
==== Front
Mater Sociomed
Mater Sociomed
Mater Sociomed
Materia Socio-Medica
1512-7680
1986-597X
AVICENA, d.o.o., Sarajevo Bosnia and Herzegovina

MSM-35-178
10.5455/msm.2023.35.178-183
Original Paper
Assessment of Medication Use Among Adolescents in Sarajevo Canton
Piljak Vanja 1
Skrbo Selma 2
Omerovic Naida 2
Trnka Anela Hadzifejzovic 3
Lagumdzija Dina 2
Smajic Nermina Ziga 2
1 Ljekarna/Apoteka Vita, Sarajevo, Bosnia and Herzegovina
2 Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Sarajevo,Sarajevo, Bosnia and Herzegovina
3 Amsal Pharmaceuticals, Vogosca, Bosnia and Herzegovina
Corresponding author: Naida Omerovic, MPharm, Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Sarajevo. Address: Zmaja od Bosne 8, 71000 Sarajevo, Bosnia and Herzegovina. Phone: +387 33 586 193. E-mail naida.omerovic@ffsa.unsa.ba. ORCID ID: https://orcid.org/0000-0002-5588-9973
9 2023
35 3 178183
29 6 2023
20 8 2023
© 2023 Vanja Piljak, Selma Skrbo, Naida Omerovic, Anela Hadzifejzovic Trnka, Dina Lagumdzija, Nermina Ziga Smajic
2023
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background:

Adolescents are a susceptible population in terms of medication use. They are not only inclined to abuse illegal substances but are also prone to nonmedical medication use, which exposes them to a significant risk of various adverse drug reactions (ADR).

Objective:

This research aims to assess medication use among adolescents in Sarajevo Canton.

Methods:

This paper features information about the most frequently used medications, reasons for their use, sources of their procurement, ADR and concurrent use with other medications and/or alcohol. To obtain this data, a questionnaire with open- and close-ended questions was created. The survey was conducted online and 444 participants were included.

Results:

Medications were used by 90.1% of adolescents. The most commonly used medications were non-opioid analgesics, antibiotics, dietary supplements, antihistamines and benzodiazepines. Mild to moderate pain was the most frequent reason for medication use. Participants were at risk of ADR, drug-drug interactions (DDI), and drug-alcohol interactions.

Conclusion:

It is up to healthcare workers, especially pharmacists, to educate and guide adolescent patients on rational medication use and inform them about potential dangers following the use of these medications.

prevalence
medication use
adolescents
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pmc1. BACKGROUND

Medication use among adolescents is not significantly determined by physiological factors (modified enzyme activity, blood flow, etc.) compared to other age groups, such as children or the elderly. It is majorly impacted by external factors (family, school, social circle, etc.), and therefore adolescents seem to be highly susceptible to medication abuse. Observing trends in medication use among adolescents can provide insight into many public health concerns, such as disease burden, healthcare access, patient compliance, etc. Nevertheless, the prevalence of medication use in this population is rarely monitored. Data regarding this population are usually presented within data for the paediatric population, where differences between children and adolescents can rarely be distinct (1).

Approximately 23% of adolescents in the United States of America (USA) used at least one prescription medication within 30 days. The use of prescription medications was higher among adolescent girls than adolescent boys (28% vs. 17.6%). Concurrent medication use among 13-19 year-olds was 10%. Nearly one in 12 concurrent users of prescription medications was potentially at risk of major drug-drug interactions (DDI) (2).

The most frequently prescribed medications among children and adolescents are antiasthmatics, antibiotics, medications for the treatment of attention deficit hyperactivity disorder, topical medications and antihistamines (1, 3).

Self-medication is a widespread phenomenon among adolescents. The prevalence ranges between 2 and 92% in different countries. The most commonly used over-the-counter (OTC) medications are analgesics, while the most common indications for self-medication are headache, allergies and fever (4). As the main reasons for self-medication, adolescents stated fast symptom relief and the great availability of OTC medications (5). European meta-analysis implied that 50% of adolescents took medications without consulting a physician (6). More adverse drug reactions (ADR) were reported among adolescents who self-medicated. To minimize this, recommendations for rational self-medication were made. Understanding the impact of various factors related to self-medication can help derive strategies aimed at minimizing drug-related health risks and raise awareness among adolescents of the potential risks of using medications without having proper information and consultations beforehand (4).

