AMITY INSTITUTE OF PHARMACY

SELF MEDICATION – RISK ASSOCIATED

AND ITS PREVENTION

Submitted by:-
TANUJA CHAUDHARY
B.PHARM (2015-2019)
A4513315070

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 SELF-MEDICATION–A CURRENT CHALLENGE

Self-medication is practised in the form of self-care of our health. During early times, self-
medication was regarded as unnecessary and potentially even unhealthy practice.
Traditionally, self-medication was known as “taking drugs, home remedies or herbs by one’s
own or advised by another person without consulting a doctor. Some of the common sources
of self-medications are family, friends, neighbours, pharmacist, previous prescribed drugs or
advertisements. Now-a-days people/patients desire to play intelligent, independent and
informed role and not just in terms of decision making but also in the management of
preventive, diagnostic and therapeutic activities which concern them. The most widely self-
medicated substances are over the counter drugs used to treat common health issues at home
and dietary supplements as they are available without prescriptions and even at supermarkets.
Patients wish to take a greater role in the maintenance of their health and to manage chronic
and recurrent illnesses, e.g. topical corticosteroid, antifungal and oral contraceptive. An urge
of self-care, feeling of sympathy toward family members in sickness, lack of time, lack of
health services, financial constraint, ignorance, misbelieves, extensive advertisement and
availability of drugs in other than drug shops are growing cause of self-medication. Self-
medication is becoming an increasingly important area within healthcare. It moves patients
towards greater independence in making decisions about management of minor illnesses,
thereby promoting empowerment. Self-care includes actions taken by individuals to promote
or ensure their health, to recover from diseases or injuries, or to manage their effects. Self-
medication is thought to reduce the load on the medical services, decrease the time spent in
waiting to see the physician, and saves cost especially in economically deprived countries
with limited health resources. However, responsible self-medication is not free of risk which
can increase the burden and out- of- pocket expenses since it may result in adverse health
effects that require medical intervention.

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 BRIEF OVERVIEW TO SELF MEDICATION

Common illnesses where patients self-medicate:- Factors leading to self-medication:-

1. Common infections 1. Social
2. Chronic non communicable diseases 2. Fragmented health care system
3. Mental illnesses 3. Waiting time
4. Health care cost
5. Lack of awareness

Sources of medicine:- Categories of medicines used for self-medication:-

1. Pharmacies 1. Anti-biotics
2. Drug stores 2. Anti-histamines
3. Medicines stored at home 3. Analgesics
4. Friends and relatives 4. Weight gain and weight reducing agents
5. Street vendors 5. Multi vitamins
6. Skin bleaching steroids

The use of medications without prior medical consultation regarding indication, dosage, and
duration of treatment is referred to as self-medication. In most illness episodes; self-
medication is the first option which makes it a common practice worldwide. Common
illnesses in which people self-medicate are common infection such as common cold, cough
etc. chronic non communicable diseases such as diabetes, and mental illnesses such as
depression or anxiety.

Factors that lead to self-medication are social factors such as lifestyle, fragmented health
care system i.e. when there are many different health “subsystems” that coexist, providing
care for different parts of a country’s population. Each of these subsystems has their own way
of financing and delivering healthcare, and each provides healthcare to different types of
people. The problem is that when these subsystems operate independently from one another,
they create major gaps in the provision of health services, often leaving out the poorest
patients; waiting time; health care cost and lack of awareness are also responsible for self-
medication.

Some categories of medicines that are often used for self-medication are antibiotics
(amoxicillin/azithromycin); analgesics (ibuprofen/aspirin); weight gain or weight reducing
tablets; multi vitamins; etc.

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 HYPOTHESIS REGARDING SELF-MEDICATION

Different drugs show different effects and therefore are used for different reasons. According
to the self-medication hypothesis, an individuals' choice of particular drug is not accidental or
coincidental, but is a result of that individuals' psychological condition, since the drug of
choice provides relief to the user according to his or her specific condition.
Specifically, addiction is assumed to function as a compensatory means to modulate effects
and treat distressful psychological states, in which individuals choose the drug that will most
effectively manage their psychiatric distress and thereby help them achieve emotional
stability. The self-medication hypotheses (SMH) were formerly given in papers by Edward
Khantzian, Mack and Schatzberg, David F. Duncan. Initially it focused on heroin use, but
follow-up paper added cocaine and was later expanded to include alcohol, and finally all drugs
of addiction. [9]

