1. Svetlana V. Doubova Dolores Mino-Leon Hortensia Reyes Morales Sergio Flores-Hernández Ricardo Pérez-Cuevas

2.  There is a high frequency of prescription of non- opioid analgesics (NOAs), second only to cardiovascular drugs.  Several studies have reported that medical doctors do not prescribe properly and patients do not use the NOAs appropriately.  This finding is evidenced by overutilization rates of up to 41% and by the frequent appearance of preventable adverse events. -42% of the medical doctors are unaware of the adverse events that NOAs cause. -34% of patients are unsure about the proper method of taking NOAs, despite the fact that these are among the most common self-medicated drugs.

3.  To develop and test two educational programs (interactive and passive) aimed at improving family doctors’ (FDs) prescribing practices and patient’s knowledge and use of NOAs. Methods:  The educational programs were conducted in two family medicine clinics belonging to the Mexican Institute of Social Security in Mexico City. The study was performed in three stages: 1) Baseline evaluation 2) Implementation of educational activities 3) Post-program evaluation.

4. EDUCATIONAL PROGRAMS INTERACTIVE (IEP) PASSIVE (PEP) FAMILY DOCTORS WORKSHOPS, DISCUSSION GROUPS, IN-SERVICE TRAINING 1 MOUNTH PATIENTS VIDEO, LIFLET, INTERACTIVE EDUCATIONAL SESSION 1 OCASION PER PATIENTE FAMILY DOCTORS CLINICAL GUIDELINE 1 OCASION PATIENTS LIFLET 1 OCASION

5. All FDs working at the clinics were invited to participate in the programs, and most (99%) of them accepted the invitation.  There were 58 FDs in the IEP group and 52 FDs in the PEP group. The eligibility criteria for patients were:  age ≥ 50 years, suffered from non-malignant pain syndrome, had received at least one NOA prescription for a period of ≥ 7 days, were under the care of the participating FDs, and were able to answer the questions posed during the interview.  The baseline and post-program evaluations included 300 patients by group.

6. The effect of the programs:  on the FDs was measured through the appropriateness of prescriptions of NOA and analyzed using the differences-in-differences estimator (D-in-D)  on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analyzing the inter- and intra- group differences before and after the programs.

7. Baseline evaluation stagePost-programs evaluation stage IEP n=58 Average proportion PEP n=52 Average proportion IEP n=58 Average proportion PEP n=52 Average proportion Paracetamol35.236.457.4*42.9 NSAIDs***89.787.276.681.4 NSAIDs contraindicated in the elderly31.324.415.6*24.0 Simultaneous prescription of multiple NSAIDs10.16.61.22.8 NSAID prescribed to patients with chronic renal failure1.3*4.61.42.4 Prescription of NSAID without gastric protectors to patients in risk of gastrointestinal adverse effects 3.8*10.31.62.9 *p<0.05 between groups A comparison of data from the IEP and PEP groups (i.e., baseline and post- program evaluation data) revealed that prescription of paracetamol increased and NSAIDs decreased in the IEP group (p < 0.05), particularly with regard to prescriptions for elderly patients.

8. IEP n= 58 PEP n=52 Pre-intervention stage Average proportion 95% confidence interval 65.2 (59.5 – 71.0) 62.0 (56.1 – 67.9) Post-intervention stage Average proportion 95% confidence interval 82.6 ( 78.0 – 87.2) 68.0 (62.8 – 73.2) Difference in the average proportion 95% confidence interval 17.4 ** (11.0 – 23.7) 6.0 (-2.3 – 14.3) Differences-in-differences estimate* 95% confidence interval 15.0 † (14.4 - 16.3) *The model was adjusted according to baseline evaluation data and seniority of the family doctors. **p < 0.0001 between pre- and post-intervention stages, within groups. **p < 0.0001 between pre- and post-intervention stages, within groups. † p < 0.0001 between IEP and PEP. In the IEP group, the mean difference in the proportion of appropriately prescribed NOAs between the baseline and post- intervention stages was 17.8% (p 0.05).

9. Table 3. Effect of educational programs on patients’ use of non-opioid analgesics. IEP n= 622 PEP n=607 Self-medication* Absolute percent difference 95% confidence interval -9.1 (-11.4 - -6.8) -13.4 (–16.1- -10.7) Knowledge about the proper way in which NOAs should be taken Absolute percent difference 95% confidence interval 8.5 (6.3 – 10.7) 8.5 (6.3 – 10.7) Knowledge about NOA adverse events* Absolute percent difference 95% confidence interval 39.6 (37.6 – 41.6) 9.2 (8.0-10.4) *Abbreviation: NOA, non-opioid analgesics. * p < 0.05. The percent differences in IEP and PEP patients reporting self-medication were –9.1% and –13.4%, respectively. The percent difference in knowledge of proper NOA administration was 8.5% in both groups, while awareness of adverse events was 39.6% in the IEP group and 9.2% in the PEP group

10.  The IEP aimed at patients and family doctors are superior to PEP in improving family doctors’ prescribing patterns and enhancing patients’ knowledge of NOA-associated adverse events.  Our findings suggest that programs aimed at improving medication use should focus on interactive educational activities.  The IEP had a positive effect on patients’ awareness of NOA-associated adverse events even though the intervention did not improve the ability of patients to identify gastrointestinal adverse events.  The IEP should be improved in this aspect, and novel programs should be developed to specifically educate patients about NOAs gastrointestinal adverse events.