Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review

Get your Head in the Game!: A Review of Factors that Impact Collegiate Student-Athlete Mental Health Using a Biopsychosocial-Structural Framework

PURPOSE OF REVIEW

Over 500,000 college students compete in the three divisions of the National Collegiate Athletic Association (NCAA) each year. The rates of most mental health issues among collegiate student-athletes approximate the rates among non-athlete college students. In recent years, greater attention has been given to recognizing and treating the mental health concerns of student-athletes. This paper examines some of the specific mental health considerations that may arise when working with student-athletes.

RECENT FINDINGS

Using a biopsychosocial-structural framework, we were able to identify several broad categories of factors that influence the mental health of student-athletes. Within those categories we identified specific diagnoses (such as physical injury), life events (such as early retirement from sport), ways of thinking (including stigma against mental health treatment), and external influences (such as racism and sexism) that impact the mental health of student-athletes. Mental health concerns among college students are common. When working with student-athletes, there are biopsychosocial-structural factors that affect the mental health of student-athletes in unique ways compared to their non-athlete college student counterparts.

Prevalence of Chronic Traumatic Encephalopathy in Athletes With Repetitive Head Impacts: A Systematic Review and Meta-Analysis

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disorder associated with repetitive head impacts (RHI), which is commonly observed in athletes participating in contact sports. This systematic review and meta-analysis aimed to provide a clearer elucidation of the prevalence, risk factors, and potential outcomes of CTE in athletes. Through a comprehensive search of PubMed, EMBASE, Web of Science, and Google Scholar (January 2015 to July 2024), we ultimately included eight eligible studies with a low risk of bias involving 1000 former contact sports athletes diagnosed by neuropathological methods. Data were analyzed in a random-effects meta-analysis. The results indicated that the pooled prevalence of CTE in contact sport athletes was 53.7% (95% CI: 37.6-69.5, I2 = 93.7%). Subgroup analyses revealed that rugby players exhibited the highest prevalence at 64.7% (95% CI: 48.5-79.5, I2 = 0%), followed by American football players at 53.0% (95% CI: 33.2-72.4, I2 = 92.9%). By participation level, the prevalence was estimated at 44.1% (95% CI: 29.6-59.1, I2 = 84.5%) in amateur athletes and 72.8% (95% CI: 50.9-90.5, I2 = 91.6%) in elite athletes. Notably, the suicide rate among individuals diagnosed with CTE was 39.0% (95% CI: 12.7-69.0, I2 = 94.4%), and the pooled prevalence of CTE in non-suicidal athletes was 30.1% (95% CI: 6.9-60.4, I2 = 97.8%). These findings reveal the high prevalence of CTE in contact sport athletes exposed to RHI, especially at elite-level competition, and emphasize suicide as a potential outcome. Further studies should incorporate more female athletes to comprehensively assess the risk factors, outcomes, and effective prevention strategies for CTE.

The Influence of Caffeine on Tolerance to Sport-Specific High-Intensity Exercise in Young Elite Soccer Players

BACKGROUND

Modern elite football places extremely high demands on the athlete's body, so it is of practical interest to study the effect of various dietary supplements on load tolerance and postexercise recovery. Furthermore, there is a lack of research on the effects of caffeine on key measures of load tolerance in football such as delayed-onset muscle soreness (DOMS), rate of perceived exertion (RPE) and heart rate (HR) at different time points after the exercise.

METHODS

54 young players aged 15-17 years from a leading Russian football academy took part in a randomised trial using the balanced placebo design. They were divided into 4 groups: 1 - told caffeine/given caffeine, 2 - told caffeine/given placebo, 3 - told placebo/given placebo and 4 - told placebo/given caffeine. All participants consumed two capsules 60 min before testing, each containing 200 mg of caffeine or placebo. Sprinting, counter-movement jump, change of direction run, dribbling, T-test and the repeated sprint ability test were used to create conditions for high-intensity sports-specific load. A visual analogue scale was used to assess the severity of muscle soreness. RPE was assessed using the Borg Rating of Perceived Exertion scale. HR immediately postexercise (HRpe), HR after 2 min of passive rest (HRrest) and recovery HR (HRrec = HRpe - HRrest) were obtained.

RESULTS

The data demonstrated that a single caffeine intake of 400 mg had no statistically significant effect on RPE (p = 0.948), HRpe (p = 0.698) or HRrec (p = 0.920) across the groups. Additionally, the severity of DOMS 24 h postexercise did not differ significantly between the groups (p = 0.077).

CONCLUSION

Acute caffeine ingestion does not affect the subjective and objective indicators of training load in young football players aged 15-17 years with low levels of anxiety and low levels of daily caffeine intake.

