1.

Description of the Research work

Pakistan being an Islamic republic state despises the use of drugs and alcohol, as direct
reference is made on its prohibition in The Quran, their holy book. Nonetheless, drugs and
alcohol are widely consumed by population of Pakistan. When Pakistan opened its door to
refugees of Iran and Afghanistan, drugs started to produce, smuggle and cultivate in the
country in increasing number. The supply of drugs became a common commotion and
slowly it made its way to educational systems. Health professionals including medical
students are said to be at higher risk of substance abuse because of relatively easy
availability to psychoactive drugs, elevated work stress, often becoming ill and death,
relative separation of medical school and disrupted sleep cycle and low social life (Naskar
& Bhattacharya, 1999; Kumar & Basu, 2000). Present study aims to explore the prevalence
of drug use and alcohol among medical students of Punjab, Pakistan so conc--rete statistical
results obtained from administrating instruments on target population will help government
to make better policies on preventing substance use.
In current study, development of behavioral, psychological and cognitive symptoms, when
an individual continuously takes substances although they know it will cause them
significant problems is defined as substance use disorder following the diagnostic criteria
from Diagnostic and statistical manual for mental disorders (DSM) 5. Substances are
classified as alcohol, tobacco, stimulants, sedative/hypnotics or anxiolytics, inhalants,
hallucinogens, cannabis and other unknown substances for diagnosis (APA, 2013).
A human body is affected by intake of drugs. It influences the neurotransmitters of brain
and its chemical functioning. Drug abuse is an indulgence of an individual with drugs to an
extent that it affects their mental and physical health. United Nations (UN) reported in 2008
that 208 million people are estimated to be involved with illegal drugs. Drug that is
commonly used is Marijuana, 3.9% population of the world takes this drug and their age
ranges between 15 to 65 years. A 25% increase in drug addiction is predicted in coming
years (Asghar, 2018)
Medical students are tomorrow’s doctors, so their field of study is more hectic and demand
more responsibilities than other subject students. Stressful nature of medical studies can
lead students to substance abuse which can have serious consequences on their capabilities
to perform as a doctor in future. As integrity of medical science requires heavy work load, it
negatively impacts on mental health of students (Yousafzai, et al., 2017).
Drugs have been present for thousands of years; many have used them while some
population has abused them. “Substance abuse refers to the harmful or hazardous use of
psychoactive substances, including alcohol and illicit drugs. Psychoactive substance use can
lead to dependence syndrome - a cluster of behavioral, cognitive, and physiological

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phenomena that develop after repeated substance use and that typically include a strong
desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful
consequences, a higher priority given to drug use than to other activities and obligations,
increased tolerance, and sometimes a physical withdrawal state” (World Health
Organization, 2019).
Substance abuse is the most common problem that is growing day by day. Humans of
different cultures search for drugs that help them to improve their mood and affect their
judgment. This may include drinking alcohol, smoking tobacco or cannabis, injecting drugs
and many other ways of drug intakes. The most common drugs frequently used are
cigarettes and alcohol (Imran, Haider, Batti, Sohail, & Zafar, 2011).The use of alcohol,
tobacco and other psychoactive drugs cause mental, physical and societal problems.
The most common risk factors that increase the likelihood of abusing substance are genetic
factors, family environment, and absence of parental support, society and mental health
(Das, Salam, Arshad, Finkelstein & Bhutta, 2016). In medical students the easy access,
relief from psychological stress, immaturity in emotions, student abused and family history
of drug use in parents are most common risk factors (Nawaz, Khan & Bukhari, 2017). High
work of academics in medical field and curiosity are some of the major factors of using
drugs (Haldar, Majumdar & Roy, 2018). Characters of personality that are linked with
psychoticism are also associated with abuse of drugs and consumption of alcohol
(Newbury-Birch, White & Kamali, 2000).
Drugs and alcohol have sometimes caused irreparable damage to the lives of abusers; they
involve themselves in questionable activities. It becomes impossible for them to maintain
their jobs, marriage, and relationships. Even lose their respect in society. They get
themselves involve in criminal activities to get access to drugs, might kill or injure someone
unintentionally and spread or get other infectious diseases. As one of the symptoms of
substance abuse indicates suicidal ideation, they might end up killing themselves (HCSA,
2019).
Drugs became the easiest way to forget realities and be at peace for short period of time.
Started just as mere curiosity, can result into lifetime addiction for a person. Many
rehabilitation centers have been inaugurated over time in Pakistan to tackle drug abuse,
along with proper treatment in clinics, but still much population of Pakistan refuse
treatments. This could be due to poor backgrounds, considering it a weakness or fear of
stigma.
2. Significance of Research
A report concluded by United Nations Office on Drugs and Crime (UNODC) in 2013 by
the title of Drug Use in Pakistan, showed that 6.7 million people in Pakistan are drug users

