Dispensing of prescribed analgesics in Norway among young people with foreign-or Norwegian-born parents
-
Tomas Log
,
Svetlana Skurtveit
Abstract
Purpose
To examine and compare dispensing of prescribed analgesics between young people with parents from countries with a Muslim majority and those with parents born in Norway.
Methods
Our study-population constituted 11,542 adolescents from the Norwegian Youth Health Surveys conducted in 2000–2003. Users and non-users of prescribed analgesics at baseline were analysed separately. Self-reported information on their parents’ birth country was used to classify them into one of the three predefined groups: Norway, countries with a Muslim majority or others. To study and compare dispensing of prescribed analgesics, data from the youth surveys were linked to the Norwegian Prescription Database (NorPD) 2004–2007. Dispensed analgesics studied were antiinflammatory and antirheumatic products (non-steroid), opioids and other analgesics and antipyretics.
Results
Among non-users of prescribed analgesics at baseline, 34% of all males with parents born in Norway received prescribed analgesics at least once during 2004–2007, compared to 36% in the group with parents from countries with a Muslim majority. The proportions of females receiving prescribed analgesics were about 44% in both of the two previously mentioned groups. Among users of prescribed analgesics at baseline, the proportion of individuals who were dispensed prescribed analgesics in 2004–2007 was generally higher than for those that were non-users at baseline. Both males and females with parents from countries with a Muslim majority reported more pain compared to those with parents born in Norway. No statistical differences were detected between participants with parents from countries with a Muslim majority compared to those with parents born in Norway in terms of prescribed analgesics dispensed or total amount of analgesics dispensed in 2004–2007. For the dispensing of all analgesics in 2004–2007 the adjusted OR for having parents from countries with a Muslim majority compared to parents born in Norway was 1.02 (0.87–1.21) among non-users of prescribed analgesics at baseline and 0.82 (0.57–1.16) among users.
Conclusions
There were no differences in the dispensing of prescribed analgesics between young people with parents born in countries with a Muslim majority and those with parents born in Norway. Nor did the amount of prescribed analgesics differ between these groups.
1 Introduction
A steadily increasing rate of migration to Western Europe has made studies on patterns of drug use in these sub-populations more relevant. Young immigrants are often defined in official statistics by their parents’ country of birth. If both parents are from foreign countries, their off springs are classified, along with their parents, as immigrants. According to this definition, there are 460,000 immigrants in Norway, which constitute 9.7% of the total population. Of these, 83% are first generation immigrants, while the remaining are born in Norway by foreign-born parents. About 25% are from Western Europe and North America, 22% from Eastern Europe and the remaining 53% from Turkey, Asia, Africa and South-and Latin America [1].
Previous studies have shown that pain perception may be different between cultures [2,3], and that various factors (i.e. potential prejudice and lack of cultural knowledge among health workers) may lead to differences in pain assessment [4] and analgesic prescribing [5]. Studies exploring use of analgesics among adolescents according to immigrant background are, however, few, and different methodologies and data collection methods are used in different populations. For example, Holstein and Hansen examined self-reported use of drugs for four common symptoms among adolescents from ethnic minority groups in Denmark [6], and found more frequent use of drugs used against headache among girls from western minorities, compared to ethnic Danes and non-western minority groups. This study did not differentiate between use of over the counter (OTC) and prescription analgesics.
A Norwegian study showed that parents from non-western countries reported use of OTC-paracetamol for more indications, more frequently and to more of their children than their Western counterparts [7]. However, another study showed that prevalences of self-reported use of OTC-analgesics among adolescents were higher among those with an ethnic Norwegian background compared to adolescents with an immigrant Muslim background [8].
A Danish study showed that significantly more ethnic Danish women used prescription medicine compared to non-western minority women, but no detailed information on use of analgesics was included [9].
From 2004 Norwegian pharmacies have been obliged by law to send electronic data on all prescriptions they dispense to the Norwegian Prescription Database (NorPD). Thus, it is possible to carry out systematic analyses of dispensing of analgesic, and others, prescription drugs in individual non-institutionalized patients in Norway [10].
In this current study, we wanted to extend the knowledge of use of analgesic drugs, prescribed-and OTC, among young people with different immigrant backgrounds. We used a longitudinal design with data on the 10th grade adolescents who participated in Norwegian Youth Surveys in 2000–2003, and we linked this information to analgesic prescription data from NorPD in 2004–2007. We hypothesized that the dispensing of prescribed analgesics to young people with parents born in countries with a Muslim majority differs from dispensing to those with parents born in Norway. The aim of the study was therefore (1) to present baseline characteristics, including use of OTC-analgesics, among adolescents according to immigrant background and gender, (2) to present prevalences of later dispensing of prescription analgesics, and (3) to explore the association between immigrant background, and other factors, on later dispensing of prescribed analgesics among adolescents and young adults. The focus and main comparison was between those with parents born in countries with a Muslim majority and those with parents born in Norway.