Exploring the Potential of Nonpsychoactive Cannabinoids in the Development of Materials for Biomedical and Sports Applications

This Perspective explores the potential of nonpsychoactive cannabinoids (NPCs) such as CBD, CBG, CBC, and CBN in developing innovative biomaterials for biomedical and sports applications. It examines their physicochemical properties, anti-inflammatory, analgesic, and neuroprotective effects, and their integration into various biomaterials such as hydrogels, sponges, films, and scaffolds. It also discusses the current challenges in standardizing formulations, understanding long-term effects, and understanding their intrinsical regulatory landscapes. Further, it discusses the promising applications of NPC-loaded materials in bone regeneration, wound management, and drug delivery systems, emphasizing their improved biocompatibility, mechanical properties, and therapeutic efficacy demonstrated in vitro and in vivo. The review also addresses innovative approaches to enhance NPC delivery including the use of computational tools and explores their potential in both biomedical and sports science contexts. By providing a comprehensive overview of the current state of research, this review aims to outline future directions, emphasizing the potential of NPCs in biomaterial science and regenerative medicine.

Mental health and well-being of elite youth athletes: a scoping review

BACKGROUND

There is increasing recognition of the prevalence and risk factors for mental health symptoms and disorders among adult elite athletes, with less research involving elite youth athletes. This scoping review aimed to characterise the mental health and well-being of elite youth athletes who travel internationally and compete for their sport.

METHOD

Four databases were searched in March 2023. Inclusion criteria were studies with elite youth athlete populations (mean age 12-17 years) reporting mental health and well-being outcomes. Data from included studies were charted by outcome, and risk/protective factors identified.

RESULTS

Searches retrieved 3088 records, of which 33 studies met inclusion criteria, encapsulating data from 5826 athletes (2538 males, 3288 females). The most frequently studied issue was disordered eating (k=16), followed by anxiety (k=7), depression (k=5) and mixed anxiety/depression (k=2). Caseness estimates (a symptom level where mental health treatment is typically indicated) for disordered eating were wide ranging (0%-14% for males; 11%-41% for females), whereas only two studies estimated caseness for depression (7% in a mixed-sex sample; 14% for males, 40% for females) and one for anxiety (8% for males, 28% for females). Common risk factors for mental ill-health included sex, athlete status (compared with non-athletes) and social/relationship factors (with coaches/parents/peers). Contradictory evidence was observed for elite/competition level, which was associated with higher and lower rates of disordered eating.

CONCLUSION

Further representative research into the mental health and well-being of elite youth athletes is needed to enhance understanding and guide prevention and intervention measures.

Prevalence and Factors Associated with Mental Health Complaints in Japanese Collegiate Athletes

Investigations into mental health epidemiology in various cultural contexts were one of the main recommendations by the recent consensus statement on mental health in athletes, but the evidence in different sporting populations is rising slowly. This study aimed to investigate the prevalence of mental health complaints in Japanese collegiate athletes. The online survey was sent to the Japanese collegiate athletes associated with UNIVAS asking about the mental health complaints experienced during their sporting careers. Out of 10,999 athletes, 269 (2.4%) reported at least one complaint. Mental health complaints were more prevalent in female (3.6%) than male (1.5%) athletes. Skill sports had the highest prevalence (4.1%) of mental health complaints, and power sports had the lowest prevalence (1.5%) of mental health complaints. This study found a very low prevalence of self-reported mental health complaints in Japanese collegiate athletes. Preventive efforts should focus on monitoring early symptoms (rather than diagnoses), especially in skill sports and female athletes. Anxiety (38%) and depression (35%) were the most reported complaints and should be targeted first.

An initial investigation into the mental health difficulties in athletes who experience choking under pressure

This study aims to determine the frequency of choking under pressure (i.e., choking) and quantify the prevalence of psychological and behavioural consequences of choking. 165 current and retired athletes (over 18 years old) from various sporting levels completed an online survey that asked about demographics, the frequency of choking, and the psychological (e.g., negative feelings toward sport, passion/enjoyment of sport negatively affected, and suicidal ideation) and behavioural (e.g., missing/skipping sport temporarily, dropping out/quitting sport, and maladaptive, risky behaviour) effects of choking. Descriptive statistics on choking frequency indicated 127 (77%) athletes in this sample experienced choking in the last year of playing their sport, and, on average, "choked" 18.25 times during that year. Of the 65 athletes currently playing sport, 36 (55.4%) experienced choking in the past month. Furthermore, 39.4% and 7.1% of athletes in this sample did not achieve higher levels of competition and had suicidal thoughts due to choking, respectively. High-performance athletes in the current sample were more likely to engage in maladaptive behaviours after choking compared to low-performance athletes. Choking more negatively affected the passion/enjoyment for sport of currently playing (i.e., excluding all retired) high-performance than currently playing low-performance athletes. This seminal study crudely quantifies the frequency of choking in athletes, but more importantly provides crucial evidence of the psychological and behavioural consequences of choking and advocates for further research into choking and athlete mental health.

