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INTERNATIONAL REVIEW OF PSYCHIATRY, 2016

VOL. 28, NO. 6, 572–578


http://dx.doi.org/10.1080/09540261.2016.1212821

REVIEW ARTICLE

Discussing prevalence, impacts, and treatment of substance use disorders


in athletes
Felipe Gila , Arthur Guerra de Andradea,b,c and Jo~ao Maurıcio Castaldelli-Maiaa,b,c
a
Department of Neuroscience, Medical School, Fundaç~ao ABC, Santo Andre, SP, Brazil; bDepartment of Psychiatry, Medical School,
University of S~ao Paulo, S~ao Paulo, SP, Brazil; cABC Center for Mental Health Studies, Santo Andre, SP, Brazil

ABSTRACT ARTICLE HISTORY


The consumption of alcohol, tobacco, and other drugs has become a concern in high-perform- Received 9 May 2016
ance athletes. Professional athletes are more exposed to drugs than the general population. Revised 4 July 2016
Although some drugs are unquestionably detrimental to performance, several studies have Accepted 9 July 2016
nevertheless shown evidence of increased consumption of these substances within this sub- Published online 11 August
2016
population. This review aimed to elucidate alcohol, tobacco, cocaine, cannabis, and opioid use
among high-performance athletes, discussing the prevalence of substance use, its impacts, and KEYWORDS
alternatives to treatment in this special population. Unfortunately, no clinical trials for the treat- Athletes; alcohol; cocaine;
ment of substance use disorders were carried out with this specific sub-population. Therefore, cannabis; opioids; tobacco
the strategies adopted for the general population should be adapted to high-performance ath-
letes. Psychological, psychosocial, psychoeducational, cognitive-behavioural, motivational inter-
viewing approaches can be implemented. As regards pharmacological treatment, medications
used in the treatment of alcohol and tobacco dependence, such as naltrexone, disulfiram, acam-
prosate, varenicline, bupropion, and nicotine replacement treatment can be used without prob-
lems. However, some medications used in cocaine and opioid dependence treatment, such as
moldafinil and methadone, are prohibited by doping enforcement agencies. Professionals
involved with athletes should be aware of the signs and symptoms of the acute effects of sub-
stances so as to enable an early identification of substance abuse problems, especially during
training periods.

Introduction these substances could be the many stressors to which


they are subjected, including the pressure for better (or
The consumption of alcohol, tobacco, and other drugs
has become a concern in high-performance athletes. the best) performance, injuries, physical pain, and even
Professional athletes are more exposed to drugs than retirement, which occurs much earlier than in most
the general population; they have an active social life other careers (Donohue, Pitts, Gavrilova, Ayarza, &
and encounter various pressures, which may lead to Cintron, 2013). In addition, those athletes in denial of
greater risk of alcohol, marijuana, and cocaine misuse mental illness can be significantly less likely to receive
(Millman & Ross, 2003). Although some drugs are treatment (Glick, Stillman, Reardon, & Ritvo, 2012).
unquestionably detrimental to performance, several They receive the necessary treatment for rehabilitation
studies have nevertheless shown evidence of increased of physical injuries, but they are much less frequently
consumption of these substances within this sub- diagnosed and treated for mental illness, especially in
population (Brisola dos Santos et al., 2016). Drug the case of substance use disorders (Glick et al., 2012).
abuse in such individuals may involve doping, in A healthy lifestyle is very desirable for athletes,
order to obtain a competitive advantage, but can also since it can give them a performance boost of 5–6%,
involve the misuse of substances such as alcohol or whilst substance use can reduce performance by 11%
cannabis without the intention of improving perform- on average (Kingsland, Wiggers, Vashum, Hodder, &
ance, thereby developing substance use disorders, just Wolfenden, 2015). This review aims to elucidate alco-
as any non-athlete (Ambrose, 2004; Hoberman, 2002). hol, tobacco, and other drug use among high-
As mentioned above, the reasons for athletes using performance athletes, discussing the prevalence of

