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

2. 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

3. 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.

4. 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

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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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