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and among which 4.25 million are addicts (Farrukh, 2018). Heroin is the most widely used
drug in Pakistan, which is followed by hashish, charas, bhang, opium, alcohol and
psychotropic drugs (PNCB, 1994). As described above through report, drug addiction is
increasing at an alarming rate in Pakistan; much concrete studies are needed to warn
population of Pakistan by its negative consequences. This research is being carried out as
not much work has been done in Pakistan to check prevalence of substance abuse
particularly in medical students. As previously a study conducted on prevalence of drug
abuse among the medical students of Lahore, Pakistan included only two medical colleges,
private and government each, so it’s results couldn’t be generalized to whole population of
medical students of Lahore and as current study will be conducted on provisional level, the
gap in this study will be filled (Imran, Haider, Batti, Sohail & Zafar, 2011). Moreover, this
study was conducted in 2011; the time gap is surely providing the significance of the
present study. Another study explored the prevalence of psychoactive drug use among
medical students of Abbottabad, Pakistan (2017) included only 1 government medical
college, no comparison with private medical college student was observed (Nawaz, Khan
& Bukhari, 2017). The current study aims to compare point prevalence among the private
and government medical colleges of Punjab, Pakistan.
Due to heavy work load medical student’s mental health is negatively affected and they
may start using drugs to overcome it, the results of this study will be helpful in making
preventive programs and facilitate interventional strategies for medical students by college
management (Yousafzai, et al., 2017). Government will be challenged to make strict
policies against the use of drugs in Pakistan not only in medical field but all over country.
Practical coping skills can be demonstrated in seminars held at medical colleges to help
them overcome drug problems. So this issue must be highlighted with credible statistical
results, so that immediate steps should be taken to save students from drug problems. Still
more understanding is needed on drug abuse problem for individuals, families and
government to overcome this problem, which can only be achieved by providing concrete
statistical numbers of the situation.
2.1: Objectives of the Research
a) To explore the point prevalence of substance use among medical students of
Punjab, Pakistan.
b) To explore the point prevalence of alcohol among medical students of Punjab,
Pakistan.
c) To compare the point prevalence of substance use and alcohol in relation to private
and government medical colleges/universities of Punjab, Pakistan.
2.2: Hypothesis

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 a) There would be significant difference in point prevalence of substance use in
relation to demographic variables of participants.
b) There would be significant difference in point prevalence of alcohol in relation to
demographic variables of participants.

3. Review of the literature

Different researches have been conducted to check prevalence of drug abuse in different
countries and also in Pakistan.
Imran, Haider, Bhatti, Sohail and Zafar (2011) did a cross sectional study to estimate the
prevalence of psychoactive substance use among medical students of 2 medical institutions
in Lahore, Pakistan. Among 1299 students 222 (17%) admitted to use psychoactive
substance in past and 46(3.6%) were still using at the time of research. Cigarettes (78.9%)
were most abused substance reported in study. Being comparative study private medical
students showed more use of substance than public medical students and males
experimented more than girls (Imran, Haider, Batti, Sohail & Zafar, 2011). As current
study’s theme is also to explore substance use prevalence with comparison of public &
government, it is very relatable to the above mentioned study.

Pitanupong and Ratanapinsirj (2016) also conducted a cross sectional research in Thailand
to check prevalence of alcohol and substance use among Prince of Songkla University
medical students. 739 students completed the questionnaires among which 53.3% reported
drinking alcohol and 7.6% had experimented with substance use. Mostly used substances
were cigarettes (5.3%). More males (60.0%) reported the abuse of drugs (Pitanupong &
Ratanapinsiri, 2018). This research is relatable to present study as both are exploring
alcohol and substance use variables separately and also the same instrument; Alcohol use
disorder identification test (AUDIT) will be used to measure alcohol.

