Prescribing and Medicines Management

Safe prescribing starts with the basics that apply to any patient. The drug should be clinically indicated and matched to the person, taking account of allergies, other conditions, pregnancy and breastfeeding, and kidney or liver function, which often change the choice or the dose. Interactions matter: common examples in this setting include non-steroidal anti-inflammatory drugs (NSAIDs) with anticoagulants or with antihypertensives, and any combination that affects the heart's rhythm, and polypharmacy raises the risk. Prescriptions should be clear and unambiguous, with the dose, route, frequency and duration specified, and the patient given enough information to take the medicine safely. In the UK, this sits within professional standards such as the General Medical Council guidance on good practice in prescribing and managing medicines.

Good prescribing is also about restraint. Using the lowest effective dose for the shortest appropriate time, reviewing continued need, and avoiding medicines that are unnecessary all reduce harm. In sport there is a particular temptation towards medicalising normal training discomfort or reaching for injections and supplements, and part of good practice is recognising when the best answer is not a prescription at all but rest, rehabilitation or reassurance.

A prescribing consideration specific to this population is the impact of medicines on the exercise response itself, which is separate from their therapeutic effect and from any anti-doping question. Beta blockers blunt the chronotropic response, so heart rate targets and any age-predicted maximum become invalid and perceived exertion should be used instead; they also reduce maximal exercise capacity, which athletes notice. Diuretics reduce plasma volume and impair thermoregulation, raising the risk of heat illness and of orthostatic symptoms. Statins are associated with muscle symptoms, and creatine kinase is difficult to interpret in a training athlete because exercise raises it independently.

Several other classes matter. Insulin and sulfonylureas carry hypoglycaemia risk during and after exercise. Sympathomimetic decongestants and stimulants raise heart rate and blood pressure. Anticholinergic drugs impair sweating and therefore heat tolerance. Opioids and sedating antihistamines impair coordination, judgement and reaction time. Non-steroidal anti-inflammatory drugs taken around prolonged endurance exercise raise the risk of acute kidney injury, particularly when combined with dehydration. Asking what a patient takes, including over-the-counter medicines and supplements, is therefore part of the exercise consultation and not only of the anti-doping one.

Away from a clinic, medicines still have to be handled within a clear governance framework, and who is responsible depends on the employing organisation, who owns the stock, the standard operating procedures in place, the relevant legal authority and the named accountable staff; the clinician remains responsible for their own prescribing, supply, administration and records. Medicines must be stored correctly, keeping to the cold chain for drugs that need refrigeration, protecting them from heat and light, checking expiry dates, and keeping an accurate log of what is held, given and disposed of. Emergency drugs for the pitchside bag need to be present, in date and familiar to the team.

Controlled drugs carry extra legal requirements around storage, records and who may lawfully possess them, and these are not set aside when a team travels. A personal controlled-drug licence covers an individual carrying their own prescribed medicine and is not the right mechanism for a doctor carrying stock for a squad; taking squad supplies across borders may require Home Office import or export licensing, appropriate custody arrangements, and permission from every destination and transit country, with rules that vary between countries. Records carried while travelling should be a secure, minimum-necessary clinical record accessible only to authorised healthcare staff, maintaining each athlete's confidentiality at borders, hotels and venues, rather than an openly shared list. Planning ahead and taking sufficient but not excessive quantities reduce problems and make safe treatment easier in an unfamiliar setting.

Two mechanisms allow someone other than the prescriber to administer or supply a medicine, and confusing them is a common governance failure in team settings. A Patient Specific Direction is a written instruction from a prescriber following individual assessment of a named patient, and it is the normal and simplest route. It can authorise supply or administration as legally appropriate, and administration is not always restricted to another registered professional: a suitably trained and competent person may administer in some circumstances, depending on the medicine, the profession, organisational policy and legal restrictions. A Patient Group Direction is a written instruction allowing named categories of registered professional to supply or administer a medicine to a defined group of patients without individual prescriber assessment. It is reserved for appropriate and limited situations, may be used only by eligible registered professional groups, requires multidisciplinary development with the necessary professional signatures and formal authorisation by the legally appropriate organisation, and cannot be created informally by a team doctor for their own squad. For a small defined squad, individual prescribing or a Patient Specific Direction will usually be more appropriate than creating a group direction.

