Alcohol Abuse and Drug Use in Sport and Performance
- Matthew P. MartensMatthew P. MartensUniversity of Missouri
Issues associated with athletics, alcohol abuse, and drug use continue to be salient aspects of popular culture. These issues include high-profile athletes experiencing public incidents as a direct or indirect result of alcohol and/or drug use, the role that performance-enhancing drugs play in impacting outcomes across a variety of professional and amateur contests, and the public-health effects alcohol abuse and drug use can have among athletes at all competitive levels. For some substances, like alcohol abuse, certain groups of athletes may be particularly at-risk relative to peers who are not athletes. For other substances, participating in athletics may serve as a protective factor. Unique considerations are associated with understanding alcohol abuse and drug use in sport. These include performance considerations (e.g., choosing to use or not use a certain substance due to concerns about its impact on athletic ability), the cultural context of different types of sporting environments that might facilitate or inhibit alcohol and/or drug use, and various internal personality characteristics and traits that may draw one toward both athletic activity and substance use. Fortunately, there are several effective strategies for preventing and reducing alcohol abuse and drug use, some of which have been tested specifically among athlete populations. If such strategies were widely disseminated, they would have the potential to make a significant impact on problems associated with alcohol abuse and drug use in sport and athletics.
Alcohol and drugs are a pervasive part of many sports, and in many ways they are inextricably linked. These links include issues such as ubiquitous alcohol advertising and sponsorship in many sports, frequent scandals involving performance-enhancing drugs (e.g., anabolic steroids and human growth hormone), and high-profile incidents among nationally known athletes that involve excessive alcohol and/or drug use. Scholarship on alcohol abuse, drug use, and sport has increased substantially, providing a more complete understanding of the phenomenon. Alcohol use among athletes has received more attention in the research literature than use of other substances, which is not surprising considering that it is abused more than drugs like marijuana, cocaine, and amphetamines. Three primary topics related to alcohol and other drug use are discussed in this article. First, rates of alcohol abuse and drug use among different groups of athletes are addressed. When possible, comparisons with relevant nonathletes norms are discussed. Second, several unique considerations associated with understanding alcohol abuse and drug use specifically among athletes are presented. Third, prevention and intervention strategies that have promise for reducing alcohol abuse and drug use in sport are explored. Finally, suggestions are provided for future directions among scholars and practitioners interested in this topic.
Prevalence of Substance Abuse in Sport
Although few studies have examined prevalence rates of alcohol abuse or other formal alcohol use disorders among athletes, several studies have examined rates of binge drinking or other indicators of at-risk alcohol consumption. Research has generally shown that younger adolescents participating in sport are more likely than those not participating in sport to report excessive alcohol use (Kwan, Bobko, Faulkner, Donnelly, & Cairney, 2014), although this relationship may differ depending upon other contextual factors. For example, one study of more than 8,000 high school students in the United States found that participating in sports was associated with an overall increase in problematic alcohol use over time, but only for adolescents who did not participate in other extracurricular activities like academic or music clubs (Mays, DePadilla, Thompson, Kushner, & Windle, 2010). Another study of more than 3,000 Norwegian adolescents found that sports participation was associated with increased likelihood of future alcohol intoxication, but only for those participating in team sports (Wichstrøm & Wichstrøm, 2009). Several large studies from the 1990s and early 2000s showed that college athletes in the United States were more likely than those not participating in formal athletics to report high-risk drinking and experience alcohol-related problems (Leichliter, Meilman, Presley, & Cashin, 1998; Nelson & Wechsler, 2001; Wechsler, Davenport, Dowdall, Grossman, & Zanakos, 1997). In these studies, more than 50% of college athletes reported at least one binge-drinking episode (typically defined as five or more drinks for men and four or more drinks for women in a single sitting) and more than 25% reported three or more binge-drinking episodes in the preceding two weeks. Comparison rates for those not participating in formal athletics were 38%–43% for at least one binge-drinking episode and 16%–21% for at least three binge-drinking episodes. College athletes were also more likely than nonathletes to report a host of academic, legal, and interpersonal difficulties associated with their alcohol use. A more recent study showed that college athletes at all competitive levels (intramural, club, and varsity) engaged in binge-drinking episodes more frequently than nonathletes (Barry, Howell, Riplinger, & Piazza-Gardner, 2015). Comparatively fewer studies have been conducted among older adults participating in organized sports, although evidence suggests both amateur and elite adult athletes in certain sports may drink more than the general adult population and/or at hazardous levels (Dietze, Fitzgerald, & Jenkinson, 2008; Kerry S O’Brien, Blackie, & Hunter, 2005; O’Farrell, Allwright, Kenny, Roddy, & Eldin, 2010). Together, the existing research suggests that, in general, those who participate in sport are at-risk for excessive alcohol use and related negative consequences.
