- Email: [email protected]
DRUG PROGRAMS
SPORTS PHARMACOLOGY
0278-5919/98 $8.00
+ .OO
DRUG PROGRAMS John A. Lombardo, MD
The use of mind-altering and performance-enhancing drugs is a human behavior that has been deemed unacceptable. In the development of a drug program, one must remember that the ultimate goal of the program is to influence or change human behavior. I will begin with an exercise with which every one can identify. Parked in your driveway is a sports car that is built for speed. You will be driving your new sports car from your house to a place 300 miles away. The road over which you will be driving is a straight, flat, four-lane interstate highway with minimal to moderate traffic. There is no speed limit or police on this road. However, before you leave, you are told that driving over 65 miles per hour (mph) is dangerous. Driving over this speed can result in loss of control of your car, and you and the passengers in your car can be injured or even killed because of this. Would you drive less than 65 mph in your new sports car? You are now driving the same car over the same road but there is now a policy. The speed limit is 65 mph. There is still no police or radar. You once again are educated about the risks of driving over 65 mph. Would you drive less than 65 mph in your new sports car? In addition to the speed limit and the education, police with radar will now be on the road. But when they stop someone for speeding, there is only a warning issued with the necessity of having your driving re-evaluated. Would you drive less than 65 mph in your new sports car? Finally, in addition to the police with radar, speed limit, and education, the punishment for speeding is 2 weeks in jail and loss of your license for 1 year. Would you now drive less than 65 mph in your new sports car?
Decisions in life are made by weighing the risks and benefits of the action being considered. When crossing a street, one weighs the risk of being struck by a car with the benefit of crossing at a specific moment.
From the Ohio State University Sports Medicine Center, Columbus, Ohio
CLINICS IN SPORTS MEDICINE VOLUME 17 * NUMBER 2 * APRIL 1998
319
320
LOMBARD0
If a behavior is deemed to be unacceptable, the risk of performing that behavior should be sufficient to deter the behavior from being repeated. There are two parts to the risk side of the equation: (1)the risk of being discovered and (2) the severity of the punishment. If risk is deemed low or nonexistent, and benefit is deemed to be high, the behavior may be deemed acceptable by the person making the choice. Drug use is an avoidable behavior. Drug dependence is a treatable disease. If this is the case, a program for which the goal is altering drugusing behavior should be constructed so that the goal can be reached. DRUGPROGRAM
There are two types of drug programs for those involved in sports. The first is the one that is administered by leagues and associations. Examples of these programs are National Collegiate Athletic Association (NCAA); United States Olympic Committee (USOC); International Olympic Committee (IOC); and professional leagues, such as the National Football League (NFL), National Basketball Association (NBA), Major League Baseball (MLB), and the Association of Tennis Professionals (ATP) drug programs. These organizations are responsible for the events and teams that they govern. They are responsible for the fairness and quality of competition, the health and safety of the athletes, and the image of their participants and events. These responsibilities are met through regulations and rules that govern the on-field activities as they relate to safe, fair, high-quality competition. I do not believe that participation in sports is a right but a privilege. Regardless as to one’s belief whether participation in sports is a right or privilege, there are responsibilities that are associated with being a participant. These responsibilities are for all associated with this visible and influential activity-administrators, coaches, medical personnel, officials, and players. The drug programs of these organizations focus on the deterrence of drug use by testing and discipline. Some include evaluation and treatment. A ”level field of competition” and positive role modeling by their participants are important goals of these programs. Some programs are subdivided into mood-altering drugs, such as marijuana, cocaine, and heroin, and performance enhancers, such as anabolic steroids, stimulants, enhancers of oxygenation, and relaxants. An example of this is the NFL, which has two separate programs-one for substance abuse and one for anabolic steroids and related substances. These different types of drugs pose different problems, and I believe that such a division is beneficial in developing a program. The second type of program is more of an employee-assistance program and is aimed at identifying individuals with drug problems so that they can be enlisted in a program to treat their disease. Irregular or sporadic users may be identified and evaluated, but rarely is extensive treatment necessary or cost effective for this individual. Often, counseling in decision making and delineation of risks of continued use are the
