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Ephedrine, Pseudoephedrine, and Amphetamine Prevalence in College Hockey Players

Most Report Performance-Enhancing Use

Lt Col Robert T. Bents, MD; Maj John M. Tokish, MD; Linn Goldberg, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 9 - SEPTEMBER 2004


ABSTRACT

BACKGROUND: Performance-enhancing drugs are used by some athletes, even though the substances may be potentially dangerous and some are banned.

OBJECTIVE: To assess the use of metabolic stimulants among collegiate hockey players.

METHODS: Surveys were administered to college hockey players on five teams. Participation was voluntary, and respondents remained anonymous. The survey included questions regarding use of specific stimulants (eg, ephedrine, amphetamines, pseudoephedrine), awareness of potential side effects, and knowledge of National Collegiate Athletic Association (NCAA) rules.

RESULTS: More than half (58%) of the 122 college hockey players who completed the survey reported past or present use of the specific stimulants. Almost half (46%) reported pseudoephedrine use to enhance performance, including 24% who indicated current use, and 38% reported ephedrine use, including 11% who admitted current use. Stimulant users had good knowledge about the potential side effects of ephedrine, including sudden death, hypertension, and insomnia. Nearly all (92%) stimulant users were aware of the current NCAA ban of ephedrine. Over 33% stated they would use a banned substance if it would help them get to the National Hockey League.

CONCLUSION: A large number of collegiate hockey players admit to using metabolic stimulants despite knowledge of side effects and the NCAA ban on two of these substances. More effective educational interventions, perhaps coupled with a stronger testing policy, may be necessary to curb this potentially dangerous practice.

College athletes today approach their sport with a high expectancy of success. Many train intensely year-round and incorporate weight training, dietary regimens, and nutritional supplements in their regimens. Of concern, however, is the use of potentially dangerous ergogenic aids for performance enhancement, such as pseudoephedrine and the banned stimulants ephedrine and amphetamines.

Dietary supplements containing ephedrine compounds for weight loss and energy enhancement were widely available through 2003 in the United States.1,2 Pseudoephedrine is a central nervous system stimulant and decongestant available in over-the-counter (OTC) cold and allergy products. The National Collegiate Athletic Association (NCAA) banned ephedrine in 1997.2 Legislation has been introduced requiring that dietary supplements containing stimulants be tested for safety prior to their sale. Certain states banned the sale of ephedra to minors13 in 2003, and the US Food and Drug Administration's (FDA's) ban on the sale of ephedra began in April 2004.4 Pseudoephedrine is not banned by the NCAA or National Hockey League (NHL).

Although the NCAA has encouraged improved education regarding banned substances, it is unclear whether the educational programs used during recruitment and enrollment in school are evaluated for compliance or efficacy. The list of NCAA-banned substances is available in pamphlets or on its Web site at https://www.ncaa.org.

An NCAA study assessed the use of metabolic stimulants among collegiate athletes; however, only 2% of the study participants were hockey players.5,6 Because of the lack of prevalence data, the availability of these agents, and the outright ban of ephedrine and amphetamines, we sought to better characterize current use among hockey athletes. We assessed five of the six teams of a men's collegiate hockey conference by anonymous survey to determine current use and student knowledge regarding ephedrine and other metabolic stimulants.

Methods

We studied one NCAA Division 1 hockey conference (six teams) at the league championship tournament where they participated in the end-of-season competition. Athletic trainers were contacted and agreed to assist in the administration of the survey. Each survey was accompanied by a cover letter ensuring the confidentiality and anonymity of each player and school. The trainers administered and collected the one-page survey before a team meeting or practice. Each survey was returned in a plain envelope that was sealed by the athlete and given to the authors.

Survey Instrument

The survey was modified from one that was validated in previous studies regarding anabolic steroid use in athletes.7,8 The US Air Force Academy Institutional Review Board reviewed and approved the survey prior to administration. The survey consisted of 23 questions divided into three sections.

The first section included demographic questions, and the second section queried about stimulant use (table 1). The athletes were asked to circle whether they had taken a specified stimulant in the past 30 days, prior to the past 30 days, or never. Specific questions assessed use of ephedrine, ephedra, ma huang, amphetamines, and pseudoephedrine. We included brand names such as Ripped Fuel (Twinlab Corporation, Hauppauge, New York), Hydroxycut (MuscleTech Research and Development Inc, Mississauga, Ontario), Xenadrine (Cytodyne LLC, Hicksville, New York) and Sudafed (Pfizer Inc, Morris Plains, New Jersey) next to the generic name to assist with recognition.

The third section contained knowledge and attitude questions. The athletes were asked to mark one of seven circles on a 7-point Likert scale of agreement, ranging from strongly disagree to strongly agree.

The average survey completion time was approximately 10 to 15 minutes. Data were tabulated using an Excel worksheet (Microsoft, Redmond, Washington), and statistical analysis was accomplished with the same program.

