Risk perception about medication sharing among patients: a focus group qualitative study on borrowing and lending of prescription analgesics

Introduction

Several studies have found that the most commonly used drugs for self-medication are analgesics.^1–8 Medication sharing is defined as borrowing or lending of drugs in situations where the receiver of these drugs is not the individual to whom the drugs are allocated.⁹ The expression “lending” medications would imply that it is a provisory transfer of the medication, provided that the amount borrowed be returned; however, an individual “borrowing” a medication usually does not give back the medication to the individual who is “lending” it.¹⁰

Knowledge and awareness on the phenomenon of medication sharing between patients is very limited.¹¹ Individuals who borrow medications may thus lose an opportunity to receive optimal treatment and may delay use of professional help, and such medication may also mask clinical presentation and severity of disease. Furthermore, this behavior may be associated with unexpected side effects, adverse drug interactions, addiction, teratogenicity, drug abuse, intentional and unintentional poisoning, and misshapen perception of ineffectiveness of medications.^{4,5,9,12–14} Beyene et al in their systematic review concluded that there is insufficient data on reasons for medication sharing, how patients decide to engage in medication sharing, whether they are aware of the potential risk, and how to estimate that potential risk.¹⁰

In this qualitative study, we analyzed experiences and opinions of patients about sharing prescription analgesics, reasons for sharing prescription analgesics, the way in which patients choose to share medications, their awareness of risk regarding sharing prescription analgesics, and how they estimate the potential risk.

Methods

Ethics

After reviewing the submitted research protocol, the Ethics Committee of the University of Split School of Medicine approved the study. The study was conducted according to the principles expressed in the Declaration of Helsinki. Informed consent, written and verbal, was obtained from all of the participants.

Participants

This qualitative study involved 40 participants in six focus groups. Number of participants and focus groups was determined based on medians reported in a study on methodological aspects of focus group studies, where the median was five focus groups. The sixth focus group was included to reach a point of saturation.¹⁵

Potential participants were prescreened by family physicians (DV, MP), and those who had received prescription analgesic at least once were invited to participate in the study.

Each focus group consisted of four to 12 participants. For the purpose of this manuscript, focus groups were coded with first six upper-case letters of the alphabet (A–F), and participants in each focus group were coded with first four to 12 lower-case letters of the alphabet (a–l). Potential participants received written information with details about research team, research protocol, guarantee of anonymity, and that the authors intended to publish study results in a research journal.

Participants included were adults aged ≥18 years who had received prescription analgesic at least once in a lifetime and spoke Croatian language. Exclusion criteria were mental health problems and an inability of verbal expression.

Research team and reflexivity

There were four researchers in the team (LP, DV, MP, and FM). Prof. LP is MD, PhD, and employed at the University of Split School of Medicine in Split, Croatia, as a researcher in the Laboratory for Pain Research and a lecturer at the Department of Histology and Embryology. DV is MD, PhD and affiliated with the University of Split School of Medicine in Split, Croatia, as a lecturer at the Department of Family Medicine. She also works as a specialist of family medicine. MP is MD, and employed at the Health Centre Imotski, Croatia. FM is MD, MSc, and works at the University Clinical Hospital Mostar, Bosnia and Herzegovina, as a specialist of clinical pharmacology and toxicology, and is the Head of the Centre for Clinical Pharmacology.

Potential participants received invitation to participate in the study together with detailed information about the study via study researcher who recruited them. Participants were also informed that they were not obliged to answer all the questions if they did not want to.

Questionnaires and focus group discussion

In addition to written information about the study that the participants received before consenting to participate, at the beginning of each focus group meeting, the same introduction about medication sharing was given by one study author (FM) to ensure that the participants understand the concept of prescription medication sharing.

Participants filled out two short questionnaires and participated in the discussion about sharing of prescription analgesics. First questionnaire was distributed before focus group discussion, and the second one after the discussion. In the first questionnaire, participants answered questions about their own behavior regarding medication sharing. In the second questionnaire, participants were asked to write their associations regarding multiple statements about medication sharing. We applied consolidated criteria for reporting qualitative research (COREQ) as an assistance tool for conducting and reporting the study.¹⁶ For discussions, semi-structured interviews were conducted with patients in order to detect whether they considered that sharing drugs is risky and if they recognized potential negative consequences of prescription analgesics sharing. Use of semi-structured interviews enabled comparison of interviews, but also provided an option to include issues raised by participants that were not anticipated, but were regarded important.¹⁷ Two questionnaires were used for triangulation purposes, to collect more data from the participants, and also to compare results of anonymous questionnaires with information shared during the focus group. Previously published literature was used to develop the questionnaires.^9,13,18,19 A list of questions used in the study is presented in the Supplementary material.