DRUG PROGRAMS
321
main parts of their program. Continued testing for all individuals who are positive help identify the problem user from the casual one. If one believes that sporadic use is not an acceptable behavior, then the program should be developed to deter such use. Once again, this means that the risk should be sufficiently great to accomplish such deterrence of this behavior. There are five main components that are essential in a drug program. These components are (1) policy, (2) education, (3) testing, (4) discipline, and (5) evaluation and treatment. As shown in the earlier exercise, all components are necessary if behavior is to be affected. For the maximal success of any organization’s drug program, all involved parties should participate in the development of the program. This involvement may be through the actual writing of the policy, developing the educational program, developing the testing program, and delineating the steps of discipline and the criteria and mechanism for evaluation and treatment. Minimally, review and discussion of the program by representatives of all involved groups is advisable. In a collegiate athletic department, this would include the administrators for the teams, student athlete support services, coaches, athletes, athletic trainers, psychologists, and team physicians. A representative from the office of student affairs and a faculty representative complete the optimal team for development of the program. COMPONENTS OF THE DRUG PROGRAM Policy
The backbone of any drug program is the document that states the program’s goals, regulations, and procedures. Goals
The goals of all drug programs should be to deter the use of the banned substances, identify individuals who have dependency problems, and provide access to treatment for such problems. Some programs state their goal is the elimination of banned drug use. Although this is the ideal end result, realistically this is impossible to attain. There will always be individuals who try banned drugs for whatever reason. When dealing with the coercive performance-enhancing drugs, a goal can be the removal of the perceived need by the players to take certain drugs so that they can compete. An example of this would be athletes who believed that anabolic steroids were needed because the people with whom they are competing have an unfair advantage by taking them. Removal of this perception is one measure of a successful program. Some programs are built on a disease model where identification, evaluation, and treatment of dependency is the main goal. There is minimal
322
LOMBARD0
discipline, and treatment is the key in these programs. Others are developed in a behavioral model, and deterrence of any use is the main goal. Discipline is formidable, and treatment may or may not play a major role in these programs. Most programs are a combination of both and fall between these two extremes. Within the policy, procedures to be followed should be stated. These include the drugs that are banned, what constitutes a violation, types of testing, method of selection of athletes to be tested, time of notification before test, consequence of missing a test, procedure to be followed after a positive test, discipline, evaluation, treatment, and appeal. Banned Substances There are two areas of drugs that are controlled by drug programs. The first is the performance-enhancing drugs used by athletes to obtain an edge in competition. These are banned because of the coercive nature of these drugs, their potential adverse effects, and the negative and improper message that permissiveness concerning their use would send to athletes of all ages. There are four types of performance enhancers that are banned. 1. Anabolic agents, including anabolic steroids, testosterone, growth hormone, and human chorionic gonadotropin. 2. Stimulants, including amphetamines, alpha-sympathomimetics (by some groups), and caffeine (by some groups). 3. Enhancers of oxygenation, including erythropoietin and the procedure blood doping. 4. Relaxants, including beta blockers and alcohol (in archery and rifle and pistol events).
