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We need to talk about the use of methylphenidate by medical students - review of the literature

Abstract:

Introduction:

Studies methylphenidate (MPH) has been used by medical students to increase their mental activity and improve the performance required during undergraduate school, generating concern regarding the risks to their physical and mental health. This scenario indicates the need for specifically aimed measures in medical schools.

Objective:

To review the literature about the use of MPH without medical indication amongst medical students.

Method:

A thorough review of the literature published in English, Spanish, and Portuguese, between 2013 and 2019, based on data made available by Pubmed and Scielo, utilizing keywords in the three above languages, along the four stages of the selection process.

Results and Discussion:

Altogether, 224 articles were found, of which 25 were selected after reading, dealing with the use of MPH or ‘cognition enhancer’ by undergraduate medical students without a doctor’s prescription. The research indicated significant variability in the frequency of consumption, related to the investigated pattern of use, use with or without indication, before or after entering University and country where the study was carried out. The most frequent justification for the use without medical indication was to attain improvement in academic performance. A lack of research with a fair appraisal of the cognition, behavioral and psychic risks involved, among them addiction and the approach of the topic in medical schools, was noted.

Conclusion:

The high rates of usage of MPH by medical students aiming at cognitive enhancement strengthens the importance of preventative actions in medical schools. The strategies must consider information concerning the risks of use (of MPH) without medical indication; non-pharmacological interventions for performance improvement; sleep hygiene measures organization for adequate study activities; broad discussions about ethical aspects and curricular structure.

Keywords:
Medical Students; Methylphenidate; Stimulants; Cognitive Enhancement

Resumo:

Introdução:

Estudos mostram que o metilfenidato (MPH) tem sido utilizado por estudantes de medicina para aumentar sua atividade mental e melhorar o desempenho exigido durante a graduação, gerando preocupações quanto aos riscos à sua saúde física e mental. Esse cenário indica a necessidade de medidas especificamente direcionadas nas escolas médicas.

Objetivo:

Revisar a literatura sobre o uso de MPH sem indicação médica entre estudantes de medicina.

Método:

Revisão minuciosa da literatura publicada em inglês, espanhol e português, entre 2013 e 2019, com base em dados disponibilizados pelo PUBMED e SCIELO, utilizando palavras-chave nos três idiomas acima, ao longo das quatro etapas do processo de seleção.

Resultados e Discussão:

Ao todo, foram encontrados 224 artigos, dos quais 25 foram selecionados após leitura, tratando do uso de MPH ou ‘potencializador da cognição’ por graduandos de medicina sem prescrição médica. A pesquisa indicou variabilidade significativa na frequência de consumo, relacionada ao padrão de uso investigado, uso com ou sem indicação, antes ou após a entrada na Universidade e país onde o estudo foi realizado. A justificativa mais frequente para o uso sem indicação médica foi a de obter melhora no desempenho acadêmico. Notou-se a carência de pesquisas com uma avaliação adequada dos riscos cognitivos, comportamentais e psíquicos envolvidos, entre eles o risco de adição e a abordagem do tópico nas escolas médicas.

Conclusão:

As altas taxas de uso do MPH por estudantes de medicina visando o aprimoramento cognitivo reforça a importância de ações preventivas nas escolas médicas. As estratégias devem considerar informações sobre os riscos do uso (do MPH) sem indicação médica; intervenções não farmacológicas para melhoria do desempenho cognitivo; medidas de higiene do sono; organização para atividades de estudo adequadas; amplas discussões sobre aspectos éticos e estrutura curricular.

Palavras-chave:
Estudantes de Medicina; Metilfenidato; Estimulantes; Aprimoramento cognitivo

INTRODUCTION

In the last decade, there has been a growing concern in the academic world regarding the continuous use of psychostimulants to improve school performance amongst undergraduate students11. Weyandt LL, White TL, Gudmundsdottir BG, Nitenson AZ, Rathkey EM, De Leon KA, et al. Neurocognitive, Autonomic, and Mood Effects of Adderall: A Pilot Study of Healthy College Students. Pharmacy 2018; 6: 58. doi: 10.3390/pharmacy6030058.
https://doi.org/10.3390/pharmacy6030058...
. These substances are characterized by their capacity to stimulate the Central Nervous System (CNS)22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109., enhancing attention and concentration. Among these substances, ‘energy beverages’ (drinks based on caffeine, guaranine, cola, and taurine), medications used for weight loss, and the drugs indicated for the treatment of attention deficit and hyperactivity disorder (ADHD) and narcolepsy stand out 22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(33. Fond G, Gavaret M, Vidal C, Brunel L, Riveline JP, Franchi JAM, et al. (Mis) of prescribed Stimulants in the medical student community: Motives and behaviors. A population-based cross-sectional study. Medicine (Baltimore) 2016; 95(16): e3366..

