Abstract

Introduction

The consumption of psychotropic drugs in Brazil and worldwide has been the subject of a number of studies because of the social and economic impacts and especially because of the implications for health in the target population¹1. Lucas ACS, Parente RCP, Picanço NS, Conceição DA, Costa KRC, Magalhães IRS, Siqueira JCA. Uso de psicotrópicos entre universitários da área de saúde da Universidade Federal do Amazonas, Brasil. Cad Saude Publica 2006; 22(3):663-671.,²2. Silva OA. Consumo de drogas de abuso no ambiente de trabalho no Brasil. Rev Bras Toxicol 1999; 11(1):7-10.. The health and public safety consequences are of great importance to society and require different approaches to reduce this serious problem²2. Silva OA. Consumo de drogas de abuso no ambiente de trabalho no Brasil. Rev Bras Toxicol 1999; 11(1):7-10..

In a 2005 study conducted in Brazil that covered 108 cities with more than 200,000 inhabitants, 8.8% of those interviewed admitted to using marijuana (at least once); 2.9% admitted to using cocaine; 3.8% admitted to using amphetamines and 5.6% admitted to using benzodiazepines³3. Carlini EA, Galduróz JCF, Noto AR, Carlini CM, Oliveira LG, Nappo AS, Moura YG, Sanchez ZVDM. II levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: 2005. Estudo envolvendo as 108 maiores cidades do país. São Paulo: Páginas & Letras; 2007.. In 2007, the death rate attributed to drug use was 4.3 per 100,000 inhabitants. Compared with the death rate of other countries in South and North America, such as Argentina (1.9/100,000), Chile (2.3/100,000), and the United States (2.4/100,000), the rate in Brazil indicates that public policies must be enacted to minimize the distribution of these substances. In addition, rates of prescription drug use, especially benzodiazepines, in the United States, Argentina, Brazil, Mexico and Chile are higher than the global average⁴4. Cruz MS, Impacto do uso de drogas na população brasileira: análise de dados epidemiológicos de indicadores – 2001 a 2007. In: Duarte PCAV, Stempliuk VA, Barroso L P, organizadoras. Relatório Brasileiro sobre drogas. Brasília: SENAD; 2009. p. 345-357..

According to a World Drug Report by the United Nations Office on Drugs and Crime (UNODC, 2011), 3.3 to 6.1% of the world's population between the ages of 15 and 64 have used illicit drugs at least once a year, which corresponds to 149 to 272 million people in this age range⁵5. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2011. EUA: UNODC; 2012. [acessado 2012 maio 1]. Disponível em: http://www.unodc.org.br
http://www.unodc.org.br... . This report notes that the death rate from illicit drugs has reached 1%, with marijuana (annual prevalence between 2.6% and 5.0%) and amphetamines, excluding ecstasy, (annual prevalence between 0.3% and 1.2%), among the most frequently used. These numbers could be even higher because various methods are used to report drug-related.

Drug abuse at the workplace costs American businesses and industries billions of dollars because of workplace mistakes and absenteeism in addition to poor performance and poor interpersonal relations⁶6. Garcia FE. The Determinants of Substance Abuse in the Workplace. The Social Sci J 1996; 33(1):55-68.. In Brazil, despite a lack of specific laws, certain companies have participated in workplace drug-testing programs since 1992. In 2004, more than 300 companies throughout the country participated in a drug study (marijuana, cocaine and amphetamines) of urine samples conducted by the University of São Paulo Laboratory (Laboratório da Universidade de São Paulo)⁷7. Silva OA, Yonamine M. Drug abuse among workers in Brazilian regions. Rev Saude Publica 2004; 38(4):552-556..

The law-enforcement profession requires dedication and long hours and produces psychological pressure and daily tension. Studies have shown that the use of psychoactive substances by these professionals is a form of escapism to alleviate difficult working conditions and a low quality of life⁸8. Garcia SI. As implicações psicossociais do ato infracional: drogas e saúde [dissertação]. Rio de Janeiro: Fiocruz; 1996.,⁹9. Zahradnik M, Stewart SH. Anxiety disorders and substance use disorder comorbidity. In: Antony MM, Stein B, editors. Oxford Handbook of Anxiety and Related Dosorders. New York: Oxford University Press; 2009. p. 565-575.. Other researchers consider drug use a result of self-esteem issues and a lack of skills in managing adverse situations¹⁰10. Bucher R. Drogas e drogadição no Brasil. Porto Alegre: Artes Médicas; 1992.,¹¹11. Campos GM, Figlie NB. Prevenção ao uso nocivo de substâncias focado no indivíduo e no ambiente. In: Diehl A, Cordeiro DC, Laranjeira R, organizadores. Dependência Química: prevenção, tratamento e políticas públicas. Porto Alegre: Artmed; 2011. p. 481-494..