The Effect of Cannabidiol on Performance and Post-Load Recovery among Healthy and Physically Active Individuals: A Systematic Review

Athlete performance and post-load recovery can be considered one of the most important and actively discussed topics in professional sport. One substance aimed at improving performance is cannabidiol (CBD), which has been actively gaining popularity with several studies published in recent years. The PubMed, Scopus, and Cochrane Library databases were searched from inception to April 2024 according to PRISMA recommendations to identify studies on the effects of CBD on exercise capacity and post-load recovery. An initial search identified 901 publications, of which seven fully met the inclusion criteria. Current evidence supports a limited beneficial effect of CBD on a number of physiological parameters, such as VO2, mean power, and relative mean power. At the same time, there were limited data on the beneficial effects of CBD on strength parameters (including vertical jump, counter movement jump, one repetition max bench press, and barbell back squat) and post-load recovery. Notably, most of the studies included in the analysis were conducted between 2021 and 2024, indicating a growing interest among researchers in the use of CBD in healthy, physically active individuals. Further studies are needed to assess the safety of different CBD administration protocols in professional athletes.

Mental health in individual versus team sports

Across all sports, there has been increasing realization that mental health symptoms and disorders in athletes are common. More specifically, there has been increasing study of differences in mental health between individual and team sport athletes. However, this topic is still under-developed, and no comprehensive review on the topic has been undertaken. This manuscript aims to provide a narrative review of mental health symptoms and disorders, spanning depression, anxiety, eating disorders, and substance use and other addictive disorders, in individual versus team sports. Findings revealed that individual sports may be associated with relatively more negative mental health than team sports. This includes depression, anxiety, eating disorders, and concepts related to exercise addiction. Substance misuse and use disorders may be an exception to this pattern, with team sport athletes exhibiting higher rates of problematic alcohol use, use of certain forms of nicotine, and possibly use of illicit substances such as marijuana. Reasons for the greater overall mental health risk in individual versus team sports may include relatively more negative self-attribution after failure and less social cohesion/support. Steps can be taken to improve the sporting environment for all athletes-across individual and team sports-in order to optimize mental health outcomes.

Screening and Referral for Behavioral Health Symptoms in Collegiate Athletes

OBJECTIVE

We aim to investigate the prevalence of behavioral health symptoms in collegiate athletes and the frequency of referrals prompted by a preparticipation behavioral health screener.

DESIGN

Athletes completed a screening battery to detect behavioral health symptoms and sports psychology clinicians designed criteria for intervention based on the severity of symptoms reported. Data from the screener was retrospectively de-identified and analyzed.

SETTING

National Collegiate Athletic Association Division-I university.

PARTICIPANTS

All athletes on active rosters were required to complete the screener as a component of the preparticipation examination.

INTERVENTIONS

Sports psychology clinicians created a protocol for intervention based on the number and severity of symptoms reported on the screener.

MAIN OUTCOME MEASURES

Communication with athletes and referrals made to behavioral health services.

RESULTS

Of the 1126 surveys completed, 39% had behavioral health symptoms necessitating behavioral health referral. Twelve percent required a safety check-in, given the severity of their symptoms. Seven percent of the respondents were newly established with behavioral health services.

CONCLUSIONS

Symptoms of behavioral health disorders are common among athletes and yet, for a myriad of reasons, many choose to forgo treatment. By implementing a behavioral health screening battery, the prevalence of behavioral health symptoms among athletes at our institution was elucidated and many athletes were newly established with behavioral health services. The tiered intervention protocol in this study allowed for appropriate assessment and triage of high-risk individuals, while simultaneously providing lower-risk individuals with appropriate resources. Surveillance for behavioral health symptoms among college athletes using a screening battery with a tiered intervention protocol can ensure at-risk athletes are identified, contacted, and referred to behavioral health services, potentially improving their athletic performance and overall well-being, while averting poor outcomes.

Disordered alcohol and substance use in Irish farmers: A cross-sectional survey

PURPOSE

Farming is a high-pressure occupation. Populations of farmers face significant health risks, including injury, mental illness, and in some cases, heavy alcohol use. However, there is little research on farmers' use of substances beyond alcohol. This study examines factors relating to Irish farmers' disordered alcohol and substance use.

METHODS

In accordance with STROBE guidelines for cross-sectional research and reporting, we examined disordered alcohol and substance use in 351 Irish farmers using the Alcohol Use Disorders Identification Tool (AUDIT) and Drug Use Disorders Identification Tool (DUDIT).

