DOI: https://doi.org/10.4414/smw.2021.20412
The mental health of elite-level athletes has attracted growing interest over recent decades [1]. However, the prevalence of psychiatric disorders in this population is still debated. Recent studies suggest rates of common mental disorders among competitive athletes equal to those in general population [2]. The psychological and physical demands of a sporting career may lead to an increased susceptibility to mental health problems and risk-taking behaviour [3]. Besides, there is an overlap between the peak competitive years in most sports and the main age of onset of mental disorders [4]. Furthermore, the use of alcohol and illicit drugs is common in the 18–29 age group, with prevalence rates of associated substance use disorders being higher than over a lifetime [5].
In substance use, recreational consumption aiming primarily at psychotropic effects is distinguished from performance-enhancing use. Recreational substance use comprises use of alcohol, cannabis, nicotine (tobacco) and non-medical, psychoactive medication (opioids, stimulants, benzodiazepines). Doping substances and methods include, among others, anabolic agents, growth factors, masking agents and blood doping. However, a strict distinction between recreational and performance-enhancing use is difficult, as psychoactive substances may be consumed for (subjectively) improving or maintaining performance. At the same time, primarily performance-enhancing substances can have psychotropic side effects.
Most scientific research on substance use among elite athletes focuses on doping; however, in recent years multiple studies exploring the prevalence of recreational substance (ab)use in different athlete populations have been conducted. With the focus on success and maximising performance in elite-level athletes, two fundamental questions regarding recreational substance use arise: First, why do elite athletes consume substances with potentially detrimental effects on both sporting performance and career (sanctions, suspension, etc.)? Second, are these causes of medical relevance and require psychiatric treatment? Existing literature has a primarily quantitative focus, with little exploration of causes and consequences of substance use for the individual athlete. Valid assertions on the prevalence of substance use disorders are therefore limited. The present review summarises the current state of research on the prevalence of psychotropic substance use among elite athletes and outlines findings in answer to the questions raised above.
We identified studies through a Medline search. Search terms comprised the following, either individually or combined: ‘(elite) athletes’, ‘recreational substance use’, ‘substance use disorder’, ‘(substance) addiction’, ‘(substance) dependence’, ‘substance abuse’, ‘illicit drugs’, ‘psychotropics’, ‘alcohol’, ‘cannabis’, ‘marijuana’, ‘tobacco’, ‘nicotine’, ‘smoking’, ‘(prescription) opioids’, ‘heroine’, ‘benzodiazepines’, ‘GHB,’ ‘stimulants’, ‘cocaine’, ‘ketamine’ and ‘amphetamines’. We confined the search to articles in English and applied no date restrictions. We retrieved the articles discussing the use of psychoactive substances by elite athletes and psychiatric diagnosis of substance use disorders in athletes. We retrieved and reviewed a total of 287 articles of which we included 46 in this paper after a comprehensive study of their content, quality check and exclusion of redundancies.
Various explanations for recreational substance use among elite athletes have been evaluated [6–8]. A simple explanation is that reasons for drug use do not differ substantially between elite athletes and the general population. However, the question as to whether athletes hazard the negative consequences of substance use or are not aware of them remains open. More specific approaches include stressors elite athletes face during and after their career. Living in a highly competitive environment they must deal with pressure to perform, limited social support due to relocation, group dynamics in team sports, injuries and physical pain [9, 10]. Both acute and long-term stress can have a severe negative impact on psychological wellbeing and may contribute to the development of mental disorders. Recent meta-interpretations identified more than hundred distinct stressors throughout a sporting career [11]. Adolescent elite athletes are subject to an elevated risk for hazardous behaviour, including substance use. On the other hand, retirement from professional sports may also foster substance abuse [12]. The impact of the surrounding network, including family, coaches and peer athletes, on an athlete’s mental health is complex and has not been conclusively examined. With regard to recreational substance use, some studies emphasise the network’s protective effects, with others suggesting that those relationships, especially with peer athletes, may encourage the use, supply and demand for drugs [13, 14].
