12.1 Introduction

Appropriate therapeutic drug use goal for the athlete begins by knowing the athlete

Goals for the Oral Healthcare Provider On Sports Medicine Team

Primary Goal: Keep athletes ready to play, infection-free, and pain-free; avoid banned drugs contributing to drug addiction.

  • Know your athlete and understand the drugs used to keep athletes infection and pain-free and the drug’s influence on athlete’s performance.

  • Be knowledgeable about resource information for both therapeutically indicated and banned drugs.

  • Understand performance-enhancing drugs (PEDs), banned dru gs, doping, and drug addiction.

and the athlete’s profile.

Athlete’s Profile (Training/Competing)

  • Youth/adolescent/weekend warrior

  • College

  • Compromised/medically complex

  • Special Olympics/Paralympics

  • Adult recreational

  • Professional

  • Elite

    • Olympic level

    • World Tournaments

A thorough diagnosis and treatment of existing oral and dental conditions should be completed prior to training and competitions. Preseason oral exam contributes to reduced infections and pain, and need for therapeutic agents during competitive seasons. Early diagnosis of conditions allows timely treatment that may reduce problems during competition and training. The oral healthcare provider must know not only the therapeutic drug treatment for oral disease conditions of athletes, but they must also be familiar with the effects of these drugs on the athlete’s ability to perform and possible contributions to addiction. Recommended treatment should keep the athlete infection- and pain-free.

Athlete Ready to Play

  • Pain-free.

  • Infection-free.

  • Hydrated.

  • Alert.

  • No clotting/bleeding issues.

  • Keep within the rules.

Athlete medical and dental treatment should not impair hydration or hemostasis. The drugs chosen for care should be used with awareness of addiction profiles and both the medical and drug history of the athlete. In addition, the provider should provide treatment that will not reduce alertness or interfere with sleep patterns during time of competition. All this should be done within the rules of the athlete’s sport. Many sports have rules about drugs from their respective governing bodies as described further in the chapter.

As this chapter is reviewed, it is important to note that any recommended treatment or lists of banned substances can frequently change and should be checked often for updated protocols and information. This chapter describes acute care for the reasonable healthy adult competitor and recommendations of some, but not all indicated oral or topical therapeutic drugs, for acute conditions. Medically, cognitively, or physically compromised athletes require modification of therapeutic recommendations and close coordination with the team or personal physicians.

Major Chapter Objectives

Drugs

  • Use: acute oral conditions

  • ****** Special considerations for athletes

    • Misuse

    • Abuse

    • Addiction

    • PEDs (performance-enhancing drugs/substances/doping)

    • Drugs/doping

    • Useful references

12.2 Therapeutic Drug Uses to Control Oral Infection and Pain in the Competitive Athlete

Etiologies of acute conditions requiring dental care include infections, pain, autoimmune conditions, and trauma. Indicated anti-infectives, analgesics, and anti-inflammatory medications are used to treat these conditions. Many common oral conditions are listed in box “Acute Oral Conditions.”

Acute Oral Conditions

  • Infections

  • Lacerations/fractures

  • Bruxism/other facial pain

    • Ability to eat

    • Sensitive teeth

    • Headaches

    • Jaw and facial pain

Traumatic fractures of the teeth and jaws and lacerations of the oral area may require immediate emergency treatment followed with more definitive or long-term care and various drug therapies. Bruxism may be considered a long-term condition, but exacerbation of acute conditions such as pain while chewing, sensitive teeth, jaw and facial pain, and headache may require immediate drug therapy. Categories of medications for acute oral facial conditions include anti-infective agents, analgesics, anesthetics, muscle relaxants, and anti-inflammatory drugs.

Medications for Acute Oral/Facial Conditions

Common Medications Used by Dentist to Treat

  • Infection

    • Anti-infective agents

    • Antimicrobials

    • Antivirals

    • Antifungals

  • Pain

    • Analgesics and local anesthetics

    • Muscle relaxants (CNS depressants)

  • Inflammatory lesions/ulceration

    • Anti-inflammatory or steroidal agents

Prescribers need to have knowledge about both the benefits and negative effects on athletes of indicated medications [1]. The long-term therapy of oral facial conditions is beyond the scope of this chapter.

12.2.1 Guidelines for the Anti-infective Agents for Common Bacterial, Fungal, and Viral Oral Pathology

Most commonly oral infections are acute conditions.

Examples of Common Oral Infections

  • Pulpitis

  • Pericoronitis

  • Periodontal abscess

  • Soft tissue lesions

    • Bacterial

    • Viral

      • Acute herpetic lesions

    • Fungal infections

      • Candidiasis

  • Aphthous and traumatic ulcers (potential secondary infection)

  • Traumatic lesion infections (lacerations/fractures)

The oral and topical anti-infective agents include antiviral, antifungal, and antibacterial.

12.2.1.1 Management of Common Acute Head and Neck Bacterial Infections

Prescribing guidelines include selecting the simplest agent for effectively treating the infection. Common antimicrobials for these oral infections are listed in box “Antimicrobials—Rx: Systemic.”