The medications more frequently utilized to improve cognitive performance are those indicated for the treatment of ADHD, which is characterized by loss of attention, mental organization, and hyperactivity/impulsivity, starting at childhood and being able to persist up to adult life, which can harm an individual’s social, academic, and professional life44. Manual diagnóstico e estatístico de transtornos mentais recurso eletrônico]: DSM-5 / [American Psychiatric Association; tradução: Maria Inês Corrêa Nascimento ... et al.]; revisão técnica: Aristides Volpato Cordioli [et al.]. 5ª ed. Porto Alegre: Artmed, 2014.. The ADHD pharmacological treatment includes using Methylphenidate (MPH)55. Dafny N. Does Methylphenidate (MPD) Have the Potential to Become Drug of Abuse? Biochem Pharmacol (Los Angel) 2014; 4:1. http://dx.doi.org/10.4172/2167-0501.1000156.
http://dx.doi.org/10.4172/2167-0501.1000...
, a stimulant drug sold in Brazil under the commercial names Concerta®, Ritalina®, and Ritalina LA®(66. Agência Nacional de Vigilância Sanitária. ANVISA (2012). Prescrição e consumo de metilfenidato no Brasil: identificando riscos para o monitoramento e controle sanitário. Boletim de Farmacoepidemiologia do SNGPC, 2(2). 1-14. Acesso em 29 de julho, 2018. Disponível em: Disponível em: http://www.anvisa.gov.br/sngpc/boletins/2012/boletim_sngpc_2_2012_corrigido_2.pdf
http://www.anvisa.gov.br/sngpc/boletins/...
, as first-class medications for therapeutic intervention22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(55. Dafny N. Does Methylphenidate (MPD) Have the Potential to Become Drug of Abuse? Biochem Pharmacol (Los Angel) 2014; 4:1. http://dx.doi.org/10.4172/2167-0501.1000156.
http://dx.doi.org/10.4172/2167-0501.1000...
),(77. Carneiro SG, Prado AST, Moura HC, Strapasson JF, Rabelo NF, Ribeiro TT, et al. O uso não prescrito de metilfenidato entre acadêmicos de medicina. Cad.Uno. FOA Health and Biological Sciences 2013; 01:53-59.),(88. Cohen YG, Segev RW, Shlafman N, Novack V, Ifergane G. Methylphenidate use among medical students at Ben-Gurion University of the Negev. J Neurosci Rural Pract 2015; 6(3): 320-5.),(99. Eslami AA, Jalilian F, Ataee M, Mirzaei-Alavijeh M, Mahboubi M, Afsar A, et al. Intention and willingness in understanding Ritalin misuse among Iranian medical college students: a cross-sectional study. Global journal of health science 2014; 6(6): 43-53.. This drug promotes an increase in attention and the control of behavioral impulses; however, it has the potential for the development of drug dependence when inadequately used66. Agência Nacional de Vigilância Sanitária. ANVISA (2012). Prescrição e consumo de metilfenidato no Brasil: identificando riscos para o monitoramento e controle sanitário. Boletim de Farmacoepidemiologia do SNGPC, 2(2). 1-14. Acesso em 29 de julho, 2018. Disponível em: Disponível em: http://www.anvisa.gov.br/sngpc/boletins/2012/boletim_sngpc_2_2012_corrigido_2.pdf
http://www.anvisa.gov.br/sngpc/boletins/...
. Therefore, the recommendation for its use should follow strict criteria, after a medical and psychological evaluation taking into account family history, development during childhood, school performance, an analysis of the use of other psychoactive substances, as well as the level of intelligence of the personality1010. Luizão AM, Scicchitanor MJ. Transtorno de déficit de atenção e hiperatividade: um recorte da produção científica recente. Rev psicopedag [online] 2014; 31 (96): 289-297. ISSN 0103-8486..

The use of stimulants to enhance mental activity has been described as an option to deal with the demands that undergraduate school requires and to improve academic performance22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109., generating concerns about the risks to the individuals’ health and quality of life. Recent investigations carried out at the University of Rhode Island, Brown University, and at the Rhode Island Memorial Hospital studied the consequences of the unprescribed use, of Adderall® (a mixture of amphetamine salts, also used to treat ADHD) by undergraduate students. The authors verified that the attention capacity improves, albeit to the detriment of the working memory functions, which, in turn, could compromise the performance of daily tasks, solving problems, and social relations as well11. Weyandt LL, White TL, Gudmundsdottir BG, Nitenson AZ, Rathkey EM, De Leon KA, et al. Neurocognitive, Autonomic, and Mood Effects of Adderall: A Pilot Study of Healthy College Students. Pharmacy 2018; 6: 58. doi: 10.3390/pharmacy6030058.
https://doi.org/10.3390/pharmacy6030058...
.

Amongst the university courses, a degree in Medical Science is considered one of the most demanding in respect to the performance of its students22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(1111. Andrade JBC, Sampaio JJC, Farias LM, Melo LP, Sousa DP, Mendonça ALB, et al. Contexto de Formação e Sofrimento Psíquico de Estudantes de Medicina. Rev Bras Edu Med 2014; 38 (2): 231-242.. Their journeys begin the moment they choose the profession, going through pre-college preparatory courses, competing with others to get into a university, and after that having to keep up the high performance during the entire graduation1111. Andrade JBC, Sampaio JJC, Farias LM, Melo LP, Sousa DP, Mendonça ALB, et al. Contexto de Formação e Sofrimento Psíquico de Estudantes de Medicina. Rev Bras Edu Med 2014; 38 (2): 231-242.. Most of the students arrive at the University hoping that the level of continued dedication demand will slack down and gets frustrated when they realize that, quite to the contrary, the rhythm of studies will continue at a very high rate of demand1111. Andrade JBC, Sampaio JJC, Farias LM, Melo LP, Sousa DP, Mendonça ALB, et al. Contexto de Formação e Sofrimento Psíquico de Estudantes de Medicina. Rev Bras Edu Med 2014; 38 (2): 231-242.. Besides this, other factors such as sleep and leisure deprivation contribute to stress and low academic performance22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.. Committed to a strenuous routine, the students may resort to means to attain efficiency in the course activities, amongst them the use of brain stimulants such as the MPH22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109..

