Sexual vitality inducer, Psychoactive and others respectively.

Table 23: The trend of nature (form) of dosage In which form you are taking / purchasing drug?

Forms of purchased drugs Frequency Percent Cumulative Percent

Tablet 554 47.4 47.4

Capsule 203 17.4 64.8

Syrup 156 13.4 78.2

Others 255 21.8 100.0

Total 1168 100.0

Figure 23: the trend of nature (form) of dosage

Others, 21.80%

Tablet, 47.40% Syrup, 13.40%

Capsule, 17.41%

The trend of form of medicines sold at medical store is mentioned in table No.23. When they were asked and checked ‘In which form you are taking / purchasing drug’; 554, 203, 156, 255 respondents replied tablet, capsule, syrup, and others respectively

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Table 24: Self medication trend (1186 samples) Who suggested (influenced by) you these Medication/Drugs? Self medication trend Frequency Percent % C.Percent

Doctor 516 44.17 44.2

Chemist / Store keeper 351 30.05 74.2

Drug advertisement 24 2.05 76.3

Others 277 23.71 100.0

Total 1168 100.0

Figure 24: self medication trend (1186 samples) Self medication trend

24%

Doctor 44% Chemist/Store keeper 2% Drug advertisement Others

30%

The trend of self medication in Hyderabad is mentioned in table No.24. When they were asked ‘who suggested (influenced) you these Medication / Drugs’; only 516 responded doctor (During last visit), 351, 24, 277 responded chemist, drug advertisement and others respectively.

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Table 25: Dose per time (1168 samples) How much quantity of drug/medication you have been taking at one time? Evaluated as per BNF standards for proper duration Frequency Percent Cum. Percent of medications

Dose per time correct /Clear / Confident 1085 92.9 92.9

Dose per time incorrect / Not Clear/Not Confident 83 7.1 100.0

Total 1168 100.0

Figure 25: Dose per time (1168 samples)

Dose per time

Dose per time correct /Clear / Confident Incorrect / Not Clear/Not Confident Dose per time

93%

Table No.25; when they were asked (1168 patient / customers without prescription) about the dose per time to see whether medication is taking properly or not; Most of them were cleared / confident or correct about the dose per time i.e.1085, only 83 out of them were unclear /not confident about dose per time.

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Table 26: Per day dose/frequency (without prescription) How many times you take the drug in a day? (Per day dose /frequency) Evaluated as per BNF standards for proper duration of Frequency Percent C. Percent medications

OD/BD/TDS etc/ Frequency correct/ Clear / confident 1064 91.1 91.1

Frequency of drug incorrect/not Clear and not confident 104 8.9 100.0

Total 1168 100.0 Total

Figure 26: Per day frequency (without prescription)

Per day frequency

OD/BD/etc/Frequency Clear and confident Frequency of drug Not Clear and not confident

91%

Table No.26 shows When 1168 patient / customers having no prescription were inquired about per day dose / frequency, about 91% of them were cleared about the per day dose / frequency, only 9 percent were not clear about the frequency dose per day.

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Table 27: Duration of therapy (without prescription) How much time/duration you will take the drug? Evaluated as per BNF standards for proper Frequency Percent C. Percent duration of medications

01 week 479 41.0 41.0

02 weeks 80 6.8 47.9

03weeks 125 10.7 58.6

04weeks 16 1.4 59.9

05weeks 177 15.2 75.1

Not sure 291 24.9 100.0

Total 1168 100.0

Figure 27: Duration of therapy (without prescription)

Duration of therapy 600

500

400

300

200

100

0 01 week 02 weeks 03weeks 04weeks 05weeks Not sure

Table No.27 demonstrate that When patients/customers with no prescription were asked about the duration of therapy; 15.9% were not follow the duration of therapy as per specified in BNF (British National Formulary) and 24.9% were totally not sure / not cleared about the duration or time period of therapy.

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Table 28: More than 01 standards/parameters together (without prescription)

Evaluated as per BNF standards for proper Frequency Percent C. Percent duration of medications

More than one parameters / standards together 1137 97.3 97.3 clear/confident /correct

More than one parameter / Standards together 31 2.7 100.0 not clear / not confident / incorrect

Total 1168 100.0

Figure 28 More than 01 parameters together (without prescription)

More than one parameters / Standards confident /correct

More than one parameter / Standards not clear / not confident / incorrect

97%

Table and figure No. 28; It has been seen that 1137 patients/customers without prescription had more than one parameters cleared. 31 patients/customers were not knowledge / unaware regarding proper follow up of more than one parameter.

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Table 29: Trend of consultation time How much time doctor gave you during recent visit? Time Frequency Percent Cumulative Percent

<3 Minutes 226 43.8 43.8

03-07 Minutes 164 31.8 75.6

08-11 Minutes 45 8.7 84.3

12-15 Minutes 39 7.5 91.9

16-20 Minutes 23 4.5 96.3

>21 minutes 19 3.7 100.0

Total 516 100.0

Figure 29: Trend of consultation time Trend of consultation time 250

200

150

100

0 <3 Minutes 03-07 07-11 11-15 165-20 >20 minutes Minutes Minutes Minutes Minutes

Customers / patients who were suggested by dr. mentioned in table No.24 have been further classified in Table no 30. It demonstrates that when they were asked about the consultation time given them by dr. 226, 164, 45, 39, 23 and 19 out of them responded; less than 3 minutes, 4 to 7 minutes inclusive, 8 to 11 minutes inclusive, 12 to 15 minutes inclusive, 16 to 20 minutes inclusive, 21 minutes or more respectively. It shows mostly patient were given less than 3 minute time in government hospital OPD. This is not sufficient time to diagnosis treatment and counseling them properly.

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Table 30: Trend of medication record / previous drug history communication from patient to doctor Did you communicate previous medication record to Doctor? Response Frequency Percent Cumulative Percent

Yes 99 19.2 19.2

No 412 79.8 99.0

To some extent 5 1.0 100.0

Total 516 100.0

Figure 30: Trend of medication record / previous drug history communication from patient to doctor

19%

Yes No To some extent

80%

Table No.30 is showing the information for facilitating doctors’ treatment decision, communicating the previous prescription / medication records who were suggested by dr. mention in table no 24. When 516 patients were asked about communication of previous history record with dr. mostly patients replied No i.e. 412 and only 99 replied Yes, only 5 patients have idea to some extent about previous the drug communication with doctor. But they did not communicate previous record to doctors during their last visit.

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Table 31 Trend of follow-up of patients in our community Did you visit doctor after due days? Improper follow-up Response Frequency Percent Cumulative Percent

Yes 151 29.3 29.3

No 365 70.7 100

Total 516 100.0

Figure 31: Trend of follow-up of patients in our community Trend of follow-up

29%

Yes No

71%

Table No.31; When 516 patients/customers suggested by dr. mentioned in table no 24 were asked their follow-up to dr. after due date, about 71 percent patient replied ‘No”, only 29% respondent replied ‘Yes’, is mentioned in table 32. It is so alarming, follow- up is too required / necessary to meet at cure of disease and counteract the drug abuse and misuse

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Table 32: Age wise misuse and abuse (without prescription, 1168 samples) Age wise distribution of customers/patients without prescriptions (Evaluated as per BNF drug information)

Incorrect Age wise Incorrect Incorrect Incorrect More than one Correct distribution Dose Total Frequency Duration parameter use/Clear without Rx together

< 15 years 6 14 20 2 45 87

16-30 years 14 17 47 7 210 295

31-45 years 18 22 69 6 226 341

46-60 years 24 26 76 8 160 294

> 61 years 21 25 79 8 18 151

Total 83 104 291 31 659 1168

Figure 32: Age wise misuse and abuse (without prescription, 1168 samples) Age wise distribution of customers/patients without prescriptions (Evaluated as per BNF drug information) 160

140 More than 1 120 parameter misuse/abuse 100 Duration 80 misuse/abuse

60 Frequency misuse/abuse 40

20 Dose misuse

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥61 years

Patients/customers have also been studied and classified according misuse in context of their ages mentioned in table No.32. out of total patients/customers 1168; 87, 295,

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341, 294, 151 having ages 15 years or less than 15 years, 16 to 30 years inclusive, 31 to 45 years inclusive, 46 to 60 year inclusive and 61years or above respectively. 509 patients/ customers have been found misusing of drug. Table 33: Area wise misuse and abuse (without prescription, 1168 samples) More than one Dose Frequency Duration Correct Area wise parameter together Total misuse misuse/abuse misuse/abuse use/Clear misuse / abuse

Sadder 6 9 28 2 74 119

Latifabad 10 9 30 4 63 116

City 12 12 35 4 80 143

Qasimabad 7 10 28 2 81 128

Heerabad 11 12 36 4 59 122

Pretabad 12 14 33 4 97 160

Fort area 11 14 34 5 75 139

Hussainabad 7 12 34 3 65 121

Market 7 12 33 3 65 120

Total 83 104 291 31 659 1168

Figure 33: Area wise misuse and abuse (without prescription, 1168 samples)

50 More than one parameter 40 misuse / abuse Duration of 30 therapy misuse/ abuse 20 Per day frequency 10 missue / abuse Per time dose 0 misuse factor

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Data has been classified according to the misuse or abuse of drugs with context to area of patient without prescription in table No.33. Out of 1168 patients/customers; 119, 116, 143,128.122,160, 139, 121, and 120; from the area of Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad, Market patients/customers without prescription respectively have been found 45, 53, 63, 47, 63, 63, 64, 56, 55 misusing and abusing of drugs.

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4.5 Misuse and Abuse and Error contributing factor (2000 samples)

2000 randomly selected samples have been evaluated and categorized collectively with different characteristics as per WHO standards/parameters for prescription writing and BNF drug information. Table 34: Age wise misuse and abuse/prescription error (Total with and without prescriptions)

Age of Dose Frequency Duration More than one Correct the misuse/ misuse/abuse misuse/ parameter together use/Clear/ Total customer abuse /error /error abuse/error misuse / abuse not error

< 15 years 10 20 45 3 71 149

16-30 years 19 23 83 9 387 521

31-45 years 24 32 106 8 411 581

46-60 years 29 35 116 11 314 505

> 61 years 27 37 117 10 53 244

Total 109 147 467 41 1236 2000

Figure 34: Age wise misuse and abuse (Total with and without prescriptions) 250

200 More than 1 parameter 150 misuse/abuse Duration misuse/abuse 100

Freq misuse/abuse 50

Dose misuse / abuse 0 ≤15 years 16-30 years 31-45 years 46-60 years ≥61 years

Data of all patients (2000) have been classified according to the parameters of issues related to misuse / abuse and age group in table No.34. 2000 patients/customers (with prescription and without prescription) have been distributed in age groups and

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contributing issues related to misuse / abuse of drug. Out of 149, 521, 581, 505, and 244 patient/ customer having ages 15 or less than 15 years, 16 to 30 years inclusive, 31 to 45 years inclusive, 46 to 60 year inclusive and 61 years or above respectively; 78, 134, 170, 191, 191 patients /customers respectively have been found misusing the drug. Table 35: Area wise misuse and abuse (Total with and without prescriptions)

Dose More than one Frequency Duration Correct misuse/ parameter Area wise misuse/abuse misuse/ use/Clear/not Total abuse together misuse /error abuse/error error /error / abuse /error

Sadder 7 13 41 3 227 291

Latifabad 15 15 52 6 154 242

City 15 17 55 5 149 241

Qasimabad 10 14 45 3 134 206

Heerabad 15 17 59 5 123 219

Pretabad 14 19 52 5 128 218

Fort area 14 19 54 6 118 211

Hussainabad 9 16 53 4 98 180

Market 10 17 56 4 105 192

Total 109 147 467 41 1236 2000

125

Figure 35: Area wise misuse and abuse (Total with and without prescriptions)

120

100 More than 1 parameter misuse / 80 abuse Duration 60 misuse/ abuse 40 Freq misuse / abuse 20

Dose misuse 0

Data (prescription and without prescription) have been arranged according to the area of patients/customers with context to drug misuse and abuse reported in table No.35. Out of 2000 surveyed patients/customers 291, 241, 241, 206, 219, 218, 211, 180, 192 patients/customers from the targeted areas of Hyderabad, Sadder, Latifabad, City, Qasimabad, Heerabad, Pretabad, Fort area, Hussainabad and Market, respectively; 64, 88, 92, 72, 96, 90, 93, 82, 87 have been seen in misusing and abusing of the drugs.

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Table 36: Misuse and abuse and prescription error factor (with prescription v/s without prescriptions)

Dose More than one Frequency Duration Correct misuse/ parameter Customers misuse/abusemisuse/ use/Clear/not Total abuse together misuse / /error abuse/error error /error abuse /error

With 26 43 176 10 577 832 Prescription

Without 83 104 291 31 659 1168 Prescription

Total 109 147 467 41 1236 2000

Figure 36 Misuse and abuse and error (with prescription v/s without prescriptions)

700

600

500 Dose related issues in drug misuse / abuse 400 Frequency 300 related issues in drug misuse / 200 abuse Duration related issue 100 misuse/abuse

0 with prescription without prescription

Table No.36; Out of 832 patients/customers with prescriptions; 255 patients/customers have been seen misusing and abusing of drug whereas out of 1168 patients/customers without prescription; 509 patients/customers have been seen misusing and abusing of drug in the study. Data reveals that 31% patients/customers with prescription and 43.55% patients/customers without prescription are misusing and abusing the drug.

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Table 37: Age wise (with prescription v/s without prescription)

Age of the customer Without prescription With prescription Total

< 15 years 87 62 149

16-30 years 295 226 521

31-45 years 341 240 581

46-60 years 294 211 505

> 61 years 151 93 244

Total 1168 832 2000

Figure 37: Age wise (with prescription v/s without prescription)

400

350

300

250 Without prescription 200

150

100 With 50 prescription

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥ 61 years

Data have been categorized according to the age wise with context to the prescription and without prescription in table No.37. It has been seen in the study that out of 149 patients/customers; 62 and 87 patients/customers with and without prescription having ages 15 years or less than 15 years. It has also observed that out of 521 patients/customers; 226 and 295 patients/customers with and without prescription respectively having ages between 16 to 30 years inclusive.

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Data revealed that out of 581 patients/customers; 240 and 341 patients/customers with and without prescription respectively having ages between 31 to 45 years inclusive. Out of 505 patients/customers; 211 and 294 patients/customers with and without prescription respectively were having ages greater ages between 46 to 60 years inclusive. It has been seen in the study that out of 244 patients/customers; 93 and 151 patients/customers with and without prescription respectively having ages 61 years or greater than 61 years. Table 38: Age wise prescription error (Contributing factor)

Age of More than one Correct Dose Frequency the Duration error parameter use/Clear/not Total error error customer together error error

< 15 years 10 20 45 3 71 149

16-30 years 19 23 83 9 387 521

31-45 years 24 32 106 8 411 581

46-60 years 29 35 116 11 314 505

> 61 years 27 37 117 10 53 244

Total 109 147 467 41 1236 2000

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Figure 38: Age wise prescription error (Contributing factor)

140

120

100 Dose error

80 Frequency error 60 Duration error 40

20 More than one parameter together error 0 ≤15 years 16-30 years 31-45 years 46-60 years ≥ 61 years

Data (2000 samples) have been categorized age wise with prescription and without prescription with context to contributing factor in misuse-abuse of the drugs mentioned in table No.38. Out of 149 patients/customers; 10, 20, 45, 3 patients/customers have been found misusing/ abusing dose, frequency, duration, more than 1 parameter respectively having ages 15 years or less than 15 years. Out of 521 patients/customers having ages between 16 to 30 years inclusive; 19, 23, 83, 09 patients/customers have been found misusing/ abusing dose, frequency, duration, more than 1 parameter respectively. Out of 581 patients/customers; 24, 32, 106, 08 patients/customers have been seen misusing/ abusing dose, frequency, duration, more than 1 parameter respectively having ages between 31 to 45 years inclusive. Out of 505 patients/customers; 29, 35, 116, 11 patients/customers have been seen misusing/ abusing dose, frequency, duration, more than 1 parameter respectively having ages between 46 to 60 years inclusive. It has been seen in the study that out of 244 patients/customers; 27, 37, 117, 10 patients/customers misusing/ abusing dose, frequency, duration, more than 1 parameter respectively having ages 61 years or greater than 61 years.

