Chapter 17: Pharmacology, Drugs and Sports

1. Chapter 17: Pharmacology, Drugs and Sports © 2011 McGraw-Hill Higher Education. All rights reserved.

2. Pharmacology is the branch of science that deals with the action of drugs on the biological systems • Specifically those that are used in medicine for diagnostic and therapeutic purposes • Used to achieve definite outcomes that improve quality of life • Various drugs and other substances are being used widely for performance enhancement or mood alteration © 2011 McGraw-Hill Higher Education. All rights reserved.

3. What is a drug? • Chemical agent used in prevention, treatment, & diagnosis of disease • Ancient practice dating back to the Egyptians • Many are derived from natural sources • Drugs which have in the past come from nature are now produced synthetically © 2011 McGraw-Hill Higher Education. All rights reserved.

4. Pharmacokinetics • Method by which drugs are absorbed, distributed, metabolized and eliminated from the body • Pharmacodynamics is the actions or effects of drugs on the body © 2011 McGraw-Hill Higher Education. All rights reserved.

5. Administration of Drugs • Must first enter the system and reach receptor tissue to be effective • Drug vehicles • Therapeutically inactive substance used to transport drug (solid or liquid) • Internal administration • Inhalation (medication through respiratory tract) • Intradermal (into the skin) • Intramuscular (medication directly into muscle) • Intranasal • Intraspinal (medication injected into the spine) © 2011 McGraw-Hill Higher Education. All rights reserved.

6. Intravenous (into a vein) • Oral (most common form) • Rectal (limited due to dosage regulation) • Sublingual/buccal (dissolvable agents placed under tongue • Intravaginal (placing drug device inside vagina) • External Administration • Inunctions (oil based medication rubbed into skin) • Ointments (long lasting topical medication) • Pastes (ointments with nonfat base) • Plasters (thick ointment, counterirritant for pain & inflammation relief, increasing circulation) • Transdermal patches (patch with slow release mechanism) • Solutions (administered externally) © 2011 McGraw-Hill Higher Education. All rights reserved.

7. Absorption of Drugs • Drug must dissolve before absorption • Rate and extent determined by chemical characteristics of drug, dosage, and gastric emptying • Bioavailability • How completely a drug is absorbed by the system • Dependent on characteristics not dosage • (Absorption rate dependent on dosage form) © 2011 McGraw-Hill Higher Education. All rights reserved.

8. Distribution • Once absorbed, drug is transported through blood to target tissue • Volume of distribution: volume of fluid/plasma in which drug is dissolved and indicates extent of distribution of that drug • Efficacy: capability of producing therapeutic effect • Potency: dose of the drug required to produce a desired therapeutic effect • Metabolism • Biotransformation of drug to water soluble compounds that can be excreted • Most takes place in liver, rest in blood and kidneys • Liver detoxifies active agents • Metabolites may be toxic © 2011 McGraw-Hill Higher Education. All rights reserved.

9. Excretion • Excretion of drug or its metabolites is controlled by kidneys • Filtered through kidneys and usually excreted in the urine (some is reabsorbed) • May also be excreted in saliva, sweat and feces © 2011 McGraw-Hill Higher Education. All rights reserved.

10. Drug Half-Life • The amount of time required for the plasma drug level to be reduced by one half • It is either measured in minutes, hours, or days depending on the drug • Critical information in determining how much of what drug to utilize • Drug steady state • The amount taken is equal to the amount excreted • Drugs with long half-lives may take days or weeks to reach steady state © 2011 McGraw-Hill Higher Education. All rights reserved.

11. Effects of Physical Activity on Pharmokinetics • Exercise decreases the absorption after oral administration • Exercise increases absorption after intramuscular or subcutaneous administration due to the increased rate of blood flow • Exercise has an influence on the amount of a drug that reaches the receptor site © 2011 McGraw-Hill Higher Education. All rights reserved.

12. Legal Concerns in Administering Versus Dispensing Drugs • Defined as a single dose of medication to be used by a patient • Dispensing constitutes providing a sufficient quantity to be used for multiple doses • By law, only licensed persons may prescribe or dispense prescription drugs for an athlete • Athletic trainers are not allowed to dispense medication unless allowed by state licensure © 2011 McGraw-Hill Higher Education. All rights reserved.