Antimicrobials

Rx: Systemic

  • Pen VK

  • Amoxicillin

  • Augmentin

  • Clindamycin

  • Erythromycin—xx

  • Azithromycin

  • Cephalosporins

Note that erythromycin is no longer an antimicrobial of choice due to its high incidence of GI distress. Use loading doses for antibacterial oral agents. This is generally double the standard dose for the initial dose.

Antimicrobials

Prescribing suggestions:

  1. 1.

    Loading dose (oral): double standard dose stat.

  2. 2.

    Stay simple.

  3. 3.

    Be alert to allergies.

  4. 4.

    Be alert to superinfections (i.e., fungal)

  5. 5.

    Be alert to resistance.

  6. 6.

    Be alert to side effects.

Review indications and contraindications before prescribing anti-infectives.

Contraindications and Considerations

  • Hypersensitivity

  • Side effects

    • GI: diarrhea/nausea

    • Yeast infection

    • Photosensitivity

    • Atypical effects

      • Tendon injury → ciprofloxin, levofloxacin

      • Cardiac arrhythmias → azithromycin, clarithromycin

      • Fatigue

Be alert to various allergic or adverse responses. Watch for superinfections, such as fungal infections, especially candidiasis. Monitor for poor responses, which may indicate inappropriate drug, or bacterial resistance. Be alert to side effects. Encourage athlete to report any of the above concerns immediately.

Hypersensitivity or prior allergic reactions should be reviewed in the medical history and reevaluated at time of treatment. Side effects of specific agents need to be reviewed in light of effect on athletic performance. Examples of side effects or adverse effects that might influence use or timing of the drug are diarrhea/nausea, drug-induced yeast infections, photosensitivity, and atypical effects.

Other contraindications include less common and atypical side effects from certain antimicrobials. Examples of cardiac arrhythmias may arise from use of azithromycin and clarithromycin. Atypical effects may include additional tendon pain or tendon damage as with fluoroquinolones (Levaquin®). Because of this, fluoroquinolones may be contraindicated for use in athletes. Dental care providers should also monitor for less common possible drug-induced fatigue or tiredness from some of these medications, such as amoxicillin, azithromycin, and ciprofloxacin. Further studies suggest fatigue may be related to illness or longer-term use of these drugs. Future studies may clarify any correlations between fatigue and certain antibacterial agents [2] (► https://www.nlm.nih.gov/medlineplus/druginfo/meds/a685001.html, ► https://www.nlm.nih.gov/medlineplus/druginfo/meds/a697037.html, ► https://www.nlm.nih.gov/medlineplus/druginfo/meds/a688016.html).

Additional bacterial skin infections of importance and frequency in athletes include Streptococcus pyogenes impetigo and methicillin-resistant Staphylococcus aureus (MRSA). These highly contagious infections are especially of concern in contact sports, with sporting equipment and contact exposure in locker rooms. Treating dentists must recognize these conditions especially on the face, and they should have knowledge of the use of appropriate agents. Small isolated impetigo lesions on the face may be treated with mupirocin (Bactroban®) topical ointment. If MRSA is suspected or more extensive lesions are noted, contact both the team physician and treating physician and athletic trainer.

12.2.1.2 Management of Common Acute Head and Neck Viral Infections

Common oral viral lesions may be treated both topically and systemically. Most common viral lesions are herpetiform lesions, which are most often caused by the herpes simplex virus (HSV) type I and type II. The athlete may have a history of frequent lesions found on the lips (herpes labialis), secondary to sun exposure or certain foods or drinks. To have the most effective reduction in pain or duration of lesions in patients with recurrent herpes lesions, they should be advised to recognize and start treatment at the first prodromal signs or prior to known etiology. Systemic treatment includes valacyclovir (Valtrex®). Topical treatment of small localized lesions includes use of penciclovir (Denavir®) [3,4,5].

Herpetic/Viral Rx

Rx: systemic (Oral)

Rx: topical (oral)

– Valacyclovir (Valtrex®) 500 mg tablets

– Penciclovir (Denavir®) 1% cream

– Disp: 4 tablets

– Disp: 2 g tube

– Sig: take two tablets bid (12 h apart)

– Sig: apply a thin coat to affected area q2h for 4 days. Start at first sign of symptoms

12.2.1.3 Management of Common Acute Head and Neck Fungal Infections

Fungal Candida infections may arise secondary to antimicrobial use, inhaler use (◘ Fig. 12.1), persistent dry mouth, or immune suppression conditions. Topical antifungals for localized oral lesions are the first line of defense, since systemic antifungals may have negative effects on liver function. Topical clotrimazole (Myclelex®) troches are effective, when used according to directions so as to maintain good contact with the effected oral tissue.

Fig. 12.1
figure 1

Special concern with inhalers

Full size image

Another more common mixed fungal infection is seen in angular cheilitis. It may be seen more frequently in cold weather or climates. Topical treatment includes application of combination of clotrimazole 1% and betamethasone (Lotrisone®) cream. Combination topical nystatin and triamcinolone acetonide (Mycolog II®) cream to affected areas.

