The use of drugs and medical students : a literature review

Study conducted at the Medical Department of the State University of Ponta Grossa (PR), Brazil. 1. 4Th-year Medical Students fo the State University of Ponta Grossa (PR), Brazil. 2. PhD in Internal Medicine; Adjunct Professor of Medicine at the Ponta Grossa State University (UEPG), Ponta Grossa (PR), Brazil. 3. Master in Science and Technology Teaching; Associate Professor of the Medical Program of the State University of Ponta Grossa (PR), Brazil.


INTRODUCTION
The beginning of medical school is marked by a drastic change in lifestyle 1 .The student is subjected to enormous stress levels during the course of their academic training, which triggers deleterious consequences in both social and psychological levels 2 .Among them, is substance abuse, which is used by some students as a means of escape and relief to the problems faced during the program 3 .These substances activate the neural circuitry of reward and pleasure, allowing for better control of stress and, therefore, used by students in search of a feeling of well-being 4 .
In fact, several studies have demonstrated there is a high prevalence of alcohol, tobacco, and illicit drug consumption among medical students 5 .The consequences of the excessive use of these substances go far beyond the organic damage already thoroughly described in the literature.Alcohol abuse, for instance, is correlated to an increase in crime, traffic violence, and absenteeism statistics 6 .In addition, the population in general expect medical students to be diego_souzasmd@yahoo.com.br,matheoaugusto@hotmail.comgustavorachid9@gmail.com, rbulykveiga@hotmail.com mssantin@hotmail.com,anafabio2009@gmail.comrole models of healthy behavior.Upon seeing them making use of such substances, people can be falsely led to believe that drug consumption is a harmless practice and may take it up in daily life.Hence, substance abuse by medical students may be considered a serious public health matter.Despite that, the situation is often underdiagnosed, since students do not seek expert help and tend to hide the problem 7 .Thus, it is essential to acknowledge the actual prevalence of substance abuse in medical schools.Moreover, it is necessary that the causes for this consumption and the possible measures to mitigate it be clarified and assessed.
The purpose of this paper is to carry out a systematic review of the literature on the use of drugs, both licit and illicit, among Brazilian medical students, seeking to identify what are the most commonly used substances, the main reasons that led to this consumption and the most widely reported risk and protective factors.

METHODOLOGY
This is a literature review study on the use of licit and illicit drugs by medical students in Brazil.The bibliographical reference used was the Scientif-ic Electronic Library Online (Scielo) and the Medical Literature Analysis and Retrieval System Online (Medline).
On June 28 of 2017, these portals were accessed and the following combinations of keywords in English were used: "medical students, drugs and Brazil".A search for references in Portuguese was also carried out using the following combinations of keywords: "estudantes de medicina e drogas".No time limit was set for the studies selected for this review.
The search conducted on Medline with the keywords in English returned 48 references.On Sci-ELO, the search returned 54 references, being 22 with keywords in English and 32 in Portuguese.Out of the total of 102 references found, were excluded all literature reviews, all studies that did not include Brazilian medical students in their samples, and all studies that did not specifically assess drug use.This process led to the exclusion of 79 papers.Out of the remaining 23 references, seven were repetitions and were therefore disregarded as well.Finally, a total of 16 articles were included in this literature review, all of which subsequently read in its entirety.Figure 1 represents the stages for the selection of papers.To identify risk factors related to sexuality and psychoactive substance use by medical students, in order to organize preventive strategies.

Main achievements
An anonymous, semi-structured questionnaire was used.
The most commonly used drug was alcohol (76.2%), with 46.5% using it at least once a week, 33.5% once a month and 2% daily; 11.1% used tobacco, with an average of 6.4 cigarettes a day.Ether spray was used by 22.6%, 98% at least once a month.Greater use of illicit drugs by men.Increased use of alcohol and tobacco throughout the program.Alcohol consumption is greater to alleviate tension, to share a behavior with colleagues and due to ease of access.

RESULTS
Table 1 presents the main data found in the papers analyzed.
After the analysis of all 16 papers, we noticed, in relation to the numbers referring to the last century, an increase in scientific studies conducted on the subject.Regarding where these studies were conducted, most of them (75.0%) were carried out in Southeast cities, with an emphasis in São Paulo where nine studies were performed (56.2%); there were only three studies (18.7% in the South region and only one (6.2%) in the Northeast 1 .No publications on the subject were found from the North and Central-West regions.
As for the methodology used, all selected papers were cross-sectional, with 14 (87.5%)being retrospective and only two (12.5%)prospective.Out of that total, 12 studies (75.0%) sought to identify the prevalence of licit and illicit drug use by medical students, as well as the likely predisposing factors and conditions associated with it.The other studies had more specific purposes, such as to assess the link between marijuana and ether sprays (lança-perfume in Portuguese) and identify how medical students faced with substance abuse by their peers reacted 15 .All data were obtained through questionnaires adapted and validated in Portuguese.
Finally, regarding the use of drugs, the studies found were unanimous in pointing out alcohol as the substance most often consumed by medical students 8- 23 .Even though the prevalence of smoking has decreased over the past years, several studies still indicate that tobacco is the second most used drug 10, 11 .Among the illicit drugs, the most often consumed were marijuana, solvents, ether sprays and anxiolytics.