13. Administering Over the Counter Drugs • Athletic trainer may be allowed to administer a single dose of nonprescription medication • Rules relative to secondary schools • Oral medications vs. wound medication • College and professional athletes • Most are of legal age and are allowed to use whatever nonprescription drugs they choose • Athletic trainer must still use reasonable care and be prudent about types of medication provided • In all cases, actions should be performed under the supervision of a physician © 2011 McGraw-Hill Higher Education. All rights reserved.

14. General Guidelines for Administration (Focus 17-1) • Should be taken as directed • Should not be used in combination without direction of physician • Do not use past expiration • Labels should not be removed • Take medications with water unless directed otherwise • Take with food or as directed • Containers should be child-proof • Provide verbal and written instructions • Patient should read label information and know dosage schedule • Medications should not be shared with other individuals • Ensure that the patient is aware of side effects and possible addictions • Be aware of interaction between meds and exercise © 2011 McGraw-Hill Higher Education. All rights reserved.

15. Record Keeping • Must maintain accurate and up to date medical records • Should include the following in log • quantity of medication given • method of administration • Should be aware of state regulations relative to ordering, prescribing, distributing, storing and dispensing of the medications • Obtaining legal counsel, working w/ state boards of pharmacy, student health clinic, physicians and establishing policies to minimize violating state laws © 2011 McGraw-Hill Higher Education. All rights reserved.

16. Name Complaint Current medications Any known drug allergies Name of medication Lot number Expiration Date Quantity of medication given Method of administration Date and time of administration Record Keeping-ATCs must maintain accurate and up to date medical records © 2011 McGraw-Hill Higher Education. All rights reserved.

17. Name of product Name and address of manufacturer, packer or distributor Net contents of package Name of active ingredients and quantity of certain other ingredients Name of any habit forming drug contained Cautions and warnings to protect consumer Adequate directions for safe, effective use Expiration date and lot number Labeling Requirements (federally mandated) © 2011 McGraw-Hill Higher Education. All rights reserved.

18. Nonprescription drugs should not be repackaged w/out meeting labeling criteria • All drugs dispensed from the athletic training room must be properly labeled • Legal liability if drugs removed from original packaging and dispensed • Unable to review contents, dosage, directions and precautions (information needed for safe use) • Same liability associated with providing prescription medication © 2011 McGraw-Hill Higher Education. All rights reserved.

19. Safety in Use of Pharmaceuticals • No drug is completely safe and harmless • Any drug under the correct conditions can be potent and dangerous, w/ every individual reacting differently • Patient must be instructed on specifics of medications (when to, how to and w/ what medication should be taken with) • Drug Responses • Individuals react differently to the same medications, w/ different conditions causing altered effects of drugs • Drugs can change with aging and relative to how they are administered • Alcohol ingestion w/ medications should be avoided © 2011 McGraw-Hill Higher Education. All rights reserved.

20. Alcohol is a CNS depressant and can increase or decrease effects of other drugs • Also used in many liquid preparations • Medication can potentially effect certain physiologic functions related to dehydration (sweating, urination, and the ability to control and regulate body temperature) • Can cause fluid depletion, further complicating illness, or make individuals sensitive to sunlight increasing risk of sunburn and allergic reactions • Different diets may impact absorption rate • Consumption of acidic foods such as fruit, carbonated drinks and vegetable juice may cause adverse reactions • Athletic trainer must know their patient’s in order to avoid potential adverse reactions © 2011 McGraw-Hill Higher Education. All rights reserved.

21. Buying Medication • Pharmacist is a vital resource, assisting in selection and purchase of nonprescription drugs, suggesting less expensive generic drugs, and acting as a general advisor • Properly storing medication is critical • Keep in locked cabinet • Maintain original container • Store away from direct light, heat, damp places and extreme cold © 2011 McGraw-Hill Higher Education. All rights reserved.

22. Traveling with Medications • When traveling with a team or individually the individual should be advised to do the following relative to medications • Medication should not be stored in a bag/luggage but carried by the athlete taking it • Sufficient supply should be packaged in case of emergency • Make sure there is a source of medication while traveling • Take copies of written prescriptions • Keep medication in original container • If traveling internationally, understand restrictions of individual boundaries © 2011 McGraw-Hill Higher Education. All rights reserved.

23. Selected Therapeutic • Widespread use in athletics and general society • Pharmaceutical labs develop compounds in vitro and then test, retest, and refine drugs in vivo before submitting it to the Food and Drug Administration (FDA) • Number of texts and databases are available for reference to determine appropriateness and effectiveness of medications for different conditions © 2011 McGraw-Hill Higher Education. All rights reserved.