CONTACT Felipe Gil gil.felipe@hotmail.com Departmento de Neurociência da Faculdade de Medicina do ABC. Avenida Lauro Gomes 2000, Vila
Sacadura Cabral, Santo Andre, SP 09060-87, Brazil
ß 2016 Institute of Psychiatry and John Hopkins University
INTERNATIONAL REVIEW OF PSYCHIATRY 573

substance use, its impacts, and alternatives to treat- athletes (Barnes, 2014; Kingsland et al., 2015), consid-
ment in this special population. ering that this substance has a harmful effect on
health in a wide variety of psychomotor skills,
reduced strength, power and muscular endurance,
Alcohol
speed, and cardiovascular endurance (Kingsland et al.,
The consumption of alcohol is very common in almost 2015). People involved with athletes must always be
all adult sub-groups in the West, including athletes. aware of strange behaviour that may emerge possibly
Alcohol is currently the most consumed legal drug in by stress or because of other psychosocial variables,
the world, at both social and sporting events (Kingsland which can be linked to alcohol misuse. It is also
et al., 2015). Alcohol is a psychoactive substance and important to assess withdrawal symptoms from alco-
produces alterations in the central nervous system and hol, acute intoxication, and dependence for proper
may cause changes in user behaviour, according to the treatment of these individuals.
dose, speed, and frequency in which it is taken. After The acute withdrawal syndrome arises when the
being ingested, the alcohol quickly reaches the blood- individual reduces or stops alcohol usually consumed;
stream and is carried by the blood to various parts of symptoms such as restlessness, tremors, tachycardia,
the body, including the central nervous system. When tachypnea, increased body temperature, anxiety, mood
in the system, it causes a reduction in motor coordin- changes, nausea, sweating, and insomnia may occur
ation and reflexes, even when taken in small doses, within 5–10 h after the reduction or cessation of alco-
causing a state of euphoria and loss of inhibitions. hol use, with peak intensity of symptoms on the
Several diseases are caused by the frequent use of alco- second or third day (Maciel & Kerr-Corr^ea, 2004).
hol. These include neural, mental, muscle, liver, gastric, These symptoms begin to improve from the fourth
pancreatic diseases, and even cancer. Alcohol is also day; anxiety or insomnia can last 15 days, which may
responsible for a series of social problems such as traffic contribute to relapse.
accidents, homicides, suicides, violence, and relation- Some complications of alcohol withdrawal syn-
ship problems (Kingsland et al., 2015). drome can include seizures, hallucinations, and delir-
Alcohol use by athletes is much discussed behind ium tremens (Sachdeva, Choudhary, & Chandra,
the scenes. It is well known that many athletes, 2015). Treatment for alcohol withdrawal syndrome is
whether elite or amateur, drink alcohol frequently, carried out with support measures, replacement of
during periods of training and on days of competi- vitamins, hospitalization when necessary, and use of
tion. However, most elite athletes stop drinking alco- benzodiazepines for relief of autonomic symptoms;
hol on the day of the sporting competition or event. which are not considered doping, being allowed in
One of the major problems caused by alcohol con- most of the sports. Diazepam or lorazepam are the
sumption in athletes is increased dehydration during most used (Perry, 2014), the last especially in the case
physical activity (Barnes, 2014). Water loss and that the patient presents important liver disorders.
increased body temperature have different physio- For treatment of alcohol dependence, total abstinence
logical effects. The physiological effects of water loss should be the goal of the treatment. This could be
depend on its source. In those athletes who do long- accomplished through strategies of psychotherapeutic,
term activities, the main source of water for sweating psychosocial, and pharmacological interventions. The
comes from plasma. This reduction in plasma volume most commonly used medications are naltrexone,
is extremely detrimental to performance because it disulfiram, and acamprosate (Bradley & Kivlahan,
reduces blood supply, oxygen, and nutrients to the 2014). Naltrexone, an opioid antagonist that acts as
muscle. It requires greater cardiac effort, and increases dampening the pleasurable effects of alcohol, which
the glycogenolysis rate and, therefore, metabolic acid- can cause nausea as the main side-effect and should
osis, among other factors. The 2% loss of body weight be discontinued if there is rising persistently transami-
caused by dehydration, induced by heat stress, can nases. Another drug used is disulfiram, an unspecific
promote loss of physical and psychological perform- inhibitor of aldehyde dehydrogenase; by inhibiting
ance. For example, in the case of football players, who this enzyme occurs accumulation of acetaldehyde in
may lose 3 l or more of sweat during a match, the the body, generating unpleasant signs and symptoms
dehydration caused by alcohol consumption may ser- and being potentially dangerous. Patients should
iously limit their performance. abstain completely from alcohol and have a total
In addition, there have been several studies show- knowledge about the risks and the principles of treat-
ing the harmful effects of the acute use of alcohol in ment; it is recommended to evaluate liver function
574 F. GIL ET AL.

