Journal of Pain & Palliative Care Pharmacotherapy. 2015;29:334–340.

Copyright © Taylor & Francis Group, LLC

ISSN: 1536-0288 print / 1536-0539 online
DOI: 10.3109/15360288.2015.1082007

ARTICLE

Patients’ Knowledge About Analgesic-Antipyretic

Medications Purchased in Community Pharmacies:
A Descriptive Study
Claire Grézy-Chabardès, Jean-Pascal Fournier, Julie Dupouy, Jean-Christophe Poutrain, and
Stéphane Oustric

AB STRACT
The objective of this study was to describe the level of knowledge about paracetamol (acetaminophen), ibupro-
fen, and aspirin of subjects who purchased nonprescription medications containing one of these drugs. We
conducted this cross-sectional descriptive study in 42 community pharmacies located in southwestern France
between July and November 2013. A six-item self-administered questionnaire was used. Participants were asked
to identify the active ingredient contained in 14 brand-name analgesic-antipyretics, to state the maximum daily
dose of paracetamol, ibuprofen, and aspirin, the recommended first-line analgesic, and precautions of use or
contraindications for paracetamol, ibuprofen, and aspirin. Among 576 participants, the identification of parac-
etamol ranged from 58% (for Dafalgan or Efferalgan) to 90% (for Doliprane), the identification of ibuprofen from
34% (for Nureflex) to 63% (for Nurofen), and the identification of aspirin was 70% (for Aspegic). The maximum
recommended daily dose of paracetamol, ibuprofen, and aspirin was known by 58.3%, 17.7%, and 19.3% of
participants, respectively, whereas 6.8%, 17.2%, and 13.2% stated supratherapeutic daily doses. Paracetamol
was correctly stated as the first-line analgesic-antipyretic by 76.2% of participants. Knowledge on major precau-
tions of use or contraindications was poor (45.8% and 53.6% for ibuprofen and aspirin use during pregnancy, and
14.1% for concurrent use of anticoagulants and ibuprofen). Purchasers of nonprescription analgesic-antipyretics
had poor knowledge on the medication they purchased.
KEYWORDS analgesics, antipyretics, nonprescription drugs, patient medication knowledge, patient safety,
primary care

INTRODUCTION safe when compliant with summaries of product

Paracetamol (British adopted name for ac-
etaminophen), ibuprofen, and aspirin are three
analgesic-antipyretics available for purchase as
nonprescription medication in most countries. Large
randomized trials have advocated that their use is
Claire Grézy-Chabardès, MD, and Jean-Christophe Poutrain, MD,
are with the Département Universitaire de Médecine Générale, Faculté
de Médecine, Université Paul Sabatier, Toulouse, France. Jean-Pascal
Fournier, MD, PhD, Julie Dupouy, MD, PhD, and Stéphane Oustric, MD,
are with the Département Universitaire de Médecine Générale, Faculté
de Médecine, Université Paul Sabatier, Toulouse, France, and with UMR
1027, INSERM, Toulouse, France.
Address correspondence to: Dr. Jean-Pascal Fournier, Département Univer-
sitaire de Médecine Générale, 133 route de Narbonne, 31062 Toulouse, France
(E-mail: jean-pascal.fournier@univ-tlse3.fr)
characteristics.1,2 Rare but serious adverse drug
reactions (ADRs) are, however, reported in real-life
practice, such as acute liver failure for paracetamol,
or gastrointestinal bleeding for ibuprofen and aspirin.
Misuse is a major cause of ADRs related to
analgesic-antipyretics. It has been estimated that 23%
of paracetamol-related emergency room visits and
7.7% of paracetamol-related hospitalizations were
caused by unintentional paracetamol overdoses in the
USA.3 The proportion of paracetamol-induced acute
liver failure among all acute liver failure cases in-
creased from 28% to 51% between 1998 and 2003,
with unintentional overdoses accounting for 48% of
those.4 Similar results from a European multicen-
ter observational study showed that 31% of acute