Other fungal lesions to observe in athletes include tinea faciale (ringworm). Again contact sports such as wrestling are a source of contagious spread of this fungal infection. Topical application of antifungal creams to small facial lesions is effective. Monitor for other lesions. Contact athletic trainer and treating and team physician with this information regarding contagious skin lesions.

12.2.1.4 Management of Common Autoimmune Mucosal Lesions

Autoimmune lesions that are painful or contribute to dehydration can be treated in acute phase with topical steroids. Simple and multiple aphthous ulcers can be painful and interfere with eating and drinking. Examples of topical ointment or gels include triamcinolone (Kenalog®) and 0.05% fluocinonide gel. For multiple intraoral lesions, dexamethasone (Decadron®) 0.5 mg/ml elixir may be indicated for topical effects. It should be used topically by rinsing, expectorating, and not swallowing to avoid systemic steroid effects. These are considered weak corticosteroid agents and are not listed on the World Anti-Doping Agency (WADA) Prohibited List.

12.2.2 Management and Guidelines for Oral Analgesics (Adults)

Analgesics for oral pain can be selected based on severity of pain and expected duration of pain. Most oral/dental analgesic treatments are for short-term acute conditions.

The athlete’s status for training, performance, or recovery should also be considered in devising pain management strategies. For all analgesics routinely use the lowest effective dose for the least amount of time to obtain pain control and reduce adverse and side effects. Always review with patient other analgesics he or she may be already taking in order to avoid overdosing or adding to addictive potential. Consult with lead team physician, if needed, to check for duplicate prescriptions in the case of opioid-containing analgesics.

Pain Analgesics

  • NSAIDS

    • Anti-inflammatory

    • Platelet effects

  • Acetaminophen (APAP)

    • Caution—dosage limitations

  • Narcotics/opioids

    • Caution: head trauma and abuse potential

    • Sedation

  • Combinations of the above

12.2.2.1 Analgesics for Mild to Moderate Acute Pain Management

Nonaddicting acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDS) are first choices for mild to moderate acute pain control. NSAIDS have an additional anti-inflammatory effect.

Acetaminophen maximum dosage recommended by the Food and Drug Administration (FDA) for adults is 4000 mg/24 h.

Maximum Acetaminophen Dose

  • Adult dose: 325–650 MG Q4–6H

  • Maximum daily dose: 4000 mg/24 h

  • The liver can only metabolize limited amounts before toxic metabolite builds up.

  • Boxed warning:

    • FDA drug safety communication: prescription of acetaminophen products to be limited to 325 mg per dosage unit

    • Boxed warning will highlight potential for severe liver failure

    • FDA Safety Announcement 1-13-2011

Johnson & Johnson the producer of acetaminophen (Tylenol®) suggests not to exceed ten tablets of 325 mg (3250 mg) or six tablets of 500 mg (3000 mg) in a 24 h period. This dosage limit is due to the concern that individuals may be taking other drugs simultaneously that also contain acetaminophen. Combination drugs containing acetaminophen are limited to 300-325 mg per tablet. Athletes should be advised to avoid taking multiple acetaminophen-containing products together in order to avoid daily overdosing. Simultaneous alcohol consumption should also be discouraged, because of detrimental effects on the liver. Inform the athlete that severe, even life-threatening liver injury will occur when they exceed consuming above therapeutic doses. As with all medications, they should report any adverse effect during use of acetaminophen. The effect of acetaminophen on bleeding when consumed at proper dosage in otherwise healthy individual is minimal. If additional drugs are also needed to treat a condition, athletes should let all healthcare providers know if they are taking acetaminophen.

12.2.2.2 NSAIDS (Nonsteroidal Anti-inflammatory Drugs)

Aspirin (ASA) acts as an analgesic and an anti-inflammatory.

Aspirin

  • NSAID

    • Analgesic

    • Antipyretic

    • Anti-inflammatory

  • Antiplatelet effect: nonreversible platelet binding

    • Prolonged bleeding after injury

  • Variable recommendations for delay prior to oral surgery

  • Non-addicting

  • Adult dosage: 325–650 MG Q4H

Dosage recommendations for adults: take 1 or 2 325 mg tablets every 4 h or 3 tablets every 6 h, but do not exceed 12 tablets in 24 h. Aspirin is also a nonreversible platelet-binding agent, which may contribute to prolonged bleeding after an injury. Bleeding or platelet effect gradually reverses itself as new platelets form over 10 days. This can be very significant in athletes since impaired clotting may lead to more bleeding in musculoskeletal injuries that are often seen in sports, especially hemarthrosis and deep tissue bruises. Recent studies recommend various time durations for delay of oral surgery procedures following ASA consumption [6, 7].

Contraindications of aspirin usage include but are not limited to pregnancy, breastfeeding, allergy history, gastric ulcer, asthma and nasal polyps, drug interactions, concomitant blood thinners, defects in blood clotting system, active peptic ulcers, and compromised renal conditions. An important side effect presents as gastrointestinal distress. There are many drug interactions with ASA, and the list should be checked before using ASA. Interactions with aspirin can be of major significance in individuals taking other medication that interfere with clotting mechanisms such as clopidogrel (Plavix®) and warfarin (Coumadin®). Alcohol should be avoided while taking ASA to avoid increased chance of gastric bleeding. Additionally, other NSAIDS and steroids may also interact negatively with ASA in some individuals. Always check for other aspirin-containing medications that the athlete may already be using. The prescriber should also be aware of the athlete who may be taking low dose aspirin to reduce probability of cardiovascular disease. This is often under reported by the patient [8].