FINDINGS

While 28% of farmers did not drink, 40% of those who did drink exceeded the AUDIT threshold for disordered use. Similarly, while 95% of farmers did not use substances, 78% of farmers who did use substances exceeded the DUDIT threshold for disordered use. Age was the most important risk factor for disordered alcohol and substance use and correlated with other main risk factors: lower income, no children, part-time farmer, and full-time off-farm roles. Disordered drinking was highest in farmers engaged in full-time education.

CONCLUSIONS

This population of Irish farmers report broadly healthy alcohol and substance use behaviors. Irish farmers may serve as a model group whose strengths can be utilized in interventions within and beyond the Irish farming community. Our results confirm the importance of analyzing demographic factors in farmers' drinking and identify younger farmers as especially at-risk for harmful alcohol and substance use.

Substance Misuse in Elite Athletes: Early Detection, Brief Intervention and Referral to Treatment

Sports medicine physicians and athletic trainers regularly encounter athletes who misuse substances that put them at risk for adverse health, social, interpersonal, academic, psychological, and performance effects. The three most encountered substances are alcohol (binge drinking), cannabis (marijuana), and tobacco/nicotine vaping. Early detection using self-report screening instruments, adverse consequences questionnaires, and urine testing are reviewed. Brief interventions that involve personalized feedback, goal setting, support system involvement, psychoeducation, contingency management, and/or motivational interviewing are highlighted. Lack of response to brief intervention or progression to a substance use disorder should prompt the consideration of referral to a substance specialty level of care.

Cannabis Is Not Doping

The World Anti-Doping Agency (WADA) classifies cannabis, all phytocannabinoids, and synthetics as doping, except for CBD. For agency, a method for doping substance must meet two criteria: performance enhancement (ergogenicity), health risk, or violation of the spirit of sports. Cannabis is neither ergogenic nor ergolytic (performance worsens), and the health risks for athletes are overestimated after 20 years of research. The significant problem remains in the complex (and difficult interpretation) definition of the spirit of sports, which transcends the objectives of sports excellence (performance and injury prevention) for moral policing. This perspective presents an evidence-based counterargument recommending the removal of cannabis and phytocannabinoids from the WADA Prohibited List.

The psychological effects of sports disruptions in NCAA Division I and II athletes during the COVID-19 pandemic: a mixed methods analysis

BACKGROUND

Improving mental health outcomes in college athletics requires better understanding of how student-athletes respond to stress-inducing events.

METHODS

Using a cross-sectional design, this study aimed to assess student-athletes' mental health status during the COVID-19 pandemic. Eligible participants (N.=489) included Division I and II student-athletes at least 18 years of age with plans to compete in the 2020-2021 sport season. Participants completed an online battery of psychological health surveys.

RESULTS

Survey results suggested high psychological strain (APSQ: 20.58±8.08), mild symptoms of anxiety (GAD-7: 7.66±5.51) and depression (PHQ-9: 7.51±5.65), and burnout (ABQ: 2.37±0.96).

CONCLUSIONS

A subset of student-athletes reported symptoms of psychological strain, depression, and anxiety warranting follow-up clinical evaluation and/or treatment according to scoring guidelines. Findings encourage psychological screening, particularly during sport-disrupting events, to better support athletes' mental health during high-stress conditions.

Exercise recommendations for patients with hypertrophic cardiomyopathy

Individuals with hypertrophic cardiomyopathy (HCM) have historically been advised to limit exercise and sports participation to mild-intensity activities due to concerns for sudden cardiac arrest (SCA). However, more contemporary data have shown SCA is rare in patients with HCM and emerging data is shifting towards support for the safety of exercise in this patient population. Recent guidelines endorse exercise in patients with HCM after a comprehensive evaluation and shared-decision making with an expert provider.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Should We be Concerned with Nicotine in Sport? Analysis from 60,802 Doping Control Tests in Italy

BACKGROUND

Nicotine is a psychostimulant drug with purported use in sports environments, though the use of nicotine among athletes has not been studied extensively.

OBJECTIVE

The aim of this study was to assess the nicotine positivity rate in 60,802 anti-doping urine samples from 2012 to 2020.

METHODS

Urine samples obtained in-competition at different national and international sports events held in Italy during the period 2012-2020 were analysed. All samples were from anonymous athletes that were collected and analysed at the WADA-accredited antidoping laboratory in Rome, Italy. Samples were analysed by gas chromatography coupled with mass spectrometry, with a cut-off concentration for nicotine of > 50 ng/mL. Results were stratified by year, sport and sex.

RESULTS

An overall mean of 22.7% of the samples (n = 13,804; males: n = 11,099; females: n = 2705) showed nicotine intake, with male samples also displaying higher positivity rates than female (24.1% vs 18.5%). Sample positivity was higher during 2012-2014 (25-33%) than 2015-2020 (15-20%). Samples from team sports displayed a higher positivity rate than those from individual sports (31.4 vs 14.1%).