Focus group locations

The first focus group (A) discussion was conducted at the premises of the Society for Diabetes in Split, with two researchers (LP and FM). Interview was conducted in a room with an open door, but nobody else was present at the premises. Focus groups B and C were conducted at the University of Split School of Medicine, with two researchers (LP and FM). The focus group D was conducted in Mostar, with one researcher (FM). Focus groups E and F were conducted at the Health Centre Imotski, with one researcher (FM).

Analysis

All discussions about medication sharing were audio-taped. Transcripts were then analyzed by using qualitative content analysis.²⁰ It is a method for analysis of semi-structured interviews with experts because it is used to encode the text to a predetermined systematic coding that can be matched and supplemented with new issues that may arise during the interview. Predefined encoding system for this study was based on risk categories that were identified in previously published literature about drug sharing.¹² Coding was done by two researchers (FM, LP) from the author team independently. Specific risks were divided into appropriate categories. Meaningful units (complete sentences or parts of sentences) were defined as the analysis unit. Results were compared among researchers. The frequency of risks mentioned in discussions and spontaneously mentioned risks were described using descriptive statistics to indicate their relative importance in individual risk categories. For questionnaires, answers were coded, and frequency of answers was presented using descriptive statistics. The data were interpreted by the study authors.

The study questionnaires and focus group discussions were in Croatian. The questions and the participants responses have been translated into English for inclusion in this paper.

Results

The study included 40 participants (25 women and 15 men). The average age of participants was 56.3 years (range 20–83 years). The key finding of the study was that for the majority of the participants, sharing of prescription analgesics was normal, and they did not worry a lot about the possible negative consequences of such behavior. Patients were more interested in reducing the suffering of pain and maintaining good interpersonal relationships than potential dangers.

Participants’ experiences and opinions about sharing analgesics

Almost all participants engaged in sharing of analgesics. Frequency of participants’ sharing of analgesics and participants’ awareness of risks related to sharing those drugs are shown in Table 1.

Table 1 Frequency of participants’ sharing of analgesics and their awareness of the risks related to sharing those drugs Notes: Ø = no answer. *This is an English translation of the original version of these questions, which were presented in Croatian.

Lending prescription pain medication (n=22, 55%) was more common than lending nonprescription pain medications (n=20, 50%). There were 15 (38%) participants who indicated that they are lending both prescription and nonprescription analgesics. Less than half of the participants (n=17, 44%) borrowed pain medication from others. Lending of analgesics was more frequent than borrowing; 31% (n=12) of participants indicated that they were lending nonprescription analgesics and borrowing analgesics; 33% (n=13) of participants mentioned lending prescription analgesics and borrowing analgesics; and 28% (n=11) of participants stated lending both, nonprescription and prescription, analgesics and borrowing analgesics. There were 28% (n=11) of participants who indicated that they never lend and/or borrow pain medications.

Participants indicated that they shared analgesics usually with family/relatives and/or friends and/or neighbors, and less usually with work colleagues and/or acquaintances.

Through discussion in focus groups, more participants (76%) indicated that they personally shared prescription analgesics than they previously declared in the first questionnaire (55%). Probably, during discussions, some participants recalled a situation in which they shared analgesics, prompted by other participants’ responses. Some participants later said they did not fully comprehend what does it mean to share medications, and for example, whether sharing medications with their wife or husband should also be reported. Participants indicated that medications prescribed to the spouse were considered a “common property” in the household. Two participants said that they shared analgesics only with their spouses (focus group participants [FGPs] Ae and Cd).

Some participants imparted their experiences and opinions about analgesic sharing.

I once gave my prescription medication Zaldiar [tramadol with paracetamol] to my sister, who is 93 years old. After a leg surgery she had severe pain. Because the first tablet of Zaldiar she took from me did not help her, she did not want to take another tablet. [FGP Bd]

I am lending and borrowing analgesics. I shared them with my children, husband, neighbors and work colleagues. It was the Aspirin from Bayer (authors note – generic name: acetylsalicylic acid). With this drug I rescued people and they rescued me when it was needed. I was careful about the expiration date; when it runs out I throw them. [FGP Bf]

One participant from focus group F recounted story from his childhood, which happened about 50 years ago. At that time, a neighbor stole one tablet of analgesic from the participant’s house. The analgesic was prescribed by a veterinarian for the participant’s cow. The next day, the neighbor confessed that to the participant’s mother. Since the neighbor claimed that the analgesic was effective, the participant’s mother decided to give the neighbor two more tablets.