In 2017, a cross sectional study was conducted to estimate prevalence of psychoactive

drugs in medical students of public sector medical college of Abbotabad, Pakistan. 89-48%
completed the questionnaire among which 21.49% admitted to abuse substance in past or
present. Cigarettes were one of the most commonly used drug (76-67%).psychological
stress (49.33%) was one of the main reason behind substance use. 46-67% students used
more than one substances. Male (71.33%) students used more drugs than females (Nawaz,
Khan & Bukhari, 2017).

Papazisis, Tsakiridis, Koulas, Siafis, Dagklis and Kouvelas (2017) conducted research to
measure prevalence of drug use in medical students of Northern Greece. 591 students
completed the anonymous survey that measured the use of drugs once in their life time and

(Page 4 of 12)
 in past year. CAGE was also used as a questionnaire in the study. Results indicated that
24.7% students used illicit drugs once in their life time and 22.7% had drinking behaviors.
Drinking habits and smoking were considered as strong risk factors for using illicit drugs
(Papazisis,Tsakiridis,Koulas,Siafis, Dagklis & Kouvelas, 2017).

Haldar, Majumdar and Roy (2018) conducted research to explore prevalence, cause and
types of substance abuse among medical students of KPC medical college, Kolkata. 452
students completed the questionnaire and 60.26% substance abuse prevalence was found in
them. Alcohol (77.29%) was one of the most commonly used drugs among others.
Academic pressure was one of the main reasons behind using drug substances. Drug abuse
was reported higher in males (75.09%) (Haldar, Majumdar, & Roy, 2018).

All the literature mentioned above are in somehow relation to the current study, be it the
prevalence theme, or comparison of private and government sector medical
college/university or study on substance use and alcohol. Also literature establishes the use
of instruments in current study along with demographic variables chosen.
4. Research Methodology
Exploratory Research Design will be used as study is exploring the point prevalence of
substance use and alcohol in medical students of Punjab, Pakistan. Medical students of
public and private medical colleges/universities of Punjab, Pakistan will be target
population. For the present study, lists of all medical colleges/universities currently
operational in Punjab will be retrieved from Pakistan Medical and Dental Council (PMDC)
official website. Medical colleges/universities will then be separated according to private
and government sector. List of number of enrolled students in each targeted medical
college/university will then be retrieved either by their website or by contacting
college/university’s officials. Multi-stage stratified proportionate random sampling
technique will be used to select the sample from target population. Proportional allocation
method will be used to determine the sample size from each stratum depending on
proportional contribution of each stratum in target population.

At first stage, target population will be stratified into stratums of cities of Punjab, Pakistan.
At second stage, each stratum of cities will be divided into sub-stratums of private and
government medical colleges of Punjab, Pakistan. At third stage, each stratum of sectors
will be divided into sub-stratums of academic year (1st, 2nd, 3rd, 4th & 5th). At fourth stage,
each stratum of academic year will be divided into sub-stratum of gender (male and
female).

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From each group target number of individuals will be randomly selected. The sample size
of the study will be determined using Taro Yamane formula (Yamane, 1967).

n= N/ 1+ N (e) ²

In this equation n represents sample size of participants, N is the size of population and e is
the level of precision. Among Punjab, Pakistan only those districts will be included in
current study, who have both private and government medical colleges/universities.
Students with any type of physical or mental illnesses will be excluded from the study.

The questionnaire consists of four parts.

The first part will consist of demographic sheet. It will include age, gender, academic year,
residence, social economic status, university/college sector, family system and parental
marriage status, monthly family income, purpose of initiation, duration of substance use
and checklist of substances participants use.

The second part will be the diagnostic instrument for substance users, The Level 2—
Substance Use—Adult measure, adapted from the National Institute on Drug Abuse
(NIDA)-Modified ASSIST (NIDA, n.d.-a), includes 10 items that measure how often an
individual used a substance in the past two weeks. The substances included are painkillers,
stimulants, sedatives or tranquilizers, marijuana, cocaine or crack, club drugs,
hallucinogens, heroin, inhalants or solvents, and methamphetamine. The interviewee
answers from 0–4 based on how many days the substance is used. The measure does not
include alcohol, tobacco or caffeine as substances (Schmit & Balkin, 2017).