12.2.2.3 Non-ASA NSAIDS

Non-ASA NSAIDS include but are not limited to over-the-counter (OTC) ibuprofen (Advil®), naproxen sodium (Aleve®), and prescription etodolac (Ultradol®) which act as analgesic and anti-inflammatory agents. Usage of these NSAIDs contribute to anticlotting effects similar to ASA; however this category of NSAIDS has a reversible effect on platelets and therefore a reversible effect on bleeding when the drug is discontinued.

Non-ASA NSAIDS

  • Reversible effect on platelet binding

    • This is very different from ASA.

  • Antipyretic

  • Analgesic

  • Non-addicting

Dosage information is seen in box “NSAID Analgesics.”

Dosage guidelines suggest using the lowest possible dose of ibuprofen for the least possible time to accomplish adequate pain control and minimize adverse and side effects. Continue to monitor the patient, and modify dose and use for shortest duration as appropriate for pain control.

Contraindications to NSAIDS include evaluating athlete’s history for allergies, asthma with nasal polyps, pregnancy, breastfeeding, concomitant blood thinners, defects in blood clotting system, active peptic ulcers, and compromised renal conditions.

When Are NSAIDS Not So Great

Drug interactions

  • Especially lithium

  • SSRI (class of antidepressants)

NSAIDs cannot be used (are contraindicated) in the following cases:

  • Allergy to ASA or any NSAID

  • Some asthmatics—especially with nasal polyps

  • During pregnancy and during breast feeding

  • Concurrent with other anticoagulants

  • Suffering from a defect of the blood clotting system

Duration of use is important in anticipating peptic ulcers or “delayed healing.” There are increasing numbers of reviews correlating some delay in healing of soft tissue and perhaps bone secondary to the reduction in the inflammatory process of these drugs. It still needs to be clarified whether dosage, duration, or genetics are factors in these possible adverse effects [9,10,11].

There is a black box warning initiated in 2005 by the Food and Drug Administration.

NSAID Black Box Warning

  • NSAIDs black box warning for both prescription and OTC products in the USA. FDA has requested that sponsors of all nonsteroidal anti-inflammatory drugs (NSAIDs) make labelling changes to their products. The FDA has recommended label changes for both the prescription and over-the-counter (OTC) NSAIDs and a medication guide for the entire class of prescription products. All sponsors of marketed prescription NSAIDs, including Celebrex (celecoxib), a cyclooxygenase-2 (COX-2) selective NSAID, have been asked to revise the labelling (package insert) for their products to include a boxed warning, highlighting the potential for increased risk of cardiovascular (CV) events and the well-described, serious, potentially life-threatening gastrointestinal (GI) bleeding associated with their use. The agency based its advice on a review of the regulatory histories and databases on the various NSAIDs. Reference:Drug Information Page. United States Food and Drug Administration, 16 June 2005 (http://www.fda.gov).

Other adverse effects include but are not limited to renal, cardiovascular, hepatic, and respiratory function.

Use of acetaminophen-NSAID combination agents continues to be evaluated. Publications support their combined use as another method of acute pain control [12,13,14,15]. Potential success of this combination would contribute to reduced prescriptions for opioid and opioid combination drugs.

12.2.2 Case Study

NSAID Analgesics Examples (Mild to Moderate Pain)

Ibuprofen (OTC)

Motrin/Advil (200 mg)

400–600 mg Q4H

Naprosyn (OTC)

Aleve® (220 mg)

1 unit Q6–8H

Etodolac (RX)

Lodine® (200–400 mg)

1 UNIT Q6–8H *MAX 1000 mg/day

12.2.2.4 Analgesics for Moderate to Severe Acute Pain Management

Opioids and opioid combination drugs are indicated for moderate to severe acute pain control. Opioid-containing analgesics are considered banned substances by some sporting organizations, and their use is limited in these cases.

WADA Prohibited In-competition Opioids

Fentanyl and its derivatives

Hydromorphone

Methadone

Morphine

Oxycodone

Oxymorphone

Pentazocine

Pethidine

Side effects are dose-dependent. Therefore lower doses express fewer or less severe side effects. The most common side effects and adverse effects are dizziness, sedation, nausea, vomiting, and constipation. Other important adverse and side effects one should monitor include respiratory depression, tolerance, and addiction.

Addictive potential is of great concern for all athletes and their healthcare providers. Opioid chemical addiction is related to multiple factors. The varied opioid receptor sites in the brain and nervous system include sites for analgesia (kappa and delta), sedation (kappa), and euphoria along with respiratory depression and reduced GI motility (mu). These receptors and others contribute to several other effects. With prolonged use of these opioid drugs, tolerance develops, and higher dosages are required to obtain the same effects of pain relief and euphoria, which also contributes to abuse and addiction.

