European Journal of Cardiovascular Medicine

Pain is one of the most common reasons for which individuals seek pharmacological relief, and analgesics  encompassing NSAIDs, paracetamol, and opioid-combination products remain among the most frequently consumed drug classes across the globe. The widespread over-the-counter (OTC) availability of these agents, combined with limited regulatory enforcement in many countries, has normalised self-medication practices among the general population.

Globally, the World Health Organization has repeatedly flagged irrational and unsupervised analgesic use as a contributor to preventable drug-related morbidity1, with gastrointestinal bleeding, acute kidney injury, and hepatotoxicity being among the most frequently documented complications of chronic or excessive NSAID and paracetamol use.

In the Indian context, self-medication with analgesics has been reported to be particularly prevalent, with community-based surveys from northern and southern India documenting non-prescription painkiller use rates ranging from 55% to over 70% among adult respondents2.

Non-medical adults individuals without formal training in pharmacology or clinical medicine — often rely on informal sources of drug information, including family members, pharmacy counter staff, advertisements, and increasingly, the internet and social media. This reliance frequently results in significant knowledge gaps regarding maximum permissible dosage, minimum safe intervals between doses, contraindications in specific populations (such as those with peptic ulcer disease, chronic kidney disease, or hepatic impairment), and the risks of combining multiple analgesic-containing formulations unknowingly.

A hospital-based study conducted among the general public in western India found that fewer than half of respondents could correctly identify the maximum recommended daily dose of paracetamol, and a similar proportion were unaware that concurrent alcohol use potentiates hepatotoxic risk3.

Further Indian studies have highlighted those with lower educational attainment and rural residence as being disproportionately represented among individuals with poor analgesic-related knowledge, underscoring the role of health literacy as a determinant of medication safety behaviour4.

Painkiller misuse is not limited to accidental overdose; it also includes prolonged use beyond the recommended duration for

chronic musculoskeletal complaints, use for indications not warranting analgesia, and dose escalation in response to perceived inadequate relief  practices that substantially heighten the risk of adverse drug reactions. Given the scale of OTC analgesic consumption and the paucity of India-specific data quantifying knowledge deficits in the general adult population, the present study was undertaken to assess the level of knowledge and awareness of painkiller misuse and its health implications among non-medical adults, and to explore the sociodemographic correlates of this knowledge.

Study Design and Setting

This was a community-based, descriptive cross-sectional study conducted over a period of four months in Santosh Medical College & Hospital, Ghaziabad.

Study Population and Sampling

Adults aged 18–65 years residing in the study area, with no formal qualification or occupational background in medicine, nursing, pharmacy, or allied health sciences, were included. Individuals who were healthcare professionals, healthcare/pharmacy students, or who declined consent were excluded. A total sample size of 420 was calculated using an expected proportion of adequate knowledge of 50% (to maximise sample size), a 95% confidence level, a 5% margin of error, and a 10% non-response adjustment. Participants were recruited using a systematic random sampling technique from selected households/community centres/outpatient waiting areas.

Data Collection Tool

Data were collected using a pre-tested, structured, self-administered questionnaire, developed after a review of the existing literature and validated by a panel of subject experts. The tool was pilot-tested on 30 participants (excluded from the final analysis) to assess clarity and internal consistency (Cronbach's alpha = 0.78). The questionnaire comprised four sections:

·       Section A: Sociodemographic characteristics (age, sex, education, occupation, residence, monthly household income)

·       Section B: Pattern of painkiller use (frequency, source of procurement, indication, duration)

·       Section C: Knowledge assessment (12 items covering dosage, duration, drug interactions, and organ-specific adverse effects), each scored as correct (1) or incorrect/don't know (0)

·       Section D: Awareness of health implications and attitude toward self-medication (Likert-scale items)

·       Based on total knowledge scores, participants were categorised as having poor (≤4), moderate (5–8), or adequate (≥9) knowledge out of a maximum score of 12.

Data Collection Procedure

Trained data collectors administered the questionnaire in the local language, ensuring anonymity and voluntary participation. Written informed consent was obtained from all participants prior to enrollment.

Ethical Considerations

The study was conducted after obtaining approval from the Institutional Ethics Committee of Santosh Medical College & Hospital, Ghaziabad. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants, and data confidentiality was maintained throughout.

Statistical Analysis

Data were entered in Microsoft Excel and analysed using SPSS software (version 26.0). Categorical variables were expressed as frequencies and percentages. The Chi-square test was used to determine the association between sociodemographic variables and knowledge categories. A p-value < 0.05 was considered statistically significant. Ethical clearance was obtained from the Institutional Ethics Committee [insert reference number], and written informed consent was taken from all participants prior to enrolment.

