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Overuse and Misperceptions of Nonsteroidal Anti-inflammatory Drugs in the United States

Published:October 11, 2016DOI:https://doi.org/10.1016/j.amjms.2016.08.028

      Abstract

      Background

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most commonly used medications worldwide. The availability of hundreds of products containing an NSAID, combined with a lack of recognition and understanding of NSAIDs, can increase the potential of consumers to inadvertently exceed the recommended NSAID dosage, which can cause potentially serious side effects. Physician and consumer education regarding the appropriate use of NSAIDs can help prevent NSAID misuse. Evaluations of current consumer patterns of NSAID use and perceptions about NSAIDs are necessary to develop targeted educational programs.

      Materials and Methods

      An online and telephone survey of 1,750 U.S. adults was conducted to obtain information about the patterns of use and perceptions about prescription and over-the-counter NSAIDs and medicines. The survey was compared to similar surveys conducted in 1997, 2001 and 2002.

      Results

      NSAIDs are widely used, with 63% of respondents reporting use within the past 12 months. NSAIDs were not well recognized by generic or brand names and many respondents were unaware or unconcerned about potential side effects. NSAID misuse was common, with 19% using more than the recommended dose and 24% using multiple NSAIDs concomitantly. NSAID use appears to have increased since 2002 but the level of NSAID awareness and pattern of NSAID misuse has not changed.

      Conclusions

      NSAIDs are widely used and often used in a manner that increases the risk of serious side effects. Sufficient knowledge and understanding of NSAIDs is lacking and educational interventions directed to consumers and physicians are needed.

      Key Indexing Terms

      Introduction

      Nonsteroidal anti-inflammatory drugs (NSAIDs), available by prescription and over the counter (OTC), are some of the most commonly used medications. In 2012, 98 million NSAID prescriptions were filled

      IMS Institute for Healthcare Informatics. The use of medicines in the United States: review of 2011. Available at: http://www.imshealth.com/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/IHII_Medicines_in_U.S_Report_2011.pdf. 2012 Accessed January 19, 2015.

      and more than 30 billion doses of prescription and OTC NSAIDs are consumed annually in the United States.

      United States Food and Drug Administration. NSAID background package for the Nonprescription Drugs Advisory Committee (NDAC). Available at: www.fda.gov/ohrms/dockets/ac/02/briefing/3882b2_02_mcneil-nsaid.htm. 2002 Accessed January 19, 2015.

      However, like any medication, NSAIDs can cause side effects. Both OTC and prescription NSAIDs can cause serious gastrointestinal (GI), cardiac and renal complications, particularly if taken inappropriately.
      • Lanas A.
      • Garcia Tell G.
      • Armada B.
      • et al.
      Prescription patterns and appropriateness of NSAID therapy according to gastrointestinal risk and cardiovascular history in patients with diagnoses of osteoarthritis.
      • Wilcox C.M.
      • Cryer B.
      • Triadafilopoulos G.
      Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs.
      • Lewis S.C.
      • Langman M.J.S.
      • Laporte J.-R.
      • et al.
      Dose-response relationships between individual nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) and serious upper gastrointestinal bleeding: a meta-analysis based on individual patient data.
      • Schneider V.
      • Lévesque L.E.
      • Zhang B.
      • et al.
      Association of selective and conventional nonsteroidal anti-inflammatory drugs with acute renal failure: a population-based, nested case-control analysis.
      • Garcia Rodriguez L.A.
      • Tacconelli S.
      • Patrignani P.
      Role of dose potency in the prediction of risk of myocardial infarction associated with nonsteroidal anti-inflammatory drugs in the general population.
      • Griffin M.R.
      • Yared A.
      • Ray W.A.
      Nonsteroidal anti-inflammatory drugs and acute renal failure in elderly persons.
      • Anderson J.L.
      • Adams C.D.
      • Antman E.M.
      • et al.
      ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.
      In the United States, approximately 26,000 deaths related to the often inadvertent misuse of OTC NSAIDs occur annually.
      • Rothman K.J.
      • Lanza L.L.
      Estimated risks of fatal events associated with acetaminophen, ibuprofen, and naproxen sodium used for analgesia.
      The existence of more than 600 NSAID-containing products contributes to unintentional overuse.

