Psychoactive drug use by m edicaI students: a review of the
national and internationalliterature
E s c o l a P a u l i s t a d e M e d i c i n a ,
F a c u l d a d e d e C i ê n c i a s M é d i c a s d a S a n t a C a s a d e S ã o P a u l o , F a c u l d a d e d e C i ê n c i a s M é d i c a s d a U n i v e r s i d a d e E s t a d u a l d e C a l 1 z p i n a s , F a c u l d a d e d e M e d i c i n a d o A B C , F a c u l d a d e d e M e d i c i n a d e M a r í l i a , F a c u l d a d e d e M e d i c i n a d e
S a n t o A l 1 z a r o , F a c u l d a d e d e M e d i c i n a d a U n i v e r s i d a d e E s t a d u a l P a u l i s t a - C a l 1 z p u s B o t u c a t u , F a c u l d a d e d e M e d i c i n a d a U n i v e r s i d a d e d e S ã o P a u l o , F a c u l d a d e R e g i o n a l d e M e d i c i n a d e S ã o J o s é d o R i o P r e t o .
N o n -m e d ica l d ru g u se a m o n g m e d ica i stu d e n ts is a m a jo r co n ce rn a m o n g re se a rch e rs a n d p o licy m a ke rs in se ve ra l co u n trie s, n o t o n ly b e ca u se o f th e p e rso n a l h a rm fu l co n se q u e n ce s th a t m a y a rise fro m th is b e h a vio r, b u t a lso fo r th e so cia l co n se q u e n ce s. T h is a rticle a im s to e va lu a te "n a tio n a l a n d in te rn a tio n a l d a ta a va ila b le o n n o n -m e d ica l d ru g -u se a m o n g m e d ica i stu d e n ts a n d risk fa cto rs a sso cia te d w ith th e se p ro b le m s, a s w e ll a s so cia l a n d in stitu tio n a l im p lica tio n s. P re va le n ce ra te s, in B ra zilia n a n d in te rn a tio n a l sa m p le s, o f a lco h o l a n d d ru g u se , a b u se a n d d e p e n d e n ce , re a so n s fo r o n se t, m e th o d o lo g ica l issu e s, a n d th e ro le o f m e d ica i e d u ca tio n a re p re se n te d , co m p a re d a n d d iscu sse d . T h e a u th o rs su g g e st so m e issu e s th a t sh o u ld b e a a d d re sse d in o rd e r to d e a l w ith th is co m p le x situ a tio n .
U N IT E R M S : D ru g s, m e d ica i stu d e n ts, d e p e n d e n cy, p re ve n tio n a n d m e d ica i e d u ca tio n .
IN T R O D U C T IO N
I
psychoactivenrecent years,drugs by m edicaI students and physiciansthe probIem of non-lnedicaI use ofhas becolne an area of grow ing interest and concern
for researchers, educationaI institutions and m edicaI
associations.l-x Physicians them seIves can be seen as
occupying diam etrically opposite, and at tim es conflicting
positions in reIation to substance m isuse; on the one hand
they have a higher prevaIence of drug m isuse, but on the
other they also have a pivotal role to pIay in the early
detection of drug m isuse, incIuding am ong colleagues, and
referral to appropriate servicesY -12
A d d re s s fo r c o rre s p o n d e n c e : A n a M a ria M e s q u ita
R u a H a d d o c k L o b o , 1272a p to . 71 -C e rq u e ira C é s a r S ã o P a u lo /S P - B ra s il- C E P 0 1 4 1 4 -0 0 2
S ã o P a u lo M e d ica i Jo u rn a llR P M 1 1 5 (1 ): 1 3 5 6 -1 3 6 5 , 1 9 9 7
The aim s of this review are three-foId. First, to
evaIuate the pubIished data on the non-m edical use of drugs
am ong B razilian m edicaI students. Secondly, to C O lnpare
these findings w ith studies froln other countries, and final1y
to Iook at how interventions ailned at identifying and
treating this probIem lnight be deveIoped.
B R A Z IL IA N S T U D IE S
To date there have been four pubIished studies
Iooking at the prevalence of drug lnisuse alnong B raziIian
m edicaI students.X .13-ISThe w ork of Silva et aI, 1985x has
various m ethodologicaI probIem s w hich Iilnit the
interpretation of the results and lnake it difficult to C 0l11pare
them w ith those of other studies. In particular, the
questionnaire that Silva et aI. used to col1ect infonnation
on drug m isuse does not seem to have been validated, there
T a b le 1
L ife tim e p re va le n ce o f p sych o a ctive su b sta n ce u se a m o n g B ra zilia n m e d ica i a n d u n ive rsity stu d e n ts
M esquita et ai. M agalhães et aI. A ndrade
1991 1991 1995
(n
=
796) (n=
1,069) (n=
3,725)% % %
A lcohol*. 82 82 89
T obacco 39 39 39
S olvents 23 28 31
C annabis 19 26 24
T ranquilizers 11 ** 11
A m phetam ines 5 ** 8
C ocaine* 4 10 5
is n o lT Ie n tio n a s to h o w th e s a m p le o f s tu d e n ts w a s o f M e d ic in e o f th e U n iv e rs ity o f S ã o P a u lo (F M U S P ) a n e l o b ta in e d , a n d th e c rite ria u s e d to d e fin e d ru g m is u s e a re h a d a re s p o n s e ra te o f 7 4 p e rc e n t (n = 7 9 6 ). A IT Io d ifie e l e x tre m e ly u n c le a r. C o n s e q u e n tly , th is s tu d y w ill n o t b e v e rs io n o fth e q u e s tio n n a ire p ro p o s e d b y W H 0 2 5 w a s a ls o c o n s id e re d fu rth e r. T h e s tu d ie s b y M e s q u ita e t a I. a n d e m p lo y e d a n d fu rth e r q u a lita tiv e in fo rm a tio n w a s o b ta in e c l A n d ra d e e t a I. 1 3 .1 5w e re b a s e d o n th e s a m e p o p u la tio n , u s in g fo c u s g ro u p s . Q u e s tio n s c o v e re d th e n o n -IT Ie d ic a l n a m e ly th e S c h o o l o f M e d ic in e o f th e U n iv e rs ity o f S ã o u s e o f 1 1 s u b s ta n c e s , w ith u s e b e in g c la s s ifie d in to : life tim e P a u lo , w h ile th a t o f A n d ra d e , 1 9 9 51 4w a s u n d e rta k e n in a u s e , u s e in th e p a s t 1 2 m o n th s a n d u s e d u rin g th e p a s t 3 0 g ro u p fo rm e d b y n in e IT Ie d ic a l s c h o o ls in th e s ta te o f S ã o d a y s . In fo rm a tio n w a s a ls o c o lle c te d o n a g e a t firs t u s e , P a u lol
c a lle d th e C o n s o rtiu m . I re a s o n s fo r u s in g , a ttitu d e s to w a rd s d ru g s a n d a ttitu d e s
T h e re a re n o s im ila r s tu d ie s o fth e g e n e ra l p o p u la tio n to w a rd s d ru g -d e p e n d e n t p a tie n ts .