CONCLUSIONS

The current data demonstrates that one in five samples from a range of 90 sports test positive for nicotine in-competition. There is a lower positivity rate in endurance versus power/strength athletes and higher positivity rate in team versus individual sports, probably accounted for by differences in physiological and psychological demands and the desire for socialisation. WADA, international and national sports federations should consider these findings with concern, proactively investigate this phenomenon and act in order to protect the health and welfare of its athletes.

Prevalence and Correlates of Mental Health Symptoms and Well-Being Among Elite Sport Coaches and High-Performance Support Staff

Background

There is growing understanding of mental health needs in elite athletes, but less is known about the mental health of coaches and support staff who work within elite sport settings. This study examined the prevalence and correlates of mental health symptoms in elite-level coaches and high-performance support staff (HPSS) and compared rates against published elite athlete samples. A cross-sectional, anonymous, online survey was administered to coaches and HPSS working in Australia’s high-performance sports system. Main outcomes were scores on validated measures of psychological distress, probable ‘caseness’ for a diagnosable psychological condition, alcohol consumption and sleep disturbance.

Results

Data were provided by 78 coaches (mean age = 46.4 years, 23.8% female) and 174 HPSS (mean age = 40.0 years, 56.7% female). Overall, 41.2% of the sample met probable caseness criteria, 13.9% reported high to very high psychological distress, 41.8% reported potential risky alcohol consumption and 17.7% reported moderate to severe sleep disturbance, with no statistically significant differences between coaches and HPSS. The most robust correlates of psychological distress and probable caseness were dissatisfaction with social support and dissatisfaction with life balance, while poor life balance was also associated with increased alcohol consumption and poor social support with sleep disturbance. Coaches and HPSS reported similar prevalence of mental health outcomes compared to rates previously observed in elite athletes, with the exception of higher reporting of alcohol consumption among coaches and HPSS.

Conclusions

Elite-level coaches and HPSS reported levels of psychological distress and probable caseness similar to those previously reported among elite-level athletes, suggesting that these groups are also susceptible to the pressures of high-performance sporting environments. Screening for mental health symptoms in elite sport should be extended from athletes to all key stakeholders in the daily training environment, as should access to programs to support mental health and well-being.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00479-y.

Substance Use and Addiction in Athletes: The Case for Neuromodulation and Beyond

Substance use, misuse and use disorders continue to be major problems in society as a whole and athletes are certainly not exempt. Substance use has surrounded sports since ancient times and the pressures associated with competition sometimes can increase the likelihood of use and subsequent misuse. The addiction field as a whole has very few answers to how to prevent and secondarily treat substance use disorders and the treatments overall do not necessarily agree with the role of being an athlete. With concerns for side effects that may affect performance coupled with organizational rules and high rates of recidivism in the general population, newer treatments must be investigated. Prevention strategies must continue to be improved and more systems need to be in place to find and treat any underlying causes leading to these behaviors. This review attempts to highlight some of the data regarding the field of substance misuse and addiction in the athletic population as well as explore possible future directions for treatment including Neuromodulation methods and Ketamine. There is a need for more rigorous, high-quality studies to look at addiction as a whole and in particular how to approach this vulnerable subset of the population.

Understanding exercise addiction, psychiatric characteristics and use of anabolic androgenic steroids among recreational athletes – An online survey study

Background

The purpose of this paper was to explore maladaptive behaviors among physically active individuals, including exercise dependence and use of anabolic steroids. Both exercise addiction (EA) and use of anabolic androgenic steroids (AAS) correlate to high amounts of exercise and EA have been linked to eating disorders and other mental health problems.

Methods

An internet survey was spread through fitness-related social media. Inclusion criteria were age ≥ 15 years and exercise frequency ≥ thrice weekly. Exercise addiction inventory identified those at-risk of EA (rEA). Characteristics of rEA were compared to those not at risk. In a separate analysis, AAS users were compared to AAS-naïve individuals.

Results

In total, 3,029 participants completed the questionnaire. Of these, 11% screened positive for being rEA, and 23% for ED. Factors associated with EA included daily exercise, social phobia, eating disorders and OCD. Risk consumption of alcohol was a negative predictor. Thirty seven participants had taken AAS the last year. These were mainly men, bodybuilders/powerlifters and more often used amphetamines and opioids.

Discussion

This exploratory study supports EA being strongly associated with eating disorders. Identified associations between EA and compulsive or anxiety disorders warrant further research to clarify if these associations arise prior to, together with, or secondary to EA.

