Substance Use in Athletes


Woodburne O. Levy, MD


Department of Psychiatry


University of South Florida




I.     Introduction (S 2,3,4)




Drug use is a major problem facing sports today


Growing attention (Daryl Strawberry- cocaine and alcohol misuse, MLB; Oksana Baiol-alcohol misuse/DUI; Chris Weber- marijuana misuse, NBA, Alain Baxter (Britishskier, 2002 Winter Olympics)- amphetamine misuse; Larisa Lazutina (RussianSkier)-darbepoetin misuse


Deaths of elite athletes (Kory Stringer- ³heat stroke², suspecteddiuretic misuse)


Drug misuse in sports has become widely reported by media (1)


Use of drugs is contrary to the rules and ethicalprinciples of athletic competition


No improvement of performance offered by most drugs


Unfair advantage provided by drugs that do improve performance


Bad role models posed by athletes using drugs


Drugs to assist performance remain widespread amongathletes despite intense efforts to eliminate the problem (2,3)


Drugs misused by athletes can be divided into threegroups:


Therapeutic drugs (diuretics, opioids, OTCs, beta-blockers,etc.)


Performance enhancing drugs (amphetamines, caffeine,catecholamines, anabolic steroids, growth hormone, etc.)


Typical drugs of misuse (alcohol, marijuana, tobacco, cocaine,etc.) (4)   


Current literature provides only partial picture ofdrug misuse in college athletes


Research is rare


Most data come from national surveys of college athletes in1985, 1989 and 1996 (5,6,7)


The goal of this lectureis to review substance misuse among athletes. To accomplish this, the lecturecovers:




Factorsinfluencing athletes to use drugs


Typesof drugs athletes use- consequences and myths


Preventingand treating drug use in athletes




II.     Historical perspective (S 5,6)




Ancient civilizations:


The ancient Greeks used mushrooms to enhance performance(possibly containing psychobilins)


Roman wrestlers used special mixtures of herbs (compositionunknown)


Egyptian athletes used the rare hooves of an Abssynian assground up boiled in oils and flavored with rose petals and rosehips believed toenhance performance (placebo effect?)


Indigenous South African tribes used local liquor called Œdop¹as a stimulant (8)




19th century:


Alcohol, caffeine, nitroglycerine, opium and strychnine werecommonly used


The first reported drug-related death occurred in 1896 when anEnglish cyclist died of an overdose of Œtrimethyl¹


World War II:


Amphetamines introduced to US troops to help keep them awakeat the battlefront


Testosterone given to German storm troopers to enhance theiraggressiveness


Fol­lowing the war, the use of amphetamines andanabolic steroids spread among sportspeople:


Danish cyclist Kurt Jensen died from a heat-related illnessafter use of amphetamines at the 1960 Rome Olympics


British cyclist Tommy Simpson dies in Tour de France in 1967due to stimulants


Anabolic steroids allegedly used by Soviet athletes in the1952 Olympics in Helsinki


At the 1968 Olympics in Mexico seven athletes, including fourmedallists, had pos­itive test results to stimulants or narcotics


7 athletes at the 1976 Montreal Olympic Games tested positivefor anabolic steroid use


At the 1988 Seoul Olympics Ben Johnson, 100 m winner, testedpositive for anabolic steroids (focused world attention)


Newer agents (describedin detail later):


Blood doping became a focus when used by Finnish distancerunners in the 1970s.


Erythro­poietin has allegedly become widespread amongendurance sportspeople.


Chinese swimmers at the 1998 World Swimming Championshipscaught trying to bring human growth hormone through customs into Australia.


Over time various substances became prohibited:


1967: IOC Medical Commission formed, prohibited the use ofperformance-enhancing drugs and commenced drug testing  (e.g. stimulants and narcotics)


 1975: ana­bolicsteroids were added to the prohibited list


1980s: caffeine and testosterone, beta-blockers, diuretics andglucocor­ticosteroids, blood doping and growth hormone were added to theprohibited list


1990: erythropoietin was added to the list




A summary of currently prohibited methods and substancesby International Olympic Committee (S 7) (9)









