CHAPTER KEY WORDS
- Alcohol abuse
- Narcan (naloxone)
- Opioid epidemic
- Stimulant abuse
At approximately 4:45 pm, the athletic trainer is notified of a stranger wandering in the high school parking lot and a woman who seems to be asleep in a car.
After school hours, the athletic trainer is the go-to person. No security is available. This is every athletic trainer’s nightmare, and, assuming the worst, 911 is called to report the situation and activate emergency medical services (EMS). The district’s go-bag and automated external defibrillator are brought onto the scene.
When on the scene, 911 is notified of a 30-something male wandering in the parking lot and acting strangely. Upon further investigation, an adult female who is unresponsive to verbal or painful stimulation and who exhibits shallow breathing, pinpoint pupils, and weak radial and carotid pulse is found in a nearby car. Suspecting an overdose, 2 doses of Narcan (naloxone) are given with an Evzio (Kaléo Inc) auto-injector.
Within a short time, police arrive with paramedics who administer additional Narcan intranasally. EMS secures the patient to a stretcher and moves her to the ambulance. Once in the unit, the patient is placed on a cardiac monitor, blood pressure cuff, and pulse oximeter. While vital signs are being assessed, intravenous access is established, and blood glucose levels are obtained. The patient becomes responsive to stimuli, is awake, alert, and oriented and is transported to the local emergency department.
Fox Chapel Area School District (Pennsylvania) and state Department of Health protocol/steps were initiated.
- Call EMS.
- Check for signs of opioid overdose.
- Commence rescue breathing/cardiopulmonary resuscitation.
- Administer Evzio (naloxone) through HCl injection.
- Continue rescue breathing/cardiopulmonary resuscitation if needed.
- Administer second dose of naloxone (by EMS upon arrival).
- Place person in recovery position.
- Transport to the local medical facility.
Athletic trainers must realize that no matter what time or place, coaches and athletes will call for the athletic trainer for all issues that may arise on campus. This is why all athletic trainers need to be Narcan-trained, and they need to incorporate this training into their school district’s alert, lockdown, inform, counter, evacuate; cardiopulmonary resuscitation; child abuse; sudden cardiac arrest; and concussion recognition preparation.
Substance abuse, particularly opioid and stimulant use, continues to capture national attention for its catastrophic and often deadly effects on adolescents and young adults. Athletes at every age and competition level have been found to use drugs or other substances, whether for performance enhancement or because of underlying substance use disorders. Health professionals who have frequent contact with this population should possess a foundational understanding of the use, misuse, and adverse effects of substance use in athletes. This chapter will focus primarily on opioids, prescription stimulants, and alcohol, as these are the most commonly encountered substances of abuse in clinical practice.
The current opioid epidemic is among the deadliest drug epidemics in American history, representing 66.4% of drug overdoses in the United States in 2016,1 causing fatalities among individuals younger than 50 years old at a faster pace than the HIV epidemic did at its peak.2 According to the National Survey on Drug Use and Health,3 2.1 million people initiated prescription pain reliever misuse in 2016. Even more astonishingly, 19.8% of this population were between the ages of 12 and 17, and 27.4% were between the ages of 18 and 25. This epidemic is fueled largely by the prevalence of prescription opioids.4 Young athletes are especially prone to substance abuse, with their first exposure to opioids often coming through prescriptions received for sports-related injuries.5 Through misuse of opioid pain medications, athletes may mask the pain of injury, allowing them to resume playing before the injury is fully healed.
