Substance Use In Athletes

1. Substance Use In Athletes Woodburne O. Levy, MD Developed for the Alcohol Medical Scholars Program

2. INTRODUCTION • Major problems facing sport today • Growing attention • Deaths of elite athletes • Increasing attention of media • Contrary to the ethical principles of athletic competition • Wide spread among athletes Developed for the Alcohol Medical Scholars Program

3. DRUGS MISUSED BY ATHLETES • Therapeutic drugs • OTCs, diuretics, opioids, beta-blockers, etc. • Performance enhancing drugs • Amphetamines, ephedrine, caffeine, anabolic steroids, growth hormone, etc. • Drugs typically misused • Alcohol, nicotine, marihuana, cocaine, etc. Developed for the Alcohol Medical Scholars Program

4. GOALS • Historical perspective • Factors influencing athletes to use drugs • Types of drugs athletes use- consequences and myths • Preventing and treating drug use in athletes Developed for the Alcohol Medical Scholars Program

5. Historical perspective • Ancient civilizations • Mushrooms, herbs, liquor • 19th Century • Alcohol, caffeine, nitroglycerine, opium, strychnine, trimethyl • World War II • Amphetamines, testosterone Developed for the Alcohol Medical Scholars Program

6. Historical perspective • Post war era • Amphetamines continue • Anabolic steroids • Newer agents • Blood doping • Erythropoietin • Growth hormone Developed for the Alcohol Medical Scholars Program

7. Currently prohibited by IOC • Drugs • Stimulants, opioids, anabolic agents, diuretics, peptide hormones • Methods • Blood doping, artificial oxygen administration, plasma expanders, pharmacological, chemical and physical manipulation • In certain circumstances • Alcohol, cannabinoids, local anesthetics,  blockers Developed for the Alcohol Medical Scholars Program

8. What factors influences athletes? • Belief that competitors take drugs • Determination to do anything to win • Pressures from coaches, parents, peers • Community attitudes and expectations • Financial rewards • Media influence • Belief of enhanced performance Developed for the Alcohol Medical Scholars Program

9. THERAPEUTIC DRUGS • OTCs • NSAIDs, laxatives, ephedrine, analgesics, weight loss meds, corticosteroids, local anesthetics • Low potential for misuse • Increased risk of further injury, GI bleed, anemia, eating disorders Developed for the Alcohol Medical Scholars Program

10. THERAPEUTIC DRUGS • Diuretics • Rapid weight loss • Boxing, wrestling, judo • Excretion or dilution of illegal substances • Overall negative impact on performance • Dehydration, hypotension, muscle cramps, electrolyte imbalance Developed for the Alcohol Medical Scholars Program

11. THERAPEUTIC DRUGS • Opioids • Prescription pain killers most common • Allow performance while injured • 75% used after injury only • Increased risk of further injury, dependence, drowsiness, mental clouding; in high doses: respiratory depression, hypotension Developed for the Alcohol Medical Scholars Program

12. THERAPEUTIC DRUGS • Beta-Blockers • Anti-tremor, anxiolytic effect • Shooters, ski jumpers, archery • Negative effect on endurance • Depression, bronchospasm, fatigue Developed for the Alcohol Medical Scholars Program

13. PERFORMANCE ENHANCING DRUGS • CNS Stimulants • Amphetamines • Delay fatigue, increase alertness, enhance speed, power, endurance, concentration • Hypertension, angina, vomiting, abdominal pain, cerebral hemorrhage, dependence, death Developed for the Alcohol Medical Scholars Program

14. PERFORMANCE ENHANCING DRUGS • CNS Stimulants • Caffeine • Shortened reaction time, improved concentration, diuresis • Glycogen sparing leading to delayed fatigue • > 12 ug/mL is a positive urine per IOC • Dyspepsia, cardiac damage, combination with other stimulants (e.g. ephedrine) may be fatal Developed for the Alcohol Medical Scholars Program

15. PERFORMANCE ENHANCING DRUGS • Systemic stimulants • Adrenalin • In local anesthetics • Ephedrine and pseudoephedrine • Cold and allergy remedies • Phenylpropanolamine • Diet pills • Similar effects to the amphetamines in high doses Developed for the Alcohol Medical Scholars Program

16. PERFORMANCE ENHANCING DRUGS • Anabolic androgenic steroids • Derivatives of testosterone • First use generally later than other drugs • Drug and method sought for maximum anabolic and minimum androgenic properties • Sprinting, weight lifting, body building • Acne, abnormal LFTs, feminization, virilization, premature closure of the epiphysial plates, behavioral changes “roid rage”, CVAs, cardiomyopathy Developed for the Alcohol Medical Scholars Program