Knowledge on substance use among elite athletes derives from two main sources: voluntary disclosure in research questionnaires and detection in anti-doping drug testing. Drug testing is performed by the World Anti-Doping Agency (WADA), its national sister organisations and sports federations. WADA publishes an annual List of Prohibited Substances and Methods. Psychoactive substances such as cannabinoids, stimulants and narcotics are banned during competition [15]. Alcohol has been removed from the prohibited list, with several sporting organisations continuing testing. WADA included nicotine on its monitoring programme in order to detect potential patterns of misuse in sport, but the conclusion is pending. Most sport federations and anti-doping agencies have introduced doping rules based on the WADA code. However, implementation of these policies and sanctioning of violations differ significantly. If WADA test results are taken as the sole source of information, recreational drug use among athletes seems rare: of 322,050 tests conducted in 2017, stimulants, narcotics and cannabinoids were found in 0.25% of all samples [16]. However, the testing system features significant gaps, especially in the youth and adolescent field. Use of alcohol and nicotine, frequent causes of substance use disorders in the general population, is not recorded by WADA. In self-report questionnaires, elite athletes report consumption rates for various psychoactive substances that are considerably higher than anti-doping test results suggest.
Nicotine is one of the most widely used psychoactive substances. It is derived from the tobacco plant for different forms of consumption. Nicotine simultaneously holds stimulant and relaxant properties and is highly addictive. Combustible and smokeless tobacco consumption can be distinguished. The most common form of nicotine uptake is through inhalation of tobacco smoke after combustion. Since the early 2000s e-cigarettes have become more widespread. Smokeless tobacco includes dry powdered snuff tobacco, chewing tobacco and snus, a moist powder tobacco product placed under the lips. Nicotine replacement therapy includes various products such as gum, transdermal patches, inhalers, etc. Smokeless tobacco products contain varying quantities of nicotine, which can reach those of combustible tobacco. Nicotine uptake via combustible and smokeless tobacco consumption holds equal addictive properties. Despite the absence of some of the deleterious effects of combustible tobacco, smokeless tobacco is associated with various adverse effects [17]. Use of smokeless tobacco products has been reported to be a relevant promoting factor for smoking initiation [18].
Compared with the general population, consumption rates of combustible tobacco among elite athletes are lower, most likely because of its detrimental effect on cardiopulmonary capacity [19]. However, there is strong evidence for common use of nicotine among elite athletes, suggesting smokeless tobacco or nicotine replacement therapy as the main route of administration. Chewing and spit tobacco became popular in the US major professional sports leagues in the 1970s, with estimates that more than a third of active MLB baseball players regularly use smokeless tobacco, in some cases publicly on-field [20]. Whereas the use of smokeless tobacco in American sports leagues has been investigated comprehensively, its prevalence outside the US is less researched. Among non-US athletes the most common smokeless tobacco product seems to be snus, with widespread use especially in winter sports [21, 22]. Analysis of urine controls conducted at the World Ice-Hockey Championships in 2009 demonstrated that between a third and half of the tested players “actively” used nicotine right before or during competition [23]. A subsequent 1-year monitoring study with professional athletes from different sports quantified the “active” nicotine use at 15%, with significantly higher prevalence rates of up to 55% in strength-based and winter sports [24]. Athletes regularly describe beneficial effects of nicotine on psycho-physiological performance in competition, training and recreation. Studies showed short-term positive effects on cognition and reaction capacity, but could not demonstrate a physical performance enhancement [25, 26]. To date it remains largely unclear whether high consumption rates are due to the addictive properties of nicotine or result from deliberate decisions of the athletes for recreational or performance-enhancing use.
Cannabis, also known as marijuana, is a psychoactive drug from the Cannabis plant that is used for medical or recreational purposes. The main psychoactive component of cannabis is tetrahydrocannabinol (THC). Cannabis can be consumed by smoking, vaporising, within food or as an extract. Cannabis is the most commonly used illegal drug in the world. Regular cannabis use has a relevant potential for dependence. In the course of drug liberalisation in the western world, there is a trend towards decriminalisation and partial legalisation of cannabis, mostly for medical purpose, but also recreational use [27]. Medical cannabis refers to the use of cannabis and cannabinoids to treat disease or improve symptoms, although there is no consensual definition [28]. Effects in recreational use include relaxation, euphoria (feeling “high”/”stoned”) and altered perception.