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Table 39: Cost of medications (with and without prescription) How did you take the cost of these medications? Response Frequency Percent Cumulative Percent

Cheaper 89 4.5 4.5

Expensive 1210 60.5 65.0

Highly Expensive 701 35.1 100.0

Total 2000 100.0

Figure 39: Cost of medications (with and without prescription)

35% Cheaper Expensive Highly Expensive

61%

All samples (2000) have been asked about the price of purchased medicine, mentioned in table No. 39. Only 4.5% patients/ customers were opinion of cheaper medicine, 60.5% responses were “expensive” 35.1% respondent replied ‘highly expensive’ when they were asked about the cost of purchased medicine.

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4.6 Patient counseling factor The other main aspect of this study is to know about the patient counseling, for this point of view other 500 patients were interviewed and questionnaire were filled during / after dispensation of medicines from the pharmacy / dispensary, using simple random sampling technique to know whether drugs were counseled properly or not. Further data have also been tested as per BNF references and other factors i.e. counseling by doctor during OPD, store keeper / dispenser during dispensation of medications time and literacy ratio of patients visited in government hospitals OPDs. The study was conducted in one of the targeted government hospital in Hyderabad. Table 40: Socio-Demographic data of total interviewed persons.

Male % Female % Age ≤15 years 21 4.2 6 1.2 16-30 years 53 10.6 28 5.6 31-45 years 84 16.8 47 9.4 46-60 years 103 20.6 59 11.8 ≥ 61 years 50 10 49 9.8 Total 311 62.2 189 37.8

Figure 40: Socio-demographic data of total interviewed persons.

120

100

60 Male Female 40

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥ 61 years

132

In table No. 40, 500 other randomly slected patients/customers have been arrnaged; they are distributed according to the classes of age with context to their gender. Out of 500 patients; 311 and 189 were male and female respectively. Out of 311 male patients/ customers; 21, 53. 84, 103, 50 were age of 15 years or less than 15 years, between 16 to 30 years, between 31 to 45 years, between 46 to 60 years, 61 years or more than 61 years respectively. Out of 189 female patients/ customers; 06, 28. 47, 59, 49 were age of 15 years or less than 15 years, between 16 to 30 years, between 31 to 45 years, between 46 to 60 years, 61 or more than 61 years respectively.

Table 41: Age of counseled patients

Age Male % Female % ≤15 years 16 4.69 5 1.4 16-30 years 36 10.56 24 7.0 31-45 years 57 16.71 29 8.5 46-60 years 68 19.94 35 10.26 ≥ 61 years 33 9.67% 38 11.1 Total 210 61.58 131 38.4

Figure 41: Age of counseled patients

120

100

35 80 29 60 38 24 40 68 57 20 5 36 33 16 0 ≤15 years 16-30 years 31-45 years 46-60 years ≥ 61 years

Male Female

500 patients/customers further classified age wise with characteristics of counseling. Out of 500 patients/customers; 341 patients/customers have been found counseled, mentioned table No. 41.

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Out of 341 counseled patients/customers; 210 and 131 were male and female patients/customers respectively. out of male patients/customers; 16, 36, 57, 68, 33 were age of 15 years or less than 15 years, between 16 to 30 years, between 31 to 45 years, 46 to 60 years, 61 years or more than 60 years respectively.

5, 24, 29, 35, 38 female patients/customers were age of 15 years or less than 15 years, between 16 to 30 years, 31 between 45 years, between 46 to 60 years, 61 years or more than 61 years respectively. Table 42: Age of un-counseled patients Age Male % Female % ≤15 years 5 3.14 1 0.62 16-30 years 17 10.69 4 2.5 31-45 years 27 16.98 18 11.32 46-60 years 35 22 24 15.09 ≥ 61 years 17 10.69 11 6.9 Total 101 63.5 58 34.5 Figure 42: Age of un-counseled patients

20 Male Female 15

0 ≤15 years 16-30 years 31-45 years 46-60 years ≥ 61 years

In table No. 42; 58 and 101 respondents were male and female out of 159 un- counseled respondents. Out of 101 male respondent; 5, 17, 27, 35, 17 male respondent were age of 15 years less than 15 years, between 16 and 30 years, between 31 to 45 years, between 46 to 60 years, more than 60 years inclusive, 61 or more than 61 years respectively.

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Out of 58 female respondent; 1, 4, 18, 24, 11 were age of 15 years less than 15 years, between 16 and 30 years, between 31 to 45 years, between 46 to 60 years, more than 60 years inclusive, 61 or more than 61 years respectively. Table 43 Education profile of total interviewed (500 samples)

Education Respd. % Male % Female % Respondents Respondent ≥ Graduate 89 17.8 70 20.52 19 11.94 Intermediate 106 21.2 77 22.58 29 18.23 ≤Matriculation 102 20.4 64 18.76 38 23.89 Illiterate 203 40.6 130 38.12 73 45.91 Total 500 100 341 100 159 100

Figure 43: Education profile of total interviewed 140

120

100

80 Male Respondents 60 female Respondents

0 ≥ Graduate Intermediate ≤Matriculation Illiterate

Data has been classified according to the educational background of 500 respondent ( counseled and un counseled) mentioned in table No. 43. 203 ( 130 male and 73 female) out of them have been found illitrate while 102 (64 male and 38 female) were matriculate or lesser than matriculate, 106 ( 77 male and 29 female) were seen intermediate, only 89 respondent (70 and 19) were graduate or higher education. Mostly respondent were illitrate.

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Table 44: if counseled, to whom they were counseled Patient counseling by Respondents % Doctor / Prescriber only 65 13 Store keeper / Dispenser / Store keeper only 58 11.6 Both Doctor and Dispenser / Store keeper 218 43.6 No counseled by any one 159 31.8 Total 500 100

Figure 44: if counseled, to whom they were counseled 250

200

150

100

0 Doctor / Prescriber Store keeper Both Doctor and No counseled by any Dispenser / Store one keeper

In table No. 44; data has been categorized to check whether, patients were counseled or not, if counseled, to whom they were counseled. Out of 500 respondent 359 were counseled and 159 were not counseled by any one, when they were asked about ‘to whom they were counseled’ out of 359 respondents; 65, 58, 218 respondent were counseled by Doctor / Prescriber, Store keeper, Doctor and dispenser / Store keeper respectively.

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Table 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient

Parameters unawareness as per BNF No. of respondents % Per time dose 29 18.2 Per day frequency 41 25.7 Duration of therapy 76 47.7 Unawareness about more than one parameter together 13 8.17 Total 159 100 Figure 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient

0 Per time dose Per day frequency Duration of therapy Unawareness about more than one parameter

Un-counseled respondents have been further categorized to check whether they were aware proper usage of medication or not in table No. 45. Out of 159 respondent; 29, 41, 76, 13 respondent were unaware regarding proper usage of medications Per time dose, Per day frequency, Duration of therapy, Proper administration and more than one parameters respectively.

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4.7 Prescription errors (All antibiotic containing prescriptions) In addition to above both samples 2000 and 500 having different characteristics, a random sample of 286 prescription, containing at least one antibiotic have been selected randomly. For further statistical treatment these 286 prescription were grouped according to specific classes of antibiotic i.e. Penicillin, Cephalosporin, Tetracycline, Quinolone, Macrolide, and amino glycoside

4.7.1 Distribution of antibiotic prescriptions according to specific drug classes 286 prescriptions have been classified according their homogeneities of characteristics.

Table 46: Trend of prescribed antibiotic in society Antibiotic Class Number of Prescription % age Penicillin 60 20.97 Cephalosporin 60 20.97 Tetracycline 52 18.18 Quinolone 60 20.97 Macrolide 18 6.29 Amino glycoside 36 12.58 Total Antibiotics 286 100

Figure 46: Trend of prescribed antibiotic in society

13% 21% 6% Penicillin Cephalosporin Tetracycline Quinolone 21% 21% Macrolide Amino glycoside

18%

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286 antibiotic containing prescriptions have been evaluated randomly to see the trend of frequently prescribed antibiotics in our community, mentioned in table No. 46. Out of 286 prescriptions; 60, 60, 52, 60, 18, 36 have been found Penicillin, Cephalosporin, Tetracycline, Quinolone, Macrolide, Amino glycoside antibiotics containing prescriptions.

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4.7.2 Errors containing antibiotic prescriptions (Penicillin) Prescriptions containing Penicillin antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 60) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions Table 47: No of errors containing antibiotic prescriptions (Penicillin) No Error categories / Parameters / standards Errors /Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 22 (36.66%) 38 (63.33%) 60 02 Writing ambiguous medication order 23 (38.33%) 37 (61.66%) 60 03 Patient’s age not mentioned 12 (20%) 48 (80%) 60 04 Patient’s weight not mentioned 53 (88.33%) 7 (11.66%) 60 05 Patient’s gender not mentioned 27 (45%) 33 (55%) 60 06 Patient’s diagnosis not mentioned 43 (71.66%) 17 (28.33%) 60 07 Misspelling of medications 15 (25%) 45 (75%) 60 08 Missed directions of use 24 (40%) 36 (60%) 60 09 Dose omission or writing incorrect dose 26 (43.33%) 34 (56.66%) 60 10 Missed or incorrect dosage form 02 (3.33%) 58 (96.66%) 60 11 Missed or incorrect Strength of medicine 26 (43.33%) 34 (56.66%) 60 12 Missed or incorrect administration route 20 (33.33%) 40 (66.66%) 60 13 Missed or incorrect frequency 18 (30%) 42 (70.00%) 60 14 Prescribing without using metric system 32 (53.33%) 28 (46.66%) 60 15 Omission of prescriber’s signature 18 (30%) 42 (70.00%) 60 16 Presence of potential drug interaction 19 (30%) 41 (68.3%) 60

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Figure 47: No of errors containing antibiotic prescriptions (Penicillin)

60 Antibiotic Prescriptions (Pencillin) 53

30 27 26 26 24 23 22 20 19 20 18 18 15 No of prescriptions / frequency prescriptions of No 12

Error categories/ standards/ peramertes

141

4.7.3 Errors containing antibiotic prescriptions (Cephalosporin) Prescriptions containing Cephalosporin antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 60) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 48: No of errors containing antibiotic prescriptions (Cephalosporin) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 16 (26.66%) 44 (73.33%) 60 02 Writing ambiguous medication order 13 (21.66%) 47 (78.33%) 60 03 Patient’s age not mentioned 16 (26.66%) 44 (73.33%) 60 04 Patient’s weight not mentioned 56 (93.33%) 4 (6.66%) 60 05 Patient’s gender not mentioned 21 (35%) 39 (65.00%) 60 06 Patient’s diagnosis not mentioned 43 (71.66%) 17 (28.33%) 60 07 Misspelling of medications 14 (23.33%) 46 (76.66%) 60 08 Missed directions of use 20 (33.33%) 40 (66.66%) 60 09 Dose omission or writing incorrect dose 24 (40%) 36 (60.00%) 60 10 Missed or incorrect dosage form 02 (3.33%) 58 (96.66%) 60 11 Missed or incorrect Strength of medicine 34 (56.66%) 26 (43.33%) 60 12 Missed or incorrect administration route 16 (26.66%) 44 (73.33%) 60 13 Missed or incorrect frequency 22 (36.66%) 38 (63.33%) 60 14 Prescribing without using metric system 35 (58.33%) 25 (41.66%) 60 15 Omission of prescriber’s signature 17 (28.33%) 43 (71.66%) 60 16 Presence of potential drug interaction 20 (33.33%) 40 (66.66%) 60

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Figure 48: No of errors containing antibiotic prescriptions (Cephalosporin)

60 Antibiotic56 Prescriptions (Cephalosporin)

40 35 34

24 22 21 20 20 20 17 16 16 16

No of prescriptions / frequency prescriptions of No 14 13

Error categories/ standards/ peramertes

143

4.7.4 Errors containing antibiotic prescriptions (Tetracycline) Prescriptions containing Tetracycline antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 52) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 49: No of errors containing antibiotic prescriptions (Tetracycline) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 21 (40.38%) 31 (59.61%) 52 02 Writing ambiguous medication order 15 (28.84%) 37 (71.15%) 52 03 Patient’s age not mentioned 12 (23.07%) 40 (76.92%) 52 04 Patient’s weight not mentioned 47 (90.38%) 5 (9.61%) 52 05 Patient’s gender not mentioned 23 (44.23%) 29 (55.76%) 52 06 Patient’s diagnosis not mentioned 34 (65.38%) 18 (34.61%) 52 07 Misspelling of medications 10 (19.23%) 42 (80.76%) 52 08 Missed directions of use 24 (46.15%) 28 (53.84%) 52 09 Dose omission or writing incorrect dose 22 (42.30%) 30 (57.69%) 52 10 Missed or incorrect dosage form 1 (1.92%) 51 (98.00%) 52 11 Missed or incorrect Strength of medicine 26 (50%) 26 (50%) 52 12 Missed or incorrect administration route 16 (30.76%) 36 (69.23%) 52 13 Missed or incorrect frequency 14 (26.92%) 38 (73.00%) 52 14 Prescribing without using metric system 27 (51.92%) 25 (48.00%) 52 15 Omission of prescriber’s signature 15 (28.84%) 37 (71.15%) 52 16 Presence of potential drug interaction 18 (34.61%) 34 (65.38%) 52

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Figure 49: No of errors containing antibiotic prescriptions (Tetracycline)

50 Antibiotic47 Prescriptions (Tetracycline) 45

35 34

30 27 26 24 25 23 22 21 20 18 16 15 15 15 14

No of prescriptions / / frequency prescriptions of No 12 10 10

5 1 0

Error categories/ standards/ peramertes

145

4.7.5 Errors containing antibiotic prescriptions (Quinolone) Prescriptions containing Quninolone antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 60) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 50: No of errors containing antibiotic prescriptions (Quinolone) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 21 (35%) 39 (65.00%) 60 02 Writing ambiguous medication order 12 (20%) 48 (80.00%) 60 03 Patient’s age not mentioned 16 (26.66%) 44 (73.33%) 60 04 Patient’s weight not mentioned 56 (93.33%) 4 (6.66%) 60 05 Patient’s gender not mentioned 34 (56.66%) 26 (43.33%) 60 06 Patient’s diagnosis not mentioned 45 (75%) 15 (25.00%) 60 07 Misspelling of medications 14 (23.33%) 46 (76.66%) 60 08 Missed directions of use 20 (33.33%) 40 (66.66%) 60 09 Dose omission or writing incorrect dose 28 (46.66%) 32 (52.33%) 60 10 Missed or incorrect dosage form 0 (0.00%) 60 (100%) 60 11 Missed or incorrect Strength of medicine 28 (46.66%) 32 (52.33%) 60 12 Missed or incorrect administration route 14 (23.33%) 46 (76.66%) 60 13 Missed or incorrect frequency 17 (28.33%) 43 (71.66%) 60 14 Prescribing without using metric system 36 (60%) 24 (40.00%) 60 15 Omission of prescriber’s signature 15 (25%) 45 (75.00%) 60 16 Presence of potential drug interaction 22 (36.66%) 38 (63.33%) 60

