Stimulant use by athletes

Amphetamine use in the United States of America (US) has more than doubled in the past 15 years and the consumption of methylphenidate increased by a third [1]. Between 2003 and 2011 the prevalence of ADHD diagnosed in children increased by 41% [2] and after the new and more inclusive DSM-5 criteria for adult ADHD [3], there have been increasing prescriptions for stimulants in adults. In 2016, according to the National Surveys on Drug Use and Health, 6.6% (approximately 16 million) of US adults used prescription stimulants, while estimates show that, in contrast, almost 5 million (2.1%) people misused prescription stimulants overall [4]. In this context, appropriate use of stimulants in athletes is controversial and confusing. While the National Collegiate Athletic Association (NCAA) bans the drug class of stimulants, it allows medical exceptions for ADHD [5]. Also, the World Anti-Doping Agency (WADA) and the International Olympic Committee (IOC) list stimulants as prohibited substances but allow Therapeutic Use Exemptions (TUE) [6].

Stimulant medications have a proven and legitimate indication for the treatment of ADHD [7], while stimulants are commonly used in the treatment of ADHD, their use in elite sports is controversial [8]. Athletes taking stimulant medications are often subject to discrimination based on the suspicion that they are using the substance as a performance enhancer [9]. In the context of sports, the likelihood of performance enhancement is a reality that might have serious and dangerous consequences [10]. Athletes might find themselves under the influence of their greater environment and see the effect of such drugs as a desired effect without it being misuse or abuse of the substance. It is therefore paramount to discuss the tension between the therapeutic use of stimulants for e.g. ADHD, and the use of stimulants in and outside sports for performance enhancement in the context of sports psychiatry. The physiological effects of these substances are well known, at the same time good evidence for the effects in athletes in general is lacking. Using methylphenidate may increase core body temperature and heart rate while exercising without being perceived by the athlete [11]. Hence, two of the major health risks are stimulant-induced cardiovascular and heat incidents, which have caused numerous fatalities among athletes during demanding exercise [12].

The ethical considerations regarding the use of stimulants in amateur and elite sports has to focus on fairness [13]. The discussion of fairness within competitive sports might seem irrelevant, considering that competition is the celebration of differences, which stem from a complex interplay between genetic predispositions and environmental factors. While we could argue that untreated health conditions might put athletes at a disadvantage in some disciplines, this might not necessarily hold true in the case of disorders treated with stimulants for other disciplines. Even if stimulants are discontinued before the competition, athletes show an improved exercise endurance with increases in several performance measures including strength, acceleration, anaerobic capacity, time to exhaustion, and maximum heart rate [14]. Hence, rather than focusing on the impact of stimulants on fairness in regards to the potential athletic outcome, the discussion should focus on the rules and regulation of the competition. This highlights the importance of TUE and the expertise of the health care provider who determines the exemption. Considering the lack of biomarkers or other physiologic measurements of ADHD, the interrater reliability of ADHD is subject to distortion [7]. Clinicians who are not used to treating athletes might misinterpret hyperactive athletic behaviors as a mental disorder. In contrast, in some disciplines ADHD might impact sport performance in a way that would simply disadvantage the participant if not being actively treated, i.e. archery or other sports that require focus and concentration. Without an open discourse about TUEs, the risk persists that athletes suffering from mental health disorders such as ADHD might not recevive adequate treatment, while other athletes that ask, are getting TUEs without meeting criteria for a diagnosis.

Sports psychiatrists need not only focus on the use of stimulant medications within sports but also outside of sports. Increasing athletes’ awareness and responsible use of stimulants will not only influence the person but also have an impact on a wider level. We believe that sports have the potential to spearhead change. Studies have shown that physical exercise represents a promising alternative or supplementary treatment option for adults with ADHD. In a recent meta-analysis, Xie et al. [15] showed that physical activity interventions on ADHD symptoms in before-after studies had beneficial effects on attention (I²=51.1%, p=0.010) and hyperactivity (I²=66.3%, p<0.001). This result was confirmed for physical activity intervention for attention problems in two-group control studies (I²=85.4%, p<0.001). In combination with the pillars of state-of-the-art psychiatric treatment such as psychopharmacology for the treatment of co-morbid disorders, psychotherapy (i.e. cognitive behavioral therapy), social interventions and healthy lifestyle changes, it is not only an opportunity for sports psychiatry to embrace evidence-based change but also a responsibility. As mental health care workers we should support people’s effort to be physically active and to do sports in a healthy and balanced way.

There is a need for action. Sports psychiatrists need to be involved in the continuing development of TUEs, national and international standards, and they should participate in TUE committees and TUE application [16, 17]. It should be the sport psychiatrists role, as an expert and well-informed medical professional to strive for the optimal use of TUEs and contribute to a legitimate use of stimulants by athletes who need it while rendering equity in sports.