DISCUSSION
Several studies on substance abuse by medical students were published in the first half of this century [10][11][12][13][14][15][16][17][18][19][20] .When that number is compared to the number of studies from the last century 8,9 , it can be noted that the academic community has been giving greater emphasis to this matter over the years.This information indicates the social importance of the subject.The study of drug consumption by medical students, and well as of the reasons that lead to that consumption, allow us to infer relevant information around the psychological stress of the academic environment and the interpersonal relationships that arise from it.This information can be used to improve the curricular approach of medical programs, reducing the number of students who turn to drugs.
Despite the importance of the subject, a shortage of studies was found in some regions of Brazil.While almost all of the articles found were produced in medical schools from the Southeast region 8-10,12,14-16,18-21 , few data were located from the South and Northeast.Worst still, no data for the Central-West and North regions was observed.That is a worrying scenario, since the small number of studies from these regions makes it impossible for the differences between Brazilian regions to adequately assessed, thus limiting the comparisons between the results found.In regard to the methodology employed, the fact that all papers 10-23 found were cross-sectional also prevents the actual consequences of substance abuse by medical students to be known, since this model does not allow us to assess the long-term situations of the scenario.In addition, almost all authors, to this moment, investigated mostly the prevalence of drug use in this population 8,10,12-14,16-18,20-23 .In this context, it is vital that longitudinal studies are carried out to thoroughly investigate the relationship between the students and these substances, seeking to identify what are the actual situations that lead to the use of drugs, the adequate way of handling the problem, and which measures can be adopted to mitigate the use of these substances.