When establishing a drug program, it is important to understand the timing of the use of these drugs. Anabolic agents are training drugs, which are not useful on the day of an event. Therefore, testing performed on the day of the event will not adequately identify users of anabolic agents. Stimulants, enhancers of oxygenation, and relaxants are all drugs that enhance the performance on the day of an event. Testing performed on the day of the event can identify users of these types of drugs. This, of course, is dependent on the availability of a urine test that can identify the drug. The second area of drugs whose use is banned by drug programs are identified by many names, ”mood altering drugs,” ”recreational drugs” (a terrible misnomer), ”drugs of abuse,” ”street drugs,” or, as I like to refer to them, ”entertainment or escape drugs.” This accurately describes the reasons that people take these substances. The four types of drugs that are included in this area are as follows: 1. Stimulants, including cocaine, amphetamines, and designer stimulants
DRUG PROGRAMS
323
2. Depressants, including marijuana, alcohol, and barbiturates 3. Hallucinogens, including LSD, mescaline, and psilocybin 4. Opiates, including heroin, morphine, and opium
Alcohol is a legal substance only for individuals who are over the legal drinking age for the state in which the athlete resides. Alcoholrelated offenses, such as driving under the influence, public intoxication, or other crime, such as assault while under the influence of alcohol, should be a violation. For those athletes who are not the legal drinking age, any use of alcohol should constitute a violation of the policy. Reinforcing a previously stated point, the policy should be developed by a group that includes representation of the athletes, team physicians, athletic trainers, coaches, faculty, administration, and parents (if dealing with high school programs). This allows for maximal input and facilitates the adoption and acceptance of the program by each of the groups. I suggest that the final draft be reviewed by each of these groups before presentation for adoption. Testing
Drug testing is performed for two main reasons: (1)early identification of drug use and (2) deterrence of drug use. Drug testing identifies individuals who are using drugs early in their drug-using behavior, which enables timely intervention to either change the behavior or treat the disease. Drug testing will identify potential and present problems before the onset of symptoms. Just as in the treatment of cancer, the medical profession performs better with early stage problems with drugs than when symptoms are evident and the disease is in a more advanced stage. As stated previously, decisions on behaviors are made weighing the risks and the benefits. Being identified as a drug user on a test can add to the risks, which may deter the use of the drug by the athlete. Urine is presently the predominate substrate for drug testing. Because it is an excrement of the body, there is no invasion of the athlete’s body for the substance to be tested as there would be with blood. Hair testing is being used in some places but has not reached the confidence level of urine testing for most programs. Hair may well represent the testing substrate of the future. There are three types or times of testing: (1) event testing, (2) random testing, and (3) just-cause testing. Event testing is the testing performed at the time of an event. The tests performed at NCAA championships or at the Olympics are examples of event tests. Event tests are timed to be sensitive for stimulants, relaxants, and enhancers of oxygenation. However, training drugs, such as anabolic agents, are less likely to be identified on event tests. Event testing is important to insure a level playing field for drugs taken on the day of competition, but should not be relied on as comprising the complete testing program.
324
LOMBARD0
Random testing is the most sensitive for training drugs, such as anabolic agents, and the entertainment/escape drugs. Most institutional and league programs have a random testing component. Randomization of people to be tested or time of testing can act as a strong deterrent if the risk of being tested is seen as high enough by the athlete. The percentage of athletes tested and frequency of testing will vary from population to population. At some universities, 10% of the athletes on each team are tested 15 to 20 times per year. Many computer programs have randomizers within the program and can perform this task easily. Tests performed because of the exhibition of symptoms that may represent drug use would constitute just cause testing. Individuals who have previously violated the program should have periodic testing performed at irregular intervals. This would be categorized as just-cause testing. Another example would be an individual who exhibits behaviors that could be a symptom of drug use. In this instance, the symptoms should be presented to an individual or panel who decides if there is just cause to test the individual. When dealing with teams, the situation may occur when the behaviors or symptoms may be widespread and not related to an individual athlete. An example of this may be a recruit who reports that there was drug use by members of the team during the recruiting trip. An unannounced team test can be performed in this instance. At some institutions, the cases are anonymously presented to a panel of three individuals who decide if there is just cause to proceed with the testing. The panel can include a physician, athletic trainer, psychologist, drug counselor, and a faculty member. The notification of the athlete should provide the shortest interval between notification and the completion of the test. The maximum time should be 24 hours and the ideal would be test at time of notification. When performing random testing, the program should minimally, if at all, interfere with the class or practice schedule of the athletes. Collection of the sample should be made after proper identification of the athlete at the testing site. The provision of the specimen should be observed to eliminate the possibility of substitution of urine. Strict chain of custody should be followed with the handling of the specimens throughout the procedure. The laboratories chosen should be appropriately accredited for the tests being performed. For testing of performance enhancers, there are two accreditations, International Olympic Committee (IOC) and College of American Pathologists (CAP). For the testing of entertainment/escape drugs, there are state and national accreditations that can be obtained, including Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (CLIA), and College of American Pathologists (CAP). There may be other certifications in different states. The medical review officer (MRO) receives the testing log of who was tested with the identifying number and the results of the tests. The MRO notifies the athlete directly or via designated individuals of the positive test. For the sake of confidentiality, the MRO should be a
DRUG PROGRAMS
325
physician who is knowledgeable in the area of drug use and drug testing. The team physician is optimal, especially at state universities. The results of drug testing are then part of the medical record and protected from disclosure by doctor-patient relationship. Procedure for a Positive Test Including Discipline
A positive drug test, an alcohol- or drug-related offense, or missing a scheduled drug test constitute violations of the drug policy. Procedures stated within the policy should be followed with each positive test. The policy should designate the following: 1. 2. 3. 4. 5.