Research on prevalence rates of cannabis use among elite athletes is partially contradictory. According to WADA drug testing results, cannabis consumption is uncommon among professional athletes [16]. In contrast, self-report surveys suggest significantly higher consumption rates, but the spread of findings is large [29]. Many studies were conducted with US college athletes, reducing validity and transferability to other athlete populations [30, 31]. Cannabis use among elite athletes seems to be less frequent than in the general population; however, in a university setting group dynamics may foster consumption. Outside the US cannabis is consumed rather in winter and team sports, with reportedly low consumption rates in endurance sports [32]. Several studies showed a positive correlation between cannabis consumption and higher rates of recreational or performance-enhancing substance use in college athletes [6, 33]. With further legalisation and destigmatisation, multiple active and former elite athletes from US sports leagues have publicly spoken about a reportedly widespread use of cannabis in professional sports. They described the existent monitoring system as inefficient, potential sanctions as non-deterrent and named both recreational and medical reasons for use. Up to now, their reports remain largely anecdotal, but indicate that cannabis (ab)use among athletes may constitute a relevant issue.
Research could not demonstrate objective performance-enhancement effects of cannabis use [34]. However, despite evidence that cannabis interferes with psychomotor skills and cognitive function, some athletes report a beneficial impact on athletic performance. In recent years, self-initiated use of cannabis as an analgesic and in treating concussion among athletes, especially in contact sports, has been increasingly reported, accompanied by some athletes’ demand for sports federations to reconsider their cannabis policy and permit its medical use [35, 36]. Until now there is little knowledge on potential benefits of cannabinoids in reducing rates of opioid prescription and prevention or treatment of traumatic brain injury.
Opioids directly bind to opioid receptors, which are found principally in the central and peripheral nervous system and gastrointestinal tract. The main medical indication for opioids is pain relief. Specific opioids are used in replacement therapy for opioid use disorders. They have a significant dependence potential when consumed continuously or without medical supervision. The misuse of prescription opioid pain relievers is shown to act as a gateway for future abuse of illicit opioids [37].
As in the general population, opioid abuse among elite athletes may present as recreational consumption or as continued use of an initial prescription for pain alleviation. Pain is common in elite athletes and often accompanies sport injuries, but may also occur independently of injury or persist after the tissue healing period [38]. Despite numerous surveys on the incidence of various sport injuries, epidemiological data on pain management in elite athletes is limited. Widespread use of analgesics among competitive athletes is presumed, but most pain relief research focused on contact sports and the use of nonsteroidal anti-inflammatory agents [39]. Knowledge of use and misuse of, and dependence on, opioid medication in elite athlete is lagging behind [40]. Primarily recreational opioid abuse among elite athletes seems to be uncommon. Pursuant to WADA, potent opioids are banned in-competition, whereas low-potency opioids, such as tramadol or codeine, are not prohibited by WADA. In recent years, WADA tests identified increased prevalence of tramadol use in certain sports, notably cycling. WADA still lists tramadol on its monitoring programme, whereas other sport associations have already banned it in-competition [41].
Studies conducted with US college athletes repeatedly demonstrated an elevated use and misuse of opioid prescription drugs compared with non-athlete students, whereas no significant difference in consumption rates of illicit opioids was shown [42, 43]. In a study on career and post-career opioid use of former NFL football players, over half of the participants reported using prescription opioids during their career and 70% of those stated at least temporary misuse. Seven percent of the former players described prolonged misuse after the end of their careers, constituting an elevated prevalence rate compared with the general population [44].
Alcohol is the most frequently consumed recreational substance in the world in almost all adult subgroups. Regular alcohol consumption is one of the main global risk factors for disease [45]. An association between alcohol abuse and other psychiatric comorbidities has been demonstrated [46]. No performance-enhancing effects have been described for alcohol. Knowledge of alcohol use among competitive athletes often derives from surveys of college students enrolled in sport programmes. Several studies demonstrated higher consumption and binge drinking rates among college athletes than in the general population [47, 48]. However, transferability of findings to other athlete groups is presumably reduced. Alcohol consumption seems to be significantly higher outside the competition season and during training periods. Athletes named mostly social and recreational reasons for drinking, with higher consumption rates in team sports than individual and endurance sports [49]. In other surveys, elite athletes described use of alcohol as a mechanism for coping with pressure to perform, anxiety and depressive symptoms [50]. Studies with athletes from contact sports showed reduced awareness of the potential hazards of alcohol drinking, raising the question of whether there is sufficient psychoeducation in this field [31, 51]. Studies on the alcohol use of retired elite athletes showed higher overall consumption rates compared with control groups, but could not demonstrate an increase in prevalence of alcohol dependency [12, 52].