every 3 months while on treatment. Acomprosate can Abrupt nicotine withdrawal can cause abstinence
be an alternative treatment for alcohol dependence—it symptoms. Symptoms appear in the first few hours
inhibits the glutamatergic excitatory activity, acting in after the last cigarette, and many smokers experience
a sub-class of glutamate receptors, especially when symptoms like an uncontrollable urge to smoke,
there is over-activity of these receptors. It should be depressed mood, dysphoria, irritability, anxiety, insom-
used only in patients over 60 kg. Unfortunately, there nia, bradycardia, increased appetite, and difficulty con-
are currently no studies comparing the best option centrating. These symptoms may persist for up to
among these medications for the treatment alcohol 6 months (Baltieri, Dar o, Ribeiro, & de Andrade,
dependence in this specific population. 2009). Treatment for nicotine dependence comprises
pharmacological and non-pharmacological approaches
such as psychotherapy and counselling. Another
Tobacco
important factor in treatment is the diagnosis of other
Tobacco use is associated with diminished quality-of- psychiatric disorders such as depression or anxiety
life, diseases, incapacity, and premature death. (Castaldelli-Maia et al., 2013; Castaldelli-Maia, Loreto,
Smoking is a direct cause and probable cause of many Carvalho, Frallonardo, & de Andrade, 2014).
types of cancer, and affects the cardiovascular system, The medications most commonly used in the treat-
the respiratory system, the digestive system, and the ment of nicotine dependence are not considered dop-
urinary system. It also pollutes the environment and ing. Bupropion, an antidepressant whose mechanism
is a cause of many accidents (fire, driving, etc.). There includes inhibition and dopamine re-uptake makes
are still certain imponderables; namely, the high eco- norepinephrine in presynaptic receptors. The usual
nomic and emotional costs of diseases caused by dose is 300 mg/day divided into two daily doses.
tobacco. Nocturnal use is not indicated because of the risk of
Although most athletes do not smoke routinely, insomnia. Its most significant potential side-effect is
even recreational tobacco use can cause performance seizure that may occur in vulnerable individuals tak-
deterioration in high-performance sports. It is esti- ing the drug in high doses. It can also be used as
mated that the proportion of athletes who smoke monotherapy or adjunctive therapy using nicotine
approaches 5% (Laine et al., 2016) and varies accord- replacement in the form of adhesives, gums, and loz-
ing to age and sex. enges; adhesives are marketed in 21, 14, and 7 mg,
Smoking before or after sporting activity is espe- and the prescribed dose depends on the amount of
cially harmful to respiratory capacity, a necessary con- nicotine used by the individual. Lozenges and gums
dition for optimum performance. As smoking is also can be used whenever the patient’s cravings are
a risk factor for coronary heart disease, those who strongest (Aveyard, Johnson, Fillingham, Parsons,
have smoked for years and suddenly decide to take up & Murphy, 2008). Varenicline was the first
physical activities should be cautious because of the molecule developed especially for smoking cessation.
risk of heart attack. If tests show that the patient is fit It is a partial agonist of the a4b2 nicotinic acetylcho-
enough, he can work with incremental levels of effort, line receptor (with 20-times more affinity for the sub-
accompanied by an expert. type a4b2). It should be used for a 12-week period,
Cigarettes worsen the performance of both profes- with a starter dose of 0.5 mg/day, rising to 2 mg/day
sional athletes and people who do physical exercises at the end of the first week (Mogensen & Bj€ ornsson,
regularly. They result in a 20–30% fall in cardiovascu- 2015).
lar activity and cause a decrease in mucus in the
respiratory system. Mucus protects the organism
Cocaine
against infectious agents such as bacteria, viruses, and
particles suspended in polluted air. Tobacco smoking Cocaine use in sports first attracted the world’s atten-
can lead to atherosclerosis (fatty plaques that appear tion in 1986, when famous basketball and football
in the wall of arteries and veins), a phenomenon that players from the US died because of cocaine use.
increases blood pressure and risk of a cardiovascular Cocaine use in high school sports peaked in the mid-
event. Additional body damage attributable to smok- 1980s, when it reached 17%, before falling sharply in
ing is also apparent in the destruction of the lining of the next decade to less than 2%. While many factors
the body’s cells and DNA alteration, symptoms motivate athletes to use cocaine, some points are par-
known as oxidative stress. As such, it is clear that ticularly noteworthy. First, cocaine is generally not
smoking can compromise the health of high-perform- used to improve performance. In addition, there is the
ance athletes. idea that athletes are vulnerable to recreational
INTERNATIONAL REVIEW OF PSYCHIATRY 575