Reasons for sharing prescription analgesics and the way in which patients choose to share medications

Distrust in physicians was indicated as one reason for engaging in medication sharing.

When it hurts, I could eat a snake if it will help. If there was no pain then I would not take anything. I trust more another patient than a doctor, honestly. I prefer an advice from a patient with the same experience than a doctor. [FGP Ac]

Inconvenience of contacting a physician and persons nearby having a drug available were reasons for medication sharing among some participants.

For me it is good to take a medication from someone because it allows me to skip a visit to the doctor and waiting in line. [FGP Dd]

Medication sharing may be fostered by unusual situations, such as when someone does not have access to a health care professional or accessibility of a drug in a pharmacy, for example, during the hiking (Bd) or working as a captain on a ship (FGP Cb). Some participants indicated willingness to share analgesics if someone has emergency situations such as “intensive pain”.

Only if someone really has a strong pain, then it is ok for me to share an analgesic. [FGP Cd]

Sometimes, prescription analgesics were shared reluctantly.

I gave ibuprofen, which I got via prescription, several times to my neighbor. I did not want to do this and I was trying to discourage her, but she insisted. [FGP Ca]

For many participants, medication sharing was something normal and the way to maintain good relations with individuals in their life. Participant Bg, who is doing a lot of fieldwork, stated that his coworkers often suffer from pain and that sharing analgesics occurs commonly among work colleagues. Participant Ec commented that in his surroundings, there exists an opinion that people who experience pain in the same location can use the same medication.

I engage in such behavior only to maintain good neighborly relations. [FGP Cc]

Medications are shared more out of necessity than for economic reasons. We are used to that. It is a habit, we do not even think about it. [FGP Da]

Two participants emphasized that they borrow only analgesics which they know well (FGPs Ee and Ek).

I think that is normal. People have always shared drugs and they always will be shared. [FGP Ea]

It is okay to help someone when it hurts him. We should not always question the situation when someone’s in pain. [FGP Ed]

Participants’ awareness of risk regarding sharing prescription analgesics and how participants estimate the potential risk

Most of the participants considered it risky to borrow analgesics from another person. As possible harmful hazards and consequences, they mentioned side effects (FGPs Aa, Ab, Ae, Af, Ba, Bc, Bd, Cb, Cd, Ea, Ec, Fb, and Fe), allergies (FGPs Ae, Bd, Cb, Ee, and Ff), fear (FGP Da), threat to life (FGPs Eb and Fb), a possibility that given analgesic does not relieve the pain (FGP Fd), a possibility that dangerous combination of drugs may happen (FGPs Ed, Ee, and Ej), potential inappropriate use of medications (FGPs Ee and Ej), and a waste of time in treatment (FGP Cc). Three participants expressed that they did not know anything about risks related to borrowing medication (FGPs Ca, Fa, and Fc).

One participant described his experience when his neighbor had serious allergic reaction to acetylsalicylic acid and emphasized:

If someone asked for an analgesic and complained of severe pain I would have told him to take them on their own responsibility. It helped me, but I do not know if it would help you. [FGP Ae]

Some participants had specific advice about using medication.

Those who have problems with the stomach should take something based on acetaminophen. People should always estimate how long they can endure the pain, because there is a risk. [FGP Bf]

I know that medications for pain affect the digestive tract, so I always reduce the recommended dosage and duration of drug administration. [FGP Bd]

Three participants stated that they always read instructions for medications written on the package insert, and therefore, they do not want to give their drugs to others (FGPs Bb, Bd, and Cd). Although, one participant commented:

If I would read side effects in instructions for medications I would never take any medications, because they can have hundred side effects on the list. [FGP Ee]

One participant said that whoever is looking for medication should read instructions and decide on their own whether to take the medication (FGP Fc). Some participants said they think more about how to alleviate the pain than they think about risks (FGPs Bg, Db, Dc, Dd, and Ea).