Results

Six teams were given the survey, but one team's head coach elected not to participate. All athletes (n=122) on the remaining five hockey teams in the conference completed the 23-item questionnaire.

Demographics. The average age was 21.9 years, and many athletes (86%) had participated in junior-level hockey after high school. The mean reported grade point average was 2.97 (on a 4.0 scale). Only 2% played a second varsity sport.

Stimulant use. More than half (58%) of the collegiate hockey players admitted to using ephedrine, pseudoephedrine, or amphetamines to enhance performance at some point. The lifetime usage rate for pseudoephedrine was 46%, ephedrine use was 38%, and amphetamine use was 16% (figure 1). More than one third (about 35%) of the athletes admitted to currently using one or more of these substances (within the past 30 days). Pseudoephedrine was used currently by 24%, and 11% admitted to using ephedrine within the last 30 days. Seven percent used amphetamines recently, and 6% reported current use of more than one stimulant (figure 2).

Knowledge of side effects. Using the agreement scale (1 = disagree completely, 7 = agree completely) nearly all players (almost 91%) agreed that ephedrine could potentially cause hypertension (average score, 5.9), sudden death (5.74), heart attack (5.68), and sleep disturbance (5.67). Among stimulant users, 92% were aware of the NCAA ban on ephedrine. No significant difference between stimulant users and nonusers was found regarding knowledge of side effects or of the NCAA ban.

Athlete attitudes. Almost 34% of all players stated that they would take a banned substance if it would help them play in the NHL. Participants estimated 16% to 20% of male athletes at their schools take supplements banned by the NCAA. Of nonstimulant users, almost 19% stated they intended to use NCAA-banned substances at some point in their college careers.

Discussion

Using stimulants to enhance athletic performance has recently come under increased scrutiny because of a number of adverse events associated with their use. Reported reactions to ephedrine range from nervousness, dizziness, tremor, and alterations in blood pressure or heart rate to chest pain, myocardial infarction, stroke, seizures, psychosis, and death.1,9-11 Of concern is that these events have been reported in healthy individuals of all ages.1,11 In addition to the NCAA's and FDA's bans on ephedra, the National Football League began drug testing for ephedrine in 2001, and the NCAA followed in 2002.

Only the NCAA study series examined ephedrine use in college athletes.5,6 This large study was designed to require 12% of NCAA student-athletes to respond to the survey. The authors found that the Division 1 athletes' self-reported use of ephedrine was 3% in 1997 and 3.6% in 2001.5,6 The authors found 4.4% of ice hockey players used amphetamines and 3.4% used ephedrine in 2001. The use of pseudoephedrine was not surveyed. In contrast, our study found 58% of current hockey players in one college conference report past or present use of at least one metabolic stimulant (ie, ephedrine, amphetamines or pseudoephedrine), and 11% admit to current use of ephedrine. Others have reported a similar prevalence (13%) of creatine and ephedrine use in the elite US Army Rangers.12

To our knowledge, our study is the first to note pseudoephedrine use for performance enhancement in college hockey players. It appears pseudoephedrine use is common in this cohort, with 24% self-reporting current use. Athletes may feel pseudoephedrine is a "safe" ergogenic aid since it is widely available in OTC cold remedies and decongestants. Numerous reports of side effects from pseudoephedrine taken at prescribed doses include ischemic colitis,13 hemorrhagic stroke,14 and sudden death.15 The NCAA does not currently have a policy regarding pseudoephedrine.

We note that 92% of athletes who reported use of stimulants in the last 30 days were aware of the NCAA ban on ephedrine. These athletes demonstrated awareness of and belief in the potential side effects of stimulant use. Other studies of high school football teams have shown that limited education efforts by healthcare providers may actually increase the propensity to use banned substances (eg, anabolic steroids)16 or have no measurable effect on student's attitudes toward use.17 These findings appear to contradict the overwhelming opinion that currently recommended education methods and testing will curb illicit ergogenic drug use. In fact, based on the previous NCAA study,5,6 ephedrine use has dramatically escalated, although hockey players may be distinctly different from other college athletes.

The only evidence-based program found to reduce athlete use of performance-enhancing substances was the ATLAS (athletes training and learning to avoid steroids) program.7 ATLAS was a team-centered, peer-taught, and coach-facilitated intervention study that involved more than 3,200 high school adolescents. In this study, new use of supplements was 50% lower among ATLAS-trained male athletes.7 It is possible that a similar approach would be effective for reducing stimulant use in college athletes.

Other research has examined "at-risk" college athletes.18,19,20 Albrecht et al21 noted that the majority of NCAA athletes are unable to correctly identify their school's drug testing program.