2 Materials and methods
2.1 Youth surveys
Data from health surveys conducted among the 10th grade students (aged 15–16 years) during 2000–2003 in five Norwegian counties were included in this study [11]. These studies were carried out by the Norwegian Institute of National Health. The main objectives of these studies are to investigate factors relevant to the health and well-being of youth, to provide a better basis for designing health services for youth and to obtain more knowledge about the causes of illness and health. Data from the Youth Surveys have been used in several studies, including some investigating potential differences between immigrants and ethnic Norwegians [12,13].
The adolescents completed self-administrated questionnaires at school in their classrooms during two lessons. A project assistant was present in each classroom to assist with regard to possible misunderstandings. Adolescents not present on the day of the survey were asked to fill in the questionnaire later. The schools were contacted if these questionnaires were not returned. The non-responders received a reminder as the questionnaires were sent to their home address with a letter requesting that they answer the questions and return the questionnaires in an enclosed addressed envelope. The questionnaires included questions on health, lifestyle, and socioeconomic and family behaviours. See Table 1 for further details on questions used in our study. The English version of the questionnaire can be found on the home page of the Norwegian Institute of Public Health [14].
Questions on drug use and other factors showing the answer alternatives used in the Youth Health Surveys (2000–2003).
| Self-administered questionnaire | Answer alternatives |
|---|---|
| Pain | |
| Have you during the last 12 months experienced pain in head, neck/shoulders, arms/legs/knees, stomach or back? | Yes/no for each of the five locations |
| Analgesics | |
| How often during the last 4 weeks have you been using prescribed analgesics? | Never; daily; every week, but not daily; less than every week; not used during the last 4 weeks |
| How often during the last 4 weeks have you been using analgesics not requiring prescription? | Never; daily; every week, but not daily; less than every week; not used during the last 4 weeks |
| Parents’ background | |
| Where is your father/mother born? In which country is your father/mother born? | Norway; other countries All available countries |
| Use of health services | |
| Have you yourself used any of the following services in the past 12 months: ordinary doctor(general practitioner), dentist/school dentist, other consultants (specialist), emergency service (“doctor on call”) | Never; 1-3 times: 4 or more times for each of the four services |
A model developed by Amundsen et al., using the percentage of inhabitants with Muslim religion in a given country, was used to define parents’ country of birth [15]. Adolescents with both parents from countries with more than 50% Muslims were coded as having parents born in countries with a Muslim majority. Likewise, adolescents with both parents born in Norway were classified as having Norwegian born parents. A third group labeled ‘others’ included all other combinations of parents’ birth countries. Pain is an important confounding factor when examining the use of analgesics and was included in our analysis. The participants were asked if they had experienced pain in different locations (head, neck/shoulders, arms/legs/knees, stomach or back) during the last 12 months. According to how many pain locations reported, they were divided into three groups (no locations, 1–2 locations and 3+ locations). Use of health services included visits to dentists, general practitioners, specialists and emergency units during the last 12 months. Participants were grouped into three groups (no use, moderate use and frequent use (more than 3 visits)). Finally, participants were grouped as either users or non-users of both prescribed analgesics and OTC-analgesics at baseline (Table 1).
2.2 Norwegian Prescription Database
Prescription data on analgesics in 2004–2007 were drawn from the NorPD, which covers all of Norway’s 4.8 million inhabitants. From 1 January 2004, all pharmacies in Norway have been obliged by law to send in electronic data on all prescriptions to the Norwegian Institute of Public Health [10]. NorPD contains information on all individuals who have received prescribed drugs dispensed at pharmacies. All prescriptions, reimbursed or not, are stored in the database, and the drugs are classified according to the Anatomical Therapeutic Chemical (ATC) classification [16]. The data collected for our study were patient unique identifying number (encrypted), sex, age, the dispensing date and drug information (ATC code and number of defined daily dosages (DDD)).
Analgesics were defined by the ATC codes and included M01A (anti-inflammatory and antirheumatic products, non-steroids), N02A (opioids) and N02B (other analgesics and antipyretics). M01As on the Norwegian market include indomethacin, diclofenac, ketorolac, piroxocam, meloxicam, ibuprofen, naproxen, ketoprofen, dexibuprofen, tolfenamic acid, celecoxib, parecoxib, etoricoxib, nabumetone and glucosamine. The opioids marketed in Norway are codeine, dextropropoxyphene, tramadol, ketobemidone, morphine, fentanyl, buprenorphine, hydromorphone, oxycodone and pethidine. Acetylsalicylic acid, paracetamol, phenazon and ziconotide make up N02B [17].
