Schukow C. Addiction, substance use, and pressure among adolescent through collegiate athletes-why we need to keep talking. HPHR. 2021;50.
For over a decade of my life, I had the privilege of playing football for my hometown of Saline, MI, and, then, the community of Hillsdale, MI (Hillsdale College). There are many experiences, memories, and life lessons I developed through football which I would not trade for the world. I learned how to be a part of a team, and work with others towards a common goal, which are both vital aspects of team-based sports according to literature reviews (Malm et. al., 2019).
These positive experiences did not come without negative ones, though. I faced mental health struggles as I learned how to cope with my various injuries and my transition from football to medical school. Sports psychologists are continuing to challenge the negative stigma behind acknowledging athletes’ mental health and well-being through talking openly and admittingly (Bauman, 2016). Battles such as addiction and substance abuse, however, were apparent in the careers of many of my former teammates, even as early as middle school. Thus, open discussion with young athletes should not only include mental health, but addiction and substance abuse, a trend increasingly impacting this population (Bump, 2018).
In 2009, the results of a survey of 2,300 high school seniors published in the Journal of Child & Adolescent Substance Abuse showed that high school athletes across the United States are more likely to use drugs than their peers and are at greater risk of abusing substances (Dunn, 2014). Strikingly, the survey found that roughly 12% of male and about 8% of female high school athletes (20% altogether) reported abusing opioids, or “painkillers”, such as codeine (Dunn, 2014). This is compared to a survey of over 13,000 high school students by the Centers for Disease Control and Prevention (CDC) in 2019, where 14.3% reported a misuse of prescription opioids at some point in their lifetimes (Jones et. al., 2020). The COVID-19 pandemic, recently, has forced many athletes into periods of isolation during their training, putting them at an increased risk of abusing substances such as cannabis as they cope with quarantine and virtual training, too (Reardon et. al., 2021).
While research remains conflicted on whether sports increase a person’s risk of abusing cannabis, studies consistently demonstrate that high school and college athletes are at a greater risk of alcohol abuse than their non-athlete peers (Williams et. al., 2020; Barros, 2008). A study published in 2011 reported roughly 57% of high school athletes admitting to drinking alcohol “within the previous month” (Terry-McElrath & O’Malley, 2011). In the same 2019 CDC survey mentioned earlier, only 29.2% of high school students reported current (i.e., “previous 30 days before the survey”) alcohol use, with 13.7% admitting to current binge drinking (Jones et. al., 2020). Unfortunately, this CDC study does not specify which respondents were “athletes” and “non-athletes”. More research needs to be done on this topic to quantify this association between adolescent- and college-athletics and drug (i.e., opioid, alcohol) abuse risk.
It is without question that exceptional dedication, perseverance, and grit are required for any athlete to excel in his or her sport, especially when transitioning from high school to college and beyond (Hodges et. al., 2017). The stresses most athletes feel to perform at high levels often challenges this delicate balance between being mental toughness and mental health, though (Bauman, 2016). Systematic reviews show that the prevalence of mental health conditions (e.g., depression, anxiety) among “elite” (i.e., college, Olympic) athletes and the general population are similar (Rice et. al., 2016). Sports psychiatrists have found, however, that injuries, performance failure, and retirement (especially early retirement) put athletes at greater risks for developing unhealthy coping mechanisms and thought patterns if not addressed appropriately (Ströhle, 2019).
Can the stress of athletics, then, potentiate the risk for substance abuse? The short answer is yes. In 2020, a literature review of substance abuse from adolescent- to elite-athletes composed at Eastern Michigan University suggests that there is a major pressure many athletes face to succeed “at all costs” (Carreathers, 2020). To reveal this, the author cited a 2011 survey of over 2100 Olympic athletes who participated in international championships in Daegu, South Korea in August 2011 and in Doha, Qatar in December 2011. Nearly 57% of respondents admitted using performance enhancing drugs (PED) such as anabolic steroids, stimulants, Erythropoietin (EPO), and Human Growth Hormone (HGH) (Ulrich, 2018; Carreathers, 2020). Furthermore, the author noted a 2017 survey of 800 athletes (both current and retired) conducted by the United States Anti-Doping Agency (USADA) where roughly 48% of respondents believed the public would perceive them negatively if they failed in their sport. Furthermore, about 61% of respondents believed that the public only cared about them as “winners” (USADA, 2019; Carreathers, 2020).
The recent rise in PED abuse among high school athletes has drawn much concern from the American Academy of Pediatrics (AAP). Pediatricians are noticing athletes at younger ages feeling similar pressures to succeed at the expense of their developmental health and personal well-being (White & Noeun, 2016). In 2013, the Partnership Attitude Tracking Study (PATS) found that 11% of teens reported using synthetic growth hormone, which was a 2-fold increase from 2012 (PATS, 2013). This study also found that anabolic steroid use among high school athletes, especially males, increased from 5% to 7% in the same time frame (PATS, 2013).
Family members play a major role in exacerbating these negative pressures young athletes may face, as suggested by results published in the 2015 GOALS survey, taken by over 21,000 National Collegiate Athletic Association (NCAA) athletes (NCAA, 2016). In this study, athletes reported “high parental/familial expectations of playing college and/or professional Olympic sports that started at a young age” as a major stressor (NCAA, 2016). The reality is that less than about 2% of all college athletes play professionally or compete in the Olympics (NCAA, 2018). Playing in college from high school is a competitive challenge as it is. Recent data released by the NCAA confirmed that nearly 8 million students played in high school sports from 2018-2019, but only 495,000 (about 6%) went on to compete at an NCAA affiliated college (NCAA, 2020).