2. OBJECTIVE

This research aims to determine the prevalence of medication use, frequency of ADR, polypharmacy and concurrent use of medications and alcohol among adolescents in Sarajevo Canton.

3. MATERIAL AND METHODS

This research was conducted among 444 adolescents in Sarajevo Canton. Inclusion criteria were that the participants were between 11 and 21 years old and that they lived in Sarajevo Canton.

An original questionnaire containing open- and close-ended questions was designed. The survey was conducted online using Google Forms, from June to September 2020.

The participants were informed about research purposes and their rights.

Statistical data analysis was conducted using methods of descriptive and inferential statistics, in Microsoft Excel 2010 and IBM SPSS 23.0, with the level of significance α = 0.05.

4. RESULTS

Out of 444 included adolescents, 202 (45.5%) were elementary and high school students, while 242 (54.5%) were university students. Next, 122 (27.5%) were adolescent boys and 322 (72.5%) were adolescent girls. The average age was 18 (18.25 ± 2.48).

A total of 400 (90.1%) of 444 adolescents stated that they had taken medications: 174 (86.1%) elementary and high school students, 226 (93.4%) university students, 96 (78.7%) adolescent boys, 304 (94.4%) adolescent girls. The difference was statistically significant regarding student groups (χ2=6.482; p=0.011; weak association V=0.121) and genders (χ2=24.495; p<0.001; weak association V=0.235).

The difference in frequency of taking medications between student groups and genders was statistically significant (χ2=23.573; p=0.001 and χ2=40.937; p<0.001, respectively) and the association between variables was weak (V=0.243) and moderate (V=0.320), respectively (Figure 1).

A total of 352 (88%) of 400 adolescents stated which medications they had used. The most frequently used medications were non-opioid analgesics, antibiotics, supplements, antihistamines and benzodiazepines (Table 1).

Figure 1, Frequency of taking medications between a) student groups and b) genders

Figure 2. Frequency of taking prescription medications between a) student groups and b) genders

Out of 352 adolescents who stated which medications they had used, 81 (23%) stated the same generic medications (duplicates) under different brand names. The most duplicated medication was paracetamol (up to five times). The prevalence of using duplicates was higher among adolescent girls than adolescent boys (26.6% vs. 11.1%). The difference was statistically significant (χ2=8.410; p=0.004) and the association between variables was weak (V=0.155).

University students and adolescent girls were more prone to taking non-prescription medications, while a larger percentage of elementary and high school students and adolescent boys usually took prescription medications (Figure 2). The difference in frequency of taking prescription medications between student groups and genders was statistically significant (χ2=17.023; p<0.001 and χ2=16.760; p<0.001, respectively) and the association between variables was weak (V=0.206 and V=0.205, respectively).

Table 1. The prevalence of medication use among adolescents in Sarajevo Canton

Medications	Number of participants	Percentage of participants	Medications	Number of participants	Percentage of participants	
Non-opioid analgesics and their combinations	294	83.5%	Antianemic agents	3	0.9%	
Antibiotics	75	21.3%	Antidepressants	3	0.9%	
Supplements	49	13.9%	Antiemetic agents	3	0.9%	
Antihistamines	35	9.9%	Antiseptics	3	0.9%	
Benzodiazepines	25	7.1%	Anti-acne agents	3	0.9%	
Antiulcer agents	15	4.3%	Opioid analgesics	3	0.9%	
Bronchodilators	12	3.4%	Anti-migraine agents	2	0.6%	
Cough medications	6	1.7%	Disease-modifying antirheumatic medications	2	0.6%	
Parasympatholytic agents	6	1.7%	Immunosuppressive agents	2	0.6%	
Decongestants	5	1.4%	Prolactin inhibitors	2	0.6%	
Glucocorticoids	5	1.4%	β-blockers	2	0.6%	
Oral antidiabetic agents	5	1.4%	Antirheumatic agents	1	0.3%	
Hormonal contraceptives	4	1.1%	Erectile dysfunction agents	1	0.3%	
Thyroid hormones	4	1.1%	Benzodiazepine-related medications	1	0.3%	
Insulin	4	1.1%		

Reasons for medication use were stated by 395 (98.8%) of 400 adolescents (Table 2).