According to Khantzian's view of addiction, drug users compensate for deficient ego function
by using a drug as an "ego solvent", which acts on parts of the self that are cut off from
consciousness by defence mechanisms. According to Khantzian, drug dependent individuals
generally experience more psychiatric distress than non-drug dependent individuals, and the
development of drug dependence involves the gradual incorporation of the drug effects and
the need to sustain these effects into the defensive structure-building activity of the ego itself.
The addict's choice of drug is a result of the interaction between the psychopharmacologic
properties of the drug and the affective states from which the addict was seeking relief. The
drug's effects substitute for defective or non-existent ego mechanisms of defence. The
addict's drug of choice, therefore, is not random.

While Khantzian takes a psychodynamic approach to self-medication, Duncan's model

focuses on behavioural factors. Duncan described the nature of positive reinforcement (e.g.,
the "high feeling", approval from peers), negative reinforcement (e.g. reduction of negative
affect) and avoidance of withdrawal symptoms, all of which are seen in those who develop
problematic drug use, but are not all found in all recreational drug users. Duncan applied a
public health model to drug dependence, where the agent (the drug of choice) infects the host
(the drug user) through a vector (e.g., peers), while the environment supports the disease
process, through stressors and lack of support. [8]

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 CHARACTERISTICS OF SELF-MEDICATION

Self-medication is becoming an increasingly important area within healthcare. It moves

patients towards greater independence in making decisions about management of minor
illnesses, thereby promoting empowerment. Self-medication also has advantages for
healthcare systems as it facilitates better use of clinical skills, increases access to medication
and may contribute to reducing prescribed drug costs associated with publicly funded health
programmes. [2] Monitoring systems, a partnership between patients, physicians and
pharmacists and the provision of education and information to all concerned on safe self-
medication, are proposed strategies for maximising benefit and minimising risk. It is widely
accepted that self-medication has an important role to play in health care and, with the
continued improvement in people's education, general knowledge and socio-economic status;
self-medication has been successfully integrated into many health care systems throughout
the world.

Self-medication products are those not requiring a medical prescription and which are
produced, distributed and sold to consumers for use on their own initiative. Responsible self-
medication can be used to prevent and treat symptoms and ailments that do not need medical
consultation or oversight. This reduces pressure on medical services, especially when these
are limited. For those populations living in rural or remote areas where access to medical
services may be difficult, patients are able to control their own conditions to a greater extent.
Only if the condition fails to respond, persists, or becomes more severe will the patient need
to seek professional medical care. [3] Self-medication is useful as it:-
 Help to prevent and treat symptoms and ailments that do not require a doctor.
 Reduce the pressure on medical services where health care personnel are
insufficient.
 Increase the awareness of health care to populations living in rural or remote
areas.
 Enable patients to control their own chronic conditions.
 Hay fever, headache, indigestion, mouth ulcer, nausea, cough, acne, allergic
conjunctivitis can be treated by self-medication.
 For healthcare systems as it facilitates better use of clinical skills, increases
access to medication and may contribute to reduce prescribed drug costs
associated with publicly funded health programs.

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 POTENTIAL BENEFITS OF SELF MEDICATION

The social and economic benefits of self-medication reflect the fact that it is voluntarily
chosen by consumers for conditions where it seems preferable to them. It will usually be
selected for use in symptoms and conditions which the user regards as sufficiently
troublesome to need medicinal treatment but not to justify consulting a physician. Only if the
condition fails to respond, persists or becomes more severe will professional medical help be
sought. Accordingly, good self-medication should offer the individual consumer:

 Efficacy: i.e. the product does what it is claimed to do;

 Reliability and safety: the individual will often choose a product which experience has
shown to be suitable. The scope and duration of self-medication can be kept within
safe limits by appropriate selection of approved indications, labelling texts, dosage
strengths and forms, and package sizes;
 Product safety when used as recommended in the instructions;
 Acceptable risk, even when used for a longer duration, at a higher dose, or somewhat
differently than recommended in the instructions;
 Wider availability of medicines;
 Greater choice of treatment;
 Direct, rapid access to treatment;
 An active role in his or her own health care;
 Self-reliance in preventing or relieving minor symptoms or conditions;
 Educational opportunities on specific health issues (i.e. stop-smoking aids and
products to treat heartburn);
 Convenience;