Limitations

Our study has a number of limitations. First, we examined only one hockey conference, and therefore our results may not be applicable to a national rate. However, this conference consists of teams from the Midwest, Northeast, and Southeast regions and, therefore, may well represent the national use prevalence and attitudes regarding supplements. Another potential limitation is our small sample size. We had 100% participation from five schools, and we believe this gives excellent representation of one conference. We also may be underestimating the use of stimulants because of the inherent reluctance to self-report banned substance use.

A Significant Problem

Stimulant use to enhance performance appears to be a significant problem in collegiate hockey. Although improved drug testing may provide a greater deterrent, effective educational interventions will likely be required to curb this alarming trend.

The views and statements contained in this article are the authors' and do not reflect those of the United States Air Force or the United States government.

References

  1. Shekelle PG, Hardy ML, Morton SC, et al: Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. JAMA 2003;289(12):1537-1545
  2. Grandjean AC, Ruud JS: Dietary supplements and athletics. Curr Opin Orthop 2002;13(2):122-127
  3. Wertheim LJ, Cazeneuve B, King P: Jolt of reality. Sports Illus 2003;98(14):69-79
  4. Knight J: Safety concerns prompt US ban on dietary supplement. Nature 2004;427(6970):90
  5. Green GA, Uryasz FD, Petr TA, et al: NCAA study of substance use and abuse habits of college student-athletes. Clin J Sport Med 2001;11(1):51-56
  6. NCAA Research Staff: NCAA study of substance abuse habits of college student-athletes. Presented to the National Collegiate Athletic Association Committee on Competitive Safeguards and Medical Aspects of Sports, June 2001. Available at https://www.ncaa.org/library/research/substance_use_habits/2001/substance_use_habits.pdf. Accessed August 11, 2004
  7. Goldberg L, Elliot D, Clarke GN, et al: Effects of a multidimensional anabolic steroid prevention intervention: the Adolescents Training and Learning to Avoid Steroids (ATLAS) program. JAMA 1996;276(19):1555-1562
  8. Goldberg L, MacKinnon DP, Elliot DL, et al: The adolescents training and learning to avoid steroids program: preventing drug use and promoting health behaviors. Arch Pediatr Adolesc Med 2000;154(4):332-338
  9. Pipe A, Ayotte C: Nutritional supplements and doping. Clin J Sport Med 2002;12(4): 245-249
  10. Gruber AJ, Pope HG Jr: Ephedrine abuse among 36 female weightlifters. Am J Addict 1998;7(4):256-261
  11. Foxford RJ, Sahlas DJ, Wingfield KA: Vasospasm-induced stroke in a varsity athlete secondary to ephedrine ingestion. Clin J Sport Med 2003;13(3):183-185
  12. Blendon RJ, DesRoches CM, Benson JM, et al: Americans' views on the use and regulation of dietary supplements. Arch Intern Med 2001;161(6):805-810
  13. Deuster PA, Sridhar A, Becker WJ, et al: Health assessment of US Army Rangers. Mil Med 2003;168(1):57-62
  14. Dowd J, Bailey D, Moussa K, et al: Ischemic colitis associated with pseudoephedrine: four cases. Am J Gastroenterol 1999;94(9):2430-2434
  15. Cantu C, Arauz A, Murillo-Bonilla LM, et al: Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs. Stroke 2003;34(7):1667-1672
  16. Franklin QJ: Sudden death after typhoid and Japanese encephalitis vaccination in a young male taking pseudoephedrine. Mil Med 1999;164(2):157-159
  17. Goldberg L, Bents RT, Bosworth EE, et al: Anabolic steroid education and adolescents: do scare tactics work? Pediatrics 1991;87(3):283-286
  18. Goldberg L, Bosworth EE, Bents RT, et al: Effect of an anabolic steroid education program on knowledge and attitudes of high school football players. J Adolesc Health Care 1990;11(3):210-214
  19. Kokotailo PK, Henry BC, Koscik RE, et al: Substance use and other health risk behaviors in collegiate athletes. Clin J Sport Med 1996;6(3):183-189
  20. Tricker R, Connolly D: Drugs and the college athlete: an analysis of the attitudes of student athletes at risk. J Drug Educ 1997;27(2):105-119
  21. Albrecht RR, Anderson WA, McGrew CA, et al: NCAA institutionally based drug testing: do our athletes know the rules of this game? Med Sci Sports Exerc 1992;24(2):242-246


Dr Bents is an orthopedic surgeon with Ashland Orthopedic Associates in Ashland, Oregon. Dr Tokish is an orthopedic surgeon in the department of orthopedic surgery at the United States Air Force Academy in Colorado Springs. Dr Goldberg is a professor of medicine and head of the division of health promotion and sports medicine in the department of medicine at Oregon Health and Science University in Portland, Oregon. Address correspondence to Lt Col Robert T. Bents, MD, 806 S Mountain Ave, Ashland, OR 97520; e-mail to [email protected].

Disclosure information: Drs Bents, Tokish, and Goldberg disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. Pseudoephedrine is mentioned in this article for an unlabeled use.


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