Prevalence and factors associated to the use of illicit drugs and psychotropic medications among brazilian undergraduates

The aim of this study was to verify the prevalence of use of psychoactive substances (PS) and its associated factors in undergraduate students of a university in southern Brazil. The study was carried out with 830 undergraduate students in the year 2016. The individuals answered a self-administered questionnaire about the PS and its prevalence of daily use, in the last 30 days or at any time of their lives, as well as socioeconomic conditions and academic variables. Caffeine-based energy drinks was the most consumed psychoactive substance (96.3%) among undergraduates in the last 30 days, followed by alcohol (64.0%). Among the illicit drugs most consumed in the last 30 days was marijuana (17.3%), while anxiolytics and amphetamines were the most prevalent psychoactive medicaments in the last 30 days. The prevalence of lifetime illicit drugs used by these students was 41.5%, where we highlight besides marijuana (38.6%) the high consumption of cocaine (7.8%), ecstasy (9.3%) and solvents. Socioeconomic and demographic factors such as gender, have children, religion, and financial background as well as academic variables were associated to recent consumption of these substances. This study concluded there is a high prevalence of use of PS among the undergraduate students, including illicit drugs.


Introduction
According to the World Drug Report (United Nations Office on Drugs and Crime [UNODC], 2018), one in 20 adults used drugs in the year 2015 (prevalence above 5%), and Cannabis was the most widely used drug in the World (UNODC, 2018). Although there are numerous studies that focus on the prevalence of use of illicit drugs by the college individuals, government or official reports do not focus in this population. College admission can be considered a vulnerable moment to start the use of psychoactive substances. It is emphasized that in college, drug use differs from high school (HS) once in HS the use of Psychoactive Substances (PS) is done at night, usually on weekends or at sporadic parties (Pillon, O'Brien, & Chavez, 2005).
Several factors have been associated with the use of psychoactive substances, such as gender, sexual behavior, income, religion, poly-drug consumption, academic performance and college time (Kerr, Ding, Burke, & Ott-Walter, 2015;Lucas et al., 2007;Silva et al., 2006;Wagner & Andrade, 2008). On the other hand, some gaps still remain within this subject, such as the use of licit psychoactive drugs, the factors associated with the use of psychotropic medications by this population, and responses in undergraduate students from all areas of knowledge.
Most of the studies have been conducted with students from health courses (Lucas et al., 2007), mainly medical students (Lemos et al., 2007). The greatest number of studies have reported on legal drugs such as tobacco and alcohol use (Peuker, Fogaça, & Bizarro, 2006;Rondina, Gorayeb, & Botelho, 2007). The prevalence of illicit drugs use in studies is variable, mainly regarding the use of marijuana in this population (Puryer & Wignall, 2016;Silva et al., 2006;Wagner & Andrade, 2008), as well as the use of psychotropic medications (Karam et al., 2000).
Since 2011, for college admission Brazil has been using a system, called SISU (Unified Selection System), based on a unified examination for the entire national territory. According to data from the Ministry of Education (2017), in 2017 more than 200,000 students were admitted in the universities via this system. The SISU favored students from all regions of Brazil to study in a College away from home. In the case of Federal University of Rio Grande, only slightly over 40% of the students were born in Rio Grande (the University's headquarters). A recent study conducted at the same college of the present study (Demenech, Dumith, Paludo, & Neiva-Silva, 2019) associated distance from the city prior to college admission with recent marijuana use.
Therefore, the aim of the study was to evaluate the prevalence of illicit drugs use and psychotropics medications in undergraduate students, as well as factors associated with the use of these substances, considering socioeconomic, demographic and academic variables, and social behavior of the students.