Economy, particularly since medical consultations will be reduced or avoided;

At the community level, good self-medication can also provide benefits such as saving scarce
medical resources from being wasted on minor conditions, lowering the costs of community-
funded health care programmes (including prescription reimbursement systems), and
reducing absenteeism from work due to minor symptoms. [3]

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 RISKS IN SELF MEDICATION PRACTICES

Self-medication has a number of potential risks. In particular, the ordinary user will usually
have no specialized knowledge of the principles of pharmacology or therapy, or of the
specific characteristics of the medicinal product used. This results in certain potential risks
for the individual consumer:

 Incorrect self-diagnosis which leads to incorrect choice of therapy

 Failure to seek appropriate medical advice promptly

 Failure to recognize special pharmacological risks which may lead to rare but severe
adverse effects

 Failure to recognize or self-diagnose contraindications, interactions, warnings and

precautions

 Failure to recognize that the same active substance is already being taken under a
different name

 Failure to report current self-medication to the prescribing physician

 Failure to recognize or report adverse drug reactions

 Incorrect route or manner of administration

 Inadequate or excessive dosage

 Excessively prolonged use

 Food and drug interactions

 Storage in incorrect conditions or beyond the recommended shelf-life

At the community level, improper self-medication could result in an increase in drug-

induced disease and in wasteful public expenditure [3]

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 Recognizing Forms of Self-Medication

Self-medication and depression

Depression is classified as a mood disorder. It’s associated with feelings of sadness, loss, and
anger. When someone is depressed, these symptoms can impact their everyday life. Treating
depression is important. It usually involves counselling, medication, or both. However, not
everyone seeks professional help to treat their depression. Some try coping with their
symptoms on their own. One way this happens is through self-medication. This can be
dangerous and it can cause even bigger problems than simply choosing not to get treatment
from trained medical professionals.

Self-medicating with food

Risks: Decreased self-esteem, worsened depression symptoms

If you’re an emotional eater, you might self-medicate with food. “Emotional eating” is using
food as a way to suppress or soothe negative emotions. This practice is also called “bingeing”
or “comfort eating.” Emotional eating may temporarily reduce stress in those who aren’t
clinically depressed, according to a 2015 study. However, bingeing is not a healthy way to
treat depression. It can negatively affect self-esteem and make symptoms of mental illness
worse. It may also have an impact on physical health through weight gain.

Self-medicating with alcohol

Forms: Beer, wine, liquor

Risks: Addiction, legal consequences

In low doses, alcohol can temporarily relieve symptoms of depression and anxiety. It can
make a person more jovial and social, give them a sense of everything being “alright,” and

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alleviate anxiety. However, when used regularly, it can lead to alcoholism, which worsens
depression and anxiety. Alcoholism may require a lengthy recovery process and can be
extremely difficult to manage. Recovery can be a life-long process. Post-traumatic stress
disorder (PTSD) is another condition that frequently results in self-medicating with
alcohol. Research shows that trauma and alcohol abuse are often linked.

Self-medicating with psychostimulants

Forms: Cocaine, amphetamines

Risks: Heart failure, death, legal consequences

People with mental health conditions may abuse psychostimulants such as cocaine and
amphetamines. This is most likely due to the feelings of euphoria these drugs can cause.
However, cocaine can be addictive and cause depression. Cocaine has a high potential for
addiction. It can be fatal when used as a recreational drug. It does major damage to the
body’s cardiovascular system. Cocaine-related deaths can occur as a result of sudden heart
failure. Amphetamines speed up the function of the heart and carry the risk of a stroke. Using
these substances may distract from depression, but the “crash” feeling after the drugs have
worn off doesn’t make them an effective solution for depression. In fact, cocaine users often
find that it worsens their symptoms.

Self-medicating with caffeine

Forms: Coffee, tea, energy drinks

Risks: Increased feelings of depression and anxiety

Caffeine is a stimulant that’s found in many foods and in drinks such as coffee and tea. While
coffee is popular for its ability to perk you up, the effects are only temporary. Once the high
wears off, your insulin levels drop, causing feelings of confusion and depression. Caffeine
can also heighten feelings of anxiety. Cut down to one cup of coffee or tea per day if you’re
sensitive to the effects of caffeine.