Stimulant medications also have recently seen an increase in misuse. Reported in the 2016 National Survey on Drug Use and Health, 1.4 million people initiated prescription stimulant misuse, with 44.9% of this population being between the ages of 18 and 25, and another 17.7% between the ages of 12 and 17. Most commonly, stimulant medications (eg, amphetamines) are prescribed for treatment of attention-deficit/hyperactivity disorder (ADHD), the most common neuropsychiatric disorder of childhood.6 Studies have demonstrated a relationship between Adderall (amphetamine and dextroamphetamine mixed salts) use and participation in organized sports, particularly high-contact sports.7 Aside from their neuropsychiatric action, stimulants can cause adverse cardiovascular effects when combined with physiologic stresses and sports. Those providing care to athletes of all levels must be aware of the potential for cardiovascular emergencies caused by concurrent use or misuse of stimulant medications and physical exertion.8
Despite recent surges in opioid and stimulant use among the general and athletic populations, alcohol remains the most commonly used psychoactive drug9 and is the most widely used drug among the athletic population. In fact, up to 88% of intercollegiate American athletes have been reported to use alcohol.10 Interestingly, several studies have demonstrated that sport participation is positively associated with greater alcohol use during adolescence and into early adulthood.11 With this in mind, it is imperative to equip health care professionals who care for athletes with the knowledge base to identify, evaluate, and respond to emergencies caused by the consumption of alcohol before, during, and after athletic events.
Misuse and Use in Athletics
In 2017, the opioid crisis in America reached the level of a public health emergency, highlighting the devastation it has caused throughout the country. Athletes are not immune to this crisis, and, in fact, some athletes may fall into a category that places them at higher risk of opioid misuse and abuse.12 Young athletes in high-contact sports, such as wrestling, football, and ice hockey, are at greater risk to engage in nonmedical use of prescription opioids.1 The driving factor is thought to be due to the greater risk of injury and subsequent requirement for pain medications, often involving opioid prescriptions. This increased risk of early exposure to opioid pain medications, combined with the stress associated with high-level competition, places athletes into a particularly vulnerable position for development of opioid misuse and abuse.
Pharmacology and Physiology
The term opioid refers to a large group of drugs, including naturally derived alkaloids from poppy seeds such as morphine and codeine, as well as their semisynthetic derivatives (eg, fentanyl) and synthetic derivatives (eg, methadone). Opioids act on 3 major classes of receptors that are widely distributed throughout the central and peripheral nervous system, as well as many other organ systems, including the gastrointestinal tract. When opioids interact with tissues in the human body, they reduce the release of neurotransmitters and primarily cause inhibition of physiologic processes, most notably decreasing transmission of pain. Routes of administration include oral, sublingual, intravenous, intranasal, transdermal, and rectal.
Recognition on the Sidelines
Opioids can have physiologic effects on the human body that manifest as both obvious and subtle physical examination findings. Neurologically, opioid use can result in changes in mood and affect, called dysphoria. At higher doses, especially in somewhat opioid-naïve patients, sedation can be achieved. Athletes may become less aware or less responsive than normal. At extremes of use, patients can become sedated. On examination, patients under the influence of opioids will develop pinpoint pupils, called miosis. Seizures have also been known to occur at lower thresholds in people who are actively using opioids.
Related to neurologic effects, opioid use can cause respiratory depression. This refers to the decreased respiratory rate and drive that occur in those under the influence of opioids. This can lead to poor ventilation and retention of carbon dioxide, leading to a respiratory acidosis, which can have deleterious effects during physical performance.
Opioids also cause changes in the gastrointestinal system, including nausea, vomiting, and constipation. This is due to overall slowing of gastrointestinal motility.
Finally, opioids can have cardiovascular effects. In line with depression of the pulmonary, gastrointestinal, and neurologic systems, opioids can also cause depression of the cardiovascular system. This manifests as decreased heart rate, called bradycardia.
Naloxone (Narcan, Evzio) is a medication used to block the effects of opioids and is therefore given in emergency settings when opioid overdose is suspected. It is a non-selective and competitive opioid receptor antagonist, rapidly displacing opioid medications from their receptors and reversing their effects. To highlight its ability to save lives, naloxone has been placed on the World Health Organization’s List of Essential Medicines. Naloxone can be given intravenously, intramuscularly, or intranasally. When given intravenously or intranasally, effects are typically seen after 2 minutes. The intramuscular route has a time-to-peak effect of 5 minutes. When administered, the effects last between 30 minutes and 1 hour. Sequential dosing may be considered every 2 to 3 minutes if the desired effect is not achieved after initial administration.
