Narcotic Analgesics

The  term  narcotics  is  commonly  used  to  refer loosely to a broad range of drugs, from marijuana to  cocaine.  More  accurately,  the  narcotic  drugs consist  of  opium  and  its  derivatives,  also  known as  opiate  drugs.  The  most  common  opiate  drugs include  heroin,  morphine,  and  codeine,  and  their use  leads  to  a  sense  of  numbness  resulting  from the suppression of the central and autonomic nervous systems. Because of these properties, narcotics  are  used  as  effective  painkillers  or  analgesics. In  fact,  morphine  and  heroin  were  commonly used as over-the-counter pain relievers in the early

1900s, but their widespread use was regulated as soon  as  the  addictive  properties  of  narcotic  analgesics were revealed. Today narcotic analgesics are used  in  the  treatment  of  chronic  pain,  and  their local  application  is  thought  to  minimize  the  side effects,  such  as  sedation,  respiratory  depression, and  nausea,  produced  by  other  local  anesthetics. Systematic  and  long-term  use  of  narcotic  analgesics, however, is not free of undesirable short and long-term side effects (e.g., cardiovascular disease, opioid-induced  hyperalgesia,  cognitive  dysfunction,  immunosuppression,  drug  addiction)  that may offset the benefits of pain relief.

Narcotic Analgesics in Sport

Although  there  is  no  scientific  consensus  about the  ergogenic  properties  of  narcotic  analgesics, athletes still use these substances for performance enhancement  purposes.  Narcotic  analgesics  are principally  used  to  alleviate  pain  resulting  from musculoskeletal  injury  and  to  induce  euphoric states.  Through  pain  reduction  before  or  during the  competition,  and  by  lowering  the  pain  associated  with  injury  or  fatigue,  narcotic  analgesics may  enable  sports  participation  and  provide  a competitive  advantage  to  overtrained  or  injured athletes. For instance, athletes may resort to narcotic  analgesics  in  order  to  recover  quickly  and cope with the pain caused by injury or fatigue in tournaments  requiring  continuous  participation and  effort  within  a  limited  time  frame,  such  as the  Olympic  Games  and  world  championships. Furthermore,  given  their  mood-altering  properties,  narcotic  analgesics  can  be  used  to  alleviate  negative  emotions,  psychological  stress,  and performance  anxiety;  thus,  they  elicit  an  indirect performance  enhancement  effect  by  improving the  athlete’s  morale.  Due  to  their  mood-altering effects, narcotic analgesics may be more common in combat sports and sports requiring fine motor control.

Regulating Narcotic Analgesics

Because  narcotic  analgesics  are  highly  addictive, harmful to health, and can be used to provide an unfair  competitive  advantage,  their  use  has  been officially  regulated  by  several  sporting  organizations  and  authorities,  including  the  International Olympic   Committee   (IOC),   the   World   AntiDoping Agency (WADA), and national anti-doping organizations (NADOs). According to the WADA 2012  list  of  prohibited  substances,  the  following narcotic analgesics are banned:

  • Buprenorphine
  • Dextromoramide
  • Diamorphine (heroin)
  • Fentanyl and its derivatives
  • Hydromorphone
  • Methadone and morphine
  • Oxycodone and oxymorphone
  • Pentazocine
  • Pethidine

Under specific circumstances, WADA may allow the use of prohibited narcotic analgesics for therapeutic use in athletes, but this requires strict implementation   of   the   Therapeutic   Use   Exemptions (TUEs) scheme and proper medical supervision.

Epidemiology of Narcotic Analgesics

The  use  of  narcotic  analgesics  is  not  widespread compared to other pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and beta-agonists. The overall prevalence of narcotic analgesics for therapeutic uses in sports is  less  than  1%.  This  is  probably  due  to  the  fact that their use may yield a positive doping test and because  other  drugs  (NSAIDs,  cyclooxygenase-1 [COX-1],  cyclooxygenase-2  [COX-2]  and  related enzymes) can be equally or more effective and elicit analgesia without the reported side effects of narcotics. However, the use of narcotic agents outside competition is an issue of major importance. There is vast anecdotal evidence in daily press about athletes who become addicted to narcotics, and as a result, they cannot train or compete at high level and accordingly withdraw from sports.

Preventing Abuse of Narcotic Analgesics: The Role of Education

Preventing  abuse  of  narcotic  analgesics  mainly rests with the physician’s knowledge and perspective on therapy and treatment of injury and pain. Thus,  strategies  to  prevent  the  abuse  of  narcotic analgesics  by  athletes  should  target  medical  and paramedical  professions  involved  in  sports  (e.g., sports   medicine   physicians,   physiotherapists, athletes,  and  coaches).  Furthermore,  strategies should  incorporate  specialized  training  courses in  medication  and  nonmedication  strategies  for pain management, as well as for raising awareness about  the  risk  for  drug  addiction.  The  available evidence  shows  that  such  educational  programs have increased sports physicians’ capacity to treat acute  and  chronic  pain  conditions  by  minimizing the addictive effects of narcotic analgesics, or even without using any medication at all. In addition, the implementation of prescription monitoring  and  surveillance  systems  for  dispensing  and administration  of  narcotic  analgesics  would  further prevent the abuse and trafficking of narcotic analgesics in sports. Finally, athletes should be also educated  on  the  harmful  health  and  performance side effects of narcotic analgesics.

References:

  1. Brennan, M. J., & Stanos, S. P. (2010). Strategies to optimize pain management with opioids while minimizing risk of abuse. PM&R, 2, 544–558.
  2. Ghodse, A. H., & Galea, S. (2010). Opioid analgesics and narcotic antagonists. In J. K. Aronson (Ed.), Side effects of drugs (Annual 32, pp. 184–224). Amsterdam: Elsevier B.V.
  3. Lippi, G., Franchini, M., & Guidi, G. C. (2006). Nonsteroidal anti-inflammatory drugs in athletes. British Journal of Sports Medicine, 40, 661–663.
  4. Stanos, S. P. (2007). Topical agents for the management of musculoskeletal pain. Journal of Pain and Symptom Management, 33, 342–355.
  5. Webster, L. R., & Fine, P. G. (2010). Approaches to improve pain relief while minimizing opioid abuse liability. The Journal of Pain, 11, 602–611.

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