Data from the youth surveys and the NorPD were linked by the unique 11-digit identification number, assigned to all individuals living in Norway. The record linkage was approved by the Norwegian Data Inspectorate and has been endorsed by the Regional Committee for Medical Research Ethics.
2.3 The study population
Altogether 11,952 adolescents (86% participation rate) were incuded in the Youth Health Surveys in 2000–2003 (Fig. 1). Those with missing data regarding use of prescribed analgesics at baseline (N = 416), were excluded. Individuals were divided into two groups according to self-reported use of prescribed analgesics for later analysis; non-users of prescribed analgesics at baseline (N = 9335) and users of prescribed analgesics at baseline (N = 2207). Through-out the paper non-users of prescribed analgesic at baseline will be referred to as earlier non-users of prescribed analgesics, while users at baseline will be referred to as earlier users.
Flow chart for the study population. Norwegian Youth Health Surveys 2000–2003.
2.4 Statistics
Earlier non-users and users of prescribed analgesics were analysed separately. A separate analysis was carried out on the entire population to investigate the impact of previous use of prescribed analgesics (daily or weekly) on later use of prescribed analgesics. χ2 test was used to assess equality of proportions and one way ANOVA to assess mean values across the ethnic groups. Logistic regression (odds ratios (ORs) with 95% confidence intervals (CIs)) was used to study the association between parents’ country of birth and other variables on later prescribed analgesic drug use (2004–2007). Parents’ country of birth, age, gender, use of health services, pain and OTC-use were included in the model. Linear regression was used to examine the association between parents’ country of birth on the amount of analgesics (DDD) purchased among users. The amount variable was log transformed as its distribution was skewed towards the higher values. Parents’ country of birth, pain and use of health services was recoded as dummy-variables, and the regression analyses were done separately for men and women. All analyses were done using SPSS 15.0 for Windows. Level of significance was set to p < 0.05.
Among earlier non-users of prescribed analgesics, power calculations revealed an ability to detect differences in the use of all analgesics between those with parents born in countries with a Muslim majority and those with parents born in Norway of 4–6% points depending on prevalence, using our sample size, a power 0.80 and a significance level of 0.05. The analysis had the ability to detect differences of 10–11% points among earlier users of prescribed analgesics.
3 Results
3.1 Baseline characteristics (2000–2003)
Among adolescents with parents born in Norway 15% of all males and 23% of all females reported earlier use of prescribed analgesics. Corresponding figures among adolescents with parents born in countries with a Muslim majority were 17% and 19%, respectively. We conducted a log likelihood test to see whether gender did influence the association between parents’ country of birth and later use of prescribed analgesics. The result was non-significant.
3.1.1 Characteristics of earlier non-users of prescribed analgesics
Adolescents with parents born in Norway reported less pain, more frequently use of health services, and a higher use of OTC analgesics, compared to adolescents with parents born in countries with a Muslim majority (Table 2a). For both genders, use of OTC-analgesics was about doubled in adolescents with a parents born in Norway compared to those with parents born in countries with a Muslim majority; 34% compared to 17% among males, and 67% compared to 37% among females.
Baseline characteristics for adolescents who were non-users of prescribed analgesics when surveyed in 2000–2003. Proportion of participants who were dispensed prescribed analgesics and defined daily dosages (DDD) among these retrieved from the Norwegian Prescription Database in 2004–2007.