substances due to some combination of the following International Olympic Committee (IOC), the US
variables: fame, fortune, free time, and a sense of Olympic Committee, the US National Collegiate
invincibility (Kingsland et al., 2015). Athletic Association, and the professional sports
Cocaine is an alkaloid derived from the coca plant, leagues specifically prohibit the use of cocaine.
with cocaine hydrochloride being the form of the Abstinence from cocaine does not produce somatic or
drug that is inhaled. The heated cocaine and crack are autonomic changes, but is related to mood symptoms,
heat resistant and inhaled in the form of smoke such as fatigue, irritability, and anxiety, that, however,
(Galdur oz, Noto, Nappo, & Carlini, 2005). The effects dissipate after a few days (Haney & Spealman, 2008).
of cocaine in the brain are complex and are very simi- After intense drug use, individuals experience the
lar to amphetamine. Many of the effects are due to crash characterized by depressive symptoms, anxiety,
interference with brain neurotransmitters, particularly agitation, and intense craving. After this period, the
dopamine and noradrenaline. Recreational users can individual goes through a withdrawal phase, with
inhale 1–3 g of cocaine per week. Smoking crack or fatigue and low physical and mental energy.
heated cocaine is the fastest way to get the drug to Treatment consists of psychological, psychosocial, and
the brain; euphoria may occur within 3–5 min and pharmacological strategies. However, there are no spe-
lasts for less than 10 min. Dependent individuals often cific medications for the treatment of cocaine depend-
make use of the substance every 10 min to keep the ence. Some medications like disulfiram, modafinil,
feeling of intense euphoria. Sometimes behavioural and topiramate have been studied and shown to have
changes are observed in athletes who may turn up to mixed results. Among these, only moldafinil is pro-
training either too early or too late, miss training hibited by WADA.
altogether, or engage in heated arguments with team-
mates. Grandiose feelings may lead to athletes having Cannabis
a distorted and misguided view of their own perform-
Seen by some users as a good way to experience
ance. At ambient temperature, cocaine reduces body
anaesthetic or relaxing effects, cannabis use is also
temperature. However, at higher body temperatures,
controversial where sports are concerned. The high
especially during exercise, the substance causes an
incidence of positive cases for cannabinoids found in
increase in body temperature, placing the athlete in a
doping testing has been scrutinized by the IOC, which
situation susceptible to hyperthermia. This may be
has had cannabis on its prohibited drugs list since
related to cocaine-induced changes in the normal
1989, as one of its prohibited substances in certain
body temperature, and a decrease in the heat loss due circumstances (Brisola dos Santos et al., 2016).
to peripheral vasoconstriction (NIDA, 2016). Nowadays, WADA lists cannabis as an in-competition
There are numerous adverse effects associated with prohibited substance. Doping analyses are conducted
cocaine abuse (da Cruz, da Cunha, de Moraes, for cannabis, hashish, or other cannabis products
Massarini, Yoshida, Tenguam, et al., 2014). However, through examination of urine for 11-nor-delta-9-tetra-
there are some of special concern for athletes. Among hydrocannabinol-9-carboxylic acid (carboxy-THC),
the most notable is sudden death due to abnormal the major metabolite of delta-9-tetrahydrocannabinol
heart rhythms, seizures, or bleeding in the brain. The (THC). Concentrations >15 ng/ml (cut-off value) for
effects of cocaine on the heart are diverse. They confirmatory analytical procedures are considered
include increased cardiovascular demand for oxygen, doping.
causing spasms of the coronary arteries that supply Cannabis is an illegal drug in many countries, and
blood to the heart muscle, the production of clots in has received much attention in the media for its
coronary arteries, promotion of premature athero- potential therapeutic uses and efforts to legalize its
sclerosis, and, in some cases, heart attacks, especially use. Studies have shown that the use of cannabinoids
in smokers (Galdur oz et al. 2005). Moreover, athletes may reduce anxiety, but do not improve sporting per-
who use cocaine may experience palpitations, anxiety, formance (Bergamaschi & Crippa, 2013). An increase
breathlessness, and chest pain (da Cruz et al., 2014). in heart rate and blood pressure, decreased cardiac
Chronic cocaine inhalers may suffer recurrent bouts output, and decreased psychomotor activity are some
of sinusitis, a pierced septum, and/or be plagued by a of the pharmacological effects of THC that will deter-
chronic stuffy nose. mine a decrease in athletic performance.
The cocaine metabolites in urine are easily Smoking marijuana reduces alertness, reaction time,
detected, even when present in very low concentra- and impairs memory (Ashton, 2001; Wadsworth,
tions. The World Anti-Doping Agency (WADA), the Moss, Simpson, & Smith, 2006). It accelerates muscle
576 F. GIL ET AL.