Who receives the test results Who notifies the athlete Who the athlete sees for evaluation Who is granted knowledge of the positive test Disciplinary action for the positive test
Each organization’s situation will be different. An example of how the results of a policy violation might be administered will be given. The MRO receives the positive test result and notifies the athlete. The athlete then undergoes evaluation for drug dependency by a drug counselor. This counselor can be a part of the organization or operate independently. The athlete is then reviewed by a management team of key individuals to the successful deterrence to future drug use. Based on the program needs management team members could include the drug counselor, team physician, athletic trainer, head coach, athletic director, academic counselor, MRO, or other key individuals. Discipline is an important aspect of any program that wishes to change behavior. The extent of the penalty is based on the balancing of two issues, the punishment necessary to deter behavior and the allowance of a human to make a mistake. For the first offense, programs vary from no discipline with counseling and periodic testing to 1-year suspension. For the second offense, most programs have a suspension from 2 weeks to expulsion. For the third offense, the discipline escalates to 1 year to expulsion. Some programs will not expel but will continue with 1-year suspensions as long as the management plan is being followed by the athlete. If the management plan is not followed, immediate suspension or expulsion is suggested. Each organization should examine its own situation before the decision on discipline. Within an athletic department, individual teams may decide on a stricter code of discipline. This should be written and signed by all team members and the coach before the season. Copies of this signed code should be given to the MRO and the athletic director. The appeal procedure should be delineated in the policy. Most universities have an appeal procedure for students in place, and this can serve as the final appeal. A management group meeting with the athlete can also serve as an appeal forum.
326
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Evaluation and Treatment
As stated previously, the athlete should be evaluated for the level of the drug problem. Most athlete’s evaluations show that the problem is drug use, not dependency. This represents a behavioral problem not a disease. Counseling on decision making and classes on drug use can be a part of the management plan. If drug dependency or repetitive drug use despite counseling is the problem, more intensive treatment in an outpatient or inpatient program is indicated. A popular part of some drug programs is the ”safe haven” or ”safe harbor” concept. The athlete who has a problem with drug-related issues can voluntarily present to the drug counselor who will initiate evaluation and treatment. There is no formal management team and no disciplinary step. Strict confidentiality is maintained. This is not available after notification of a pending drug test, after a drug test or a missed test, or after a drug-related incident. SUMMARY Drug programs can be a positive method to assist athletes in the decision-making process concerning drug use. The keys to a successful drug program include the following: (1)inclusion of all involved parties in the development and administration of the program, (2) a reliable testing program that is sensitive for the drugs banned, (3) a disciplinary program that is consistent, (4)an evaluation and treatment program to prevent recurrence of the behavior or one that will treat the disease, and (5) the maintenance of confidentiality that will foster the confidence and support of all involved parties in the program. Address reprint requests to John A. Lombardo, MD The Ohio State University Sports Medicine Center 2050 Kenny Road Columbus, OH 43221
0278-5919/98 $8.00
+ .OO
DRUG PROGRAMS John A. Lombardo, MD