th a t c o u ld b e u s e d fo r c o m p a ris o n , th e re fo re , w e re v ie w e d T h e p re v a le n c e fig u re s a re s h o w n in T a b le s 1 a n e l 2 . s e v e ra l s tu d ie s o f d ru g u s e a m o n g u n iv e rs ity s tu d e n ts in A p a rt fro m a lc o h o l a n d to b a c c o , th e m o s t C O IT IIT Io n lyu s e e l g e n e ra l. I()-2 3U n fo rtu n a te ly , th e s e a ls o s u ffe r fro m s e rio u s s u b s ta n c e s w e re c a n n a b is a n d tra n q u iliz e rs , b o th o f w h ic h
m e th o d o lo g ic a l p ro b le m s , a s w a s p o in te d o u t b y A lm e id a w e re m o re c o m m o n ly u s e d b y s tu d e n ts in th e fin a l y e a rs F ilh 0 2 4 in a re v ie w o f d ru g m is u s e in B ra z il in 1 9 9 1 . T h e s e o f m e d ic a I s c h o o I.
p ro b le m s in c lu d e : u n re p re s e n ta tiv e s a m p le s , n o n - Q u a lita tiv e d a ta fro m th e fo c u s g ro u p s s u g g e s te c l th a t s ta n d a rd iz e d d e fin itio n s o f d ru g m is u s e , u s e o f n o n - c o m p e titiv e n e s s , h e a v y w o rk lo a d s , c o n ta c t w ith p a tie n ts , v a lid a te d q u e s tio n n a ire s o f u n k n o w n re lia b ility , u n c le a r a n d th e p ro x im ity o f th e re s id e n c y e x a lT Iin a tio n w e re s e e n d a ta c o lIe c tio n m e th o d s a n d in a d e q u a te d a ta a n a ly s is . a s c o n trib ,u to ry fa c to rs fo r d ru g u s e .
Ai
th e S a lT Ie titT Ie , C o n s e q u e n tly , o n ly th e lT IO re m e th o d o lo g ic a lly rig o ro u s s tu d e n ts re p o rte d th a t th e ir s c ie n tific k n o w le d g e o f th e s tu d y b y M a g a lh ã e s e t a I., 1 9 9 1 2 0 w ill b e u s e d fo r e ffe c ts o fth e s e s u b s ta n c e s p ro te c te d th e m fro tT I d e v e lo p in g c o m p a ris o n . T h e s tu d ie s b y M a g a lh ã e s e t a I., 1 9 9 1 , d ru g -re la te d p ro b le m s .M e s q u ita e t a l., 1 9 9 5 a n d A n d ra d e e t a I., 1 9 9 5 w ill b e A lo g is tic re g re s s io n a n a ly s is re v e a le d th a t th re e e x a m in e d in m o re d e ta il in th e fo llo w in g s e c tio n . fa c to rs w e re a s s o c ia te d w ith a g re a te r p ro b a b ility o f e lru g
M a g a lh ã e s e t a I ., 1 9 9 1 . T h is s tu d y w a s u n d e rta k e n u s e , e x c lu d i,n g c a n n a b is a n d th e u s e o f in h a la n ts a n e l u s in g a re p re s e n ta tiv e s a m p le (n = 1 ,0 6 9 ) o f u n iv e rs ity tra n q u iliz e rs in th e p a s t 1 2 m o n th s : b e in g to w a rd s th e e n e l s tu d e n ts fro m v a rio u s fa c u ltie s in th e c ity o f S ã o P a u lo , o f th e m e d ic a I c o u rs e , a p p ro v in g o f d ru g e x p e rilT Ie n ta tio n u s in g a n in s tru m e n t b a s e d o n th a t re c o m m e n d e d fo r s tu d e n t b y o th e rs , a n d fre q u e n tin g b a rs a s a le is u re a c tiv ity . O n e s u rv e y s b y th e W o rld H e a lth O rg a n iz a tio n (W H O ).2 5 T h e fa c to r w a s a s s o c ia te d w ith a re d u c e d ris k o f d ru g ta k in g ; a u th o rs e x a m in e d th e p re v a le n c e o f th e n o n -m e d ic a l u s e n o t h a v in g s o m e o n e ,to c o n fid e in a b o u t p e rs o n a l p ro b le n ls . o f 1 1 p s y c h o a c tiv e s u b s ta n c e s o v e r tw o tim e p e rio d s : A n d r a d e , 1 9 9 5 - T h is s tu d y , u n d e rta k e n in 1 9 9 4 , life titn e u s e a n d u s e in th e p re v io u s th re e m o n th s . T h e e n c o m p a s s e d a ll s tu d e n ts a t n in e ln e d ic a l s c h o o ls in th e p re v a le n c e o f u s e o f th e v a rio u s
s u b s ta n c e s is s h o w n in T a b le 1 . A m o n g th e illic it d ru g s , c a n n a b is w a s th e m o s t c o m m o n ly u s e d , w ith 2 6 p e rc e n t re p o rtin g life tim e u s e , o f w h o m 4 p e rc e n t d e s c rib e d th e m s e lv e s a s h e a v y u s e rs (s m o k in g o n c e o r m o re p e r d a y ). F a c to rs th a t w e re a s s o c ia te d w ith IT IO refre q u e n t d ru g u s e w e re : h o lid a y s , tra v e lin g , frie n d s , e a s e o f o b ta in in g th e d ru g a n d p e rs o n a l c ris e s . F a c to rs w h ic h s e e m e d to p ro te c t a g a in s t d ru g u s e w e re : liv in g w ith fa m iJ y , h a v in g a g irlfrie n d o r b o y frie n d , h e a lth p ro b le ln s a n d w o rk p ro b le m s .
M e s q u ita e t a I ., 1 9 9 5 - T h is
s tu d y w a s u n d e rta k e n in 1 9 9 1 * D i,fferences betw een M agalhães et al.'s and A ndrade's studies
(J<2
test, a m o n g s t a lI s tu d e n ts a t th e S c h o o l p< 0.01).M E S Q U IT A , A .M .; LA R A N JE IR A ; R .; D U N N ,J. - P sychoactive drug use by m edicai
students: a review of the national and internationalliterature
Table 2
Use of psychoactive substances by 8razilian m edicai students in Andrade's (A) and M esquita et al.'s (8)
sam ples, by academ ic year.
Substance Type of use
1st
A
B
2nd
A
B
3rd
A
B
Year
4th
A
B
5th
A
B
6th
A
B
Alcohol Lifetim e 84 84 90 80 87 92 89 91 92 91 92 89
Past 12 m onths 78 78 84 77 79 87 83 86 87 83 87 87
Past 30 days 43 73 48 68 45 80 48 77 51 73 53 74
Tobacco Lifetim e 34 32 39 29 41 46 35 34 45 52 43 48
Past 12 m onths 21 17 22 14 25 23 20 17 29 17 22 17
Past 30 days 9 16 9 7 9 12 8 14 12 4 7 11
Cannabis Lifetim e 18 7 23 12 26 24 23 30 30 20 29 24
Past 12 m onths 11 5 17 10 20 15 15 19 20 4 14 14
Past 30 days 6 3 9 7 9 12 8 14 12 4 7 11
Solvents Lifetim e 26 2'0 33 20 32 28 29 24 35 19 34 28
Past 12 m onths 19 9 23 15 20 18 16 9 22 5 17 13
Past 30 days 10 7 12 11 10 7 6 9 12 5 9 8
Tranquilizers Lifetim e 7 4 7 4 11 8 13 9 12 17 17 24
Past 12 m onths 4 1 5 2 7 8 9 7 6 13 1 13
Past 30 days 2 1 2 2 4 7 4 6 3 11 8 11
Am phetam ines Lifetim e 3 1 6 1 10 5 9 7 8 7 12 9
Past 12 m onths 2 O 5 1 7 5 5 4 6 3 7 4
Past 30 days 1 O 1 O 4 4 1 3 3 2 2 4
Cocaine Lifetim e 2 1 4 O 6 5 4 7 6 4 6 7
Past 12 m onths O O 2 O 3 3 3 5 4 1 3 5
Past 30 days O O 1 O 2 3 1 4 2 2 2 3
S ta te o f S ã o P a u lo a n d h a d a re sp o n se ra te o f 7 1 p e rc e n t
(n = 3 ,7 2 5 ). T h e a u th o r u se d a m o d ifie d v e rsio n o f th e
in stru m e n t th a t h a d b e e n u se d b y M e sq u ita e t a I. (1 9 9 5 ).