In contrast to the literature on alcohol abuse, research on recreational drug use and sport suggests that those participating in athletics may be less likely than others to use a variety of substances (Lisha & Sussman, 2010). A meta-analysis of 17 studies examining drug use among adolescents found that those participating in sport were significantly less likely than those not participating in sport to report cannabis use (Diehl et al., 2012). Another systematic review of longitudinal studies among adolescents found that athletic participation was inversely associated with the use of drugs other than cannabis (Kwan et al., 2014). Research among college athletes in the United States has also found that athletes were less likely than nonathletes to report marijuana use (Wechsler et al., 1997), and rates of other drug use among this group are generally lower than population norms (Johnston, O’Malley, Bachman, Schulenberg, & Miech, 2015; Rexroat, 2014). Finally, the limited research on illicit drug use among elite athletes at both the adult and adolescent level also suggests lower prevalence rates relative to the general adult population (Dunn, Thomas, Swift, & Burns, 2011; Peretti-Watel et al., 2003).
Drug use in sport is often most associated with a variety of substances designed to improve athletic performance (e.g., anabolic steroids, human growth hormone). Many of these substances are illegal without a prescription and/or banned by sporting agencies. Several high-profile incidents have involved athletes being punished for the use of the substances, such as Ben Johnson losing the 100-meter track gold medal in the 1988 Olympics for steroid use, Lance Armstrong being stripped of seven Tour de France cycling titles for performance-enhancing drug use, and a number of top athletes in United States receiving suspensions for steroid or other performance-enhancing drug use. Such incidents may create the impression that performance-enhancing drug use is rampant in athletics, but the research evidence is equivocal. A meta-analysis of nine studies found an overall positive association between adolescent sports participation and anabolic steroid use (Diehl et al., 2012). In contrast, a study of more than 16,000 high school students in the United States reported no differences in steroid use between those who did and did not participate in athletics (Miller, Barnes, Sabo, Melnick, & Farrell, 2002). A 2013 study of approximately 21,000 college athletes in the United States indicated that only 0.4% of the sample used anabolic steroids in the preceding 12 months (Rexroat, 2014). In comparison, a national study of college students reported an annual prevalence rate of 0.5% (Johnston et al., 2015).
Rates of performance-enhancing drug use may be higher among elite athletes, where the stakes and incentives for optimal performance are quite high. A recent review of the literature concluded that the “doping” rate among elite athletes was between 14% and 39%, although there was considerable variation among different types of sports and hard data on the question is lacking (de Hon, Kuipers, & van Bottenburg, 2015). These estimates are consistent with several anecdotal reports in the popular press estimating that performance-enhancing drug use rates are relatively high among elite adult athletes, particular in certain sports (e.g., American football or track and field).
The Sporting Context, Alcohol Abuse, and Drug Use
Research has generally shown that, particularly among adolescents, sport participation is associated with positive psychosocial outcomes (Clark, Camiré, Wade, & Cairney, 2015). This finding extends to prevalence rates of some substances (e.g., cannabis and other illicit drugs), where sport participation has been shown to be a protective factor. Yet, for other substances (e.g., alcohol) sport participation serves as a risk factor. Such contradictory findings illustrate the importance of understanding the roles various sport-related factors play in either promoting or inhibiting alcohol abuse and drug use. It is also important to explore such factors considering the ethical issues inherent in the use of some substances in sport (i.e., performance-enhancing drugs) and the degree to which the use of other substances can lead to unique negative consequences for athletes (e.g., failed drug tests, negative publicity, poor sporting performance). Several factors that are somewhat unique to the sporting context are discussed.