24. Drugs to Combat Infection • Local Antiseptics and Disinfectants • Antiseptics are substances that can be placed on living tissue for killing bacteria or inhibiting growth • Disinfectants are used to combat microorganisms but should be applied to non-living objects • Germicides (generic name) designed to destroy bacteria, fungicides, sporicides and sanitizers © 2011 McGraw-Hill Higher Education. All rights reserved.

25. Alcohol • Most widely used skin disinfectant • Ethyl alcohol (70% by weight) and isopropyl alcohol (70% by weight) are equally effective • Inexpensive and nonirritating, kill bacteria immediately with the exception of spores • No long lasting germicidal action, can be used as an antiseptic or astringent • 70% solution can be used to disinfect instruments • Also can be utilized as mild anesthetic and topical skin dressing when combined with 20% Benzoin • Phenol • Early antiseptic and disinfectant in medical profession • Used to control disease organisms • Found in various concentrations and emollients • Derivatives include, resorcinol, thymol, and common house cleaner Lysol © 2011 McGraw-Hill Higher Education. All rights reserved.

26. Halogens • Chlorine, bromine, fluoride (used for antiseptic effect) • Iodophor or halogenated compounds create a much less irritating solution than tincture of iodine • Betadine solution- excellent germicide, very effective for skin lesions, abrasions and lacerations • Oxidizing agent • Hydrogen peroxide is commonly used in the athletic training • Readily decomposes in presence of organic substances and has little use as an antiseptic • Cleanses infected cutaneous and mucous membranes • Dilute solution can be used to treat inflammatory mouth and throat conditions © 2011 McGraw-Hill Higher Education. All rights reserved.

27. Antifungal Agents • Medicine used to treat fungi (Epidermophyton, Trichophyton, and candida albicans) • Numerous antifungal agents • Some can be used against deep seated fungal infections • Others are administered orally • Must be carefully monitored by physician • Antibiotics • Chemical agents that are produced by microorganisms • Interferes w/ necessary metabolic processes of pathogenic microorganisms © 2011 McGraw-Hill Higher Education. All rights reserved.

28. Used topically or as systemic medication • Indiscriminate use can produce hypersensitivity and prevent development of natural immunity or resistance to subsequent infections • Must be carefully controlled by physician • A number of antibiotics are available • Penicillin and Cephalosporins • Most important antibiotic • Useful in skin and systemic infections • Interferes w/ metabolism of bacteria • Bacitracin • Antibacterial agent • Tetracycline • Wide group of antibiotics that have broad antibacterial spectrum • Usually oral, modifies infection rather than eradicating it completely © 2011 McGraw-Hill Higher Education. All rights reserved.

29. Erythromycin • Used for streptococcal infection and mycoplasma pneumoniae • Same general spectrum as penicillin but can be used with individuals allergic to penicillin • Sulfonamides • Group of synthetic antibiotics • Make pathogens vulnerable to phagocytes and certain enzymatic actions • Quinolones • New group of antibiotics with broad spectrum of activity • Must be carefully monitored for adverse effects © 2011 McGraw-Hill Higher Education. All rights reserved.

30. Drugs for Asthma • Used to treat chronic inflammatory lung disorder • National Asthma Education and Prevention Program has established guidelines for diagnosis and treatment; NATA also has position statement • Goals of asthma therapy are to prevent chronic and troublesome symptoms, maintain normal lung function, prevent exacerbation and provide adequate pharmacotherapy with minimal adverse effects • Portable hand-held inhalers are available • Meter dosed inhalers (pressurized canister) • Dry powder inhalers • Nebulizer • Often individuals become dependent on inhalers • Treatment should not just be drug based © 2011 McGraw-Hill Higher Education. All rights reserved.

31. Figure 17-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

32. Drugs that Inhibit Pain and Inflammation • Pain Relievers • Numerous drugs and procedures can be used • Reasons for effectiveness • Excitatory effect on an individual impulse is depressed • Individual impulse is inhibited • Perceived impulse is decreased • Anxiety created by pain or impending pain is decreased © 2011 McGraw-Hill Higher Education. All rights reserved.

