Use of methylphenidate by university students in the health area Uso de metilfenidato por estudantes da área de saúde Uso de metilfenidato por estudiantes universitarios en el área de salud

Methylphenidate is the drug most frequently used in the treatment of attention deficit hyperactivity disorder. However, due to its psychostimulant properties, this substance has been used to stimulate productivity and increase intellectual capacity in several areas of study. In this work, the characteristics of the use of methylphenidate among pharmacy, nursing, and medical students of a university in the capital of Bahia were analyzed. In this cross-sectional study, 338 students from different semesters of the aforementioned courses were interviewed. The instrument used for data collection was a standardized self-completed questionnaire applied by the researchers. Altogether, 76% of respondents were female and the average age was 22 years old. The frequency of students who used or who had already used methylphenidate at some point in their academic life was higher among medical students (12%). The main justification for the use of this substance was the higher concentration to study (59%). Also, 92% of respondents claimed to use Methylphenidate without medical supervision and 80% indicated the time of the tests as the time of greatest use of this drug. These results show high non-prescribed use of methylphenidate among health care students.


Introduction
Nowadays, some psychotropic substances, modifying the ways of being, living, and working, are only secondarily used to minimize suffering and, in many cases, to enhance student performance (Brant & Carvalho, 2012).
Called pharmacological cognitive enhancement, the idea of using legally prescribed or over-the-counter drugs to "turbine the brain" has become an alternative to improve brain capacity in school performance. The purpose of using these drugs is the possibility of altering the brain process, aiming to improve memory, mood, and attention in healthy people (Barros;Ortega, 2011).
Methylphenidate hydrochloride is one of the most consumed drugs to stimulate productivity. This is part of the group of amphetamines (such as cocaine), which is commonly sold under the names Concreta, Ritalin, and Ritalin LA (Coli, Silva & Nakasu, 2016).
Methylphenidate is a psychostimulant and its use is legally authorized for the treatment of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). When consumed in the dosage prescribed by a doctor, its use helps in the performance of the school and academic activities, increasing the capacity of executive functions, increasing concentration, and minimizing the effects of fatigue (Itaborahy, 2009).
Despite the aforementioned indication, three "non-medical" uses of this drug are known: recreational, to increase vigilance and availability during leisure; aesthetic, to help with weight loss; and cognitive, to improve professional and academic cognitive performance (Barros;Ortega, 2011).
However, the university is a space where, quite frequently, the use of these drugs in an exacerbated way occurs, as it is an environment that encourages research, learning and that requires a high degree of dedication from students. Under these Development, v. 10, n. 8, e45310817540, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i8.17540 3 conditions, healthy university students have been using psychoactive substances, without prescription or medical supervision to enhance mental activities, aiming to optimize academic efficiency (Finger;Silva;Falavigna, 2013).
Methylphenidate is a black stripe drug and is included in the set of controlled drugs, so may have serious side effects (Gray, 2007). Therefore, it is essential to expand scientific studies and disseminate their results regarding the risks and adverse effects due to the indiscriminate use of methylphenidate by university students, also because the use of this substance, without medical supervision, can bring irreparable harm to health.
Thus, this study aims to identify the prevalence of the use of methylphenidate by university students in the health area and the main risks and side effects due to the use of methylphenidate by them without specialist supervision.

Methodology
This is a descriptive cross-sectional study, with questionnaires applied to the pharmacy, medicine, and nursing students at a university in the capital of Bahia.
The sample was defined by calculating the Sample Error Estimate for a finite population of 2536 enrolled students, distributed in the semesters of the aforementioned courses. Thus, assuming a sampling error of 5%, the confidence level of 95%, and through the formula n= Z 2 .P.Q.N/e 2 . (N-1)+Z 2 .Q.P, we defined that the required sample size (n) was at least 338 individuals. In this formula, we consider that n is the required sample size, "Z" is the confidence level, "P" is the expected amount of hit (%), Q is the expected amount of error (%), N is the total population and finally, e is the level of accuracy.
Thus, 338 were applied questionnaires, respecting the minimum number of students interviewed. The inclusion criteria used were being a pharmacy, medicine, or nursing student and being over 18 years old. Therefore, we used a semistructured data collection instrument, consisting of questions that allowed the assessment of the sociodemographic profile (gender, age group, marital status, monthly income) in the students from nursing, pharmacy, and medicine courses. Participants were informed about the research, its importance, and objectives and after signing the Informed Consent Form (ICF), they answered the questionnaire. The researchers read the questions to the students to guarantee the absence of misinterpretation.
This research complies with the norms of Resolution nº 466, of December 12, 2012, and was approved by the Research Ethics Committee of Universidade Salvador, under opinion nº 4.232.241.
For data tabulation and analysis, we used the GraphPad Prisma program (5.0), with a significance level of 5%.
Descriptive data statistics interpreted the answers to the questionnaires and Pearson's correlation related to the variables and knowledge acquired in the analyzed courses.