In a study conducted at 12 military police units in the state of Goiás (GO) in the cities of Goiânia and Aparecida de Goiânia, 221 corps members were examined and the following results were observed: a) drug use at any time: tobacco, 39.9%; alcohol, 87.8%; marijuana, 8.1%; cocaine, 1.8%; stimulants, 7.2%; solvents, 10.0%; sedatives, anxiolytics and antidepressants, 6.8%; LSD, 0.5%; b) drug use in the last year: tobacco, 15.4%; alcohol, 72.9%; stimulants, 6.3%; solvent, 0.5%; sedatives, anxiolytics and antidepressants, 3.7%; c) drug use in the last month: tobacco, 14.5%; alcohol, 57.5%; stimulants, 5.0%; solvents, 0.5%; sedatives, anxiolytics and antidepressants, 3.7%¹²12. Costa SHN, Cunha LC, Yonamine M, Pucci LL, Oliveira FGF, Sousa CG, Mesquita GA, Vinhal LB, Dalastra J, Leles CR. Survey on the use of psychotropic drugs by twelve military police units in the municipalities of Goiânia and Aparecida de Goiânia, state of Goiás, Brazil. Rev Bras Psiquiatr 2010; 32(4):389-395..

Drug consumption in the military environment creates a need for rigorous and adequate control against these modern “chemical weapons” that cause gradual dependence and human degradation¹³13. Verstraete AG, Pierce A. Workplace drug testing in Europe. Forensic Sci Int 2001; 121(1-2):2-6.,¹⁴14. Meririnne E, Mykkänen S, Lillsunde P, Kuoppasalmi K, Lerssi R, Laaksonen I, Lehtomäki K, Henriksson M. Workplace drug testing in a military organization: results and experiences from the testing program in the Finnish Defence Forces. Forensic Sci Int 2007; 170(2-3):171-174.. A study conducted in Finland, a country in which illicit drug use in the military is extremely low, showed that drug-testing efficiency in a military organization is an important method of improving security at work and a successful preventative strategy. Constant awareness campaigns and improved working conditions are also tools that can, in combination, have positive results in reducing the alarming number of users of these harmful substances¹⁴14. Meririnne E, Mykkänen S, Lillsunde P, Kuoppasalmi K, Lerssi R, Laaksonen I, Lehtomäki K, Henriksson M. Workplace drug testing in a military organization: results and experiences from the testing program in the Finnish Defence Forces. Forensic Sci Int 2007; 170(2-3):171-174..

As with any civil organization, the military forces are not free from issues related to the use of drugs, including alcohol and illicit drugs. Because the military forces are specialized operations that involve the handling of weapons, the consumption of drugs in a military environment creates a need for rigorous and adequate control aimed at minimizing the development of chemical dependency because their use can affect public safety¹³13. Verstraete AG, Pierce A. Workplace drug testing in Europe. Forensic Sci Int 2001; 121(1-2):2-6.,¹⁴14. Meririnne E, Mykkänen S, Lillsunde P, Kuoppasalmi K, Lerssi R, Laaksonen I, Lehtomäki K, Henriksson M. Workplace drug testing in a military organization: results and experiences from the testing program in the Finnish Defence Forces. Forensic Sci Int 2007; 170(2-3):171-174..

Thus, the present study aimed to survey the prevalence of psychotropic drug use in military police units in GO, Brazil through the detection of marijuana, cocaine, amphetamine, methamphetamine, opiates and benzodiazepines in urine samples to support the implementation of random drug testing in active duty officers.

Methods

The design of this study was initially assessed and approved by the Ethics in Research Committee of the Federal University of Goiás (Universidade Federal de Goiás). The study was conducted in accordance with the Declaration of Helsinki (2008 revision)¹⁵15. Associação Médica Mundial. Declaração de Helsinque da Associação Médica Mundial (WMA). Princípios Éticos para Pesquisa Médica envolvendo Seres Humanos. Helsinque, Finlândia, Junho 1964; Revisada em 2008. Helsinque: WMA; 2008..