Whether high school, college, or beyond, one major gateway to substance abuse, namely opioid, is suffering a sports-related injury (Ford et. al., 2018). Fortunately, injuries caused me to miss only one game out of my over forty college football game career. In middle school, I began learning how to “play through pain”, as many athletes do. In 2014, a longitudinal survey found that approximately 21% of male and 14% of female adolescent athletes suffer sports-related injuries annually (Veliz et. al., 2014).
During my five-year career at Hillsdale College, I recall playing through multiple bone contusions, pes anserine bursitis, patella tendonitis, numerous grade I ankle sprains, a grade II/III right ankle sprain, a grade II right MCL sprain, a partial hamstring tear, numerous “jammed” fingers, and multiple shoulder stingers. Balancing my need to “play through the pain” versus my need to rest and recover was an ongoing challenge, as football became so deeply ingrained in my identity, as sport does for many athletes (Malm et. al., 2019).
The number one cause of drug-related overdose deaths in the United States are due to opioids, which has increased 4-fold from 16,849 in 1999 to 70,237 in 2017 (Singh et. al., 2019). Among adolescent athletes, a 2014 survey revealed that males were more likely to be prescribed, abuse (i.e., “to get high”), and misuse (i.e., “taking too much”) opioids when compared to non-athlete peers (Veliz et. al., 2014). In 2020, a systematic review revealed that high school athletes have a 28-46% lifetime risk of opioid use, too (Ekhtiari et. al., 2020). Regarding how most adolescents obtain non-prescription opioids, a 2015 review showed that nearly 53% of those age 12 and older obtained them “free” from a family member or friend who often had a prescription (Tetrault & Butner, 2015).
As these and other studies show, an association exists between substance use and sports from adolescent to college-aged athletes. Reflecting on my career as a small-town, Division II athlete, I acknowledge how many other college athletes attend larger universities and play in bigger venues, thus, potentially feeling more pressure surrounding their abilities to perform. However, these issues of addiction, substance abuse, and mental health impact athletes of all ages, and we cannot not afford to shy away from addressing them today or in the future.
While more professionals involved with sports are recognizing the mental health struggles many athletes from adolescence to college may experience, this open conversation must continue to include addiction and substance use. Pressures elite athletes often face, such as to succeed and win, have trickled down to adolescents, who also feel familial pressures to play sports in college and beyond. Substances such as PEDs, cannabis, alcohol, and opioids are increasingly impacting young athletes, too.
An important step in addressing this issue of substance abuse is through prevention, which may be in the form of team- and community-based didactic education programs (Reardon & Creado, 2014). Athletes who may already be struggling with substance abuse should be seen by clinicians, who can help them through empathetic motivational interviewing (Reardon & Creado, 2014). When counseling young athletes, clinicians should address their goals (i.e., sport versus life after sport), and discuss any conflicts between personal values and drug-behaviors they may be facing (Reardon & Creado, 2014). Although resistance may be felt by athletes towards clinicians when discussing drug abuse, clinicians should avoid argument and propose different alternative ideas without imposing, heavily suggesting, or insisting upon them (Reardon & Creado, 2014).
Perhaps the most important thing clinicians, family members, and community members can do to address this issue is encourage athlete self-worth/efficacy (Reardon & Creado, 2014). In other words, we need to ensure that athletes know they are “good enough”, and that “winning”, or “success” should not be dependent on the inappropriate use of substances, rather hard work and determination. Athletes who are physically dependent on drugs, though, may need pharmacologic interventions (such as naltrexone for opioid and/or alcohol dependence), as well as twelve-step rehabilitation and/or cognitive behavior therapy (Reardon & Creado, 2014).
Policy makers, physicians, and community members should continue promoting and encouraging awareness and prevention programs (Veliz & McCabe, 2015), as well as treatment centers. Michael’s House in Palm Springs, CA, is an example of a treatment center where athletes struggling with addiction and substance use can get the professional help and support they may need (Michael’s House, 2021). What is important about treatment centers such as this one is that they can clinically address potential co-morbid psychiatric conditions such as depression, which is seen in about 25% of college athletes (Wolanin et. al., 2016). Marshall Mintz, a sports psychologist, said in an article written by Linda Flanagan in The Atlantic that “the incidence of anxiety and depression among scholastic athletes has increased over the past 10 to 15 years” (Flanagan, 2019).
A 2015 National Athletic Trainers’ Association study, also cited in Flanagan’s article, found that “many student athletes report higher levels of negative emotional states than non-student-athlete adolescents” (Neal et. al., 2015; Flanagan, 2019). Substance abuse effects areas of the brain impacted by mental health conditions such as depression and anxiety, thus comorbidity is relatively common (Carreathers, 2020). However, more research needs to be done to understand this complex association, and its relationship to athletics.
Above all else, I encourage coaches, family members, and community members to continue talking openly about addiction, substance use, and mental health with young athletes. Doing so, we can foster safer and healthier competitive environments for all athletes moving forward.
The author would like to acknowledge Mark Schuby, substance abuse counselor at Saline Area Schools (Saline, MI), and Laura Arrick, librarian at Henry Ford Wyandotte (MI) Hospital, for their reviews of this paper.
The author has no known conflicts of interest to disclose and did not receive any financial support for this paper.
Correspondence concerning this article should be addressed to: Casey P. Schukow, Michigan State University College of Osteopathic Medicine – Detroit, 4707 St Antoine, Detroit, MI, 48201.
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Casey Paul Schukow is a fourth-year medical student at Michigan State University College of Osteopathic Medicine (MSUCOM).