The Cultural Context of Alcohol and Sport
Despite the potential negative effects of alcohol use on athletic performance (Barnes, 2014), in many countries alcohol and sport are inextricably linked. Alcohol beverage companies throughout the world serve as major sponsors for leagues, teams, and in some cases even individual athletes (Collins & Vamplew, 2002). There are several mechanisms by which these associations might translate to individual drinking behavior. One involves an indirect association: athletes, most of whom have likely been following sport from a young age, have strongly ingrained ideas associating athletic participation with alcohol consumption. A second is a more direct association, where athletes receive free or discounted alcohol products due to sponsorship from a beverage company. Two studies of athletes in Australia and New Zealand, ranging from club to national level, revealed positive associations between alcohol sponsorship and individual alcohol consumption (O’Brien & Kypri, 2008; O’Brien, Miller, Kolt, Martens, & Webber, 2011).
Another cultural aspect of sport that may relate to drinking behavior involves popularity and prestige. Athletes, particularly those who are successful and well-known, are often afforded higher social status than their peers, which can lead to significant social opportunities (Holland & Andre, 1994; Tricker, Cook, & McGuire, 1989). At the adolescent and collegiate level, successful athletes may find that they are regularly invited to social gatherings where alcohol or other drugs are provided. Athletes old enough to go to bars, clubs, and other public establishments may find that other patrons are eager to socialize with them, including purchasing their drinks. Additionally, a club or bar owner may provide free drinks to athletes of a certain stature to encourage their patronage. Basic behavioral economics principles indicate that the likelihood of substance use will increase with lower price and greater availability (Murphy, Correia, & Barnett, 2007). Thus, athletes who may be at-risk for developing a substance abuse problem may often find it relatively easy to be in social settings where alcohol and drugs are readily available.
Athletes have clear incentives to perform at an optimal level in their sport. The reward value of such incentives generally increase as athletes progress to more elite competitive levels, culminating in major awards, international recognition, educational opportunities in the form of university scholarships, and the opportunity to make one’s (often well-compensated) livelihood in sport. Thus, some athletes will be tempted to use substances that have the potential to make them stronger and faster, thereby improving their athletic performance. Indeed several studies among athletes at varying competitive levels have shown that the primary reason athletes choose to use performance-enhancing substances is to improve their athletic performance (Miller, Barnes, Sabo, Melnick, & Farrell, 2002; Rexroat, 2014). Conversely, concerns about the impacts certain substances can have on athletic performance may serve as an important deterrent among athletes. Research among college students in the United States suggests that concerns about athletic performance is an important reason they choose not to use certain substances, although factors such as health-related concerns and lack of desire to experience the substance’s effects seem to be more salient factors (Rexroat, 2014). Addressing the role certain substances can play in inhibiting athletic performance could be a potentially useful component of interventions designed to prevent and reduce drug use among athletes.
A unique aspect of many athletes’ lives involves the yearly rhythms surrounding their competitive season. Although many athletes train year-round, they have defined periods when their athletic performance is more salient and relevant. For example, the formal competitive season for a college football player in the United States runs from August (the start of official practice) through December or January (depending upon the date of the final game). These athletes may have other obligations throughout the year, such as spring practice and off-season workouts, but they are not participating in formal competitions. Athletes who limit alcohol and drug use due to performance-related concerns may choose to increase their use outside of these formal competitive seasons. Several research studies have shown that transitioning from in- to off-season serves as a risk factor for heavy drinking among athletes. Studies among college athletes in the United States found heavier alcohol consumption outside of their athletic season, including one longitudinal study that reported average drinking rates doubled during the off season (Bower & Martin, 1999; Martens, Dams-O’Connor, & Duffy-Paiement, 2006; Thombs, 2000). Another study of professional Australian Football League players showed a dramatic increase in risky drinking between pre-season and in-season time periods versus the off season (Dietze et al., 2008). The use of other substances may follow a similar pattern, and suggests the need for targeted intervention/prevention efforts for athletes transitioning out of their competitive seasons.
Formal testing for the presence of certain drugs, particularly during an athlete’s competitive season, is another factor that almost certainly impacts drug use among these groups. Elite athletes at the international level are regularly tested for both performance-enhancing and illicit drug use, as are athletes in many major professional sports leagues and major amateur organizations (e.g., college athletes at National Collegiate Athletic Association member institutions). Several studies have shown that drug testing serves as a deterrent to banned substances (Coombs & Ryan, 1990; Dunn, Thomas, Swift, Burns, & Mattick, 2010), and may partially account for relatively low prevalence rates of certain illegal drugs. However, one study among adolescents in the United States showed that randomized testing reduced drug use but increased other risk factors for use, such as perceived norms and less risky beliefs about drug use (Goldberg et al., 2003). Further, if athletes are aware of their testing schedule, they may be able to organize their use around times when it would not trigger a positive test. Fear of a positive drug test almost certainly inhibits short-term drug use for some athletes, but the degree to which drug testing provides a more general impact on the substance use habits of athletes is more difficult to determine.