Prohibited procedures



Prohibited under certain circumstances







Blood doping










Administering artificial oxygen carriers







Anabolic agents


Anabolic androgenic steroids


Beta-2 agonists



Other plasma expanders



Local anesthetics







Pharmacological, chemical and physical manipulation







Peptide hormones, mimetics and analogs













III.   Factors influencingathletes to use drugs   (S 8)




A belief that their competitors are taking drugs


A determination to doanything possible to win


Pressure from coaches,parents and peers


Community attitudes and expectations of success


Financial rewards


Influence from the mediain facilitating these expectations and rewards (8)


Belief in multiple benefits to be accrued:



  1. An increase in strength and endurance


  1. Delay in the onset of fatigue


  1. Increased ability to concentrate


  1. Decreased sensitivity to pain (10)





IV. Types of Drugs Athletes Use- Consequences and Myths




Therapeutic Drugs  (S 9,10,11,12)




OTCs(analgesics, laxatives, ephedrine, weight loss medications, NSAIDs, localanesthetics, corticosteroids, decongestants)


Carry extremely low potential for misuse when used fortreatment of appropriate illness


Selected subgroups of athletes may misuse certain classes orparticular types of substance


Gymnasts, ice-skaters ­diet pills and laxatives (to maintainweight limit)


Runners- caffeine and ephedrine containing products  (­ endurance/alertness)


Most athletes- will use analgesic and/or corticosteroidsfollowing injury


5% of college athletes, mostly females, report appetitesuppressants (6)


Adverse effects: ­ risk of further injury,gastrointestinal blood loss, anemia, and eating disorders






Excretion enhancement to lose weight rapidly prior tocompetition where weight limits are set (boxing, wrestling, weight- lifting,judo, light­weight rowing)


Used in combination with other dehydration techniques such asuse of a sauna, exercise in hot conditions and food and water restrictions


To aid the excretion prior to testing or dilute the presenceof illegal substances in the urine


Overall they have negative impact on the performance


Adverse effects: dehydration, hypotension, muscle cramps andelectrolyte disturbances






Prescription painkillers are the most common opioid misused byathletes (11)


Narcotics permit athletes to compete with musculoskeletalinjuries


75% of collage athletes use opioids for sport related injuriesonly (6)


Adverse effects: ­ risk of further injury,possible dependence, drowsiness, mental clouding, and in high doses:respiratory depression, hypotension, muscle rigidity






Used for their anxiolytic and anti-tremor effects


Used in shoot­ing and archery, bobsled, luge, soccer andski jumping


Beta-blockers may have negative effects on both anaerobic andaerobic endurance.


Adverse effects: depression, bronchospasm, worsening vascularproblems, fatigue (8)




Performanceenhancing drugs




CNSStimulants:  AMPHETAMINES    (S 13)


Clinically used since the 1930s to delay fatigue and increasealertness, enhance speed, power, endurance and concentration (12)


Use diminished in collage athletes since mid 1980s (1985-8% to1996-3%) (6,7)


Deaths occurred even when Œnormal¹ doses of amphetamines havebeen used when undertaking maximal physical activity


Adverse effects: hypertension, angina, vomiting, abdominalpain, cerebral hemorrhage, possible dependence














CNS Stimulants: CAFFEINE  (S 14)


Causes increased alertness, shortened reaction time, improvedconcentration and diuresis


 Increases fatmetabolism and hence may delay fatigue due to glycogen sparing (13)


IOC defines a positive test result if urine concentration >12 mg/mL.(Approx. 8 cups of coffee over a 2-3 hour period)


Adverse effects: dyspepsia, cardiac damage, combination ofcaffeine with other stimulants (e.g., ephedrine) may be fatal (14)




Systemic Stimulants   (S 15)


Adrenalin is permitted with local anesthetics


Ephedrine and pseudoephedrine are found in most OTCs cold andallergy remedies


Phenylpropanolamine is a common is diet pills: Acutrim, Dexatrim


Inconclusive evidence of enhanced athletic performance usingtherapeutic doses (15)


Adverse effects: high doses are similar effects to theamphetamines 






Include derivatives of testosterone


Use in collage athletes range from 1%-5%, appears stable sincethe mid 1980s, majority of use begin in collage (6,7)


Prevalence likely higher in the professional athlete, butsignificant use the high school and collage athlete as well (17)


Many sources, but as high as 38% obtained from a physician (7)


Particularly used in power sports such as weight-lifting,sprinting, body building    and throwing