The team dentist who prescribes opioid medications for dental or oral pain in athletes must be aware that these patients may be taking opioids for other concurrent injuries and should prescribe accordingly to minimize contributing to overdose, abuse, and addiction. Misuse of opioids is correlated with several different individual profiles. Pain, concussions, and concurrent alcohol use correlated with misuse in an NFL player study [16]. Misuse of opioids by adolescent athletes is higher in those with a current history of substance abuse [17].

In the USA, any opioid-containing agents fall into Schedule II DEA classification, because of their abuse potential. This requires written prescriptions without refills. Emergency prescriptions must follow state prescribing regulations. Some sports medicine teams request that all opioid prescriptions go through one provider for their athletic team. This provides for better monitoring of multiple opioid prescriptions and their contributions to misuse and overdosage.

12.2.2.5 Opioid Combination Drugs

Also for moderate to severe pain, acetaminophen or NSAID combination with opioids has the same issues as each of these agents creates independently. The combination agents allow for lower doses of opioids and therefore less adverse opioid effects for equivalent pain control.

The same concerns about addiction exist for the opioid combination drugs as the individual opioid analgesics. Same guidelines for selecting analgesic dosage apply for opioid-containing drugs and recommend to routinely use the lowest effective dose for the least amount of time to obtain pain control and reduce adverse and side effects

12.2.2 Case Study

Opioid Analgesics Examples (Moderate to Severe Pain)

APAP (300mg)* + codeine (30 mg)

Tylenol 3

1 tab Q4H *MAX APAP 4000MG

Hydrocodone (5 mg) + APAP (300 mg)

Vicodin®

1–2 tab Q4–6H; do not exceed 8 tablets per day

Hydrocodone (7.5 mg) + APAP (300 mg)

Vicodin ES®

1 tab Q4–6H; do not exceed 5 tablets per day

Hydrocodone (2.5 mg) + ibuprofen (200 mg)

Vicoprofen ®

1 tab Q4–6H; do not exceed 5 tablets per day; use less than 10 days

12.2.2.6 Concomitant Use of Other Addictive Drugs

Athletes, especially those with frequent travel schedules through time zones such as younger and professional athletes, may be using hypnotic drugs to combat disrupted sleep patterns. Zolpidem (Ambien®) and eszopiclone (Lunesta®) belong to a class of hypnotic drugs to treat insomnia. They are not currently banned by the World Anti-Doping Agency (WADA). These drugs also have an addictive profile. Dentists must be aware that the athlete may be taking these drugs, which add to the addictive and depressive potential, when they are used alone or in combination with opioid-containing drugs.

12.2.3 Local Anesthetics for Analgesia

Local anesthetics are used for pain control during dental procedures and for short-term pain control, when definitive care may be delayed.

The commonly used local anesthetics, including those combined with epinephrine, are not banned during elite athletic competitions governed by the World Anti-Doping Agency (WADA: website ► www.wada-ama.org/) policies. (WADA LIST-2015)

12. Case Study

Local Anesthetics (Duration of Pulpal Anesthesia)

Local anesthetics

Duration of pulpal anesthesia (infiltration) (approximate values)

2% lidocaine

5 min

2% lidocaine plus 1:100,000 epinephrine

60 min

3% mepivacaine

30 min

4% articaine plus 1:100,000 epinephrine

60 min

4% articaine 1:200,000 epinephrine

60 min

0.5% bupivacaine Plus 1:200,000 epinephrine

Up to 7 h

Reference: ► http://www.dentalanesthesia.com/pdfs/LA_ADA_PainPosterFront.pdf

12. Case Study

Local Anesthetics *according to WADA(2015)

  • Lidocaine w/ and w/o epinephrine*

  • Carbocaine

  • Articaine w/ and w/o epinephrine*

  • Duration of action

§*WADA Permitted—2015

figure a

12.3 Drug Sources Available to the Athlete

Within the multidisciplinary sports medicine team, several prescribers may be prescribing drugs to the athlete. The physician, dentist, athletic trainer, physical therapist, and psychologist may be a therapeutic drug provider. In addition to the sports medicine team, the athlete may be receiving drugs from family, friends, team members, and street drug vendors, overseas, and by way of the Internet and through social media contacts.

Other Drug Sources Used and Abused by Athletes

  • Rx by dentist

  • Rx by physician

  • Dispensing by team athletic trainers

  • Over the counter (OTC)

  • Herbals/supplements

  • Performance-enhancing substances

  • Illegal drugs

  • *Online ordering

  • Unknown contaminants (in supplements)

Use of excess drugs from multiple prescriptions is a common source of additional drugs. Sports medicine healthcare providers who manage athlete’s pain must closely monitor the amount of addictive drug prescribed for the athletes and communicate with other members of the medical team in order to use the minimum amount of drug to effectively manage the pain and to minimize “leftover drugs” that may be shared with team members.

Addictive, performance-enhancing, and banned drugs may also be obtained through herbals, supplements, illegal drugs, and unknown contaminants. Drug interactions, banned substances, and side effects can also contribute to overdose and addiction.

Additional Drugs in the Mix

  • Drug interactions

  • Banned substances

    • Some may be illegal.

