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:

 

Historicalperspective

 

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)

 

 

 

 

 

Drugs

  

 

Prohibited procedures

  

 

Prohibited under certain circumstances

  

 

 

Stimulants

  

 

Blood doping

  

 

Alcohol

  

 

 

Narcotics

  

 

Administering artificial oxygen carriers

  

 

Cannabinoids

  

 

 

Anabolic agents

 

Anabolic androgenic steroids

 

Beta-2 agonists

  

 

Other plasma expanders

  

 

Local anesthetics

  

 

 

Diuretics

  

 

Pharmacological, chemical and physical manipulation

  

 

Glucocorticosteroids

  

 

 

Peptide hormones, mimetics and analogs

  

 

 

  

 

Beta-blockers

  

 

 

 

 

 

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

 

 

 

DIURETICS

 

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

 

 

 

OPIOIDS

 

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

 

 

 

BETA-BLOCKERS

 

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 

 

 

 

ANABOLIC ANDROGENICSTEROIDS    (S 16)

 

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)

 

 

 

BETA-2 AGONISTS    (S 17)

 

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

 

 

 

 

 

PITUITARYAND SYNTHETIC GONADOTROPHINS   (S 18)

 

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

 

 

 

CORTICOTROPHINS   

 

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

 

 

 

GROWTHHORMONE (GH)    (S 19)

 

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)

 

 

 

ERYTHROPOIETIN    (EPO) (S 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)

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOOD DOPING

 

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)

 

 

 

FOOD SUPPLEMENTS  (S 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:

 

 

 

Creatine

 

Colostrum

 

Antioxidants

 

Sodium bicarbonate

 

B-complex vitamins

 

Proteins and amino acidsincluding glutamine

 

 

 

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

 

 

 

Typicaldrugs of misuse

 

 

 

OVERVIEW   (S22)

 

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

 

 

 

CANNABINOIDS   (S 25)

 

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

  

 

 

Diuretics

  

 

Diuretics

  

 

 

Masking agents

  

 

Masking agents

  

 

 

Peptide hormones, mimetics and analogs

  

 

Peptide hormones, mimetics and analog

  

 

 

Narcotics

  

 

 

  

 

 

Stimulants

  

 

 

  

 

 

 

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

 

 


 

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