| Male Parents’ country of birth |
Female Parents’ country of birth |
|||||||
|---|---|---|---|---|---|---|---|---|
| Norway (N = 3676) | Country with a Muslim majority (N = 84) | Others (N = 129) | p-Value | Norway (N = 3440) | Country with a Muslim majority (N = 390) | Others (N =617) | p-Value | |
| Baseline characteristics 2000-2003 | ||||||||
| Age[a] (mean (SD)) | 18.7(1.0) | 19.4(0.7) | 19.2 (0.9) | <0.01 | 18.7(1.0) | 19.5 (0.7) | 19.2(1.0) | <0.01 |
| Pain locations (%) | ||||||||
| None | 32.1 | 29.0 | 33.8 | <0.01 | 18.1 | 19.6 | 17.6 | n.s.[*] |
| 1–2 | 49.0 | 43.1 | 44.0 | - | 46.3 | 41.6 | 45.8 | – |
| 3+ | 18.9 | 27.9 | 22.2 | - | 35.6 | 38.8 | 36.6 | – |
| Health services (%) | ||||||||
| No use | 14.8 | 19.2 | 16.5 | n.s.[*] | 8.0 | 17.7 | 10.5 | <0.01 |
| Moderate use | 60.0 | 56.4 | 61.8 | - | 59.4 | 61.3 | 61.8 | – |
| Frequent use | 25.2 | 24.4 | 21.7 | - | 32.5 | 21.0 | 27.7 | – |
| OTC-analgesics1[b] (%) | ||||||||
| Non-user | 66.2 | 83.0 | 71.6 | <0.01 | 33.4 | 62.8 | 46.1 | <0.01 |
| User | 33.8 | 17.0 | 28.4 | - | 66.6 | 37.2 | 53.9 | – |
| Dispensing of drugs 2004-2007 | ||||||||
| Proportion of participants who received analgesics (%) | ||||||||
| All analgesics (NSAID/opioids/others) | 34.1 | 35.7 | 31.5 | n.s.[*] | 44.2 | 43.8 | 37.8 | 0.012 |
| NSAIDs | 28.9 | 27.1 | 24.9 | n.s.[*] | 39.2 | 37.2 | 33.2 | 0.018 |
| Opiods | 12.2 | 14.8 | 13.5 | n.s.[*] | 16.2 | 19.2 | 14.9 | n.s.[*] |
| Other analgesics | 3.1 | 2.7 | 2.7 | n.s.[*] | 4.3 | 4.1 | 4.0 | n.s.[*] |
| Amount used2[c] (median DDD (min-max)) | ||||||||
| All analgesics | 17.5 (2.5–462.5) | 15.0 (2.5–197.5) | 15.4 (2.5–130.0) | 0.025 | 20.0(2.5–1700.0) | 20.0 (2.5–508.3) | 20.0 (2.5–2043.6) | n.s.[*] |
| NSAIDs | .20.0 (3.3–450.0) | 16.0 (3.5–172.5) | 15.0 (5.0–127.0) | n.s.[*] | 20.0 (5.0–1700.0) | 20.0 (5.0–440.0) | 20.0 (3.3–633.3) | n.s.[*] |
| Opioids | 6.7 (2.5–129.1) | 6.7 (2.5–33.3) | 6.7 (2.5–50.0) | n.s.[*] | 6.7(1.7–355.0) | 6.7 (2.5–68.3) | 5.0 (2.5–843.6) | n.s.[*] |
| Other analgesics | 16.7 (2.9–116.7) | 16.7 (3.3–50.0) | 8.3 (3.3–43.3) | n.s.[*] | 16.3 (1.7–216.7) | 16.7 (3.3–83.3) | 16.3 (3.3–566.7) | 0.027 |
3.1.2 Characteristics of earlier users of prescribed analgesics
Except for self-reported pain, parallel trends in baseline characteristics were observed in the earlier user-subgroup, compared to non-users (Table 2b). Thus, adolescents with parents born in Norway reported more frequently use of health services, and a higher use of OTC analgesics, compared to adolescents with parents born in countries with a Muslim majority (Table 2b). However, and irrespective of parental background, the frequency of use of health services and use of OTC-analgesics was at a higher level among earlier users compared to non-users of analgesics. For example, in the user subgroup 84% of all males and 92% of all females with parents born in Norway reported use of OTC-analgesics compared to 34% of all males and 67% of all females in the non-user subgroup.
Baseline characteristics for adolescents who were users of prescribed analgesics when surveyed in 2000–2003. Proportion of participants who were dispensed prescribed analgesics and defined daily dosages (DDD) among these retrieved from the Norwegian Prescription Database in 2004–2007.
| Male Parents’ country of birth |
Female Parents’ country of birth |
|||||||
|---|---|---|---|---|---|---|---|---|