      United States Food and Drug Administration. Consumer Health Information. Available at: http://www.fda.gov/ForConsumers/ConsumersUpdates/ucm336581.htm. 2013 Accessed January 19, 2015.

      Exceeding NSAID dosage limits can increase the risk for side effects. For example, major GI bleeding risk is more than doubled when a single daily low-dose aspirin is combined with an NSAID.
      • Sørensen H.T.
      • Mellemkjaer L.
      • Blot W.J.
      • et al.
      Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin.
      The potentially serious side effects of NSAIDs, combined with their accessibility and widespread use, make public awareness of appropriate NSAID use and the risks of NSAID misuse important public health concerns. The Alliance for Rational Use of NSAIDs (Alliance) is a public health coalition dedicated to educating about the safe and appropriate use of NSAIDs, raising awareness of unsafe pain medication habits and motivating individuals to read and follow medicine warnings and dosage limits.
      Knowledge of current patterns of NSAID use and consumer perceptions regarding NSAIDs is lacking. It has been more than a decade since the last large-scale survey was conducted in the United States evaluating the use of NSAIDs.
      • Wilcox C.M.
      • Cryer B.
      • Triadafilopoulos G.
      Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs.

      National Council on Patient Information and Education. Attitudes and beliefs about the use of over-the-counter medicines: a dose of reality. Available at: http://www.bemedwise.org/survey/final_survey.pdf. 2002 Accessed March 1, 2015.

      Between 1997 and 2002, 3 surveys of U.S. adults were conducted to determine the usage patterns of nonprescription analgesics, including OTC NSAIDs and prescription NSAIDs. Overall, these surveys revealed that NSAIDs were widely used, were generally believed to be safe, were commonly used at dosages that exceeded recommendations, were frequently taken inappropriately and consumers were mostly unaware or unconcerned about the potential NSAID toxicities.
      It has been more than a decade since these surveys were conducted, so the Alliance commissioned a survey to evaluate the current patterns of use and public perception of OTC and prescription analgesics, focusing on NSAIDs in particular. In this article, we present the findings of our current survey and juxtapose the results with those of the previous surveys to understand trends in NSAID awareness and use to help develop appropriate educational interventions that might reduce NSAID misuse and accompanying increased risk for adverse events (AEs).

      Materials and Methods

      The survey, conducted by Harris Interactive Inc. (HI) from September 23 to October 10, 2013, was commissioned by the Alliance, a coalition of professional and consumer-facing healthcare organizations (www.NSAIDalliance.com). The purposes were to determine (1) the usage of OTC and prescription analgesics, including NSAIDs, and the dosages used by the U.S. population; (2) the extent to which Americans understand the potential AEs of these medications; and (3) whether Americans talk with healthcare providers (HCPs) about OTC and prescription analgesics, including NSAIDs.
      U.S. residents aged 18 years and older were eligible for the survey that was conducted online and by telephone. Online respondents were recruited from online panels. Phone respondents were recruited via random digit dialing. To ensure comparability of data across modes, standards were implemented, such as reversing scales to account for recency effects on the phone and primacy effects online. For both web and phone data, figures from the 2012 Current Population Survey (CPS from the Census) for education, age by sex, race and ethnicity, region and household income were weighted where necessary to bring them into line with the population of U.S. residents aged 18 years and older. The weighting algorithm also included a propensity score variable to permit adjustments for attitudinal and behavioral differences between those who are online, join online panels or responded to the survey versus those who did not. The weighting algorithm for the phone data included variables for number of phone lines, number of adults in household and recent “phonelessness” to account for the probability of selection. Data from the phone and web were combined into a representative total using a postweight to account for the proportion of the population who use the Internet, based on Pew 2013 data. The final postweighted data were nationally representative.
      The current survey design paralleled those of 3 surveys conducted from 1997 to 2002. The methods of the first 2 surveys are described in detail elsewhere.
      • Wilcox C.M.
      • Cryer B.
      • Triadafilopoulos G.
      Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs.
      The first survey, commissioned by the American Gastroenterological Association (AGA), was conducted in 1997 by Roper Starch Worldwide and included 4,799 U.S. adults screened for OTC and prescription NSAID use. A National Consumers League (NCL)-sponsored survey was performed in 2002 by HI and included 3,557 U.S. adults screened for OTC analgesic medication use, including NSAIDs. The third survey, commissioned by the National Council on Patient Information and Education (NCPIE), was conducted in 2001 by HI and included 1,011 U.S. adults screened for OTC medicine use, including NSAIDs.