Stimulants are a heterogeneous group of substances increasing activity of the central nervous system and body. Most of them have sympathomimetic effects and are associated with elevated dopamine release. Stimulants are used worldwide as prescription medicines for treatment of various medical disorders, as well as both legally or illicitly without prescription for performance enhancement or sought-after psychoactive effects. The overarching term comprises prescription drugs (methylphenidate, modafinil, etc.) and illicit substances (cocaine, “speed”, etc.) [53]. The main medical purpose is the treatment of impulse controls disorders (attention deficit hyperactivity disorder, ADHD), with further therapeutic off-label use [54]. There is significant abuse potential of use outside therapeutic indications. The use of stimulants for performance enhancement became widespread among both endurance and team sport athletes in the mid-20th century [55]. The current prohibited list published by the WADA comprises 69 different stimulants, all effectively detectable with present drug testing [15]. Use of recreational stimulant drugs such as cocaine or 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) among elite athletes is rare according to doping tests results, with limited data on self-reported use available. There has been anecdotal evidence from US sports league athletes describing common cocaine consumption and lax doping controls. Recent years saw a significant increase of so-called therapeutic use exemptions (TUEs) for stimulants in athletes with diagnosed ADHD [56]. Prevalence of ADHD among elite athletes has not been investigated conclusively, but it is expected that rates are not less than in the general population [57]. Although stimulant medication is a well-established (if not always uncontroversial) treatment option for ADHD in the general population, the use of prescription stimulants is highly disputed in professional sports due to its potential/alleged performance enhancing effects.
There is little knowledge on the prevalence of further psychoactive substance use among elite athletes. Gamma-hydroxybutyric acid (GHB) has been popular in bodybuilding for allegedly anabolic effects. It is used in a recreational setting for euphoriant effects. GHB is medically approved for the treatment of narcolepsy, with positive effects on restorative night sleep making it potentially attractive for high-performance athletes [58]. Several works describe the use of anxiolytics and hypnotics by elite athletes dealing with anxiety, sleep disorders and pressure to perform [59, 60]. Benzodiazepines hold a high dependence potential when used autonomously or over longer periods. Ecstasy (MDMA), “speed” (amphetamine) and ketamine are popular club drugs, but their prevalence among elite athletes has not been specifically investigated so far.
According to self-report surveys, recreational substance use among elite athletes seems to be more prevalent than official urine test figures suggest. Some of the described causes and patterns of consumption indicate harmful and hazardous substance use. However, based on available research, assertions on the prevalence of substance use disorders among elite athletes are limited. Large-sample, longitudinal control studies retrieving not only quantity and frequency of substance use, but also capturing diagnostic criteria of substance use disorders are therefore needed. So far, study participants were often US college athletes. Future research should therefore include adolescent and adult elite athletes from various international sporting organisations, to account for differing living, training and competition conditions, as those presumably influence substance use patterns. Assessment of consumption rates should preferably combine self-report declaration and verification via urine testing, as a false consensus effect was described in previous studies: Athletes partially underreported own substance use, but overestimated consumption rates of peer athletes [61]. Knowledge on prevalence and patterns of substance use among athletes provides the basis for future prevention, screening and therapeutic interventions for associated psychiatric disorders. Studies demonstrated in some athletes a reduced risk evaluation for substance use, illustrating the need for prevention measures [33, 62]. Treatment of substance use disorders in athletes may be challenging, as their daily routine is defined by training, competition and underlying stress factors difficult to assess. The development of specific treatment concepts is required to meet the needs of elite athletes, especially as strong reluctance to seek professional psychiatric support have been described [63]. We hope that in the future more athletes struggling with substance use disorders can benefit from disorder-specific treatment.
Mental and physical health cannot be separated. Over past decades, studies investigating mental health disorders in elite athletes demonstrated relevant prevalence rates in this population. Symptoms may be related to sport and interfere with performance. Recreational substance use in elite athletes was overshadowed by doping and attracted little scientific attention in the past, but is now researched more intensively. Our review adds to the knowledge of earlier works by including recent studies [7, 64]. In our opinion, sports medicine as a cross-sectional subject should integrate knowledge on prevalence rates and treatment options of common mental disorders among elite athletes. The International Olympic Committee (IOC) and various sports association recently launched programmes raising awareness of mental health disorders in professional sports (such as the IOC, “Heads up” and “State of mind” campaign) [2]. According to the findings of our review, recreational substance use is common among elite athletes and may lead to hazardous patterns of use and substance use disorders. Management of mental disorders in professional sports must involve both treatment of individual athletes affected and optimisation of conditions in which athletes live, train and compete.