Controlled drugs carry additional statutory requirements. What applies depends on the schedule, on whether the medicine is held as stock or is patient-specific, on the professional role, on the care setting and on organisational licence and policy. Schedule 2 drugs including morphine and diamorphine attract the strictest controls. Schedule 3 is mixed: buprenorphine and temazepam are subject to safe custody requirements but that does not generalise across the whole schedule. Schedules 4 and 5 are progressively less restrictive. Safe custody means a compliant locked cabinet where it applies. Keeping a running balance in the register is recommended good practice rather than a universal statutory requirement in every setting, and destruction requirements differ between stock medicines and patient-returned ones. Carrying team stock across borders is considerably more complex than a patient travelling with their own prescription. It may require Home Office advice, compliance with the destination country's import requirements, approval from an organisational pharmacy or controlled drug lead, and secure transport with chain of custody documentation. The practical discipline on tour is documented custody with authorised access, administration records identifying what was given to whom, and reconciliation on return, proportionate to the medicines actually carried. A periodic stock check of the team bag against the register, covering quantities, expiry dates, storage conditions and whether contents match the agreed formulary, is a useful local governance standard rather than a statutory interval, and it is straightforward and revealing.

The step that sets sports prescribing apart is checking every medicine against the anti-doping rules before it is given, though this check must never delay emergency or clinically necessary care: where treatment is urgent, the clinician treats first, documents fully, and addresses the anti-doping process as soon as practicable. For non-urgent prescribing, a resource such as Global Drug Reference Online is used to check the exact UK product against the current World Anti-Doping Agency (WADA) Prohibited List; the search reference is recorded, and the check is repeated after any change of product, route, dose or competition timing and when the annual rules change. Global Drug Reference Online checks medicines, not supplements, and a product sold under a similar name in another country may have a different formulation, so nothing is assumed from the name alone.

Two principles are essential. First, a doctor's prescription alone does not permit an athlete to use a prohibited substance; where a prohibited drug is genuinely the right treatment and a therapeutic use exemption (TUE) is required, it is applied for prospectively, with retrospective applications allowed only where the applicable anti-doping rules permit, such as emergency or insufficient-time circumstances, and a retrospective application is not guaranteed to be approved. Second, supplements are a real hazard, because they are poorly regulated and can be contaminated with prohibited substances; recognised batch-testing schemes reduce, but cannot eliminate, this risk, and they do not certify that a supplement works or guarantee that an athlete avoids an anti-doping rule violation. Under the principle of strict liability, an athlete is generally responsible for whatever is found in their sample. Clear records of what was prescribed, why, and the checks performed protect both the athlete and the clinician.

• •Match the drug to the patient, checking allergies, comorbidities, pregnancy, and kidney and liver function, and screen for interactions such as NSAIDs with anticoagulants; reduce risk from polypharmacy.
• •Who is responsible for team medicines depends on the organisation, stock ownership and standard operating procedures; the clinician remains responsible for their own prescribing, supply and records.
• •Store medicines correctly (cold chain, heat, light, expiry) and keep secure, confidential, minimum-necessary records; controlled drugs carry extra legal requirements even when travelling.
• •A personal controlled-drug licence is for an individual's own medicine; carrying squad stock abroad may need Home Office import or export licensing and permission from every country involved.
• •Anti-doping checks must not delay urgent care; treat first when needed, document, and check the exact product on Global Drug Reference Online, recording the reference.
• •A prescription alone does not permit a prohibited substance; retrospective therapeutic use exemptions are allowed only where the rules permit and are not guaranteed, and batch-tested supplements reduce but do not remove contamination risk.