Use of Psychoactive Substances among Biological and Health Sciences Students from Bahia/Brazil

1. Introduction

The consumption of psychoactive substances is not a recent phenomenon. Since prehistoric times these substances have been present among different cultures. Throughout history, its use has not only been associated with medicine and science, but also with recreational use, culture, mysticism and religion [1].

According to data presented in the United Nations Office on Drugs and Crime [2], in 2017, about 217 million people between 15 and 64 years old used some psychoactive substance at least once in the previous year, which corresponded to about 5.5% of the world population in this age group, in that year. The report also shows that, in 2017, about 35 million people suffered from substance use disorders and, consequently, should receive some type of health care and/or treatment, however, it is estimated that only one in seven of these people have actually managed to obtain it.

According to data from the 3rd National Survey on the Use of Drugs by the Brazilian Population [3], coordinated by the Oswaldo Cruz Foundation (Fiocruz), the most consumed illicit substance in Brazil is cannabis: 7.7% of Brazilians aged between 12 and 65 have used it at least once in their lives. In second place is cocaine, which was consumed by 3.1% of the population. Approximately 1.4 million people between 12 and 65 years old reported have used crack and similar drugs at some point in their lives, which corresponds to 0.9% of the research population. As for licit substances, more than half declared having already consumed alcoholic drink [3].

Some epidemiological studies were carried out in Brazil with the aim of verifying the prevalence of drug use among the university population. Among several pieces of information, higher consumption of alcohol and other psychoactive substances was evidenced among college students when compared with the general population and high school students [4].

Drugs such as anxiolytics, opioid analgesics and amphetamines, in addition to being drugs accepted and used worldwide in modern medicine as important therapeutic resources, have also been used in an abusive manner and causing as much harm as illicit drugs [5].

The abusive use of these drugs can have major toxicological implications. Between 1986 and 2006, 1,220,987 cases of intoxication were registered in Brazil, by the National System of Toxic-Pharmacological Information (SINITOX), with a total of 7,597 deaths (0.6%). Since 1994, medications became the first position among the causes of intoxication between the selection of toxic agents in the study, corresponding to 24.5% of the cases that were registered in the country [6].

The main reasons that lead to the beginning of the use of a psychoactive substance is the feeling of pleasure, known as positive reinforcement. Therefore, individuals increasingly engage in recreational consumption of psychoactive substances (without therapeutic purposes) as an attempt to find relief from day-to-day difficulties or just out of curiosity to try new situations [7,8].

Regarding the consequences of the consumption of psychoactive substances among college students, we have mainly: car accidents, violence, risky sexual behavior, decrease in the academic performance, decreased perception and attention and stress [9].

University students from health courses deserve a special mention when it comes to the use of psychotropic drugs, as they will be responsible for the health education and care of the population in the future, as well as identifying and referring patients with problems related to the use of psychotropics and also because they serve as a model for their patients [10]. The use of psychoactive substances by academics in the health area is a concerning factor, as it causes damage to the physical and mental health of the student, along with the society [11].

Thus, the main objective of this study was to describe the risks and the profile of consumption of psychoactive substances by students of the Biological and Health Sciences courses at the Federal University of Bahia (UFBA).

2. Materials and Methods

Sampling and Selection

A cross-sectional study was carried out from September 20, 2019 to June 15, 2021, with students from Biological and Health Sciences at UFBA being the target population. UFBA offers 14 undergraduate courses in this area of knowledge, they are: Biological Sciences, Natural Sciences, Nutrition, Gastronomy, Pharmacy, Nursing, Biotechnology, Public Health, Animal Science, Veterinary Medicine, Medicine, Dentistry, Speech–Language Pathology and Physiotherapy.

According to data from the Superintendence of Academic Administration (SUPAC) at UFBA, about 7,943 students these courses were enrolled when we started the research. The sample size calculation was performed using the Epidat 3.0 program, considering a confidence level of 95%, a margin of error of 5% and an expected proportion of 50% for the events studied, resulting in a sample size of 367 students, but with an additional of 10%, taking into account the cases of non-valid answers, 404 students was the number established as the minimum sample size.

Data Collection

For data collection, a standardized, anonymous fulfilment questionnaire was used and applied online. The dissemination of the research was done in the classroom and online, through the collaboration of professors from the Institute of Health Sciences (ICS) at UFBA and the Faculty of Pharmacy. The e-mails of the students were requested in the classroom, in the virtual learning platform of UFBA (Moodle) and also to the faculty of all courses to send the link to the questionnaire.