Q u e stio n s w e re a sk e d a b o u t th e u se o f th e sa m e 1 1
su b sta n c e s o v e r th e sa m e th re e tiln e p e rio d s d e sc rib e d in
th e p re v io u s stu d y . T h e fu H sta tistic a l a n a ly sis o f th e se re su lts
h a s y e t to b e p u b lish e d a n d th e p re v a le n c e fig u re s p re se n te d
h e re in T a b le s 1 , 2 a n d 4 a re d e riv e d fro m th e fin a l re p o rt
th a t w a s se n t to th e stu d y 's re se a rc h fu n d in g b o d y .
COM PARISONS BETW EEN THE THREE
STUDIES
O n e o f th e p ro b le m s in c o m p a rin g th e stu d ie s o f
M e sq u ita e t a I. a n d A n d ra d e is th a t so m e o f th e stu d e n ts
in te rv ie w e d in th e fo rm e r w e re a lso in te rv ie w e d in th e
la tte r. H o w e v e r, a s th e re w a s a th re e -y e a r tiln e g a p b e tw e e n
th e stu d ie s, w e c a lc u la te th a t th is o v e rla p re p re se n ts n o
m o re th a n 1 0 p e rc e n t o f A n d ra d e 's to ta l sa m p le .
A s th e q u e stio n n a ire s in a ll th re e stu d ie s w e re
c o m p le te d a n o n Y ln o u sly , th e re w a s n o w a y o f a p p ro a c h in g
th o se stu d e n ts w h o w e re n o t p re se n t o n th e d a y o f th e
su rv e y . S in c e v a rio u s a u th o rs h a v e su g g e ste d th a t in stu d ie s
o f stu d e n t p o p u la tio n s, th o se stu d e n ts w h o a re a b se n t o n
th e d a y o f th e su rv e y a re m o re lik e ly to b e d ru g L lse rs,1 .5
th e tru e p re v a le n c e o f d ru g m isu se m a y h a v e b e e n
u n d e re sti m a te d .
C o m p a rin g th e tw o stu d ie s o f m e d ic a I stu d e n ts (se e
T a b le 2 ), th e fo llo w in g sim ila ritie s c a n b e se e n : th e
p re v a le n c e o f d ru g u se te n d s to in c re a se fro m th e first to
six th y e a r fo r m o st su b sta n c e s a n d o v e r In o st tim e in te rv a ls;
th e se q u e n c e o f life tim e d ru g u se fro ln h ig h e st to 1 0 w e st
p re v a le n c e fig u re s fo llo w s th e sa ln e o rd e r: a lc o h o l,
to b a c c o , s o lv e n ts , c a n n a b is , tra n q u iliz e rs , a m p h e ta m in e s
to c o c a in e ; a n d th e re te n d s to b e a p ro m in e n t in c re a s e in
th e p re v a Ie n c e o f tra n q u iIiz e r u s e in th e fifth a n d s ix th
y e a rs . T h e re m a rk a b le in c re a s e in th e re c e n t u s e o f
tra n q u iliz e rs c a n b e v e rifie d in b o th s tu d ie s .
In T a b Ie 1 , s ta tis tic a I c o m p a ris o n s u s in g th e c h
i-s q u a re d te s t b e tw e e n u n iv e rs ity s tu d e n ts in g e n e ra l a n d
m e d ic a I s tu d e n ts s h o w th a t m e d ic a I s tu d e n ts h a v e a h ig h e r
life tim e p re v a Ie n c e o f a Ic o h o l u s e ( 8 9 v s . 8 2 p e rc e n t,
p < O .O I) a n d a Io w e r life tim e p re v a le n c e o f c o c a in e u s e
( 5 v s . 1 0 p e rc e n t, p < O .O l). U n iv e rs ity s tu d e n ts s h o w th e S a lT Ie d e c lin in g a rd e r o f p re v a le n c e o f s u b s ta n c e m is u s e
fro m a lc o h o l to c o c a in e , a s s e e n in th e o th e r tw o s tu d ie s .
A Ith o u g h s e v e ra l a u th o rs h a v e o b s e rv e d th a t u s e o f
p re s c rip tio n d ru g s is m o re c o m m o n a m o n g m e d ic a I s tu d e n ts ,1 .5 .1 2 w e w e re u n a b Ie to in v e s tig a te th is , a s
M a g a lh ã e s e t a I. d id n o t a s k a s e p a ra te q u e s tio n a b o u t tra n q u iIiz e r u s e , b u t c o m b in e d it w ith a m p h e ta m in e u s e .
B o th M e s q u ita e t a I. a n d A n d ra d e d e m o n s tra te d th e re Ia tiv e Iy h ig h p re v a le n c e o f tra n q u iIiz e r u s e a m o n g
m e d ic a I s tu d e n ts ( 1 1 a n d 8 p e rc e n t in th e p a s t 3 0 d a y s , re s p e c tiv e Iy ).
M a g a lh ã e s e t a l.'s 1 9 9 1 s tu d y lT Ia rk s a tu rn in g p o in t
in th is re s p e c t. T h e y w e re c o n c e rn e d a b o u t s u c h fa c to rs
a s s a m p Iin g m e th o d s th a t a llo w d a ta to b e c o lle c te d o n
re p re s e n ta tiv e s a m p le s o f th e ta rg e t p o p u la tio n , th u s
p e rm ittin g a g re a te r d e g re e o f g e n e ra liz a tio n , th e u s e o f
v a Iid a te d q u e s tio n n a ire s , a n d th e fo rm u la tio n o f tT Io re
p re c is e o b je c tiv e s . M o re re c e n t s tu d ie s , s u c h a s M e s q u ita
e t a I., h a v e a d o p te d a m ix tu re o f q u a n tita tiv e a n d q u a lita tiv e
m e th o d s to m o re fu lly in v e s tig a te th e p ro b le m .
T h e s tu d ie s o f M e s q u ita e t a l. a n d A n d ra d e h a v e
e n a b le d fu rth e r a d v a n c e s , in c lu d in g th e fo llo w in g : (I) th e
u s e o f m o re s p e c ific h y p o th e s e s ; ( 2 ) m o re rig o ro u s a n e l
d iv e rs e s ta tis tic a l m e th o d s , e .g . lo g is tic re g re s s io n a n a ly s is ,
w h ic h p e rm it m o re c o m p Ie x a n a Iy s e s th a n s im p le b iv a ria te
c o rre la tio n s ; a n d (3 ) s ta n d a rd iz e d tT Ie th o d o lo g ie s w h ic h
a llo w fo r th e re p ro d u c tio n a n d c o m p a ris o n o f re s u lts w ith
th o s e o f o th e r s tu d ie s .
It is im p o rta n t to p o in t o u t th a t m e d ic a I s tu e le n ts d iffe r
fro m u n iv e rs ity s tu d e n ts m a in ly in re Ia tio n to a lc o h o l a n e l
life tim e c o c a in e u s e . F in a lly , life tim e u s e o f b o th c o c a in e
a n d a m p h e ta m in e s , a s u s e o f tra n q u iliz e rs d u rin g th e la s t 3 0 d a y s , p re s e n te d c o n s id e ra b ly h ig h e r ra te s a m o n g
m e d ic a I s tu d e n ts .