A final sport-related contextual factor to address when considering substance use among athletes is ethical issues related to performance-enhancing drug use. This consideration is almost wholly unique to the athletic environment, as it is one of the only arenas where an individual may be incentivized to take a substance that would allow him or her to be physically superior to a specified opponent. Health or societal concerns regarding substance use can be applied across almost any group, but sport is unique in that use of certain substances may undermine the core foundation of the entity. Virtually all sports are based on the notion that each competitor agrees to a specified set of rules and regulations, which in many instances involve the types of drugs and other performance-enhancing techniques that are allowable. For example, in many professional sports leagues, athletes are allowed to take certain narcotic painkillers, but cannot take anabolic steroids or human growth hormone. Sporting organizations are motivated to ensure that athletes do not use drugs that are banned by their governing body, as it is important that they convey to the public that they are attempting to enforce the ideal of all athletes playing by the same rules. Further, sporting organizations are also motivated for their athletes to be perceived as living up to some sort of ideal (e.g., serving as a “role model” for children), which is why use of certain substances that have no performance benefits still results in suspension and other punishments. Many athletes therefore find themselves in situations regarding drug use that seem arbitrary, and at times hypocritical, in terms of the substances they can ingest. For example, they may be suspended for using a substance legal in several countries and states in the United States (cannabis), but they are allowed to use narcotic painkillers in an effort to facilitate their return to the practice or competitive arena.
Intervention and Prevention Strategies for Alcohol Abuse and Drug Use
A number of effective intervention and prevention strategies for alcohol abuse and drug use have been identified. This section of the chapter will address those strategies that have been well-studied and have the strongest empirical support. When possible, research that has examined these approaches specifically among athletes is presented here. Most of these studies focus on alcohol use, but in some cases their findings may translate to other substances.
Motivational Enhancement Interventions
The term “motivational enhancement” refers to a group of interventions, often sharing similar characteristics, which are designed to enhance an individual’s motivation to change a target behavior(s). Most of these interventions are founded in motivational interviewing, which is a theoretical and therapeutic approach that helps clients resolve ambiguity about behavior change (Miller & Rose, 2009). Motivational interviewing-based approaches are designed to help individuals identify their own reasons for change and support specific efforts toward change. A common feature of motivational enhancement interventions is personalized feedback, where the individual receives personalized information about the behavior in question. Theoretically, this feedback helps increase internal discrepancies in the individual that subsequently result in behavior change. Popular components of this feedback include personalized social norms information (i.e., how the individual’s drinking behavior and perception of “typical” drinking among a specific reference groups compares to actual drinking norms), typical drinking levels (e.g., estimated blood alcohol concentration on a heavy drinking occasion) and risks associated with such levels, and a summary of problems associated with the behavior in question (e.g., specific negative consequences experienced over the past 30 days as a result of alcohol consumption). These interventions also sometimes include an alcohol skills training component (Dimeff, Baer, Kivlahan, & Marlatt, 1999).
Overall, there is considerable empirical support for the efficacy of motivational enhancement interventions. Several meta-analyses have shown that brief (1–2 sessions) in-person interventions are effective at reducing at-risk alcohol and drug use (Burke, Arkowitz, & Menchola, 2003; Jensen et al., 2011; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). Further, interventions that provide personalized feedback in the absence of individual clinician contact have also been shown to be efficacious at impacting substance use (Miller et al., 2013). A handful of studies have examined the efficacy of motivational enhancing interventions specifically among athletes, with promising results. For example, in one study, Martens and colleagues (2010) found that a personalized feedback-only intervention was effective among a sample of college athletes at reducing peak blood alcohol concentration. Another study by Doumas et al. (2010) found that a feedback-only intervention was effective among high-risk drinkers at reducing average weekly drinking, drinking to intoxication, and peak number of drinks consumed on a single occasion. Finally, a recent study by Cimini et al. (2015) provided similar support for the efficacy of a single-session in-person motivational enhancement intervention. Together, these findings suggest that brief, motivational enhancement interventions have considerable potential in reducing harmful alcohol consumption among athletes.