The questionnaire was prepared based on questions from the WHO ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), which is a test to identify problems related to the use of alcohol and other substances, through a score generated at the end of its application. ASSIST was validated in Brazil in 2004 and oriented for use in primary health care. Its psychometric properties identify the use of psychoactive substances and its associated problems in a first contact with the individual [12].

According to the ASSIST score, the risk of developing problems related to substance use was classified, where individuals with scores up to 10 for alcohol and up to 3 for other drugs are considered low-risk users, that is, although they occasionally use these substances, they still do not have problems related to this use. Subjects with scores between 11 and 26 for alcohol and between 4 and 26 for other drugs may have harmful or problematic substance use and are at moderate risk of developing problems due to drug use. Persons with scores of 27 or more for any drug are at high risk of developing disorders due to consumption of the investigated substance.

In addition, questions from questionnaires used in other works on the subject were added, such as a work applied among medical students in Salvador [13]. The questionnaire of the Brazilian Center for Information on Psychotropic Drugs (CEBRID) of the VI National Survey on the Consumption of Psychotropic Drugs among Elementary and High School Students in the Public and Private Education Networks in the 27 Brazilian Capitals was also used as a reference. The main variables collected were related to the sociodemographic profile (sex, age, ethnicity, income) and consumption of psychoactive substances, both lifetime use and the consumption in the last 3 months of these substances.

This study was approved by the Research Ethics Committee of the Faculty of Pharmacy at UFBA (CEP-FACFAR/UFBA no. 3,158,711). For data collection, the following eligibility criteria for students were adopted: (i) be at least 18 years old, (ii) be enrolled in one of the Biological and Health Sciences undergraduate courses at UFBA, (iii) sign the Informed Consent Form and agree to participate in the research.

Statistical Analysis

Data were analyzed using the SPSS program (Statistical Package for the Social Sciences – Inc. Chicago, Illinois), version 20 for Windows. Descriptive measures are presented in tables with percentages, mean, median, minimum, maximum and standard deviation. The value of “n” refers to the size of the evaluated sample.

The normality assumption was studied using the Shapiro-Wilk test. Quantitative data were compared between independent groups (gender) in order to verify a possible relationship, using the Mann-Whitney test. Comparisons between groups in relation to categorical data were performed using the Chi-square test. In cases where there were expected frequency values lower than five, Fisher's exact test was used.

All results were considered significant for a probability of significance lower than 5% (p<0.05), with at least 95% confidence in the conclusions presented.

3. Results

514 responses being obtained. 12 responses were excluded because they did not meet the inclusion criteria (9 students were not enrolled in Biological and Health Sciences courses at UFBA and 3 respondents were under age), thus resulting in 502 validated responses. Most respondents were female (72.9%), brown-skinned (39.2%), with income between 1-3 minimum wages (46.8%) and mean age of 25.2 years with a standard deviation of 7.7 years (Table 1).

Regarding the students' course, we had the highest numbers of responses in the Biological Sciences (15.5%), Speech–Language Pathology (14.7%) and Pharmacy (12.4%) courses, but data were obtained from all courses of Biological and Health Sciences (Table 2).

For the use of psychoactive drugs with medical prescription, throughout their lives, 437 participants (87.1%) reported that they had never used them. The 65 participants (12.9%) who revealed that they had used them at some point in their lives, often in association, of the following classes: antidepressants, sedatives/hypnotics, anticonvulsants, antipsychotics, medications for the treatment of Attention Deficit Hyperactivity Disorder (ADHD), mood stabilizers, and drugs for the treatment of mania episodes, as shown in Table 3.

This study revealed that for psychoactive substances used throughout life, at least once and recreationally/without prescription, alcohol was the most used substance (83.3%), followed by cannabis (37.5%) and tobacco products (32.5%). The same pattern of frequency of use was repeated for recreational/non-prescription consumption in the last 3 months, with alcohol (72.9%), followed by cannabis (19.9%) and tobacco products (16.9%) as the most consumed substances. However, changes were observed in the frequency of consumption for some substances (Table 4).

Consumption of psychoactive substances in the last 3 months was compared between males and females. Only tobacco and cannabis had statistically significant results (p < 0.05), with higher consumption by males for both substances (Table 5).