The athletic characteristics of Olympic sports to assist anti-doping strategies

The determinants of success in Olympic Games competition are specific to the athletic demands of the sporting event. A global evaluation to quantify the athletic demands across the spectrum of the Olympic Games sport events has not previously been conducted. Thus far, the interpretation and the comparison of sport physiological characteristics within anti-doping organisations (ADOs) risk assessments remains subjective without a standardised framework. Despite its subjective assessment, this information is a key component of any anti-doping programme. Sport characteristics inevitably influence the type of substances and/or methods used for doping purpose and should be captured through a comprehensive analysis. Seven applied sport scientists independently conducted an assessment to quantify the athletic demands across six preselected athletic variables. A Principal Component Analysis was performed on the results of the panel's quantitative assessment for 160 Olympic Sport events. Sport events were clustered using the Hierarchical Density Based Spatial Clustering of Applications with Noise (HDBSCAN) algorithm. The HDBSCAN identified 19 independent cluster groups, 36 sport events remained statistically unassigned to a cluster group representing unique and eventspecific athletic demands. This investigation provides guidance to the anti-doping community to assist in the development of the sport specific physiology component of the risk assessment for Olympic Games disciplines. The dominant athletic characteristics to excel in each of these individual events will highlight areas of how athletes may strive to gain a competitive advantage through doping strategies, and inform the development of an effective and proportionate allocation of testing resources.

Do varsity college athletes have a greater likelihood of risky alcohol and cannabis use than non-athletes? Results from a National Survey in Brazil

OBJECTIVE

We examined the prevalence of risky alcohol and cannabis use among Brazilian varsity college athletes and whether this group had a greater likelihood of risky use than non-athletes.

METHODS

In 2009, Brazilian college students (n=12,711) were recruited for a national stratified random survey. Their sociodemographic characteristics, mental health, substance use, and participation in varsity sports were assessed. Binary logistic regression models were used to examine the association between varsity athlete status and moderate to high-risk alcohol and cannabis use.

RESULTS

Among varsity athletes, 67.6 and 10.7% reported risky alcohol and cannabis use, respectively. Varsity athletes had greater odds of risky alcohol consumption than non-athletes (aOR = 2.02, 95%CI 1.08-3.78). Varsity athletes also had greater odds of risky cannabis use than non-athletes in unadjusted analyses (OR = 2.57, 95%CI 1.05-6.28), although this relationship was attenuated after covariate adjustment.

CONCLUSIONS

Among college students in Brazil, varsity athletes had a higher prevalence of risky alcohol and cannabis use than non-athletes. The rates were considerably higher than those observed among samples of U.S. college athletes. Future research should examine the use of these substances among varsity college athletes in other middle-income countries since these findings will likely guide prevention and treatment efforts.

Performance-enhancing drugs and the Olympics

The rules of fair play in sport generally prohibit the use of performance-enhancing drugs (PEDs). The World Anti-Doping Agency (WADA) oversees global antidoping regulations and testing for elite athletes participating in Olympic sports. Efforts to enforce antidoping policies are complicated by the diverse and evolving compounds and strategies employed by athletes to gain a competitive edge. Now between the uniquely proximate 2021 Tokyo and 2022 Beijing Olympic Games, we discuss WADA's efforts to prevent PED use during the modern Olympic Games. Then, we review the major PED classes with a focus on pathophysiology, complexities of antidoping testing, and relevant toxicities. Providers from diverse practice environments are likely to care for patients using PEDs for a variety of reasons and levels of sport; these providers should be aware of common PED classes and their risks.

Pre-bout hypertension in the combat sports athlete: clearance recommendations

Hypertension is one of the most prevalent medical disorders in the world and is associated with significant cerebrovascular and cardiovascular morbidity. Pre-bout blood pressure (BP) elevation is extremely common, and ringside physicians must accurately assess the accompanying risk of adverse cerebrovascular and cardiovascular events in the decision to allow participation in combat sports. It is strongly recommended that a ringside physician consider disqualifying a combat sports athlete with severe pre-bout hypertension (systolic BP ≥160 mm Hg and/or diastolic BP ≥100 mm Hg, or stage 2 hypertension in children when indexed by gender, age, and height) from that bout, if it persists despite rest and repeated measurement with accurate equipment. This recommendation is congruent with that of the American College of Sports Medicine, the American College of Cardiology, and the American Heart Association, which recommend non-clearance for sports or exercise testing when BP exceeds those thresholds. Severely elevated BP, as defined above, confers markedly increased risk of morbidity and mortality. Exercise further raises BP markedly. The combination of severely elevated blood pressure and cranial trauma during combat sports is a risk factor for intracranial hemorrhage with a direct impact on the morbidity and mortality associated with ringside combat sports events. Combat sports athletes with SBP ≥130 or DBP ≥90 - and their coaches and families, if available and the athlete consents - should be educated on the causes of hypertension, its acute and chronic risks, and the possible future implications for bout clearance, and the athletes should be referred for evaluation and management.