Alcohol and Drug Skills Training Programs
Another class of interventions involve those designed to teach individuals specific skills and strategies that are used to reduce alcohol and drug use and limit the likelihood of experiencing substance-related problems. Most of these programs have focused on alcohol use, and their specific content can vary widely and include both alcohol-specific topics and general lifestyle factors (Larimer & Cronce, 2007). The delivery of these types of programs can also vary considerably, including individually in the context of a motivational interviewing-based session (Martens, Smith, & Murphy, 2013), in a group format (Fromme & Corbin, 2004), or via a computer without personal contact (Carey, Henson, Carey, & Maisto, 2009). Overall, empirical support for these types of programs has been mixed, which is not surprising considering the diversity of approaches (Cronce & Larimer, 2011).
Only a few studies have examined the efficacy of alcohol skills programs specifically among athletes. One early study found no effects for a single session program delivered in a group setting that included general educational information about alcohol and other drugs, stress management, and strategies to alleviate peer pressure associated with substance use (Marcello, Danish, & Stolberg, 1989). This study was limited by factors such as a low sample size and high dropout rate. Other skills programs are presented in the literature, but they have either not been formally evaluated (Curry & Maniar, 2004; Meilman & Fleming, 1990) or have not been subjected to peer review (Wyrick et al., 2009). Considering that many sporting entities mandate that their athletes receive some degree of education/training on alcohol and drug-related issues, implementing skills-based programs that have shown evidence of efficacy in the general population could have a significant impact on the alcohol and drug use habits of athletes at a variety of competitive levels.
One of the most efficacious strategies for intervening with individuals experiencing alcohol and drug disorders is contingency management, with one meta-analysis indicating that it had the strongest effects of any psychosocial intervention in terms of treating substance use disorders (Dutra et al., 2008). Contingency management interventions are based on basic operant behavior principles, where target behavior is reinforced and therefore likely to increase. For example, patients in a contingency management program for a drug-use disorder may receive a cash payment or voucher each time they provide a negative urine sample. The level of reinforcement often increases over time, with consecutive instances of the target behavior yielding escalating rewards (Budney, Moore, Rocha, & Higgins, 2006). Theoretically, the individual will initially engage in the behavior (e.g., being abstinent from alcohol or drugs) to receive the tangible reward associated with the intervention. Over time, the individual will begin to experience other reinforcers that naturally occur due to decreased substance use, such as better relationships and job performance. Ideally, these reinforcers will be powerful enough to cause the individual to continue to engage in the target behavior even after the contingency management intervention has ended. For example, an athlete in a contingency management program whose sport performance improves after ceasing drug use may be likely to continue to refrain from drug use even when he or she no longer receives the financial incentives associated with the program.
To date no studies have been published that examined the efficacy of contingency management interventions specifically among athletes. Due to the fact that many sporting organizations already routinely test athletes for various substances, implementing such a program in certain athletic settings may be somewhat easier than the typical outpatient or inpatient clinic. Indeed, many organizations already have a punishment-related system affiliated with drug testing (e.g., suspensions for positive drug tests); a contingency management system would involve the reverse of this, where athletes received incentives for negative drug tests. Such a program would likely be most appropriate for athletes who have been experiencing fairly significant alcohol and drug problems and are attempting to eliminate their use of the substances.
Twelve-step programs are likely the mode of alcohol and drug abuse intervention most familiar to the general public. They are most frequently affiliated with Alcoholics Anonymous or Narcotics Anonymous (AA/NA). AA or NA programs have historically been the most common route for individuals to engage in a 12-step program, but there are examples of individual interventions designed to facilitate the 12-step process (e.g., Project MATCH Research Group, 1997). Twelve-step programs conceptualize addiction as a disease, and therefore complete abstinence is the desired outcome. “Working” a 12-step program involves a series of steps, which include behaviors such as admitting that one is powerless over addiction (Step 1), asking God or a higher power to remove shortcomings (Step 7), and carrying the 12-step message to other alcoholics/addicts (Step 12).