Type of Study, Sampling and Inclusion Criteria
A cross-sectional study was performed and the sample consisted of undergraduate students of both genders, minimum 18 years of age, who were attending a course at the Federal University of Rio Grande (FURG) between March and November 2016. The sample comprised of 23 undergraduate courses from FURG, divided into the Exact, Human and Biological / Health areas.
The sample calculation considered the total number of students in the year 2015 in the different areas: Human (n = 3248), Exact (n = 3985) and Biological / Health (n = 1269), totaling 8,505 students. For the calculation it was considered 95% confidence interval (95% CI) and significance level 5% and, considering the population of each area as homogeneous. Upon finishing calculation, it was concluded that, the right number of students participating in the study divided into three areas were: Human 229, Exact: 232, Biological/Health: 356: totaling 817 individuals, but 830 questionnaires were applied.
The socioeconomic and demographic profile as well as the academic variables of the students were collected through a self-administered questionnaire in the classroom. The data collection instrument contained 49 open and closed questions.
The daily use prevalence of PS has been estimated as well as prevalence in the last 30 days, or at any time of the life. Psychoactive substances such as caffeine, power drinks, alcohol, nicotine (tobacco), Marijuana, anxiolytics, amphetamines, ecstasy, cocaine, solvents, morphine, heroin, LSD, crack, cocaine and others were the ones investigated.
To study associated factors we use prevalence of use in the last 30 days and students were divided into four groups: Group 1 -students who did not use illicit drugs or psychoactive medicaments in the last 30 days; Group 2 -students who took illicit drugs (not consumer of psychoactive medicaments in the last 30 days); Group 3 -students who took psychoactive medicaments (but did not use illicit drugs) in the last 30 days) and Group 4 -students who took both illicit drugs and psychoactive medicaments in the last 30 days. Those students who did not respond to any information regarding the use of psychoactive substances contained in the questionnaire were excluded from the analysis of the associated factors.
The independent variables were age, gender, skin color, marital status, children, religion practice, resident city, residency, asset index, year of undergraduate course, graduation area, hours of sleep per day, frequency of delays in class, frequency of sleep in class, average grades and sleeping trouble.
To estimate the socioeconomic level characteristics of domicile, presence of maid and household goods (bathroom, maid, car, microcomputer, refrigerator, washer, DVD, microwave, motorcycle and clothes dryer) were taking into consideration.

Data analysis
Data was analyzed by statistical analysis software STATA, version 11.0 from a Microsoft Excel file with questionnaire responses, which were previously double-typed in Epi-Data 3.4. STATA 11.0 program was used for the analysis. Prevalence was calculated based on the 820 questionnaires applied because 10 questionnaires ignored questions regarding the use of PS and were excluded from the analysis of the associated factors. Subsequently, the association between different variables was tested by Chi-square test, Fisher's test and ANOVA with a statistical significance level of 5% for two-tailed tests.

Ethical aspects
This research respected the ethical precepts recommended by Resolution 466/2012 of the National Health Council of the Ministry of Health, which regulates research involving human beings. Thus, the present study was submitted to the Committee of Ethics in Research in the Health Area of the Federal University of Rio Grande (CEPAS / FURG) by this committee (195/2015).

Results and discussion
The data of prevalence of lifetime use, recent use and regular use of PS are summarized in Table 1. In all three scenarios, caffeine was the most consumed PS among undergraduate students. The use of alcohol at any time of the life was prevalent in more than 80% of the study population, although their daily use is low in this population. The use of nicotine-based cigarettes at any time of the life had a prevalence of more than 40% individuals, but daily use was slightly more than 4%.
Among the illicit drugs most consumed at any time of the life were: marijuana (38.6%), ecstasy (9.3%), solvents (9.2%) and cocaine (7.8%), while the overall prevalence of illicit drug used at any time of the life was 41.5 %. Anxiolytics and amphetamines were the psychoactive drugs most experienced by undergraduate students, but their continuous and daily use had low prevalence in this population. About 39% of the respondents indicated that they had used psychotropic medications at some point in their lives.  *Includes "lança perfume" -ethyl chloride-based drug; "cola de sapateiro" -toluene-based drug and "loló" -drug based on ether and chloroform; ** Includes anorectic (5), antidepressants (2 (3), mushroom tea (5); *** Includes anorectic (1), mushroom tea (5), "loló" (1).
The mean age of the students was 24.7 years of age (median 22). Most of the interviewees were female, white, single and without children. Less than 17% of them live alone and the others live with relatives, colleagues, their partner, or others. Approximately half of them follow some religion. The predominant income class is C (C1 + C2), with monthly average family income of 1,451 dollars (Table 2).
Regarding the academic variables, about 40% were in the first year of college, almost 58% did not perform activities other than studying. Almost half of the students reported no studying or just studying in the exam period. At the time of exams, college students usually studied 5 hours/day. Half the students were scarcely or never late for classes, but almost half reported having slept during class. Most students considered their academic performance to be average or good and their scores ranging from average to above average (Table 3). Almost half reported sleeping problems and two-thirds said that other people in their home use PS. Among those interviewed, 17.1% made continuous use of medications, 64.4% had recently used alcohol and 15.9% had recently used cigarettes (Table 4).
The investigation of the associated factors was made based on sociodemographic and economic, academic and behavioral variables among undergraduates. Among sociodemographic variables, age was a factor associated with the use of PS, where students in groups 2 (use of illicit drugs) and 4 (use of illicit drugs and psychoactive drugs) were significantly younger than students who did not recently used PS. Still, males were associated with illicit drug use either alone (Group 2) or combined with medication (Group 4), while medicaments use (Group 3) was associated with female gender. White skin color was associated with the combined use of illicit drugs and psychoactive drugs.
The fact of not having a child has been shown to be a variable associated with the use of illicit drugs (combined or not with drugs), as well as the fact of not being a religious person. The PS use was not associated with the marital status or with whom the student lives in the residence. Income and social class also did not show to be factors associated with the use of PS.
Among the academic variables, only the year of the course and the area of study were factors associated with the use of PS (Table 3). Students of the first year of college make use of illicit psychoactive medicaments (alone or combined with illicit drugs), while students of final years using more illicit drugs (combined or not with psychoactive drugs). Acta Scientiarum. Health Sciences, v. 42, e46774, 2020 Table 3. Association between academic variables and use of psychoactive substances in undergraduate students (N = 820).