A person lending his/her own medication may be exposed to the following risks, according to the participants: remorse/moral responsibility (FGPs Aa, Ab, Ae, Bc, Bd, Bg, Cb, Cc, Cd, Ca, Da, Db, Ec, Ee, Ef, Eh, Ei, Ej, Ek, El, Fb, and Ff), legal accountability (FGPs Dd, Ed, Ee, Ef, Ek, and El), remains without his/her own medications (FGPs Ca, Cc, Da, Eb, Ee, Eg, Ek, and El), imputation (FGP Ca), and regrets if the medication would not help (FGPs Fd and Fe). Two participants considered that a person lending his/her own medications could not be subject to any of risks indicated by other focus group members (FGPs Ea, Fc, and Fg). One participant stated:

The responsibility exists only if children are involved. [FGP Bf]

One participant commented:

I ran out of the medication when I give it. I do not like to give medication. That’s why I often say that I do not have a medication, although I have it. I do not know how a drug will affect someone else. I do not want to be responsible if something happens and someone might say that I poisoned that person. I’m afraid that I will be charged if something bad happens. I do not want to hear something like – who knows whether the medicine was fresh, who knows what she gave her [...] I do not like to talk to others about medications that I am taking so that they would not ask me to give them some. Some other people like to list medications they are taking and they like to inquire about other people’s medications. [FGP Ca]

One participant stated:

[...] I think it is a greater sin to not give someone an analgesic when it hurts, than the risk that something bad will happen if I give it [....] [FGP Db]

Similarly, a participant said:

Helping people should be the most important. [FGP Dc]

There were 45% of participants who indicated that sharing prescription analgesics is riskier than sharing nonprescription analgesics. Several participants expressed having more confidence in medications that were prescribed by their doctor than in medication they bought themselves (FGPs Bb, Ca, Cb, Cc, Ea, Ec, Ed, and Eg). Their explanation was that their doctor knows “pains” better and which medicines are adequate.

In the second questionnaire, participants were asked to provide free associations and open-ended answers related to the risk of taking analgesics from other people (Table 2), to indicate how they would describe individuals who give their drugs to others (Table 3) and individuals who take drugs from others (Table 4). Most of the participants responded to these questions, indicating either approval of behaviors involving sharing prescription medications, or neutral position, or their disagreement and condemnation.

Table 2 Free associations related to the question: What comes to your mind first, in relation to a risk of taking pain medications from other people? Note: The original responses were given in Croatian and have been translated to English.

Table 3 Free associations related to the question: How would you describe people who give their drugs to others? Note: The original responses were given in Croatian and have been translated to English.

Table 4 Free associations related to the question: How would you describe people who take drugs from others Note: The original responses were given in Croatian and have been translated to English.

More than half of participants (n=22, 55%) had negative free associations related to risk of taking prescription pain medications from other people. Only seven respondents (18%) had positive and six respondents had neutral free associations related to that risk. Half of the respondents described individuals who give their prescription drugs to others positively, while 14 (35%) respondents described them negatively. Thus, individuals who took prescription drugs from others were described negatively by half of respondents.

The great majority of participants noted that physicians should take measures to prevent sharing of prescription analgesics among patients. They suggested that physicians should warn, advise, instruct, inform, and educate patients about harmful consequences of sharing prescription medication. A participant from focus group D commented that it is “necessary to accelerate procedures at the family doctor and provide prescriptions for medications adapted to current needs and condition of a patient”.

As possible benefits of giving one’s analgesics to others, most frequent answers were pain relief and helping another person (21 participants). Financial savings and gratefulness were mentioned as potential benefits of medication sharing too. Five participants did not see any benefit in sharing prescription analgesics. Two respondents considered that the risk is greater than the benefit.

Thirteen participants considered that there are no harmful consequences in refusing to give someone an analgesic. Other participants mentioned the following as possible harmful consequences: pain/suffering (n=4), their own guilty conscience (n=5), and fear of the worsening of interpersonal relationships (n=5). One participant wrote that others might think she is a cheapskate if she refused them.

Discussion

Participants expressed various opinions related to sharing prescription analgesics, ranging from approving, neutral, and disapproving. Certain risks, but also benefits of this behavior, were recognized. As potential reasons for sharing prescription analgesics, participants indicated unusual situations when professional help is not available, distrust in physicians, inconvenience of contacting a physician, availability of a drug with persons nearby, financial savings, and accessibility of a drug in a pharmacy.

Even though this study was of qualitative nature and involved 40 participants, due to nature of the focus group methodology, prevalence of medication-lending behavior was considerably higher compared to other studies, where reported rate for lending medication was 6%–23%.^{5,9,10,13,18,21–24} However, our findings correlate with study of Ali et al which found that 54% of respondents admitted to sharing their medications with friends and family members.²⁵ Prevalence for borrowing pain medication among our participants was 43.6%. In other studies, the reported ratio was 5.0%–51.9%.^{4,5,9,10,13,18,19,21–23} In one study, more than half of students took leftover medications from family or friends,²⁵ and borrowing was less prevalent than lending, like in two previous studies.^18,24 However, in five studies, borrowing was more prevalent than lending.^5,9,13,21,22 About one-third of participants reported both lending and borrowing analgesics. In two other studies, 12%–16% indicated both borrowing and sharing medications.^5,22

During discussions, more patients indicated engaging in prescription medication-sharing behavior compared to the first questionnaire. This could be due to their lack of understanding that sharing involves any other person, and some of them said that they did not consider that giving or taking a drug from spouse was “sharing medications” because they live in the same household and they considered their medications as their joint ownership. Some participants may have forgotten about such experiences, but they were prompted after hearing others’ experiences. Participants’ opinions may be influenced by group norms and may lead to bias. This is why we gave two anonymous questionnaires to the participants. Furthermore, we encouraged them to be open and detailed in their responses.