The average number of doses ingested when these students consumed alcoholic drinks was also compared between males and females. Gender has an effect on the number of doses of alcohol ingested, with males ingesting on average more doses than females, with a statistically significant difference, p < 0.001 (Table 6).

According to the ASSIST score, the risk of developing problems related to the use of the substances presented in the questionnaire was calculated. Only alcohol, cannabis, inhalants and antidepressants showed a percentage of individuals at high risk of developing problems (Table 7).

Regarding substance use with the aim of staying awake longer, 191 (38%) participants revealed that they had already used some psycho stimulant substance for this purpose.

4. Discussion

For the demographic characteristics of the sample studied, the predominance of gender was females and the average age of students around 25 years old are in accordance with the characteristics reported in other studies carried out among students in the health area in Brazil [14,15].

The recreational use of psychoactive substances, both for use in life and for use in the last 3 months, showed that the prevalence of alcohol (83.3% and 72.9% respectively), cannabis (37.5% and 19.9% respectively) and tobacco (32.5% and 16.9% respectively) were the highest.

The information present in the national literature is that students in the health area have a high prevalence for the use of these substances. In a private university in southern Brazil, data were collected regarding the use of psychoactive substances by students in the health area. The lifetime prevalence of alcohol use was 90%, tobacco 35% and cannabis 26.9% ([15]). A study carried out with medical students at a college in Paraná found a lifetime prevalence of alcohol use of 78%, followed by tobacco with 38.6% and cannabis with 26.1% [16].

The difference in the present study was the higher prevalence of cannabis in relation to tobacco, which may be due to a possible change in the consumption profile in between university students. The findings are in line with the results of a study carried out among medical students in Uruguay, revealing that 72.1% used psychoactive substances. The most used substances in the last 12 months were: alcohol (24.3%), cannabis (19.3%) and tobacco (16.4%) [16].

Cannabis consumption becomes more common in environments with less judgment towards its users, which is increasingly being observed in the university environment. A survey carried out among students at a university in the state of Minas Gerais showed different ways of using cannabis in the university environment, such as to boost social interaction, to feel as part of the group and to build identity [17].

The present study also found the consumption of psychotropic drugs without a medical prescription in the last 3 months among students from Biological and Health Sciences at UFBA, such as: sedatives/hypnotics (5.2%), antidepressants (4.6%), amphetamines (1.8%), methylphenidate (1.6%) and opioids (1.4%). A survey of nursing students in the United States revealed that excessive drinking was reported by 61% of participants, 18% reported using cannabis, and 10% reported using drugs without a medical prescription [18].

In a study of French pharmacy students, 21.5% of participants used illegal drugs, 9.4% used psychotropic medications, 3.3% both psychotropic medications and illegal drugs in the last 3 months. Psychotropic medications were used with a medical prescription (49%), for self-medication (42.4%) or for recreational purposes (26.3%) [19].

Self-medication can have serious consequences for the patient's health, such as allergic reactions and an increased risk of developing dependence. In addition, this practice can increase the risk of errors related to dose, intoxication, undesirable effects and drug interactions, evidencing that the use of any medication must be under medical prescription [20].

As for the use of psychotropic medication with medical prescription, 12.9% of the participants revealed that they had already used it at least at some point in their lives. Among the main classes of drugs mentioned, we had antidepressants with a prevalence of 84.6% and sedatives/hypnotics, such as anxiolytics, with a prevalence of 26.2% among students who reported this type of use.

This consumption of anxiolytics and antidepressants by the university population is observed in the literature. In a survey carried out with health students at a university in the state of Minas Gerais, symptoms of depression and anxiety were identified in 52.3% and 41.1% of the participants, respectively. It was observed that 5.3% of college students use medication to treat these symptoms. The study concluded that depression and anxiety are prevalent mood disorders among university students and, therefore, the importance of progressive measures for monitoring and treatment [21].

A study carried out in the Northeast region of Brazil revealed that the prevalence of anxiety and depression among students in the health area was much higher than in the general population. Concluding that these data point to the urgent need for greater attention and care for these future professionals, in order to be emotionally better prepared and healthier to deal with individual and group human health [22].

