CONSUMPTION OF BENZODIAZEPINES WITHOUT PRESCRIPTION AMONG FIRST-YEAR NURSING STUDENTS AT THE UNIVERSITY OF GUAYAQUIL , SCHOOL OF NURSING , ECUADOR

This study aimed to determine the consumption of benzodiazepines without prescription among firstyear students from a nursing school of a public University in Ecuador. This is a descriptive, transversal and explanatory study with a quantitative approach. A questionnaire was used for data collection. The population studied was of 181 students. The results showed that 10.5% of the students had consumed benzodiazepine without prescription once in their lives. Of these, 6.1% consumed benzodiazepine in the last year, and 3.9% are currently consuming it. The diazepam was the most consumed BZD without prescription and pharmacies, were the place of higher access. The main reasons for the benzodiazepine consumption were: insomnia, anxiety, stress, depression, family and economical problems. The use of benzodiazepines with non-medicinal purposes is related to problems such as memory loss, retirement syndrome and sedation. When benzodiazepines are consumed jointly with alcohol or other drugs they can lead to coma or death. This study shows the serious consequences benzodiazepines cause when used by nursing students in Ecuador.


INTRODUCTION
The consumption of medicines without prescription has been a frequent behavior in every culture and period."This behavior has been transformed into an ability to satisfy health necessities, to share medicines with family members or from the social circle and to use medicines left from other prescriptions (1) ." The illegal consumption of benzodiazepines entails health risks because of a lack of professional orientation.This situation can hide a disease, complicate a symptomatological state and consequently delay the recovery.For instance, it is important to say that isolated auto-medication produces harmful and undesirable consumption.These drugs, which belong to a group of small tranquilizers, due to their wide therapeutic power, are the reason for abuse and are prescribed in excess in general medical practice (2)(3) .
As depressants of the central nervous system (CNS), they develop tolerance in few weeks of treatment.Sedation and sleepiness can deteriorate mental and motor functions, reduce the capability of attention, concentration and decision and cause anterograde amnesia.Therefore, it is important to call attention to these effects, which can be presented as an overdose when combined with other depressants of the CNS (2) .They produce physical dependence when used for a long time and, when interrupted in an abrupt way, this can cause the abstinence syndrome . Acute intoxication, either accidental or suicidal, with these drugs is very frequent, even though mortality by overdose is very low (less than 1%) (5) .They are also used for phobic confusion, panic, post-traumatic stress, convulsive disorders, syndrome of alcohol abstinence and barbiturates, in insomnia crises and, also, in cases of anxiety (used worldwide) (6) .
There is much information about drugs like alcohol, tobacco, marijuana and cocaine, among others.Statistics about usage are emphasized, despite the lack of interest by researchers, not only due to their importance, but also due to the consequences they entail.The lack of qualitative data leads to a consequent lack of information about the matter.
The free sale of medicine has risen worldwide and institutions in control are not severe enough to stop this growth, which is characterized as epidemic.
This fact evidences that auto-medication is present in the population in general: workers, housewives, medical students, university students and professionals -highlighting health care professionals, among whom this behavior is regular.They have knowledge, more access to information about health and also a relation to medicines, which have been the main factors to make this practice regular.
Traditionally, Latin America has been considered one of the regions that provides and promotes transport of drugs to the world.However, in recent years, it has experienced a quick change, ceasing to be a productive region and starting to be a consumer . Data are found about the rise of the illegal use of tranquilizers and amphetamines in the urban and peripheral areas of Latin America, a situation that has been promoting prescription without medical permission or the irrational prescription of medicines prepared with psychotropic substances, developing dependence (8) .These are drugs of easy access in drugstores and pharmacies, because they are an alternative to make various health problems better, noticing a generalized tendency towards automedication.Therefore, they change from one medicine to another according to doses and frequencies they establish.
International authorities consider that diagnosing drug consumption in the school population represent one of the most efficient instruments to obtain knowledge, not only about the current problem situation, but also as a way of previewing drug consumption in the future .
In this sense, with a view to updating information, exchanging experiences and promoting scientific knowledge, research has been performed about drugs in the population in general, students and workers from South and Central America since the beginning of 2000.It was reported that benzodiazepine tranquilizers, such as Diazepam and Alprazolam, without prescription are also worrying.
The countries with the highest proportion are Paraguay, Bolivia and Colombia, with 7.1%, 7% and 6.4% respectively (10) .
Studies in seven countries in 2003 showed that the most consumed drug in Paraguay is "Jarra Loca" (a mixture of alcohol and tranquilizers), which is a dangerous combination because it enhances the sedative effects.In the Dominican Republic, the tranquilizers consumed without prescription appear with high levels, 12.8% for women and 6.5% for men (11)   .It is a problem not only at schools, because an increase has been noticed inabuse among adults -especially benzodiazepines, which are mixed with alcohol most of the times (12) .
In Ecuador, in 1998, the prevalence of tranquilizer consumption at school was 6.6%, more than stimulants (3.6%), and the average age was 14.3 years old.As to gender, the consumption behavior did not show a significant difference, with 8.2% for females and 8% for males.However, 23% of the interviewed parents used pills for anxiety (to sleep, to calm down, to feel good, among others) .
The parents' behavior can be considered an example that influences their children's behavior.
In 2002, the prevalence of tranquilizers consumption in secondary education students in Ecuador was 5.9%, with 13.6 years as the average age for the first consumption, emphasizing that 51.1% of the interviewed population used tranquilizers with prescription (9) , a situation which reveals that a high percentage of students use these substances in a suspicious way.Research in that country performed in 2005 highlights that the use of tranquilizers without prescription was higher for stimulants (6.1%), with the age for the first consumption at 13 years and 4 months .
Nursing students, as young people with a professional future in health care, find themselves in an inflexible cultural context that promotes contact with legal and illegal drugs (12) .Therefore, it is a challenge to research this human resource because the population is vulnerable to auto-medication.
Teaching practice has allowed the researcher to observe students' behavior: their desires, problems, insecurities, fears and anxiety about the Complementary Groups.In the first group, the majority do not work, having enough time to accomplish their academic tasks.However, the second group, also denominated professionalization group of nursing assistants, was created to promote access to the bachelor's degree and improve knowledge and care quality, with a view to renewing the nursing group.
Those students play many roles (father, mother, workers and students).The studies are totally paid for by the students (enrolments and installments).
The interview instrument was a questionnaire about the history of psychoactive drugs (13) , which was adapted to the necessities of the study, with structured questions, consisting of characteristics of the interviewed person, general and specific questions related to BZD consumption, consisting of 25 items in total.
The study was approved by the Bioethical Committee of the University.The participants were informed about the research, signing the free and informed consent term.As for the statistics, frequencies and percentages were used, obtained by Microsoft Excel.The research results were presented in tables and graphs.