A total of 560 patient data

A total of 420 participants completed the questionnaire, yielding a response rate of 93.3%. The sociodemographic characteristics of the study population are summarised in Table 1

Table 1: Sociodemographic Characteristics of Study Participants (N = 420)

Regarding patterns of use, 287 participants (68.3%) reported having used a painkiller without a doctor's prescription at least once in the preceding six months, most commonly for headache (46.0%), musculoskeletal/body pain (33.4%), and dental pain (12.9%). Pharmacies were the most frequently cited source of procurement (61.3%), followed by home medicine cabinets (24.0%) and recommendations from friends/family (14.7%).

Table 2: Overall Knowledge Level Regarding Painkiller Use and Misuse (N = 420)

As shown in Table 2, only about one-third of participants (34.5%) demonstrated adequate overall knowledge, while nearly a quarter (24.8%) showed poor knowledge of safe painkiller use.

Table 3: Item-wise Awareness of Health Implications of Painkiller Misuse

Overall, 41.2% of participants were unaware of at least one major organ-specific complication associated with painkiller misuse, and awareness was lowest with regard to the risks of combining multiple OTC products containing the same active pharmaceutical ingredient.

Table 4: Association Between Sociodemographic Variables and Knowledge Category

*Statistically significant (p < 0.05). Lower educational attainment, rural residence, and absence of any prior personal experience of an adverse drug effect were significantly associated with poorer knowledge scores

The present study found that more than two-thirds of non-medical adults had used painkillers without medical prescription in the preceding six months, yet only about one-third demonstrated adequate knowledge of safe use, dosage limits, and associated health risks. These findings are consistent with the broader pattern of high self-medication prevalence coupled with limited pharmacological literacy observed across community-based studies.

Similar knowledge gaps have been documented in Indian settings; a study among the urban population of a metropolitan city reported that fewer than 40% of respondents could correctly identify the maximum recommended duration of continuous NSAID use without medical supervision5, a figure closely comparable to the 41% awareness level for prolonged-use risk observed in the present study.

The observed association between lower educational attainment and poorer knowledge scores aligns with the broader health literacy, which consistently identifies education as one of the strongest determinants of appropriate medication-use behaviour.

This concurs with an earlier Indian community survey which similarly found that respondents with education below the secondary level were nearly three times more likely to demonstrate poor knowledge of analgesic safety compared with graduates6.

The rural–urban disparity noted in the present findings has also been reported in a multi-state Indian assessment of OTC medicine use, attributed in part to reduced access to pharmacist counselling and lower penetration of structured health education programmes in rural primary care settings7.

The relatively low awareness (41.4%) regarding the risks of inadvertently combining multiple OTC products containing the same active ingredient — a common cause of unintentional overdose, particularly with paracetamol present in numerous combination cold and flu preparations — is of particular clinical concern. This finding reinforces the need for clearer front-of-pack labelling and active pharmacist-led counselling at the point of dispensing, rather than relying solely on printed package inserts, which are seldom read in full by lay consumers.8-11.

The association between prior personal experience of an adverse effect and higher current knowledge scores suggests that experiential learning, while informative, is an inadequate and potentially harmful substitute for proactive health education — knowledge gained only after harm has already occurred defeats the purpose of preventive awareness. This underscores the urgent need for pre-emptive, community-level educational interventions rather than reliance on reactive learning following an adverse event.12-14.

Strengths of this study include the use of a validated tool and a reasonably large community sample. Limitations include the cross-sectional design, which precludes causal inference; reliance on self-reported data, which is subject to recall and social desirability bias; and the restriction of the sample to a single geographic setting, which may limit generalisability. Future longitudinal and multi-centric studies incorporating intervention arms (e.g., structured pharmacist counselling) would help establish causal pathways and evaluate the effectiveness of corrective educational strategies.15-18.

This study demonstrates that a substantial proportion of non-medical adults possess inadequate knowledge and awareness regarding safe painkiller use and the potential health consequences of misuse, despite a high prevalence of non-prescription analgesic consumption. Educational attainment, place of residence, and prior adverse-effect experience emerged as significant correlates of knowledge level. These findings highlight an urgent need for community-based health education campaigns, stricter regulation and clearer labelling of OTC analgesic products, and active pharmacist involvement in counselling consumers at the point of sale, in order to reduce the burden of preventable medication-related harm.

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