No financial support and no other potential conflict of interest relevant to this article was reported.
1 Reardon CL , Hainline B , Aron CM , Baron D , Baum AL , Bindra A , et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019;53(11):667–99. doi:.https://doi.org/10.1136/bjsports-2019-100715
2 Rice SM , Purcell R , De Silva S , Mawren D , McGorry PD , Parker AG . The Mental Health of Elite Athletes: A Narrative Systematic Review. Sports Med. 2016;46(9):1333–53. doi:.https://doi.org/10.1007/s40279-016-0492-2
3 Hughes L , Leavey G . Setting the bar: athletes and vulnerability to mental illness. Br J Psychiatry. 2012;200(2):95–6. doi:.https://doi.org/10.1192/bjp.bp.111.095976
4 Kessler RC , Amminger GP , Aguilar-Gaxiola S , Alonso J , Lee S , Ustün TB . Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. 2007;20(4):359–64. doi:.https://doi.org/10.1097/YCO.0b013e32816ebc8c
5 Merikangas KR , McClair VL . Epidemiology of substance use disorders. Hum Genet. 2012;131(6):779–89. doi:.https://doi.org/10.1007/s00439-012-1168-0
6 Buckman JF , Yusko DA , White HR , Pandina RJ . Risk profile of male college athletes who use performance-enhancing substances. J Stud Alcohol Drugs. 2009;70(6):919–23. doi:.https://doi.org/10.15288/jsad.2009.70.919
7 Gil F , de Andrade AG , Castaldelli-Maia JM . Discussing prevalence, impacts, and treatment of substance use disorders in athletes. Int Rev Psychiatry. 2016;28(6):572–8. doi:.https://doi.org/10.1080/09540261.2016.1212821
8 Reardon CL , Creado S . Drug abuse in athletes. Subst Abuse Rehabil. 2014;5:95–105. doi:.https://doi.org/10.2147/SAR.S53784
9 Markser VZ . Sport psychiatry and psychotherapy. Mental strains and disorders in professional sports. Challenge and answer to societal changes. Eur Arch Psychiatry Clin Neurosci. 2011;261(Suppl 2):S182–5. doi:.https://doi.org/10.1007/s00406-011-0239-x
10 Sarkar M , Fletcher D . Psychological resilience in sport performers: a review of stressors and protective factors. J Sports Sci. 2014;32(15):1419–34. doi:.https://doi.org/10.1080/02640414.2014.901551
11 Arnold R , Fletcher D . A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. J Sport Exerc Psychol. 2012;34(3):397–429. doi:.https://doi.org/10.1123/jsep.34.3.397
12 Kontro TK , Sarna S , Kaprio J , Kujala UM . Use of Alcohol and Alcohol-Related Morbidity in Finnish Former Elite Athletes. Med Sci Sports Exerc. 2017;49(3):492–9. doi:.https://doi.org/10.1249/MSS.0000000000001137
13 Grossbard J , Hummer J , LaBrie J , Pederson E , Neighbors C . Is Substance Use a Team Sport? Attraction to Team, Perceived Norms, and Alcohol and Marijuana Use Among Male and Female Intercollegiate Athletes. J Appl Sport Psychol. 2009;21(3):247–61. doi:.https://doi.org/10.1080/10413200903019145
14 Tamminen KA , Holt NL . Adolescent athletes’ learning about coping and the roles of parents and coaches. Psychol Sport Exerc. 2012;13(1):69–79. doi:.https://doi.org/10.1016/j.psychsport.2011.07.006
15World Anti-Doping Agency (WADA). 2019 WADA Prohibited List. Available at: https://www.wada-ama.org/sites/default/files/wada_2019_english_prohibited_list.pdf. Published 2019 [accessed 2020 May 2].
16World Anti-Doping Agency (WADA). 2017 Anti-Doping Testing Figures. Available at: https://www.wada-ama.org/sites/default/files/resources/files/2017_anti-doping_testing_figures_en_0.pdf. Published 2018 [accessed 2020 May 2].