G E N E R A L C O N S ID E R A T IO N S A B O U T
B R A Z IL IA N S T U D IE S IN T E R N A T IO N A L S T U D IE S O F D R U G U S E
A M O N G M E D IC A L S T U D E N T S
U s in g th e d a ta b a n k s M e d lin e a n d L iIa c s , 2 2 a rtic le s
p u b lis h e d b e tw e e n 1 9 7 0 a n d 1 9 9 5 o n d ru g u s e a m o n g n o n
-B ra z ilia n m e d ic a I s tu d e n ts w e re fo u n d . M o s t o f th e lT IO re re c e n t s tu d ie s w e re c o n d u c te d in th e U n ite d S ta te s ,1 .2 .4 .5 .1 2 .2 ()
w ith th e e x c e p tio n o f o n e s tu d y u n d e rta k e n in C u b a /) a n e l
a n o th e r th a t u s e d a s a m p le o b ta in e d fro tT I 4 2 d itfe re n t
c o u n trie s .2 7
S a m p Ie s : In th e s tu d ie s b y B a ld w in
e t a L I a n d M c A u liffe e t a L ,5 s tra tifie e l
ra n d o m s a m p le s w e re u s e d b a s e e i o n c rite ria s u c h a s : g e o g ra p h ic re g io n ,
m e d ic a I s c h o o I s iz e , ty p e o f s c h o o l
(p riv a te a r p u b lic ) a n d th e p ro p o rtio n o f
fe m a Ie s tu d e n ts . In o th e r s tu d ie s , s a m p le
s e le c tio n w a s s im p Iy b a s e d o n s p e c ific
m e d ic a I s c h o o ls a n e l s p e c ific y e a rs . In th e
s tu d y b y C ro fto n e t a I. ,2 7 n o in fo rm a tio n
is p ro v id e d a s to h o w th e s a tT Ip le w a s s e le c te d .
D a ta c o lle c tio n : In a lI th e s tu d ie s , w ith th e e x c e p tio n o fth a t o fC ro fto n e t a l.,2 7
R e c e n t u s e
L o w e s t H ig h e s t
6 4 8 8 7 1 3 . 7 9 3 . 6 3 1 2 . 8 0 . 3 3
O
20
P r e v a le n c e
L ife tim e u s e
L o w e s t H ig h e s t
9 6 9 8 . 1
32
55
5 3 6 8 2 0 3 7 2 0 2 3 1 9 3 7
T a b le 3
H ig h e s t a n d lo w e s t p r e v a le n c e f ig u r e s f o r p s y c h o a c t iv e s u b s t a n c e u s e a m o n g m e d ic a i s t u d e n t s f o u n d in t h e in t e r n a t io n a l lit e r a t u r e
S u b s ta n c e
T h e e a rIy s tu d ie s o f d ru g u s e in B ra z iI te n d e d to b e fa irly s im p le p re v a le n c e s tu d ie s , o fte n w ith u n c le a r
o b je c tiv e s a n d Iittle th o u g h t g iv e n to m e th o d o lo g ic a l
d e s ig n o T h e s e s tu d ie s ra re ly d id m o re th a n a tte m p t to
c o rre la te d ru g u s e w ith s u c h v a ria b le s a s s o c ia l c la s s , a n d
u s e d s ta tis tic a l a n a ly s e s n o m o re c o m p lic a te d th a n th e c h i-s q u a re d te s te
A lc o h o l
T o b a c c o
C a n n a b is
T r a n q u iliz e r s
A m p h e ta m in e s
C o c a in e
M E S Q U IT A , A .M .; L A R A N J E IR A , R .; D U N N ,J . - P s y c h o a c tiv e d r u g u s e b y m e d ic a i s tu d e n ts : a r e v ie w o f th e n a tio n a l a n d in te r n a tio n a llite r a tu r e
2 2 1 O 1 9 7 2 6 6 2 2 1 0
32
1 0 2 5 5 1 3 1 098
9 4 8 7 B a ld w in e t a i.1 9 9 1
(n = 2 ,0 4 6 )
V a ria b le s stu d ie d : T h e
I1 1 a jo rity o f stu d ie s, w ith th e
e x c e p tio n o f C ro fto n e t a l.:2 1
a n d M e n e n d e z a n d C a la b u c h ,c )
a sk e d q u e stio n s a b o u t th e u se
o f lic it d ru g s, i llic it d ru g s a n d
n o n p re sc rip tio n I1 1 e d ic a tio n s.
L ife tim e u se a n d u se d u rin g th e
p re v io u s y e a r a n d p re v io u s 3 0
d a y s w e re th e m o st C O I1 1 I1 l0 n ly
u se d tiI1 1 e in te rv a ls. S o n le
stu d ie s a lso a sk e d a b o u t
life tim e a b u se a n d d e p e n d e n c e .
T h is w a s a sse sse d e ith e r b y
I1 1 e a n s o f se lf-re p o rt O I' b y u se
o f th e C A G E q u e stio n n a i re fo r
a lc o h o l d e p e n d e n c e .
S o c io d e I1 1 o g ra p h ic d a te
w e re c o lle c te d in a ll su rv e y s.
O th e r stu d ie d a sp e c ts in c lu d e d :
a c c e ss to d ru g s, re a so n s fo r
u se , a ttitu d e s to w a rd s d ru g u se
b y p h y sic ia n s, k n o w le d g e o f
p re v e n tio n a n d tre a tn le n t
p ro g ra I1 1 s, p e rso n a lity fa c to rs
a sso c ia te d ,w ith a b u se i
d e p e n d e n c y , k n o w le ,d g e o f
d ru g -re la te d d a n g e rs, a n d th e
ty p e o f d ru g a b u se tra in in g
o ffe re d b y th e I1 1 e d ic a l sc h o o l.
P rin c ip a l fin d in g s: A s
c a n b e se e n in T a b le 3 , w ith th e
e x c e p tio n o f a m p h e ta n lin e s,
th e re is a re l1 1 a rk a b le d e g re e o f
v a ria tio n in th e u se o f a li
re p o rte d su b sta n c e s, b e it fo r
1i fe tiI1 1 e o r re c e n t u se . B e c a u se
o f th e d iffe re n c e s in th e w a y
th e stu d ie s w e re u n d e rta k e n , it
is d iffic u lt to in te rp re t h o w 1 1 1 u c h o f th is v a ria tio n is re a l,
a n d h o w m u c h is a I1 1 e th o d o lo g ic a l iI1 1 p lic a tio n . M a d d u x
e t a I.12fo u n d a p re v a le n c e o f su b sta n c e a b u se o f 1I p e rc e n t, w h ic h in c o n ju n c tio n w ith illic it su b sta n c e u se w a s
a sso c ia te d w ith a d e p re ssiv e a ffe c t. M c A u liffe e t a I.5fo u n d
th a t 1 6 .5 p e rc e n t o f stu d e n ts h a d I1 1 e t c rite ria fo r d ru g a b u se
a t S O llle tim e d u rin g th e ir li v e s. T h e S a llle a u th o rs a lso
fo u n d th a t 5 .2 p e rc e n t o f stu d e n ts re p o rte d h a v in g
e x p e rie n c e d d ru g d e p e n d e n c y , w h ic h c O l1 1 p a re s to tl:e 2 .8
p e rc e n t o f stu d e n ts w h o w e re fo u n d to b e C A G E p o si ti v e
in M e n e n d e z a n d C a la b u c h 's stu d y .()
C o m p a rin g tw o N o rth A ln e ric a n g ro u p s, B a ld w in e t
a1.I Co n f i r n l e d t h a t 1 1 1e d i c a Is t u d e n t s h a d a h i g h e r 6 3 2 1 2 7 2 1 7 1 2 8 2 9 1 4 7 4 3
22
8 9 287
5 3 A n d ra d e1 9 9 5
(n = 3 ,7 2 5 )
L ife tim e *
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s L ife tim e
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s *
L ife tim e *
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s ** L ife tim e *
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s L ife tim e *
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s T y p e o f U s e
L ife tim e *
P a s t 1 2 m o n th s *
P a s t 3 0 d a y s *
Table 4
Comparison of the prevalence of psychoactive substance use among
final-year medicai students from one Brazilian and one North American study.