The use of mind-altering and performance-enhancing drugs is a human behavior that has been deemed unacceptable. In the development of a drug program, one must remember that the ultimate goal of the program is to influence or change human behavior. I will begin with an exercise with which every one can identify. Parked in your driveway is a sports car that is built for speed. You will be driving your new sports car from your house to a place 300 miles away. The road over which you will be driving is a straight, flat, four-lane interstate highway with minimal to moderate traffic. There is no speed limit or police on this road. However, before you leave, you are told that driving over 65 miles per hour (mph) is dangerous. Driving over this speed can result in loss of control of your car, and you and the passengers in your car can be injured or even killed because of this. Would you drive less than 65 mph in your new sports car? You are now driving the same car over the same road but there is now a policy. The speed limit is 65 mph. There is still no police or radar. You once again are educated about the risks of driving over 65 mph. Would you drive less than 65 mph in your new sports car? In addition to the speed limit and the education, police with radar will now be on the road. But when they stop someone for speeding, there is only a warning issued with the necessity of having your driving re-evaluated. Would you drive less than 65 mph in your new sports car? Finally, in addition to the police with radar, speed limit, and education, the punishment for speeding is 2 weeks in jail and loss of your license for 1 year. Would you now drive less than 65 mph in your new sports car?
Decisions in life are made by weighing the risks and benefits of the action being considered. When crossing a street, one weighs the risk of being struck by a car with the benefit of crossing at a specific moment.
From the Ohio State University Sports Medicine Center, Columbus, Ohio
CLINICS IN SPORTS MEDICINE VOLUME 17 * NUMBER 2 * APRIL 1998
319
320
LOMBARD0
If a behavior is deemed to be unacceptable, the risk of performing that behavior should be sufficient to deter the behavior from being repeated. There are two parts to the risk side of the equation: (1)the risk of being discovered and (2) the severity of the punishment. If risk is deemed low or nonexistent, and benefit is deemed to be high, the behavior may be deemed acceptable by the person making the choice. Drug use is an avoidable behavior. Drug dependence is a treatable disease. If this is the case, a program for which the goal is altering drugusing behavior should be constructed so that the goal can be reached. DRUGPROGRAM
There are two types of drug programs for those involved in sports. The first is the one that is administered by leagues and associations. Examples of these programs are National Collegiate Athletic Association (NCAA); United States Olympic Committee (USOC); International Olympic Committee (IOC); and professional leagues, such as the National Football League (NFL), National Basketball Association (NBA), Major League Baseball (MLB), and the Association of Tennis Professionals (ATP) drug programs. These organizations are responsible for the events and teams that they govern. They are responsible for the fairness and quality of competition, the health and safety of the athletes, and the image of their participants and events. These responsibilities are met through regulations and rules that govern the on-field activities as they relate to safe, fair, high-quality competition. I do not believe that participation in sports is a right but a privilege. Regardless as to one’s belief whether participation in sports is a right or privilege, there are responsibilities that are associated with being a participant. These responsibilities are for all associated with this visible and influential activity-administrators, coaches, medical personnel, officials, and players. The drug programs of these organizations focus on the deterrence of drug use by testing and discipline. Some include evaluation and treatment. A ”level field of competition” and positive role modeling by their participants are important goals of these programs. Some programs are subdivided into mood-altering drugs, such as marijuana, cocaine, and heroin, and performance enhancers, such as anabolic steroids, stimulants, enhancers of oxygenation, and relaxants. An example of this is the NFL, which has two separate programs-one for substance abuse and one for anabolic steroids and related substances. These different types of drugs pose different problems, and I believe that such a division is beneficial in developing a program. The second type of program is more of an employee-assistance program and is aimed at identifying individuals with drug problems so that they can be enlisted in a program to treat their disease. Irregular or sporadic users may be identified and evaluated, but rarely is extensive treatment necessary or cost effective for this individual. Often, counseling in decision making and delineation of risks of continued use are the