334

liver failure cases requiring transplant with no clini-
cally identifiable etiology were caused by paracetamol
or nonsteroidal anti-inflammatory drug (NSAID)
overdoses.5
In order to explain unintentional overdose and
misuse of analgesic-antipyretics, studies were con-
ducted to assess patients’ knowledge about these
medications (identification of the active ingredi-
ent, daily dosage, and contraindication). Knowledge
about paracetamol was found to be consistently in-
adequate; 45% to 80% of patients could correctly
identify paracetamol in the brand-name medications,
and 2% to 63% knew the maximum recommended
daily dose.6–14 Ibuprofen and aspirin were poorly
evaluated, with even lower rates of knowledge.15–18
However, most of these studies had selected partici-
pants who were not necessarily users of nonprescrip-
tion analgesic-antipyretics (but emergency attendees
or primary care center attendees), and none of the
aforementioned studies directly compared knowledge
about paracetamol, ibuprofen, and aspirin. Thus,
we conducted an observational study aiming to de-
scribe the level of knowledge about paracetamol,
ibuprofen, and aspirin in patients who purchased
nonprescription medications containing one of these
drugs.
METHODS
Study Population and Setting
A cross-sectional descriptive study was conducted
from July to November 2013, in 42 community
pharmacies of Haute-Garonne, southwestern France.
Pharmacy staff were asked to hand out a self-
administered questionnaire to any subject aged over
16, who purchased a nonprescription medication
containing paracetamol, ibuprofen, or aspirin, and
who agreed to participate.
Recruitment of Community Pharmacies
Community pharmacies of the area were identi-
fied using the French telephone directory and were
randomly sampled. Pharmacies were first contacted
by telephone and were invited to participate. Forty
questionnaires were provided to each participating
pharmacy. We aimed to recruit up to 42 pharma-
cies, corresponding to a 10% convenient sample of
the pharmacies in the area. No ethical approval was
sought, since this study was only observational and all
data were collected anonymously.19

C 2015 Taylor & Francis Group, LLC
C. Grézy-Chabardès et al. 335
Questionnaire Design
A two-page, self-administered questionnaire was de-
signed, based on questionnaires used in three sim-
ilar studies.7,10,11 The questionnaire was tested in
two community pharmacies before the beginning of
the study. Closed questions were used as often as
possible.
The first section included six questions on non-
prescription analgesic-antipyretic medications. Ques-
tion 1, similarly to a previously used questionnaire,7
listed a total of 14 brand-name medications: seven
nonprescription medications containing paraceta-
mol only (Doliprane, Dafalgan, and Efferalgan, the
three best-selling paracetamol-only nonprescription
medications in France),20 ibuprofen only (Nurofen,
Advil, and Nureflex), or aspirin only (Aspegic); three
nonprescription medications containing paracetamol
in combination with other active ingredients (Ac-
tifed: paracetamol, pseudoephedrine; Prontalgine:
paracetamol, codeine, cafeine; and Fervex: parac-
etamol, ascorbic acid [vitamin C], phéniramine);
three prescription medications containing parac-
etamol in combination with other active ingredi-
ents (Codoliprane: paracetamol, codeine; Lamaline:
paracetamol, opium, caffeine; and Ixprim: paraceta-
mol, tramadol); and one nonprescription medication
containing none of the three studied drugs (Spasfon:
phloroglucinol). Participants were asked to identify
the active ingredient in each medication. Response
choices were “paracetamol,” “aspirin,” “ibuprofen,”
or “none of these drugs”; there was an additional re-
sponse choice “do not know.” In questions 2 to 4,
participants were asked to state the maximum daily
dose recommended for an adult in the context of self-
medication of paracetamol (3–4 g), ibuprofen (1.2 g),
and aspirin (3 g).21 Participants were also asked to
state the drug that is recommended as the first-line
analgesic (question 5). Question 6 asked participants
to identify the drugs for which there was a precaution
or contraindication in case of pregnancy (ibuprofen
and aspirin) or anticoagulant use (ibuprofen and as-
pirin).
The second section collected basic demographic
data (age, gender, current state of pregnancy, and ed-
ucation level).
Data Analysis
Quantitative variables are represented as abso-
lute number (percentage), unless otherwise stated.
Variables with missing data were coded with an
“unknown” category. For the statistical analysis,
Pearson’s chi-square test or Fisher’s exact test was
performed when appropriated with a two-sided
336 Journal of Pain & Palliative Care Pharmacotherapy

TABLE 1. Participants’ characteristics (N = 576) Supplementary Table 1. Among the participants,