Athletes generally use agents that have maximum anabolic andminimal androgenic side effects, such as Dehydroepiandrosterone (DHEA)  (16)


Methods such as ³cycling² (drug free period), ³pyramid²(increasing daily dose), ³stacking² (different steroids simultaneously),attempt to ¯side effects (8)


Adverse effects: skin changes, reduced immunity, abnormalliver function, feminization in males, virilization in women, premature closureof the epi­physial plates in teenagers, behavioral change ³roid rage²,cardiomyopathy, CVAs (18,19)






They are classed in the category of Œsympathomimetic amines¹and are therefore considered stimulants


Include isoproterenol, epinephrine and norepinephrine


Have anabolic properties


Adverse effects: cardiac arrhythmias in overdose, headaches




Peptide Hormones:  HCG 


Human chorionic gonadotrophin (hCG) stimulates sex steroidhormone biosynthesis


Therapeutic uses are limited (infertility)


Mainly abused by male athletes to increase testosterone andepitestosterone without increasing the urinary ratio, making detectiondifficult


Maintains testicular volume in the male athlete using anabolicsteroids


Adverse effects: ovarian cysts, risk of thromboembolic eventwhen used with other ovulation stimulating agents








Clomiphene, cyclofenil and tamoxifen, have anti-estrogeneffects and combat some of the side effects of testosterone.


Clomiphen increases in gonadotropin releasing hormone (GnRH)and increase endogenous testosterone


LH stimulates Leydig (interstitial) cells of the testes toproduce testosterone


Adverse effects: ovarian cysts, ovarian hyperstimulationsyndrome






Adrenocorticotropic hormone (ACTH) increases secretion ofadrenal androgens, which are moderately active male sex hormones


These are converted to testosterone in extra-adrenal tissues


Ergogenic effect of ACTH is negligible as its cataboliceffects cancel out its anabolic effects


Adverse effects: rare and related to excess corticosteroids-pituitary suppression, decreased immunity, osteoporosis, hyperglycemia






GH is essential for normal growth


Athletes use GH for anabolic effects:


Increases muscle mass


Decreases fat mass (18)


Adverse effects: gigantism (younger athlete), acromegaly(adult athlete), hypothy­roidism, ischemic heart disease, congestivecardiac failure, cardiomyopa­thy, myopathies, arthritis, diabetes mellitus,impotence, osteoporosis (19,20)






EPO stimulates the bone marrow and increases red blood cellproduction


Recombinant EPO available since 1985 is mainly used byendurance athletes


EPO increases red cell mass, and extra oxygen-carryingcapacity, which increases energy production by oxidation (the most importantenergy source for endurance) glucose and free fatty acids


EPO provides blood doping without transfusion


Associated with number of deaths in endurance cyclists 


Adverse effects: cerebrovascular accident (especially withdehydrat­ing endurance exercise) (21)
















Administration of red blood cells, artificial oxygencarriers  (perfluorocarbons,synthetic or modified hemoglobins), and related blood products to increase redblood cell mass


Improves oxygen-carrying capacity


Adverse effects: allergic reactions, risk of blood-bornediseases, sludging of blood, particularly in the cerebral circulation. (21)






Viewed as a legal means of gaining the edge over opponents


76 to 100% of athletes report their use vs. 50% of the generalpopulation  (14)


Very few products available are based on valid scientifictrials


Products may, or may not, con­tribute to improvedperformance


Ergogenic aids permitted in sport:










Sodium bicarbonate


B-complex vitamins


Proteins and amino acidsincluding glutamine




Adverseeffects: not well studied, scattered reports of renal failure with excessiveintake




Typicaldrugs of misuse






Marijuana, cocaine, and alcohol are most commonly used (as ingeneral population)


New recreational drugs arrive on the scene from time to time,such as gamma hydroxy butyrate (GHB)


No significant difference between substance misuse in collegeathletes and non-athletes (2,7)


Most typical drugs of misuse generally have a negative effecton performance


National surveys of college athletes from 1985-1996 reporteddecreasing use of cocaine, marijuana, and amphetamines, but increasing use ofsmokeless tobacco (6,7,22)


Athletes first use drugs in junior or senior high school(6,23)


Higher prevalence of use among Caucasians  (7)