33. Counterirritants and Local Anesthetics • Analgesics give relief by causing systemic and topical analgesia • Application causes local increases in circulation, redness, rise in skin temperature • Mild pain can often be reduced w/ counterirritants • Examples include • Liniments • Analgesic balms • Spray coolants • Alcohol • Menthol • Cold • Local anesthetics (injected by physician) © 2011 McGraw-Hill Higher Education. All rights reserved.

34. Narcotic Analgesics • Most derived from opium or are synthetic opiates (morphine and codeine) • Depress pain impulse and respiratory center • Examples include • Codeine (morphine like action, found in cough suppressants; Vicodin) • Morphine (dangerous due to respiratory effects, habit forming qualities) • Propoxyphene hydrochloride (slightly stronger than aspirin and can be fatal if mixed with sedatives or depressants) • Meperidine (Demerol - substitute for morphine, effective when given intravenously or intramuscularly) © 2011 McGraw-Hill Higher Education. All rights reserved.

35. Non-narcotic Analgesics and Antipyretics • Designed to suppress all but most serious pain w/out losing consciousness • Acetaminophen • Tylenol - effective analgesic and antipyretic but has no anti-inflammatory activity • Does not irritate GI system and is often replacement for aspirin in non-inflammatory conditions • Over-ingestion can lead to liver damage © 2011 McGraw-Hill Higher Education. All rights reserved.

36. Drugs to Reduce Inflammation • Acetylsalicylic Acid (Aspirin) • Widely used analgesic, anti-inflammatory, antipyretic and abused drug • Helps reduce pain, fever and inflammation • Adverse reactions generally GI related • Over-ingestion can lead to ear ringing and dizziness, Reye’s syndrome (adolescents) • Allergic reactions result in anaphylaxis -- asthmatics may be at risk for reactions • Should be avoided w/ contact sports as it prolongs clotting time © 2011 McGraw-Hill Higher Education. All rights reserved.

37. Nonsteroidal Anti-inflammatory Drugs (NSAID’s) • Anti-inflammatory, antipyretic and analgesic properties • Inhibit prostaglandin synthesis and effective for osteo- and rheumatoid arthritis • Used primarily to reduce pain, stiffness, swelling, redness, fever associated w/ localized inflammation • Fewer side effects and longer duration than aspirin • Should not be used in place of acetaminophen or aspirin for headaches or increased temperature • Individuals w/ nasal polyps, associated bronchospasm or history of anaphylaxis should not receive NSAID’s © 2011 McGraw-Hill Higher Education. All rights reserved.

38. Can cause GI reactions, headache, dizziness, depression, tinnitus, • Taken in conjunction w/ heavy alcohol use can produce stomach bleeding • NSAIDs are associated with increased risk of adverse cardiovascular events • Myocardial infarction, stroke, new onset or worsening of existing hypertension • If necessary - should use the lowest effective dose for shortest duration of time, consistent with patient goals • NSAIDS may increase risk of GI bleeding, ulceration and perforation © 2011 McGraw-Hill Higher Education. All rights reserved.

39. Corticosteroids • Used primarily for chronic inflammation of musculoskeletal and joint problems • Prolonged use can create complications • Fluid and electrolyte disturbances • Musculoskeletal and joint impairment • Dermatological problems • Neurological impairment • Endocrine dysfunction • Ophthalmic conditions • Metabolic impairment • Cortisone is primarily injected • Can have negative effect on ligaments and tendons • Also administered through iontophoresis and phonophoresis © 2011 McGraw-Hill Higher Education. All rights reserved.

40. Drugs that Produce Skeletal Muscle Relaxation • Include methocarbamol (Robaxin) and carisoprodol (Soma) • Due to overall relaxation effect, physicians believe these are less specific to muscle relaxation than once believed (also cause drowsiness) • Used to eliminate muscle guarding and spasm • Do not appear to be superior to analgesics or sedatives in either acute or chronic conditions © 2011 McGraw-Hill Higher Education. All rights reserved.

41. Drugs Used to Treat Gastrointestinal Disorders • Includes stomach upset, gas formation due to food incompatibilities, acute or chronic hyperacidity • Poor eating habits may lead to digestive dysfunction such as diarrhea or constipation • Antacids • Neutralize acidity in upper GI, reducing pepsin activity (particularly on mucosal nerve endings • Relief of acid indigestion, heart burn, peptic ulcers © 2011 McGraw-Hill Higher Education. All rights reserved.