Skinner is the author of Drug Abuse Screening Test (DAST-10). It is used as a screening
instrument of drug problems for population, evaluating case in clinical settings and assist
in treatment selection. It is used to find out quantitative index for the extent of drug abuse
problems. It can be self-administered and used in an interview format. People who are
under the influence of drugs and facing withdrawals shouldn’t be administered this test.
This test includes over use of prescribed medicines and non-prescribed drugs such as
cannabis, narcotics, solvents and hallucinogens etc. as drug abuse. It does not include
alcohol.

DAST-10, a short version of original DAST-28 will be used in this study. It contains 10
items. DAST-10 is highly correlated (r=.98) with another short version DAST-20(r= .99)
and has excellent internal consistency reliability (.92 for total sample and .74 for drug
abuse) (Skinner, 2006). Item responses are Yes/No, score 1 is given to all the responses of

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 Yes and 0 to all the responses of No. Total scores are yielded by summing all item’s
responses, it can range from 0 to 10. For interpretation cut off scores are given, which
indicate at what level an individual has drug abuse problem.

It is a 10-item screening and assessment tool which is developed by World Health

Organization (WHO). It is used to assess behaviors of individuals with drinking problems,
using alcohol and alcohol related issues. A self-report version of AUDIT will be used in
this study, as DSM-5 diagnostic measure and DAST-10 doesn’t cover alcohol usage. A
test-retest reliability of AUDIT was analyzed and results indicated high reliability (r= .86).
Validity of this instrument has also been reported very good (Babor, Higgins-Biddle,
Saunders & Monteiro, 2001). Many studies have been conducted that use AUDIT as a
prevalence measure, such as a study in Thailand by Lapham used AUDIT to estimate the
prevalence of alcohol disorder in emergency rooms of 3 regional hospitals (Lapham,
Skipper, Brown, Chadbunchachai, Suriyawongpaisal & Paisarnsilp, 1998). Scoring is easy
to summarize. Each statement’s response has a score range from 0 to 4. Total score is
obtained to summing all the scores of responses and it would show at which level is an
individual at risk of developing the alcoholic problem. Total score can range from 0 to 40.
Cut off scores of 8 or more indicate moderate and high levels of alcohol use in them
(Babor, Higgins-Biddle, Saunders & Monteiro, 2001).

A pilot study on 26 medical students will be conducted to evaluate the comprehensibility

of the instruments being used in the current study. After it, permission from all the selected
medical colleges/universities’ officials will be taken. All the students will be approached in
their classes and will be briefed about the current study. Written consent will be taken
from all the participants and questionnaires will be self-administered in groups.

Data will be analyzed using SPSS (Statistical Package of Social Sciences) 21.0.
Descriptive and inferential statistics will be used to compute demographic information and
point prevalence for current study.

Official permission from authors of instruments will be taken. Participant’s privacy and
confidentiality would be maintained. They would be allowed to withdraw from the study
whenever they want. It would be ensured that data would be only used for research
purposes.
5. Implications of the Research
i. The findings of this study will be helpful in making preventive programs and facilitate
interventional strategies for medical students by college management

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 ii. Government will be challenged to make strict policies against the use of drugs in
Pakistan not only in medical field but all over country.
iii. Practical coping skills can be demonstrated in seminars held at medical colleges to
help them overcome drug problems.

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6. References
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Asghar, S. (2018).Drug abuse in Pakistan reaches alarming level. The Nation.Retrieved

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Babor, T.F., Higgins-Biddle, T.C., Saunders, J. B., & Monteiro, M. G. (2001).The Alcohol
Use Disorders Identification Test (AUDIT) (2nd ed.). World Health Organization
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Farrukh, S. (2018). Pakistan’s huge drug addiction problem.Pakistan Today.Retrieved

from https://www.pakistantoday.com.pk/2018/02/22/pakistans-huge-drug-addiction-
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Kumar, P., & Basu, D. (2000). Substance abuse by medical students and doctors. Journal
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 association with smoking and alcohol use.HippokratiaQuaterly Medical Journal,
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 7. APPENDIX

Turnitin Originality Report

Tested on May 02, 2019, by Turnitin Anti Plagiarism Software Provided by Higher Education
Commission, Pakistan to the Instructor of the University of Gujrat, Punjab, Pakistan.

Synopsis Title: PREVALENCE OF SUBSTANCE USE AND ALCOHOL AMONG

MEDICAL STUDENTS OF PUNJAB, PAKISTAN.

Scholar’s Name: SAFA RIZWAN

Institution: University of Gujrat

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