A total of 299 urine samples from active duty officers (285 males and 14 females) who are members of the police force of the state of Goiás were collected voluntarily and anonymously from March to October 2008. The urine samples were collected at the beginning of the work shift after signing the free and informed consent form. The samples originated from 12 different military police units in the cities of Goiânia and Aparecida de Goiânia, and they were subject to a immunochromatographic screening test (Multi-DrugOneStep Test, Inlab Diagnostics®) with the following detection cut-off values: methamphetamine 500 ng/mL; amphetamine 1000 ng/mL; opiates/morphine 300 ng/mL; cannabinoids (tetrahydrocannabinol) 50 ng/mL; cocaine (benzoylecgonine) 300 ng/mL and benzodiazepines 300 ng/mL. These tests were validated by Costa et al.¹⁶16. Costa SHN, Cunha LC, Doles LA, Yonamine M, Campos SV, Penna KGBD, Nascente KRSM. Revisão crítica do uso de testes rápidos imunológicos para verificar o consumo de substâncias psicoativas. Rev Bras Toxicol 2005; 18(2):123-130. and acquired by the Dean's Office for Research and Post-Graduate Studies of the Federal University of Goiás (Pró-Reitoria de Pesquisa e Pós-Graduação da Universidade Federal de Goiás), and they were capable of detecting the presence of two or more of the tested drugs for each individual.

Samples that tested positive for illicit drugs were confirmed by a gas chromatography–mass spectrometry (GC-MS) analysis conducted at the Toxicological Analysis Laboratory of the University of São Paulo (Laboratório de Análises Toxicológicas da Universidade de São Paulo – LAT-USP) (Hewlett Packard 5972 mass spectrometer coupled to a Hewlett Packard 6890 gas chromatograph, which was equipped with 30 m x 0.25 mm x 0.1 µm HP-5MS fused-silica capillary column; Hewlett Packard, Little Falls, USA). The cut-off values used for the technical confirmation were 11-nor-9-COOH-Δ⁹-THC 15 ng/mL; amphetamine/methamphetamine 200 ng/mL; and benzoylecgonine 150 ng/mL. In summary, the samples were subject to liquid-liquid extraction, solid phase extraction or liquid phase microextraction, chemical fractionation and injection into a GC-MS according to published methods that are routinely used in toxicological and anti-doping analyses conducted at LAT-USP¹⁷17. Eller SCWS, Gonçalves FL, Paranhos BAPB, Costa JL, Lourenço FR, Yonamine M. Analysis of 11-nor-9-carboxy–9-tetrahydrocannabinol in urine samples by hollow fiber-liquid phase microextraction and gas chromatography-mass spectrometry in consideration of measurement uncertainty. Forensic Toxicol 2014; 32:282-291.–¹⁹19. Yonamine M, Silva OA. Confrmation of cocaine exposure by gas chromatography–mass spectrometry of urine extracts after methylation of benzoylecgonine. J Chromatogr B 2002; 773(1):83-87.. Samples that tested positive for benzodiazepines were not confirmed by GC-MS because the immunochromatographic method is sensitive and specific enough for identification.

Sample size calculations were performed using the StatCalc tool of the software EpiInfo™ version 3.5 according to the study population size and drug use data from epidemiological studies conducted by the Brazilian Center of Information on Psychotropic Drugs (Centro Brasileiro de Informações sobre Drogas Psicotrópicas)⁵5. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2011. EUA: UNODC; 2012. [acessado 2012 maio 1]. Disponível em: http://www.unodc.org.br
http://www.unodc.org.br... as well as other prevalence studies conducted in Brazil²2. Silva OA. Consumo de drogas de abuso no ambiente de trabalho no Brasil. Rev Bras Toxicol 1999; 11(1):7-10.,¹²12. Costa SHN, Cunha LC, Yonamine M, Pucci LL, Oliveira FGF, Sousa CG, Mesquita GA, Vinhal LB, Dalastra J, Leles CR. Survey on the use of psychotropic drugs by twelve military police units in the municipalities of Goiânia and Aparecida de Goiânia, state of Goiás, Brazil. Rev Bras Psiquiatr 2010; 32(4):389-395.. Thus, the sample size estimate of the population studies (N = 1709) was 287 samples. A significance level of 0.05 was set for the tested drugs, with an expected frequency of 1.0%.

Results

The distribution of the study subjects in relation to age and gender is shown in Table 1.

The frequency of psychotropic drug use was obtained from an analysis of the samples provided by the 299 participants in the study and is shown in Figure 1.

There were no cases of multiple drug use. Out of the six positive cases in the immunological screening analysis, three were confirmed positive and three were confirmed negative by GC/MS.

Among the positive cases, 57.1% corresponded to the use of benzodiazepines; 28.6% corresponded to the use of cannabinoids and 14.3% corresponded to the use of amphetamines.