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Self-medicating with cannabis

Forms: Marijuana

Risks: Worsened symptoms of depression, legal consequences

Compared to illicit substances (such as opioids, cocaine, and amphetamines), marijuana, or

cannabis is, by far, the most widely used substance among those with depression. While there
are some assertions among cannabis users that cannabis treats depression, more studies are
needed to determine the benefits and possible disadvantages of marijuana as a potential
treatment for depression. Studies show that too much marijuana can worsen symptoms of
depression.

Self-medicating with opiates and opioids

Forms: Codeine, heroin, methadone

Risks: Worsened depression symptoms, death, legal consequences

Opiates, such as codeine and morphine, are drugs derived from the poppy plant. Any drug
that mimics the effects of an opiate is called an opioid. Opioids include heroin, oxycodone,
and methadone. The World Drug Report estimated that in 2013, 40.9 to 58 million people
worldwide used opiates and opioids. Depression is common among users of these drugs.
When depression and opiate use or abuse are combined, the results can be deadly.[10]

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 SELF-MEDICATION WITH ANTIMICROBIAL DRUGS

Self-medication can be defined as the use of drugs to treat self-diagnosed disorders or

symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent
disease or symptoms. It is usually selected by consumers for symptoms that they regard as
troublesome to require drug therapy but not to justify the consultation of a prescriber. In
developing countries, most illnesses are treated by self-medication. A major shortfall of self-
medication is the lack of clinical evaluation of the condition by a trained medical
professional, which could result in missed diagnosis and delays in appropriate treatments.
A major problem with self-medication with antimicrobials is the emergence of human
pathogens resistance. Antimicrobials resistance is a current problem world-wide particularly
in developing countries, where antibiotics are often available without a
prescription. Resistance to antimalarials drugs has also been reported in many third world
countries. Reasons for this resistance include the irrational use of antimalarials, including
their indiscriminate non-prescription use.
In Sudan there is suspicion that self-medication is high. A reason for this is the fact
that in Sudan most drugs can be obtained from pharmacies and drug stores without the
requirement of a prescription. As a result, minor ailments are often treated with
antimicrobials. In addition, self-treatment of malaria is common following self-diagnosis
mainly based on presumptive symptoms of malaria. Self-medication with antimicrobials has
the potential to harm society at large as well as the individual patient. Policy makers should
be concerned if the spectrum of drugs available without a prescription includes
antibiotics. The increase in antibiotics resistance in developing countries is of current public
and professional concern as it results in multiple resistant organisms difficult to treat.
It is widely believed that human malpractices such as inadequate dosing, incomplete
courses and indiscriminate drug use have contributed to the emergence and spread of
antimicrobial resistance. The consequence of this is the loss of relatively cheap drugs that
will require new drugs development, which will be more expensive and will further
disadvantage patients in developing countries such as Sudan. The rational use of antibiotics is
thus of utmost importance to limit the increase in bacterial resistance. [5]

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 CASE STUDIES

Scenario 1

M. K., a 36 years old, truck driver working in the oil fields suffered from a cough productive
of whitish sputum, for the past 10 weeks. He visited many pharmacies and used 18 different
products during the past weeks, including cough products, common cold products,
antihistamines, decongestant, nasal sprays, antibiotics and analgesics according to advice
from relatives, friends, pharmacists and some doctors; but without relief. He also used
various home remedies and herbs suggested by family and friends but without benefit. M. K.
finds it difficult to work and takes time off during the job. The cough now is worse
awakening him at night with chest discomfort. He had taken a medical leave and decided to
see a doctor who referred him to a chest physician. The chest physician took an appropriate
history, examined the patient, requested a chest X-ray which showed hyperinflation, the Peek
Expiratory Flow Rate was 65% of the expected and the CBC (Complete Blood Count) was
normal. A diagnosis of bronchial asthma was made and; severity was assessed. The patient
was started on step 2 of asthma treatment; regular corticosteroid plus when required
salbutamol Metered Dose Inhalers (MDI) was prescribed.

Problems

• In appropriate self-medication.

• Delayed diagnosis for a serious health condition.

• Economic burden on the patient and the health care system.

• Home remedies and herbs are not free from adverse effects; they might have worsened the
patient’s condition

• The patient’s health suffered longer than necessary, and missed many work days.

Solutions

• Campaign of health education to the public highlighting the adverse effects of self-
medication.

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• Advice healthcare workers on recommending medication after appropriate a diagnoses has
been made.