This subject is essential to all Higher Medical Education institutions and those that render student support. This essay aims to make a literature revision concerning the usage of MPH among medical students without a doctor’s prescription, seeking a better understanding of the aspects of using psychostimulants and promoting preventive actions to offer medical students better learning conditions and quality of life.

METHOD

A comprehensive revision was carried out in international and Brazilian national literature, focusing on articles published in the last seven years (January 2013 through December 2019). In addition, the authors included articles written in English, Spanish and Portuguese, about the usage of MPH without medical indication by medicine students based on data made available by Pubmed/Medline and Scielo, using the following as keywords or key expressions in these three languages, respectively:

Medical Students; Methylphenidate; Stimulants and Cognitive Enhancement.

Estudiantes de Medicina; Metilfenidato; Estimulantes; Mejora Cognitiva.

Estudantes de Medicina; Metilfenidato; Estimulantes; Aprimoramento Cognitivo.

To this effect, a selective structure was established, comprising four stages, which included articles focusing on the scope of the research, follows: title of the article, analysis of the abstracts, dynamic reading of the articles, and complementary search in the bibliographic references of the selected ones, which met the same appropriate criteria concerning the topic, abstracts, and dynamic reading.

RESULTS

In total, 224 articles were found, of which 09 were from the Scielo database, and 215 from Pubmed. The repeated articles or the ones that did not address MPH use by medical students without clinical orientation were excluded, as shown in Figure 1.

Figure 1
Flowchart of the stages, exclusions and partial result.

The publications concerning cognitive intensifiers that included the use of MPH were maintained, resulting in 20 articles that were revised and had their bibliographical references assessed. In this process, 69 articles were submitted to the forementioned screening method, plus another five articles to be analyzed. Thus, in total, 25 articles were selected for this review (Table 1) and the highlights of the review are presented in Chart 1.

Table 1
Description of the selected articles.
Chart 1
Highlights of the review on the use of psychostimulants by medical students.

DISCUSSION

The study indicated significant variability in the frequency of consumption, related to the pattern of use investigated, use with or without indication, before or after entering University and country where the study was performed. Among the assessed articles, the students from Latin American countries were the ones who showed a higher prevalence of MPH use. A Puerto Rican survey showed the highest prevalence (47.4 %)1212. Acosta DL, Fair CN, Gonzalez CM, Iglesias M, Maldonado N, Schenkman N, et al. Nonmedical use of d-Amphetamines and Methylphenidate in Medical Students. PRHSJ 2019; 38(3): 185-188., followed by 45% of the students interviewed in a Paraguayan school, of which 33% used the drug without adequate clinical indication1313. Franco Netto ROR, Franco Netto JAR, Silva Junior NZ, Silva SM, Vaz LHS, Aguero MAF, et al. Incidencia del uso no prescrito del Metilfenidato entre Estudiantes de Medicina. Rev Inst. Med. Trop 2018;13(1): 16-22. doi:10.18004/imt/20181316-22.
https://doi.org/10.18004/imt/20181316-22...
. Then comes a total of 34.2% of the students from a medical school in the Rio Grande do Sul, Brazil, of which 23% used it without adequate indication1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.. The other two studies carried out in Brazil22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(77. Carneiro SG, Prado AST, Moura HC, Strapasson JF, Rabelo NF, Ribeiro TT, et al. O uso não prescrito de metilfenidato entre acadêmicos de medicina. Cad.Uno. FOA Health and Biological Sciences 2013; 01:53-59.) indicated higher rates of use when compared to other countries such as the USA, with 18%1515. Emanuel RM, Frellsen SL, Kashima KJ, Sanguino SM, Sierles FS, Lazarus CJ. Cognitive enhancement drug use among future physicians: findings from a multi-institutional census of medical students. J Gen Intern Med 2013; 28(8):1028-1034., Israel88. Cohen YG, Segev RW, Shlafman N, Novack V, Ifergane G. Methylphenidate use among medical students at Ben-Gurion University of the Negev. J Neurosci Rural Pract 2015; 6(3): 320-5. and Africa with 17%1616. Retief M, Verster C. Prevalence and correlated nonmedical stimulants and related drug use in a sample of South African undergraduate medical students. S Afr J Psychiatr 2016; 22(1):a795. http://dx.doi.org/10.4102/sajpsychiatry.v22i1.795.
http://dx.doi.org/10.4102/sajpsychiatry....
, North of Iran with 11%1717. Fallah G, Moudi S, Hamidia A, Bijani A. Stimulant use in medical students and residents requires more careful attention. Caspian Journal of Internal Medicine 2018; 9(1):87. PMid:29387325 PMCid:PMC5771366. and a study in Pakistan with 9%1818. Javed N, Ahmed F, Saeed S, Amir R, Khan H, Iqbal SP. Prevalence of Methylphenidate Misuse in Medical Colleges in Pakistan: A Cross-sectional Study. Cureus 2019; 11(10): e5879. doi: 10.7759/cureus.5879.
https://doi.org/10.7759/cureus.5879...
.

The most recent study in Brazil, published in 2016, showed consumption (at least once in the lifetime) of 20%22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109. of the students, and another study carried out in Rio de Janeiro77. Carneiro SG, Prado AST, Moura HC, Strapasson JF, Rabelo NF, Ribeiro TT, et al. O uso não prescrito de metilfenidato entre acadêmicos de medicina. Cad.Uno. FOA Health and Biological Sciences 2013; 01:53-59. in 2013 indicated a rate of 23.7% of use during the lifetime of those students that participated in the study. At a literature review carried out in 2013, it was described, this same group of students, a percentage of use of 3 to 16%1919. Finger G, da Silva ER, Falavigna A. Use of Methylphenidate among medical students: a systematic review. Rev Assoc Med Bras 2013; 59: 285-289., while 14.5%1919. Finger G, da Silva ER, Falavigna A. Use of Methylphenidate among medical students: a systematic review. Rev Assoc Med Bras 2013; 59: 285-289. admitted they had already used MPH to improve academic performance.