Main reason for using these drugs was recreation, notperformance enhancement (7)




ALCOHOL   (S 23)


Most frequently used drug by collage athletes (> 80%) withrates similar to non-athletic college students (7,24)


Some believe small doses enhance performance by reducingtension and boosting self-confidence


The strongest predictor of drinking patterns in studentathletes are: residence in a fraternity or sorority, engagement in other riskybehavior, previous binging in high school (22)


Adverse effects: Cardiovascular and GI complications,nutritional deficiencies, dependence, excessive heat production, dehydration,negative effect on: reaction time, hand-eye co-ordination, accuracy, balance,gross motor skills and strength








COCAINE   (S 24)


Cocaine has a minimal performance-enhancing effect associatedwith height­ened arousal and increased alertness with low doses


Causes over confidence leading to increased risk of injury


Adverse effects: impaired hand-eye coordination, distortedsense of time and inappropriate aggression, myocardial infarction, arrhythmia,seizures, stroke, dependence






Most frequent illegal drug used in the United States


Male high school athletes had higher incidence thannon-athletic peers (opposite for females) (25)


Most college athletes report initially use in high school


Adverse effects: amotivational syndrome and decreasedtestosterone with long-term use, impairment of psychomotor skills, distortedperception of time and impaired concentration, impaired exercise performance  (26)




NICOTINE    (S 26)


Majority of use in the form of smokeless tobacco (males>> females (22))


Baseball players are at the particular risk, chiefly becauseof intense target marketing to adolescent boys by tobacco manufacturers,distribution of free tobacco to college players, convenience of using duringgames, and the promotion by professional players who often serve as role modelsto the youth


Survey in California colleges in early 1990s showed that 52%of baseball and 26% of varsity football players used smokeless tobacco in thepast 12 months


Adverse effects: cardiovascular disease, pulmonary disease,oral cancers, nicotine dependence similar to that of cigarette smoking (27)






V.    Preventing and treating druguse in athletes




Drug testing    (S 27)




Hasbecome common in amateur and professional sports




















Differentdrugs are usually tested for in different settings  (28)






Tested for in a competition



Tested for in an out-of-competition




Anabolic agents



Anabolic agents











Masking agents



Masking agents




Peptide hormones, mimetics and analogs



Peptide hormones, mimetics and analog



















65%of college athletes agree with testing, 37% agree that positive should resultin disqualification


67% of college athletes believe that drug testing deters drug use (29)










Drug Programs  (S 28, 29)




Programs administered by leagues and associations such asNCAA, NFL, NBA


Responsible for relevant events, fairness, quality ofcompetition, safety, the image of their participants and events


Deter use by testing and discipline


Some include evaluation and treatment


Coaches can discourage use (22)


Programs identify individuals with drug problem to facilitatetreatment


The keys to successful drug program include:


Inclusion of all involved parties in development andadministration


A reliable and sensitive testing program


Consistent discipline


Evaluation and effectiveness


Maintenance of confidentiality (30)


Prevention must begin at or before the junior high and highschool level (10)




Challenges  (S 30)




Most drugs are not prescribed by physicians


Many athletes view drugs as essential for success (15)


Easy access to drugs


Athletes place physicians in a dilemma when they ask thattheir drug use to be monitored for side effects (1)


Physicians can:


Determine why athleteswant drugs


Discuss other aspects per­formance and external pressuresfrom parents, coaches, other com­petitors, officials or media


Give honest appraisal


Explore other options, including nutrition, massage, sportspsychology and training methods


Discuss ethics of drug use in ath­letes (10,31)


The success of prevention and treatment programs relies on thecooperation of athletes, coaches, trainers, sports psychologists, athleticadministrators, health education and team physicians


Collaboration is needed between sporting community andgovernment support at international level to standardize anti-doping policiesand practices (32)


UCLA study pioneered method for surveying student-athletesevery 4 years to identify trends in substance use (7)




Summary    (S31)




Substance use in athletes dates back to ancient times


There are multiple factors influencing athletes to use drugs


Types of drugs used range from therapeutic and performanceenhancing drugs to typical drugs of misuse


Programs are in place to address drug use in this population








Tricker R, Cook DL, McGuire R. Issues related to drug abuse incollege athletics: athletes at risk. Sport Psychol 1989; 3:155-156