Main achievements
All studies reported that alcohol was the substance most widely consumed by medical students.The prevalence of alcohol consumption in this population ranged from 66.34% to 97.3%.These differences can be explained by the variation in the sample size of each study, as well by the particular differences between the populations assessed -such as in which year of medical school the students were and their social class.Despite that, it is important to report that, even though there is a high prevalence of alcohol consumption, it remained stable between 1996 and 2001 19 .
In 1999, Kerr-Corrêa et al. 9 assessed, in retrospect, the use of drugs in 3,725 medical students and showed that, even though 90% of them understood that alcoholism was a public health issue, 80% of the students in the sixth year classified their link to alcoholism patients as week or bad.That data shows that medical programs are effective in teaching the deleterious consequences caused by alcohol abuse.However, they fail to supply practical and theoretical foundations so that the students can handle these situations appropriately.
Considering that most medical undergraduate students seem to understand the harmful effects of alcohol consumption, the high prevalence of the habit is contradictory.The situation seems to stem from the fact that alcohol is the most socially accepted drug 9 and, therefore, its consumption is not seen as something that should be discouraged nor assessed by expert health professionals.
For example, even though some students declared that when faced with friends abusing alcohol they felt compelled to personally intervene in the situation, when there was an abuse of any other type of drug these same students judged it was necessary the intervention of an expert health professional 14.Ergo, the assessed students do not see alcoholism as a problem as dangerous as the consumption of other types of drugs.Thus, they tend to be more permissive with alcohol ingestion.
Despite all that, it is important to note that even though the studies identified a high prevalence of alcohol consumption, the frequency of ingestion was not equally high.Petroianu et al. 20 , for example, reported that 46.9% of students assessed by him consumed alcohol in rare occasions over the previous year and only 0.6% of them declared to intake it on a daily basis.This data is corroborated by a study by Paduani et al. 16 , that affirms that 27.86% of students consumed alcohol once or twice a week, whereas only 1% did so daily.
Even though alcohol intake is not frequent, it is noteworthy that the habit is often associated with the concomitant use of other psychoactive substances, leading to risk behaviors 20 .The association of alcohol and tobacco, another licit drug, was the most often reported in the literature 22 .
In fact, tobacco was the second most used drug by Brazilian medical students, but its prevalence also varied considerably among the studies.Passos et al. 10 and Boniatti et al. 11 , for example, observed that around 54% of the students had used tobacco at some point of their lives, while other authors 12,17,23 reported lower prevalence of about 20%.Like with alcohol consumption, the difference between the results may be explained by the different number used as a sample in the studies, as well as the socioeconomic level of each participant student.Among the students who smoked, only 3.3% reported to do it daily; the rest claimed to smoke on rare casual occasions over the year 20 .
It is possible that this low rate of student smokers, when compared to the vast number of drinkers, is due to the several anti-smoking measures employed by the Ministry of Health in recent years.Among them is the creation of laws that forbid smoking in enclosed spaces, that vetoed commercial advertisement of cigarettes and that disclose, as a warning, the harmful effects of smoking.
With respect to illicit drugs, 48.6% of students reported to have used some illicit drug at least once in their life 11 .In most studies, marijuana was the most commonly used, with a consumption prevalence estimated in 10% to 31% 11,14,17,20 .This is particularly worrying, since the prior use of marijuana was asso-ciated with a higher probability of using other illicit drugs.For example, students who made use of marijuana are seven times more likely to become etherspray users than the general population 8 .
Despite this, the consumption of other substances also showed a significant prevalence.In 2006, Passos et al. 10 assessed 1,054 students and reported that 24.2% had already made use of tranquilizers, 18.4% of inhalants, and 3.4% of cocaine.These results were similar to those found in several other studies 11,12,23 .Even though the consumption of illicit drugs is lower than that of socially acceptable substances, 45% of the students reported knowing where to buy it and 62% believe it would be easy to buy it, if they so desired 10 .Some studies 9,11,13-15 sought to understand the reasons that led the students to the consumption of drugs.In the study by Kerr-Correa et al. 9 , out of a total of 3,725 students, 60% were not able to explain the reason for using drugs, whereas 17% did so out of curiosity, and 9.0% for fun.These data differ in the literature.Boniatti et al. 11 , for example, observed that 39.1% of the 183 students in the study made use of these substances out of curiosity and 31.5% for fun.It is possible that this divergence is due to the different number of participants in each study, since the first one assessed a larger sample than the second.Finally, some studies 13-15 mentioned the stressful nature of the medical program as an initial cause and motivator for drug consumption.Regardless of the initial reason, friends were most often named as the person who first introduced students to the experimental use of these substances 9 .
Regarding gender, most studies observed that men had a higher tendency to consume all types of drugs, with the exception of anxiolytics and antidepressants, which were most often consumed by females 9,12-14, 21 .Moreover, the use of psychoactive substances tends to begin at an early age, alcohol being the most prematurely used with an average starting age of 14.4 (SD=2.5) 10 .According to Passos et al. 10 , the average starting age for other drugs are: tobacco (15.6), marijuana (17.4), inhalants (17.7), tranquilizers (18.1) and cocaine (18.5).
Several studies demonstrated that the use of licit drugs, tranquilizers and ether sprays increases over the course of the medical program 9,13,14, 16 .Based on that, it can be deduced that students make use of these drugs as an escape mechanism, suggesting there are stressful factors or triggers within the program.Among these factors are: the pressure to which the student is subjected, the huge workload, significant amount of work and responsibility, social and family deprivation, the need to handle situations of human suffering and death, tiredness and the search for good academic results 24 .Nevertheless, it is worth pointing out that all studies analyzed were cross-sectional and, therefore, are not capable of establishing cause and effect relationships between these variables.
Regarding the use of prescription drugs, the prevalence of antidepressant use was of 11.4% 22 , whereas 23% of students reported having taken methylphenidate without a prescription 23 .It is possible that these drugs are used as a way to relieve the stress of upcoming residency tests at the end of the program, as well as a way of handling the extreme work shifts and changes in the sleep/wake cycle.
Finally, the factors related to an increase in the consumption of alcohol and other drugs included: being a male, having a favorable attitude towards the use of alcohol and other substances, and missing classes for no good reason 9 .The factors related to the protection against this type of attitude were: living with parents, not having close links with drug users, disapproving of drug consumption, religious practices and being employed.

CONCLUSION
After analyzing the selected papers, we observed a high consumption of psychoactive substances, despite the medical students' understanding of its harmful effects.Several reasons may contribute to this type of attitude, especially the stress to which they are subjected to during the medical program.However, the absence of longitudinal studies in the literature makes it difficult to comprehend the actual causes of this reality.
Considering the vast number of medical schools in Brazil, it is evident the need to conduct more studies in different regions of the country, especially in the North and Central-West.In addition, we recommend that comparative studies are carried out to follow the students over time so that specific preventive measures and treatments can be made available to them.

STATEMENT OF CONFLICT OF INTERESTS
The authors declare there are no conflicts of interest.

were excluded because they did not evaluate the use of drugs, or Brazilian medical students, or they were review articles.
*Articles