A total of 397 (99.3%) of 400 adolescents answered from whom they had usually procured medications (Table 2). The difference was statistically significant regarding student groups (χ2=27.885; p<0.001; weak association V=0.263) and genders (χ2=18.818; p=0.002; weak association V=0.127).

A total of 399 (99.8%) of 400 adolescents who took medications stated whether they had had ADR. No ADR were reported by 271 (67.9%), 60 (15%) stated that they had experienced ADR, while 68 (17%) were not sure whether or not they had experienced ADR. Out of 60 participants who had had ADR, 30 (50%) reported ADR to their physician, 19 (31.7%) to a family member, four (6.7%) to their pharmacist, while the remaining seven (11.7%) did not report ADR to anyone.

The frequency of concurrent medication use among adolescent boys and adolescent girls was 40.6% and 28.6%, respectively. The difference in frequency of concurrent medication use between genders was statistically significant (χ2=6.189; p=0.034) and the association between variables was weak (V=0.121).

A total of 90 (22.5%) of 400 adolescents who took medications stated which medications they had taken simultaneously. Potential DDI were examined using online platforms (Drugs.com and Drugbank.com). Under the risk of potential DDI were 20 (22.2%) adolescents.

The difference in frequency of simultaneous use of medications and alcohol was statistically significant regarding student groups (χ2=11.738; p=0.003; weak association V=0.171) and genders (χ2=9.866; p=0.019; weak association V=0.163) (Table 2). Out of 35 adolescents who stated they had simultaneously consumed medications and alcohol, 28 (80%) stated which medications they had taken. The most common medications were non-opioid analgesics (67.9%), benzodiazepines (17.9%), antibiotics (14.3%) and antiulcer agents (10.7%).

Table 2. Reasons for medication use, sources of medication procurement and frequency of simultaneous use of medications and alcohol among adolescents in Sarajevo Canton

	Elementary and high school students	University students	Adolescent boys	Adolescent girls	
Reasons for medication use	N=171
n (%)	N=224
n (%)	N=95
n (%)	N=300
n (%)	
Mild to moderate pain	97 (56.7)	170 (75.9)	36 (37.9)	231 (77)	
Illness	116 (67.8)	84 (37.5)	57 (60)	143 (47.7)	
Being overwhelmed with problems	24 (14)	25 (11.2)	14 (14.7)	35 (11.7)	
Need for tranquillity	18 (10.5)	19 (8.5)	10 (10.5)	27 (9)	
Contraception	4 (2.3)	1 (0.4)	1 (1.1)	4 (1.3)	
Leisure	2 (1.2)	2 (0.9)	2 (2.1)	2 (0.7)	
Other	5 (2.9)	5 (2.2)	4 (4.2)	6 (2)	
Sources of medication procurement	N=172
n (%)	N=225
n (%)	N=94
n (%)	N=303
n (%)	
Recommendation from a physician	101 (58.7)	104 (46.2)	55 (58.5)	150 (49.5)	
Recommendation from a pharmacist	23 (13.4)	61 (27.1)	10 (10.6)	74 (24.4)	
Parents	34 (19.8)	20 (8.9)	14 (14.9)	40 (13.2)	
Friends	0 (0)	1 (0.4)	1 (1.1)	0 (0)	
By oneself	13 (7.6)	36 (16)	11 (11.7)	38 (12.5)	
Illegally	1 (0.6)	3 (1.3)	3 (3.2)	1 (0.3)	
Drinking alcohol simultaneously with medications	N=173
n (%)	N=226
n (%)	N=95
n (%)	N=304
n (%)	
Never	164 (94.8)	200 (88.5)	81 (85.3)	283 (93.1)	
Sometimes	6 (3.5)	25 (11.1)	13 (13.7)	18 (5.9)	
Often	2 (1.2)	0 (0)	0 (0)	2 (0.7)	
Always	1 (0.6)	1 (0.4)	1 (1)	1 (0.3)	

5. DISCUSSION

The prevalence of medication use among adolescents in Sarajevo Canton was 90.1%, which is higher than the prevalence determined in other studies (2, 7, 8). The main reason for this can be the way the questionnaire was formulated, e.g. the questions did not refer to a specific time, unlike in other studies where the prevalence data were referring to the medication use in the last seven (8) or 30 days (9).