Anabolic Androgenic Steroids in Orthopaedic Surgery: Current Concepts and Clinical Applications

Despite the well-documented effects of testosterone and its synthetic derivatives—collectively termed anabolic androgenic steroids (AASs)—on the musculoskeletal system, the therapeutic use of these agents has received limited investigation within the field of orthopaedic surgery. In the last 2 decades, preclinical and clinical research has started to identify promising applications of the short-term use of AASs in the perioperative period. There is evidence to suggest that AASs may improve postoperative recovery after anterior cruciate ligament reconstruction and total joint arthroplasty. In addition, AASs may augment the biological healing environment in specific clinical scenarios including muscle injury, fracture repair, and rotator cuff repair. Current literature fails to present strong evidence for or against the use of AASs in orthopaedics, but there is continuous research on this topic. The purpose of this study was to provide a comprehensive overview of the current status of AAS applications in orthopaedic surgery, with an emphasis on preclinical data, clinical studies, and future directions.

The Mental Health of Athletes: Recreational to Elite

ABSTRACT

Athletes at all levels of competition are susceptible to mental health symptoms and disorders, and this has been a topic of increased research attention in recent years. The most common such conditions will be highlighted in this article, with a clinical focus on unique aspects of presentation, diagnosis, and management among athletes. Conditions addressed include depression, anxiety and related disorders, eating disorders, sleep concerns, attention-deficit/hyperactivity disorder, bipolar and psychotic disorders, and substance use disorders and behavioral addictions. Athletes experience particular physiologic and psychosocial demands that impact how they present symptomatically and how treatment modalities, including psychotherapy and pharmacologic treatments, impact them.

COVID-19 Lockdown 2020 Changed Patterns of Alcohol and Cannabis Use in Swiss Elite Athletes and Bodybuilders: Results From an Online Survey

Objectives: During the COVID-19 pandemic, increased patterns of substance use have been reported in the general population. However, whether this also applies to athletes is not yet clear. This study aimed to detect changes in alcohol consumption and cannabis use in elite athletes and bodybuilders during the first COVID-19 lockdown in Switzerland. Methods: Between April 25 and May 25, 2020, a cross-sectional online survey was conducted among bodybuilders and Swiss elite athletes who were active in Olympic sports and disciplines approved by the International Olympic Committee (IOC) on at least the national level. The collected data included information on alcohol and cannabis use during the last month (lockdown) and in the year before COVID-19 lockdown (pre-lockdown), daily training times, existential fears on a scale from 1 to 100, Patient Health Questionnaire-9 for depression (PHQ-9), Insomnia Severity Index (ISI), and State-Trait Anxiety Inventory (STAI). Results: N = 275 athletes (elite athletes: n = 193; bodybuilders: n = 82) was included in this study. Both pre-lockdown and during lockdown, more bodybuilders used cannabis (both time points: p < 0.001) than elite athletes, and more elite athletes drank alcohol (pre-lockdown: p = 0.005, lockdown: p = 0.002) compared to bodybuilders. During lockdown, fewer athletes drank alcohol compared to before, but those who continued drinking did so on more days per week (p < 0.001, Eta2 = 0.13). Elite athletes were more likely to increase their drinking with 17.7 vs. 8.2% in bodybuilders. When compared to pre-lockdown measures, the number of athletes using cannabis did not change during lockdown. Only three of 203 elite athletes reported using cannabis during lockdown; this contrasts with 16 of 85 bodybuilders. In a multivariate regression model, existential fears and a lower ISI score were significant predictors for increased alcohol consumption during the lockdown in the entire sample. In a model based on elite athletes only, male sex and a lower ISI score predicted increased alcohol consumption. In a bodybuilder-based model, predictors of increased alcohol consumption were existential fears and trait anxiety. Conclusion: We suggest identifying athletes who are at risk for increased alcohol and cannabis use; we suggest this to be able to professionally support them during stressful times, such as the COVID-19 pandemic.

Substance Use and Its Impact on Athlete Health and Performance

The pressure to gain mass, power, explosiveness, and endurance and to obtain a performance edge continues to a part of sports. Anabolic agents, including selective androgen receptor modulators along with peptides, hormones, and metabolic modulators, continues to evolve. Methods to promote transcription to modify gene expression are a part of the evolution. In order to monitor and improve doping detection, the Athlete Biological Passport has been created. This article provides an up-to-date review of alcohol, anabolic androgens and related agents, stimulants, opioids, and cannabis and related compounds and their effects on athlete health and performance.