fatigue, thereby reducing the duration of the exercise anxiety, craving, increased blood pressure and heart
(Renaud & Cormier, 1986). Changes in appetite and rate, nausea, vomiting, and muscle spasms.
food cravings because of marijuana use can impair There is a recommended protocol for the treatment
nutrition and affect body mass (Cota et al., 2003; of opioid withdrawal based on the definition of the
Kirkham, 2009). Thus, smoking marijuana can have abstinence syndrome by the following criteria (Baltieri
detrimental effects on athletic performance, and these et al., 2004): (1) Mydriasis, (2) 10 mm Hg increase in
negative effects should deter athletes from using systolic blood pressure, (3) 10 bpm increase in heart
cannabis. rate, and (4) sweating, chills, sighs, body pain, diar-
The many specific factors that may drive or stop rhoea, rhinorrhea, and lacrimation. If the patient has
cannabis use among athletes have received little atten- two or more criteria, they should receive 10 mg of
tion. A recent review (Brisola dos Santos et al., 2016) methadone, with vital parameters being checked every
found increased cannabis use amongst adult athletes 4 h, receiving 10 mg of methadone again if presenting
with any of the following characteristics: caucasian, more than two criteria. The total dose in the first
male, practicing ‘Sliding sports’, and those who also 24-h is half divided on the second day, and 5 mg
use performance enhancing drugs (PEDs), for recre- reduced daily till the complete removal. After the last
ational or non-sporting performance enhancement dose of methadone, clonidine is initiated at doses of
purposes. There are no medications approved in any 0.3–1.2 mg. In addition to the drug therapy mainten-
country for cannabis dependence treatment. Typical ance phase with clonidine, it is important to introduce
strategies are non-pharmacological in nature and psychoeducational, cognitive behavioural therapy, and
include relapse prevention, motivational interviewing, psychosocial approaches. In the case of high-perform-
and contingency management (Budney, Hughes, ance athletes, all treatment should be done with the
Moore, & Vandrey, 2004). individual away from his sporting activity, since, in
addition to the severity of the framework, medications
Opioids for treatment are prohibited by doping.

The prescription of opioids is increasingly recognized


as one of the most important current health problems Disclosure statement
in the sports field. It can lead to physical and/or men- Dr. Castaldelli-Maia receives Pfizer Independent Grant for
tal problems, and even death (NIDA, 2014; Simoni- Learning and Change (IGLC) managed by Global Bridges
Wastila, Ritter, & Strickler, 2004). Data from the (Healthcare Alliance for Tobacco Dependence Treatment)
National Survey on Drug Use and Health (NSDUH) hosted at Mayo Clinic, to support free smoking cessation
treatment training in addiction/mental health care units
indicate that 12.7% of the population aged 26 and
in Brazil (grant IGLC 13513957), which had no relation-
over have already misused non-prescribed prescription ship with the present study. Dr. A. G. Andrade is
opioids. Male adolescents participating in organized Executive President of the Center for Information on
sports are more likely to use and abuse opioids. At Health and Alcohol (CISA), which had no funding rela-
any one time there are 7.5 million adolescents in the tionship with this project. All other authors have no con-
US participating in high-school sports, with an antici- flicts of interest.
pated annual 2 million athletic injuries. In a study
that followed 1540 teenage students, it was found that ORCID
male athletes were more likely to use and abuse
Felipe Gil http://orcid.org/0000-0003-1928-7796
opioid drugs at least once a year more than their
non-athlete peers, whereas their female counterparts
were not.
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