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Figure 50: No of errors containing antibiotic prescriptions (Quinolone)

60 56 Antibiotic Prescriptions (Quinolone) 50 45

40 36 34

30 28 28

22 21 20 20 17 16 15 No of prescriptions / frequency prescriptions of No 14 14 12

0 0

Error categories/ standards/ peramertes

147

4.7.6 Errors containing antibiotic prescriptions (Macrolide) Prescriptions containing Macrolide antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 18) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 51: No of errors containing antibiotic prescriptions (Macrolide) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 6 (33.33%) 12 (66.66%) 18 02 Writing ambiguous medication order 5 (27.77%) 13 (72.22%) 18 03 Patient’s age not mentioned 4 (22.22%) 14 (77.77%) 18 04 Patient’s weight not mentioned 14 (77.77%) 4 (22.22%) 18 05 Patient’s gender not mentioned 8 (44.44%) 10 (55.55%) 18 06 Patient’s diagnosis not mentioned 12 (66.66%) 6 (33.33%) 18 07 Misspelling of medications 5 (27.77%) 13 (72.22%) 18 08 Missed directions of use 06 (33.33%) 12 (66.66%) 18 09 Dose omission or writing incorrect dose 8 (44.44%) 10 (55.55%) 18 10 Missed or incorrect dosage form 1 (5.55%) 17 (94.44%) 18 11 Missed or incorrect Strength of medicine 10 (55.55%) 8 (44.44%) 18 12 Missed or incorrect administration route 6 (33.33%) 12 (66.66%) 18 13 Missed or incorrect frequency 4 (22.22%) 14 (77.77%) 18 14 Prescribing without using metric system 10 (55.55%) 8 (44.44%) 18 15 Omission of prescriber’s signature 5 (27.77%) 13 (72.22%) 18 16 Presence of potential drug interaction 3 (33.33%) 15 (83.33%) 18

148

Figure 51: No of errors containing antibiotic prescriptions (Macrolide)

16 Antibiotic Prescriptions (Macrolide) 14 14

12 12

10 10 10

8 8 8

6 6 6 6 5 5 5 4 4 No of prescriptions / frequency prescriptions of No 4 3

2 1

Error categories/ standards/ peramertes

149

4.7.7 Errors containing antibiotic prescriptions (Amino glycoside) Prescriptions containing Amino glycoside antibiotic have been evaluated to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 36) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 52: No of errors containing antibiotic prescriptions (Amino glycoside) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 10 (27.77%) 26 (72.22%) 36 02 Writing ambiguous medication order 9 (25%) 27 (75.00%) 36 03 Patient’s age not mentioned 8 (22.22%) 28 (77.77%) 36 04 Patient’s weight not mentioned 31 (86.11%) 5 (13.8%) 36 05 Patient’s gender not mentioned 13 (36.11%) 23 (63.88%) 36 06 Patient’s diagnosis not mentioned 22 (61.11%) 14 (38.88%) 36 07 Misspelling of medications 8 (22.22%) 28 (77.77%) 36 08 Missed directions of use 13 (36.11%) 23 (63.88%) 36 09 Dose omission or writing incorrect dose 16 (44.44%) 20 (55.55%) 36 10 Missed or incorrect dosage form 1 (2.77%) 35 (97.22%) 36 11 Missed or incorrect Strength of medicine 17 (47.22%) 19 (52.77%) 36 12 Missed or incorrect administration route 10 (27.77%) 26 (72.22%) 36 13 Missed or incorrect frequency 9 (25%) 27 (75.00%) 36 14 Prescribing without using metric system 20 (55.55%) 16 (44.44%) 36 15 Omission of prescriber’s signature 9 (25%) 27 (75.55%) 36 16 Presence of potential drug interaction 10 (27.77%) 26 (72.22%) 36

150

Figure 52: No of errors containing antibiotic prescriptions (Amino glycoside)

35 Antibiotic Prescriptions (Aminoglycoside) 31 30

25 22 20 20 17 16 15 13 13

10 10 10 10 9 9 9 No of prescriptions/ frequency 8 8

1 0

Error categories/ standards/ peramertes

151

4.7.8 Errors containing antibiotic prescriptions (Total prescriptions) All parameters/standards have been evaluated from all prescriptions collectively to check the errors at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 286) A C  100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions AB= Total number of prescriptions

Table 53: No of errors containing antibiotic prescriptions (Total prescriptions) No Error categories / Parameters / standards Errors / Not Not error / Total followed followed Prescription 01 Date and patient’s name not mentioned 96 (33.56%) 190 (66.43) 286 02 Writing ambiguous medication order 77 (26.92%) 209 (73.07) 286 03 Patient’s age not mentioned 72 (25.17%) 214 (74.82) 286 04 Patient’s weight not mentioned 257 (89.86%) 29 (10.13) 286 05 Patient’s gender not mentioned 126 (44.05%) 160 (55.94) 286 06 Patient’s diagnosis not mentioned 199 (69.58%) 87 (30.41) 286 07 Misspelling of medications 66 (23.07%) 220 (76.920) 286 08 Missed directions of use 107 (37.14%) 179 (62.58) 286 09 Dose omission or writing incorrect dose 124 (43.35%) 162 (56.64) 286 10 Missed or incorrect dosage form 07 (2.44%) 279 (97.55) 286 11 Missed or incorrect Strength of medicine 141 (49.30%) 145 (50.69) 286 12 Missed or incorrect administration route 82 (28.67%) 204 (71.32) 286 13 Missed or incorrect frequency 84 (29.37%) 202 (70.62) 286 14 Prescribing without using metric system 155 (54.19%) 131 (45.80) 286 15 Omission of prescriber’s signature 79 (27.62%) 207 (72.37) 286 16 Presence of potential drug interaction 92 (32.16%) 194 (67.83) 286

152

Figure 53: No of errors containing antibiotic prescriptions (Total prescriptions)

300 Antibiotic Prescriptions

257 250

199 200

155 150 141 126 124 107 96 100 92 82 84 77 79

No of prescriptions/ frequency 72 66

7 0

Error categories/ standards/ peramertes

153

4.7.9 Errors containing all antibiotic prescriptions Errors in all prescriptions have been evaluated at analysis sheet as per WHO parameters for prescription writing, British national formulary and Drug information hand book parameters/ standards (Total prescription = 286) A C   100 AB C= Percentage of prescriptions containing errors, A= Number of errors containing prescriptions, AB= Total number of prescriptions Table 54: No of errors containing all antibiotic prescriptions All Error categories Penicillin Cephalosporin Tetracycline Quinolone Amino Macrolide antibiotics # / Parameters / Total Total Total Total glycoside Total Rx (18) Rx Total standards Rx (60) Rx (60) Rx (52) Rx (60) Total Rx (36) (286) Date and 01 patient’s name 22(36.66%) 16(26.66%) 21(40.38%) 21(35%) 6(33.33%) 10(27.77%) 96(33.56%) not mentioned Writing 02 ambiguous 23(38.33%) 13(21.66%) 15(28.84%) 12(20%) 5(27.77%) 9(25%) 77(26.92%) medication order Patient’s age not 03 12(20%) 16(26.66%) 12(23.07%) 16(26.66%) 4(22.22%) 8(22.22%) 68(23.77%) mentioned Patient’s weight 04 53(88.33%) 56(93.33%) 47(90.38%) 56(93.33%) 14(77.77%) 31(86.11%) 257(89.86%) not mentioned Patient’s gender 05 27(45%) 21(35%) 23(44.23%) 34(56.66%) 8(44.44%) 13(36.11%) 126(44.05%) not mentioned Patient’s 06 diagnosis not 43(71.66%) 43(71.66%) 34(65.38%) 45(75%) 12(66.66%) 22(61.11%) 199(69.58%) mentioned Misspelling of 07 15(25%) 14(23.33%) 10(19.23%) 14(23.33%) 5(27.77%) 8(22.22%) 66(23.07%) medications Missed 08 24(40%) 20(33.33%) 24(46.15%) 20(33.33%) 06(33.33%) 13(36.11%) 107(37.14%) directions of use Dose omission 09 or writing 26(43.33%) 24(40%) 22(42.30%) 28(46.66%) 8(44.44%) 16(44.44%) 124(43.35%) incorrect dose Missed or 10 incorrect dosage 02 (3.33%) 02(3.33%) 1(1.92%) 0(0.00%) 1(5.55%) 1(2.77%) 07(2.44%) form Missed or incorrect 11 26(43.33%) 34(56.66%) 26(50%) 28(46.66%) 10(55.55%) 17(47.22%) 141(49.30%) Strength of medicine Missed or incorrect 12 20(33.33%) 16(26.66%) 16(30.76%) 14(23.33%) 6(33.33%) 10(27.77%) 82(28.67%) administration route Missed or 13 incorrect 18(30%) 22(36.66%) 14(26.92%) 17(28.33%) 4(22.22%) 9(25%) 84(29.37%) frequency Prescribing 14 without using 32(53.33%) 35(58.33%) 27(51.92%) 36(60%) 10(55.55%) 20(55.55%) 160(55.94%) metric system Omission of 15 prescriber’s 18(30%) 17(28.33%) 15(28.84%) 15(25%) 5(27.77%) 9(25%) 79(27.62%) signature Presence of 16 potential drug 19(30%) 20(33.33%) 18(34.61%) 22(36.66%) 3(33.33%) 10(27.77%) 92(32.16%) interaction

154

Figure 54: No of errors containing all antibiotic prescriptions

A total of 1815 errors were noticed in all antibiotics’ prescription with an average of 6.35 errors per prescription,

155

4.8 Role of Doctor, Field Manager / Medical representative and Retailer in the eradication of misuse and abuse of drugs

Other aspect of this study is to know the role of Doctor, Field Manager / Medical representative and Retailer in the eradication of misuse and abuse of drugs. 1)50 doctors were randomly selected for interview Table 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse.

Have you discussed with your patients regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 21 42.0 42.0 42.0

No 25 50.0 50.0 92.0

Some time 4 8.0 8.0 100.0

Total 50 100.0 100.0

Figure 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse.

Have you discussed with your patients regarding misuse and abuse of drugs and their Complications / harmful effects on health? 30

0 Yes No Some time

The role of doctor in the eradication of drug misuse and abuse mentioned in table No. 55, that doctor is key person and responsible to communicate properly all the draw

156

backs / complications of misuse and abuse to patients, Out of 50 doctors , 21 replied “Yes” 25 replied “No” and 4 play the role in some times. 2)50 medical representatives/field managers were randomly selected for interview Table 56: Role of Medical Representative / Field Manager

Have you discussed with your Subordinate (in case of field manager) Doctor regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Frequency Percent Valid Percent Cumulative Percent

Yes 5 10.0 10.0 10.0

No 43 86.0 86.0 96.0 Valid Some time 2 4.0 4.0 100.0

Total 50 100.0 100.0

Figure 56: Roles of Medical representative / Field Manager

Have you discussed with your Subordinate (in case of field manager) Doctor regarding misuse and abuse of drugs and their Complications / harmful effects on health? 50 45 40 35 30 25 20 15 10 5 0 Yes No Some time

While analyzing the role of middle men (Medical Representative / Field manager) is reported in table No. 56, Middle man is the key person of company who is responsible to detail all the feature of product including the strength and weakness with doctors. But we enquire the role of communication of drug misuse and abuse complication on the body of patients, Out of 50, only 5 responded “Yes” 43 responded “No’ just 2 replied “Sometimes”.

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Table 57: Sales promotions approaches of companies for Prescriptions generation

How you (Company) convinced your prescriber regarding prescription generation? (Trend of Dr's Prescription, Feedback from nearby Medical store)

Valid Cumulative Frequency Percent Percent Percent Regular Visit 1 2.0 2.0 2.0

Samples 5 10.0 10.0 12.0

Regular Visit & Samples 15 30.0 30.0 42.0

Giveaways / patients adds 2 4.0 4.0 46.0

Regular Visit Giveaways / patient 19 38.0 38.0 84.0 ads & Samples

Commitment (Foreign trip, Local 8 16.0 16.0 100.0 or abroad sponsorships, Car or vehicle or others, percentage fixed over selling medicines and others)

Total 50 100.0 100.0

Figure 57: Sales promotions approaches of companies for Prescriptions generation

How you (Company) convinced your prescriber regarding prescription generation? 20 18 16 14 12 10 8 6 4 2 0 Regular Visit Samples Regular Visit & Giveaways / Regular Visit Commitment Samples patients adds Giveaways / patient ads & Samples

158

Table No. 57 demonstrated the promotional styles / approaches of different companies for the generation of prescriptions / pharmaceutical business. Out of 50, It was found that on regular visit, on samples, on regular visits and samples, on Giveaways / patients adds, on Regular Visit Giveaways / patient ads & Samples, and commitment ( fully unethical involvement in the promotion of drugs) are 1, 5, 15, 2, 19 and 8 respectively. 3)50 Retailer /storekeeper were randomly selected for interview Table 58: Inspection of medical stores / pharmacies

In how much time drug regulating agency person visits your pharmacy/Store?

Frequency Percent Valid Percent Cumulative Percent

Valid 01 Week 1 2.0 2.0 2.0

02 Weeks 2 4.0 4.0 6.0

03 Weeks 1 2.0 2.0 8.0

04 Weeks 3 6.0 6.0 14.0

05 weeks and onwards 13 26.0 26.0 40.0

Not fixed time 30 60.0 60.0 100.0

Total 50 100.0 100.0

Figure 58: Inspection of medical stores / pharmacies

In how much time drug regulating agency person visits your pharmacy/Store? 35

0 01 Week 02 Weeks 03 Weeks 04 Weeks 05 weeks and Not fixed time onwards

159

Table No. 58 shows the result of inspection information at medical store / pharmacy. It is very necessary to visit drug agency personnel for selling and pharmacy practices, it was recorded that out of 50 retailers / medical stores, visit / inspections by inspectors in “01 week” , “02 Weeks” , “03 Weeks” , “04 Weeks” , “05 weeks and onwards” and “ Not fixed time” are 1, 2, 1, 3, 13,and 30 respectively.

Table 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals)

Dose drug regulatory agency person enquire during inspection/ visits regarding limitation, easy availability of control drugs and their misuse and abuse of drug and there side effects / Complications/ harmful effects on customer health?

