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Abstract
Background Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used in sports medicine to reduce time of incapacity.
Objective To describe the frequency of NSAIDs use by athletes in the XV Pan-American Games.
Methods All athletes who were tested by the anti-doping control filled a form. The voluntarily declared medications were recorded and categorised according to sport modality, sex, region and control situation according to the World Anti-Doping Agency.
Results Among the 1261 athletes tested (231 out-competition (OC) and 1030 in-competition (IC); 733 men and 528 women), 63% reported use of drugs, NSAIDs being the most frequently (64% of users) used medications. The use of medications was not significantly different between sexes or among different regions of the world. The number of users of only one type of NSAID was higher than those who used more than one type of NSAIDs or a combination with analgesics (335 vs 168 cases). IC reports presented higher use of NSAIDs than OC.
Conclusion Athletes tested by the anti-doping control of the XV Pan-American Games reported a high frequency of NSAIDs use. The frequent utilisation in competition suggests that these medications might be used as ergogenic aid.
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The practice of competitive sports, due to the specific demands that are related to intensity, volume, load progression, sports modality and the presence of contact or repetitive movements, frequently leads to bone-joint and/or musculoskeletal injury.1 2 The exposure of these tissues to mechanical, chemical or thermal stress tends to result in damage and a consequent inflammatory process, characterised by the reduction in the capacity to produce strength and in the range of movement, pain and sensitivity to touch, as well as increase in temperature, rigidity and swelling.3 Depending on the magnitude of the trauma, the use of non-steroidal anti-inflammatory drugs (NSAIDs), in combination with immobilisation or cryotherapy, is a common practice in sports medicine for the reduction of the time of incapacity.4
Previous surveys on the use of NSAIDs by athletes who participate in international sports events have reported this class of drugs to be the most frequently used5,–,9; however, the conditions associated with the use of these medications by athletes were not apparent. Therefore, the objective of the present study was to investigate quantitatively and qualitatively the causes behind the use of NSAIDs among the athletes participating in the XV Pan-American Games. Our hypothesis was that there were differences in the rates of use when comparing regions, sex, type of NSAIDs and mainly time of analysis (in-competition (IC) or out-of-competition (OC)).
Methods
During the XV Pan-American Games, the Medical Committee of the Pan-American Sports Organization (PASO-MC), following the guidelines of the World Anti-Doping Agency (WADA), selected 1261 athletes for anti-doping checks in the IC and the OC conditions among the 5662 participating athletes (22.2%). The selection of the athletes in the IC condition followed the criteria established by the International Federations of each form of sports as well as the availability of tests by country and form established by the PASO, with the medalists being a priority. The selection of athletes in the OC condition was made at random by the Anti-Doping Administration and Management System, while observing a quota of 5% of each delegation. With the approval and supervision of the PASO-MC, the information contained in the doping control form provided was collected. In the IC condition, the athletes were conducted to the collection point immediately after their event for the biological material and voluntarily answered the questions contained in the doping control form. The same procedures were carried out in the OC condition at any time during the athletes' stay in the Olympic village. It should be noted that there was no physical or verbal contact with the athletes, and the forms filled out by them were identified by number codes, unavailable to the researchers. It should be highlighted that no athlete was compelled to ensure the veracity of the information given. Therefore, it is not possible to certify the reliability of the answers, as recognised by previous studies.5 However, it is believed that the confidential conditions in which the information was collected and recorded as well as the richness of detail offered by each athlete in responding to the questions suggest the reliability of the collected data. The protocol of the study was approved by the PASO-MC, which, considering that anonymity of the participants was warranted, waived the need for informed consent.
In order to correctly classify the drugs of the international pharmacopeia, sports physicians were consulted. The medications were initially classified according to their main pharmacological agent into five groups: anti-inflammatory, analgesics, antibiotics, antiflu and others (contraceptives, antidepressant, antihistamines, anticonvulsivants, antifungals, hypoglycemic drugs, antiasthma, antacids, laxatives, eye drops, dermatological creams and muscle relaxants). For the purposes of the analysis, the anti-inflammatory medicines were grouped into COX-2 selective and non-selective as well as corticosteroids.10 The 42 participating countries were grouped into three regions: North America, Central America and the Caribbean and South America. Also, the users and non-users of NSAIDs were grouped by sex.