Results and Discussion
From the analysis of the student's profile, we could detect that 40% of respondents (n=136) are from the pharmacy course, 30% (n=101) from the medicine course, and 30% (n=101) from the nursing course. Of these, 76% are woman (n=258) and 83% (n=278) are under 25 years old, as shown in Table 1. Table 1. Distribution of students, by course, included in the study according to gender and age.
A survey conducted by Micoulaud and Macgregor (2014) to show the early use of methylphenidate showed results similar to those of this research. These authors detected a prevalence of 76% of females and a prevalent age group of approximately 22 years old. On the other hand, Habibzadeh (2011) in an Iranian survey found a mean age similar to the aforementioned studies (21.4 years old), however, with a predominance of males.
The students in this study were divided between the 10 semesters of the 03 courses above, with a predominance (75.7%) among the first 5 semesters, as shown in Table 2. When asked about the amount of sleep, the vast majority of students (83%) answered that they sleep, on average, between 4 and 8 hours a day. In addition, 53% of students rated sleep quality as good, and 31% considered it poor.
In research carried out by , the vast majority of respondents slept, on average, between 4 and 8 hours a day. In addition, 56.7% of these individuals stated that their sleep quality was good and another 28.8% classified it as poor. In this work, we also observed that the lesser amount of sleep and the poor quality of sleep were considered the main factors for the alteration in the academic performance of the respondents. According to Pereira et al (2015), students during class time should sleep an average of 8 hours a day to perform their academic activities well.
Another important data analyzed was the level of stress in the studies. Thus, 58% of students considered their stress levels moderate in their studies and 41% considered it high. Furthermore, 22% stated that the concentration for such activity is bad and 63% reported it to be good.
A study by Pereira, Miranda, and Passos (2010) with nursing students found that 81% of individuals considered stressed with academic activities. Chaves et al. (2016) conducted a study with first-year students at the Centro Universitário Herminio Ometto in São Paulo and observed that 57% of university students already had symptoms of stress. Furthermore, Cestari et al. (2017) in research carried out with nursing students found that 64% of students were stressed about their studies.
According to Gervásio (2012) As for the need to use some substance or stimulant compound to improve the performance of academic activities, 9% answered that they always use some psychostimulant and 23% reported that they sometimes feel the need to use some stimulant compound. Psychostimulants have goals that permeate increased alertness and motivation, minimizing the need for rest, in addition to showing improvement in mood and cognitive behavior and antidepressant properties. The main substances used for these purposes are caffeine, methylphenidate, modafinil, piracetam, energy drinks, and amphetamines (Morgan et al., 2017).
A survey conducted by  pointed out that 4.1% of respondents used some psychostimulant and, among these, 60% reported using methylphenidate. Therefore, when asked if they use or have used Methylphenidate, 7% (n=25) of the students interviewed in this research said yes, being 12% (n=12) medical students, 4% (n=6) pharmacy students, and 7% (n=7) nursing university students.
Methylphenidate is the most consumed psychoactive substance in the world and also the most used for recreational According to Finger et al. apud Silveira et al. (2015), the most used drug among medical students is methylphenidate hydrochloride. This stimulates the central nervous system and its mechanism of action consists of blocking dopamine reuptake, releasing dopamine and norepinephrine into the synaptic cleft. According to Silva (2010), this psychostimulant can benefit some brain functions; however, when excessively consumed, they cause adverse results to those expected, and may even cause seizures.
Also, this psychostimulant is one of the drugs with the highest prescription rate in the world, being used in many countries for the pharmacological treatment of ADHD and some specific cases of depressive disorder and fatigue. When prescribed with appropriate doses, the chances of this substance leading to addiction are very small, therefore, it is safe with a good level regarding side effects (Cesar et al., 2012).
The data presented in this research is similar to the study carried out by Cruz et al. (2011), which pointed out that 8.6% of the medical students at the Federal University of Bahia (UFBA) analyzed had already made or used Methylphenidate.
In a survey carried out by these researchers at UFBA, the illegal sale of methylphenidate hydrochloride was highlighted, without the need for a medical prescription. This research also addressed the level of knowledge of university students regarding the abusive and indiscriminate use of the drug, demonstrating the practice of purchasing medication, especially psychoactive drugs, without prescription and proper professional guidance. However, research carried out in different cities in Brazil with medical students, by Pires et al (2018), Silva Junior et al. (2016, and Lage et al. (2015), showed that the use of methylphenidate was even greater, being 29%, 23%, and 28.4%, respectively.