Valid Frequency Percent Percent Cumulative Percent

Valid Yes 7 14.0 14.0 14.0

No 39 78.0 78.0 92.0

Some times 4 8.0 8.0 100.0

Total 50 100.0 100.0

Figure 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) Dose drug regulatory agency person enquire during inspection/ visits regarding limitation, easy availability of control drugs and their misuse and abuse of drug and there side effects / Complications/ harmful effects on customer health? 45 40 35 30 25 20 15 10 5 0 Yes No Some times

The role of drug regulating agencies for the eradication drug misuse and abuse including enquiry of easy availability of drugs at medical stores / pharmacies reported in table No. 59. Out of 50 storekeepers / retailers, 07 responded “Yes” enquiry by drug

160

regulating agencies, 39 responded “No” and 04 responded “Sometimes” discussed all features / and enquiry. Table 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy)

Do you change the brand of any medicine prescribed by the Doctor?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 23 46.0 46.0 46.0

No 14 28.0 28.0 74.0

Rarely 13 26.0 26.0 100.0

Total 50 100.0 100.0

Figure 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy)

Do you change the brand of any medicine prescribed by the Doctor? 25

0 Yes No Rarely

Table No. 60 reported the brand change without consultation of doctor at pharmacy stores information of our community, out of 50 retailer / store keepers, 23 responded “Yes” 14 responded “No” and 13 responded “rarely”

161

Table 61: Role of retailer / store keeper (Reasons of change of prescriptions)

Why you change the brand / generic of medicine?

Frequency Percent Valid Percent Cumulative Percent

Non availability 6 12.0 12.0 12.0 low price option 7 14.0 14.0 26.0

Patient wishes 3 6.0 6.0 32.0

Support to specific company 6 12.0 12.0 44.0

Other reason 1 2.0 2.0 46.0

Rarely change 13 26.0 26.0 72.0

No change 14 28.0 28.0 100.0

Total 50 100.0 100.0 Figure 61: Role of retailer / store keeper (Reasons of change of prescriptions)

Why you change the brand / generic of medicine? 16 14 12 10 8 6 4 2 0 Non low price Patient Support to Other reason Rarely No change availability option wishes specific change company

The trend of prescription change at medical store in our society reported in Table No.61, it was found that out of 50 retailers / medical store keepers change the prescriptions due to “Non availability” of drugs, “low price or quality option” of available medicines, “Patient wishes”, “Support to specific company”, “others reasons” “rarely change’ and “No change” the drugs at any caste are 6, 7, 3, 6, 1, 13 and 14 respectively.

163

Table 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy)

Do you dispense drugs when patient brings empty blister / pack/bottles of prescription drugs?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 47 94.0 94.0 94.0

No 2 4.0 4.0 98.0

Rarely 1 2.0 2.0 100.0

Total 50 100.0 100.0 Figure 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy)

Do you dispense drugs when patient brings empty blister / pack/bottles of prescription drugs? 50 45 40 35 30 25 20 15 10 5 0 Yes No Rarely

Table No. 62 demonstrated the result of refilling or re dispensing criteria for the medicines at medical stores, the trend of dispensing and re-dispensing approaches at medical stores. Out of 50 retailers, 47 responded “Yes” that on just availability of any empty blister pack/ bottles or others, 02 responded “No” and 01 responded that “Rarely” re-dispensed / refilling criteria approaches in our society.

164

Table 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies)

Do you keep prescription record of controlled / psychoactive / sedative and Hypnotics medicines?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 5 10.0 10.0 10.0

No 42 84.0 84.0 94.0

Rarely 3 6.0 6.0 100.0

Total 50 100.0 100.0

Figure 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies)

Do you keep prescription record of controlled / psychoactive / sedative and Hypnotics medicines? 45 40 35 30 25 20 15 10 5 0 Yes No Rarely

Table No. 63 demonstrated the result of keeping records for controlled drugs at pharmacies / medical stores trends. Out of 50 retailers / store keeper 05 replied “Yes”, 42 replied “No” and 03 responded rarely they kept record.

165

Table 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies)

What are your criteria of dispensed / selling prescription drugs? Frequency Percent Valid Percent Cumulative Percent Prescription 2 4.0 4.0 4.0 No any Valid 48 96.0 96.0 100.0 Requirement Total 50 100.0 100.0

Figure 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies)

What are your criteria of dispensed / selling prescription drugs? 60

0 Prescription No any Requirement

Table No. 64 reported the survey result of dispensing criteria for prescription drugs at medical stores / pharmacies. Out of 50 retailers, 02 replied “Yes” the “Prescriptions” is must for these drugs, and 48 responded “No any requirement / criteria” for dispensing of prescriptions drugs.

166

Table 65: Role of retailer / store keeper (Knowledge of medicines)

Can you differentiate the brands between OTC and prescription drugs?

Cumulative Frequency Percent Valid Percent Percent

Valid Yes 24 48.0 48.0 48.0

No 21 42.0 42.0 90.0

To Some extent 5 10.0 10.0 100.0

Total 50 100.0 100.0

Figure 65: Role of retailer / store keeper (Knowledge of medicines)

Can you differentiate the brands between OTC and prescription drugs? 30

0 Yes No To Some extent

Table No. 65, demonstrated the knowledge of store keeper / retailers including assistant / technicians regarding classification of drugs. Out of 50 retailers/ store keepers 24 responded “Yes”, 21 responded ‘No” and just 05 responded “To some extent” regarding knowledge of differentiation between prescription and over the counter drugs.

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4.9 Statistical testing / analysis 4.9.1 Regression modal Applied simple regression modal; where ‘Number of Parameter(s) missed in prescription’ and ‘Consultation time given to patient’ have been taken dependent and independent variable respectively.

Table 66: Descriptive statistics; Number of parameter missed and consultation time given to patient

Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Number of Parameter(s) 832 0 3 0.32 0.512 missed in prescription

Consultation time given 832 3 15 9.35 3.872 to patient

Valid N (list wise) 832

Table No. 66 shows average parameters missed in prescription are 0.32 and average consultation time for patient is 9.35 with S.D 0.512, 3.872 respectively and no of observations are 832

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Table 67: SPSS output for correlation between number of parameter missed and Consultation time given to patient

Correlations

Number of Consultation Parameter(s) time given to missed in patient prescription

Number of Parameter(s) Pearson Correlation 1 -0.401** missed in prescription Sig. (2-tailed) 0.000

N 832 832

Consultation time given to Pearson Correlation -0.401** 1 patient Sig. (2-tailed) 0.000

N 832 832

**. Correlation is significant at the 0.01 level (2-tailed).

Table No. 67 shows there is relation (negative correlation) between Number of Parameter(s) missed in prescription and Consultation time given to patient hence r= - 0.401, which is significant at 0.01 significance level in 2 tailed test

Table 68: SPSS output for input of data for regression modal

Variables Entered/Removedb

Model Variables Entered Variables Removed Method

1 Consultation time given to . Enter

patienta a. All requested variables entered. b. Dependent Variable: number of Parameter(s) missed in prescription

Table No. 68 shows the input of variables for regression line

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Table 69: SPSS output for modal summary of number of parameter missed and Consultation time given to patient

Model Summary b

Model R R Square Adjusted R Square Std. Error of the

Estimate

1 0.401a 0.161 0.160 0.469 a. Predictors: (Constant), Consultation time given to patient b. Dependent Variable: Number of Parameter(s) missed in prescription

Table No. 69 is an output of SPSS17, Value 0. 401 shows there is relation between the both variables, having standard error of estimates 0.469, R square and adjusted r square is 0.161 and 0.160 respectively

Table 70: SPSS output for significance of F (ANOVA) number of parameter missed and Consultation time given to patient

ANOVAb

Model Sum of df Mean Square F Sig.

Squares

1 Regression 35.089 1 35.089 159.198 0.000a

Residual 182.939 830 0.220

Total 218.028 831 a. Predictors: (Constant), Consultation time given to patient b. Dependent Variable: Number of Parameter(s) missed in prescription

Table-70 Value of Significance is > 0.01 F test (35.089, 1) shows our model is significantly good for prediction.

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Table 71: SPSS output for explanatory and explained variable

Coefficientsa

Model Unstandardized Standardized Coefficients Coefficients

B Std. Error Beta T Sig.

1 (Constant) 0.819 0.043 19.256 0.000

Consultation time -0.053 0.004 -0.401 -12.617 0.000 given to patient a. Dependent Variable: Number of Parameter(s) missed in prescription

Table No. 71 Output of SPSS17 tells about the information of explanatory variables. It provides necessary information to predict our explained variable.

Table 72: SPSS output for C.I (95%)

Coefficientsa

Model 95.0% Confidence Interval for B

Lower Bound Upper Bound

1 (Constant) 0.736 0.903

Consultation time given to patient -0.061 -0.045 a. Dependent Variable: Number of Parameter(s) missed in prescription

Table-72 shows confidence interval for slope

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Table 73: Residual Statistics (Number of parameter(s) missed)

Residuals Statisticsa

Minimum Maximum Mean Std. Deviation N

Predicted Value 0.02 0.66 0.32 0.205 832

Std. Predicted Value -1.460 1.639 0.000 1.000 832

Standard Error of .016 0.031 0.023 0.005 832 Predicted Value

Adjusted Predicted Value 0.02 0.66 0.32 0.205 832

Residual -0.660 2.340 0.000 0.469 832

Std. Residual -1.406 4.984 0.000 0.999 832

Stud. Residual -1.409 4.995 0.000 1.001 832

Deleted Residual -0.663 2.350 0.000 0.470 832

Stud. Deleted Residual -1.410 5.069 0.001 1.003 832

Mahal. Distance 0.008 2.687 0.999 0.854 832

Cook's Distance 0.000 0.056 0.001 0.004 832

Centered Leverage Value 0.000 0.003 0.001 0.001 832 a. Dependent Variable: Number of Parameter(s) missed in prescription

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Figure 66: Probability, Probability plot for regression (Number of parameter missed and Consultation time given to patient)

Graph No. 66 shows expected and observed cumulative probabilities for regression analysis

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Figure 67: Graph the regression equation and the data points.

Graph No. 67 shows the line of best fit and points of data. Variable consultation time given to patient has been arranged with x-axis and Number of parameter(s) missed in prescription has been arranged with y-axis

Interpretation of calculation of regression modal

(i) General formation of model for simple regression line y= α + β(x) y = Dependent variable α= Constant β=Slope of line x= Regressor (ii) After applying above modal Where y = Number of parameter(s) missed in prescription x= consultation time given to patient

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y= 0.819+ (-0.053) (Consultation time given to patient) Number of parameter(s) missed in prescription = 0.819+ (-0.053) (Consultation time given to patient) (iii) Testing hypothesis about the predictor “Consultation time given to patient”

(a) H0 (Null Hypothesis): β = 0 (Consultation time given to patient is not a useful predictor of Number of parameter(s) missed in prescription)

(b) H1 (Alternative Hypothesis): β ≠ 0 (Consultation time given to patient is a useful predictor of Number of parameter(s) missed in prescription) (c) Level of significance = 0.05 (d) Reject the null hypothesis if p value is less than 0.05 Conclusion: since p value is 0.000 ≤ 0.05 in table no 72, rejecting our null hypothesis at α=0.05 is being concluded that β ≠ 0; hence repressor is a useful predictor of “number of premaster(s) missed in prescription” (iv) 95% C.I for slope Table no 73 shows that we are 95% confident that the slope of the true regression line is somewhere between -0.061 and -0.045, hence we are 95 percent confident that every increased minute in consultation get, their average Number of parameter(s) missed in prescription decreases somewhere between 0.061 and 0.045

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4.9.2 Testing hypothesis of proportion of gender with respect to drug misuse and abuse Null hypothesis = Proportion of male patients equal to female patients (no difference between proportions) with respect to drug misuse and abuse in Hyderabad Alternative Hypothesis = Proportion of male patients is not equal to female patients (difference between proportions) with respect to drug misuse and abuse in Hyderabad Symbolic expression / Notation of Null and Alternative Hypothesis

H0= Null Hypothesis

H1= Alternative Hypothesis

H0: P1 = P2

H1: P1 ≠ P2 Where

P1 = Proportion of male patients in Hyderabad

P2 = Proportion of female patients in Hyderabad Level of significance α = 0.05 For this test-statistics to test the hypothesis is ̂ − ̂ = 1 1 ̂ + Where

̂ = Proportion of males in drug misuse and abuse in the city of Hyderabad

̂= Proportion of females in drug misuse and abuse in the city of Hyderabad

̂= Statistical technique of estimating common population proportion on the assumption that the both gender are alike with respect to the drug misuse and abuse among the patients in Hyderabad.

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i.e.

n1 pˆ1  n2 pˆ 2 pˆ  and qˆ 1 pˆ c c c n1 n2

The test Statistics Z, for large sample size approximately standard normal, Critical region for this test is │Z│>1.96 101 pˆ 1   0.3247 311 58 pˆ   0.3068 2 189 101 58 159 pˆ    0.318 c 311189 500 so that qˆc  0.682 that 0.3247  0.3068 thus Z   1 1  0.138 0.682     311 189  0.0179  0.2168 0.0085064 0.0179   9.7061 0.0018442 Since the calculated value z =9.7061 falls in the critical region, so we reject the null hypothesis, it shows P1 ≠ P2 and concludes on the basis of data, that both grander male and female are different with respect to the drug misuse and abuse.

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4.9.3 Analysis of 286 prescriptions and 95% confidence interval for µ 95 % confidence interval for µ of errors have been computed to analyze the degree of errors properly

Table 74: Descriptive measure on errors in antibiotic containing prescription Errors Cumulative

Frequency Percent Valid Percent Percent Valid 1 10 3.5 3.5 3.5 2 23 8.0 8.0 11.5 3 26 9.1 9.1 20.6 4 29 10.1 10.1 30.8 5 31 10.8 10.8 41.6 6 32 11.2 11.2 52.8 7 32 11.2 11.2 64.0 8 39 13.6 13.6 77.6 9 34 11.9 11.9 89.5 10 2 .7 .7 90.2 11 6 2.1 2.1 92.3 12 9 3.1 3.1 95.5 13 4 1.4 1.4 96.9 14 6 2.1 2.1 99.0 15 2 .7 .7 99.7 16 1 .3 .3 100.0 Total 286 100.0 100.0

Table No. 74 shows highest frequency of variable 8 errors, i.e. 39 observation have been recorded

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Table 75: Standard deviation and mean of errors

Statistics

No. of errors

N Valid 286

Missing 0

Mean 6.35

Std. Deviation 3.138

Sum 1815

Table No. 76 shows the mean of error per prescription is 6.35, and standard deviation is 3.138 where sum of errors in all prescription is 1815. Table 76: Case processing output of SPSS for validating and missing observation for C.I

Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

No. of errors 286 100.0% 0 0.0% 286 100.0%

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Table 77: 95% confidence interval for mean and other statistical tools for numbers of error

Descriptives Statistic Std. Error No. of errors Mean 6.35 0.186 95% Confidence Interval Lower Bound 5.98 for Mean Upper Bound 6.71 5% Trimmed Mean 6.21 Median 6.00 Variance 9.848 Std. Deviation 3.138 Minimum 1 Maximum 16 Range 15 Interquartile Range 4 Skewness 0.500 0.144 Kurtosis 0.046 0.287

Table No. 77 shows; A total of 1815 errors were noticed in all antibiotics’ (286) prescription with an average of 6.35 errors per prescription, with standard deviation 3.138, 95% confidence interval was computed for µ hence 5.98 and 6.71.

