Psychoactive drug use by medicaI students : a review of the national and internationalliterature

Escola Paulista de Medicina, Faculdade de Ciências Médicas da Santa Casa de São Paulo, Faculdade de Ciências Médicas da Universidade Estadual de Cal1zpinas, Faculdade de Medicina do ABC, Faculdade de Medicina de Marília, Faculdade de Medicina de Santo Al1zaro, Faculdade de Medicina da Universidade Estadual Paulista Cal1zpus Botucatu, Faculdade de Medicina da Universidade de São Paulo, Faculdade Regional de Medicina de São José do Rio Preto.


INTRODUCTION I
n recent years, the probIem of non-lnedicaI use of psychoactive drugs by medicaI students and physicians has becolne an area of growing interest and concern for researchers, educationaI institutions and medicaI associations.lx Physicians themseIves can be seen as occupying diametrically opposite, and at times conflicting positions in reIation to substance misuse; on the one hand they have a higher prevaIence of drug misuse, but on the other they also have a pivotal role to pIay in the early detection of drug misuse, incIuding among colleagues, and referral to appropriate servicesY-12 The aims of this review are three-foId.First, to evaIuate the pubIished data on the non-medical use of drugs among Brazilian medicaI students.Secondly, to COlnpare these findings with studies froln other countries, and final1y to Iook at how interventions ailned at identifying and treating this probIem lnight be deveIoped.

BRAZILIAN STUDIES
To date there have been four pubIished studies Iooking at the prevalence of drug lnisuse alnong BraziIian medicaI students.X.13-IS The work of Silva et aI, 1985 x has various methodologicaI probIems which Iilnit the interpretation of the results and lnake it difficult to C0l11pare them with those of other studies.In particular, the questionnaire that Silva et aI.used to col1ect infonnation on drug misuse does not seem to have been validated, there 1357 is no lTIention as to how the sample of students was of Medicine of the University of São Paulo (FMUSP) anel obtained, and the criteria used to define drug misuse are had a response rate of 74 percent (n=796).A ITIodifieel extremely unclear.Consequently, this study will not be version ofthe questionnaire proposed by WH0 2 5 was also considered further.The studies by Mesquita et aI. and employed and further qualitative information was obtainecl Andrade et aI.13.15were based on the same population, using focus groups.Questions covered the non-ITIedical namely the School of Medicine of the University of São use of 11 substances, with use being classified into: lifetime Paulo, while that of Andrade, 1995 14 was undertaken in a use, use in the past 12 months and use during the past 30 group formed by nine ITIedical schools in the state of São days.Information was also collected on age at first use, Paulo l called the Consortium.I reasons for using, attitudes towards drugs and attitudes There are no similar studies ofthe general population towards drug-dependent patients.that could be used for comparison, therefore, we reviewed The prevalence figures are shown in Tables 1 anel 2. several studies of drug use among university students in Apart from alcohol and tobacco, the most COITIITIonly useel general.I()-23 Unfortunately, these also suffer from serious substances were cannabis and tranquilizers, both of which methodological problems, as was pointed out by Almeida were more commonly used by students in the final years Filh0 24 in a review of drug misuse in Brazil in 1991.These of medicaI schooI.problems include: unrepresentative samples, non-Qualitative data from the focus groups suggestecl that standardized definitions of drug misuse, use of non-competitiveness, heavy work loads, contact with patients, validated questionnaires of unknown reliability, unclear and the proximity of the residency exalTIination were seen data colIection methods and inadequate data analysis.
as contrib,utory factors for drug use.Ai the SalTIe titTIe, Consequently, only the lTIOremethodologically rigorous students reported that their scientific knowledge of the study by Magalhães et aI., 1991 20 will be used for effects ofthese substances protected them frotTIdeveloping comparison.The studies by Magalhães et aI., 1991, drug-related problems.Mesquita et al., 1995 and Andrade et aI., 1995 will be A logistic regression analysis revealed that three examined in more detail in the following section.
factors were associated with a greater probability of elrug Magalhães et aI., 1991.This study was undertaken use, excludi,ng cannabis and the use of inhalants anel using a representative sample (n=1,069) of university tranquilizers in the past 12 months: being towards the enel students from various faculties in the city of São Paulo, of the medicaI course, approving of drug experilTIentation using an instrument based on that recommended for student by others, and frequenting bars as a leisure activity.One surveys by the World Health Organization (WHO).25 The factor was associated with a reduced risk of drug taking; authors examined the prevalence of the non-medical use not having someone,to confide in about personal problenls.of 11 psychoactive substances over two time periods: Andrade, 1995 -This study, undertaken in 1994, lifetitne use and use in the previous three months.The encompassed all students at nine lnedical schools in the prevalence of use of the various substances is shown in Table 1.
Among the illicit drugs, cannabis was the most commonly used, with 26 percent reporting lifetime use, of whom 4 percent described themselves as heavy users (smoking once or more per day).Factors that were associated with ITIOrefrequent drug use were: holidays, traveling, friends, ease of obtaining the drug and personal crises.Factors which seemed to protect against drug use were: living with famiJy, having a girlfriend or boyfriend, health problelns and work problems.
Mesquita et aI., 1995 -This study was u ndertaken in 1991 State of São Paulo and had a response rate of 71 percent (n=3,725).The author used a modified version of the instrument that had been used by Mesquita et aI. (1995).
Questions were asked about the use of the same 11 substances over the same three tilne periods described in the previous study.The fuH statistical analysis of these results has yet to be published and the prevalence figures presented here in Tables 1, 2 and 4 are derived from the final report that was sent to the study's research funding body.