    • Some illegal substances not banned.

  • Side effects

    • Performance impairment

    • Medical compromise

  • Multiple drug sources

    • Overdose

    • Addiction

Drug addiction and abuse is a major concern in today’s sports arena. The sports medicine team’s contributions to long-term drug problems come from lack of oversight, multiple sources of addictive drugs, and pain/depression profiles developed because of chronic pain from injuries and concussions. This includes abuse of alcohol and illegal drugs. Specific psychiatric and psychological aspects of substance abuse and addiction are beyond the scope of this text but play a major role in their development. Members of the sports medicine team are encouraged to consult with those healthcare providers experienced and trained in the treatment of addiction and substance abuse. Proper drug prescribing by the team or sports dentist can contribute to helping reduce this severe abuse pattern in some athletes [18, 19].

12.4 Performance-Enhancing Drugs/Substances and Doping

12.4.1 Doping

Doping is defined by the use and misuse of substances banned by sports governing bodies and anti-doping organizations or methods that may enhance athletic performance. Major organizations governing doping regulations are the World Anti-Doping Agency (WADA), US Anti-Doping Agency (USADA), and National Collegiate Athletic Association (NCAA). Doping includes pharmacologic doping with performance-enhancing drugs and substances (PEDs).

Performance-Enhancing Drugs/Doping

  • Innocent-banned substances

    • In OTC preparations

    • In herbal preparations

      • As contaminant

      • As metabolic breakdown product

In addition, doping includes blood transfusions and artificial oxygen carriers such as modified hemoglobins, which increase oxygen levels.

12.4.2 Performance-Enhancing Drugs/Substances (Referred to in This Chapter as PEDs)

The rationale for use of performance-enhancing drugs (PEDs) varies among athletes.

Performance-Enhancing Drugs/Doping

Athlete’s rules to follow:

  1. 1.

    Avoid prohibited/banned drugs and substances/doping.

  2. 2.

    Avoid drug masking.

  3. 3.

    Use only permitted dosages.

  4. 4.

    Verify that all substances are known and permitted for use.

Several surveys of athletes in many age ranges and skill levels indicate the drive to win and succeed in sport and image are among the many psychological factors influencing the use of PEDs. The lure of awards and money drive some. Image, social acceptance, and influence of peers may drive others to use PEDs. Concurrent substance abuse is also a consideration. For athletes, doping’s lure is to improve skill strength, endurance, and recovery specific to their sport [20,21,22,23]. Correct data on use of PEDs is difficult to obtain, since most studies evaluate one drug, one sport, and one age group or gender and make good evaluations across the board difficult [23].

These specific desires drive the athlete’s search for enhancement of energy bursts, endurance, strength, muscle mass, and improved recovery by using performance-enhancing drugs. Some PEDs are consumed to influence and effect weight control, focus, attention, and recovery time. Additionally, some of these agents increase pain masking and general competitiveness. Use of PEDs is found in a wide range of age and skill levels including but not limited to adolescent athletes and elite competitors. Efforts to test and survey for the use of PEDs continue throughout the sports world [24, 25].

Examples of PEDs cross a wide spectrum of drug categories.

Categories of Performance-Enhancing Drugs (PEDs)

Examples

Examples

AAS—anabolic androgenic steroids

Non-AAS ergogenic agents

 

– Human growth hormone

 

– DHEA

Herbals (ephedra)

Stimulants

Supplements (creatine)

Insulin

Laxatives

Beta blockers

Caffeine

Diuretics

Nicotine

Illegal drugs

NSAIDs

Erythropoietin-stimulating agents

Alcohol

Combinations of the above

Each of these categories’ effects may add to one or more aspects of performance enhancement as listed in box “Performance-Enhancing Drugs/Doping.” Many substances are believed by athletes to increase performance levels or mask use of performance-enhancing substances. Although measurements of the actual benefits are not well-supported by quality research, the probable mechanisms of many PEDs are described below.

One of the most common drug categories that test positive is the group of anabolic adrenergic steroid (AAS) agents [26, 27].

They include testosterone, testosterone analogs, and designer steroid drugs. Testosterone analogs are drugs that mimic the chemistry and physiologic function of testosterone. Testosterone is a hormone that is naturally found in the body and along with several of the testosterone analogs is used for specific medical care. Androgenic refers to male sex characteristics, and anabolic refers to muscle-building ability. These AAS agents are taken to enhance muscle mass, image, and performance. These agents are not approved for performance enhancement in sports. In addition to use as PEDs, strong psychosocial factors contribute to the initiation of androgenic steroid use [28].

These androgenic anabolic steroids (AAS) are chemicals that attach to specific steroid muscle receptor sites triggering a cascade of protein synthesis, which contributes to increased muscle mass. Besides increasing muscle mass, anabolic steroids may help athletes recover from a hard workout more quickly by reducing the muscle damage that occurs during the session. This enables athletes to work out harder and more frequently without overtraining.

