Treatment of Substance Abuse Problems in Sport Penelope P. Ziegler, M.D. Williamsburg Place and The William J. Farley

1. Treatment of Substance Abuse Problems in SportPenelope P. Ziegler, M.D.Williamsburg Place and The William J. Farley CenterWilliamsburg, VA

2. Substances of Concern Legal substances and “process addictions” Alcohol Nicotine Food Gambling Illicit drugs Marijuana Stimulants “Club drugs”- ecstasy, GHB, ketamine, etc. Heroin Prescription drugs Opioids Sedatives Stimulants- Ritalin, Adderal, etc. Performance enhancing substances Steroids Other hormones and substances Over-the-counter drugs

3. What Do They Have in Common? All stimulate the midbrain’s reward system by increasing dopamine levels Repeated overstimulation of this pathway in vulnerable individuals leads to permanent brain alterations = addiction Vulnerabilities: Genetic Acquired

4. Genetic Vulnerabilities Family history of addictive disorders Alcoholism Other drug addiction Compulsive gambling Eating disorders Family history of bipolar disorder

5. Acquired Vulnerabilities Exposure to drugs in utero Early onset of drug use Certain psychiatric disorders Bipolar disorder Attention deficit hyperactivity disorder When untreated, greatly increases risk of developing addiction Treatment reduces this risk Post traumatic stress disorder

6. Levels of Sport Involved Secondary schools College athletics Professional sports “Weekend warriors” Unofficial team sporting leagues and activities

7. Impact of Substance Use Impaired academic function leading to ineligibility for sports participation Impaired physical functioning leading to sports injuries Impaired adherence and participation in rehab leading to delayed healing Impaired function on re-entry into sport leading to re-injury

8. Hierarchy of Problems Curiosity and experimentation Regular, non-problematic social use Use in violation of rules of sport or law Repeated use in situations which could cause danger to self or others (abuse) Out of control use; inability to cut down or stop use; continued use despite adverse consequences; development of tolerance and/or withdrawal; impairment of social and occupational function due to use (addiction)

9. Development of Addiction In vulnerable individuals, once drug use starts, progressive changes in brain function and structure lead to changes in behavior. Drug taking moves from experimentation to regular use to compulsive, out of control use. Without help, the addicted person is unable to stop or control use despite increasingly severe negative consequences, and despite his/her efforts.

11. Primary Treatment (Prevention) Studies show that most drug prevention efforts have been woefully ineffective Exception is focusing on impact of substance use on participation and performance in sport At elementary school level, using coaches and sport stars to educate kids about risks of substance use At secondary and collegiate level, using sports pros in recovery sharing their stories Using sports psychologists and athletic trainers to identify risks and train athletes in coping skills needed

12. Secondary Treatment(Early Intervention) Working with athletes who are experimenting with or abusing drugs and/or performance-enhancing substances but not yet addicted Using specialized approaches Intensive education Identification of specific risk factors Peer group therapy Attendance at open 12-Step meetings Meeting young recovering athletes

13. Tertiary Treatment(Addiction Treatment) Intensive treatment at level of care appropriate for individual’s illness Treatment providers (physicians, counselors, rehab centers) needs to work with sports system Coach Athletic trainer Student assistance program, player assistance program that oversees athlete’s recovery Family

14. Case #1 19 year old single African American sophomore female on basketball scholarship to large midwestern university At risk of ineligibility due to non-attendance at classes and practice Minor ankle sprain leads to a routine, schedule appointment at sports medicine outpatient clinic She arrived for appointment with alcohol on her breath.

15. Red Flags Change in behavior and performance Non-attendance at classes Non-attendance at practice Alcohol on breath at a scheduled clinic appointment

16. Case #1 (continued) Evaluation showed alcohol abuse and history of anxiety and sleep disturbance since date rape freshman year Referred for Early alcohol intervention program Individual sexual trauma counseling Coaching on resistance to peer pressure Continued on team with understanding that further missed practices or alcohol use would result in suspension and referral to higher level of care

17. Case #2 20 year old white male junior running back at Ivy League college had car wreck following a game; BAC was 0.18 in E.R. Urine drug screen positive for cocaine and methylphenydate (Ritalin). Sustained a fractured wrist and dislocated shoulder in wreck. Seen for consultation in hospital by addiction specialist; diagnosis: middle stage addiction to alcohol and stimulants.

18. Special Issue: Prescription Stimulants High school and college athletes use prescription stimulants for 3 reasons Performance enhancement Study aids Euphoria, especially when “snorted” These drugs are readily available From peers From family doctor From student health center

19. Case #2 (continued) Referred to a residential treatment program for addiction that was able to incorporated intensive physical rehab program. Assisted in connecting with a sponsor who was a recovering pro NFL player. Able to return to school in spring semester and return to team for fall season with ongoing outpatient treatment, support and monitoring program. Decided on career in counseling rather than pro ball.

20. Case #3 40 year old, married Latino business owner admitted to an addiction rehab center for treatment of alcohol and opioid addiction. In college, had been a “star” varsity soccer player until sustaining a knee injury; rehab had been complicated by his drinking and unrecognized abuse of prescribed pain medication. Never returned to the soccer team; now has chronic pain in knee; still taking opioids daily, and alcohol use has escalated out of control. Chronic, low-level depression related to sedentary life style, obesity and self-hatred.

21. Missed Opportunities Signs of problems following college injury Drinking escalated following injury, drinking alone, drinking to self-medicate Abuse of pain meds Missing PT appointments, not showing interest in or motivation for rehab Ways to intervene Expressions of concern or caring Arranging for visit by counselor or specialist Don’t diagnose or judge; suggest assessment, help Who can intervene Sports medicine doctors Physical therapists and trainers Coaches Peers

22. Case #3 During treatment, detoxified from alcohol and opioids and started on a pain management protocol, including PT and acupuncture. Physical rehab and exercise improved physical conditioning, leading to weight loss and improved self esteem. Began playing golf and swimming with peers while in treatment. Now coaching son’s soccer team and walking 5 miles daily; recently started long distance swimming competitions.