Variables
Group 1   Among the behavioral variables, sleeping problems, use of continuous medications, recent consumption of alcohol and cigarettes were associated with the use of PS (Table 4). Sleeping problems and continued use of medications were associated with the use of psychoactive drugs (combined or not with illicit drugs), while recent alcohol and cigarette use was associated with the use of illicit drugs (combined or not with psychoactive drugs).
The prevalence of PS in the studied population was elevated, both for licit and illicit substances and psychotropic medications. We highlight the high consumption of energy drinks containing caffeine, alcohol and tobacco among the legally consumed substances. Marijuana, ecstasy, solvent and cocaine among the illicit drugs and anxiolytics and amphetamines among psychotropic drugs. The study contributes to the elucidation of factors associated with drug use, illicit drugs and psychotropic drugs, such as age, skin color, gender, marital status, religious practice, use of tobacco and alcohol, and medications for continuous use, difficulty sleeping, and academic as well as time, such as socioeconomic and demographic variables of college and area of knowledge. On the other hand, it showed that for this population, factors that are commonly reported were not associated to the uses of IDs and PMs. Among them it is income, social class, academic performance and PS use by a roommate (Dahlin, Joneborg, & Runeson, 2005;Galduróz, Noto, Nappo, & Carlini, 2004;Picolotto, Libardoni, Migott, & Geib, 2010).
These issues are discussed in different epidemiological studies reporting the prevalence of drug use among college and high school students, showing that that population represents a group with high susceptibility to abuse (Galduróz et al., 2004;Miranda, Demenech, & Miranda, 2018). Regarding psychoactive in general, studies indicate variation in prevalence of recent use (last 30 days) and over a lifetime (Galduróz et al., 2004;Gebreslassie, Feleke, & Melese, 2013;Hall, Irwin, Bowman, Frankenberger, & Jewett, 2005), may be associated with different cultural, social and economic factors. This pattern of variation was also seen in the different studies conducted with Brazilian college students, where the prevalence of PS use in the present study was also divergent (Lamberti et al., 2017;Silva et al., 2006;Wagner & Andrade, 2008).
Among the psychoactive substances, caffeine-based energy drinks had the highest prevalence of use, but this topic is still little explored in the scientific literature, perhaps because they are substances that are legally commercialized (Chang, Peng, & Lan, 2017;Donald, 2017;Teixeira et al., 2007). In general, studies with the student and college population have addressed the prevalence of power drinks and their association with factors such as parental education and living alone (Azagba, Langille, & Asbridge, 2014;Oteri, Salvo, Caputi, & Calapai, 2007). However, the extent of the issue on the use of caffeine and college, has not been well elucidated. Few articles address the use of caffeine in college populations (Chang et al., 2017;Penafort et al., 2016). One of them was the study by Chang et al. (2017) conducted with Taiwanese college students who observed a higher prevalence of caffeine-containing tea (95%) than coffee use (57%). In a Brazilian scenario, Penafort et al. (2016) observed a high prevalence (72.3%) of caffeine use among college students but did not address its associated factors. However, in despite of the high prevalence, the present study showed a higher rate and great part of the use refers to the consumption of coffee and 'chimarrão' (a typical Brazilian drink based on Ilex paraguariensis (Bracesco, Sanchez, Contreras, Menini, & Gugliucci, 2011).
The behavioral and academic factors experienced by the college population, such as graduation time, delay, sleep and low performance on classes were already associated with the use of PS (Cabrita et al., 2004;Dahlin et al., 2005;Nascimento & Avallone, 2013). As for academic factors, such as undergraduate time, we indicate here that first-year students consume more drugs combined or not with illicit drugs. This behavior may be associated with daily stress and different problems that may result in emotional and academic failure (Dahlin et al., 2005). In addition, among the studies (Cabrita et al., 2004;Nascimento & Avallone, 2013) to which the use of marijuana reported that a great part of the interviewees who had already made use of some substance (alcohol and psychoactive drugs) felt sleep during the classes. These results are like those found in the present study, to which most individuals reporting sleep in the classroom made use of all substances.
As for the prevalence and association with the use of psychotropic drugs, the female sex has been associated with the use of these substances, while the male sex has been associated with the use of illicit drugs alone or in conjunction with medications. The use of anxiolytics and amphetamines by the female sex may be due to a greater occurrence of physical and mental illnesses and why female students are considered to be more stressed than male students (Tavolacci et al., 2013;Wagner & Andrade, 2008). This pattern was similar to that found in the present study and in the others, such as, Passos, Alvarenga, Santos, and Aquino (2006), Cabrita et al. (2004) and Wagner & Andrade, 2008), for which females made significant use of these substances.