Characteristic No. of subjects (%)
93 (16.1%) reported inappropriately that Efferal-
gan contains aspirin (instead of paracetamol) and
Gender 81 (14.1%) that Advil contains paracetamol (instead
Women 386 (67.0) of ibuprofen). From 46.0% to 77.1% of partici-
Including pregnant 9 (2.3)
Age
pants indicated they did not know the active ingre-
16–39 188 (32.6) dient of medications containing paracetamol in com-
40–59 243 (42.2) bination (Supplementary Table 1). Participants aged
60–86 141 (24.5) over 60 years consistently reported less correct re-
Unknown 4 (0.7) sponses than younger participants (Supplementary
Academic degree
Less than high school 164 (28.5)
Table 2).
High school graduate 136 (23.6)
Undergraduate and postgraduate 273 (47.4)
Unknown 3 (0.5) Knowledge of the Recommended Maximum
Analgesic-antipyretic purchased
Daily Dose
Paracetamol only 328 (56.9)
Aspirin only 25 (4.3) Maximum recommended daily doses reported by
Ibuprofen only 78 (13.5)
participants are presented in Table 3. Supratherapeu-
2 analgesic-antipyretics 44 (7.6)
3 analgesic-antipyretics 1 (0.2) tic daily doses were reported by 6.8%, 17.2%, and
Unknown 100 (17.4) 13.2% of all participants for paracetamol, ibuprofen,
and aspirin, respectively. Participants aged over 60 re-
ported less frequently the correct maximum recom-
significance level of 5%. Data were collected using mended daily dose for ibuprofen, and reported more
EpiData Entry (version 3.1, EpiData Association, frequently that they did not know the maximum rec-
Odense, Denmark) and analyzed with Stata version ommended daily dose for ibuprofen (Supplementary
11.0 (StataCorp, College Station, TX, USA). Table 3).

RESULTS Knowledge of the Drug Recommended as the

Study Population
Seventy-three community pharmacies were con-
tacted in order to attain the final recruitment target
of 42 pharmacies (participation rate 57.5%). Three
to 40 questionnaires were filled in each participat-
ing pharmacy, resulting in a total of 586 question-
naires. Ten incomplete questionnaires were excluded,
and the 576 remaining questionnaires were ana-
lyzed. Characteristics of participants are presented in
Table 1. There were 386 (67.0%) women, of whom
9 (2.3%) were pregnant. Mean age was 47.8 years
(standard deviation: 16.1 years, range: 16–86 years).
The name of the purchased analgesic-antipyretic
was filled for 476 (82.6%) participants. Paraceta-
mol was the most commonly purchased medica-
tion (371 participants, 64.4%). Ibuprofen and aspirin
were purchased by 118 (20.4%) and 33 (5.7%) par-
ticipants, respectively. Forty-five (7.8%) participants
purchased two or more nonprescription analgesic-
antipyretics.
Identification of the Active Ingredient
Identification rates of active ingredients in analgesic-
antipyretic medications are presented in Table 2 and
First-Line Analgesic
Paracetamol was correctly stated as the first-
line analgesic-antipyretic by 439 (76.2%) partici-
pants, with no difference according to patients’ age
(Supplementary Table 4). Twenty-two (3.8%) par-
ticipants did not respond and 35 (6.1%) patients re-
sponded “do not know.”
Knowledge of the Major Precautions or
Contraindications of Use
Contraindications or precautions of use for ibupro-
fen and aspirin during pregnancy were correctly iden-
tified by 264 (45.8%) and 309 (53.6%) partici-
pants, respectively, and more frequently by women
than men (50.8% vs. 35.8% for ibuprofen, chi-
square test, P = .001; and 59.6% vs. 41.6% for as-
pirin, chi-square test, P < .0001). Three hundred
and fifty-six (61.8%) participants correctly identified
the risk of concomitant use of anticoagulants and
aspirin. Eighty-one (14.1%) participants correctly
identified the risk of concomitant use of anticoagulant
and ibuprofen, including 8 (5.7%) for the subgroup
of participants aged over 60 years (Supplementary
Table 5).

Journal of Pain & Palliative Care Pharmacotherapy

 C. Grézy-Chabardès et al. 337

TABLE 2. Identification of the active ingredient contained in analgesic-antipyretic medications (single analgesic-antipyretic only)

Analgesic-
antipyretic Paracetamol only Ibuprofen only Aspirin only

Product name Doliprane Dafalgan Efferalgan Nurofen Nureflex Advil Aspegic

Overall
Identification 516 (89.6) 339 (58.8) 336 (58.3) 365 (63.4) 197 (34.2) 245 (42.5) 405 (70.3)
of the
correct
active
ingredient
“Do not know” 39 (6.8) 171 (29.7) 134 (23.3) 171 (29.7) 332 (57.6) 207 (35.9) 128 (22.2)
Wrong response 21 (3.7) 66 (11.5) 106 (18.4) 40 (6.9) 47 (8.2) 124 (21.5) 43 (7.5)