Data are expressed as mean (SD). In order to analyse the dependent variables in the bi-varied context, the χ2 test was used in conjunction with residual analysis and the calculation of the relative risk. The significance level was set at p≤0.05.
Results
Among the 1261 athletes selected for anti-doping control, 231 (18.3%) were done in the OC situation and 1030 (81.7%) in the IC situation. Figure 1 shows the absolute distribution of the checks by participating type of sports. Since the number of checks is representative of the number of athletes, the type of sports with the highest number of participants has the highest number of tests. The stratification by sex showed that 733 tested athletes were men (26.5±5.8 years) while 528 were women (25.0±5.9 years).
Frequency of athletes evaluated by the anti-doping control during the XV Pan-American Games according to the sport modality.
The majority of the athletes (62.8 %) declared the use of one or more drugs not prohibited in the WADA list. Figure 2 shows that the most frequently used medications were NSAIDs, followed by analgesics, antibiotics and antiflu drugs. Among NSAIDs users, non-selective COX-2 anti-inflammatory drugs were more frequently used (84.4%) than the COXIBs (14.1%) and corticosteroids (1.5%). The use of NSAIDs was not significantly different in women (60.6% of 366) when compared to men (65.9% of 426; p=0.122). Only 82 athletes among 335 users reported the simultaneous use of more than one type of NSAIDs, and 86 athletes reported the use of NSAIDs in association with paracetamol or acetylsalicylic acid.
Frequency of athletes who reported use of different classes of medications. NSAIDs, non-steroidal anti-inflammatory drugs.
Table 1 shows the absolute number and percentages of athletes according to the geographical origin and use of NSAIDs. No statistically significant difference was noted among the regions in regard to the percentage of athletes tested (p=0.78), confirming that the PASO-MC selection process for anti-doping testing was evenly distributed among the regions. Likewise, the reported use of NSAIDs was similar among regions. There was a trend (p=0.054) for a higher utilisation of NSAIDS in the IC (65.1%) when compared to the OC conditions (56.6%).
Absolute number (n) of athletes and percentages (%) stratified by the reported use of NSAIDs and by the geographical region
In order to verify the influence of the schedule of competition on the declared use of NSAIDs, the forms were grouped according to the respective competition temporal duration (table 2). Figure 3 demonstrates that both short- and long-duration competition schedules presented similar behaviour to the general analysis in the IC condition. However, comparing the groups, only sports with long-duration schedules presented a preponderance of NSAIDS use in the OC condition.
Sport modalities of the Pan-American competition program classified according by the duration of the event
Frequency of non-steroidal anti-inflammatory drugs (NSAIDs) use in-competition (IC) and out-of-competition (OC) for all athletes (general) as well as for athletes which participated in sports with competitions schedules of short and long duration. Asterisk represents intragroup significant difference between users and non-users (p≤0.05).