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4.9.4 Analysis of variance ANOVA is powerful test for significance between the averages of three or more independent groups. 286 randomly selected prescription containing antibiotics; Amino glycoside, Cephalosporin, Macrolides, Penicillin, Quinolone, Tetracycline have been further analyzed. These antibiotic groups are highly prescribed in Hyderabad rather than others Hypothesis

(a) H0: µAmino glycoside = µ Macrolides = µ Quinolone = µPenicillin = µCephalosporin = µTetracyclines Where µ represents the mean of errors in prescriptions

(b) H1: not H0

Descriptives

No. of errors

N Mean Std. Std. 95% Confidence Minimum Maximum Deviation Error Interval for Mean

Lower Upper Bound Bound

Amino 36 5.72 3.048 0.508 4.69 6.75 1 13 glycoside

Cephalosporin 60 6.42 3.044 0.393 5.63 7.20 1 14

Macrolides 18 6.06 1.798 0.424 5.16 6.95 3 9

Penicillin 60 6.23 3.244 0.419 5.40 7.07 1 15

Quinolone 60 6.15 2.530 0.327 5.50 6.80 1 14

Tetracycline 52 7.15 4.031 0.559 6.03 8.28 1 16

Total 286 6.35 3.138 0.186 5.98 6.71 1 16

Table No. 78 shows descriptive measure of statistics on the no of error in antibiotics containing prescriptions, where sample size is different. Mean error in prescription is 6.35, where Tetracycline has been seen with highest mean of errors and SD than other antibiotic prescription i.e. 7.15 and 4.031respectively.

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Table 79: SPSS output for homogeneity of variance for numbers of errors

Test of Homogeneity of Variances

No. of errors

Levene Statistic df1 df2 Sig.

4.539 5 280 0.001

Formulation of null hypothesis and Alternative Hypothesis 2 2 2 2 2 (a) H0: σ Amino glycoside = σ Macrolides = σ Quinolone = σ Penicillin = σCephalosporin = 2 σ Tetracyclines

(b) H1: not H0 (c) α=0.05 Table No. 79 clearly indicates that p values of Levene’s Statistic is less than 0.05, rejecting the hypothetical statement of H0, it is being concluded that assumption of homogeneity variances is not met, therefore variances are not equal. Table 80: SPSS output for ANOVA (numbers of errors in antibiotic containing prescription)

ANOVA

No. of errors

Sum of Squares Df Mean Square F Sig.

Between Groups 52.828 5 10.566 1.074 0.375

Within Groups 2753.903 280 9.835

Total 2806.731 285

Table No 80 indicates p value is 0.375. There is no difference between the mean errors in prescription.

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Figure 68: Errors in prescriptions

Figure No. 86 showing mean of number of errors in antibiotic containing prescriptions Conclusion Based on the calcuation of one way ANOVA (F (5,280) = 1.074, p = 0.375>0.05), we accepted the null hypothesis; the evidences are too enough to conclude that means are equal. Combine 95% C.I of Number of errors is between 5.98 and 6.71 inclusive. Mean 6.35 errors have been noticed per prescription, where Amino glycoside containing prescription found with least mean of errors (µ = 5.72, σ = 3.04, N=36) and Tetracycline containing prescription found highest mean of errors (µ=7.15, σ =4.03, N= 52).

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4.9.5 Chi-square tests The chi square test is used widely to conclude whether there is a association between two variables. A signle-way test of (goodness of fit) chi-square arranges classes or their categories in single dimension. The test of chi square analyses whether people are dealt across the classes as would be mean there is no relationship or relation between the variable. Table 81: Output of SPSS for role of doctors for improper usage of drugs and their complications especially drug misuse and abuse

Have you discussed with your patients regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Observed N Expected N Residual

Yes 21 16.7 4.3

No 25 16.7 8.3

Some time 4 16.7 -12.7

Total 50

Table 82: Chi-square test results for table 81

Test Statistics

Have you discussed with your patients regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Chi-Square 14.920a

Df 2

Asymp. Sig. 0.001 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 82 shows, p-0.001 is less than 0.05 level on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the classes based on the discussion about the complication with patients by dr.

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Table 83: Output of SPSS for role of Medical Representative / Field Manager

Have you discussed with your Subordinate (in case of field manager) Doctor regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Observed N Expected N Residual

Yes 5 16.7 -11.7

No 43 16.7 26.3

Some time 2 16.7 -14.7

Total 50

Table 84: Chi-square test results for table 83

Test Statistics

Have you discussed with your Subordinate (in case of field manager) Doctor regarding misuse and abuse of drugs and their Complications / harmful effects on health?

Chi-Square 62.680a

Df 2

Asymp. Sig. 0.000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 84 shows, p<0.001 on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the categories based on the discussion about the complication with subordinate of pharmaceutical sells / marketing manager by their managers.

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Table 85: Output of SPSS for role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals)

Observed N Expected N Residual

Yes 7 16.7 -9.7

No 39 16.7 22.3

Some times 4 16.7 -12.7

Total 50

Table 86: Chi-square test results for table 85

Test Statistics

Does drug regulatory agency person enquire during inspection/ visits regarding limitation, easy availability of control drugs and their misuse and abuse of drug and there side effects / Complications/ harmful effects on customer health?

Chi-Square 45.160a

Df 2

Asymp. Sig. 0.000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 86 shows, p-0.000 is less than 0.05 on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the categories based on enquiry during inspection/ visits regarding limitation, easy availability of control drugs and their misuse and abuse of drug and there side effects / Complications/ harmful effects on customer health by drug regulatory agency person

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Table 87: SPSS output for role of retailer / store keeper

Do you change the brand of any medicine prescribed by the DR.?

Observed N Expected N Residual

Yes 23 16.7 6.3

No 14 16.7 -2.7

Rarely 13 16.7 -3.7

Total 50

Table 88: Chi-square test results for table 87 (Do you change the brand of any medicine prescribed by the DR.?)

Test Statistics

Do you change the brand of any medicine prescribed by the DR.?

Chi-Square 3.640a

Df 2

Asymp. Sig. 0.162 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 88 shows, p-0.162 is greater than 0.05 on 2 degree of freedom. Therefore we cannot reject the null hypothesis, it is being concluded that there is no significant difference between the classes based on changing the brand by shopkeeper/salesman of medical store.

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Table 89: SPSS output for role of retailer / store keeper (Trend of re dispensing approaches at medical stores / Pharmacy)

Do you dispense drugs when patient brings empty blister/pack/bottles of prescription drugs?

Observed N Expected N Residual

Yes 47 16.7 30.3

No 2 16.7 -14.7

Rarely 1 16.7 -15.7

Total 50

Table 90: Chi-square test results for table no 89

Test Statistics

Do you dispense drugs when patient brings empty blister/pack/bottles of prescription drugs?

Chi-Square 82.840a

Df 2

Asymp. Sig. 0.000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 90 shows, p-0.000 is less than 0.05 on 2 degree of freedom. Therefore null hypothesis is being rejected, and being concluded that there is significant difference between the classes based on dispensing drugs to customer by shopkeeper/salesman of medical store.

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Table 91: SPSS output for role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / Pharmacies)

Do you keep prescription record of controlled / psychoactive / sedative and hypnotics medicines?

Observed N Expected N Residual

Yes 5 16.7 -11.7

No 42 16.7 25.3

Rarely 3 16.7 -13.7

Total 50

Table 92: Chi-square test results for table no 91

Test Statistics

Do you keep prescription record of controlled / psychoactive / sedative and Hypnotics medicines?

Chi-Square 57.880a

Df 2

Asymp. Sig. 0.000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 92 shows, p-0.000 is less than 0.05 on 2 degree of freedom. Therefore null hypothesis is being rejected, and being concluded that there is significant difference between the classes based on record of controlled drugs at store.

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Table 93: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies

What are your criteria of dispensed / selling prescription drugs?

Observed N Expected N Residual

Prescription 2 25.0 -23.0

No any requirement 48 25.0 23.0

Total 50

Table 94: Chi-square test results for table no 93

Test Statistics

What are your criteria of dispensed / selling prescription drugs?

Chi-Square 42.320a

Df 1

Asymp. Sig. 0.000 a. 0 cells (0.0%) have expected frequencies less than 5. The minimum expected cell frequency is 25.0.

Table No. 94 shows, p-0.000 is less than 0.05 on 1 degree of freedom. Therefore null hypothesis is being rejected, and being concluded that there is significant difference between the classes based on criteria of dispensed drugs at medical store.

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Table 95: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies)

Can you differentiate the brands between OTC and prescription drugs?

Observed N Expected N Residual

Yes 24 16.7 7.3

No 21 16.7 4.3

To Some extent 5 16.7 -11.7

Total 50

Table 96: Chi-square test results for table no 95

Test Statistics

Can you differentiate the brands between OTC and prescription drugs?

Chi-Square 12.520a

Df 2

Asymp. Sig. 0.002 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 16.7.

Table No. 96 shows; p-0.002 is less than 0.05 level on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the classes based on differentiating OTC and prescription drugs

Table 97: SPSS output for trend of sales of drug ‘with prescription and without prescription’ Have you Prescription for these medications?

Observed N Expected N Residual

Yes 832 1000.0 -168.0

No 1168 1000.0 168.0

Total 2000

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Table 98: Chi-square test results for table no 97

Test Statistics

Have you Prescription for these medications?

Chi-Square 56.448a df 1

Asymp. Sig. 0.001 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 1000.0.

Table No. 98; p-0.001 is less than 0.05 levels on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the classes based on trend of prescription. Table 99: SPSS output for trend of store keeper inquiry about prescription

Does Store keeper inquire you about prescription?

Observed N Expected N Residual

Yes 906 666.7 239.3

No 792 666.7 125.3

Some time 302 666.7 -364.7

Total 2000

Table 100: Chi-square test results for table no 99

Test Statistics

Does Store keeper inquire you about prescription?

Chi-Square 308.956a df 2

Asymp. Sig. 0.000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 666.7.

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Table No. 100 shows that p-0.000 is less than 0.05 on 2 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the classes based on trend of store-keeper inquiry about prescription. Table 101: SPSS output for trend of counseling for proper medication usage at government hospital

Have you counseled by professionals person regarding proper medication usage? Observed N Expected N Residual Yes 341 250.0 91.0 No 159 250.0 -91.0 Total 500

Table 102 Chi-square test results for table no 101

Test Statistics Have you counseled by professionals person regarding proper medication usage? Chi-Square 66.248a Df 1 Asymp. Sig. 0.000 a. 0 cells (0.0%) have expected frequencies less than 5. The minimum expected cell frequency is 250.0.

Table No. 102 shows, p<0.001, level on 1 degree of freedom. Rejecting the null hypothesis, it is being concluded that there is a significant difference between the counseled and un-counseled patients for proper medication usage.

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4.10 Discussion

The purpose of this study to investigates the causes of drug abuse and misuse and their related contributing factors. Prescription errors as a contributing factor in drug misuse and abuse and their impact on the health of patients in our society, In first phase of reported studies, 832 prescriptions were analyzed to check that whether they meet or not the basic standards of prescription writing as described by World Health Organization (WHO), De Vries TP et al., (1995)25 . These errors may be considered as main contributing factors for prescription errors and may lead to drug misuse and abuse. All the collected prescriptions, (832) were categorized in four types; the specialist prescriptions (type 1), 469 (56.4%), general practicing prescriptions (type 2), 165 (19.8%), hospitals or clinics or medical centers printed prescriptions (type 3), 131 (15.7%), and the prescription generated by a non-qualified persons or quacks (type 4). The 4th type prescriptions, generated by a non-qualified persons or quacks, were found without name or any information of doctor, hospital, or clinic and the maximum errors were also found in this type. Because these prescriptions are generated by non- qualified persons, therefore it becomes solemn concern in our health care system that these are the peoples who are mainly contributing in drug misuse and abuse and resulting in wrong diagnosis, wrong drug, wrong dose, wrong frequency and wrong duration. Various prescription errors considered in the study are dose per time, per day frequency, duration of therapy and more than one of these factors together. In all 832 prescriptions analyzed, over all 30.6% errors were found. This is almost in accordance with the results reported by Gandhi et al (2005)213 who reported 29%, and much lower as compared with the finding of Mugoyela et al. (2008)214, who reported 55.1% over all prescribing errors. The dose per time is considered as a basic required factor in prescriptions during dispensing and administration process. Our result shows that in 3.1% of total prescriptions dose per time was not written. Subsequently fourth type prescriptions were found with 11.94% errors, which showed maximum dose per time error among all type of prescriptions. In one study Y.M Irshaid et.al. (2005)144 had reported that dose per time was absent in 19.4% of prescriptions, which is greater than our results. On the other hand Balbaid OM et. al. (1998)215 in their study have reported that 7.6%

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of the prescription did not contain dose per time. In another study results, reported by Bawazir (1993)216 it has been shown that the dose per time of the medication was incomplete or missed in the 4% of evaluated prescriptions. Per day frequency of dose and duration of therapy are two other basic and essential parameters of WHO guidelines for prescription writing. These make the patient to be facilitated to know that how many doses has to be taken by patient on daily basis and for how much duration the therapy may be continued. At the same time this facilitates the dispenser for proper dispensing of medication. Our results show that in 5.2% prescriptions frequency of dose and in 21.2% prescriptions duration of therapy was not mentioned. These both errors were found at maximum rate in type 4 prescriptions, as errors found were 14.92% and 44.76% respectively. By comparing our study results with other studies we found that Balbaid OM et al (1998)215 has mentioned 6.9% errors in frequency of dose and 10.2% errors in duration of therapy. In our results it became clear that frequency of dose and duration of therapy errors were found worse in type 4 prescriptions, which is more than the result reported by Balbaid OM et al (1998) 215. However, in case of prescription errors in all four types prescriptions it is clear that errors in case of frequency of dose the values are lower and in case of the duration of therapy the values are higher than reported by Balbaid OM et al (1998) 215. The date of issue of prescriptions has also important consideration. The dispensing process mainly rely on the date of generation of prescriptions to dispense the correct dose for right duration of treatment and more important in refilling process of prescriptions. It also helps to find out the prescription addicted patients easily. In these studies it has been found that in all collected prescriptions, on the basis of date on prescriptions, 8.3% prescriptions were found very old and 11.8% were without date of generation of prescription.