se lf-c o m p le te d , a n o n y m o u s q u e stio n n a ire s w e re u se d w h ic h
w e re 1 1 1a i le d to stu d e n ts. In so m e c a se s, th e stu d e n ts w e re
p a id to p a rtic ip a te in th e stu d y . S tu d e n ts w h o d id n o t re tu rn
th e q u e stio n n a ire w e re th e n m a ile d a n a d d itio n a l tw o c o p ie s
b e fo re b e in g c o n sid e re d n o n -re sp o n d e rs. T h e re sp o n se ra te s
v a rie d fro m 3 7 to 1 0 0 p e rc e n t. T h e q u e stio n n a ire s h a d
g e n e ra lly b e e n a d a p te d fro m th o se u se d in p re v io u s stu d e n t
su rv e y s, th u s fa c ilita tin g c O I1 1 p a riso n b e tw e e n stu d ie s.
In C ro fto n e t a I.'s I1 1 u lti-c e n te r a n d In u lti-c o u n try
stu d y , th e m e th o d o f d a ta c o lle c tio n u se d w a s le ft to th e
d isc re tio n o f th e lo c a l stu d y c o o rd in a to rs. F u rth e r d e ta ils
a re n o t g iv e n b e y o n d th e in fo rm a tio n th a t th e q u e stio n
-n a ire s w e re c O I1 1 p le te d in th e stu d e n ts' c la ss ro o m s.
*
X
2, p < 0 .0 1** F is h e r's E x a c t T e s t, o n e -ta ile d , p = 0 .0 0 1 4 2 A m p h e ta m in e s
C o c a in e T ra n q u iliz e rs C a n n a b is A lc o h o l
T o b a c c o S u b s ta n c e
p ro b a b ility o fu sin g a lc o h o l, tra n q u iliz e rs a n d p sy c h e d e lic
d ru g s (e x c lu d in g L S D ).
A c c o rd in g to M c A u liffe e t a I.'s stu d y ,5
" e x p e rim e n ta tio n " w a s th e m o st c o m m o n ly re p o rte d
re a so n fo r u sin g d ru g s, a n d re c re a tio n a l u se w a s fo u n d to
b e tw ic e a s c o m m o n a s se lf-m e d ic a tio n . K o ry a n d C ra n d a lI,
1 9 8 6 ,4 fo u n d th a t re c re a tio n a l u se o f a n in d iv id u a l d ru g
w a s a p o sitiv e p re d ic to r o f th e u se o f o th e r su b sta n c e s.
M a d d u x e t a I., 1 9 8 6 ,1 2 sh o w e d th a t first-tim e u se o f
c o c a in e a n d b e n z o d ia z e p in e s o c c u rre d m o re c o m m o n ly
d u rin g ln e d ic a l sc h o o l th a n in h ig h sc h o o l. T h e a u th o rs
su g g e ste d th a t first-tim e b e n z o d ia z e p in e u se d u rin g
tn e d ic a l sc h o o l w a s p ro b a b ly d u e to e a se o f a c c e ss to th e se
d ru g s, w h ile first-tim e c o c a in e u se w a s m o re d e p e n d e n t
o n a g e , a te n d e n c y a lso o b se rv e d in n o n -m e d ic a l stu d e n ts.
M c A u liffe e t a I. 5 d isc o v e re d th a t th e p re v a le n c e o f
d ru g u se w a s e v e n h ig h e r in th e c lin ic a I y e a rs o f m e d ic a I
sc h o o l, w h ile K o ry a n d C ra n d a 1 I4 fo u n d th a t d ru g u se w a s
a sso c ia te d w ith a g e , g e n d e r, a n d a g re a te r n u m b e r o f
a b se n c e s.
C O M P A R IS O N O F T H E B R A Z IL IA N A N D N O R T H A M E R IC A N S T U D IE S
T o fa c ilita te c o m p a riso n b e tw e e n th e B ra z ilia n a n d
N o rth A m e ric a n stu d ie s, B a ld w in e t a l.'s stu d y w ilI b e
fo c u se d o n b e c a u se a lth o u g h it o n ly p ro v id e s d a ta o n fin a l
y e a r stu d e n ts, it h a s a Ia rg e re p re se n ta tiv e sa m p le a n d u se s
th e sa m e c rite ria fo r d ru g u se .
B a ld w in e t a I.. 1 9 9 1 -th is stu d y w a s u n d e rta k e n in
1 9 8 7 a n d u se d a la rg e n a tio n a l sa m p le o f m e d ic a I stu d e n ts
(n = 2 ,0 4 6 ) fro m 2 3 N o rth A m e ric a n m e d ic a I sc h o o ls.
S e le c tio n c rite ria in c lu d e d th e g e o g ra p h ic a l re g io n in
w h ic h th e sc h o o l w a s lo c a te d , siz e , a n d w h e th e r th e
in stitu tio n w a s p riv a te o r p u b lic o T h e sa m p Iin g p ro c e d u re
a Iso to o k in to a c c o u n t th e stu d e n t se x ra tio . D a ta w e re
c o lIe c te d u sin g a n o n y m o u s, se lf-c o m p Ie te d q u e stio n n a ire s
re tu rn e d b y m a il.
T a b le 4 c o m p a re s th e re su lts o fB a Id w in e t a l.'s stu d y
w ith th e d a ta o n fin a l y e a r stu d e n ts fro m A n d ra d e 's stu d y .
In te rm s o f life tim e u se , N o rth A m e ric a n stu d e n ts sh o w e d
a sig n ific a n tly h ig h e r p re v a le n c e fo r th e u se o f a lc o h o l,
to b a c c o , c a n n a b is, a m p h e ta m in e s a n d c o c a in e (p < O .O O l).
B ra z ilia n stu d e n ts sh o w e d a h ig h e r 1 2 -m o n th p re v a le n c e
fo r to b a c c o , tra n q u iliz e r a n d a m p h e ta m in e u se , a n d a
h ig h e r 3 0 -d a y p re v a le n c e fo r tra n q u iIiz e rs a n d
a ln p h e ta m in e s u se .