However, this relationship may also be influenced by self-medication. Silva et al., (2012) reported that self-medication among students at the same university studied in this study is high. This behavior is associated with several factors, such as gender, marital status, children, drug use, last year in a health course, and availability of medication.
Another factor associated to the use of these substances, mainly illicit drugs, is the non-practice of religion, which has already been mentioned in different studies (Silva et al., 2006;Tavares, Béria, & Lima, 2004). This same scenario was identified in the present study where the use of drugs with potential for abuse was seen in a greater proportion among individuals who do not practice religion, whereas a large portion of the population that does not consume IDs and MPs is practicing of some religion.
The lifetime prevalence of marijuana use was high when compared to other studies, where prevalence ranged from 16% to 27% (Arria et al., 2010;De Micheli & Formigoni, 2004;Furtado et al., 2017;Lamberti et al., 2017). On the other hand, the study of Stempliuk et al. (2005) reported a prevalence of 39% in Brazilian college students, a value like that presented in the present study. Regarding the prevalence of recent use, the results presented were similar to previous studies, which showed a variation between 2% and 4% (Atwoli, Mungla, Ndung'u, Kinoti, & Ogot, 2011;Dantas et al., 2017;Makanjuola, Daramola, & Obembe, 2007). The high prevalence presented by this population may be associated with different factors already related to the use of illicit drugs in general. These factors are demonstrated in detail by Demenech, Dumith, Paludo, and Neiva-Silva, L (2019), to which marijuana use was associated with males, the migration of students, the highest age, living alone and having family members.
The use of cocaine and crack within the university can discern how much the different effects of these drugs have spread without social barriers, thus causing an impact on public health as a whole (Kessler & Pechansky, 2008). Among illicit drugs, cocaine is widely used and different studies address prevalence between 0 and 4.4% (Furtado et al., 2017;Makanjuola et al., 2007;Neto, Fraga, & Ramos, 2012), for use in college population. These data differ from the results found in the present study, which showed a high prevalence of recent and lifetime use (0.7 and 7.9%). Regarding the use of crack in the academic environment the prevalence found in previous studies were 0.2 and 0.6% (Makanjuola et al., 2007;Neto et al., 2012) corroborating the results evidenced in the present study.
Among the illicit drugs as marijuana, cocaine and crack are drugs that have a wide distribution and commerce throughout the world and its consumption can cause serious health damage (Teo & Fenech, 2008). Although, the prevalence of illicit drug use in general varies among studies, here the prevalence of lifetime use varies between 25% and 45% (Bitancourt et al., 2016;Stempliuk et al., 2005). The present study showed higher rates found for the Brazilian population. The studies indicate as factors associated with going to parties at least twice a week, poor parenting, permissive parents or disinterested in academic achievement, poor school performance, friends or parents also users. Nevertheless, there are differences, mainly regarding the economic factor where different studies report the association of abuse with the fact of working and have a high socioeconomic level, unlike studies that report that only studying and having low income is a risk factor (Furtado et al., 2017;Picolotto et al., 2010).
Based on the factors associated with the use of the substances studied, we emphasize that the basic profile of the student who does not consume drugs and psychoactive medications is of a student who has children, practices a religion, older than the average presented, and black skin color. On the other hand, females and students that attend the initial years characterize students who make use mainly of psychoactive medicines. The use of illicit drugs is mainly related to the male gender, the whites, younger than the average presented and attending the last year of college.

Conclusion
Prevalence of psychoactive substance use among undergraduates was elevated, both for legally accepted substances and for illicit drugs and psychotropic drugs. Socioeconomic and demographic variables (age, gender, children and religion), academic (college time and area of knowledge) and behavioral (sleep in class combined with alcohol and continued use) were associated with the use of illicit drugs and psychotropic medications. We emphasize the need for studies that identify the effects on health in this population, as well as actions and programs of prevention and health education within the universities, developed as health promotion measures.