Potential Role of Cannabidiol on Sports Recovery: A Narrative Review

The use of cannabidiol (CBD) among athletes is becoming extensive and frequent. This could be due to the elimination of CBD from the list of prohibited substances by federations and international institutions of sport. The legalization and resulting production, and commercialization of CBD, could increase its intake in sports professionals. This commercialization of cannabinoids has fueled a race to study their properties, benefits, and risks for health and performance in athletes. Although there is evidence that suggests some beneficial properties such as anxiolytics, antidepressants, anti-inflammatory, and antioxidants among others, the evidence presented so far is neither clear nor conclusive. There are significant gaps in knowledge of the physiological pathways that explain the role of CBD in sports performance. This mini-review examines evidence suggesting that CBD has the potential to be used as a part of the strategies to recover from fatigue and muscle damage related to physical and cognitive exertion in sports.

Mephentermine Misuse: An Impending Crisis among Sportspersons

Mephentermine is a sympathomimetic amine, frequently used as a vasopressor. It is structurally comparable to amphetamines, and World Anti-Doping Agency has prohibited its use as a performance-enhancing drug. However, its illegal consumption by several sportspersons and those appearing for physical endurance tests is a growing concern for health-care professionals. We present a case of misuse of intravenous mephentermine by a young male who abruptly increased its amount a few days prior to the sports competition and developed acute psychosis. The case report highlights the need for strict regulations for procuring methamphetamine and effective treatment strategies for managing its misuse.

Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training

ABSTRACT

Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.

Update on integrative treatment of psychiatric symptoms and disorders in athletes

Primary objective: In this review, we detail the issues and disorders athletes present with, guidelines for making diagnostic formulations and treatment goals, and strategies for delivering integrated treatment attuned to the athlete and their team and/or sport. In addition, we highlight special issues associated with athletes and their families. Reasoning: Data suggests athletes experience comprable incidence and prevalence rates to the general population of psychiatric disorders. The mental and physical demands placed on athletes are unique and may increase their susceptibility to certain mental health problems. The current literature regarding integrative interventions in athletes is sparse and largely anecdotal. We provide a summary of the scientific evidence from a literature review conducted by the IOC Consensus Committee on Mental Health in Elite Athletes, reviews and expert clinical strategies recommended by the authors of four books on sports psychiatry written since 2012, and our own review of the literature related to psychotherapy with elite and non-elite- athletes. Main outcomes and results: At the moment there are no randomized controlled trials assessing the use of psychotherapy or medication for mental illness in athletes to guide treatment. Controlled studies examining psychological interventions in collegiate athletes have demonstrated improvements in mental health symptomology. Although these studies were limited to collegiate athletes they assist in providing a foundation for elite athletes as well. For the assessment and management of the mental health needs of athletes' to be on a par with their physical needs, more high-quality scientific epidemiological and treatment intervention studies are needed. Conclusions: Development of specific models of psychiatric intervention for athletes with significant psychopathology and impairment appears to be warranted. These interventions should include individual, family/marital, and group psychotherapy with or without medication using evidence-based treatments.

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.

International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health

Objectives

To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders.

Methods

We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool.

Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1

The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches).

Conclusion

The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.

Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes

BACKGROUND

Little is known about how cannabis knowledge and attitudes impact cannabis use behavior.

OBJECTIVE

To test the knowledge-attitudes-behavior paradigm in active adult athletes.

DESIGN

The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data.

PARTICIPANTS

Self-defined active adult athletes (n = 1161).

MAIN MEASURES

Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use.

KEY RESULTS

A three-cluster solution was the best fit to the data. The clusters were named Conservative (n = 374, 32.2%), Unsure (n = 533, 45.9%), and Liberal (n = 254, 21.9). There was a significant difference among the clusters for all 11 attitudes items (all p < 0.001). Attitude cluster membership was significantly different by age (p < 0.001), primary sport (p < 0.05), and knowledge about cannabis (p < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user (p < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. (p < 0.001).

CONCLUSIONS

Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.

The Effects of Electronic Nicotine Delivery Systems on Athletes

The rapid rise in popularity of Electronic Nicotine Delivery Systems (ENDS), or vaping, has not eluded the athletic population. Increasing use of youth sports participants, as well as collegiate and professionals, means sports medicine providers and coaches alike should be familiar with the effects of these devices. Current evidence demonstrates an impact on both the cardiovascular and pulmonary systems. These effects appear less significant than smoking tobacco cigarettes, but the extent and longevity of the consequences of ENDS use is unclear. Mechanisms for recovery, such as sleep and injury healing, also are affected. Lastly, the emergence of life-threatening pulmonary disease associated with ENDS use may have devastating effects on an athlete. This article will highlight the recent literature on the impact of ENDS on athletes and athletic performance, as well as the potentially life-threatening consequences of use.

The Very Important Person (VIP) and the Headache Medicine Physician

Headache medicine specialists often treat VIPs but little is known about whether these encounters are different than with other patients. Questions considered include who is a VIP, should you treat a VIP like any other patient, and what are the challenges and advantages? A non-random sampling of comments is presented from headache medicine specialists. Eleven principles are presented to consider in these encounters.