      National Council on Patient Information and Education. Attitudes and beliefs about the use of over-the-counter medicines: a dose of reality. Available at: http://www.bemedwise.org/survey/final_survey.pdf. 2002 Accessed March 1, 2015.

      Although the survey questions were similar, the total respondents, survey populations, question wording and answer choices were not identical to the previously conducted surveys, so results could only be compared directionally.

      Results

      The total number of participants surveyed was 1,750; 1,500 participants completed the survey online and 250 participants completed the survey by phone. The overall incidence rate was 85.2% (completed responses / surveys attempted × 100). There was no statistical difference between the results derived from the online and phone cohorts. Overall, the survey population was similar to those of previous surveys, including mean age, health status, education and income (Table 1). The 1997 AGA survey population included a larger percentage of women compared with the current and NCL surveys. Similar use of medicinal products and nearly identical number and frequency of medicines were seen between the Alliance and 2001 NCPIE cohorts.
      TABLE 1Characteristics of the survey populations.
      Characteristic2013 Alliance2001 NCPIE2002 NCL1997 AGA
      (n = 1,750)(n = 1,011)(n = 3,557)(n = 258)
      Exclusive OTC NSAID users only.
      Mean age, years484547
      Female, %535266
      White, %817486
      High school graduate, %373633
      College graduate, %181622
      Household income <$50,000, %393745
      <$35,000; adjusted for inflation = approximately $50,000.
      Current health, good to excellent, %848581
      Visited a doctor in the past year, %7974
      Mean number of medications in the past month (OTC or Rx)3
      Medicines taken in the past 6 months
       Vitamins, %7063
       OTC, %5959
       Rx, %6654
       Minerals, %1826
       Dietary or herbal supplements, %2623
      Number of OTC medicines vs. 5 years ago
       More, %2122
       About the same, %5654
       Fewer, %1820
      Frequency of OTC medicines vs. 5 years ago
       More frequently, %2119
       About the same, %5554
       Less frequently, %2022
      – Not available; AGA, American Gastroenterological Association; Alliance, Alliance for Rational Use of NSAIDs; NCL, National Consumers League; NCPIE, National Council on Patient Information and Education; NSAIDs, nonsteroidal anti-inflammatory drugs; OTC, over the counter; Rx, prescription.
      a Exclusive OTC NSAID users only.
      b <$35,000; adjusted for inflation = approximately $50,000.

      NSAID Awareness and Patterns of Use

      Awareness of NSAIDs was generally poor. Ibuprofen, correctly identified as an NSAID by approximately half of respondents, was the most well-recognized NSAID (Figure 1). Less than half of the respondents could recognize any other NSAID by name (brand or generic), and the same percentage of people who could identify naproxen as an NSAID were unsure if any products were NSAIDs. Tylenol was incorrectly identified as an NSAID by one-third of respondents, and only a minority of respondents identified Alka-Seltzer and aspirin powders as NSAIDs.
      FIGURE 1
      FIGURE 1Proportion of the 2013 Alliance Survey respondents that identified a product as an NSAID. Alliance, Alliance for the Rational Use of NSAIDs.
      NSAIDs were used by 63% of respondents in the previous 12 months; 5% used prescription NSAIDs, 35% used OTC NSAIDs and 23% used both (Figure 2). It should be noted that the actual use of NSAIDs in this population may be as high as 78% because 15% of respondents were unsure if they used NSAIDs. In the 1997 AGA survey, only 17% of respondents (807 of 4,799) used NSAIDs in the previous 12 months; 5% used prescription NSAIDs and 5.4% used OTC NSAIDs only. These results suggest that overall use of OTC NSAIDs increased substantially since 1997, whereas prescription use has not fluctuated.
      FIGURE 2
      FIGURE 2NSAID use in the United States in 2013. A, NSAID use in the previous 12 months in the Alliance Survey. B, Duration of OTC NSAID use in the Alliance Survey. C, Duration of prescription NSAID use in the Alliance Survey. NSAID, nonsteroidal anti-inflammatory drug; OTC, nonprescription NSAIDs; Rx, prescription NSAIDs; Alliance, Alliance for the Rational Use of NSAIDs.