RESULTS AND DISCUSSION
Participants were 181 first-year nursing students, classified into the Regular and Complementary Groups.
Table 1 showsthat 110 (60.8%) students answered that they did not consume BZD and that 20 (11%) did not answer the question.The sum of both shows a meaningful percentage (71.8%),which can suggest that the answers were not sincere.Fourteen students had consumed BZD with prescription (7.7%); 19 (10.5) used these products at least once without prescription; 11 (6.1%) used them in the last year and until the moment (during the interviews, 7 (3.9%)students).These results coincide with international studies (10,14) and, at a local level, with an experimental study performed among university students (15) .As for the consumption of benzodiazepines without prescription according to gender, a gap is noticed, with high female consumption when compared to men, 35 (94.6%) respectively.These are meaningful results that coincide with other studies, in which women prefer the consumption of medication drugs without prescription (12, 16)   .Table 2 discloses that, among 20 students from the Regular course who reported BZD consumption without prescription, five worked, while According to the data in Table 3, the most consumed BZD without prescription is Diazepam, with 40% for both groups of students, followed by Alprazolam with 20% for the Regular and 17.6% for the Complementary Group.These results coincide with studies performed in other countries (14) .Other studies mentioned the use of Flunitrazepam.As for the reason for the consumption, 35.3% of the students from the complementary course and 25% from the regular course say that the reason is because of insomnia and sleep disorders, the most found symptoms in research.The occurrence of these symptoms is high and damages the quality of life, presenting negative consequences for the family, work and social activities (18)   ..The role of the pharmacies as medicine "sellers" must be  investigated and controlled to reduce irresponsible consumption of medicines (19) .Other ways of obtaining drugs are: friends, medicine boxes and access to medical samples among students from the Complementary group, who work at the health institutions.
possibility of not fighting against them, besides taking decisions.These are situations that sometimes lead to medication use with the objective of relieving moments of discomfort instantaneously.In view of these factors, this study aimed to determine the use of BZD without prescription in first-year nursing students, considering sociodemographic characteristics, types of benzodiazepines, frequency, dose, reason and ways of access.METHODOLOGY This is a cross-sectional, descriptive and exploratory study with a quantitative focus, carried out at the Nursing School of the University of Guayaquil, Ecuador.The population was composed of 181 first-year nursing students, of both genders, over 18 years old, regularly enrolled at the school and attending classes as part of the Regular and

2 -
17 students from the Complementary course worked and were Nursing Assistants.The places of work were hospitals, 12 (70.6%)at the emergency and ICU; 47.1% in high-level critical units and units with high levels of stress, such as psychiatry; and 8 students worked night shifts.These facts can affect their academic development, causing alterations and dysfunctions during the day due to the paperwork, besides their low salary.It is easy to understand the economic and emotional overload they go through, a situation that can lead to career desertion -a phenomenon growing in universities, considering that the students look for jobs or occupations that can offer them more respectable economic, social and work conditions Use of BZD without prescription according to socioeconomic variables among first-year Nursing students.Guayaquil, Ecuador, 2007

Table 1 -
BZD consumption in first-year students.