Seven studies were carried out on the difference in use between the genders, without significant differences. Five, however, indicated a higher rate of consumption of psychostimulants (including MPH) by the male gender 33. Fond G, Gavaret M, Vidal C, Brunel L, Riveline JP, Franchi JAM, et al. (Mis) of prescribed Stimulants in the medical student community: Motives and behaviors. A population-based cross-sectional study. Medicine (Baltimore) 2016; 95(16): e3366.),(99. Eslami AA, Jalilian F, Ataee M, Mirzaei-Alavijeh M, Mahboubi M, Afsar A, et al. Intention and willingness in understanding Ritalin misuse among Iranian medical college students: a cross-sectional study. Global journal of health science 2014; 6(6): 43-53.),(1515. Emanuel RM, Frellsen SL, Kashima KJ, Sanguino SM, Sierles FS, Lazarus CJ. Cognitive enhancement drug use among future physicians: findings from a multi-institutional census of medical students. J Gen Intern Med 2013; 28(8):1028-1034.),(1717. Fallah G, Moudi S, Hamidia A, Bijani A. Stimulant use in medical students and residents requires more careful attention. Caspian Journal of Internal Medicine 2018; 9(1):87. PMid:29387325 PMCid:PMC5771366.),(2020. Abbasi-Ghahramanloo A, Fotouhi A, Zeraati H, Rahimi-Movaghar A. Prescription drugs, alcohol, and illicit substance use and their correlations among medical sciences students in Iran. Int J High Risk Behav Addict 2015; 4: e 21945., while one of these specified the use of MPH99. Eslami AA, Jalilian F, Ataee M, Mirzaei-Alavijeh M, Mahboubi M, Afsar A, et al. Intention and willingness in understanding Ritalin misuse among Iranian medical college students: a cross-sectional study. Global journal of health science 2014; 6(6): 43-53.. Only one article described a higher prevalence of use by the female gender2121. Silveira VI, Oliveira RJF, Caixeta MR, Andrade BBP, Siqueira RGL, Santos GB. Uso de psicoestimulantes por acadêmicos de medicina de uma Universidade do Sul de Minas Gerais. Rev Univ Vale Rio Verde 2015; 13(2):186-192..

Some studies suggest that the majority of the medical students that use MPH started using it after entering the University. A study carried out in the USA says that 57% of the interviewed students who had already used MPH declared having started using it during college1515. Emanuel RM, Frellsen SL, Kashima KJ, Sanguino SM, Sierles FS, Lazarus CJ. Cognitive enhancement drug use among future physicians: findings from a multi-institutional census of medical students. J Gen Intern Med 2013; 28(8):1028-1034. and a study carried out in Brazil pointed to the fact that 64% of the students with a background of use claimed they started using this substance during the medical course22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.. In a North American study performed with students of Osteopathic Medicine, the authors found that the frequency of students that admitted the use of psychostimulants without medical indication was higher than the diagnosis rate in the population2222. Wasserman JA, Fitzgerald JE, Sunny MA, Cole M, Suminski RR, Dougherty JJ. Nonmedical use of stimulants among medical students. J Am Osteopathic Assoc 2014; 114: 643-53..