Some athletes use testosterone to boost their performance. Synthetic modifications of testosterone known as testosterone analogs or designer steroids are the adrenergic anabolic agents that are more frequently used by athletes. Designer steroid agents are illegal and created to (1) duplicate the physiologic effects of androgenic anabolic steroids and (2) to avoid detection by current doping drug tests. Several different forms may be taken together in what is called a “stacking” protocol . They may also be taken in a “cycling” protocol where the steroid agents are taken for time periods around performance, stopped, and then started again. Pyramiding combines the cycling and stacking [29].

Antiestrogen drugs such as Tamoxifen® can be used to mask synthetic testosterone from binding to receptors. High doses of synthetic testosterone (testosterone agonists) can increase estrogen production in the body. Tamoxifen® can block the estrogen receptors and then can hide or mask the effects of the extra testosterone-like drugs.

Stimulants are agents that simulate natural endogenous adrenaline (epinephrine) and norepinephrine. The physiologic effects are increased alertness, reaction time, concentration, sense of increased energy, and a decreased appetite. Any of these effects may be considered contributions to specific performance or fitness for sport training and competition. These are banned on the WADA list. Other types of stimulants include caffeine and nicotine and some herbals and supplements such as ephedrine.

Human growth hormone (HGH) has a gonadotrophic effect resulting in increased muscle mass and muscle repair. Insulin also leads to increased muscle mass along with increased glycogen as muscle fuel, which may influence endurance [26].

Beta-blocking agents block the adrenergic beta receptors in the cardiovascular and respiratory system. This may result in a calming effect and slower heart rate by blocking the normal effects of adrenaline (epinephrine) on these receptors.

NSAIDS are analgesics, which can delay perception of pain or soreness. This would allow continuation of activity by the athlete when injured.

Laxatives increase bowel movements and may be used for weight loss. Diuretics result in increased urine excretion. This may also contribute to weight loss. It is also a way to dilute and eliminate banned drugs and mask them from detection in the urine.

Creatine is made in the body and is also available in some foods and as a supplement. Creatine contributes to increased contraction power by increasing the body’s production of adenosine triphosphate (ATP), which is an energy source for muscle cells. It is thought to contribute to power by quick and short bursts of energy.

Erythropoietin-stimulating agents (EPA) such as erythropoietin (EPO) increase the production of red blood cells. Increased levels of red blood cells allow for more oxygen binding and increased oxygen available for muscle tissue. This additional oxygenation may contribute to more endurance and faster recovery [28].

Inadvertent doping or innocent-banned performance-enhancing drugs can be found in OTC preparations and in herbal preparations and some foods as a contaminant or a metabolic breakdown product (◘ Fig. 12.2). Inadvertent doping occurs when an athlete uses a therapeutic drug to treat an illness or consumes food, drink, or OTC preparations without realizing that it also contains a banned substance. Examples might include cold or sinus medications and untested dietary supplements. An example is consumption of pseudoephedrine in cold and allergy preps. Even though the athlete may not be taking the drug to enhance performance, when they are actively participating in competitive sport, they are at risk of testing positive for a prohibited substance or for banned levels of a substance.

Fig. 12.2
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Banned substances that may be overlooked

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Drug masking is taking a drug or drugs to hide the existence of a banned drug from urine or blood testing. Diuretics are an example. Diuretics may be used to flush a banned or illegal substance from urine prior to time of testing.

Drug urinary level limitations for accepted drugs : For athletes falling under WADA or NCAA regulations, some accepted drugs may be banned when blood or urine levels exceed certain limitations. An example is pseudoephedrine, which is not on the WADA (2015) banned list. However it is not acceptable above 150 mg/ml in the urine (◘ Fig. 12.3). In the case of caffeine, it is not banned by WADA (2015) but is a monitored drug in 2018. For NCAA regulations, caffeine is not allowed in urinary levels above 15 mcg/ml.

Fig. 12.3
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Example of phone app infrormation to assist providers who treat elite athletes

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Gene doping is the use of genetically modified cells or nucleic acids or their analogs to enhance performance (WADA definition). As gene therapies develop, the possibility of using these procedures for performance enhancement will contribute to sophisticated doping [30].

12.4.3 National and International Organizations Governing Doping in Sports

A sports governing body has many functions including the following:

  1. 1.

    Upholding the rules of the sport and punishing those who break the rules (fining and banning teams and clubs and athletes)

  2. 2.

    Promoting the sport to attract new players and spectators

  3. 3.

    Organizing competitions (such as the World Cup, championships, college championships, and running the national teams)

  4. 4.

    Fight against doping and corruption in sport (► http://www.teachpe.com/gcse_society/governing_bodies.php)

Many governing bodies fall under the International Olympic Committee (IOC), and in the USA, many college sports fall under the National Collegiate Athletic Association (NCAA).

Sports governing bodies coordinate with anti-doping organizations and drug regulations to reduce doping and the use of PED substances in sports by athletes: both athletes and prescribers have rules to follow to maintain doping-free sport competition. Both athletes and prescriber must be familiar with banned substances for a sport, avoid drug masking and inadvertent doping, and stay within permitted drug dosages. Drug testing for PEDs is more commonly done with urine and blood level testing. Because of harmful effects of some legal drugs, some suggest monitoring these levels also [1].