M E S Q U IT A , A .M .; L A R A N J E IR A , R .; D U N N ,J . - P s y c h o a c tiv e d r u g u s e b y m e d ic a i
s tu d e n ts : a r e v ie w o f th e n a tio n a l a n d in te r n a tio n a llite r a tu r e
A lth o u g h th e d iffe re n c e s in th e life titn e p re v a le n c e
o f d ru g u se b e tw e e n th e tw o p o p u la tio n s (in p a rtic u la r
c a n n a b is a n d c o c a in e ) a re g re a te r th a n p a st 3 0 d a y s u se ,
th e B ra z ilia n sa tn p le h a d a g re a te r te n d e n c y to w a re ls
re c e n t n o n -m e d ic a l u se o f tra n q u iliz e rs a n e l
a m p h e ta m in e s. T h e se re su lts m a y su g g e st a g re a te r
te n d e n c y to w a rd s d ru g e x p e rim e n ta tio n a ln o n g N o rth
A m e ric a n stu d e n ts, a n d p o ssib ly m o re d e p e n d e n c y
p ro b Ie m s a m o n g th e B ra z ilia n sa m p le , in re g a rd s to th e se
m e d ic a tio n s.
M E T H O D O L O G IC A L C O N S ID E R A T IO N S O F
T H E IN T E R N A T IO N A L S T U D IE S
A fa c to r c o m m o n to v irtu a lIy a lI th e stu d ie s is th e
u se o fa n o n y m o u s, se lf-c o m p le te d q u e stio n n a ire s w h ic h
w e re m a ile d b a c k to th e re se a rc h g ro u p s. A lth o u g h th is
ln e th o d a llo w s re a c h in g a la rg e r p o p u la tio n a n e l is
w ith o u t a d o u b t c h e a p e r, th e re lia b ility o f so m e o f th e
re sp o n se s m a y b e q u e stio n a b le . F u rth e r, th e re sp o n se
ra te is o fte n lo w e r th a n th e " in lo c o " e la ta c o Ile c tio n
p ro c e d u re , a n d th e se stu d ie s ra re ly c o m p a re th e
n o n re sp o n d e n t a n d re sp o n d e n t g ro u p s a s to so c io
-d e m o g ra p h ic v a ria b le s.
It is a lso im p o rta n t to q u e stio n th e p re c isio n o f th e
d a ta c o lle c te d , a s th e a u th o rs o f th e stu d ie s n e v e r p re se n te e i
a d e fin itio n o f th e a b u se a n d d e p e n d e n c y c rite ria to th e
re sp o n d e n ts. O th e r stu d ie s h a v e sh o w n th a t tn e d ic a l
stu d e n ts h a v e a g e n e ra l la c k o f k n o w le d g e in re la tio n to
d ru g s a n d d ru g ln isu se ,2 X -3 2in c lu d in g d iffic u lty in n la k in g
su b sta n c e a b u se -re la te d d ia g n o se s.3 1 -3 4 T h e re fo re , se
lf-re p o rts o f a b u se a n d d e p e n d e n c y p ro b a b ly la c k v a lie lity
a n d re lia b ility , a n d sh o u Id o n ly b e m a d e u sin g v a lie la te e l
d ia g n o stic sc a Ie s.
P re c ise q u e stio n in g o f th e re a so n s fo r d ru g u se is
o fte n Ia c k in g . M o st stu d ie s c a n b e c ritic iz e e l fo r n o t
d iffe re n tia tin g e x p e rim e n ta l, re c re a tio n a I, se lf-tre a ttn e n t
a n d u se o f d ru g s fo r th e p u rp o se o f im p ro v in g p e rfo n n a n c e ,
w h ic h w o u Id p e rm it a m o re p re c ise c o n c lu sio n a s to th e
g ro u p s, situ a tio n s a n d su b sta n c e s u rg e n tly re q u irin g
a tte n tio n .
S e v e ra l o f th e stu d ie s sh o w th a t in itia tio n in to e lru g
u se o c c u rs d u rin g m e d ic a I sc h o o I, b u t b e c a u se c o m p a riso n
d a ta fro ln a g e -a n d -so c ia I-c la ss-m a tc h e e l n o n -ln e d ic a l
stu d e n ts is ra re Iy p re se n te d , it is d iffic u lt to k n o w h o w
m u c h e x p e rie n c e s p a rtic u la r to tn e d ic a l
school
a rere sp o n sib le fo r th is.
D IS C U S S IO N
T h e c u r r e n t p ic tu r e o f p s y c h o a c tiv e s u b s ta n c e u s e
a ln o n g m e d ic a I s tu d e n ts , in s p ite o f a lI n a tio n a l a n d
in te r n a tio n a l s tu d ie s , is s tilI f a r f r o m c le a r . T h e r e s u lts f r o m
b o th B r a z ilia n a n d in te r n a tio n a l s tu d ie s a r e r e m a r k a b ly
c o n s is te n t, a lth o u g h th e r e a r e s o m e n o ta b le d if f e r e n c e s in
th e p r e v a le n c e o f c a n n a b is a n d c o c a in e u s e b y N o r th
A m e r ic a n a n d B r a z ilia n s tu d e n ts .
B y a n d la r g e , a lc o h o l is th e d r u g w ith th e h ig h e s t
lif e tim e p r e v a le n c e a n d s titn u la n ts th e lo w e s t. O f p a r tic u la r
c o n c e r n a ln o n g th e B r a z ilia n s tu d ie s is th e r e la tiv e ly h ig h
p r e v a le n c e o f r e c e n t tr a n q u iliz e r a n d a ln p h e ta m in e u s e ,
w h ic h in c r e a s e s w ith tiln e s p e n t a t m e d ic a I s c h o o l. I n d e e c t,
th e r e is a g e n e r a l tr e n d f o r th e r e p o r tin g o f d r u g u s e to
in c r e a s e f o r a lI c a te g o r ie s a s s tu d e n ts p a s s f r o m th e f ir s t
to th e f in a l y e a r . I t is im p o r ta n t to p o in t o u t th a t th e
B r a z ilia n s tu d ie s w e r e n o t c a r r ie d o u t w ith n a tio n a l
s a m p le s , a n d th e r e f o r e th e r e s u lts m a y r e f le c t r e g io n a l
tr e n d s .
T h e h ig h e r p r e v a le n c e r a te s o f n o n - m e d ic a l u s e o f
a m p h e ta m in e s a n d tr a n q u iliz e r s in th e B r a z ilia n s a m p le
m a y b e a s s o c ia te d w ith v a r io u s f a c to r s : l) a lth o u g h
c o n tr o lI in g a c c e s s to th e s e s u b s ta n c e s h a s r e c e iv e d m o r e
a tte n tio n in th e p a s t f e w y e a r s , it is s tilI n o t d if f ic u lt to
o b ta in th e ln w ith o u t g o in g th r o u g h p r o p e r p r o c e d u r e s ; 2 )
th e is s u e o f d r u g m is u s e a m o n g m e d ic a I s tu d e n ts h a s b e e n
a d d r e s s e d b y D .S . s o c ie ty f o r m o r e th a n 2 0 y e a r s n o w ,3 .3 5
th r o u g h c o n f e r e n c e s , iln p le m e n ta tio n o f d r u g - u s e p o lic ie s
a t m e d ic a I s c h o o ls , a n d p r e v e n tio n p r o g r a m s . T h e r e f o r e ,
th e lo w e r p r e v a le n c e r a te s p r e s e n te d b y th e N o r th
A m e r ic a n s a m p le s lT la y r e tle c t th e r e s u lts o f th e s e a c tio n s ;
a n d th is d if f e r e n c e m a y a ls o b e v e r if ie d in th e g e n e r a l
p o p u la tio n , r e f le c tin g a m a jo r g o v e r n m e n ta l a n d s o c ia l
a ttitu d e to w a r d s d r u g u s e .