DRUG PROGRAMS
321
main parts of their program. Continued testing for all individuals who are positive help identify the problem user from the casual one. If one believes that sporadic use is not an acceptable behavior, then the program should be developed to deter such use. Once again, this means that the risk should be sufficiently great to accomplish such deterrence of this behavior. There are five main components that are essential in a drug program. These components are (1) policy, (2) education, (3) testing, (4) discipline, and (5) evaluation and treatment. As shown in the earlier exercise, all components are necessary if behavior is to be affected. For the maximal success of any organization’s drug program, all involved parties should participate in the development of the program. This involvement may be through the actual writing of the policy, developing the educational program, developing the testing program, and delineating the steps of discipline and the criteria and mechanism for evaluation and treatment. Minimally, review and discussion of the program by representatives of all involved groups is advisable. In a collegiate athletic department, this would include the administrators for the teams, student athlete support services, coaches, athletes, athletic trainers, psychologists, and team physicians. A representative from the office of student affairs and a faculty representative complete the optimal team for development of the program. COMPONENTS OF THE DRUG PROGRAM Policy
The backbone of any drug program is the document that states the program’s goals, regulations, and procedures. Goals
The goals of all drug programs should be to deter the use of the banned substances, identify individuals who have dependency problems, and provide access to treatment for such problems. Some programs state their goal is the elimination of banned drug use. Although this is the ideal end result, realistically this is impossible to attain. There will always be individuals who try banned drugs for whatever reason. When dealing with the coercive performance-enhancing drugs, a goal can be the removal of the perceived need by the players to take certain drugs so that they can compete. An example of this would be athletes who believed that anabolic steroids were needed because the people with whom they are competing have an unfair advantage by taking them. Removal of this perception is one measure of a successful program. Some programs are built on a disease model where identification, evaluation, and treatment of dependency is the main goal. There is minimal
322
LOMBARD0
discipline, and treatment is the key in these programs. Others are developed in a behavioral model, and deterrence of any use is the main goal. Discipline is formidable, and treatment may or may not play a major role in these programs. Most programs are a combination of both and fall between these two extremes. Within the policy, procedures to be followed should be stated. These include the drugs that are banned, what constitutes a violation, types of testing, method of selection of athletes to be tested, time of notification before test, consequence of missing a test, procedure to be followed after a positive test, discipline, evaluation, treatment, and appeal. Banned Substances There are two areas of drugs that are controlled by drug programs. The first is the performance-enhancing drugs used by athletes to obtain an edge in competition. These are banned because of the coercive nature of these drugs, their potential adverse effects, and the negative and improper message that permissiveness concerning their use would send to athletes of all ages. There are four types of performance enhancers that are banned. 1. Anabolic agents, including anabolic steroids, testosterone, growth hormone, and human chorionic gonadotropin. 2. Stimulants, including amphetamines, alpha-sympathomimetics (by some groups), and caffeine (by some groups). 3. Enhancers of oxygenation, including erythropoietin and the procedure blood doping. 4. Relaxants, including beta blockers and alcohol (in archery and rifle and pistol events).