In a study carried in a University in the Brazilian state of Minas Gerais, half of the students who used psychostimulants did it before the exams2121. Silveira VI, Oliveira RJF, Caixeta MR, Andrade BBP, Siqueira RGL, Santos GB. Uso de psicoestimulantes por acadêmicos de medicina de uma Universidade do Sul de Minas Gerais. Rev Univ Vale Rio Verde 2015; 13(2):186-192.. Another study in Puerto Rico found a rate of 60.3%1212. Acosta DL, Fair CN, Gonzalez CM, Iglesias M, Maldonado N, Schenkman N, et al. Nonmedical use of d-Amphetamines and Methylphenidate in Medical Students. PRHSJ 2019; 38(3): 185-188.. These findings emphasize that the stimulants seem to be considered a facilitator for “good” results in the exams2121. Silveira VI, Oliveira RJF, Caixeta MR, Andrade BBP, Siqueira RGL, Santos GB. Uso de psicoestimulantes por acadêmicos de medicina de uma Universidade do Sul de Minas Gerais. Rev Univ Vale Rio Verde 2015; 13(2):186-192.. Other studies also pointed out that the motivation leading to the use of MPH without a medical indication aimed at better academic performance2323. Roncero C, Egido A, Rodriguez-Cintas L, Perez-Pazos J, Collazos F, Casas M. Substance use among medical students: a literature review 1988- 2013. Actas Esp Psiquiatr 2015; 43(3): 10921., increasing waking hours, improving concentration, attention capacities, and extended memory22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(33. Fond G, Gavaret M, Vidal C, Brunel L, Riveline JP, Franchi JAM, et al. (Mis) of prescribed Stimulants in the medical student community: Motives and behaviors. A population-based cross-sectional study. Medicine (Baltimore) 2016; 95(16): e3366.),(77. Carneiro SG, Prado AST, Moura HC, Strapasson JF, Rabelo NF, Ribeiro TT, et al. O uso não prescrito de metilfenidato entre acadêmicos de medicina. Cad.Uno. FOA Health and Biological Sciences 2013; 01:53-59.),(88. Cohen YG, Segev RW, Shlafman N, Novack V, Ifergane G. Methylphenidate use among medical students at Ben-Gurion University of the Negev. J Neurosci Rural Pract 2015; 6(3): 320-5.),(99. Eslami AA, Jalilian F, Ataee M, Mirzaei-Alavijeh M, Mahboubi M, Afsar A, et al. Intention and willingness in understanding Ritalin misuse among Iranian medical college students: a cross-sectional study. Global journal of health science 2014; 6(6): 43-53.),(1212. Acosta DL, Fair CN, Gonzalez CM, Iglesias M, Maldonado N, Schenkman N, et al. Nonmedical use of d-Amphetamines and Methylphenidate in Medical Students. PRHSJ 2019; 38(3): 185-188.),(1313. Franco Netto ROR, Franco Netto JAR, Silva Junior NZ, Silva SM, Vaz LHS, Aguero MAF, et al. Incidencia del uso no prescrito del Metilfenidato entre Estudiantes de Medicina. Rev Inst. Med. Trop 2018;13(1): 16-22. doi:10.18004/imt/20181316-22.
https://doi.org/10.18004/imt/20181316-22...
),(1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.),(1515. Emanuel RM, Frellsen SL, Kashima KJ, Sanguino SM, Sierles FS, Lazarus CJ. Cognitive enhancement drug use among future physicians: findings from a multi-institutional census of medical students. J Gen Intern Med 2013; 28(8):1028-1034.),(1717. Fallah G, Moudi S, Hamidia A, Bijani A. Stimulant use in medical students and residents requires more careful attention. Caspian Journal of Internal Medicine 2018; 9(1):87. PMid:29387325 PMCid:PMC5771366.),(1818. Javed N, Ahmed F, Saeed S, Amir R, Khan H, Iqbal SP. Prevalence of Methylphenidate Misuse in Medical Colleges in Pakistan: A Cross-sectional Study. Cureus 2019; 11(10): e5879. doi: 10.7759/cureus.5879.
https://doi.org/10.7759/cureus.5879...
),(2121. Silveira VI, Oliveira RJF, Caixeta MR, Andrade BBP, Siqueira RGL, Santos GB. Uso de psicoestimulantes por acadêmicos de medicina de uma Universidade do Sul de Minas Gerais. Rev Univ Vale Rio Verde 2015; 13(2):186-192.),(2424. Kudlow PA, Naylor KT, Xie B, McIntyre RS. Cognitive enhancement in Canadian medical students. J Psychoact Drugs 2013; 45: 360-365.),(2525. Micoulaud-Franchi J-A, MacGregor A, Fond G. A preliminary study on cognitive enhancer consumption behaviors and motives of French Medicine and Pharmacology students. Eur Rev Med Pharmacol Sci 2014; 18:1875-1878.. In addition, research in Iran revealed the role of social groups in the indication of brain stimulants1717. Fallah G, Moudi S, Hamidia A, Bijani A. Stimulant use in medical students and residents requires more careful attention. Caspian Journal of Internal Medicine 2018; 9(1):87. PMid:29387325 PMCid:PMC5771366., also considered a motivator for consumption without medical indication.

A Belgium study of 2019, set to investigate what would be “behind” the need of the students seeking cognitive enhancement, questioned 3,159 students that used non-therapeutic stimulant medications2626. De Bruyn S, Wouters E, Ponnet K, Van Hal G. Popping smart pills in medical school: Are competition and stress associated with the misuse of prescription stimulants among students? Subst Use Misuse 2019; 54(7): 1191-1202. doi: 10.1080/10826084.2019.1572190.
https://doi.org/10.1080/10826084.2019.15...
. The authors pointed out that the clearer the perception that the medical school is a competitive environment, the more significant the levels of stress and the higher the probability for inadequate stimulant use. The research reveals that, contrary to expectations, the association of competition with stress was significantly stronger in those students who wanted to become general practitioners, with the consequent use of stimulants, compared to those aiming to have a medical specialization2424. Kudlow PA, Naylor KT, Xie B, McIntyre RS. Cognitive enhancement in Canadian medical students. J Psychoact Drugs 2013; 45: 360-365.. In another study, medical supervisors and medical students reported greater use of psychostimulants, without medical indication, than the Pharmacy course students. These three groups showed stress rates roughly two times higher than the adult population in general2727. Bidwal MK, Ip EJ, Shah BM, Serino MJ. Stress, drugs, and alcohol use among health care professional students: a focus on prescription stimulants. J Pharm Pract. 2014;28(6):535-542..

A study carried out in the state of Rio Grande do Sul, Brazil, determined that 14.3%1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106. of the users of stimulants were associated with alcohol consumption, and 5.7% admitted using MPH in parties as well1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.. These findings suggest that the most frequent use was not related to social activities or parties, such as the other psychoactive substances, but was probably associated with academic performance improvement. This research also realized that MPH users who used it together with alcohol, with or without a medical prescription, showed alcohol consumption patterns that were considered a health risk1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.. The MPH, when associated with alcohol, produces a euphoric effect decreases the sensation of inebriation or drunkenness1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.. However, this combination produces a toxic metabolite, and its effect on the organism remain little known1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106..