17 Benowitz NL . Nicotine addiction. N Engl J Med. 2010;362(24):2295–303. doi:.https://doi.org/10.1056/NEJMra0809890
18 Severson HH , Forrester KK , Biglan A . Use of smokeless tobacco is a risk factor for cigarette smoking. Nicotine Tob Res. 2007;9(12):1331–7. doi:.https://doi.org/10.1080/14622200701705209
19 Šaranović SĐ , Vićić J , Pešić I , Tomović M , Batinić Đ , Antić M , et al. The Influence of Tobacco Use on Pulmonary Function in Elite Athletes. Int J Environ Res Public Health. 2019;16(19):3515. doi:.https://doi.org/10.3390/ijerph16193515
20 Severson HH , Klein K , Lichtensein E , Kaufman N , Orleans CT . Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003. Tob Control. 2005;14(1):31–6. doi:.https://doi.org/10.1136/tc.2004.007781
21 Alaranta A , Alaranta H , Patja K , Palmu P , Prättälä R , Martelin T , et al. Snuff use and smoking in Finnish olympic athletes. Int J Sports Med. 2006;27(7):581–6. doi:.https://doi.org/10.1055/s-2005-865826
22 Martinsen M , Sundgot-Borgen J . Adolescent elite athletes’ cigarette smoking, use of snus, and alcohol. Scand J Med Sci Sports. 2014;24(2):439–46. doi:.https://doi.org/10.1111/j.1600-0838.2012.01505.x
23 Marclay F , Saugy M . Determination of nicotine and nicotine metabolites in urine by hydrophilic interaction chromatography-tandem mass spectrometry: Potential use of smokeless tobacco products by ice hockey players. J Chromatogr A. 2010;1217(48):7528–38. doi:.https://doi.org/10.1016/j.chroma.2010.10.005
24 Marclay F , Grata E , Perrenoud L , Saugy M . A one-year monitoring of nicotine use in sport: frontier between potential performance enhancement and addiction issues. Forensic Sci Int. 2011;213(1-3):73–84. doi:.https://doi.org/10.1016/j.forsciint.2011.05.026
25 Mündel T . Nicotine: Sporting Friend or Foe? A Review of Athlete Use, Performance Consequences and Other Considerations. Sports Med. 2017;47(12):2497–506. doi:.https://doi.org/10.1007/s40279-017-0764-5
26 Zandonai T , Chiamulera C , Mancabelli A , Falconieri D , Diana M . A Preliminary Investigation on Smokeless Tobacco Use and Its Cognitive Effects Among Athletes. Front Pharmacol. 2018;9:216. doi:.https://doi.org/10.3389/fphar.2018.00216
27 Russell C , Rueda S , Room R , Tyndall M , Fischer B . Routes of administration for cannabis use - basic prevalence and related health outcomes: A scoping review and synthesis. Int J Drug Policy. 2018;52:87–96. doi:.https://doi.org/10.1016/j.drugpo.2017.11.008
28 Whiting PF , Wolff RF , Deshpande S , Di Nisio M , Duffy S , Hernandez AV , et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015;313(24):2456–73. doi:.https://doi.org/10.1001/jama.2015.6358
29 Brisola-Santos MB , Gallinaro JG , Gil F , Sampaio-Junior B , Marin MC , de Andrade AG , et al. Prevalence and correlates of cannabis use among athletes-A systematic review. Am J Addict. 2016;25(7):518–28. doi:.https://doi.org/10.1111/ajad.12425
30 Lisha NE , Sussman S . Relationship of high school and college sports participation with alcohol, tobacco, and illicit drug use: a review. Addict Behav. 2010;35(5):399–407. doi:.https://doi.org/10.1016/j.addbeh.2009.12.032
31 Yusko DA , Buckman JF , White HR , Pandina RJ . Alcohol, tobacco, illicit drugs, and performance enhancers: a comparison of use by college student athletes and nonathletes. J Am Coll Health. 2008;57(3):281–90. doi:.https://doi.org/10.3200/JACH.57.3.281-290
32 Peretti-Watel P , Guagliardo V , Verger P , Pruvost J , Mignon P , Obadia Y . Sporting activity and drug use: Alcohol, cigarette and cannabis use among elite student athletes. Addiction. 2003;98(9):1249–56. doi:.https://doi.org/10.1046/j.1360-0443.2003.00490.x