| Norway (N = 650) | Country with a Muslim majority (N = 84) | Others (N = 129) | p-Value | Norway (N = 1035) | Country with a Muslim majority (N = 89) | Others (N = 181) | p-Value | |
| Baseline characteristics 2000-2003 | ||||||||
| Age[a] (mean (SD)) | 18.8(1.0) | 19.5 (0.7) | 19.2 (0.7) | <0.01 | 18.7(1.0) | 19.5 (0.8) | 19.1 (0.8) | <0.01 |
| Pain locations (%) | ||||||||
| None | 16.7 | 11.7 | 8.5 | n.s.3[*] | 9.0 | 6.3 | 6.3 | n.s.3[*] |
| 1–2 | 50.0 | 53.2 | 52.1 | – | 39.8 | 32.5 | 35.0 | – |
| 3+ | 33.3 | 35.1 | 39.2 | – | 51.2 | 61.3 | 58.8 | – |
| Health services (%) | ||||||||
| No use | 5.7 | 11.9 | 7.8 | n.s.3[*] | 3.8 | 2.2 | 7.7 | 0.015 |
| Moderate use | 50.6 | 46.4 | 49.6 | – | 43.0 | 56.2 | 42.5 | – |
| Frequent use | 43.7 | 41.7 | 42.6 | – | 53.2 | 41.6 | 49.7 | – |
| OTC–analgesics1[b] (%) | ||||||||
| Non–user | 16.0 | 25.0 | 24.4 | 0.020 | 8.0 | 27.6 | 14.3 | <0.01 |
| User | 84.0 | 75.0 | 75.6 | – | 92.0 | 72.4 | 85.7 | – |
| Dispensing of drugs 2004–2007 | ||||||||
| Proportion of participants who received analgesics (%) | ||||||||
| All analgesics (NSAID/opioids/others) 41.4 | 41.4 | 36.9 | 38.8 | n.s.3[*] | 52.0 | 49.4 | 49.7 | n.s.3[*] |
| NSAIDs | 34.6 | 28.6 | 32.6 | n.s.3[*] | 46.6 | 39.3 | 43.6 | n.s.3[*] |
| Opiods | 14.5 | 21.4 | 15.5 | n.s.3[*] | 22.1 | 18.0 | 20.4 | n.s.3[*] |
| Other analgesics | 5.2 | 1.2 | 4.7 | n.s.3[*] | 6.5 | 5.6 | 5.0 | n.s.3[*] |
| Amount used2[c] (median DDD (min–max)) | ||||||||
| All analgesics | 20.0 (2.5–2402.1) | 13.3 (2.5–57.0) | 15.2 (3.3–450.0) | n.s.3[*] | 25.0 (2.5–1764.2) | 20.0 (2.5–400.0) | 24.2 (2.5–2200.0) | n.s.3[*] |
| NSAIDs | 20.0 (5.0–900.0) | 10.0 (7.0–57.0) | 15.2 (5.0–450.0) | 0.019 | 22.3 (2.5–1685.0) | 20.0 (5.0–400.0) | 20.0 (3.3–2200.0) | n.s.3[*] |
| Opioids | 6.7 (2.5–1808.4) | 6.7 (2.5–18.3) | 5.8 (2.5–40.8) | n.s.3[*] | 6.7 (2.5–443.3) | 8.8 (2.5–25.0) | 6.7 (2.5–157.8) | n.s.3[*] |
| Other analgesics | 8.3 (3.3–116.7) | 8.3 (8.3–8.3) | 16.3 (6.7–25.0) | n.s.3[*] | 16.7 (3.3–166.7) | 16.7 (3.3–50.0) | 16.7 (8.2–133.3) | n.s.3[*] |
3.2 Dispensing of prescription analgesics in 2004–2007 among earlier non-users and users of prescribed analgesics
In the earlier non-users of analgesics subgroup, about a third of all males, and about 44% of the females were dispensed at least one prescription on an analgesic in the period 2004–2007, with no differences according to parental background (Table 2a). A parallel trend in dispensing of prescription analgesics, but at a somewhat higher level, was observed among earlier users of prescribed analgesics (Table 2b). About 41% of all males and 52% of all females with parents born in Norway were dispensed a prescription analgesic in the period 2004–2007, compared to 37% of the males and 49% of the females with parents born in countries with a Muslim majority.
3.3 Parental background, and other baseline characteristics (2000–2003), and their association to later dispensing of prescription analgesics (2004–2007)
In both subgroups (earlier non-users and users of prescribed analgesics), adjusted ORs revealed no significant associations between parental background and later dispensing of prescription analgesics (Tables 3a and 3b).
Association between various factors and dispensing of prescribed analgesics in 2004–2007 among new users of prescribed analgesics. Unadjusted and adjusted odds ratio (OR) with 95% confidence intervals.