The medical schools in South Africa adopted the posture of not providing information about the indications and effects of MPH in the first five semesters of the course2828. Jain R, Chang C, Koto M, Geldenhuys A, Nichol R, Joubert G. Non-medical use of methylphenidate among medical students of the University of the Free State. S Afr J Psychiat 2017; 23: a1006. doi: 10.4102/sajpsychiatry.23.1006
https://doi.org/10.4102/sajpsychiatry.23...
. They based this decision on research carried out in 2017, in which the higher percentage of consumption was reported by students attending the third year of medical school (18.5%), raising the hypothesis that the knowledge about the pharmacological effects of the substance can contribute to its demand and misuse2828. Jain R, Chang C, Koto M, Geldenhuys A, Nichol R, Joubert G. Non-medical use of methylphenidate among medical students of the University of the Free State. S Afr J Psychiat 2017; 23: a1006. doi: 10.4102/sajpsychiatry.23.1006
https://doi.org/10.4102/sajpsychiatry.23...
.

Brazilian and Paraguayan studies found a higher rate of psychostimulant consumption (including caffeine, methylphenidate, modafinil, piracetam, energy drinks, and amphetamines) by the students attending the first years of medical school. In the state of Rio Grande do Sul, the rates were decreasing according to the year of the course: from 69.2% in the 1st year, to 61.5% in the 2nd, 40.8% in the 3rd year, and 34.8% in the 4th year22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109. moreover, in the state of Minas Gerais the rates went from 65.78% in the 1st year, to 64.10% in the 2nd and 41.02% in the 3rd year2121. Silveira VI, Oliveira RJF, Caixeta MR, Andrade BBP, Siqueira RGL, Santos GB. Uso de psicoestimulantes por acadêmicos de medicina de uma Universidade do Sul de Minas Gerais. Rev Univ Vale Rio Verde 2015; 13(2):186-192.; furthermore, in Universidad Internacional Tres Fronteras, in Paraguay, the rates were 22% in the first year, 32% in the second, 18% in the third and 14% in the fourth and fifth years1313. Franco Netto ROR, Franco Netto JAR, Silva Junior NZ, Silva SM, Vaz LHS, Aguero MAF, et al. Incidencia del uso no prescrito del Metilfenidato entre Estudiantes de Medicina. Rev Inst. Med. Trop 2018;13(1): 16-22. doi:10.18004/imt/20181316-22.
https://doi.org/10.18004/imt/20181316-22...
, differently from those observed in the American2828. Jain R, Chang C, Koto M, Geldenhuys A, Nichol R, Joubert G. Non-medical use of methylphenidate among medical students of the University of the Free State. S Afr J Psychiat 2017; 23: a1006. doi: 10.4102/sajpsychiatry.23.1006
https://doi.org/10.4102/sajpsychiatry.23...
and Puerto Rican1212. Acosta DL, Fair CN, Gonzalez CM, Iglesias M, Maldonado N, Schenkman N, et al. Nonmedical use of d-Amphetamines and Methylphenidate in Medical Students. PRHSJ 2019; 38(3): 185-188. studies, which showed similar ratesamong all years.

One aspect that deserves special attention is the obtaining of a controlled medication without an appropriate prescription. MPH is sold only under medical prescription in Brazil and other countries. In Brazil, the prescription necessarily requires the yellow prescription pad for controlled drugs (A3). In addition, the packaging has a black strip across the box, which indicates that it can only be sold with a medical prescription, and it carries information concerning the risk of chemical and psychological dependence according to specifications 344 of SVS/MS Ordinance of May, 19982929. Brasil. Poder Executivo. Portaria Ministerial nº 6 de 29 de janeiro de 1999. Aprova a Instrução Normativa da Portaria SVS/MS nº 344 de 12 de maio de 1998 que institui o Regulamento Técnico das substâncias e medicamentos sujeitos a controle especial. Diário Oficial da União, Brasília, DF, 01 fev. 1999.. Despite these measures, a recent study showed that 24.3% of the MPH user students obtained it through a ‘self-written prescription,’ and 15% obtained it from a friend1212. Acosta DL, Fair CN, Gonzalez CM, Iglesias M, Maldonado N, Schenkman N, et al. Nonmedical use of d-Amphetamines and Methylphenidate in Medical Students. PRHSJ 2019; 38(3): 185-188..

This fact flashes a red alert on the risks of self-medication and the importance of medical assessment for the consumption of prescribed medications by undergraduate medical students. An Iranian study pointed to a rate of 4.9% related to the misuse of medicaments requiring a medical prescription (in this study, opioids, tranquilizers, and MPH were taken into consideration)2020. Abbasi-Ghahramanloo A, Fotouhi A, Zeraati H, Rahimi-Movaghar A. Prescription drugs, alcohol, and illicit substance use and their correlations among medical sciences students in Iran. Int J High Risk Behav Addict 2015; 4: e 21945.. Considering that all of them are medications that offer risks of dependence, it is relevant to question whether the easy access to these drugs can contribute to this self-medication behavior and the trivialization of the use by future doctors.