COMPARISONS BETWEEN THE THREE STUDIES
One of the problems in comparing the studies of Mesquita et aI.and Andrade is that some of the students interviewed in the former were also interviewed in the latter.However, as there was a three-year tilne gap between the studies, we calculate that this overlap represents no more than 10 percent of Andrade's total sample.
As the questionnaires in all three studies were completed anonYlnously, there was no way of approaching those students who were not present on the day of the survey.Since various authors have suggested that in studies of student populations, those students who are absent on the day of the survey are more likely to be drug Llsers,1.5 the true prevalence of drug misuse may have been underesti mated.
Comparing the two studies of medicaI students (see Table 2), the following similarities can be seen: the prevalence of drug use tends to increase from the first to sixth year for most substances and over Inost time intervals; the sequence of lifetime drug use froln highest to 10west prevalence figures follows the salne order: alcohol, tobacco, solvents, cannabis, tranquilizers, amphetamines to cocaine; and there tends to be a prominent increase in the prevaIence of tranquiIizer use in the fifth and sixth years.The remarkable increase in the recent use of tranquilizers can be verified in both studies.
In TabIe 1, statisticaI comparisons using the chisquared test between university students in general and medicaI students show that medicaI students have a higher lifetime prevaIence of aIcohol use (89 vs. 82 percent, p<O.OI) and a Iower lifetime prevalence of cocaine use (5 vs. 10 percent, p<O.Ol).University students show the SalTIedeclining arder of prevalence of substance misuse from alcohol to cocaine, as seen in the other two studies.
AIthough several authors have observed that use of prescription drugs is more common among medicaI students,1.5.12 we were unabIe to investigate this, as Magalhães et aI.did not ask a separate question about tranquiIizer use, but combined it with amphetamine use.Both Mesquita et aI.and Andrade demonstrated the reIativeIy high prevalence of tranquiIizer use among medicaI students (11 and 8 percent in the past 30 days, respectiveIy).
Magalhães et al.'s 1991 study lTIarks a turning point in this respect.They were concerned about such factors as sampIing methods that allow data to be collected on representative samples of the target population, thus permitting a greater degree of generalization, the use of vaIidated questionnaires, and the formulation of tTIore precise objectives.More recent studies, such as Mesquita et aI., have adopted a mixture of quantitative and qualitative methods to more fully investigate the problem.
The studies of Mesquita et al. and Andrade have enabled further advances, including the following: (I) the use of more specific hypotheses; (2) more rigorous anel diverse statistical methods, e.g.logistic regression analysis, which permit more compIex anaIyses than simple bivariate correlations; and (3) standardized tTIethodologies which allow for the reproduction and comparison of results with those of other studies.
It is important to point out that medicaI stuelents differ from university students mainly in reIation to alcohol anel lifetime cocaine use.Finally, lifetime use of both cocaine and amphetamines, as use of tranquilizers during the last 30 days, presented considerably higher rates among medicaI students.