Results in Patients for Whom the Name of the
Purchased Medication Was Filled
The 476 (82.6%) patients for whom the name of the
medication purchased was filled were younger than
others (Supplementary Table 5). Restricting the anal-
ysis to these patients did not materially change the
study results (Supplementary Tables 6 to 10).
DISCUSSION
In this study, subjects who purchased nonpre-
scription analgesic-antipyretics had poor knowledge
about these medications. Medications containing
paracetamol-only were correctly identified by 58%
to 90% of participants, and medications contain-
ing ibuprofen-only were correctly identified by 34%
to 63% of participants. More than half of the par-
ticipants stated that they did not know the rec-
ommended maximum daily dose for ibuprofen and
aspirin, whereas 6.8%, 17.2%, and 13.2% stated a
supratherapeutic daily dose for paracetamol, ibupro-
fen, and aspirin, respectively. One out of two par-
ticipants knew about the risk of aspirin or ibuprofen
TABLE 3. Reported maximum daily dose for
analgesic-antipyretic medications
Reported dose Paracetamol Ibuprofen
Therapeutic 336 (58.3) 102 (17.7)
dose∗
Supratherapeutic 39 (6.8) 99 (17.2)
dose
Infratherapeutic 66 (11.5) 45 (7.8)
dose
‘Do not know’ 119 (20.7) 320 (55.6)
No response 16 (2.8) 10 (1.7)
∗As recommended for an adult in the context of self-medication
(paracetamol: 3–4 g; ibuprofen: 1.2 g; aspirin: 3 g).20
use during pregnancy and less than 15% knew about
the risk of concomitant use of anticoagulants and
ibuprofen.
The identification rates of paracetamol in prod-
ucts that contain paracetamol-only in our study is
consistent with results from previous studies (45%
to 80%; Table 4).7,8,10–13 However, comparing our
results with studies from the UK and the USA
should be cautious; there is only one brand-leader
among paracetamol-based nonprescription medica-
tion in these countries (Tylenol in the USA, Panadol
in the UK), as opposed to three in France (Doliprane,
Dafalgan, and Efferalgan). Interestingly, in our study,
the rate of identification of paracetamol is 30%
higher in the best-selling paracetamol-only brand-
name medication (Doliprane),20 suggesting that the
most commonly used medications (i.e., the most fa-
miliar to the patients) are the most easily identified.
Also, rates of identification tended to be greater for
brand names sharing orthographical and phonologi-
cal similarities with the nonproprietary names (“asp”
for Aspegic/aspirin, “fen” for Nurofen/ibuprofen).
The study results support the notion that famil-
iarity and orthographical/phonological similarities
have a strong influence on the correct identifica-
tion of medication.22,23 Overall, given the low iden-
tification rates of active ingredients, the mention
of international nonproprietary names on packaging
(mandatory in Europe since 2004) appears currently
Aspirin insufficient.24 In Australia, stakeholders (including
patients) have been consulted and have advocated
111 (19.3) for equal prominence of international nonproprietary
names and brand names on drug packaging.25 The
76 (13.2)
impact of this recommendation on patients’ knowl-
54 (9.4) edge on nonprescription medications remains to be
assessed.
328 (56.9) Eight previous studies have evaluated knowl-
7 (1.2) edge of the maximum recommended daily dose
of paracetamol and have found results similar
to those of our study (Table 4).6–13 All but
two of the studies reported 4.4% to 23% of


C 2015 Taylor & Francis Group, LLC
338 Journal of Pain & Palliative Care Pharmacotherapy

TABLE 4. Patients’ knowledge about paracetamol: Results of the present and previous studies
Authors Present study Boudjemai6 Wood7 Herndon8 Wolf9 Hornsby10 Fosnocht11 Stumpf12 Chen13
Year 2013 2012 2009 2013 2009–2011 2007–2008 2007 2003 2000
Country France France UK USA USA USA USA USA USA
Study characteristics
Participants Adult purchasers All adults All adults All adults All adults All adults All adults All adults All adults
Setting Community ED ED Primary Clinics Primary care ED Primary ED
pharmacies care center center care
center
Design SAQ Interview SAQ SAQ Interview IAQ SAQ SAQ SAQ
No. of participants 576 73 910 102 500 284 1009 104 103
Age, mean 47.8 43 38.7 NA 49.3 51 38 52.3 NA
Female (%) 67 52 53 59.8 62.6 70 57 34.6 62