42. Sodium bicarbonate or baking soda are popular • Antacids w/ magnesium tend to have laxative effect • Those w/ aluminum and calcium cause constipation • Overuse can cause electrolyte imbalance • Antiemetics • Used to treat nausea and vomiting • Working locally • Work on mucosal lining of stomach (may be more placebo) • Working centrally • Affect brain, making it less sensitive to nerve impulses from inner ear and stomach • Variety of meds available, but may cause drowsiness © 2011 McGraw-Hill Higher Education. All rights reserved.

43. Carminatives • Provide relief from flatulence (gas) • Inhibit gas formation and aid in expulsion • Cathartics (laxatives) • Must be under direct supervision of physician • Constipation may be symptomatic of serious disease • Indiscriminate use may render individual unable to have normal bowel movements • May cause electrolyte imbalance • Antidiarrhoeals • Diarrhea tends to be a symptom, not a disease • Result of emotional stress, allergies, adverse drug reactions, or different intestinal problems © 2011 McGraw-Hill Higher Education. All rights reserved.

44. Antidiarrheal (continued) • Acute diarrhea • Accompanied by chills, vomiting, intense abdominal cramps/pain • Will typically run course and stop when irritating agent removed from system • Chronic diarrhea • May lasts for days or weeks and may be the result of more serious disease states • Treat with Kaolin (absorb chemicals and pectin), substances that add bulk to stool • Systemic agents (except Imodium AD) are prescription drugs • Most are opiate derivatives and will cause drowsiness, dry mouth, and constipation • Do not treat antibiotic induced diarrhea as it may be protective symptom in antibiotic induced pseudomembranous colitis © 2011 McGraw-Hill Higher Education. All rights reserved.

45. Histamine-2 Blockers • Reduce stomach acid output by blocking histamine on certain stomach cells • Used to treat peptic and gastric ulcers and GI hypersecretory conditions • Drug examples include Cimetidine (Tagamet) and ranitidine (Zantac) • Protein Pump Inhibitors (Prilosec) • Used to suppress gastric acid secretion • Treats erosive esophagitis, symptoms of gastroesophageal reflux disease • Also used in prevention of gastric ulcers, part of multidrug regimen for Helicobacter pylori in patients with duodenal ulcers © 2011 McGraw-Hill Higher Education. All rights reserved.

46. Drugs Used to Treat Colds and Allergies • Nasal Decongestants • Number of topical nasal decongestants available • Prolonged use may cause rebound congestion and dependency • Combat Methamphetamine Epidemic Act • Bans over-the-counter retail sales of cold meds with pseudoephedrine • Limits amount of pseudoephedrine that can be sold to an individual each month • Regulated sellers also must go through federally mandated self-certification process • Athletic trainers must be familiar with new state laws in order to remain compliant © 2011 McGraw-Hill Higher Education. All rights reserved.

47. Cough Medications • Suppress cough (antitussives) or produce fluid in respiratory system (expectorant) • Few side effects from nonnarcotic antitussives and are not addictive • Narcotic antitussives contain codeine • Little evidence that expectorants are any more effective on reducing cough than simply drinking water © 2011 McGraw-Hill Higher Education. All rights reserved.

48. Antihistamines • Often added to decongestants • Opposes histamine actions, but have little effects on the common cold • Beneficial in allergies • Impairs body’s ability to dissipate heat • Non-sedating antihistamines pose less risk for heat-related illnesses • Sympathomimetics • Often used to reduce spasm of bronchiole smooth muscle • May cause heat related problems • Epinephrine (EpiPen) • Athletic trainers can receive instruction on use • Used to treat anaphylaxis resulting from food or insect bites © 2011 McGraw-Hill Higher Education. All rights reserved.

49. Drugs to Control Bleeding • Vasoconstrictors • Most often administered externally at sites of profuse bleeding • Epinephrine or adrenaline commonly used • Acts immediately, constricting vessels --very valuable in instances of epistaxis (nosebleed) • Hemostatic Agents • Drugs that immediately inhibit bleeding (under investigation) • Thrombin © 2011 McGraw-Hill Higher Education. All rights reserved.

50. Anticoagulants • Heparin • Prolongs clotting time but will not dissolve clot once formed • Controls extension of a thrombus already present • Coumarin derivatives • Acts by suppressing formation of prothrombin in the liver • Given orally, they can be used to slow clotting time in certain vascular disorders © 2011 McGraw-Hill Higher Education. All rights reserved.