| All analgesics |
NSAIDs |
Opioids |
Other analgesics |
|||||
|---|---|---|---|---|---|---|---|---|
| Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | |
| Parents’ country of birth | ||||||||
| Norway | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Country with a Muslim majority | 1.03(0.89–1.20) | 1.02(0.87–1.21) | 0.92 (0.79–1.08) | 0.93(0.78–1.10) | 1.24(1.02–1.51) | 1.15(0.93–1.43) | 0.92 (0.61–1.38) | 1.02(0.66–1.60) |
| Others | 0.83 (0.73–0.94) | 0.84 (0.74–0.96) | 0.79 (0.70–0.90) | 0.82(0.71–0.94) | 1.01 (0.85–1.19) | 1.02(0.85–1.22) | 0.93 (0.67–1.28) | 1.05(0.74–1.47) |
| Pain locations | ||||||||
| None | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| 1-2 | 1.32(1.18–1.47) | 1.21 (1.08–1.35) | 1.31 (1.17–1.47) | 1.19(1.06–1.34) | 1.24(1.06–1.46) | 1.13 (0.96–1.33) | 1.51 (1.09–2.09) | 1.37(0.98–1.91) |
| 3+ | 1.96(1.74–2.22) | 1.64(1.44–1.86) | 1.96(1.73–2.22) | 1.62(1.42–1.86) | 1.90(1.61–2.25) | 1.57(1.31–1.88) | 2.48 (1.78–3.46) | 2.06(1.44-2.93) |
| Sex | ||||||||
| Male | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Female | 1.48(1.36–1.61) | 1.30(1.19–1.43) | 1.57(1.44–1.71) | 1.39(1.26–1.53) | 1.34(1.19–1.50) | 1.16(1.02–1.33) | 1.44(1.15–1.79) | 1.18(0.93-1.51) |
| Health services | ||||||||
| No use | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Moderate use | 1.05(0.92–1.20) | 0.97 (0.85–1.12) | 1.07(0.94–1.23) | 0.99 (0.86–1.15) | 0.98 (0.82–1.19) | 0.91 (0.75–1.11) | 1.01 (0.71–1.43) | 1.04 (0.70–1.53) |
| Frequent use | 1.55(1.34–1.79) | 1.30(1.11–1.51) | 1.59(1.37–1.84) | 1.33(1.13–1.56) | 1.41 (1.16–1.72) | 1.18(0.96–1.47) | 1.33 (0.91–1.92) | 1.13 (0.74–1.73) |
| OTC-analgesics[c] | ||||||||
| Non-user | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| User | 1.47(1.35–1.60) | 1.19(1.08–1.32) | 1.48(1.35–1.61) | 1.16(1.05–1.29) | 1.41 (1.26–1.58) | 1.26(1.10–1.44) | 1.53(1.23–1.91) | 1.28(1.00–1.65) |
Association between various factors and dispensing of prescribed analgesics in 2004–2007 among previous users of prescribed analgesics. Unadjusted and adjusted odds ratio (OR) with 95% confidence intervals.
| All analgesics |
NSAIDs |
Opioids |
Other analgesics |
|||||
|---|---|---|---|---|---|---|---|---|
| Unadjusted OR | Adjusted OR[a],[b] | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | Unadjusted OR (95% CI) | Adjusted OR[a],[b] (95% CI) | |
| Parents’ country of birth | ||||||||
| Norway | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Country with a Muslim majority | 0.83 (0.61–1.14) | 0.82(0.57–1.16) | 0.72(0.52–1.00) | 0.77(0.53–1.11) | 1.03(0.70–1.53) | 0.93 (0.59–1.44) | 0.56 (0.24–1.30) | 0.59(0.23–1.52) |
| Others | 0.90(0.70–1.14) | 0.94 (0.72–1.22) | 0.89 (0.69–1.14) | 0.92 (0.70–1.21) | 0.95 (0.70–1.30) | 0.88 (0.62–1.24) | 0.80(0.46–1.39) | 0.80 (0.43–1.51) |
| Pain locations | ||||||||
| None | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| 1-2 | 1.38(1.02–1.87) | 1.32(0.97–1.81) | 1.46(1.06–2.01) | 1.38(0.99–1.91) | 1.15(0.75–1.75) | 1.11 (0.71–1.71) | 1.37 (0.63–2.95) | 1.32(0.61–2.87) |
| 3+ | 1.91 (1.41–2.59) | 1.63(1.19–2.23) | 1.93(1.41–2.65) | 1.64(1.18–2.28) | 1.74(1.15–2.62) | 1.50(0.98–2.30) | 1.69 (0.79–3.61) | 1.62 (0.75–3.52) |
| Sex | ||||||||
| Male | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Female | 1.56(1.31–1.85) | 1.39(1.15–1.68) | 1.67(1.40–1.99) | 1.47(1.21–1.78) | 1.49(1.19–1.86) | 1.41 (1.09–1.81) | 1.28 (0.88–1.88) | 1.23(0.80–1.91) |
| Health services | ||||||||
| No use | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Moderate use | 1.21 (0.82–1.80) | 1.18(0.77–1.83) | 1.15(0.76–1.72) | 1.07(0.68–1.67) | 0.93 (0.56–1.55) | 0.81 (0.46–1.41) | 1.14(0.48–2.69) | 1.27 (0.44–3.61) |
| Frequent use | 1.76(1.19–2.61) | 1.66(1.07–2.56) | 1.73(1.15–2.60) | 1.55 (0.99–2.42) | 1.35 (0.82–2.24) | 1.18(0.67–2.05) | 1.04 (0.44–2.46) | 1.12(0.39–3.21) |
| OTC-analgesics[c] | ||||||||
| Non-user | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| User | 1.02(0.80–1.31) | 0.87(0.66–1.14) | 1.07(0.83–1.37) | 0.86 (0.65–1.14) | 0.89 (0.66–1.21) | 0.81 (0.57–1.14) | 0.77(0.47–1.27) | 0.59 (0.34–1.02) |
Other independent factors associated to later dispensing of prescription analgesics were; increasing number of pain locations, female gender, and more frequently use of health services. The strongest predictors of later dispensing of prescription analgesics, with adjusted ORs above 1.6, were increasing number of pain locations and frequent use of health services (among earlier users of prescribed analgesics only). Use of OTC-analgesics was associated to later dispensing of prescription analgesics among earlier non-users of prescribed analgesics only.