• Advice healthcare workers to refer patients to the appropriate specialty in order to prevent
prolonging patient's suffering, subjecting them to needless complications and to over burden
them with an extra out of pocket expenditure.

• Identify triggering factors and the role of occupation on bronchial asthma so as to avoid
them.

Scenario 2

A 9 months old baby boy developed watery diarrhoea, six motions per day. The mother gave
her baby metronidazole suspension which she already had at home. After using the drug for
two days the diarrhoea didn't stop, she went to the pharmacy and was given co-trimaxozole
suspension. Nevertheless the diarrhoea did not settle. Two days later, the child developed oral
thrush, refused feeding and his general condition deteriorated. The mother stopped the
medication and took him to a traditional healer, who cut the baby’s uvula. The baby’s
condition got worse and was taken to the hospital. He was diagnosed as sepsis with
malnutrition and was admitted for 15 days. The specialist instituted the appropriate
management and counselled the mother and advised her on how to deal with such conditions
if experienced in the future.

Problems

Inappropriate management of diarrhoea:

• The mother didn’t seek medical advice from the start.

• Inadvertent use of medicines stored at home; leftover antibiotics.

• Resorting to the traditional healer.

• Irrational dispensing of antibiotics by the pharmacist.

• Failure of the pharmacist in counselling and providing proper advice. Consequently this led
the mother to seek help from traditional healers.

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• The pharmacist did not provide the mother with ORS and Zinc Sulphate according to the
national guidelines and Integrated Management of Childhood Illness– Federal Ministry of
Health.

• Inappropriate self-medication with metronidazole and irrational dispensing of co-trimexzole

delayed the diagnosis and led to grave consequences. .

• The cost of over-the-counter drugs and consequences of self-medication can be more

expensive than seeking proper medical care. It can also delay the proper treatment.

Solutions

• Diarrhoea is a common childhood illness. The mainstay of management is oral rehydration

solution and zinc supplement. However the use of antibiotics and metronidazole to treat
diarrhoea in children is very common.

• Pharmacists and other health care professionals should be trained and motivated to follow
standard treatment guidelines when dealing with health problems.

• Regulations to limit public access to antibiotics should be enforced.

• The public awareness about self-medication and antibiotic use should be raised especially in
regard to children.

• Educational programmes using different forms of media should educate the public about the
adverse impact of resorting to traditional healers.

Scenario 3

A24 old lady was brought in a bad condition to the Emergency Room in Khartoum teaching
hospital. Upon arrival, she was hypoglycaemic, severely hypotensive with impaired
consciousness. Two days prior to admission the patient, according to her family, has started
to complain from myalgia, malaise, anorexia, diarrhoea, abdominal pain and vomiting. The
history taken from a family member has shown that the patient, advised by a friend of hers,
was using tablets known as ''annajma'' bought from a local market, for the last 6 months to
gain weight, as she thought she was too skinny. The patient has stopped her medicine 3 days
earlier, because she thought they were useless. The tablets were identified as dexamethasone

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2 mg tablets. Laboratory investigations have revealed sodium blood level of 124 mEq/ml
(normal 135 - 145mEq/ ml), blood sugar was 50 mg/ dl (normal 150 mg/ dl). Blood pressure
measurement was 50/ 40 mm Hg (normal 120/ 80 mm Hg). The treatment for adrenal crisis
was instituted. The patient was immediately cannulated for IV access, and given treatment in
form of dextrose, normal saline, and hydrocortisone planned to continue the treatment for the
following 48 hours. Unfortunately, the patient's condition deteriorated, and passed.

Problems

This case illustrates the risks associated with self-medication with systemic corticosteroids,
which has become a common practice by many Sudanese ladies recently to gain weight and
whiten skin. Corticosteroids are known to cause water and salt retention leading to weight
gain. Glucocorticoids have high adverse effect profiles, and should be used only under close
medical supervision when clearly indicated. Chronic use Fatal Outcomes of Street Sold
Medications: "Annajma" Example Practice Issues of glucocorticoids is the most common
cause of adrenal crisis which represents a true endocrine emergency, a life threatening
condition if untreated. Systemic corticosteroids used for more than 3 weeks require dose
tapering to allow for the hypothalamic pituitary adrenal axis recovery.

Solutions

The importance of raising awareness of the public about the risks involved with
corticosteroids self-medications and the problems of obtaining medication items from sources
other than pharmacies. More effort is required from the concerned authorities to prohibit
medicines to be obtained from channels other than the official channels.