Discussion

The prevalence of drug use in the present study was 2.34%, which is higher than that found by another study conducted in 2004⁷7. Silva OA, Yonamine M. Drug abuse among workers in Brazilian regions. Rev Saude Publica 2004; 38(4):552-556. in which the profile of illicit drug abuse in the work environment in five regions of Brazil was studied through immunoassay screening and GC/MS confirmation and found at a prevalence of 1.8%. However, this difference could have been caused by the additional inclusion of prescription drugs in the present study; thus, the presence of benzodiazepines was assessed and accounted for 1.34% of the total, whereas cannabinoids and amphetamines accounted for 1.0%.

In relation to the 2nd Assessment on the Use of Psychotropic Drugs (II Levantamento Sobre o Uso de Drogas Psicotrópicas) conducted in 2005 through a validated questionnaire, the central-west region showed a percentage of marijuana dependence of 0.6%; benzodiazepine dependence of 0.2% and stimulant dependence of 0.2%. In that assessment, which covered all regions of Brazil, the overall percentage of marijuana dependence was 1.2%; benzodiazepine dependence was 0.5% and stimulant dependence was 0.2%⁵5. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2011. EUA: UNODC; 2012. [acessado 2012 maio 1]. Disponível em: http://www.unodc.org.br
http://www.unodc.org.br... . In the present study, marijuana, amphetamine and benzodiazepine use was detected in 0.67%, 0.33% and 1.34% of the study group, respectively, and similar values for amphetamines and marijuana and higher values for benzodiazepines were observed in the central-west region. However, the overall percentage of marijuana dependence in Brazil (1.2%) is higher than the percentage found in the present study⁵5. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2011. EUA: UNODC; 2012. [acessado 2012 maio 1]. Disponível em: http://www.unodc.org.br
http://www.unodc.org.br... .

The results of the present study corroborate those found by Souza et al.²⁰20. Souza ER, Schenker M, Constantino P, Correia BSC. Consumo de substâncias lícitas e ilícitas por policiais da cidade do Rio de Janeiro. Cien Saude Colet 2013; 18(3):667-676., who evaluated the use of licit and illicit drugs among civilian and military police in Rio de Janeiro (RJ), Brazil through a pre-tested questionnaire and showed that the consumption of psychoactive substances is up to 10 times higher in military police officers.

Considering the nature of military activity, especially operational activities, the development of emotional instability that requires treatment with psychiatric drugs is frequently observed²¹21. Orlandi P, Noto AR. Uso indevido de benzodiazepínicos: um estudo com informantes-chave no município de São Paulo. Rev Latino-am Enfermagem 2005; (13):896-902.–²³23. Mura P, Kintz P, Papet Y, Ruesch G, Piriou A. Evaluation de six tests rapides pour le despitage du cannabis dans la sueur, la salive et les urines. Acta Clin Belg 1999; 1:35-38., and this situation can be observed by the higher prevalence of benzodiazepine use in the present study. Another relevant aspect is that the majority (63.2%) of the study participants are middle aged (≥ 35 years old), which corroborates the observations of a study conducted in 2005²²22. Colombia. Ministerio del Interior. Consejo Nacional para el Control de Estupefacientes; 2006. [[acessado 2009 janeiro 8]. Disponível em: http://www.conacedrogas.cl/inicio/obs_naci.php
http://www.conacedrogas.cl/inicio/obs_na... in which benzodiazepine users described through interviews the therapeutic benefits of the drug for treating sleep and anxiety disorders.

Studies performed in military institutions in other countries have shown that psychoactive drug use (primarily marijuana and amphetamines) is responsible for serious issues in the workplace as well as in the home environment and indicated that such use deserves special attention through the implementation of prevention programs and/or policies to deter drug use²⁴24. Jedrzejczak M. Drug addiction among service soldierscauses of phenomenon development. Przegl Epidemiol 2002; 56(1):169-177.–²⁷27. Bray RM, Hourani LL. Substance use trends among active duty military personnel: findings from the United States Department of Defense Health Related Behavior Surveys, 1980-2005. Addiction 2007; 102(7):1092-1101.. These data corroborate those of Souza et al.²⁰20. Souza ER, Schenker M, Constantino P, Correia BSC. Consumo de substâncias lícitas e ilícitas por policiais da cidade do Rio de Janeiro. Cien Saude Colet 2013; 18(3):667-676., who showed that among military officers, the use of illicit substances increased work-related problems (4.9%) and work absence (4.4%).

The prevalence of abusive drug use found in the present study indicates the potential for implementing random testing to detect psychoactive substance use by military police officers on active duty as an alternative for referring users to a multidisciplinary health team and, if successful, reintegrating the users into the workforce. Thus, it is possible to collaborate to decrease health problems, tardiness, absenteeism, poor performance (alternation between high and low productivity, impaired judgment, insubordination and memory lapses) and poor interpersonal relations.