GENERAL CONSIDERATIONS ABOUT BRAZILIAN STUDIES INTERNATIONAL STUDIES OF DRUG USE AMONG MEDICAL STUDENTS
Using the data banks Medline and LiIacs, 22 articles published between 1970 and 1995 on drug use among non-Brazilian medicaI students were found.Most of the lTIOre recent studies were conducted in the United States,1.2.4.5.12.2() with the exception of one study undertaken in Cuba/) anel another that used a sample obtained frotTI 42   The earIy studies of drug use in BraziI tended to be fairly simple prevalence studies, often with unclear objectives and Iittle thought given to methodological designo These studies rarely did more than attempt to correlate drug use with such variables as social class, and used statistical analyses no more complicated than the chisquared teste  As can be seen in Table 3, with the exception of amphetanlines, there is a rel11arkable degree of variation in the use of ali reported substances, be it for 1ifetiI11e or recent use.Because of the differences in the way the studies were undertaken, it is difficult to interpret how 111uch of this variation is real, and howmuch is a I11ethodological iI11plication.Maddux et aI.12 found a prevalence of substance abuse of 1I percent, which in conjunction with illicit substance use was associated with a depressive affect.McAuliffe et aI. 5 found that 16.5 percent of students had I11etcriteria for drug abuse at SOllle time during their li ves.The Sallle authors also found that 5.2 percent of students reported having experienced drug dependency, which cOl11pares to tl:e 2.8 percent of students who were found to be CAGE posi ti ve in Menendez   self-completed, anonymous questionnaires were used which were 111 ai led to students.In some cases, the students were paid to participate in the study.Students who did not return the questionnaire were then mailed an additional two copies before being considered non-responders.The response rates varied from 37 to 100 percent.The questionnaires had generally been adapted from those used in previous student surveys, thus facilitating cOI11parison between studies.
In Crofton et aI.'s I11ulti-center and Inulti-country study, the method of data collection used was left to the discretion of the local study coordinators.
Further details are not given beyond the information that the questionnaires were cOI11pleted in the students' class rooms.was the most commonly reported reason for using drugs, and recreational use was found to be twice as common as self-medication.Kory and CrandalI, 1986,4 found that recreational use of an individual drug was a positive predictor of the use of other substances.Maddux et aI., 1986,12 showed that first-time use of cocaine and benzodiazepines occurred more commonly during lnedical school than in high school.The authors suggested that first-time benzodiazepine use during tnedical school was probably due to ease of access to these drugs, while first-time cocaine use was more dependent on age, a tendency also observed in non-medical students.
McAuliffe et aI. 5 discovered that the prevalence of drug use was even higher in the clinicaI years of medicaI school, while Kory and Cranda1I 4 found that drug use was associated with age, gender, and a greater number of absences.

COMPARISON OF THE BRAZILIAN AND NORTH AMERICAN STUDIES
To facilitate comparison between the Brazilian and North American studies, Baldwin et al.'s study wilI be focused on because although it only provides data on final year students, it has a Iarge representative sample and uses the same criteria for drug use.
Baldwin et aI.. 1991this study was undertaken in 1987 and used a large national sample of medicaI students (n=2,046) from 23 North American medicaI schools.Selection criteria included the geographical region in which the school was located, size, and whether the institution was private or publico The sampIing procedure aIso took into account the student sex ratio.Data were colIected using anonymous, self-compIeted questionnaires returned by mail.In terms of lifetime use, North American students showed a significantly higher prevalence for the use of alcohol, tobacco, cannabis, amphetamines and cocaine (p<O.OOl).Brazilian students showed a higher 12-month prevalence for tobacco, tranquilizer and amphetamine use, and a higher 30-day prevalence for tranquiIizers and alnphetamines use.Although the differences in the lifetitne prevalence of drug use between the two populations (in particular cannabis and cocaine) are greater than past 30 days use, the Brazilian satnple had a greater tendency towarels recent non-medical use of tranquilizers anel amphetamines.
These results may suggest a greater tendency towards drug experimentation alnong North American students, and possibly more dependency probIems among the Brazilian sample, in regards to these medications.