      NSAID Misuse

      In the current survey, as in past surveys, many respondents reported using NSAIDs inappropriately. Although most respondents used NSAIDs for an appropriate duration, 8% took OTC NSAIDs for >10 days and 7% took prescription NSAIDs for a year or longer, although chronic use may not represent misuse as much as higher risk use (Figure 2B and C). Importantly, at least one-fifth of respondents reported using more than the dose recommended on the label (frequency or amount per ingestion) of their OTC or prescription NSAID (7% were unsure), a similar proportion to what was reported in the 1997 AGA survey (Figure 3). In addition, up to 35% of respondents in the current survey reported using more than 1 NSAID concomitantly, which may have included use of aspirin or non-aspirin NSAIDs; 10% used >1 OTC NSAID together (7% were unsure) and 14% used OTC and prescription NSAIDs concomitantly (4% were unsure).
      FIGURE 3
      FIGURE 3Misuse of NSAIDs and OTC medicines. AGA, American Gastroenterological Association; Alliance, Alliance for the Rational Use of NSAIDs; NCPIE, National Council on Patient Information and Education; OTC, nonprescription; Rx, prescription. *Note that 24% is use of >1 OTC NSAID and use of OTC and prescription NSAIDs combined. In addition, 11% of respondents were unsure if they had used NSAIDs (OTC or prescription) concomitantly, so concomitant use could be as high as 35%.
      Many respondents also reported using more than the recommended dose of an OTC medicine (28% [3% unsure]) (Figure 3), primarily by taking more than the recommended number of pills at a time (71%) or the next dose sooner than directed (47%) (Table 2). Similar results were reported in the NCPIE and NCL surveys (Figure 3 and Table 2).
      TABLE 2Patterns of use of NSAIDs and OTC medicines.
      2013 Alliance2001 NCPIE2002 NCL1997 AGA
      (n = 1,750)(n = 1,011)(n = 3,557)
      OTC medicine use for pain in past 6-12 months, %737883
      Reason for Rx NSAID/OTC pain medicine use, %n = 258
      Exclusive OTC NSAID users only.
       Arthritis/joint pain, %29/27–/40–/33
       Back pain, %39/38–/40–/15
       Headache, %40/74–/36–/22
       Sports/exercise-related pain, %14/18–/20
       Musculoskeletal, %20/19
       Other, %24/10–/29
      Frequency of Rx/OTC NSAID use, %
       Daily6/7–/1553/27
       Weekly2/8–/29
       Monthly2/4–/27
       As needed16/41–/73
       Rarely25/22
       Never49/18
      Most commonly used OTC NSAID, %n = 567
      Respondents who used prescription and OTC pain relievers.
       Ibuprofen (non-branded)403357
       Ibuprofen (trade name)
        Advil231625
        Motrin949
       Naproxen (non-branded)80.3
       Naproxen (trade name)—Aleve19911
       Other1024
      Likelihood of using >1 OTC medicine at a time if have >1 symptom, %
       Extremely37
       Very1215
       Somewhat3114
       Not very3329
       Not at all2132
      Method for using more than recommended dose of OTC medicine, %
       More than recommended number of pills at one time716929
       Next dose sooner than recommended476334
       More than recommended number of dosages per day254419
       Longer duration than recommended, %8
       Other, %28
      Reason for using more than recommended dose of OTC medicine, %
       Believed it would bring quicker relief396967
       Had severe symptoms516867
       Recommended dose did not alleviate symptoms416457
       Had taken Rx version previously173824
       Instructed by HCP2219
       Other75
      –, Data not available; AGA, American Gastroenterological Association; Alliance, Alliance for Rational Use of NSAIDs; NCL, National Consumers League; NCPIE, National Council on Patient Information and Education; NSAIDs, nonsteroidal anti-inflammatory drugs; OTC, over the counter; Rx, prescription.
      a Exclusive OTC NSAID users only.
      b Respondents who used prescription and OTC pain relievers.