Despite the known potential dependence properties of the substance, the only cross-sectional study carried out in the state of Rio de Janeiro, Brazil, showed a prevalence of 10.8%77. Carneiro SG, Prado AST, Moura HC, Strapasson JF, Rabelo NF, Ribeiro TT, et al. O uso não prescrito de metilfenidato entre acadêmicos de medicina. Cad.Uno. FOA Health and Biological Sciences 2013; 01:53-59. of students that claimed they had to increase the dose to attain the same effect, suggesting a possible development of tolerance, one of the diagnostic criteria for dependence55. Dafny N. Does Methylphenidate (MPD) Have the Potential to Become Drug of Abuse? Biochem Pharmacol (Los Angel) 2014; 4:1. http://dx.doi.org/10.4172/2167-0501.1000156.
http://dx.doi.org/10.4172/2167-0501.1000...
. Although the included articles have not explored MPH dependence of in detail, suggestions were there for broader research on this topic1414. Silveira RR, Lejderman B, Ferreira PEMS, Rocha GMPR. Patterns of nonmedical use of methylphenidate among 5th and 6th year students in a medical school in Southern Brazil. Trends Psychiatry Psychother 2014; 36(2)-101-106.. Some references deal with the dependence on this medication as something more theoretical than practical33. Fond G, Gavaret M, Vidal C, Brunel L, Riveline JP, Franchi JAM, et al. (Mis) of prescribed Stimulants in the medical student community: Motives and behaviors. A population-based cross-sectional study. Medicine (Baltimore) 2016; 95(16): e3366.; however, the increase in consumption by the young people seeking cognitive enhancement deserves attention and care, for its use without therapeutic indication can raise the potential of dependence. According to Dafny55. Dafny N. Does Methylphenidate (MPD) Have the Potential to Become Drug of Abuse? Biochem Pharmacol (Los Angel) 2014; 4:1. http://dx.doi.org/10.4172/2167-0501.1000156.
http://dx.doi.org/10.4172/2167-0501.1000...
, sensitization can increase the experienced effects when compared to those experienced at the first use of the same dose, which can be considered an additional warning signal for the need to evaluate groups regarding the chemical dependence.

An US article published in 2013 measured the consumption pattern of stimulants, with a predominance of amphetamine salts and MPH1515. Emanuel RM, Frellsen SL, Kashima KJ, Sanguino SM, Sierles FS, Lazarus CJ. Cognitive enhancement drug use among future physicians: findings from a multi-institutional census of medical students. J Gen Intern Med 2013; 28(8):1028-1034.. Among the users, an average frequency of drug use ranged from 10 to 12 occasions during a 30 day period, which consisted in most cases in oral administration (92%), with a smaller percentage (18%) of inhaled administration, associated or not with oral administration1313. Franco Netto ROR, Franco Netto JAR, Silva Junior NZ, Silva SM, Vaz LHS, Aguero MAF, et al. Incidencia del uso no prescrito del Metilfenidato entre Estudiantes de Medicina. Rev Inst. Med. Trop 2018;13(1): 16-22. doi:10.18004/imt/20181316-22.
https://doi.org/10.18004/imt/20181316-22...
. In 2018, an Iranian study demonstrated that most interviewed individuals consumed these substances through an oral route (79.6%). However, 6.1% said they consumed it by an intravenous route and 2% by the inhaled route1717. Fallah G, Moudi S, Hamidia A, Bijani A. Stimulant use in medical students and residents requires more careful attention. Caspian Journal of Internal Medicine 2018; 9(1):87. PMid:29387325 PMCid:PMC5771366.. Thus, although the selected studies indicate the use of MPH primarily by oral administration, it is essential to follow a possible increase in the other means of administration of these substances, keeping in mind that the use of intravenous or intranasal drugs implies more severe damage and potential risks such as of overdose.

Addressing the possible consequences of MPH use, Beyer3030. Beyer C, Staunton C, Moodley K. The implications of methylphenidate use by healthy medical students and doctors in South Africa. MBC Med Ethics, 2014; 15:20. points to the need for more comprehensive studies that an demonstrate whether the cognitive improvement justifies the risk of eventual harm to the body. Moreover, a study with undergraduate medical students disclosed the presence of side effects, among them, body pain, headache, tachycardia, anxiety18, cardiac arrhythmias and glaucoma3030. Beyer C, Staunton C, Moodley K. The implications of methylphenidate use by healthy medical students and doctors in South Africa. MBC Med Ethics, 2014; 15:20. in African undergraduate students, and in Paraguayan undergraduate students, tachycardia, decreased appetite and tremors1313. Franco Netto ROR, Franco Netto JAR, Silva Junior NZ, Silva SM, Vaz LHS, Aguero MAF, et al. Incidencia del uso no prescrito del Metilfenidato entre Estudiantes de Medicina. Rev Inst. Med. Trop 2018;13(1): 16-22. doi:10.18004/imt/20181316-22.
https://doi.org/10.18004/imt/20181316-22...
.

The therapeutic effects of MPH on those suffering from ADHD appeal to the students without such diagnosis22. Morgan HL, Petry AF, Licks PAK, Ballester AO, Teixeira KN, Dumith SC. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Rev Bras Edu Med 2017; 41 (1): 102-109.),(1010. Luizão AM, Scicchitanor MJ. Transtorno de déficit de atenção e hiperatividade: um recorte da produção científica recente. Rev psicopedag [online] 2014; 31 (96): 289-297. ISSN 0103-8486.. Nevertheless, using the substance as an intensifier to attain success in exams3131. Cohen JL, Ma E, Rogers AJ. Nonmedical Use of Prescription Stimulants by Medical Students: A Call to Action. Acad Med 2017; 92(7): 901. doi: 10.1097/ACM.0000000000001753.
https://doi.org/10.1097/ACM.000000000000...
can harm the cognitive functions, such as the capacity to solve problems11. Weyandt LL, White TL, Gudmundsdottir BG, Nitenson AZ, Rathkey EM, De Leon KA, et al. Neurocognitive, Autonomic, and Mood Effects of Adderall: A Pilot Study of Healthy College Students. Pharmacy 2018; 6: 58. doi: 10.3390/pharmacy6030058.
https://doi.org/10.3390/pharmacy6030058...
, in addition the risk of acquiring a chemical dependence55. Dafny N. Does Methylphenidate (MPD) Have the Potential to Become Drug of Abuse? Biochem Pharmacol (Los Angel) 2014; 4:1. http://dx.doi.org/10.4172/2167-0501.1000156.
http://dx.doi.org/10.4172/2167-0501.1000...
),(66. Agência Nacional de Vigilância Sanitária. ANVISA (2012). Prescrição e consumo de metilfenidato no Brasil: identificando riscos para o monitoramento e controle sanitário. Boletim de Farmacoepidemiologia do SNGPC, 2(2). 1-14. Acesso em 29 de julho, 2018. Disponível em: Disponível em: http://www.anvisa.gov.br/sngpc/boletins/2012/boletim_sngpc_2_2012_corrigido_2.pdf
http://www.anvisa.gov.br/sngpc/boletins/...
),(1919. Finger G, da Silva ER, Falavigna A. Use of Methylphenidate among medical students: a systematic review. Rev Assoc Med Bras 2013; 59: 285-289.. These consequences can, in turn, worsen academic performance, making what seemed an apparent advantage a new problem to be dealt with3131. Cohen JL, Ma E, Rogers AJ. Nonmedical Use of Prescription Stimulants by Medical Students: A Call to Action. Acad Med 2017; 92(7): 901. doi: 10.1097/ACM.0000000000001753.
https://doi.org/10.1097/ACM.000000000000...
.