Discussion
The present survey confirms previous observations of frequent use of NSAIDs IC and adds to previous studies in demonstrating that these drugs are also frequently used in the OC condition. Moreover, the trend for a more frequent use of NSAIDs IC than OC suggests that athletes might be using these medications as ergogenic aid. Our findings are consistent with the observations in the anti-doping control of the Sydney Olympic Games in 20005 in which 20% of the athletes reported use of NSAIDs. In another report on Canadian athletes who participated in the Olympic Games of 1996 and 2000, the frequency of use was even higher.6 In the FIFA World Cup of Football of 2002 and 2006, NSAIDs were reported to be used by more than 40% of players.7 Furthermore, 39 of the 42 Italian teams participating in professional football competitions during the 2003/2004 season were asked about the use of NSAIDs, and the values found were even higher (92.6% declared users).8 The frequency of NSAIDs use by men and women athletes in our study is in line with the literature4; however, the expectation of the higher use of non-opioid analgesics by men due to their lower tolerance to pain was not confirmed.10
Some athletes may use NSAIDs IC to reduce pain and discomfort and to improve performance. The anti-inflammatory action of NSAIDs is based on the inhibition of prostaglandin endoperoxide synthase (or COX) which responds to the biosynthesis of the endoperoxide prostaglandins G2 and H2 (PGG2 and PGH2) from the cleaving of the cell membrane and the release of arachidonic acid.11 12 The production of the eicosanoids PGG2 and PGH2 is followed by the formation of the autacoids prostacyclin, thromboxane and other prostaglandins. Nevertheless, because prostaglandins, thromboxanes and prostacyclins play roles in several homeostatic functions in vital organs, the use of these substances during intense exercise may lead to gastrointestinal discomfort, dyspepsia, nausea, gastric bleeding and ulcers,13 haemorrhage, allergic reactions,14 kidney failure,15 liver damage, central nervous system dysfunctions,6 inhibition of the tissue regeneration process,16 oedema, hypertension, inhibition of the renal excretion of water and sodium17 and bone metabolism alterations.18 Since there is no evidence that NSAIDS may improve performance in non-injured athletes, these effects may counteract the pain-reducing action of these drugs.
An interesting finding of the present study is the trend (p=0.054) for more frequent utilisation of NSAIDs in the IC condition when compared with OC. It is known that prostaglandins enhances the effect of bradykinins and histamines in the alteration of the nociceptor excitability threshold and also attracts and activates the neutrophils to the affected area, provoking a second step of damage which heightens the local pain sensation. Therefore, due to the negative association between pain and capacity for exercise,19 it is possible that athletes might be using NSAIDs to improve performance during competition.
Another possible reason for the use of NSAIDs would be the attempt to minimise the magnitude of the inflammatory response resulting from the repetitive practice of the sport, such as those of long duration competition schedules (Chart 1). Indeed, athletes involved in long-duration competition schedules reported higher frequency of NSAIDs in the OC condition. However, the information available in the literature is controversial on the use of NSAIDS with this goal.20,–,22 It is also questionable to what extent the use of NSAIDs could affect the incidence of injuries and the chronic submission to training loads, which are essential for athletes at this level.23
The anti-inflammatory medications derived from propionic acid, like naproxen, ketoprofen and ibuprofen, were the most frequently found, perhaps because of the ease of access, price and the lower associated risk of adverse effects when compared with the derivatives of acetic acid, like indometacine and diclophenac as well as the oxicams like piroxicam, meloxicam and tenoxicam.4
The present survey has several limitations. First, we did not evaluate all athletes that participated in the games, but only those selected for doping control. Second, our data are based on the voluntary report of the athletes, which was not confirmed by blood testing. Third, we do not have information on the length of time of use, dosage and means of administration or the presence of injury. Despite these limitations, the athletes reported frequent use of NSAIDs, and our observations, together with the previous evidence, indicate that more studies are needed to evaluate the impact of NSAIDs IC as well as OC.
In conclusion, athletes who participated in the anti-doping control of the XV Pan-American Games reported a high frequency of NSAIDs, with no differences in use comparing regions, gender or type of NSAIDs. The higher frequency of NSAIDs use IC compared to the OC evaluation suggests that these medications might be used as ergogenic aid. More studies are needed to evaluate the effects of NSAIDs on exercise performance and on physiological systems that may be affected by these medications during exercise.
What is already known on this topic
▶ Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used by athletes in competition.
▶ There is no information on the reasons for the use of non-steroidal anti-inflammatory by athletes on competition and out of competition.
What this study adds
▶ Athletes tested by the anti-doping control of the XV Pan-American Games reported a high frequency use of NSAIDs.
▶ The frequent utilisation in competition suggests that these medications might be used as ergogenic aid
Acknowledgments
The researchers would like to thank the Organising Committee of the XV Pan-American Games, particularly the Medical Committee for permitting the access in the anti-doping control service.
References
Footnotes
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Competing interests None.
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Ethics approval This study was conducted with the approval of the Medical Committee of the Pan-American Sports Organization.
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Provenance and peer review Not commissioned; not externally peer reviewed