17. PERFORMANCE ENHANCING DRUGS • Beta 2 agonists • Isoproterenol, epinephrine, norepinephrine • Sympathomimetic amines, anabolic properties • Cardiac arrhythmias in overdose, headaches • Peptide hormones: HCG • Increases testosterone • Maintains testicular volume with anabolic steroid use • Ovarian cysts Developed for the Alcohol Medical Scholars Program

18. PERFORMANCE ENHANCING DRUGS • Pituitary and synthetic gonadotropins • Increases testosterone, anti- estrogenic • Ovarian cysts • Corticotropins • Increase testosterone • Rare and related to excess corticosteroids- pituitary suppression,  immunity, osteoporosis, hyperglycemia Developed for the Alcohol Medical Scholars Program

19. PERFORMANCE ENHANCING DRUGS • Growth hormone • Increase muscle mass & decrease fat mass • Gigantism, acromegaly, hypothyroidism, cardiac disease, myopathies, arthritis, diabetes mellitus, impotence, osteoporosis Developed for the Alcohol Medical Scholars Program

20. PERFORMANCE ENHANCING DRUGS • Erythropoietin (EPO) • Stimulates RBC production • Increases oxygen carrying capacity • CVAs • Blood doping • RBC transfusion, artificial oxygen carriers • Increases oxygen carrying capacity • Allergic reactions, sludging of blood Developed for the Alcohol Medical Scholars Program

21. FOOD SUPPLEMENTS • Viewed as legal means of gaining edge • 76-100% of athletes use vs. 50% general population • May or may not contribute to enhanced performance • Creatine, colostrum, antioxidants, sodium bicarbonate, vitamins, proteins, amino acids • Adverse effects not investigated Developed for the Alcohol Medical Scholars Program

22. TYPICAL DRUGS OF MISUSE • Most common: marijuana, cocaine, alcohol • Generally have negative effect on performance • Substance misuse same in college athletes vs. non-athletes • Decrease in use of marijuana, amphetamines and cocaine, but increase in smokeless tobacco use, 1985-1996 • Most drugs first used in junior or senior high school (for recreation not performance) Developed for the Alcohol Medical Scholars Program

23. TYPICAL DRUGS OF MISUSE • Alcohol • Most frequently used • Negative impact on reaction time, hand-eye coordination, balance, strength • Excessive heat production and dehydration • Cardiovascular and GI complications, nutritional deficiencies, dependence Developed for the Alcohol Medical Scholars Program

24. TYPICAL DRUGS OF MISUSE • Cocaine • Minimal performance enhancing effect • Heightened arousal and increased alertness with low doses • Over confidence leading to increased risk of injury • MI, CVA, seizures, arrhythmias, dependence Developed for the Alcohol Medical Scholars Program

25. TYPICAL DRUGS OF MISUSE • Cannabinoids • Most frequent illegal drug used in the US • Male athletes have higher incidence than non-athletic peers (opposite for females) • Initial use in high school • Psychomotor impairment, distorted perception, amotivational syndrome; decreased testosterone with long-term use Developed for the Alcohol Medical Scholars Program

26. TYPICAL DRUGS OF MISUSE • Nicotine • Majority use in form of smokeless tobacco • Males >> females • 52% of baseball players, 26% of varsity football players used smokeless tobacco (early 1990s California college survey) • Highest risk for baseball players • Cardiovascular and pulmonary disease, oral cancers, dependence Developed for the Alcohol Medical Scholars Program

27. PREVENTION AND TREATMENT • Drug testing • Commonplace in amateur and professional sports • 65% of college athletes agree with testing • 37% agreed that positive should result in disqualification • 67% of college athletes believe that drug testing deters drug use Developed for the Alcohol Medical Scholars Program

28. DRUG PROGRAMS • Administered by leagues and associations (NCAA, NFL, NBA) • Responsible for relevant events, fairness, quality of competition, safety, image of their athletes and events • Deter use by testing and discipline • Some include evaluation and treatment • Coaches can discourage use Developed for the Alcohol Medical Scholars Program

29. DRUG PROGRAMS • Identify individuals with drug problem to facilitate treatment • Keys to successful drug program: • Inclusion of all involved parties • Reliable and sensitive testing program • Consistent discipline • Evaluation of effectiveness • Confidentiality • Early prevention Developed for the Alcohol Medical Scholars Program

30. CHALLENGES • Most drugs not prescribed • Viewed as essential for success • Easy access to drugs • Physician dilemma/role • Monitoring side effects • Why?, discuss pro/cons, appraisal, explore options • Need for collaboration Developed for the Alcohol Medical Scholars Program

31. SUMMARY • Substance use in athletes dates to ancient times • Multiple factors why athletes use drugs • Types of drugs used range from therapeutic and performance enhancing to typical drugs of misuse • Programs are in place to address drug use in athletes Developed for the Alcohol Medical Scholars Program