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Treatment of Substance Abuse Problems in Sport

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 Treatment of Substance Abuse Problems in Sport Powered By Docstoc
					Treatment of Substance
Abuse Problems in Sport


Penelope P. Ziegler, M.D.
Williamsburg Place and
The William J. Farley Center
Williamsburg, VA
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
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
    Genetic Vulnerabilities

Family history of addictive disorders
– Alcoholism
– Other drug addiction
– Compulsive gambling
– Eating disorders
Family history of bipolar disorder
   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
Levels of Sport Involved

   Secondary schools
   College athletics
   Professional sports
   “Weekend warriors”
   Unofficial team sporting
   leagues and activities
  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
   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)
  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.
Brain Circuits Involved in
     Drug Addiction


                                     PFC
                      INHIBITORY
                                      ACG
                       CONTROL
                                  OFC             Hipp
                                     SCC
                        MOTIVATION/               VP
                          DRIVE     NAcc                 REWARD
                                           Amyg
                                                  MEMORY/
                                                  LEARNING
           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
         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
         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
              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.
            Red Flags
Change in behavior and performance
– Non-attendance at classes
– Non-attendance at practice
Alcohol on breath at a scheduled
clinic appointment
      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
              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.
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
     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.
                 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.
         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
                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.