Unsportsmanlike Conduct
Substance abuse among athletes an all-too-common problem

By Patricia Agostino, RN, CEN, CCRN
April 25, 2005

Substance abuse among athletes is a recognized problem in sports and the abuse of drugs has been implicated at every level of competition. Athletes, coaches, trainers, and health professionals must be alert to the possibility of drug use in athletes and the catastrophic effects many of these substances have on the cardiovascular system.

Athletes might use drugs for therapeutic, recreational or social reasons, as performance-enhancing (ergogenic) aids, or to mask the presence of other drugs during drug testing.¹ The American College of Sports Medicine reported in 2000 that the abuse of recreational drugs, such as cocaine, among athletes far outweighs the abuse of ergogenic drugs.

Athletes are thought to be vulnerable to recreational substance abuse because of some combination of the following variables: fame, fortune, free time, and a feeling of invincibility.² Recreational drugs are largely performance-impairing (ergolytic) drugs.

Ergolytic drugs

Cocaine is an alkaloid extracted from the leaves of the Erythroxylum coca bush grown in South America. Its therapeutic use is that of a local anesthetic. It is available as a hydrochloride salt, which can be taken orally, intravenously, intranasally, and as the “free base” or “crack” form, which can be smoked. Cocaine is metabolized by the plasma and liver cholinesterases into water-soluble metabolites, which are excreted in the urine.³ Individuals with hereditary cholinesterase deficiency may have a fatal reaction to even small doses of cocaine.⁴

Myocardial infarction (MI) has been reported in first-time and chronic cocaine users with and without risk factors for coronary artery disease. Acute MI has occurred with all routes of administration and is not dose dependent.

The pathophysiology of cocaine induced MI remains unclear, but probably includes an increase in myocardial oxygen demand, coronary vasospasm, and increased thrombotic potential.¹ Cocaine causes an increase in heart rate, systemic blood pressure, and left ventricular contractility. It induces marked constriction of coronary arteries. Even small amounts of the drug cause vasoconstriction of epicardial coronary arteries so that myocardial oxygen supply decreases, even as demand increases.

Cocaine enhances platelet activity, which may cause clot formation in coronary arteries, increase production of endothelin (a potent vasoconstrictor), and decrease production of nitric oxide (a potent vasodilator). When taken systemically, cocaine blocks the presynaptic uptake of norepinephrine and dopamine, and acts as a powerful sympathomimetic agent.³

The occurrence of an acute MI in a young athlete without cardiovascular risk factors should raise suspicion of occult cocaine use.

Cocaine also has been associated with aortic dissection, endocarditis, dilated cardiomyopathy, deep vein thrombosis, cardiac dysrhythmia, and stroke.^1,3

Alcohol: the often-forgotten drug

Alcohol abuse has been implicated in the development of heart disease for more than a century. Adverse consequences of alcohol abuse are hypertension, stroke, coronary events, lipid abnormalities, cardiac arrhythmias, systolic dysfunction, and dilated cardiomyopathy.^1,4 The precise mechanism by which alcohol produces hypertension is unknown.¹

Excessive alcohol ingestion may increase the risk of stroke threefold in young athletes. The highest incidence of stroke occurs in nonalcoholic men who drink more than 300 grams on weekends. (12 ounces of beer = 13 grams).¹ Alcohol abuse should be considered in athletes with new-onset hypertension or with unexplained stroke.¹

Marijuana, diuretics, and tobacco

Marijuana is derived from the Cannabis sativa plant and can be smoked or eaten. Its use decreases exercise performance, stroke volume, and increases heart rate.^1,4

Athletes misuse diuretics before competition in an attempt to dilute urinary concentration of other prohibited drugs and sometimes to lose weight quickly to make a certain weight class. Diuretics can deplete potassium and cause cardiac dysrhythmias and death.¹

Athletes use smokeless tobacco for its nicotine properties. Nicotine is a central stimulant that relaxes skeletal muscles, constricts blood vessels, and increases heart rate and blood pressure. Nicotine can cause coronary artery spasm and lower the threshold for ventricular fibrillation, and death has been reported in athletes using smokeless tobacco following vigorous exercise.¹

Ergogenic drugs

Athletes use stimulants in an effort to increase time to exhaustion by masking the physiologic response to fatigue.¹ Amphetamines are sympathomimetic agents, which increase heart rate, respiration, and blood pressure.