      NSAID Perceptions

      Perceptions about the safety and efficacy of prescription and OTC NSAIDs were also evaluated in the Alliance survey (Table 3). Prescription NSAIDs were thought to be more effective by 42% of respondents and safer by 19%. OTC NSAIDs were thought to be more effective by 12% of respondents and safer by 31%. Similar results were reported in the AGA survey, except that a higher percentage of respondents believed that OTC NSAIDs were more effective than prescription NSAIDs (25%). Half of the respondents in the current survey, compared with approximately one-sixth in the AGA survey, were unsure about the safety and efficacy of OTC versus prescription NSAIDs.
      TABLE 3Perception of NSAID safety and efficacy.
      2013 Alliance2002 NCL1997 AGA
      (n = 1,750)(n = 3,557)
      More effective at relieving pain, %n = 807
      OTC or prescription NSAID users.
       Rx4254
       OTC1225
       Unsure4617
      Safer, %n = 807
      OTC or prescription NSAID users.
       Rx1933
       OTC3132
       Unsure5015
      Do you believe you are at risk from NSAID side effects, %6n = 258
      Exclusive OTC NSAID users.
      /549
      Prescription NSAID users.
       High risk173/–
       Moderate risk4815/–
       Ordinary risk2951/–
       No risk29/24
      Are you concerned about NSAID side effects, %n = 247
      Prescription NSAID users who were aware of NSAID side effects.
       Very1022
       Somewhat2027
       Slightly3325
       No362532
      If concerned about NSAID side effects, what body systems affected, %
       Digestive system2142
       Heart10
       Kidneys3112
       All the above40
       None4
       Unsure11
      How have you reduced risk of NSAID side effects, %n = 258
      Exclusive OTC NSAID users.
       Prevent or treat with medicine41
       Discuss with HCP132
       Change behavior (diet, exercise and medication)1911
       Discontinue NSAID13
       Nothing6239
      Are there warning signs of NSAID side effects, %n = 807
      OTC or prescription NSAID users.
       Yes4727
       No1328
       Unsure4012
      If there are warning signs, what types of symptoms are signs of NSAID side effects, %n = 549
      Prescription NSAID users.
      /258
      Exclusive OTC NSAID users.
       Stomach pain7554/65
       Nausea and vomiting6511/14
       Heartburn43–/10
       Bleeding5910/3
       Other31
      –, Not available; AGA, American Gastroenterological Association; Alliance, Alliance for Rational Use of NSAIDs; NCL, National Consumers League; NSAIDs, nonsteroidal anti-inflammatory drugs; OTC, over the counter; Rx, prescription.
      a OTC or prescription NSAID users.
      b Exclusive OTC NSAID users.
      c Prescription NSAID users.
      d Prescription NSAID users who were aware of NSAID side effects.
      Approximately one-third of respondents in the Alliance survey felt they were at no risk from NSAID AEs (Table 3), and nearly 70% were not at all or only slightly concerned about NSAID AEs. This lack of concern is slightly increased compared with past surveys. Among respondents who were slightly, somewhat, or very concerned about NSAID AEs, 40% were aware that NSAIDs could cause digestive, cardiac and renal AEs. Most respondents had done nothing to reduce the risk of NSAID AEs. These results are similar to what was reported in the AGA survey, although there was a notable increase (from 2% to 13% increase) in the percentage of respondents who discussed reducing NSAID AEs with their HCP.
      Almost half of the respondents in the current survey believed there would be warning signs for NSAID AEs. Among these respondents, most believed that symptoms would be GI (stomach pain, nausea and vomiting or heartburn). These results are similar to what was reported in the AGA survey.