Prescribers should be alert to misuse and PEDs in addition to considering preventive measures for and education of athletes. Testing for specific substances has become more advanced as doping has become more sophisticated [31]. Student PED drug surveys expose incomplete conclusions and legal issues [32].

12.4.4 Anti-doping Organizations

The World Anti-Doping Agency (WADA) was established in 1999 (◘ Fig. 12.4).

Fig. 12.4
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Levels of substance prohibition

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It is an international and independent agency whose mission is to support drug-free sport. The organization’s goal is to bring consistency to anti-doping policies and regulations across the world through governing sport bodies. Of importance to the prescriber for elite athletes is the annual Prohibited List. This allows the prescriber to search for drugs that are banned in particular sports, in competition, or out of competition. As part of the sports medicine team, a dentist should be aware if the athlete and his or her sport are covered by a governing body or affiliation to WADA. As stated and described on the WADA) website (► www.wada-ama.org.org), “The World Anti-Doping Code is the document that brings consistency to anti-doping rules, regulations and policies worldwide.” Drugs, substances, and methods of performance enhancement are described in several categories by WADA.

According to the WADA website (► www.wada-ama.org), a substance can be placed on the Prohibited List “According to the Code, if a substance or method is found to meet two of three following criteria: enhances performance, poses a threat to athlete health, violates the spirit of sport. The Prohibited List includes the following: those substances and methods that are banned or prohibited from use both in and out of competition, prohibited in competition only, and prohibited in particular sports. The list is updated annually. Some drugs are banned only when their urine or blood levels exceed an indicated concentration. Monitored substances: some substances are being monitored for potential performance enhancement abuse, and they may be banned at a later date. Monitored drugs are currently not prohibited, but the list) must be checked annually for possible movement of these monitored substances to the Prohibited List.

Therapeutic Use Exemption substances (TUEs): These are drugs that may be banned; however they are approved for use through therapeutic use exemption applications. These are specified drugs used by athletes to treat specific diagnosed illnesses. WADA works with the standards of International Standard for Therapeutic Use Exemptions (ISTUE) to ensure uniformity between sports and countries in the process of granting TUEs. TUE Physician Guideline documents are created by the TUE committee working with WADA and international standards for TUE.

The Prohibited Methods List is divided into three categories: manipulation of blood and blood components, chemical and physical manipulation, and gene doping.

If a substance is not listed, athletes and healthcare providers should check with the sports governing body to verify allowed use of the drug in sport.

The US Anti-Doping Agency (USADA website: ► www.usada.org) is a signatory to the World Anti-Doping Code. This organization manages the anti-doping program for all US Olympic Committee-recognized governing bodies, events, and athletes in and out of competition.

The National College Athletic Association (NCAA website: ► www.ncaa.org) publishes the US guidelines for proper drug use in college sports.

The guidelines are published on their website (► http://www.ncaa.org/2015-16-ncaa-banned-drugs). The website posts a very important statement to all athletes: Note to Student-Athletes: It is your responsibility to check with the appropriate or designated athletics staff before using any substance. There is NO complete list of banned substances. Do not rely on this list to rule out any label ingredient. It is your responsibility to check with the appropriate or designated athletics staff before using any substance.

It is also the prescriber’s responsibility to be familiar with these rules and prescribing guidelines [33].

Many other resources for appropriate therapeutic drug use and information for drug-free sport are available from governing sports bodies, Internet, and specific apps for smartphones and tablets. At this time, the WADA Prohibited List is available as an app for smartphones and tablets. It is updated in January of each year. Position papers and consensus reports written by various athletic-related organizations also provide guidelines for therapeutic agent use in sport. The National Athletic Trainers’ Association has published valuable resources for athletic trainers and those on the sports medicine team [34].

Other important resources are listed in ◘ Fig. 12.5.

Fig. 12.5
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Anti-doping specific resources that are available to the health professional (adapted from REF figureTandon S, Bowers LD, Fedoruk MN Treating the elite athlete: anti-doping information for the health professional. Mo Med. 2015 Mar-Apr;112(2):122–8)

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12. Case Study

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USADA

The US Anti-Doping Agency (USADA) is the national anti-doping organization (NADO) in the USA for:

  • Olympic sport

  • Paralympic sport

  • Pan-American sport

  • Parapan American sport

The organization is charged with managing the anti-doping program, including in-competition and out-of-competition testing, result management processes, drug reference resources, and athlete education for all US Olympic Committee (USOC)-recognized sport national governing bodies, their athletes, and events.

12.5 Summary

In summary, the team dentist must assess and diagnose the athlete. They should (1) be aware of the indicated therapeutic drugs to treat acute oral conditions, (2) not violate rules of governing bodies, or (3) compromise the athlete’s ability to compete. Therapeutic drugs should help the athlete remain pain-free and infection-free. These drugs should not interfere with hydration, alertness, or clotting. In addition, the team dentist must be aware of addictive drugs by responsible prescribing (◘ Fig. 12.6) and realize that other prescribers and sources may provide the athlete with addictive drugs. The team/sports dentist can use alternative medications when possible and minimize dosage and amount prescribed as appropriate for the individual athlete’s needs.

Fig. 12.6
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Know your Athletes patients

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