Trend of self medication and sale of medication without prescription also contribute a lot to drug misuse and abuse. This practice is also seen on large scale in Hyderabad, Pakistan. Out of 2000 interviewed patients, during or after dispensation of medicines at pharmacy / medical store, the results show that 1168 (58.4%) patients/customers were without prescriptions. According to data collected from patients/customers without prescription, we found that the drugs including analgesics/painkillers, sedatives/hypnotics, antibiotics, antacids, cough suppressants,

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sexual vitality inducers, psychoactive and others related groups were commonly sold without availability of prescriptions, whereas, prescription is mandatory for the purchase of these drugs. Furthermore it was found that the sale of drugs without prescription was 15.9% analgesics/painkillers, 12.1% sedatives/hypnotics, 8.6% antibiotics, 9.2% antacids, 5.3% cough suppressants 1% sexual vitality inducers, 9.2% psychoactive, and 38.6 % others groups. In a study conducted in Nigeria by Oyetundel et al (2010)62 reported that the sale of drugs without prescription, especially antibiotics, were common. It was found that antibiotics were sold without prescriptions in routine practice and about 38.79% people were those who purchase the medicines, including antibiotics, without prescription just by telling the name of medicine at pharmacy/medical store. Among these 38.79% without prescription buyers, 90% were those who had no any awareness regarding the usage and duration of therapy of antibiotics. In our studies sell of antibiotics without prescription is 8.6% which is much lower than study conducted by Oyetundel et al (2010)62. We also found that among all without prescription selling antibiotics, ampiclox was the most selling brand antibiotic. Some other studies had also been reported for the extent of purchase of antibiotics without prescriptions and these are mainly focused on the consumption/self medication of antibiotics drugs. In surveys Al-Bakari et al. (2005)217 and Vaanaen et al. (2006)218 have reported 46% and 41% antibiotics, respectively, were purchased without prescription. The patients without prescription were further found that the root cause, in purchase is just making the decision of self medication. However, this decision of self medication in 55.8% patients was influenced / suggested by self judgment, chemist, drug advertisement, friends, relatives, neighbors etc., and about 44.2%, patients/customers were influenced/ suggested by the doctor. Self medication is the main considering area of self caring and the most important component of health care of public source in the health care system. Self medication process also encompass the usage of drugs by the customers for self apparent health issue or continuity use of drugs prescribed earlier by health professionals (WHO 2000)110 As mentioned above our results shows that the trend self medication is 55.8% in Hyderabad Pakistan and the frequency of self medication varies with age, different classes of the peoples including students of schools, colleges and universities, and

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country to country. The ratio of self medication is lower, 45%, in Turkey, which were reported by Buke et al. (2005)219 and higher, 94%, in Hong Kong by Lau (1995)220. One study Deshpande et al. (1997)221 reported that 31% of peoples visited pharmacies/medical stores and practiced as self medication. Subsequently, another study was performed by Syed Nabeel et al. (2008)149on self medication issues in Karachi, Pakistan. and results are higher as compared to our reported result. In the same study common cause of self medication identified was generally the previous experience of use of drugs in similar types of diseases/problems. The most common problems that encourage the students for self medication were headache, fever and flu. Mostly most common consumed self medicated drugs among university students were all types of pain killers, antipyretics, and anti allergy and antibiotics, this study also done by Syed Nabeel et al. (2008)149. Another study discussed that during self medication it is possible to cure the minor problems that do not need doctor’s consultation and decrease the over load on health care systems in the backward countries where there are limited resources of health care systems. According to Vucic VA. et al. (2005)222, 88% self medication occur among medical and non medical students in Croatia, which is higher than our reported information on self medications. In one other study conducted on mothers of Pakistani people Haider S. et al. (1995)223, it was discussed that 61.3% samples used their past experience for self medication; this is more than our reported results. Our results showed that in all without prescriptions patients / customers interviewed, majority of them, 43.6%, were not clear regarding dose per time, per day frequency and duration of therapy.

Availability of prescriptions is a basic requirement for dispensing of prescriptions or sell of prescriptions drugs. Ethically pharmacists / store keepers are bound to enquire about availability of prescription from patients / customers during dispensing process of prescription drugs. Out of 2000 interviewed patients / customers, 49.4% of patients / customers were even not asked regarding availability of prescriptions for dispensing the drugs. Furthermore, age of peoples is also a considerable factor in drug misuse and abuse. There are special instructions from manufacturer for all dosage forms which are available in market that “KEEP AWAY FROM CHILDREN” but our result showed that in 7.4% cases the medicines were sold

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to < 15 years age children. It reflects easy availability of drugs and also very high purchase of medicines without any restriction.

The consultation time generally comprises in three major portions, i.e. diagnosis, prescription drug decision and patient counseling. An optimum time is required by doctor for proper consultation of patients. This is necessary for proper diagnosis, depending on the nature of disease and proper drug selection.. However, our result show that 43.8% of patients / customers were given less than three minutes for consultation and the time not enough time for diagnosis, treatment decision and counseling. To facilitate the doctor to decide proper treatment, it is essential to communicate him previous medication record or previously prescribed medications by patients. In our results it has been found that 79.8% of doctors informed that patients / customers did not communicated previous medication record to them during their visits. These practices may lead to drug resistant, drug-drug interaction and eventually drug abuse and misuse. On other hand improper follow-up by patients was commonly observed in our community. Future treatment strategy of doctor for patient is largely dependent upon proper feedback / follow-up by patient. Our results shows that trend of improper follow-up by patients, as directed by the doctor, was 70.7%.

Doctors / Physicians, medical store keeper, medical representatives and drug regulating agency person are the key persons in healthcare systems. The responsibility and participation of these professionals is to assure proper diagnosis, proper treatment strategy and proper counseling to get required outcomes of the therapy. During the consultation the patients be counseled and be communicated for proper drug usage, complications / harmful effects of the drug and misuse and abuse. Our study analyzed the role of doctor in the eradication of misuse and abuse of drugs. For this purpose out of 50 general physicians, 25 replied with “No” 21 replied with “Yes”, when they were asked that whether they have communicated all possible measures to avoid drug complications and drug abuse and misuse. However, only 4 showed that sometimes they had fulfilled their role. Subsequently, Medical representative / field manager also plays an active role in the eradication of drug misuse and abuse. While exploring the role of middle men (medical representative / field manager) and ethically / unethically promotion

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approaches in the eradication drug abuse and misuse in our community, middle men is the key person in the pharmaceutical marketing / company. Ethically he is responsible to detail or deliver all the features of product including the strength, efficacy, etc, and drawbacks (side effects / adverse effect etc) to the medical practitioners. However, our results show that out of 50 medical representative / field managers, only 5 responded “Yes” when they were asked that either they had detailed all features of the medication, 43 responded “No’ and just 2 responded that they detailed all features at very few time or on special occasions. Considering the styles of pharmaceutical marketing and selling companies regarding unethical or ethical promotion of drugs in these studies 50 sales men / medical representative from different companies or pharmaceutical business were interviewed. It was found that only 1 sales man responded that the style of his company is just based upon regular visit at the chamber / clinic of prescriber, 5 responded that they only rely on samples distribution approach, 15 were those who responded that their promotional activities includes regular visits and sample approach, only 2 responded that they do through patients aids and giveaways, 19 were those who responded that they do regular visits, samples, give away and patient aids and rest of 8 only were seen in the involvement of different unethical approaches for the generation of prescriptions. As the visit of drug controlling agency responsible persons at pharmacies / medical stores was studied, it is observed that out of 50 retailers / medical stores keepers interviewed, 30 responded that there were no fixed schedule or time for inspections of drug controlling authorized responsible persons at medical stores. It is very necessary to mention that the inspection or visits at pharmacies / medical stores by drug agency persons is highly desired for minimizing the drug abuse and misuse. Regular visits or inspections can push the pharmacy or medical store persons to sell the drugs as per available prescription and would reduce the easy availability of prescription drugs and also inspections will results to follow other required parameters at pharmacy or medical stores. In the present study the issue concerning the availability of different brands of same drug was evaluated. A total of 50 retailers / store keeper were interviewed. Among these 23 responded that they can replace the brand of any drug easily without consultation of prescriber at medical stores. This practice puts down an unethical impact in our health care system which may lead to serious consequences like drug

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abuse and misuse. 13 replied that they change the brands rarely and they do this in intense need or requirement only. Both the retailer and consumer are equally involved in this erroneous practice. We also evaluated the possibilities and reasons for the change of prescription at pharmacy/medical store. Our result show that out of 50 interviewed retailers / store keepers, 6 replied that they had changed prescriptions due to unavailability of that specified drugs at their stores, 7 responded that they change prescription for the reason of low price or quality of dosage forms, 3 were those who replied that they change only on patient’s desire for specified drug purchase, 6 changed as they only keep drug brands of some specified company due to favorable promotion activity for retailers / store keepers , and only 1 of them hide the reasons. So, it was observed that out of 50 retailers, 14 used to follow doctor’s prescription or as doctor had suggested. The dispensing the medicines with or without prescription and re-dispensing / refilling criteria of prescriptions at medical stores were evaluated. Our result show that out of 50 retailers / store keepers only 2 of them responded that prescription is necessary for prescription drugs, and remaining 48 responded that there are no any criteria for dispensing the prescription drugs at their stores. Out of 50 retailers / store keepers 47 responded that they use to re-dispense the medication even without prescription or refilling can be made just on availability of any empty blister packs, empty bottle or others. Therefore, this practice is resulting in easy availability of drugs and everybody can purchase any type of drug without any restrictions and leading to drug abuse and misuse in our society. Keeping the record of controlled drugs is necessary and legal at pharmacy/ medical stores. However it was found that out of 50 store keeper / retailers, 42 answered that they do not keep any record in their pharmacy / medical store. This again put down ghastly image in order to keep the prescriptions record, especially for controlled drugs if these are available at their shops. Further it was also evaluated that retailer / store keepers differentiate between OTC and prescriptions drug or not. Our result demonstrates that out of 50 retailers / store keepers 21 responded that they had no idea or knowledge regarding sorting of over the counter drugs and prescriptions drug listings. If the person doesn’t know the demarcation between OTC and prescription drugs, it may generate quandary for the enquiry of prescription at pharmacy / medical stores.

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In our present investigation we identified the extent of errors in antibiotic containing prescriptions. A total of 286 prescriptions were collected and evaluated for the presence of errors on the basis of various authenticated drug references. In our study, the error type dose omission, or wrong dose represented 43.35% of the prescriptions. This data is on par with the findings of Costa LA et al. (2008)224 who reported that 49.6% and 28.6% of the prescriptions were having too high doses (wrong dose) and missing doses respectively. The study by Phalke Vaishali D et al. (2011)225 revealed the similar results, they identified that 54.3% of prescriptions did not have the correct and calculated doses and in 35.1% of prescriptions the doses were not mentioned clearly. In a study by Folli Hugo L et al. (1987)226 in terms of wrong dose they found that 55.1% of the medication orders contained the overdose and 26.9% contained the under dose errors. It also stated that most of the serious or potentially lethal errant medication orders include the antibiotics. In contrast to our results Balbaid OM et al. (1998)215 revealed that 7.6% of prescriptions did not contain the dose at all. Another study by Irshaid Y.M et al. (2005) 144 revealed that 19.4% of the prescriptions were deficient in dose units. A study by Gandhi Tejal K et al. (2005)213 reported 54% of the dose errors; it also revealed that antibiotic was the most common class of medications contained 25% of the prescribing errors. Absence of the patient’s weight in most of the prescriptions (89.86%) corresponds to the findings of Phalke Vaishali D et al. (2011) 225 and Irshaid Y.M et al. (2005)144 they found that none of the prescriptions contained the patient’s weight. Relating to the pateint’s diagnosis our data revealed that 69.58% of the prescriptions were missing the diagnosis but it is in contrast to the Irshaid Y.M et al. (2005) 144 who identified 15.1% prescriptions, Bawazir S. (1993)216 who reported 9.8% prescriptions and Balbaid OM et al. (1998) 215 found only 6.8% of prescriptions. Concerning the strength of medications, it is the most important when a drug is available in market in more than one strength. We found that 49.30% of the prescriptions either have wrong or missing strength. This result is parallel to the report of Irshaid Y.M et al. (2005) 144 who stated that 52.8% of prescriptions were missing the strength of medications. On the other hand our result is dissimilar to that of reported by Phalke Vaishali D et al. (2011)225, who identified that 26.8% of prescriptions did not contain the strength.

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A large number of deficiencies were also found regarding the gender and age of the patient. Our study investigated that in 44.05% and 23.77% of the prescriptions the prescriber did not mention the gender and age of the patients respectively. However, a study by Phalke Vaishali D et al. (2011) 225 found 10% and 11% of prescriptions in which the gender and age of the patient were not written respectively. Balbaid OM et al. (1998)215 identified only 10% and 4.1% of prescriptions were missing the patients age and sex respectively. Furthermore, Irshaid et al. (2005)144 found 22.7% and 48.7% of prescriptions did not contain the age and gender of the patient. Approximately all of these studies reported the dissimilar results. We identified a significant number of prescriptions 37.14% which did not contain the directions for patients. Our result is comparable to the findings of Phalke Vaishali D et al. (2011) 225 who recognized that 45.9% of prescriptions were missing the patient’s instructions. Irshaid Y.M et al. (2005) 144 revealed that 7.1% of the prescriptions were missing the patient’s instructions and majority of the prescriptions 90.7% had only partial patient’s instructions. On the other hand Bawazir S. (1993)216 noticed that 4% of the prescriptions were lacking in instructions for use. Our findings regarding the name of patient and date on prescriptions revealed the errors in 33.56% of prescriptions. This number is much higher than the findings by Balbaid OM et al. (1998) 215 who explored only 8.7% of prescriptions on which dates were not mentioned. Francois P et al. (1997)227 reviewed 866 prescriptions and found only 4.5% of prescriptions which were missing the dates. In case of the drugs which can be administered by more than one route, it is necessary to mention their routes. We evaluated that 28.67% of prescriptions were deficient in mentioning routes of drug administration. This result is somewhat similar to the findings of Phalke Vaishali D et al. (2011)225, who reported 24.7% prescriptions not containing routes of drug administration. But our results conflicted those reported by Gandhi Tejal K et al. (2005)213 and Bawazir S. (1993)216 only 13% and 0.1% respectively. Regarding the error type writing an ambiguous medication order, we explored that 26.92% of prescriptions were not written clearly. Our result is dissimilar to the others reported. Balbaid OM et al. (1998)215, Irshaid Y.M et al. (2005)144, Meyer TA (2000)79 and Makonnen et al (2002)228 reported 7.2%, 64.3%, 15% and 15% of prescriptions respectively having poor and incomprehensible hand writing.

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There are a number of studies who suggested for implementing computer based system for prescribing the drugs, Javier Rodrı´guez-Vera F et al., (2002)229; Ruud J M Ter Wee et al., (1991)230. Nightingale PG et al. (2000)231 and Meyer TA (2000)79 suggested that electronic prescription system can be used to improve the prescription writing by removing the illegible prescriptions. The studies by Bates DW et al. (1998)232 and Anton C et al. (2004)231 proved to reduce the medication and prescribing errors by using computer based system of prescribing medications. De Vries et al. (1995)25 reported that educational training programs can also lead to improve the prescription writing. Akoria Obehi A et al. (2008)234 studied the effect of educational intervention on prescription writing and reported the improvement. These data clearly show that there is a need for introducing computerized physician order entry system (CPOE) to improve the prescription writing and reducing the errors. There have been many studies conducted on drug-drug interaction, which is critical issue in health care system. In our study potential drug interaction were observed in 32.16% of the prescriptions. In a study carried by Lars Bjerrum et al. (2003)112 it is reported that 62% persons were exposed to potential drug interaction, with single drug, and 38% with two or more different drugs.