R e g a r d in g th e c o m p a r is o n o f th e p r e v a le n c e
p r e s e n te d b y th e B r a z ilia n s s a m p le s o f u n iv e r s ity a n d
ln e d ic a l s tu d e n ts , th e r e s e e m s to b e little d if f e r e n c e e x c e p t
f o r lif e tiln e u s e o f ' a lc o h o l a n d c o c a in e . T h e lo w e r
p r e v a le n c e r a te o f c o c a in e u s e v e r if ie d in th e m e d ic a I
s tu d e n ts ' s a m p le m a y b e r e la te d to th e ir e x p o s u r e d u r in g
th e ir tr a in in g to th e h a r m f u l e f f e c ts o f th is s u b s ta n c e .
H o w e v e r , th e ir in c r e a s e d k n o w le d g e o f th e e f f e c ts a n d
p r o p e r tie s o f m e d ic a tio n s s e e m s to g iv e th e m a f a ls e s e n s e
o f c o n tr o l o v e r th e ir o w n u s e o f th e s e s u b s ta n c e s .1 5 T h is ,
a llie d to f a c ilita te d a c c e s s to th e m e d ic a tio n s , e n h a n c e s
th e p r o b a b ility o f m e d ic a I s tu d e n ts e le c tin g th e m a s th e ir
d r u g s o f c h o ic e .
T h e h ig h e r p r e v a le n c e r a te s o b s e r v e d in th e la s t y e a r
o f ln e d ic a l s c h o o l ( th e s ix th y e a r in B r a z il) , \v h e n c o m p a r e d
to th e in itia l y e a r s , d e s e r v e c o n s id e r a tio n . D if f e r e n t le v e I s
S ã o P a u lo M e d ic a i J o u rn a l/R P M 1 1 5 (1 ): 1 3 5 6 -1 3 6 5 , 1 9 9 7
o f d r u g in v o lv e m e n t d u e to v a r io u s p e r s o n a l r e a s o n s3( ) a r e
e x p e c te d a c r o s s a lI g r o u p s o f s o c ie ty , a n d th e r e f o r e , th is
e f f e c t s h o u ld a ls o b e r e f le c te d in th e ln a jo r ity o f ln e d ic a l
s tu d e n ts a n d f a c u lty m e m b e r s , a s w e lI a s p r a c titio n e r s . lO
A s h a s a lr e a d y b e e n r e m a r k e d , th e r e is a c o n s p ic u o u s
la c k o f in f o r m a tio n a b o u t th e r e a s o n s f o r d r u g u s e , th e
c o n te x t in w h ic h it o c c u r s , th e p e r s o n a lity tr a its o f th o s e
in v o lv e d a n d h o w th e s e r e la te to o th e r r is k f a c to r s .
F u r th e r m o r e , o n c e d r u g u s e h a s b e e n in itia te d , little is
k n o w n a b o u t w h a t m a in ta in s th is b e h a v io r . T h e s e q u e s tio n s
p o in t to a r e a s w h e r e f u r th e r r e s e a r c h is n e e d e d , a n d a ls o
to th e n e e d to c o m b in e q u a n tita tiv e I n e th o d o I o g ie s w ith
q u a lita tiv e o n e s to o b ta in a ln o r e c O ln p le te p ic tu r e o f d r u g
u s e .
I n th e s tu d y b y M e s q u ita e t a I ., 1 9 9 1 ,1 5 s tu d e n ts
b e lie v e d th a t s tr e s s w a s a n iln p o r ta n t f a c to r in d r u g u s e , in
p a r tic u la r s tr e s s a s s o c ia te d w ith c O ln p e titiv e n e s s , th e g r e a t
n u m b e r o f h o u r s w o r k e d , c e r ta in a s p e c ts o f c lin ic a I w o r k ,
a n d th e p e n d in g r e s id e n c y e x a m . H o w e v e r , e v e n h e r e
s tu d e n ts m a y b e o v e r s im p lif y in g a n d r a tio n a liz in g th e
s itu a tio n . F o r e x a m p le , a r e th e r e a s o n s f o r u s in g c a n n a b is
th e s a m e a s th o s e f o r u s in g c o c a in e o r ln is u s in g a I c o h o l?
A s y e t w e a r e u n a b le to a n s w e r th e s e q u e s tio n s .
H o w e v e r , a m o r e th o r o u g h e v a lu a tio n o f th e r e a s o n s
f o r th e u s e o f th e s e d r u g s b y ln e d ic a l s tu d e n ts w o u ld s u r e ly
in d ic a te f a c to r s th a t in c r e a s e th e p r o b a b ility o f d r u g - r e la te d
p r o b le m s a s s o c ia te d w ith th e ln e d ic a l p r o f e s s io n a n e l
e n v ir o n lu e n t. T h a t I n e d ic a l s tu d e n ts e x p e r ie n c e
c o n s id e r a b le s tr e s s is w ith o u t q u e s tio n , a s h a s b e e n s h o w n
b y o th e r s tu d ie s .3 7 .3 XM c C u e , 1 9 8 2 ,3 x d e s c r ib e e l a v a r ie ty
o f s tr e s s e s th a t s tu d e n ts e x p e r ie n c e , f o r e x a ln p le : in tiln a te
a n d f r e q u e n t c o n ta c t w ith p a in a n d s u f f e r in g , p h y s ic a l a n d
e m o tio n a l c o n ta c t w ith p a tie n ts , d e a th , a n d th e u n c e r ta in ty
o f m u c h o f m e d ic a I s c ie n c e in c o n tr a s t to th e d e s ir e s th a t
p a tie n ts h a v e f o r c e r ta in ty a n d g u a r a n te e s .
I n o n e s tu d y o f B r a z ilia n m e d ic a I s tu d e n ts , M a r tin s ,
1 9 9 4 ,3 7 f o u n d th r e e ln a in a r e a s in w h ic h r e s ie le n ts
e x p r e s s e d d if f ic u ltie s : b r e a k in g b a d n e w s , tr e a tin g p a tie n ts
w ith te r m in a l d is e a s e , a n d th e f e a r o f c o n tr a c tin g in f e c tio u s
d is e a s e s . T h e r e s id e n ts a I s o p o in te d to tw o p a r tic u la r
s tr e s s e s : f e a r o f m a k in g a ln is ta k e a n d la c k o f tiln e to s p e n e l
w ith f a m ily a n d f r ie n d s .
D r u g u s e b y m e d ic a I s tu d e n ts c a n c a u s e a v a r ie ty o f
p r o b le m s , d e p e n d in g o n th e d e g r e e o f in v o lv e ln e n t th a t
th e s tu d e n t h a s w ith th e d r u g . T h e e f f e c ts o f o c c a s io n a I
u s e la r g e ly d e p e n d o n th e c ir c u m s ta n c e s in w h ic h h e u s e s
th e d r u g , b u t m a y r a n g e f r o ln n o d is c e r n ib le e f f e c t to a
s e r io u s im p a ir ln e n t in a c a d e ln ic p e r f o r ln a n c e a n e l
c o n c e n tr a tio n d if f ic u ltie s . T h e r e is a I s o a n in c r e a s e d r is k
o f a b u s e o r e v e n d e p e n d e n c y la te r in lif e , w ith th e
a s s o c ia te d p e r s o n a l a n d s o c ia l c O ln p lic a tio n s th a t e n s u e .
E a r ly d e te c tio n o f d r u g p r o b le ln s f o r th is p o p u I a tio n ,
M E S Q U IT A , A .M .; L A R A N J E IR A , R .; D U N N ,J . - P s y c h o a c tiv e d ru g u s e b y m e d ic a i
ideally w hile the student is still in m edicaI schooI, should
be a priority of any drug prevention/intervention program o
To better facilitate such early detection, there is an
urgent need for research investigating the risk factors
associated w ith initiation into drug use. Such studies need
to go beyond the confines of m erely exam ining factors
related to the pressures of m edicaI training, and look at
factors that predate entry into m edicaI school, such as
fam ily problem s, personality traits and prior
experim entation w ith other drugs.