University students (93.4%) and adolescent girls (94.4%) used medications more than elementary and high school students (86.1%) and adolescent boys (78.7%). This is similar to the results by Qato et al. (2018), where medication use was significantly higher among adolescent girls than adolescent boys (28% vs. 17.6%) (2), and by Moreas et al. (2012) (64.3% vs. 45.7%) (7). Medication use (in the last month) was higher among adolescent girls, but not statistically significant, in the study by Martin et al. (2019) (27.2% vs. 26.9%) (10). However, they only analysed prescription medications, which can be the cause of lower prevalence than ours.

Medication use was significantly higher among university students and adolescent girls, particularly regarding once-a-month frequency (15.5% vs. 5.7% and 14.5% vs. 1%, respectively). However, everyday medication use was slightly higher among elementary and high school students, which can be associated with childhood illnesses that slowly disappear as the child grows up. Considering that mild to moderate pain was the most common reason for medication use among adolescent girls, the significantly higher once-a-month frequency was probably related to menstrual pain (dysmenorrhea).

The five most commonly used medication groups were non-opioid analgesics, antibiotics, supplements, antihistamines and benzodiazepines. Similar results were stated by Gualano et al. (2014), where the most common OTC medications among adolescents were analgesics, cough medications, dermatological agents, supplements and antibiotics (6). These differences could be because both OTC and prescription medications were considered in our research, while they only analysed OTC medications, which can explain why cough medications were ranked higher. Dermatological agents were not considered separately in our research but were sorted under different medication groups (glucocorticoids, antibiotics, etc.). Albatti et al. (2017) also stated non-opioid analgesics as the most commonly used OTC medications (11). Among the most frequently used prescription medications among adolescents, Martin et al. (2019) stated stimulants, bronchodilators and oral contraceptives (10). The prevalence of using bronchodilators was 3.7%, similar to ours (3.4%). However, the prevalence of using oral contraceptives was lower in our research (1.1%) compared to theirs (3.7%). Use of opioids among adolescents in Sarajevo Canton was 0.9%, which was much lower than the average in the USA. The use of stimulants was not recorded among adolescents in Sarajevo Canton (12). Butorac et al. (2011) also stated non-opioid analgesics as one of the most commonly used medication groups. However, the prevalence of using anxiolytics and antidepressants was much higher or rather the same as for non-opioid analgesics (13). Use of antidepressants among adolescents in Sarajevo Canton was much lower, even negligible. Among adolescents in the USA, the most commonly nonmedically used prescription medications were opioids, tranquillizers, stimulants and sedatives (14). The prevalence of nonmedical use of opioids among adolescents in 2015 was 5.4%, while that of tranquillizers, benzodiazepines and non-benzodiazepines was 1.7%. For stimulants, that number was 2.9% in 2012. In Europe, the average nonmedical use of tranquillizers and sedatives was 5.6% (ranging between 1.5% and 13.6%). Therefore, adolescents in Sarajevo Canton fit in the European average with a 7.1% prevalence of the use of benzodiazepines. A 1.8% prevalence of the use of oral antidiabetic agents among adolescent girls in Sarajevo Canton is concerning. These medications were probably used in the therapy of polycystic ovary syndrome or insulin resistance, a common condition in women diagnosed with this syndrome (15), especially considering that none of the adolescent boys stated the use of oral antidiabetic agents.

The prevalence of OTC medication use was significantly higher among university students and adolescent girls. A high prevalence of OTC medication use among adolescents, ranging between 52.6% and 94.5%, was also determined in other studies (6, 7, 11, 16). Antipyretics and anti-inflammatory medications were the most commonly used medications among adolescents who self-medicated (17), and factors affecting self-medication included age, gender, family practices and tobacco and alcohol consumption (4, 18). Adolescents are frequently associated with inappropriate self-medication behaviours, such as not reading medication labels or instructions, which can result in overdose or polypharmacy (19, 20). Butorac et al. (2011) stated that more frequently, high school students self-medicated, while university students took prescription medications (13). These results are different from ours, where 26.4% of elementary and high school students and 11.9% of university students only used prescription medications.