Out of 500 interviewed patients, 159 (31.8%) were not counseled by any health professional and 341 (68.2%) were counseled by the prescriber, store keeper /dispenser or both. Whereas, out of 159 un-counseled patients, 76 (47.7%), 41 (25.7%) and 29 (18.2%) were unclear regarding duration of therapy, frequency and dose per unit time respectively. The number of patients who were unaware about proper administration method and more than one parameters together 13 (8.17%). On the other hand, among 341(68%) counseled patients, 218 (63.92%) were counseled by both prescriber and store keeper, 65(19.06%) by prescriber and 58(17.0%) by store keeper /dispenser only. As the age of patient is considered, it was observed that the patients in the age groups 46-60 years and more were mostly unaware regarding proper medication usage. However it was noticed that a large proportion of about 40.6 % patients who visited hospital were illiterate. In our study we found that a significant number of patients 159 (31.8%) were not counseled by any health professional due to which they were unaware regarding proper medication usage. In a study by Ascione Frank J et al. (1985)235 surveyed 400 community pharmacies in Michigan and found that the community pharmacists were failed to counsel most of the patients and only

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instructions were written on the drug label. In our study we found similar scenario that substantial number of patients 159 (31.8%) were not counseled at all. In another study regarding non compliance of patients to drug therapy found that the major causative factor was patient’s failure to understand the effectiveness of drug therapy. It was noticed that a significant number of the prescriptions contained the incomplete information and unclear patients’ instructions (Convington et al., 1979)139. A randomized controlled trial study by Peveler Robert et al. (1999)236 reported that adherence to antidepressant drug therapy increases with the patient counseling. Similarly our study revealed that 100% of the uncounseled patients were unaware regarding proper medication use and therefore adherence markedly affected. McDonald Heather P et al. (2002)237 also reported that counseling was observed as one of the factor that improved patients’ adherence to drug therapy. Our study noted that the major fraction of the unaware patients were illiterate 73 (45.91%). This clearly shows that uneducated patients should be counseled intensely. Furthermore, Kagashe Godeliver AB et al. (2011)238 studied in HIV and antihypertensive clinics that proper counseling by the pharmacist as a part of health care team can lead to improvement in patient care. Similarly our study noticed that due to lack of counseling a significant proportion, 31.8%, of patients were unaware regarding proper medication usage. This suggests that there is strong need of counseling on drug therapy to patient.

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4.11 Impact on society

Drug Abuse and misuse are two different terms but both have very strong relation. Drug misuse means the abnormal use of medication which is not under supervision of any medical practitioner and in which the person faces physical, social, psychological and legal problems. However, drug Abuse is a following step to drug misuse and lead very harmful effects not only on an individual but to the whole society. Generally, a majority of people think that growing trend of drug abuse and misuse leads the devastating impact on society by both physical and financial aspects. For instance many multivitamin (vital products), anabolic steroids, narcotic analgesics, tranquilizers, antibiotics, etc., have been widely used without knowing their adverse effects on body and their financial impact. It has been generally noticed that the people who are basically drug addicts spent a lot of money on different drug substances without knowing the harmful consequences of addiction of those substances and finally it results not only increase rate of drug induced mortality but also include a great financial/economic loss. Subsequently, many sedatives, hypnotic agents like benzodiazepines and other cautionary drugs have been misused on daily basis as tranquilizers rather than evaluating their harms. The use of these agents without guidance of any physician or medical practitioner adverse the harmful effect of drugs and also create toxicity, which is fatal to health. Antibiotic drugs are misused globally and specially in Pakistani society. This growing trend of antibiotic misuse developed antibiotic induced resistance and other toxic effects on human body. It is noticed generally in Pakistani society that whenever people become ill and develop some infection, the antibiotics are taken without knowing the severity of infection and without knowing the type of microbe involved in that infection. For instance if someone is sick because of fungal infection and if the drug used for its treatment is antibacterial then it is irrational to use such drug, but such happenings occur in our society. The misuse of antibiotics leads to microbial resistance ultimately leading to decreased efficiency of the drug in particular family or community. Not only patients themselves are responsible but doctors, pharmacists and other health related people are also involved who do not fulfill their duties. It is duty of doctor and

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pharmacist to council patients properly about the correct medication, correct dose for the particular pathology and also to ensure the rational therapy. In Pakistani society it is general observation that the pharmacies and medical stores are derived by non professional, non technical and untrained people rather than a qualified and well trained staff. This results in the lack of proper counseling and easy dispensing of drugs without availability of prescription in our society. Due to such immoral practice, there is an abrupt increase in drug abuse and drug misuse and also in other drug related problems. It is also seen that non-technical person do not know the use, side effects, contraindications and other drug related issues, they just know about the purchase and sell of drug in our community which directly influence on the health of people. A pharmacist is a person who knows all the aspects of the drug usage and the management of the majority of drug related problems. An untrained person can sell the cautionary drugs without prescription of a physician and or doctor and even though dispense the medication without the proper counseling, but a pharmacist will never encourage this practice. The study is conducted for the purposes those will ultimately help to create an awareness regarding drug abuse and misuse. For example, side effects of self- medication, drug addiction, drug-induced resistance, toxicity due to abundance of drug substance in body and proper implementation of WHO guideline for the health care system. This study will make the people vigilant enough for drug related problems and also develop the importance of pharmacist in medical and health sector in our region. Therefore, it is concluded from the above described facts that the growing trend of drug abuse and misuse affects the society defectively. It is the responsibility of government to promptly curb the abrupt growing trend of drug abuse and misuse by announcing a clear verdict and punishment for all the people involved in these unlawful activities. However, there must be pharmacist to run each medical store or pharmacy. There shall be clear policies regarding cautionary drug sell and purchase. These practices will not only improve the quality of health of people in our society but splendidly control the drug induced mortality.

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CHAPTER # 05

Conclusion 5.1 Conclusion • Trend of sales at medical stores in Hyderabad city shows that sale with prescription sales is 41.6% and without prescription sales is 58.4%. It reflects easy availability of drugs without prescription on large scale, whereas, on other side 49.4% of patients/customers were even not asked about availability of doctors’ prescription by medical store keeper. • Maximum patients/customers without prescription (13.7%) were found in Pretabad, on the other hand maximum customers/patients with prescription (8.6%) were found in Saddar, Hyderabad. • It was observed that 29.1 % patients/customers were between 31–45 years ages. • Trend of selling and dispensing medicines with prescription (41.6%) at pharmacies/medical stores, was further evaluated. These prescriptions were categorized in four types. Specialist prescriptions (56.4%), General practitioner prescriptions (19.8%), Hospital/Medical center prescriptions (15.7%) and prescriptions without name and addresses of doctor (8.1%; this includes non qualified persons/quacks as well). • Considering significance of prescription error factor in drug misuse and abuse, the error found was 30.6% in all above four categories of prescriptions. The maximum errors were found in the type 4 (this includes non qualified persons/quacks as well). Collectively 8.3% prescriptions were found very old and 11.8% were without date of generation of prescriptions. • Trend of self medication is another factor of drug misuse and abuse seen on large scale in Hyderabad. Large portion of patients/customers generally perceived that self medication is certainly a primary source of curing the disease in our society. According to data collected from patients/customers without prescription (58.4%), the decision of self medication, in 55.8% patients/customers, is influenced or suggested by self judgment, chemist, drug advertisement, friends, relatives, neighbors, etc and in 44.2 by doctor.

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Certainly, the pharmacist can play a main role regarding counseling the customers/patients to make up-to-date options about self medication process at pharmacy/medical store. The communication of rational drug use messages during the sale of prescription as well as OTC products will be proper to the management of problems of drug misuse and abuse rather than just product selling the drugs for business purpose. • In the present study it was found that majority of these patients/customers, 43.6%, were not clear regarding per time dose, per day frequency and duration of therapy. In 7.4% cases medicines were sold to < 15 years age children. • Major therapeutic classes of drugs which are sold without prescription includes analgesics/painkillers (15.9%), sedative/hypnotics (12.1%), antibiotics (8.6%), antacid (9.2%), cough suppressant (5.3%), sexual vitality inducer (1%), psychoactive (9.2%) and others groups (38.6%). • As the nature of the dosage form of medicines is considered, mostly tablet form (47.4%) was purchased by patients/customers. • It was observed that > 46 years age customers are involved mostly in drug misuse and abuse. • An optimum time is required by doctor for proper consultation of the patient but it was found that majority of patients, 43.8 % of those visited doctor, were given less than 03 minutes for consultation which lead to improper consultation time regarding proper diagnosis, medication decisions and counseling time for proper use of drugs. • To facilitate doctors to make treatment decision, it is important to communicate the previous prescription or medication record, but about 79.8% patients/customers responded that they did not communicate previous record during their last visit. • Trend of improper follow-up by patient, who has further visited doctor on directions, is about 70.7%. • Improper Patients counseling is considered as one of the main contributing factor in drug misuse and abuse. The data reflects that about 31.8 % patients were unaware of proper usage of the medicines they receive. This sufficient number of patients was not properly counseled for drug use.

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• The reasons for improper counseling are patient’s illiteracy, heavy OPDs and busy pharmacies. About 40.6% patients visiting hospital were illiterate. As the age of patient is considered, it was observed that the patients having the ages 46 years and above were mostly unaware regarding rationale use of medicines. The chances for improper counseling increase when there are heavy OPDs and busy pharmacy because it diverts the attention of prescriber and dispenser. • Mostly a single prescriber attends heavy OPD in limited time period, which leads to improper counseling. Moreover most of the pharmacies or medical stores are being run without professional persons (pharmacists). Also trends that pharmacies and medical stores are run by unqualified/untrained persons and with limited number of workers are normal practices in Hyderabad Pakistan. • The data regarding prescriptions errors in antibiotic prescriptions in Hyderabad, Pakistan, reveals that majority of the prescription errors were related to the incomplete information on the prescriptions, and poor and incomprehensible hand writing, leading to various problems. The highest proportion of the prescriptions (89.86%, n=257) failed to demonstrate the patient’s weight and the least number of prescriptions (2.44%, n=07) contained the dosage form errors. • The physicians were found much busy due to a large number of patients’ influx therefore unable to pay proper attention to the prescription writing and patient’s counseling. Pharmacist can also play an important role in preventing the errors by reviewing the prescriptions. • The drug – drug interaction is also one the serious concern currently in our society. There have been many studies performed on this problem. It was found in our study that 32.16% of antibiotics containing prescriptions were with potential drug –drug interactions. • The roles of different health care professionals i.e., doctors, retailers/store keepers and pharmaceutical company marketing personals is very important in health care system for eradication of drug abuse and misuse in our society. It has been highly observed that there is lack of communication between these personnel and patients/customers regarding rational drug use. One side majority of pharmacies/medical stores have no any dispensing criteria for

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prescription and over the counter drugs, and on the other side majority were unable to classify the prescription and without prescription drugs. This results in easy availability of all types of drugs to general public.

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Recommendations

5.2 Recommendations • Trend of sales of drugs at pharmacies/medical stores without prescription or self medication is increasing day by day in our society in general and in Hyderabad in particular. The Government must take action and preventive measures on top priority so that except OTC products all the prescription medicines must be dispensed only on prescription generated by qualified persons. • Pharmacies or medical stores should keep prescription records, especially of controlled drugs to minimize the drug misuse and abuse in the society. • Retail pharmacies or medical stores must be run under well trained/qualified person (Pharmacists) and qualified technical staff or assistants be employed for proper counseling , for dispensing the medicines with established criteria of dispensing and to counter act the dispensing errors and other issues in our society. • Number of doctors, pharmacists and Pharmacy staffs must be increased, especially at government hospitals and their dispensaries, to curb some of the factors contributing in drug abuse and misuse, such as busy pharmacies and heavy out patients OPD. • Proper communication between doctors, pharmacist, dispensing staff and patient/customer for the proper use of medication is very important to minimize the problems. • Government should make strategy to control the self medication and design effective campaigns to control the self medication problem by launching educational, training and awareness programs regarding complications or harmful effects of self medication on the health of patient. • Prescription medicines must be dispensed only on the basis of prescription. • The patients must be motivated by their prescriber for the proper follow up in case of long term therapy to cure the chronic diseases. Where as it is responsibility of the patient to co-operate with prescriber and provide complete feedback during the course of treatment, if he is so directed. • The patient must communicate all the previous medication record to doctor during their visits to facilitate the doctor’s for accurate decisions, for proper therapy.

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• All the staff at pharmacy/medical store must be able to differentiate between OTC and prescription drugs as per standard operating procedures or guidelines at the time of dispensing or selling of medication. • Prescriber must follow all the available parameters or standards for prescription writing as given by WHO. • It is responsibility of the Physicians, Paramedical staff, community health workers, pharmacists, drug controlling authorities, personals of pharmaceutical sales/ marketing and all health related people to play their role from their side to minimize the drug abuse and misuse in our society. • The physicians and other health care related people should be provided with educational trainings and awareness camps as per WHO guidelines to improve their prescription writing skills to eradicate the prescription errors. Computerized physician order entry system should be introduced. • Proper strategies be employed to avoid heavy OPDs and busy Pharmacies. An optimum time must be utilized by the prescriber/doctor for proper consultation, as per instruction of WHO or nature of the disease, i.e. history, diagnosis and counseling. However, at pharmacies it is necessary to dispense medicines properly to ensure the rational use of drugs and also to encounter the problems of drug misuse and abuse. • Drug regulating agency's rules and regulation should be implemented by the policy makers and health care managers to change the habit of prescriber to prescribe the drug as per standard instructions. The drug controllers must plan regular visits/inspections giving more concentration to control the easy availability of drugs at medical stores. This will help to counteract the sales of medicines without prescription at medical stores. • Ministry of health must take effective action against illegal/unethical promotion of pharmaceutical companies. • These results would be used for all health institutions for better planning and monitoring to insure patient safety and to reduce the drug misuse and abuse problems. • A mass campaign is required by government and non-government organizations to increase the knowledge and awareness, regarding the drug abuse and misuse

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problems, of public, doctors, pharmacists, nurses, representatives of pharmaceutical companies, etc.