While the use of amphetamines such as dextroamphetamine and methamphetamine has declined, there has been an increase in the use of “designer” stimulant drugs such as Ecstasy, (MDMA, methylenedioxmethamphetamine),^2,3 which mimic the effects of amphetamines.⁴ Pseudoephedrine — sold over the counter in cold medicines — and ephedrine — marketed aggressively to athletes as a dietary supplement — also mimic amphetamines in high doses.^1,5

Erythropoietin, a prescription subcutaneously administered medication for anemia, is a glycoprotein that stimulates red blood cell production. The increase in red blood cells is believed to improve oxygen consumption and benefit endurance. Complications include hypertension, congestive heart failure, and death.¹

Anabolic steroids are synthetic derivatives of the male sex hormone testosterone. Attempts to separate the anabolic form from the androgenic, or masculinizing effects, have been unsuccessful and these agents are referred to as anabolic-androgenic steroids.

Therapeutic use of steroids include hypoplastic anemia and growth disorders. Athletes administer 10 to 200 times the therapeutic dose in an effort to increase muscle mass and enhance performance.¹

Cardiovascular events linked to anabolic steroid abuse include fatal and nonfatal MI. Steroid abuse increases the risk of sudden death by increasing left ventricular mass and responsiveness to catecholamines. Steroid abuse also causes increased low-density lipoprotein, decreased HDL, and sodium and water retention.¹

The danger of supplements

Athletes often buy products marketed as “nutritional supplements,” which are unregulated and may contain varying amounts of androgens, pro-hormones or steroid precursors, such as dehydroepiandrosterone and androstenedione.⁵

Human growth hormone (HGH) is a naturally occurring pituitary hormone responsible for growth. Athletes may use it for its anabolic effect, but data on its effects are limited. The most common side effect of HGH excess is acromegaly — a serious systemic condition typically caused by a benign tumor of the pituitary gland that secretes excessive growth hormone. Coronary artery disease and cardiomyopathy have been described with its use.^1,4 HGH, or somatotropin replacement therapy, is a biosynthetic growth hormone administered by injection under a physician’s supervision for medically indicated cases.

However, HGH “precursors” are marketed as homeopathic remedies in pill or powder form for weight loss, increased muscle mass, energy, performance, and anti-aging properties, with dubious effects. Injectable HGH as prescribed by physicians is touted and offered on some websites as the real thing.

A 2001 study by the National Collegiate Athletic Association of nearly 14,000 student-athletes regarding the use of alcohol, amphetamines, anabolic steroids, cocaine, ephedrine, marijuana, psychedelics, and smokeless tobacco reported that a majority of student athletes engage in substance abuse, especially alcohol.⁶ Being educated on the facts of substance abuse in the sports world can only improve the care provided to this “majority.”

Patricia Agostino, RN, CEN, CCRN, is a staff nurse in the ICU of Stamford Hospital, Stamford, Conn.

References

1. Cregler L. Substance abuse in sports: The impact of cocaine, alcohol, steroids, and other drugs. In: Williams RA, ed. The Athlete and Heart Disease. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:131-153.

2. American Academy of Family Physicians. American College of Sports Medicine Current Comments: Statement on Cocaine Abuse Among Athletes. Available at: www.aafp.org/afp/20001015/clinical.html. Accessed November 3, 2004.

3. Lange R, Hillis D. Cardiovascular complications of cocaine use. NEJM. 2001; 345(5): 351-357.

4. Tricker R, et al. Drugs in sports. Available at: www.drugfreesport.com/choices/ drugs/index.html. Accessed November 3, 2004.

5. Pipe A, Ayotte C. Nutritional supplements and doping. Clin J Sport Med. 2002; 12(4):245-249.

6. Green GA, et al, NCAA study of substance use and abuse habits of college student-athletes. Clin J Sports Med. 2001; 11(1):51-56.