Besides this, an Indian study addressed some ethical questions concerning the prescription of cognitive stimulants to individuals who do not need them, creating an even more severe behavioral problem when they are self-prescribed by future doctors3030. Beyer C, Staunton C, Moodley K. The implications of methylphenidate use by healthy medical students and doctors in South Africa. MBC Med Ethics, 2014; 15:20.),(3232. Chandramouleeswaran S, Edwin NC, Rajaleelan W. Dealing with requests for pharmacological cognitive enhancement from healthy students. Indian J Med Ethics 2016; 1(3): 196.. Furthermore, this study proposes a reflection about the competition for higher grades among medical students and the use of medications to boost this performance, since the stimulant does not create skills, but rather intensifies a condition that already exists in a person, which can be improved through different strategies, not of a pharmacological nature and exempt from acute and chronic risks3131. Cohen JL, Ma E, Rogers AJ. Nonmedical Use of Prescription Stimulants by Medical Students: A Call to Action. Acad Med 2017; 92(7): 901. doi: 10.1097/ACM.0000000000001753.
https://doi.org/10.1097/ACM.000000000000...
.

National3333. Chazan AClS, Campos MR, Portugal FB. Qualidade de vida de estudantes de medicina da UERJ por meio do Whoqol-bref: uma abordagem multivariada.Ciênc. saúde coletiva[online]. 2015, vol.20, n.2, pp.547-556.),(3434. Fontes EOC, Santos SA, Santos ATRA, Melo EV, Andrade TM. Burnout Syndrome and associated factors among medical students: a cross-sectional study. Clinics 2012; 67(6):573-579. and international3535. Dyrbye LN, Thomas MR, Power DV, Durning S, Moutier C, Massie FS, Harper W, Eacker A, Szydlo DW, Sloan JA, Shanafelt TD. Burnout and Serious Thoughts of Dropping Out of Medical School: A Multi-Institutional Study. Acad Med 2010; 85(1):94-102.),(3636. Tempski P, Bellodi PL, Paro HB, Enns SC, Martins MA, Schraiber LB. What do medical students think about their quality of life? A qualitative study. BMC Med Educ. 2012 Nov 5;12:106. studies have pointed out that the required workload and the predominantly transmitting pedagogy, combined with impacts on lifestyle, social relationships, and poor sleep quality, have been associated with emotional exhaustion, dehumanization, and feelings of dissatisfaction and inefficiency among medical students. The students report factors related to a decrease in their quality of life, including competition, unprepared teachers, excess of activities, medical school schedules that demand exclusive dedication, contact with pain, death, and suffering, and harsh social realities, as well as frustrations with the program and insecurity regarding their professional future. The scarcity of time for studying, leisure activities, relationships, and rest can influence the use of substances, including psychostimulants. These data indicate the necessity of national quantitative and qualitative studies to discuss these difficulties in our universities and subsidize ways of approaching them adapted to our scenario.

CONCLUSION

An analysis of the articles reveals that MPH misuse consumption rates among medical students is a matter of concern. The undergraduate medical school students that use the substance without medical indication, generally speaking, resort to MPH to enhance academic performance, both in the study and when facing exams. Few studies have evaluated the cognitive, behavioral, and psychological risks, including the dependence associated with such consumption patterns. Finally, some studies addressed the ethical aspects related to the context of use, besides the trivialization of self-prescribed medicines.

Considering this scenario, we highlight the importance of prevention actions inside medical schools, by providing information concerning the risks of MPH consumption without clinical indication, educational programs that can help to deal with the University routine, behavioral strategies aimed to improve cognitive performance, with emphasis on measures covering sleep hygiene, study organization, mnemonic activities and the valorization of measures that improve quality of life, such as physical and recreational activities. Such initiatives can stimulate the self-confidence of innate capabilities and contribute to maintain the future doctors’ physical and mental health.

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  • 2
    Evaluated by double blind review process.
  • SOURCES OF FUNDING

    The authors declare no sources of funding.

Edited by

Chief-Editor: Daniela Chiesa. Associate Editor: Maurício Abreu Pinto Peixoto.

Publication Dates

  • Publication in this collection
    30 Mar 2022
  • Date of issue
    2022

History

  • Received
    05 Aug 2021
  • Accepted
    04 Feb 2022
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