METHODOLOGICAL CONSIDERATIONS OF THE INTERNATIONAL STUDIES
A factor common to virtualIy alI the studies is the use ofanonymous, self-completed questionnaires which were mailed back to the research groups.Although this lnethod allows reaching a larger population anel is without a doubt cheaper, the reliability of some of the responses may be questionable.
Further, the response rate is often lower than the "in loco" elata coIlection procedure, and these studies rarely compare the nonrespondent and respondent groups as to sociodemographic variables.
It is also important to question the precision of the data collected, as the authors of the studies never presenteei a definition of the abuse and dependency criteria to the respondents.
Other studies have shown that tnedical students have a general lack of knowledge in relation to drugs and drug lnisuse,2X-32including difficulty in nlaking substance abuse-related diagnoses.31 -34 Therefore, selfreports of abuse and dependency probably lack valielity and reliability, and shouId only be made using valielateel diagnostic scaIes.
Precise questioning of the reasons for drug use is often Iacking.Most studies can be criticizeel for not differentiating experimental, recreationaI, self-treattnent and use of drugs for the purpose of improving perfonnance, which wouId permit a more precise conclusion as to the groups, situations and substances urgently requiring attention.
Several of the studies show that initiation into elrug use occurs during medicaI schooI, but because comparison data froln age-and-sociaI-class-matcheel non-lnedical students is rareIy presented, it is difficult to know how much experiences particular to tnedical school are responsible for this.