33 Buckman JF , Farris SG , Yusko DA . A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances. Drug Alcohol Depend. 2013;131(1-2):50–5. doi:.https://doi.org/10.1016/j.drugalcdep.2013.04.023
34 Kennedy MC . Cannabis: Exercise performance and sport. A systematic review. J Sci Med Sport. 2017;20(9):825–9. doi:.https://doi.org/10.1016/j.jsams.2017.03.012
35 Ware MA , Jensen D , Barrette A , Vernec A , Derman W . Cannabis and the Health and Performance of the Elite Athlete. Clin J Sport Med. 2018;28(5):480–4. doi:.https://doi.org/10.1097/JSM.0000000000000650
36 Zeiger JS , Silvers WS , Fleegler EM , Zeiger RS . Cannabis use in active athletes: Behaviors related to subjective effects. PLoS One. 2019;14(6):e0218998. doi:.https://doi.org/10.1371/journal.pone.0218998
37 Somogyi AA , Barratt DT , Coller JK . Pharmacogenetics of opioids. Clin Pharmacol Ther. 2007;81(3):429–44. doi:.https://doi.org/10.1038/sj.clpt.6100095
38 Hainline B , Turner JA , Caneiro JP , Stewart M , Lorimer Moseley G . Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Med. 2017;51(17):1259–64. doi:.https://doi.org/10.1136/bjsports-2017-097890
39 Warden SJ . Prophylactic misuse and recommended use of non-steroidal anti-inflammatory drugs by athletes. Br J Sports Med. 2009;43(8):548–9. doi:.https://doi.org/10.1136/bjsm.2008.056697
40 Zideman DA , Derman W , Hainline B , Moseley GL , Orchard J , Pluim BM , et al. Management of Pain in Elite Athletes: Identified Gaps in Knowledge and Future Research Directions. Clin J Sport Med. 2018;28(5):485–9. doi:.https://doi.org/10.1097/JSM.0000000000000618
41 Baltazar-Martins JG , Plata MDM , Muñoz-Guerra J , Muñoz G , Carreras D , Del Coso J . Infographic. Tramadol: should it be banned in athletes while competing, particularly in road cycling? Br J Sports Med. 2020;54(2):120–1. doi:.https://doi.org/10.1136/bjsports-2018-100473
42 Ford JA , Pomykacz C , Veliz P , McCabe SE , Boyd CJ . Sports involvement, injury history, and non-medical use of prescription opioids among college students: An analysis with a national sample. Am J Addict. 2018;27(1):15–22. doi:.https://doi.org/10.1111/ajad.12657
43 Veliz P , Epstein-Ngo Q , Austic E , Boyd C , McCabe SE . Opioid use among interscholastic sports participants: an exploratory study from a sample of college students. Res Q Exerc Sport. 2015;86(2):205–11. doi:.https://doi.org/10.1080/02701367.2014.983219
44 Dunne EM , Striley CW , Mannes ZL , Asken BM , Ennis N , Cottler LB . Reasons for Prescription Opioid Use While Playing in the National Football League as Risk Factors for Current Use and Misuse Among Former Players. Clin J Sport Med. 2020;30(6):544–9. doi:.https://doi.org/10.1097/JSM.0000000000000628
45 Griswold MG , Fullman N , Hawley C , Arian N , Zimsen SRM , Tymeson HD , et al. Alcohol use and burden for 195 countries and territories, 1990-2013;2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10152):1015–35. doi:.https://doi.org/10.1016/S0140-6736(18)31310-2
46 Hasin DS , Stinson FS , Ogburn E , Grant BF . Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830–42. doi:.https://doi.org/10.1001/archpsyc.64.7.830
47 Ford JA . Alcohol use among college students: a comparison of athletes and nonathletes. Subst Use Misuse. 2007;42(9):1367–77. doi:.https://doi.org/10.1080/10826080701212402
48 Mastroleo NR , Barnett NP , Bowers KM . Association between sex, race/ethnicity, season, day of week, and alcohol use and related risks in college student athletes and nonathletes. J Am Coll Health. 2019;67(5):422–32. doi:.https://doi.org/10.1080/07448481.2018.1484367