Prevalence Among Athletes
The category of stimulants is broad and can include prescriptions amphetamines, such as those used for ADHD, and recreational stimulants. Recreational stimulants can be both legal, such as caffeine, or illegal, such as methamphetamines or Ecstasy (3,4-methylenedioxy-methamphetamine, or MDMA). The National Collegiate Athletic Association has acknowledged that the number of student-athletes testing positive for stimulant medications has increased 3-fold in recent years.13 In addition, a 2008 study found that 8% of Major League Baseball players in 2009 obtained exemptions for stimulants.14 The diagnosis of ADHD in children and adolescents has increased in recent years, leading an increase in stimulants use among young athletes. Sports medicine physicians and athletic trainers should identify athletes who are prescribed stimulants and monitor them for adverse effects.15
Pharmacology and Physiology
In general, a stimulant is a psychoactive substance with central nervous system stimulation and mood-altering properties. Exact mechanisms of action are complicated, but most likely involve inhibition of neurotransmitter uptake, specifically monoamine, at the nerve–nerve junction. Stimulants can be consumed orally, intranasally, intravenously, or through inhalation.
Recognition on the Sidelines
As the name implies, stimulants tend to speed up most body processes.
In the cardiovascular system, stimulants cause increased heart rate, thereby increasing cardiovascular output. Increased cardiovascular output, combined with increased systemic vascular resistance, causes increases in blood pressure. Stimulant use can also lead to palpitations, heart attack, and fatal cardiac arrhythmias. Any athlete known to use stimulants who suddenly collapses on the sidelines should be attached to an automated external defibrillator immediately, as the chance of fatal arrhythmia causing the collapse is high.
In addition to cardiovascular signs and symptoms, stimulants also contribute to neurologic changes, including confusion, increased alertness, psychoses, and, at the extreme, seizures. Athletes combining stimulants with rigorous physical activity, such as sporting events, are also at increased risk of developing rhabdomyolysis, which is rapid breakdown of skeletal muscle, leading to renal failure, lactic acidosis, and dehydration. Athletes using stimulants may also be noted to have excessive sweating.
Prevalence Among Athletes
Alcohol is the most widely used drug among the athletic population, including almost 90% of collegiate athletes.10 Alcohol use disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders-5, is separated into mild, moderate, and severe subclassifications. The diagnosis of alcohol use disorder is beyond the scope of this text, but health care providers should be aware of a wide spectrum of alcohol use in adolescents and adults. In particular, young men between the ages of 18 and 24 are at an increased risk of problem drinking.10 This is also notably the age group in which sport participation is the highest.
Pharmacology and Physiology
Alcohol, or ethanol, is a naturally occurring substance created by the fermentation of sugars by yeasts. It is legally available in many forms, including beer, wine, and liquor. Alcohol is a psychoactive substance and functions as a central nervous system depressant.
Recognition on the Sidelines
Alcohol is considered an performance-impairing, or ergolytic, drug. As such, alcohol intoxication in athletes can predispose them to deleterious physiologic effects and possibly leads to the need for emergency care on the sideline.
Alcohol concentrations over 100mg/dL weaken the pumping force of the heart, even in young, otherwise healthy individuals, predisposing athletes to cardiovascular insufficiency. This may manifest as lessened exercise tolerance and greater likelihood of syncopal events.10 Alcohol can affect the electrical system of the heart as well by causing myocardial irritability, resulting in potentially fatal atrial arrhythmias.10
In athletes who have a history of exercise-induced asthma, use of alcohol has been identified as a precipitating factor for acute exacerbations.10
It is well-known and understood that alcohol use impairs judgment and slows reaction time. Therefore, alcohol use during sporting events that require complex coordination and judgment can increase risk of injury.