Different behaviors may be associated with different types of medications. Our participants indicated that they share mostly paracetamol and nonsteroidal anti-inflammatory medications like in the previous studies.^1–4,19,26 Participants shared analgesics mostly with family, friends, and neighbors. In previous studies, it was found that medications were usually shared with family and friends.^{7,10,19,22,27–30} In some cultures, sharing medications is a way of expressing care for family members when they are ill.^26,31,32 Desire to help others or oneself was the most reported explanation for sharing analgesics.

Borrowing medication for pain management was cited as an important reason in the study of Daniel et al.⁹ In three earlier studies, the main situation in which borrowing occurred involved a person already taking a medicine but running out of it or having the similar medical problem as the person who had the medicine.^5,13,25 Such reasons are usually describing participants who share their medications with spouses. Some participants lent their leftover analgesics. In previous studies, primary explanations for lending behavior were having leftover medications.^5,13 Our participants reported the inconvenience of visiting a physician as a reason for sharing analgesics, like in the previous studies.^18,22

Many of our participants (61%) were aware of risks related to the borrowing of analgesics, compared to 41% of borrowers aware of risks. Despite the possible risk, most of the participants considered that sharing analgesics is an acceptable behavior. These findings could suggest that those who are sharing and borrowing analgesics are underestimating potential health risks that are associated with this behavior. In an earlier study, many respondents were also aware of and worried about risk related to sharing of medications.³² One study found that those who borrowed or shared medication considered they were at a lesser risk of side effects if they take other people’s medicines.²² Goldsworthy and Mayhorn in their study found that 37% of borrowers had experienced an adverse effect or an allergic reaction.¹⁸ A study conducted in Australia found that people older than 65 years thought that sharing strong analgesics and the same prescription medication seemed to be acceptable.²⁴ In another study, adolescents assumed that medications would be shared if obtained from a family member or someone who “had the same problem” or someone who “knows something” about medicines, and in the case of pain.⁹

Written instructions for sharing analgesics were not taken by 65% of borrowers, which are worse than results of the study where half borrowers reported receiving written instructions as package inserts.¹⁸ In one study, results showed that more than 60% of participants did not try to read the package inserts of their medications.³³ Some of the participants in our study mentioned intentionally using a lower dose of prescribed medication. One study found that the noncompliance to pharmacological therapy was associated with sharing analgesics.³⁴

Even though the focus of our study was to analyze sharing of prescription analgesics between human beings, one case about sharing a medication prescribed to an animal was also described by a participant. We decided to describe this too, because maybe this behavior should be separately investigated, in order to see how often people engage in using medications intended for animals.

Our study indicated that physicians should be aware about patients’ benevolent opinions about sharing prescription analgesics. Physicians should educate patients about dangers of such behavior, but also about the fact that over-the-counter medications are not harmless. Our recent study about opinions of pain management physicians regarding sharing of prescription analgesics among patients showed that majority of them believe that this is a negative behavior and that patients should be educated about its dangers.³⁵

Limitations

Limitations of this study are those that are inherent for focus group discussions. There may be dominant persons in a group who can influence the conversation and tendencies toward socially acceptable and normative discourse. In this study, sample size was small due to study design.

Future large-scale quantitative studies can use these data for generating new hypothesis that may provide new insights about prevalence of sharing prescription medication and perceived risks. Additionally, we did not find any studies testing interventions for preventing such behavior, and therefore, such studies would be useful.

Conclusion

The attitude that sharing prescription analgesics is a positive behavior is prevalent among patients, where potential benefits outweigh risks. Physicians should be aware of the existence of this phenomenon among patients and warn patients about dangers of such behavior. Future quantitative studies should explore these attitudes on a large scale. There is also a need for testing interventions for reducing sharing of prescription analgesics.

Disclosure

The authors report no conflicts of interest in this work.

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Supplementary material

Table S1 Questionnaires used during focus group discussions Note: This is an English translation of the original version of this questionnaire, which was presented in Croatian.