DISCUSSION
The current picture of psychoactive substance use alnong medicaI students, in spite of alI national and international studies, is stilI far from clear.The results from both Brazilian and international studies are remarkably consistent, although there are some notable differences in the prevalence of cannabis and cocaine use by North American and Brazilian students.
By and large, alcohol is the drug with the highest lifetime prevalence and stitnulants the lowest.Of particular concern alnong the Brazilian studies is the relatively high prevalence of recent tranquilizer and alnphetamine use, which increases with tilne spent at medicaI school.Indeect, there is a general trend for the reporting of drug use to increase for alI categories as students pass from the first to the final year.It is important to point out that the Brazilian studies were not carried out with national samples, and therefore the results may reflect regional trends.
The higher prevalence rates of non-medical use of amphetamines and tranquilizers in the Brazilian sample may be associated with various factors: l) although controlIing access to these substances has received more attention in the past few years, it is stilI not difficult to obtain theln without going through proper procedures; 2) the issue of drug misuse among medicaI students has been addressed by D.S. society for more than 20 years now,3.35through conferences, ilnplementation of drug-use policies at medicaI schools, and prevention programs.Therefore, the lower prevalence rates presented by the North American samples lTlayretlect the results of these actions; and this difference may also be verified in the general population, reflecting a major governmental and social attitude towards drug use.
Regarding the comparison of the prevalence presented by the Brazilians samples of university and lnedical students, there seems to be little difference except for lifetilne use of' alcohol and cocaine.The lower prevalence rate of cocaine use verified in the medicaI students' sample may be related to their exposure during their training to the harmful effects of this substance.However, their increased knowledge of the effects and properties of medications seems to give them a false sense of control over their own use of these substances.15 This, allied to facilitated access to the medications, enhances the probability of medicaI students electing them as their drugs of choice.The higher prevalence rates observed in the last year of lnedical school (the sixth year in Brazil), \vhen compared to the initial years, deserve consideration.Different leveIs São Paulo Medicai Journal/RPM 115(1): 1356-1365, 1997 of drug involvement due to various personal reasons 3 () are expected across alI groups of society, and therefore, this effect should also be reflected in the lnajority of lnedical students and faculty members, as welI as practitioners.lO As has already been remarked, there is a conspicuous lack of information about the reasons for drug use, the context in which it occurs, the personality traits of those involved and how these relate to other risk factors.Furthermore, once drug use has been initiated, little is known about what maintains this behavior.These questions point to areas where further research is needed, and also to the need to combine quantitative InethodoIogies with qualitative ones to obtain a lnore cOlnplete picture of drug use.
In the study by Mesquita et aI., 1991,15 students believed that stress was an ilnportant factor in drug use, in particular stress associated with cOlnpetitiveness, the great number of hours worked, certain aspects of clinicaI work, and the pending residency exam.However, even here students may be over simplifying and rationalizing the situation.For example, are the reasons for using cannabis the same as those for using cocaine or lnisusing aIcohol?As yet we are unable to answer these questions.
However, a more thorough evaluation of the reasons for the use of these drugs by lnedical students would surely indicate factors that increase the probability of drug-related problems associated with the lnedical profession anel environluent.
That Inedical students experience considerable stress is without question, as has been shown by other studies.37 .3X McCue, 1982,3x describeel a variety of stresses that students experience, for exalnple: intilnate and frequent contact with pain and suffering, physical and emotional contact with patients, death, and the uncertainty of much of medicaI science in contrast to the desires that patients have for certainty and guarantees.
In one study of Brazilian medicaI students, Martins, 1994,37 found three lnain areas in which resielents expressed difficulties: breaking bad news, treating patients with terminal disease, and the fear of contracting infectious diseases.The residents aIso pointed to two particular stresses: fear of making a lnistake and lack of tilne to spenel with family and friends.
Drug use by medicaI students can cause a variety of problems, depending on the degree of involvelnent that the student has with the drug.The effects of occasionaI use largely depend on the circumstances in which he uses the drug, but may range froln no discernible effect to a serious impairlnent in acadelnic perforlnance anel concentration difficulties.There is aIso an increased risk of abuse or even dependency later in life, with the associated personal and social cOlnplications that ensue.Early detection of drug problelns for this popuIation, ideally while the student is still in medicaI schooI, should be a priority of any drug prevention/intervention programo To better facilitate such early detection, there is an urgent need for research investigating the risk factors associated with initiation into drug use.Such studies need to go beyond the confines of merely examining factors related to the pressures of medicaI training, and look at factors that predate entry into medicaI school, such as family problems, personality traits and prior experimentation with other drugs.
Most medicaI schools in Brazil lack a structural framework which would allow students with drug problems to be identified.One possibility would be to have a type of tutorial system, in which a designated professional, with a pastoral/counselling function, would meet with a small group of students on a regular basis from the start of the course untiI the end.This type of approach would permit the development of a more trusting and confidential relationship than is normally possible with academic staff.Such a professional would be ideally placed to identify students with drug or other psychological problems, and to offer treatment where appropriate.Treatment would have to be completely confidential and held away from school premises to ensure that students would not be identified as "drug addicts" by their cIassmates.