Analysing stated reasons for medication use, one can observe that the biggest difference regarding student groups was concerning illness and regarding genders was concerning mild to moderate pain. Mild to moderate pain was the most common reason for medication use among university students (75.9%) and the second most common reason among elementary and high school students (56.7%), while it was an almost negligible reason in the study by Butorac et al. (2011), even though analgesics were one of the most commonly used medication groups (13). The number of adolescent girls was almost double the number of adolescent boys included in our research (77% vs. 37.9%) and adolescent girls more commonly used medications for mild to moderate pain compared to adolescent boys, which can explain these discrepancies.

It was expected that university students would have a higher necessity for medications as they are usually overwhelmed with problems (exams) and need tranquillity, but these reasons were more commonly stated by elementary and high school students (24.5% vs. 19.7%). However, the use of benzodiazepines, well-known anxiolytics and hypnotics, was higher among university students compared to elementary and high school students (7.9% vs. 6%). Elementary and high school students used medications due to illness more than university students (67.5% vs. 37.5%), which can be associated with childhood illnesses that they overcome with age.

Adolescent girls consulted healthcare workers more, while adolescent boys were more prone to taking medications from their friends or illegally. Both student groups consulted healthcare workers almost equally (72.1% vs. 73.3%), but university students consulted pharmacists more compared to elementary and high school students (27.1% vs. 13.4%). A bigger number of elementary and high school students took medications from their parents (19.8% vs. 8.9%), while a greater number of university students self-medicated (16% vs. 7.6%). Albatti et al. (2017) had similar results (11). The most common source of medication procurement was a pharmacist (51.64%), followed by parents (34.33%), family (5.4%), and lastly friends and social networks (1.95%). Only OTC medications were examined, so the recommendation by a physician was not mentioned. The main sources of procurement among adolescents in the USA who nonmedically used medications were prescriptions written for them, their family or friends (14). Data indicated that parents were the most frequent source of procurement of medications that were used for nonmedical purposes, except for stimulants, where friends were the main source. Interestingly, adolescents in Sarajevo Canton did not use stimulants, and only a small percentage took medications from their friends.

In our research, 15% of adolescents stated that they had experienced ADR, which is a lot less frequent than in the study by Gualano et al. (2014), where the ADR frequency among adolescent girls was 31.1%, while among adolescent boys 19.6% (6). However, 17% of adolescents in our research were not sure whether or not they had experienced ADR, and therefore the real ADR frequency was probably higher. Gomes et al. (2020) stated that ADR were more common among adolescent girls, but more serious ADR were present among adolescent boys (21).

Concurrent medication use among adolescents in our research was relatively high and significantly more frequent among adolescent boys than adolescent girls (41.1% vs. 28.6%), which is similar to results by Qato et al. (2018), where concurrent medication use was also more frequent among adolescent boys (2). According to them, one in 12 participants (8.3%) was at risk of DDI, which was a smaller prevalence compared to ours (22.2%). However, their study also included children (0-19 year-olds). They also stated that the risk of DDI among adolescent girls was almost 20%, which is similar to our results.

Simultaneous use of medications and alcohol was more frequent among adolescent boys than adolescent girls (14.7% vs. 6.9%) and among university students than elementary and high school students (11.5% vs. 5.3%). The most commonly used medications with alcohol were non-opioid analgesics and benzodiazepines in the study by Butorac et al. (2011), which is similar to our results (13). The risk of drug-alcohol interactions was present in 27 of 28 adolescents who stated they had used medications with alcohol, which is very concerning. The majority of adults who end up with a medication/alcohol use disorder had their first contact with these substances as adolescents (22).

6. CONCLUSION

The prevalence of medication use among adolescents in Sarajevo Canton is relatively high, and therefore this population is at higher risk of ADR, DDI and drug-alcohol interactions. However, considering that over 70% of adolescents who use medications consult with healthcare workers beforehand, it is up to healthcare workers, especially pharmacists, to educate and guide adolescent patients on rational medication use and inform them about potential dangers following the use of these medications.

Acknowledgements:

The authors would like to acknowledge all participants of this study.

Patient consent form:

All participants were informed about the subject of the study.

Author contribution's:

V.P. and N.Z.S. gave substantial contributions to the conception or design of the work in the acquisition, analysis or interpretation of data. S.S. and N.O. had a part in the article preparing for drafting or revising it critically for important intellectual content. All authors gave final approval of the version to be published.

Conflict of interest:

None.

Financial support and sponsorship:

None..
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