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Summary of Contents Certificate i Dedication ii Acknowledgements iii Abstract iv Contents viii List of Tables xii List of Figures xv Contents

TITLE

Growing Trend of Drug Abuse and Misuse and Its Impact on Society: A Case Study of Hyderabad City

Contents Chapter-1 Introduction ...... 1 1.1 Drug ...... 1 1.2 Medicine ...... 1 1.3 Abuse ...... 1 1.4 Misuse ...... 1 1.5 Drug Abuse ...... 1 1.6 Drug Misuse ...... 2 1.7 Drug dependence / addiction ...... 2 1.8 Manual of Drug law ...... 4 1.9 Prescription drugs ...... 4 1.10 Over the counter drug (OTC) ...... 4 1.11 Prescription and its parts ...... 5 1.12 Prescription and dispensation ...... 6 A. Receiving ...... 6 B. Reading and Checking ...... 6 C. Dating and Numbering ...... 9 D. Labeling ...... 9

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E. Taking out and preparing the prescribed medication ...... 10 F. Packaging ...... 10 G. Rechecking ...... 10 H. Delivering and Patient Counseling ...... 10 I. Filling and Recording ...... 10 J. Pricing the Prescription ...... 10 1.13 Errors ...... 10 1.14 Medication error ...... 11 1.14.1 Types of medication error ...... 11 1.15 Prescription error ...... 12 1.15.1 Prescription errors types ...... 13 1.15.2 Reasons of errors...... 13 1.16 Dispensing error ...... 14 1.17 Guidelines for good dispensing of prescription ...... 15 1.18 Parameters/Standards for good prescription writing...... 19 1.19 Self medication ...... 20 1.20 Psychoactive drugs ...... 20 1.21 Patient counseling ...... 21 1.22 Antibiotic misuse ...... 23 1.22.1 Antibiotic’s prescription errors ...... 24 1.23 Role of pharmacist ...... 25 1.24 Hyderabad city ...... 27 1.25 World Health Organization (WHO) ...... 28 1.26 W.H.O Guidelines to good prescribing ...... 28 1.27 British National Formulary (BNF) ...... 29 1.28 Lexi-Comp’s Drug Information Handbook ...... 31 1.29 Case study ...... 32 1.30 Statement of problems ...... 33 1.31 Aims and objectives of study ...... 34 1.32 Scope of study ...... 34 1.33 Ethical clearances ...... 34 Chapter-2 Literature Review...... 35

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Chapter-3 Research Methodology ...... 81 3.1 Collections of data: ...... 81 3.2 Analysis of data: ...... 81 3.2.1 Analysis of 2000 samples...... 82 3.2.2 Analysis of 500 samples...... 83 3.2.3 Analysis of 286 samples...... 83 3.2.4 Analysis of 50 samples (Doctors) ...... 84 3.2.5 Analysis of 50 samples (Drug promoting individuals) ...... 84 3.2.6 Analysis of 50 samples (Retailers) ...... 84 Table (i): Analysis sheet 01 ...... 85 Table (ii): Analysis sheet 02 ...... 85 Table (iii): Analysis sheet 03 ...... 85 Table (iv): Analysis sheet 04 ...... 86 Chapter-4 Results, Statistical analysis and Discussion ...... 87 4.1 Randomly collected 2000 patients/customers ...... 87 4.2 With prescription (Samples 832) ...... 96 4.3 Prescription error ...... 100 4.4 Without prescription (Samples 1168) ...... 109 4.5 Misuse and Abuse and Error contributing factor (2000 samples) ...... 124 4.6 Patient counseling factor ...... 132 4.7 Prescription errors (All antibiotic containing prescriptions) ...... 138 4.7.1 Distribution of antibiotic prescriptions according to specific drug classes ... 138 4.7.2 Errors containing antibiotic prescriptions (Penicillin) ...... 140 4.7.3 Errors containing antibiotic prescriptions (Cephalosporin) ...... 142 4.7.4 Errors containing antibiotic prescriptions (Tetracycline) ...... 144 4.7.5 Errors containing antibiotic prescriptions (Quinolone) ...... 146 4.7.6 Errors containing antibiotic prescriptions (Macrolide) ...... 148 4.7.7 Errors containing antibiotic prescriptions (Amino glycoside) ...... 150 4.7.8 Errors containing antibiotic prescriptions (Total prescriptions) ...... 152 4.7.9 Errors containing all antibiotic prescriptions ...... 154 4.8 Role of Doctor, Field Manager / Medical representative and Retailer in the eradication of misuse and abuse of drugs ...... 156 4.9 Statistical testing / analysis ...... 168

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4.9.1 Regression modal ...... 168 4.9.2 Testing hypothesis of proportion of gender with respect to drug misuse and abuse ...... 176 4.9.3 Analysis of 286 prescriptions and 95% confidence interval for µ ...... 178 4.9.4 Analysis of variance ...... 181 4.9.5 Chi-square tests ...... 184 4.10 Discussion ...... 194 4.11 Impact on society ...... 205 Chapter-5 5.1 Conclusion ...... 207 5.2 Recommendations ...... 211 References ...... 214

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List of Tables

Table 1: Trend of sales of drug ‘with prescription and without prescription’ ...... 87 Table 2: Sex of the customers / patients ...... 88 Table 3: Number of male & female (customers/patients) with and without prescription ...... 89 Table 4: Age of the customers/patients ...... 90 Table 5: Age of the customers/patients with prescription ...... 91 Table 6: Age of the customers/patients without prescription ...... 92 Table 7: Area of customers/patients interviewed ...... 93 Table 8: Area wise prescription and without prescription ...... 94 Table 9: Trend of store keeper inquiry about prescription ...... 95 Table 10: Customers’/Patients' prescription analyzed ...... 96 Table 11: Evaluation of prescription that how much it is old on the basis of issued date ...... 97 Table 12: Distribution of prescription categories/types area wise ...... 99 Table 13: Category/Type 01 prescriptions (469 samples) ...... 100 Table 14: Category/Type 02 prescriptions (165 samples) ...... 101 Table 15: Category / Type 03 prescriptions (131 samples) ...... 102 Table 16: Category/Type 04 prescriptions (67 samples) ...... 103 Table 17: Total prescription errors in all categories/types (832 samples) ...... 104 Table 18: Area wise errors in all 04 type of prescription (832 samples) ...... 105 Table 19: Age of customers/patients and errors in all 04 categories/types of prescriptions (832 samples) ...... 107 Table 20: Age of the customers/patients ...... 109 Table 21: Patients/Customers area wise ...... 110 Table 22: Trend of purchased dosage form (1168 samples) ...... 111 Table 23: The trend of nature (form) of dosage ...... 112 Table 24: Self medication trend (1186 samples) ...... 113 Table 25: Dose per time (1168 samples) ...... 114 Table 26: Per day dose/frequency (without prescription) ...... 115 Table 27: Duration of therapy (without prescription) ...... 116 Table 28: More than 01 standards/parameters together (without prescription) ...... 117 Table 29: Trend of consultation time ...... 118 Table 30: Trend of medication record / previous drug history communication from patient to doctor ...... 119 Table 31 Trend of follow-up of patients in our community ...... 120 Table 32: Age wise misuse and abuse (without prescription, 1168 samples) ...... 121 Table 33: Area wise misuse and abuse (without prescription, 1168 samples) ...... 122 Table 34: Age wise misuse and abuse/prescription error (Total with and without prescriptions) ...... 124 Table 35: Area wise misuse and abuse (Total with and without prescriptions) ...... 125 Table 36: Misuse and abuse and prescription error factor (with prescription v/s without prescriptions) ...... 127 Table 37: Age wise (with prescription v/s without prescription) ...... 128 Table 38: Age wise prescription error (Contributing factor) ...... 129 Table 39: Cost of medications (with and without prescription) ...... 131 Table 40: Socio-Demographic data of total interviewed persons...... 132 Table 41: Age of counseled patients ...... 133 Table 42: Age of un-counseled patients ...... 134

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Table 43 Education profile of total interviewed (500 samples) ...... 135 Table 44: if counseled, to whom they were counseled ...... 136 Table 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient ...... 137 Table 46: Trend of prescribed antibiotic in society ...... 138 Table 47: No of errors containing antibiotic prescriptions (Penicillin) ...... 140 Table 48: No of errors containing antibiotic prescriptions (Cephalosporin) ...... 142 Table 49: No of errors containing antibiotic prescriptions (Tetracycline) ...... 144 Table 50: No of errors containing antibiotic prescriptions (Quinolone) ...... 146 Table 51: No of errors containing antibiotic prescriptions (Macrolide) ...... 148 Table 52: No of errors containing antibiotic prescriptions (Amino glycoside) ...... 150 Table 53: No of errors containing antibiotic prescriptions (Total prescriptions) ...... 152 Table 54: No of errors containing all antibiotic prescriptions ...... 154 Table 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse...... 156 Table 56: Role of Medical Representative / Field Manager ...... 157 Table 57: Sales promotions approaches of companies for Prescriptions generation .. 158 Table 58: Inspection of medical stores / pharmacies ...... 159 Table 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... 160 Table 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy) ...... 161 Table 61: Role of retailer / store keeper (Reasons of change of prescriptions) ...... 163 Table 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy) ...... 164 Table 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies) ...... 165 Table 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies) ...... 166 Table 65: Role of retailer / store keeper (Knowledge of medicines) ...... 167 Table 66: Descriptive statistics; Number of parameter missed and consultation time given to patient ...... 168 Table 67: SPSS output for correlation between number of parameter missed and Consultation time given to patient ...... 169 Table 68: SPSS output for input of data for regression modal ...... 169 Table 69: SPSS output for modal summary of number of parameter missed and Consultation time given to patient ...... 170 Table 70: SPSS output for significance of F (ANOVA) number of parameter missed and Consultation time given to patient ...... 170 Table 71: SPSS output for explanatory and explained variable ...... 171 Table 72: SPSS output for C.I (95%) ...... 171 Table 73: Residual Statistics (Number of parameter(s) missed) ...... 172 Table 74: Descriptive measure on errors in antibiotic containing prescription ...... 178 Table 75: Standard deviation and mean of errors ...... 179 Table 76: Case processing output of SPSS for validating and missing observation for C.I...... 179 Table 77: 95% confidence interval for mean and other statistical tools for numbers of error ...... 180 Table 78: SPSS output for ANOVA ...... 181 Table 79: SPSS output for homogeneity of variance for numbers of errors ...... 182

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Table 80: SPSS output for ANOVA (numbers of errors in antibiotic containing prescription) ...... 182 Table 81: Output of SPSS for role of doctors for improper usage of drugs and their complications especially drug misuse and abuse ...... 184 Table 82: Chi-square test results for table 81 ...... 184 Table 83: Output of SPSS for role of Medical Representative / Field Manager ...... 185 Table 84: Chi-square test results for table 83 ...... 185 Table 85: Output of SPSS for role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... 186 Table 86: Chi-square test results for table 85 ...... 186 Table 87: SPSS output for role of retailer / store keeper ...... 187 Table 88: Chi-square test results for table 87 ...... 187 Table 89: SPSS output for role of retailer / store keeper (Trend of re dispensing approaches at medical stores / Pharmacy) ...... 188 Table 90: Chi-square test results for table no 89 ...... 188 Table 91: SPSS output for role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / Pharmacies) ...... 189 Table 92: Chi-square test results for table no 91 ...... 189 Table 93: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies ...... 190 Table 94: Chi-square test results for table no 93 ...... 190 Table 95: SPSS output for role of retailer / store keeper (Trend of dispensing criteria prescription drugs at medical stores / pharmacies) ...... 191 Table 96: Chi-square test results for table no 95 ...... 191 Table 97: SPSS output for trend of sales of drug ‘with prescription and without prescription’ ...... 191 Table 98: Chi-square test results for table no 97 ...... 192 Table 99: SPSS output for trend of store keeper inquiry about prescription ...... 192 Table 100: Chi-square test results for table no 99 ...... 192 Table 101: SPSS output for trend of counseling for proper medication usage at government hospital ...... 193 Table 102 Chi-square test results for table no 101 ...... 193

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List of Figures

Figure 1: Trend of sales of drug ‘with prescription and without prescription’ ...... 87 Figure 2: Sex of the customers / patients ...... 88 Figure 3: Number of male & female (customers/patients) with and without prescription ...... 89 Figure 4: Age of the customers/patients ...... 90 Figure 5: Age of the customers/patients with prescription ...... 91 Figure 6: Age of the customers/patients without prescription ...... 92 Figure 7: Area of the customers/patients ...... 93 Figure 8: Area wise prescription and without prescription ...... 94 Figure 9: Trend of store keeper inquiry about prescription ...... 95 Figure 10; Customers’/Patients' prescription (Samples 832) analyzed ...... 96 Figure 11: Evaluation of prescription that how much it is old on the basis of issued date ...... 98 Figure 12: Distribution of prescription categories/types area wise ...... 99 Figure 13: Category/Type 01 prescription (469 samples) ...... 100 Figure 14: Category/Type 02 prescriptions (165 samples) ...... 101 Figure 15: Category/Type 03 prescriptions (131 samples) ...... 102 Figure 16: Category/Type 04 prescriptions (67 samples) ...... 103 Figure 17: Total prescription errors in all categories / types (832 samples) ...... 104 Figure 18: Area wise errors in all 04 categories / type of prescription (832 samples) 105 Figure 19: Age of customers/patients and errors in all 04 categories/types of prescriptions (832 samples) ...... 107 Figure 20: Age of the customers/patients ...... 109 Figure 21: Patients/customers area wise ...... 110 Figure 22: Trend of purchased dosage form (1168 without prescription customers/patients) ...... 111 Figure 23: the trend of nature (form) of dosage ...... 112 Figure 24: self medication trend (1186 samples) ...... 113 Figure 25: Dose per time (1168 samples) ...... 114 Figure 26: Per day frequency (without prescription) ...... 115 Figure 27: Duration of therapy (without prescription) ...... 116 Figure 28 More than 01 parameters together (without prescription) ...... 117 Figure 29: Trend of consultation time ...... 118 Figure 30: Trend of medication record / previous drug history communication from patient to doctor ...... 119 Figure 31: Trend of follow-up of patients in our community ...... 120 Figure 32: Age wise misuse and abuse (without prescription, 1168 samples) ...... 121 Figure 33: Area wise misuse and abuse (without prescription, 1168 samples) ...... 122 Figure 34: Age wise misuse and abuse (Total with and without prescriptions) ...... 124 Figure 35: Area wise misuse and abuse (Total with and without prescriptions) ...... 126 Figure 36 Misuse and abuse and error (with prescription v/s without prescriptions) . 127 Figure 37: Age wise (with prescription v/s without prescription) ...... 128 Figure 38: Age wise prescription error (Contributing factor) ...... 130 Figure 39: Cost of medications (with and without prescription) ...... 131 Figure 40: Socio-demographic data of total interviewed persons...... 132 Figure 41: Age of counseled patients ...... 133 Figure 42: Age of un-counseled patients ...... 134 Figure 43: Education profile of total interviewed ...... 135

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Figure 44: if counseled, to whom they were counseled ...... 136 Figure 45: Unawareness regarding proper use of parameters of medication (Contributing parameters in drug misuse and abuse) Un-counseled patient ...... 137 Figure 46: Trend of prescribed antibiotic in society ...... 138 Figure 47: No of errors containing antibiotic prescriptions (Penicillin) ...... 141 Figure 48: No of errors containing antibiotic prescriptions (Cephalosporin) ...... 143 Figure 49: No of errors containing antibiotic prescriptions (Tetracycline) ...... 145 Figure 50: No of errors containing antibiotic prescriptions (Quinolone) ...... 147 Figure 51: No of errors containing antibiotic prescriptions (Macrolide) ...... 149 Figure 52: No of errors containing antibiotic prescriptions (Amino glycoside) ...... 151 Figure 53: No of errors containing antibiotic prescriptions (Total prescriptions) ...... 153 Figure 54: No of errors containing all antibiotic prescriptions ...... 155 Figure 55: Role of doctors for improper usage of drugs and their complications especially drug misuse and abuse...... 156 Figure 56: Roles of Medical representative / Field Manager ...... 157 Figure 57: Sales promotions approaches of companies for Prescriptions generation 158 Figure 58: Inspection of medical stores / pharmacies ...... 159 Figure 59: Role of retailer / store keeper (Trend of enquiry by drug regulating agencies personals) ...... 160 Figure 60: Role of retailer / store keeper (trend of prescription change at medical store / pharmacy) ...... 161 Figure 61: Role of retailer / store keeper (Reasons of change of prescriptions) ...... 163 Figure 62: Role of retailer / store keeper (Trend of re dispensing approaches at medical stores / pharmacy) ...... 164 Figure 63: Role of retailer / store keeper (Trend of record keeping of controlled drugs at medical stores / pharmacies) ...... 165 Figure 64: Role of retailer / store keeper (Trend of dispensing criteria of prescription drugs at medical stores / pharmacies) ...... 166 Figure 65: Role of retailer / store keeper (Knowledge of medicines) ...... 167 Figure 66: Probability, Probability plot for regression (Number of parameter missed and Consultation time given to patient) ...... 173 Figure 67: Graph the regression equation and the data points...... 174 Figure 68: Errors in prescriptions ...... 183

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