When the person who identifies drug misuse in a student is a physician, his or her own attitudes toward, and personal experience with, drug use come into play.Physicians with more liberal attitudes to drug use and those who have experimented with drugs in the past may be more disposed to play down the importance of drug misuse by colleagues or students, and consequently be Iess Iikely to intervene at an early stage and offer treatment.
Extensive literature exists showing that medicaI students have negative attitudes towards patients with drugdependency problems.32 .39,40-44It is Iikely that these attitudes are formed or at least ~einforced during medicaI schooI.If medicaI schooIs are to have a pivotaI role in preventing drug and aIcohol probIems among students, then these attitudes need to be more effectiveIy chaIlenged.However, at the present time the amount of drug and aIcohoI training that most medicaI students receive is minimap.32,41,44-46and fragmented. 3.7 .3239.41.47 Nocks 44 states that negative attitudes towards drug-dependent patients increase during the medicaI course because students feeI inadequately prepared to manage these situations.
Regarding drug-relat~d problems, they may Iack the necessary skilIs to identify drug problems and deaI with deniaI.3 .32.39According to Negrete,35 such difficuIties are aggravated by the unhelpfuI attitudes that many clinicians have towards this group of patients, including a distaste for illnesses characterized by frequent relapses, Inoralistic attitudes towards patients who drink toa Inuch, beliefs that drug and alcohoI misuse are social rather than InedicaI problems, and the difficulty many physicians have in comprehending why patients misuse drugs at alI.ConsequentIy, when faced with a drug or alcohoI abusing colIeagues or classmates, the student Inay be paralyzed into inaction due to a combination of fear of confronting the person and inappropriate therapeutic nihilism.Often the Iittle contact that students have with drug and alcohoI dependent patients is fairly short-tenn and is Iikely to be with those patients who have Inore chronic problems associated with psychiatric and physicaI complications. 3 .32 .41.44.4XThey are unlikely to see patients who have achieved stable abstinence and social reintegration, first because these patients often drop out of treatment, and secondly because such an outcolne Inay take several years to achieve.Consequently, students Inay not believe that these patients can be successfu IIy rehabilitated, and therefore become unduly pessilnistic in their outIook.
While physicians aIlegedIy make bad patients, they may aIso make bad physicians when the patient they are treating is another doctor.There may be an unwillingness for colIeagues to take control of the situation, allowing the doctor-patient to take Iiberties that would not be aIlowed with ordinary patients.Thus corridor consuItations, inadequate supervision and permitting selfprescribing are common, behaviors that are rationalized on the grounds that busy schedules and on-caII commitments make it difficult to find time to make proper consultations.
These Iessons are Iearned earlY on at medicaI schooI, particularly in relation to the use of benzodiazepine to relieve symptoms of stress or induce sleep after a period of on-call duty.While such behavior may not lead to drug dependency, it is undesirable.23 Indeed, consideration should be given to prohibiting self-prescribing alnong physicians, and onIy allowing physicians to prescribe to colleagues who have registered with them as patients.SpeciaIized services for students and practicing physicians need to be developed to counteract this tendency and to provide medicaI professionaIs with the treatlnent service they deserve.
In BraziI, it is common practice for finaI-year InedicaI students to have facilitated access to prescription drugs.Drugs are often donated by pharmaceuticaI companies for use with impoverished patients who cannot afford to pay for them, and in some institutions, medicaI students themseIves staffthese small pharmacies.Such easy access onIy encourages students to seIf-prescribe.Later, this Inay Iead to the inappropriate or improper prescribing of psychotropic drugs by one doctor to a colIeague, patient, or even to hilnself.In Brazil, consideration should be given to ending the relatively unlimited and unsupervised access that Inany students and physicians have to pharmacies.
To really tackle the problem of drug and alcohol Inisuse by Inedical students and physicians, particularly in tenns of prevention, early identification and treatment, we Inust do much more than siInply tinker with the medical school curricululn.The following six recommendations offer a fralnework of where to go from here: I. Review the curriculum, not only regarding the amount oftilne spent dealing with this subject during the course, but also as to the themes and techniques employed, in order to increase the knowledge base that Inedical students have about drug and alcohol Inisuse.In particular, information about misuse by medicaI professionals and how to identify and de aI with such problelns Inust be covered and emphasized, especialIy reinforcing the dangers involved in self-prescription.2. Provide for better and more appropriate clinicaI experience with patients with drug and alcohol problems, based on directly supervised case managelnent.3. Require medical school authorities to develop a systeln in which students who are having problelns during the medicaI school course can be identified and counselled, such as the modified tutorial systenl Inentioned above.,A silnilar systeln needs to be developed for residents and other physicians.4. Organizations representing the Inedical profession, such as regional medicaI counsels, need to develop a systeln whereby students and physicians identified as having drug and alcohol problems can be assessed and treated confidentially.In resistant cases, there Inay need to be an element of cOlnpulsion.5. Fonnulate and inlplement a fonnal policy regarding drug-related issues in the school of nledicine, applicable to alI melnbers of the acadelnic cOlnlnunity: board of directors, staff, faculty and students.6. Undertake further research to investigate risk factors for drug and alcohol Inisuse, and whether these can be minimized.
.M.; LARANJEIRA, R.; DUNN,J.-Psychoactive drug use by medicai students: a review of the national and internationalliterature São Paulo Medicai JournallRPM 115(1): 1356-1365, 1997 and Calabuch's study.()Comparing two North Alnerican groups, Baldwin et a 1.I C o n f i r nl e d t h a t 111 e d i c aIs t u de n t s h a d a h i g h e

Table 2
Use of psychoactive substances by 8razilian medicai students in Andrade's (A) and Mesquita et al.'s (8) samples, by academic year.

Table 3
Highest and lowest prevalence figures for psychoactive substance use among medicai students found in the international literature Substance

Table 4
compares the results ofBaIdwin et al.'s study with the data on final year students from Andrade's study.