Alcohol has been reported as a significant factor in spinal injuries occurring in recreational sports by inhibiting depth perception. Balance also is greatly diminished when the vestibular system is impaired by alcohol, further increasing risk of injury.
Response to Suspected Substance Abuse or Intoxication
Regardless of the suspected substance, it is crucial for athletic organizations at all levels to have a policy in place directing first-line caregivers with the proper actions to take in emergency situations involving substance use.12 In the event of hemodynamic instability as a result of substance use, the proper basic life support or advanced life support protocol must be followed, including naloxone administration if opioid use is suspected.
Appropriately addressing sideline emergencies relating to substance use and misuse begins with prevention. Several state interscholastic athletic associations have published recommendations for monitoring substance use in athletes. Most of these policies have centered on the opioid crisis but could easily be adapted to other substances. A proactive approach to prevention of substance misuse must involve all members of the sports medicine team. This includes student–athletes, parents or guardians, coaches, athletic trainers, and sports medicine physicians. A proactive approach to substance misuse includes the following key facets:
- Providing education and awareness at the organizational level to athletes, parents/guardians, and coaches.
- Supporting educational efforts within the school community.
- Employing lower risk, first-line analgesic treatment strategies, such as nonsteroidal anti-inflammatory drugs, acetaminophen, local anesthetics, and cryotherapy, and reserving opioids for more serious injuries or extreme pain.
- Avoiding direct prescribing or dispensing of opioid prescriptions to athletes and avoiding opioid administration in unsupervised environments.
- In school environments, ensuring that prescribers or parents/guardians notify the school nurse or athletic trainer regarding persons who are prescribed stimulants or opioids; school policies should facilitate this process.
- Developing a directed policy for the athletic organization that can be implemented on the sideline regarding athletes suspected to be under the influence of a substance before, during, or after sport participation.
- Making long-term referral resources readily available to athletes to treat not only the acute phase of intoxication, but also the possibility of underlying addiction. This includes a patient-centered approach to treatment.
Substance use and abuse in athletics are becoming increasingly prevalent, and it is vital that health professionals who care for athletes at every level have a foundational understanding of these substances’ effects on performance, as well as their adverse effects. Opioids, both prescription and non-prescription, are the fastest growing drug of abuse and are widely prevalent among athletes. Athletes are at higher risk for traumatic injury, making it more likely that they will receive prescription opioid pain medications. Naloxone is a life-saving reversal agent for opioid overdose and should be administered rapidly in the field.
In addition to opioids, alcohol continues to be the most used drug globally. It is an ergolytic agent, meaning that it has negative effects on performance and can predispose athletes to musculoskeletal injury as well as cardiac and pulmonary adverse effects. Stimulants, mainly prescription agents for the treatment of ADHD, are also prevalent among adolescent athletes. Although primarily neuropsychiatric in their effects, stimulants can cause adverse cardiovascular and heat tolerance effects when combined with physiologic stress, such as sports participation. Regardless of the substance involved, athletic organizations at every level must have a protocol in place to identify athletes who are using substances, whether prescribed or recreationally.
CHAPTER REVIEW QUESTIONS
- While covering a high school football game, one of the athletes is noted to be less alert than usual, more agitated, and complaining of being nauseated. When examining him, the athletic trainer notes his pupils are smaller than normal. Which substance is this athlete most likely under the influence of?
- Which of the following questions is true regarding naloxone?
a) it is used primarily as a reversal agent when stimulant overdose is suspected
b) it can be given intravenously only
c) it can be given every 2 to 3 minutes if no effect is seen after initial administration
d) it typically takes 30 minutes to see a true effect
- Key facets to addressing substance use at the organizational level include which of the following?
a) providing education and awareness at the organizational level to guardians/parents
b) attempting to use conservative measures for treatment of pain, including nonsteroidal anti-inflammatory drugs, acetaminophen, local agents, and cryotherapy
c) avoiding administering opioid medications to adolescents in an uncontrolled environment
d) all the above
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