Alcohol and Substance Misuse in Sport

Alcohol is the substance most commonly misused, and sport has its own drinking culture around celebration, team bonding and, sometimes, coping with pressure or disappointment. Recreational drugs such as cannabis, cocaine and stimulants are also used, and several of these are prohibited in competition. Prescription and analgesic misuse deserves particular attention in sport: opioids used after injury, and sedatives, can be misused or lead to dependence, which is why an opioid is prescribed for a clear indication, for a limited duration, with regular review and a planned reduction in dose where appropriate, rather than an open-ended supply. Image and performance enhancing drugs (IPEDs), such as anabolic steroids, are a further category, misused to change physique or performance, and they carry real harms to the heart, liver, mood and musculoskeletal system as well as being prohibited. The drivers behind misuse include performance pressure, injury and pain, coexisting mental health problems, the surrounding culture, and difficult transitions such as deselection and retirement. Because so many of these substances are prohibited in sport, misuse and anti-doping concerns often overlap.

Recognition rests on noticing a pattern rather than any single sign, and the clues are behavioural, physical and performance related. They include a decline in form or reliability, missed sessions, mood and personality change, withdrawal from team-mates, financial or relationship difficulties, and physical signs or injuries that do not add up. Concern may first be raised by others around the athlete. Because substance misuse and mental health problems so often travel together, the clinician asks about mood, anxiety and sleep as well, and keeps in mind that using a substance may be an attempt to self-manage a mental health problem. The manner of the enquiry matters: a calm, private, non-judgemental conversation is far more likely to help than confrontation, and it is often the first step towards someone accepting support.

Assessment is clinical and non-judgemental, supported by validated tools. For alcohol, the shorter Alcohol Use Disorders Identification Test, the AUDIT-C, is a quick initial screen, and the full Alcohol Use Disorders Identification Test (AUDIT) gives a fuller assessment of severity, while structured questions help assess other substances. The clinician gauges the level of use and risk, screens for dependence and for coexisting mental health problems, and considers the physical effects. Management is matched to that assessment and to local pathways. For risky but non-dependent use, a brief intervention, meaning clear, supportive advice and information, is effective and can be delivered opportunistically. Harmful drinking or milder alcohol dependence may be managed with alcohol-focused psychological treatment, whereas withdrawal or more severe dependence needs specialist management, so assessment and referral follow the severity rather than a single route for everyone. Importantly, where dependence is suspected, alcohol, benzodiazepines and other dependence-forming medicines are not stopped abruptly, because withdrawal can be dangerous and needs an individualised, appropriately supervised plan. Coexisting anxiety, low mood or other mental health problems are treated in their own right, and after injury, careful opioid prescribing with review helps prevent reliance developing. The anti-doping dimension is always considered: whether a substance is prohibited depends on the specific substance and the timing, with cannabinoids, specified narcotics and stimulants generally prohibited in competition and anabolic agents prohibited at all times, while alcohol is not prohibited, so the specific substance and the athlete's situation are checked and support and anti-doping obligations are handled together. Confidentiality is respected within its usual limits, and safeguarding takes priority for children and young athletes.

• •The International Olympic Committee consensus statement on mental health in elite athletes covers alcohol and substance misuse alongside other mental health conditions.
• •Current NICE guidance on alcohol-use disorders, on medicines associated with dependence, and on drug misuse informs identification, brief intervention, safe withdrawal, and referral for specialist treatment.
• •The World Anti-Doping Agency prohibited list and UK Anti-Doping set out which substances are prohibited and when, and the special handling of substances of abuse.
• •National Health Service and national drug and alcohol services provide information, support and treatment.

• •Substance misuse often coexists with mental health problems and may be a way of coping with them.
• •Screen with the shorter Alcohol Use Disorders Identification Test, then use the full test to assess severity.
• •Match care to severity: brief advice or alcohol-focused therapy for milder problems, specialist input for more.
• •Do not stop alcohol or dependence-forming medicines abruptly where dependence is suspected; withdrawal needs a supervised plan.
• •After injury, prescribe opioids for a clear indication and limited duration, with review, to prevent reliance.
• •Prohibition depends on the substance and timing: cannabinoids, some narcotics and stimulants in competition, anabolic agents always, alcohol not prohibited.