The positive results show that immunological tests (screening) for drug abuse studies should be confirmed by the more sensitive GC-MS method because of the possibility of false-positive results²⁸28. Reinhard VED, Mídio AF. Revisão dos métodos analíticos para detecção de canabinóides em material biológico. Rev Bras Toxic 1995; 8(2):29-40.–³⁰30. Peat M. Workplace Drug Testing. Clarke's Analysis of Drugs and Poisons: in pharmaceuticals, body fluids and postmortem material. London: Pharmaceutical Press; 2002. p. 68-79.. Such false positives were observed in three samples, two for methamphetamine (500 ng/mL) and one for opiates (300 ng/mL), which was most likely because of the detection limits of the tests used in the present study³⁰30. Peat M. Workplace Drug Testing. Clarke's Analysis of Drugs and Poisons: in pharmaceuticals, body fluids and postmortem material. London: Pharmaceutical Press; 2002. p. 68-79.,³¹31. De La Torre R, Segura J, De Zeeuw R, Eillians J. Recommendation for the reliable detection of illicit drugs in urine in the European Union, with special attention to the workplace. Ann Clin Biochem 1997; 34(Pt 4):339-344..

The results obtained in the present study were generated from urine samples donated voluntarily by the subjects, and positive results were still obtained. If the toxicological analysis is to be included in the work environment, it should be implemented at different times during employment, such as upon hiring and after accidents or incidents at work, through voluntary and random testing when there is reasonable suspicion of a troop member, and during rehabilitation of the individual³²32. Odo SA, Araújo AC, Santos AF, Toledo FCP, Yonamine M, Silva OA, Leite MC. Indicações e limites das análises toxicológicas para substâncias psicoativas. Rev Psiquiatr Clin 2000; 27(1):50-56..

The use of psychoactive substances is classified according to the frequency and quantity of consumption, characteristics of the individual, and socio-cultural context, which varies from simple experimentation to occasional use, abuse or even dependence. Thus, a possible limitation of the present study is that only a single sample collection was performed; therefore, it was not possible to classify the individuals as dependent. Authors have suggested that not all individuals who experiment with certain types of psychoactive substance become habitual users or dependent, with the majority only trying these substances once, which is inconsistent with proponents of the theory of escalation, in which the use of one drug is succeeded by the use of a stronger drug at a heavier frequency³³33. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV- TR. 4th ed. Washington: APA; 2002.–³⁵35. Aragão ATM, Milagres E, Figlie NB. Qualidade de vida e desesperança em familiares de dependentes químicos. Psico-USF 2009; 14(1):117-123..

The delicate question of drug use in the military environment requires a more engaged presence of the state in attending to what is expected by public security agents. Such attention will directly benefit society, which is affected by the quality of the safety and services provided by officers³⁶36. Figueiredo AEB, Souza ER. Sofrimento psíquico em policiais civis do Estado do Rio de Janeiro. Cien Saude Colet 2013; 18(3):633-644.,³⁷37. Pinto LW, Domingo-Salvany A, Brugal MT, Barrio G, González-Saiz F, Bravo MJ, La Fuente L, ITINERE Investigators. Gender differences in health related quality of life of young heroin users. Health Qual Life Outcomes 2010; 8:145.. As suggested by Minayo³⁸38. Minayo MCS. Valorização profissional sob a perspectiva dos policiais do Estado do Rio de Janeiro. Cien Saude Colet 2013; 18(3):611-620., the success of important organizations, such as police departments, depend on maintaining the motivation of their agents and offering proper working conditions and psychologically favorable environments.

Conclusion

The results of the present study showed the prevalence of psychoactive substance use among public safety professionals stationed in military police units in the state of Goiás. This prevalence can be considered significant compared with the average in the general population. Therefore, the present study indicates that specific laws are required for the implementation of biological sample testing to verify the use of psychoactive substances in active duty officers as an additional method of minimizing the abuse of these substances in this field.

Acknowledgment

The authors would like to thank the Toxicological Analysis Laboratory of the University of São Paulo (Laboratório de Análises Toxicológicas da Universidade de São Paulo) and Dean's Office for Research and Post-Graduate Studies of the Federal University of Goiás (Pró-Reitoria de Pesquisa e Pós-Graduação da Universidade Federal de Goiás) for allowing us to perform the screenings and chromatographic tests. We would also like to thank the Research Support Foundation of the State of Goiás (Fundação de Amparo à Pesquisa do Estado de Goiás, FAPEG) for the constant financial support.

References

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