The association between self reported baseline use of prescribed analgesics and later dispensing of prescribed analgesics was analysed in a separate multivariable analysis in the entire study-population. In this analysis daily/weekly baseline use was the strongest predictor of later dispensing of prescription analgesics with an OR of 1.76 (1.36–2.29).
The linear regression analyses revealed no significant association between parents’ country of birth and of amount of prescription analgesics dispensed (results not presented in the tables).
4 Discussion
Our study did not reveal any association between parents’ country of birth and later dispensing of prescribed analgesics. Further, prevalences of later dispensing of prescription analgesics were similar in young people with parents from countries with a Muslim majority and those with parents born in Norway, although at a higher level among those reporting earlier use and among females in general. The trend of an overall increased use of prescription drugs among ethnic Danish women [9] does not seem to apply for prescribed analgesics in our sample.
Among adolescents reporting to be earlier non-users of pre-scribed analgesics (10th grade); a third of all males and above 40% of all females were dispensed a prescription analgesic during the follow-up period. In our study, adjusted analyses revealed an independent effect of female gender on later dispensing of prescribed analgesics. Our observation of an increasing rate of dispensing with age, and more frequent dispensing among females, is supported by cross-sectional data on analgesic drug use from NorPD. In 2007 6% of all males and 8% of females aged 10–19 years had prescribed analgesics dispensed, while among 20–29 year olds the figures were 17% and 21%, respectively [18]. Medicine use among young people in general is documented to be widespread and increasing [19,20,21,22]. This is especially true for young females, in whom use of drugs for a variety of complaints grows considerably during the teenage years [23]. The observed difference in dispensing of prescription analgesics between males and females in our study is supported by both national and international studies [24,25,26,27]. Menstruation-related disorders in women may be an obvious contributing factor to this observed difference. On the other hand, one qualitative study exploring the use of analgesics revealed that young women relied on analgesics to cope with perceived pressures and social anxieties, as part of their attempt to meet everyday goals involving performance and participation [28]. Our observations may add information to this area of research; increased dispensing of prescribed analgesics among female adolescents seems to exist irrespective of cultural and religious background.
Although no differences in the dispensing of prescribed analgesic were observed, there was higher prevalence of self-reported baseline use of OTC-analgesics in adolescents with parents born in Norway compared to adolescents with parents from countries with a Muslim majority. A parallel trend in use of OTC-analgesics according to immigrant background was observed in a previous Norwegian study [8]. The difference in use of OTC-analgesics was notable among earlier non-users of prescribed analgesics in particular; the prevalence of use was about doubled in adolescents with parents born in Norway compared to those with parents born in countries with a Muslim majority; totalling a third of all men and two-third of all women in this subgroup.
A recently published German study found that a non-immigrant background was associated to a higher overall use of OTC-medication among children and adolescents [29]. In Germany, families with an immigrant background are associated with a lower household income. This aspect was in the German study high-lighted as one possible explanation to the observed difference in use, as OTC-drug expenses in adolescents are not covered by health insurance but paid for by parents or themselves. In this case one may expect a more frequently use of health services by adolescents with an immigrant background, in order to receive prescription for reimbursed analgesics instead of self-medication (in Norway, analgesics for intense chronic pain are reimbursed [30]). Our analyses did not reveal information to support this hypothesis; young people with an immigrant background reported less frequently use of health services and similar dispensing of prescription analgesics compared to those with parents born in Norway. Another explanation to differences in OTC analgesic use according to immigrant background may be that OTC use is more subject to patient choice compared to use of prescribed drugs that are mainly based on a decision made by the physician. Potential cultural differences towards drug use may therefore remain hidden in studies of pre-scribed drugs.
Interestingly, among earlier non-users of prescribed analgesics, an independent effect of use of OTC-analgesics on later initiation of prescription analgesics was observed. Baseline use of OTC-analgesics is based on self-report, with its inherent limitations, but still our observations may be interpreted as early self-medication of analgesics can develop into use of prescription drugs. Previous drug use seems to have an important and independent effect on later drug use; multivariable analyses revealed a 70% increased risk of having a prescription analgesic dispensed among adolescents reporting daily or weekly baseline use of prescription analgesics, still after adjustment for indication of use (self-reported pain at baseline).