The role of pharmacists in responding to symptoms and dispensing drugs without

prescriptions fits well with the extended role of pharmacists in providing pharmaceutical
care. It is substantial and requires a mix of good knowledge and skills; like how to
differentiate between minor and serious symptoms, listening skills, questioning skills and
good knowledge about evidence-based treatments for different ailments. [6]

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 Recommendation to overcome irresponsible self–medication

• Regulatory authorities are required to continuously review and classify medicinal products
on the basis of safety, efficacy, and contribute to enforcement and implementation of laws
and regulations.

• Adaptation of self-medication protocols by Ministry of Health and provision of reference

materials and training activities for healthcare workers to meet local needs.

• Continuing education for pharmacists should be undertaken and supported to ensure

maintenance of pharmacist's capacity to respond to the changing health needs of the public

• National pharmaceutical associations should develop certain performance standard, based

on the concept of pharmaceutical care.

• Pharmacies survive commercially through product sales, but these should never be their
principal focus. Product selection must be appropriate to the need and circumstances of the
patient, and based on informed judgment and whenever necessary and appropriate, the patient
must be referred to physician.

• Expansion of health insurance services to universal coverage can reduce the prevalence of
self- medication practices.

Response to symptoms by Pharmacist

Pharmacists are frequently used as an alternative and less expensive source of medical care,
and the first place to call for advice about minor conditions and medications.

• When pharmacists receive requests from the public for advice on a variety of symptoms
thought to be related to mild self-limiting minor ailment, they may supply a medicine, if truly
indicated with advice to consult a medical practitioner if the symptoms persist.

• Pharmacists should hold fully the responsibility and accountability for dispensing drugs
without prescriptions in pharmacy.

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• In responding to symptoms, pharmacists are required to follow a systematic approach
according to a logical sequence.

• This can be accomplished by first identifying the patient, establishing the profile of
symptoms, establishing drug history, herbals or other traditional remedies, establishing
possible existence of risk factors and finally differentiate between minor and serious
symptoms, which is the most challenging step, before making a decision.

• Symptoms like nausea, vomiting, indigestion and burning urination MAY or MAY NOT be
due to mild diseases. When drug treatment is appropriately recommended, the patient is
advised to come again for evaluation of treatment outcome if symptoms persist.

Figure 1 Flow chart of role of pharmacist in responding to symptoms

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 CONCLUSION

Consumers need independent information to ensure the safe, effective and rational use of
drugs in self-medication. Advice to the consumer/patient should include a description of how
to use the product without medical supervision and the circumstances in which referral for
medical advice is necessary. In many cases, self-medication products are also understood to
mean alternative medicines, food supplements, vitamins, herbs or other substances contained
in commercially available products. Many are also sold in pharmacies or health food stores
and have not been clinically tested and do not have a scientific basis for their recommended
medicinal use. Moreover, certain products can cause severe safety problems. In highly
regulated markets, pharmacists and other health care providers that recommend alternative
medicines expose themselves to malpractice and liability claims if a patient is either injured
or has treatment inappropriately delayed as a result of recommending such products.

In conclusion, self-medication can facilitate access to medicines and reduce health care costs.
But more specific studies are needed to evaluate the impact and role of self-medication in the
diversity of settings of different health care sectors. The combined efforts of industry and
regulators must meet the expectations of consumers by providing products which are safe,
effective, good value for money, and accompanied by complete and relevant information.
High ethical standards should be applied to the provision of information, promotional
practices and advertising. The content and quality of such information and its mode of
communication remains a key element in educating consumers in responsible self-
medication. [3]

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 REFERENCES

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012703/
2. https://www.ncbi.nlm.nih.gov/pubmed/11735659
3. http://apps.who.int/medicinedocs/en/d/Jh1462e/1.html
4. https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2125.2003.01716.x
5. https://sites.ualberta.ca/~csps/JPPS8(2)/A.Awad/sudan.htm
6. http://apps.who.int/medicinedocs/documents/s22205en/s22205en.pdf
7. https://link.springer.com/article/10.2165/00002018-200124140-00002
8. https://www.addictioninfo.org/articles/258/1/The-Self-Medication-Hypothesis/Page1.html
9. https://en.wikipedia.org/wiki/Self-medication
10. https://www.healthline.com/health/depression/forms-self-medication

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