These results show that the non-therapeutic use of methylphenidate is a common practice by Brazilian university students, mainly by medical students, and the main objectives indicated by them to justify the use of these substances were the improvement of alertness and the increased concentration for academic activities (Maier et al., 2013;Wilens et al., 2008 apud Cordeiro andPinto, 2017).
Studies carried out in some countries such as South Africa, the United Kingdom, Brazil, Switzerland, and the United States were concerned about the large increase in the consumption of over-the-counter psychostimulants by academics (Lage et al, 2015;Singh et al., 2014;Beyer et al., 2014;Maier et al., 2013;Hall et al., 2005;Barret et al., 2005apud Silva Júnior et al., 2016.
Another survey carried out in this area, in France, showed that out of 206 respondents, 139 (67.4%) had consumed at least one psychoactive substance in the last 12 months. In the United Kingdom and Ireland, 877 university students participated in an online questionnaire and approximately 9.4% claimed to have used some medication for cognitive improvements (Franchi et al., 2014;Singh;Bard;Jackson, 2014apud Cordeiro & Pinto, 2017. In Switzerland, 13.8% of students stated that they used psychostimulants without professional supervision at least once in their lives. In the United States, studies show that the use of psychostimulants without a medical prescription is 35% among university students (Maier et al., 2013;Wilens et al., 2008apud Cordeiro, & Pinto, 2017. The use of methylphenidate without a medical prescription is worrisome, as prescription A (yellow color) is required, which is difficult to access, even for prescribing professionals (Cruz et al., 2013).
The use of this substance without a medical prescription by academics, mainly in the health area, has been a reason for research and fear due to its cardiovascular effects and the risk of dependence. Some studies have shown that at the university level, the prevalence of healthy students who use methylphenidate or have already used it for academic improvement ranges from 3 to 35.5% (Low & Gendaszek, 2002;Teter et al., 2003;Barret et al., 2005;Desantis et al., 2008;Dupont et al., 2008;Wilens et al., 2008;Habibzadeh et al., 2011;Herman et al., 2011apud Silva Junior et al., 2016. In this study, 92% of the population who claimed to use this stimulant responded that they used this drug without a prescription, and more than half (52%) of the students reported that they used this substance on their own, while 35 % stated that it was an indication from friends and 9% from a pharmacist. Coli, Silva, and Nakasu (2016)  The students in this research stated that the factors that led them to use methylphenidate were the highest concentration to study (59%) and the longest waking time to carry out this practice (27%). Similar results were observed in the work of Pasquini (2013), in which 84.21% of students confirmed the desire to increase concentration to study. In the studies by Carneiro et al (2013), Sebastian and Alfonso (2014), and Silva Júnior et al. (2016), 54.05%, 71.3%, and 63.8% of students respectively reported having an improvement in academic performance, mainly due to improved concentration.
In this study, students also reported that they experienced one or more side effects after using methylphenidates, such as insomnia, decreased appetite, anxiety, nausea, euphoria, abdominal pain, dizziness, and lack of interest. In other studies, the main effects observed were tachycardia, palpitation, loss of appetite, anxiety, tremors, and dry mouth (Carneiro et al., 2013;Silva Júnior et al., 2016).
The indiscriminate use of this psychostimulant can lead to numerous risks, compromising the users' physical and mental health. Individuals who use Methylphenidate tend to believe that this substance will enhance the level of studies; however, if the individual does not have any type of pathology that generates attention deficit, the effects can be adverse, such as anorexia, insomnia, headache, arrhythmia, and dependence (Carneiro et al., 2013).

Final Considerations
Through this work, we could observe that Methylphenidate is a central nervous system stimulant that has been used, without a medical prescription, by healthy individuals who aim to improve their performance in academic activities. Its use without medical supervision is not recommended because it is a black stripe drug, which can pose serious health risks.
We found that the non-prescribed use of Methylphenidate by Brazilian university students in the health area is a reality and requires care by health professionals to face it, including through socio-educational techniques to raise awareness of these students in the sense of using psychostimulants only with medical indication.
The justifications for the use of methylphenidates, such as increasing concentration for studies and being able to spend more time awake aiming at better results in the course of academic activities, raise the importance of new studies on this psychostimulant, aiming to increasingly spread the concept of this drug and its function.