Knowledge of the recommended maximum daily dose of paracetamol

Recommended daily dose
3–4 g∗ 58.3% 63% — 50.0% NA — — — NA
4g 29.5% 30% 50.4% 22.5% NA 33% 7% 2.5% NA
>4 g 6.8% 15.0% 4.4% 3.9% 23.8% 10.0% 5.4% 2.0% 18.0%
(supratherapeutic)
Do not know 20.7% 7.0% 6.4% 4.9% — 34.0% 56.3% 28.0% 2.0%

Identification of the content of paracetamol containing medications

Paracetamol only 58.3%– NA 80.0% 79.4% NA 46.0% 45.0% 71.2% —
89.6%

Note. ED = emergency department; SAQ = self-administered questionnaire; IAQ = investigator-administered questionnaire; NA = not
applicable.
∗As recommended for an adult in the context of self-medication for paracetamol: 3–4 g.20

participants stating a supratherapeutic daily dose
for paracetamol.6,7,9–11,13 Two studies found lower
reporting rates of supratherapeutic daily dose for
paracetamol, but participants in these studies were
better educated.8,12 No daily-dose-awareness studies
have been conducted for aspirin or ibuprofen to the
best of our knowledge. The present study suggests
that knowledge of the recommended maximum daily
doses for aspirin and ibuprofen is worse than that for
paracetamol.
Although several studies (including ours) have
reported poor patient knowledge about antipyretic-
analgesic medications, only one has assessed the as-
sociation between lack of knowledge and misuse. A
recent large population-based Internet survey showed
that poor knowledge of active ingredients and maxi-
mum recommended daily doses were independently
associated with unintended overuse of paracetamol
(>4 g/day).26 To our knowledge, no study has yet as-
sessed this association for ibuprofen or aspirin. Fur-
ther studies are required to ascertain the association
between lack of knowledge and misuse of ibuprofen
or aspirin.
Strengths and Limitations
To our knowledge, the present study is one of the
largest in this field of research, and the first to concur-
rently evaluate knowledge about the three antipyretic-
analgesic agents available as nonprescription
medications. The use of self-administered question-
naires, with closed questions and “do not know”
options, has allowed the minimization of social
desirability, “yes-saying,” and interviewer biases.27
On the other hand, this study does have some limita-
tions. First, a selection bias might have affected our
results: some patients’ characteristics, such as low
literacy, or motor/sensory impairment, are barriers
to participation in surveys that use self-administered
questionnaires.27 The patients who were the most
interested in the study topic might also be more likely
to participate. We were not able to analyze charac-
teristics of subjects who declined or were not able to
participate in the present study. Second, the name of
the antipyretic-analgesic purchased was not filled in
17.4% of questionnaires; this may cast doubt as to the
application of our study inclusion criteria. However,
a comparison between participants with the missing
and nonmissing variable did not show significant dif-
ferences (Supplementary Tables 6 to 10). Third, our
questionnaire was designed on the basis of previously
used questionnaires,7,10,11 allowing a comparison of
the study results. Although our questionnaire was
tested prior the beginning of the study, it has not
been formally validated. Fourth, we selected study
participants based on their purchase of a nonpre-
scription antipyretic-analgesic. It is thus uncertain
how pharmacy or pharmacy staff counseling before
the administration of the questionnaire may have
influenced the study results. A multicenter com-
munity pharmacy–based study recently showed
that counseling was heterogeneous and sometimes

Journal of Pain & Palliative Care Pharmacotherapy


inadequate in the context of a customer’s request for
nonprescription antipyretic-analgesic.28
CONCLUSION
Subjects who purchase nonprescription analgesic-
antipyretics have poor knowledge about these med-
ications with respect to the active ingredient, max-
imum daily dose, and precautions of use. Further
studies are required to ascertain the association be-
tween lack of knowledge and misuse, especially for
ibuprofen and aspirin.
ACKNOWLEDGMENTS
The authors thank all the participating pharmacies
and Dr. Koray Tascilar, (Department of Epidemi-
ology, McGill University, Montreal) for his critical
comments and help during editing of the manuscript.
SUPPLEMENTAL MATERIAL
Supplemental data for this article can be accessed on
the publisher’s website.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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