When establishing a drug program, it is important to understand the timing of the use of these drugs. Anabolic agents are training drugs, which are not useful on the day of an event. Therefore, testing performed on the day of the event will not adequately identify users of anabolic agents. Stimulants, enhancers of oxygenation, and relaxants are all drugs that enhance the performance on the day of an event. Testing performed on the day of the event can identify users of these types of drugs. This, of course, is dependent on the availability of a urine test that can identify the drug. The second area of drugs whose use is banned by drug programs are identified by many names, ”mood altering drugs,” ”recreational drugs” (a terrible misnomer), ”drugs of abuse,” ”street drugs,” or, as I like to refer to them, ”entertainment or escape drugs.” This accurately describes the reasons that people take these substances. The four types of drugs that are included in this area are as follows: 1. Stimulants, including cocaine, amphetamines, and designer stimulants
DRUG PROGRAMS
323
2. Depressants, including marijuana, alcohol, and barbiturates 3. Hallucinogens, including LSD, mescaline, and psilocybin 4. Opiates, including heroin, morphine, and opium
Alcohol is a legal substance only for individuals who are over the legal drinking age for the state in which the athlete resides. Alcoholrelated offenses, such as driving under the influence, public intoxication, or other crime, such as assault while under the influence of alcohol, should be a violation. For those athletes who are not the legal drinking age, any use of alcohol should constitute a violation of the policy. Reinforcing a previously stated point, the policy should be developed by a group that includes representation of the athletes, team physicians, athletic trainers, coaches, faculty, administration, and parents (if dealing with high school programs). This allows for maximal input and facilitates the adoption and acceptance of the program by each of the groups. I suggest that the final draft be reviewed by each of these groups before presentation for adoption. Testing
Drug testing is performed for two main reasons: (1)early identification of drug use and (2) deterrence of drug use. Drug testing identifies individuals who are using drugs early in their drug-using behavior, which enables timely intervention to either change the behavior or treat the disease. Drug testing will identify potential and present problems before the onset of symptoms. Just as in the treatment of cancer, the medical profession performs better with early stage problems with drugs than when symptoms are evident and the disease is in a more advanced stage. As stated previously, decisions on behaviors are made weighing the risks and the benefits. Being identified as a drug user on a test can add to the risks, which may deter the use of the drug by the athlete. Urine is presently the predominate substrate for drug testing. Because it is an excrement of the body, there is no invasion of the athlete’s body for the substance to be tested as there would be with blood. Hair testing is being used in some places but has not reached the confidence level of urine testing for most programs. Hair may well represent the testing substrate of the future. There are three types or times of testing: (1) event testing, (2) random testing, and (3) just-cause testing. Event testing is the testing performed at the time of an event. The tests performed at NCAA championships or at the Olympics are examples of event tests. Event tests are timed to be sensitive for stimulants, relaxants, and enhancers of oxygenation. However, training drugs, such as anabolic agents, are less likely to be identified on event tests. Event testing is important to insure a level playing field for drugs taken on the day of competition, but should not be relied on as comprising the complete testing program.
324
LOMBARD0
Random testing is the most sensitive for training drugs, such as anabolic agents, and the entertainment/escape drugs. Most institutional and league programs have a random testing component. Randomization of people to be tested or time of testing can act as a strong deterrent if the risk of being tested is seen as high enough by the athlete. The percentage of athletes tested and frequency of testing will vary from population to population. At some universities, 10% of the athletes on each team are tested 15 to 20 times per year. Many computer programs have randomizers within the program and can perform this task easily. Tests performed because of the exhibition of symptoms that may represent drug use would constitute just cause testing. Individuals who have previously violated the program should have periodic testing performed at irregular intervals. This would be categorized as just-cause testing. Another example would be an individual who exhibits behaviors that could be a symptom of drug use. In this instance, the symptoms should be presented to an individual or panel who decides if there is just cause to test the individual. When dealing with teams, the situation may occur when the behaviors or symptoms may be widespread and not related to an individual athlete. An example of this may be a recruit who reports that there was drug use by members of the team during the recruiting trip. An unannounced team test can be performed in this instance. At some institutions, the cases are anonymously presented to a panel of three individuals who decide if there is just cause to proceed with the testing. The panel can include a physician, athletic trainer, psychologist, drug counselor, and a faculty member. The notification of the athlete should provide the shortest interval between notification and the completion of the test. The maximum time should be 24 hours and the ideal would be test at time of notification. When performing random testing, the program should minimally, if at all, interfere with the class or practice schedule of the athletes. Collection of the sample should be made after proper identification of the athlete at the testing site. The provision of the specimen should be observed to eliminate the possibility of substitution of urine. Strict chain of custody should be followed with the handling of the specimens throughout the procedure. The laboratories chosen should be appropriately accredited for the tests being performed. For testing of performance enhancers, there are two accreditations, International Olympic Committee (IOC) and College of American Pathologists (CAP). For the testing of entertainment/escape drugs, there are state and national accreditations that can be obtained, including Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (CLIA), and College of American Pathologists (CAP). There may be other certifications in different states. The medical review officer (MRO) receives the testing log of who was tested with the identifying number and the results of the tests. The MRO notifies the athlete directly or via designated individuals of the positive test. For the sake of confidentiality, the MRO should be a
DRUG PROGRAMS
325
physician who is knowledgeable in the area of drug use and drug testing. The team physician is optimal, especially at state universities. The results of drug testing are then part of the medical record and protected from disclosure by doctor-patient relationship. Procedure for a Positive Test Including Discipline
A positive drug test, an alcohol- or drug-related offense, or missing a scheduled drug test constitute violations of the drug policy. Procedures stated within the policy should be followed with each positive test. The policy should designate the following: 1. 2. 3. 4. 5.