Regarding the number of doses of alcohol consumed, males ingest more doses compared to females, this prevalence was also found in a survey carried out with students in the health area of a higher education institution in Rio Grande do Sul [23]. Society's pressure contributes to this type of behavior, as males are usually encouraged to consume alcohol since adolescence, while for females this type of practice is often condemned.

For the use of psychoactive substances in the last 3 months, the results found in the present study revealed a higher consumption of tobacco and cannabis among men when compared to women, showing a greater habit of smoking among male students. Other studies carried out among Brazilian college students also found this higher consumption of tobacco and cannabis by males [13,14,24,25].

Our results revealed 38% of respondents had already used some psycho stimulant substance to stay awake, such as stimulant drinks, drugs and coffee. In a survey conducted among medical students in the state of Minas Gerais, 52.9% used these psycho stimulant substances, revealing that this type of practice is common among university students [26].

According to the ASSIST intervention guide, the reference score for alcohol is: 0-10 no intervention; 11-26 short intervention; 27 or more refer to intensive care. As for the other substances: 0-3 no intervention; 4-26 short intervention; 27 or more refer to intensive care. When determining the level of intervention of the participants of the present study, it was found that a short intervention is necessary for all psychoactive substances, associated with an intervention for intensive treatment in some alcohol (1.2%), cannabis (0.8%) and inhalants (0.2%) users.

Alcohol was the substance that presented the highest proportion of individuals in need of more intensive treatment. Several authors have associated the use of alcohol with a series of risk behaviors, involvement in accidents and violent occurrences, learning difficulties, deficiency in the development and structuring of cognitive-behavioral skills [27,28].

Analysis of the first and second wave of the US National Epidemiological Survey on Alcohol and Related Conditions (NESARC) revealed that the cumulative probability of transitioning from use to dependence was 67.5% for nicotine, 22.7% for alcohol, 20.9% for cocaine and 8.9% for cannabis users [29]. A meta-analysis [30] including 21 studies among people in the general population who have used cannabis, showed a prevalence and risk of 22% (18–26%) have cannabis use disorder, 13% (8–18%) have cannabis abuse and 13% (10–15%) have cannabis dependence. The risk of developing cannabis dependence increased to 33% (22–44%) among young people who engaged in regular (weekly or daily) use of cannabis. Then, the risk to develop cannabis dependence is lower than nicotine, alcohol, and cocaine, but is greater among those who initiate earlier and use more frequently.

Short-term cannabis intoxication impairs basal cognitive functions like episodic memory, attentional control, and motor inhibition in a THC-dose-dependent manner, although significant individual differences exist. The elevate levels of THC in the recreative cannabis nowadays, in comparison to 40 years ago, increase the risk to installation of psychotic disorders, in addition to cognitive impairment [31]. It is worth mentioning that the compulsive consumption of any psychoactive substance can lead to the emergence of problems for the user's health, generating cognitive, psychological and social disorders, both for the individual and for their families.

The results of the present study must be considered in the context of some limitations. We did not have the same numbers of participants between the different courses, with students from the Natural Sciences, Nursing and Veterinary Medicine courses being less represented. However, this selection bias seems to be limited, since the data found on the consumption of psychoactive substances by students of Biological and Health Sciences at UFBA seem to be in agreement with what was observed in the scientific literature.

Considering that information obtained through self-report may be affected by some information bias, was resolved to use the questions from already validated questionnaires, such as the ASSIST proposed by the WHO and the CEBRID questionnaire. In addition, we believe that the respondents, university students of legal age, are aware of the importance of the veracity of their report. However, it was impossible to verify if the same student answered twice or more.

It was possible to determine the consumption profile of college students in the Health and Biological Sciences Area at UFBA, with a prevalence of alcohol, cannabis and tobacco use, in that specific order. The consumption profile varied in relation to other studies in the literature, in which cannabis appears most commonly as the third most consumed substance among university students. This may be related to the online application of our questionnaire, making participants feel more comfortable to report all their experiences, thus revealing a possible change in the consumption pattern for this substance.

The results of the ASSIST score, associated with the high prevalence of use of some drugs, indicate the need for local intervention, in order to prevent risky behavior, damage to mental health and consequences for students’ cognition and performance. Educational measures can be taken to reduce the damage to the health of these students, such as the possibility of including topics about the use of psychoactive substances into the university's various undergraduate courses. In addition, monitoring and referring students with mood disorders, such as anxiety and depression.