49 Martens MP , Dams-O’Connor K , Beck NC . A systematic review of college student-athlete drinking: Prevalence rates, sport-related factors, and interventions. J Subst Abuse Treat. 2006;31(3):305–16. doi:.https://doi.org/10.1016/j.jsat.2006.05.004
50 Miller BE , Miller MN , Verhegge R , Linville HH , Pumariega AJ . Alcohol misuse among college athletes: self-medication for psychiatric symptoms? J Drug Educ. 2002;32(1):41–52. doi:.https://doi.org/10.2190/JDFM-AVAK-G9FV-0MYY
51 O’Brien CP , Lyons F . Alcohol and the athlete. Sports Med. 2000;29(5):295–300. doi:.https://doi.org/10.2165/00007256-200029050-00001
52 Gouttebarge V , Jonkers R , Moen M , Verhagen E , Wylleman P , Kerkhoffs G . The prevalence and risk indicators of symptoms of common mental disorders among current and former Dutch elite athletes. J Sports Sci. 2017;35(21):2148–56. doi:.https://doi.org/10.1080/02640414.2016.1258485
53 Ciccarone D . Stimulant abuse: pharmacology, cocaine, methamphetamine, treatment, attempts at pharmacotherapy. Prim Care. 2011;38(1):41–58. doi:.https://doi.org/10.1016/j.pop.2010.11.004
54 Wilens TE , Spencer TJ . The stimulants revisited. Child Adolesc Psychiatr Clin N Am. 2000;9(3):573–603, viii. doi:.https://doi.org/10.1016/S1056-4993(18)30108-1
55 Deventer K , Roels K , Delbeke FT , Van Eenoo P . Prevalence of legal and illegal stimulating agents in sports. Anal Bioanal Chem. 2011;401(2):421–32. doi:.https://doi.org/10.1007/s00216-011-4863-0
56 Han DH , McDuff D , Thompson D , Hitchcock ME , Reardon CL , Hainline B . Attention-deficit/hyperactivity disorder in elite athletes: a narrative review. Br J Sports Med. 2019;53(12):741–5. doi:.https://doi.org/10.1136/bjsports-2019-100713
57 Poysophon P , Rao AL . Neurocognitive Deficits Associated With ADHD in Athletes: A Systematic Review. Sports Health. 2018;10(4):317–26. doi:.https://doi.org/10.1177/1941738117751387
58 Brunt TM , van Amsterdam JG , van den Brink W . GHB, GBL and 1,4-BD addiction. Curr Pharm Des. 2014;20(25):4076–85. doi:.https://doi.org/10.2174/13816128113199990624
59 Taylor L , Chrismas BCR , Dascombe B , Chamari K , Fowler PM . Sleep Medication and Athletic Performance-The Evidence for Practitioners and Future Research Directions. Front Physiol. 2016;7:83. doi:.https://doi.org/10.3389/fphys.2016.00083
60 Zandonai T , Lugoboni F , Zamboni L . A risk for athletes: when the desire to sleep becomes a nightmare. A brief case report on benzodiazepine addiction. Psychopharmacology (Berl). 2018;235(11):3359–60. doi:.https://doi.org/10.1007/s00213-018-5047-9
61 Uvacsek M , Nepusz T , Naughton DP , Mazanov J , Ránky MZ , Petróczi A . Self-admitted behavior and perceived use of performance-enhancing vs psychoactive drugs among competitive athletes. Scand J Med Sci Sports. 2011;21(2):224–34. doi:.https://doi.org/10.1111/j.1600-0838.2009.01041.x
62 Thomas JO , Dunn M , Swift W , Burns L . Elite athletes’ perceptions of the effects of illicit drug use on athletic performance. Clin J Sport Med. 2010;20(3):189–92. doi:.https://doi.org/10.1097/JSM.0b013e3181df5f87
63 Castaldelli-Maia JM , Gallinaro JGME , Falcão RS , Gouttebarge V , Hitchcock ME , Hainline B , et al. Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. Br J Sports Med. 2019;53(11):707–21. doi:.https://doi.org/10.1136/bjsports-2019-100710
64 McDuff D , Stull T , Castaldelli-Maia JM , Hitchcock ME , Hainline B , Reardon CL . Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review. Br J Sports Med. 2019;53(12):754–60. doi:.https://doi.org/10.1136/bjsports-2019-100669
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