Who receives the test results Who notifies the athlete Who the athlete sees for evaluation Who is granted knowledge of the positive test Disciplinary action for the positive test
Each organization’s situation will be different. An example of how the results of a policy violation might be administered will be given. The MRO receives the positive test result and notifies the athlete. The athlete then undergoes evaluation for drug dependency by a drug counselor. This counselor can be a part of the organization or operate independently. The athlete is then reviewed by a management team of key individuals to the successful deterrence to future drug use. Based on the program needs management team members could include the drug counselor, team physician, athletic trainer, head coach, athletic director, academic counselor, MRO, or other key individuals. Discipline is an important aspect of any program that wishes to change behavior. The extent of the penalty is based on the balancing of two issues, the punishment necessary to deter behavior and the allowance of a human to make a mistake. For the first offense, programs vary from no discipline with counseling and periodic testing to 1-year suspension. For the second offense, most programs have a suspension from 2 weeks to expulsion. For the third offense, the discipline escalates to 1 year to expulsion. Some programs will not expel but will continue with 1-year suspensions as long as the management plan is being followed by the athlete. If the management plan is not followed, immediate suspension or expulsion is suggested. Each organization should examine its own situation before the decision on discipline. Within an athletic department, individual teams may decide on a stricter code of discipline. This should be written and signed by all team members and the coach before the season. Copies of this signed code should be given to the MRO and the athletic director. The appeal procedure should be delineated in the policy. Most universities have an appeal procedure for students in place, and this can serve as the final appeal. A management group meeting with the athlete can also serve as an appeal forum.
326
LOMBARD0
Evaluation and Treatment
As stated previously, the athlete should be evaluated for the level of the drug problem. Most athlete’s evaluations show that the problem is drug use, not dependency. This represents a behavioral problem not a disease. Counseling on decision making and classes on drug use can be a part of the management plan. If drug dependency or repetitive drug use despite counseling is the problem, more intensive treatment in an outpatient or inpatient program is indicated. A popular part of some drug programs is the ”safe haven” or ”safe harbor” concept. The athlete who has a problem with drug-related issues can voluntarily present to the drug counselor who will initiate evaluation and treatment. There is no formal management team and no disciplinary step. Strict confidentiality is maintained. This is not available after notification of a pending drug test, after a drug test or a missed test, or after a drug-related incident. SUMMARY Drug programs can be a positive method to assist athletes in the decision-making process concerning drug use. The keys to a successful drug program include the following: (1)inclusion of all involved parties in the development and administration of the program, (2) a reliable testing program that is sensitive for the drugs banned, (3) a disciplinary program that is consistent, (4)an evaluation and treatment program to prevent recurrence of the behavior or one that will treat the disease, and (5) the maintenance of confidentiality that will foster the confidence and support of all involved parties in the program. Address reprint requests to John A. Lombardo, MD The Ohio State University Sports Medicine Center 2050 Kenny Road Columbus, OH 43221