Toohey JV, Corder BW. Intercollegiate sports participation andnon-medical drug use. Bull Narc 1981; 33:23-27


Toohey JV. Non-medical drug use among intercollegiate athletesat five American universities. Bull Narc 1996; 30:61-64


Jonas AP, Sickles RT, Lombardo JA. Substance abuse. ClinSports Med 1992; 11:379-401


Anderson WA, Albrecht RR, McKeag DB, et al. The substance useand abuse habit of college student athletes. Mission KS, National CollegiateAthletic Association  June 1985


Anderson WA, Albrecht RR, McKeag DB, et al.  A National Survey of Alcohol and DrugUse by College Athletes. The Physician And Sportsmedicine 1991; 19: 91-104


Green GA, Uryasz FD, Petr TA, et al. NCAA study of substanceuse and abuse habits of college students-athletes. Clin J Sport Med 2001;11:51-56


Brukner P, Khan K. Drugs and the Athlete in Clinical SportsMedicine. The McGraw-Hill Companies, 2001; 872-899


Mottram DR. Banned drugs in sport. Does the InternationalOlympic Committee (IOC) list need updating? Sports Med 1999; 27:1-10


Dyment PG. Drug misuse by adolescent athletes. Ped Clin NorthAm 1982; 29:1363-1368


Nativ A, Puffer J. Lifestyles and health risks in collegiateathletes. J Fam Pract 1991; 33:585-590


Hickey G, Fricker P. Attention deficit hyperactivity disorder.CNS stimulants and sport. Sports Med 1999; 27:11-13


Tamopolsky MA. Caffeine and endurance performance. Sports Med1994; 18: 109-25


Ahrendt DM. Ergogenic aids: counseling the athlete. Am FamPhysician 2001; 63:842-843


Smith DA, Perry PJ. The efficacy of ergogenic agents inathletic competition. Part II: Other performance enhancing agents. Ann Pharm1992; 26:653-659


Lindstrom M, Nilsson AL, Katzman PL, et al. Use ofanabolic-androgenic steroids among body builders-frequency and attitudes. J InternMed 1990; 227: 407-411


Choi PL, Parrott AC, Cowan D. Adverse behavioral effects ofanabolic steroids in athletes: a brief review. Clin Sports Med 1989; 1: 183-187


Haupt HA. Anabolic steroids and growth hormone. Am J SportsMed 1993; 21: 468-474


Mochizuki RM, Richter KJ. Cardiomyopathy and cerebrovascularaccident associated with anabolic-androgenic steroid use. Phys Sports Med 1988;18:109-114


Macintyre JG. Growth hormone and athletes. Sports Med 1987;4:129-142


Ekblom B. Blood doping and erythropoietin. The effects ofvariation in hemoglobin concentration and other related factors on physicalperformance. Am J Sports Med 1996; 24:540-542


Wechsler H, Davenport AE, Dowdall GW, et al. Binge drinking,tobacco and illicit drug use and involvement in college athletics. A survey ofstudents at 140 American colleges. J Am Coll Health 1997; 45:195-200


Iven VG. Recreational drugs. Sports Pharm 1998; 17:245-259


O¹Brien CP. Alcohol and sport. Impact of social drinking onrecreational and competitive sports performance. Sports Med 1993; 15:71-77




Ewing BT. High school athletes and marijuana use. J Drug Edu1998; 28:147-157


Renaud AM, Cormier Y. Acute effects of marihuana smoking onmaximal exercise performance. Med Sci Sports Exerc 1986; 18:685-689


Walsh MM, Hilton JF, Ernster VL, et al. Prevalance, patternsand correlates of spit tobacco use in college athlete population. AddictiveBehav 1994; 19:411-417


Birkeland KI, Hemmersbach P. The future of doping control inathletes. Issues related to blood sampling. Sports Med 1999; 28:25-33


Bowers LD. Athletic drug testing. Clin Sports Med 1998;17:299-318


Lombardo JA. Drug Programs. Clin Sports Med 1998; 17:319-326


Dawson RT. Drugs in sport- the role of the physician. JEndocrinol 2001; 170:55-61


Verroken M. Drug use and abuse in sports. Baillieres BestPract Res Clin Endocrinol Metab 2000; 14:1-23