      Medicine Information Sources

      Only 34% of respondents in the current survey received information about an OTC medicine from a HCP (doctor, pharmacist, nurse or other medical professional) in the past 6 months, even though 25% of those who did not receive information saw a HCP regarding the condition they were treating with OTC medicine. Compared with the 2001 NCPIE survey, there was a trend toward less discussion with HCPs regarding OTC medicines over the past decade, but among respondents who received information from a HCP, 61% discussed potential OTC NSAID AEs.
      Overall, 50% and 57% of respondents, respectively, were not at all or not very likely to talk to a HCP about taking an OTC pain reliever or taking more than the recommended dose of OTC medicine. A minority of respondents in both the current and NCPIE surveys were very or extremely likely to talk to a HCP about taking an OTC pain reliever (26% and 36%, respectively) or taking more than the recommended dose of an OTC medicine (23% and 30%, respectively).
      Most respondents in the current survey reported that they read prescription medicine packaging information when taking a medication for the first time (81% read directions for usage, 71% read dosage level and 64% read AEs); however, only 43% read warnings about usage of prescription medicine with OTC medicine. In contrast to high prescription label literacy, most respondents reported that they do not read important OTC medicine packaging information. In particular, 26% of respondents read the active ingredients, 20% read the brand and 42% read everything on the label. Although these numbers are low, there seems to be some improvement in this area compared with the NCPIE and NCL surveys; only 4% of respondents in the NCPIE survey and 16% in the NCL survey reported that they read everything on an OTC label.
      About half of the respondents in the current survey would read the label again if they were thinking about taking an OTC with prescription medicine (49%), with another OTC medicine (46%) or if they have not taken the OTC medicine in a long time (50%). These numbers are lower than those from the 2001 NCPIE survey, where approximately 70% would re-read the label in each instance.