Analysing predictors of later dispensing of prescription analgesics separate in the baseline-use subgroups, the strongest predictors of later dispensing of prescription analgesics, were increasing number of pain locations and frequent use of health services (among earlier users of prescribed analgesics only). This is expected, as pain is the indication for the use of analgesics. The major impact of pain on the dispensing of prescription analgesics shows the importance of including information on specific clinical variables in the analysis and interpretation of patterns of drug use. Even after adjustment for pain locations, increasing use of health services seems to have an impact of more frequently dispensing of prescribed analgesics.
The group with parents from Muslim countries reported more pain at baseline compared to those with parents born in Norway. This is surprising considering that they used less OTC-analgesics and health services at baseline and did not appear to use more prescribed analgesics at follow-up compared to the group with Norwegian born parents. We can only speculate why they report more pain, but studies have shown that there exist differences in pain perceptions between cultures [2,3]. The findings regarding OTC, health services and use of prescribed analgesic may be explained by the costs associated with these services [29]. In addition, studies have shown that pain assessment and prescription of opioids might be affected by the patient’s ethnicity [4,5].
There are some limitations in our study. Information on parents’ country of birth, use of health services, pain and past drug use, is based on self-report and subject to recall bias. A recent study showed that the validity of self-reported use of prescribed drugs varied according to drug group [31]. Self-reported use of analgesics had the lowest sensitivity (48.5%) and one of the lowest specificities (80.0%), compared to other groups of drugs. In our study the self-reported use of prescribed analgesics is used as a basis for stratification into groups of non-users and previous users at baseline. The dependent variable, dispensing of analgesics prescriptions during 2004–2007, is register-based and therefore offers an advantage compared to other studies in this field of research.
Compliance is always an issue when using prescription data in studies of drug use. We do not have any information on the extent to which dispensed prescription drugs were actually consumed. However, our data are based on dispensed drugs rather than only prescribed drugs, which may limit errors due to primary non-compliance [32]. Hypothetically, different cultural attitudes to prescribed medicines could be present in the actual administration of the purchased drugs, which could explain the divergence between studies examining prescribed analgesics and self-reported use of OTC analgesics.
In conclusion, this study did not reveal any association between immigrant background and later dispensing of prescribed analgesics in adolescents and young adults. However, whereas dispensing of prescription analgesics seems to be equal, differences in the use of OTC-analgesics seems to exist, with an increased use among adolescents and young adults with parents born in Norway compared to those with parents from countries with a Muslim majority.
DOI of refers to article: 10.1016/j.sjpain.2010.12.004.
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Funding: This research was funded by the University of Tromsø, and data was provided by the Norwegian Institute of Public Health.
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Conflict of interest: No conflicts of interest are known to the authors.
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© 2010 Scandinavian Association for the Study of Pain
Articles in the same Issue
- Editorial comment and review
- Redheads, pain mechanisms and genetics: Lessons learned from inconclusive studies
- Clinical pain research
- Pain sensitivity and experimentally induced sensitisation in red haired females
- Editorial comment
- Assessment and mechanisms of mechanical allodynia
- Clinical pain research
- The perception threshold counterpart to dynamic and static mechanical allodynia assessed using von Frey filaments in peripheral neuropathic pain patients
- Editorial comment
- Pain during pharmacologically induced termination of pregnancy
- Clinical pain research
- The level of unpleasantness of pain influences the choice of home treatment during medical abortion
- Editorial comment
- Botulinum toxin for the treatment of pain?
- Original experimental
- Dysport® for the treatment of myofascial back pain: Results from an open-label, Phase II, randomized, multicenter, dose-ranging study
- Editorial comment
- Trends in analgesic drug use evaluated by national prescription data bases: Differences between immigrants and native citizens of Norway
- Observational studies
- Dispensing of prescribed analgesics in Norway among young people with foreign-or Norwegian-born parents
Articles in the same Issue
- Editorial comment and review
- Redheads, pain mechanisms and genetics: Lessons learned from inconclusive studies
- Clinical pain research
- Pain sensitivity and experimentally induced sensitisation in red haired females
- Editorial comment
- Assessment and mechanisms of mechanical allodynia
- Clinical pain research
- The perception threshold counterpart to dynamic and static mechanical allodynia assessed using von Frey filaments in peripheral neuropathic pain patients
- Editorial comment
- Pain during pharmacologically induced termination of pregnancy
- Clinical pain research
- The level of unpleasantness of pain influences the choice of home treatment during medical abortion
- Editorial comment
- Botulinum toxin for the treatment of pain?
- Original experimental
- Dysport® for the treatment of myofascial back pain: Results from an open-label, Phase II, randomized, multicenter, dose-ranging study
- Editorial comment
- Trends in analgesic drug use evaluated by national prescription data bases: Differences between immigrants and native citizens of Norway
- Observational studies
- Dispensing of prescribed analgesics in Norway among young people with foreign-or Norwegian-born parents