M ost m edicaI schools in B razil lack a structural
fram ew ork w hich w ould allow students w ith drug
problem s to be identified. O ne possibility w ould be to have
a type of tutorial system , in w hich a designated
professional, w ith a pastoral/counselling function, w ould
m eet w ith a sm all group of students on a regular basis
from the start of the course untiI the end. This type of
approach w ould perm it the developm ent of a m ore trusting
and confidential relationship than is norm ally possible w ith
academ ic staff. Such a professional w ould be ideally placed
to identify students w ith drug or other psychological
problem s, and to offer treatm ent w here appropriate.
Treatm ent w ould have to be com pletely confidential and
held aw ay from school prem ises to ensure that students
w ould not be identified as "drug addicts" by their
cIassm ates.
W hen the person w ho identifies drug m isuse in a
student is a physician, his or her ow n attitudes tow ard,
and personal experience w ith, drug use com e into play.
Physicians w ith m ore liberal attitudes to drug use and those
w ho have experim ented w ith drugs in the past m ay be m ore
disposed to play dow n the im portance of drug m isuse by
colleagues or students, and consequently be Iess Iikely to
intervene at an early stage and offer treatm ent.
Extensive literature exists show ing that m edicaI
students have negative attitudes tow ards patients w ith
drug-dependency problem s.32.39,40-44It is Iikely that these attitudes
are form ed or at least ~einforced during m edicaI schooI. If m edicaI schooIs are to have a pivotaI role in preventing
drug and aIcohol probIem s am ong students, then these
attitudes need to be m ore effectiveIy chaIlenged. H ow ever, at the present tim e the am ount of drug and aIcohoI training
that m ost m edicaI students receive is m inim ap.32,41,44-46and
fragm ented.3.7.3239.41.47N ocks44states that negative attitudes
tow ards drug-dependent patients increase during the
m edicaI course because students feeI inadequately
prepared to m anage these situations.
R egarding drug-relat~d problem s, they m ay Iack the
necessary skilIs to identify drug problem s and deaI w ith
deniaI.3.32.39A ccording to N egrete,35 such difficuIties are
aggravated by the unhelpfuI attitudes that m any clinicians
have tow ards this group of patients, including a distaste
for illnesses characterized by frequent relapses, Inoralistic
attitudes tow ards patients w ho drink toa Inuch, beliefs that
drug and alcohoI m isuse are social rather than InedicaI
problem s, and the difficulty m any physicians have in
com prehending w hy patients m isuse drugs at alI.
C onsequentIy, w hen faced w ith a drug or alcohoI
abusing colIeagues or classm ates, the student Inay be
paralyzed into inaction due to a com bination of fear of
confronting the person and inappropriate therapeutic
nihilism . O ften the Iittle contact that students have w ith
drug and alcohoI dependent patients is fairly short-tenn
and is Iikely to be w ith those patients w ho have Inore
chronic problem s associated w ith psychiatric and physicaI
com plications.3.32.41.44.4XThey are unlikely to see patients
w ho have achieved stable abstinence and social
reintegration, first because these patients often drop out
of treatm ent, and secondly because such an outcolne Inay
take several years to achieve. C onsequently, students Inay
not believe that these patients can be successfu IIy
rehabilitated, and therefore becom e unduly pessilnistic in
their outIook.
W hile physicians aIlegedIy m ake bad patients, they
m ay aIso m ake bad physicians w hen the patient they are
treating is another doctor. There m ay be an unw illingness
for colIeagues to take control of the situation, allow ing
the doctor-patient to take Iiberties that w ould not be
aIlow ed w ith ordinary patients. Thus corridor
consuItations, inadequate supervision and perm itting
self-prescribing are com m on, behaviors that are rationalized
on the grounds that busy schedules and on-caII
com m itm ents m ake it difficult to find tim e to m ake proper
consultations.
These Iessons are Iearned earlY on at m edicaI schooI,
particularly in relation to the use of benzodiazepine to
relieve sym ptom s of stress or induce sleep after a period
of on-call duty. W hile such behavior m ay not lead to drug
dependency, it is undesirable.23 Indeed, consideration
should be given to prohibiting self-prescribing alnong
physicians, and onIy allow ing physicians to prescribe to
colleagues w ho have registered w ith them as patients.
SpeciaIized services for students and practicing physicians
need to be developed to counteract this tendency and to
provide m edicaI professionaIs w ith the treatlnent service
they deserve.
In B raziI, it is com m on practice for finaI-year InedicaI
students to have facilitated access to prescription drugs.
D rugs are often donated by pharm aceuticaI com panies for
use w ith im poverished patients w ho cannot afford to pay
for them , and in som e institutions, m edicaI students
them seIves staffthese sm all pharm acies. Such easy access
onIy encourages students to seIf-prescribe. Later, this Inay
Iead to the inappropriate or im proper prescribing of
M E S Q U I T A , A . M . ; L A R A N J E I R A , R . ; D U N N , J . - P s y c h o a c t iv e d r u g u s e b y m e d ic a i s t u d e n t s : a r e v ie w o f t h e n a t io n a l a n d in t e r n a t io n a llit e r a t u r e
psychotropic
drugs by one doctor to a colIeague, patient,
or even to hilnself. In Brazil, consideration
should be given
to ending the relatively unlim ited
and unsupervised
access
that Inany students
and physicians
have to pharm acies.
To really
tackle
the problem
of drug and alcohol
Inisuse by Inedical
students
and physicians,
particularly
in tenns of prevention,
early identification
and treatm ent,
w e Inust do m uch m ore than siInply tinker w ith the m edical
school curricululn.
The follow ing
six recom m endations
offer a fralnew ork
of w here to go from here:
I.
Review the curriculum ,
not only regarding the am ount
oftilne spent dealing w ith this subject during the course,
but also as to the them es and techniques
em ployed, in
order to increase
the know ledge
base that Inedical
students
have
about
drug
and alcohol
Inisuse.
In
particular,
inform ation
about
m isuse
by m edicaI
professionals
and how to identify and de aI w ith such
problelns Inust be covered and em phasized,
especialIy
reinforcing
the dangers involved in self-prescription.
2.
Provide
for better
and
m ore
appropriate
clinicaI
experience
w ith
patients
w ith
drug
and
alcohol
problem s,
based
on
directly
supervised
case
m anagelnent.
3.
Require m edical school authorities to develop a systeln
in w hich students
w ho are having
problelns
during
the m edicaI
school
course
can be identified
and
counselled,
such
as the m odified
tutorial
systenl
Inentioned
above.
,Asilnilar
systeln
needs
to be
developed
for residents
and other physicians.
4.
O rganizations
representing
the Inedical
profession,
such as regional m edicaI counsels,
need to develop a
systeln w hereby students and physicians
identified
as
having drug and alcohol problem s
can be assessed and
treated
confidentially.
In resistant
cases,
there
Inay
need to be an elem ent of cO lnpulsion.
5.
Fonnulate
and inlplem ent
a fonnal
policy regarding
drug-related
issues
in the
school
of nledicine,
applicable to alI m elnbers of the acadelnic cO lnlnunity:
board of directors,
staff, faculty
and students.
6.
U ndertake
further research
to investigate
risk factors
for drug and alcohol
Inisuse,
and w hether
these can
be m inim ized.
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