      Discussion

      The results of the current study suggest that NSAID use in the United States has increased, with 63% of respondents reporting NSAID use in the past year compared with 17% in the 1997 AGA survey, but the degree of NSAID awareness and patterns of misuse have not changed. The use of NSAIDs may be underestimated because many respondents do not know what products are NSAIDs and they are unsure if they have used NSAIDs. Although there have been modest improvements in some areas of NSAID use, there is still a lack of awareness about NSAIDs and their side effects, which creates an environment where NSAIDs can be easily and inadvertently misused.
      Consistent with prior observations, the results of the current survey demonstrate that NSAIDs continue to be commonly misused. As many as 26% of respondents have exceeded recommended NSAID dosages and up to 35% have used NSAIDs concomitantly, suggesting that as many as 70 million Americans per year place themselves at risk for adverse outcomes. Similarly, 8% of respondents took OTC NSAIDs for >10 days and 7%, or 22 million Americans, took prescription NSAIDs for a year or longer or use OTC NSAIDs daily (Figure 2B and C and Table 2). Our population was a representative sampling of U.S. NSAID users at average risk of developing AEs from these medications. If we had sampled a population of individuals at high risk of developing serious NSAID-related AEs, our results may have indicated even higher levels of NSAID misuse, as revealed in a recent Dutch survey of patients at high risk of experiencing NSAID AEs.
      • Koffeman A.R.
      • Valkhoff V.E.
      • Celik S.
      • et al.
      High-risk use of over-the-counter non-steroidal anti-inflammatory drugs: a population-based cross-sectional study.
      The patterns of NSAID use which we have observed have risk consequences. A 2007 systematic review of 17 prospective observational studies from various western countries concluded that 11% of preventable hospital admissions were almost exclusively related to NSAID overtreatment and AEs.
      • Howard R.L.
      • Avery A.J.
      • Slavenburg S.
      • et al.
      Which drugs cause preventable admissions to hospital? A systematic review.
      In addition, the medical literature unequivocally demonstrated increased risk for GI, cardiac and renal AEs with increasing dose and duration of NSAID use.
      • Lanas A.
      • Garcia Tell G.
      • Armada B.
      • et al.
      Prescription patterns and appropriateness of NSAID therapy according to gastrointestinal risk and cardiovascular history in patients with diagnoses of osteoarthritis.
      • Wilcox C.M.
      • Cryer B.
      • Triadafilopoulos G.
      Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs.
      • Lewis S.C.
      • Langman M.J.S.
      • Laporte J.-R.
      • et al.
      Dose-response relationships between individual nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) and serious upper gastrointestinal bleeding: a meta-analysis based on individual patient data.
      • Schneider V.
      • Lévesque L.E.
      • Zhang B.
      • et al.
      Association of selective and conventional nonsteroidal anti-inflammatory drugs with acute renal failure: a population-based, nested case-control analysis.
      • Garcia Rodriguez L.A.
      • Tacconelli S.
      • Patrignani P.
      Role of dose potency in the prediction of risk of myocardial infarction associated with nonsteroidal anti-inflammatory drugs in the general population.
      • Griffin M.R.
      • Yared A.
      • Ray W.A.
      Nonsteroidal anti-inflammatory drugs and acute renal failure in elderly persons.
      • Anderson J.L.
      • Adams C.D.
      • Antman E.M.
      • et al.
      ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.
      For this reason, the Food and Drug Administration and multiple medical societies provided guidance that states that any OTC or prescription NSAID should be used at the lowest effective dose for the shortest duration needed to achieve a therapeutic effect.
      NSAIDs׳ AEs are often underestimated and are not well understood. As was reported in past surveys, greater than two-thirds of respondents still believed they were at no or slight risk for NSAID AEs, and fewer were very concerned about AEs than in past surveys. Only 40% of respondents in the current survey were aware that NSAIDs could cause digestive, cardiac and renal AEs. Only 10% of respondents were currently aware of the cardiac risk with NSAIDs. Cardiac risk was not included in past surveys because it was not until 2005 that NSAIDS were widely appreciated to have cardiac risk; it did not appear in the NSAID label until 2006.
      The misuse of NSAIDs and misperceptions about their AEs may stem from the lack of discussions about NSAIDs with HCPs and a lack of attention to label information. In the current survey, as with the 2001 NCL survey, although comparisons between surveys are directional only, 46-57% of respondents were unlikely to talk to a HCP about taking an OTC pain reliever, were taking greater than 1 OTC at a time or were taking more than the recommended dose. A more optimistic observation is that more respondents in the current survey than in the 2001 NCL survey (61% versus 37%) had discussed OTC NSAID side effects with their HCP, which may signal an improvement in this area. Although most respondents do not read important OTC medicine packaging information, reading of labels has improved. In the current survey, 42% of respondents read everything on the label compared with 4% in NCPIE survey. These results highlight the need to remind HCPs to ask about OTC and pain relief medications, because patients are likely to be taking NSAIDs but unlikely to volunteer such information.
      A potential criticism of this survey is that the population was not representative of the greater U.S. population of NSAID users. However, with 1,750 respondents there is more than enough power to yield a statistically representative sample of the U.S. population with 95% confidence and a 3% margin of error. Limitations inherent in all surveys include the potential for respondents׳ misunderstanding of questions or the inability of to formulate iterative additional questions based on the respondent׳s response. In addition, accuracy and completeness of NSAID exposure is limited by the nature of the instrument used, and this survey did not use questions identical to the older surveys, which along with potential differences in the respondent populations, make direct comparisons between survey results difficult.

      Conclusions

      Although NSAID use remains ubiquitous, sufficient knowledge and awareness of NSAIDs are lacking. This should create a public health concern. As a lack of NSAID recognition and understanding remains, users are often inadvertently taking these medications inappropriately, placing millions of American at risk each year. Although people in pain require relief, educational interventions directed to the general public and physicians continue to be needed to ensure the safe and appropriate use of NSAIDs.

      Acknowledgments

      The authors acknowledge Holly Capasso-Harris, PhD for editorial services and for article preparation assistance.

      Appendix A. Supplementary material

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