There is evidence to suggest that 12-step programs are as efficacious as other interventions/treatments (Ouimette, Finney, & Moos, 1997; Project MATCH Research Group, 1997). However, it can be difficult to examine the efficacy of individual 12-step programs; by definition, they are usually anonymous and assignment to appropriate control conditions is logistically challenging. No published studies have examined the efficacy of 12-step programs among athletes, although numerous athletes have undoubtedly participated in such programs. If an athlete has a significant alcohol abuse and/or drug use problem and is open to abstinence as a treatment goal, then encouraging them to consider a 12-step program would be appropriate.
Environmental interventions to refer to a broad class of interventions designed to impact behavior by changing the external environment in such a way as to inhibit alcohol and drug use. The interventions addressed thus far in this chapter are individual interventions, in that they are designed to change thoughts, behaviors, and emotions of specific individuals who receive the intervention. In contrast, environmental interventions are not necessarily targeted to specific individuals but are designed to create a context that disincentivizes alcohol and drug use among all of those in the environment. Most of these interventions have focused on alcohol use because it is a legal substance readily available in most communities. An example of a well-known environmental intervention involved raising the drinking age in the United States from 18 to 21, which resulted in a decrease in alcohol consumption and traffic crashes (Wagenaar & Toomey, 2002).
Many environmental interventions involve attempts to create policies or rules that limit access to alcohol, such as restricting times when alcohol can be sold or outlawing drink discounts or other specials that might encourage heavy alcohol use (Toomey, Lenk, & Wagenaar, 2007). Other interventions focus on creating, publicizing, and enforcing rules against alcohol and drug use (e.g., alcohol-free dormitories on college campuses). A number of studies have shown that environmental interventions can be efficacious at impacting the target behavior (see Middleton et al., 2010; Task Force on Community Preventive Services, 2010; Toomey et al., 2007), but they can also pose unique challenges. Implementing environmental interventions often requires considerable coordination among a variety of parties, some of whom actually benefit from substance use. For example, if a group of bar owners believed that drink specials yielded more patrons and greater profits, it might be challenging to convince them to outlaw such specials in an attempt to limit heavy drinking.
Another means of conceptualizing environmental interventions for alcohol and drug abuse is behavioral economics theory, which posits that the decision to use substances is related to availability and price of both the substances themselves and alternative sources of reinforcement (Vuchinich & Tucker, 1988). For example, all else being equal, adolescent alcohol use would theoretically be lower in a community that had numerous alcohol-free social activities available that were reinforcing to young people than a community that did not have such alternative activities. Behavioral economic theory also posits that alcohol and drug use will be lower when individuals are orientated toward future rewards incompatible with substance use, such as successful educational and vocational outcomes (Murphy & Dennhardt, 2016). Therefore, environmental interventions that promote such a future-based orientation may result in diminished desire to obtain short-term reinforcement from alcohol and drug use.
To date, only one large controlled trial has examined the efficacy of an environmental alcohol intervention among athletes. In this study, the researchers evaluated the efficacy of the Good Sports program (Rowland, Allen, & Toumbourou, 2012), which was implemented at community football clubs in Australia. This program includes a variety of environmental interventions grouped across three accreditation levels. An example of a level 1 intervention strategy is serving alcoholic drinks only in standard drink amounts, an example of a level 2 strategy is not serving shots of liquor, and an example of a level 3 is having and distributing a written alcohol policy to club members. An initial study showed that clubs with higher accreditation levels reported less alcohol use than clubs with lower accreditation levels (Rowland et al., 2012). Subsequently, researchers conducted a trial where 88 football clubs were randomized to the intervention or control condition. After the intervention, participants in the intervention condition reported less risky alcohol use than those in the control condition (Kingsland et al., 2015).
Considering these promising findings, as well as the overall support for different types of environmental interventions in other populations, athletic organizations should consider contextual strategies designed to limit alcohol and other drug use. Many large organizations have clear rules and policies built into their larger systems, such as suspensions for positive drug tests or alcohol-related arrests. Individual teams, clubs, or schools/universities could build more specific, targeted policies into their systems. For example, a high school or adolescent sporting club might ask team members to sign a pledge to refrain from alcohol and drug use, whereas a collegiate or adult club might ask team members to pledge to limit their alcohol consumption in some way. Consistent with behavioral economic theories, organizations could also promote social activities that do not involve substance use. Such strategies may be particularly useful among adolescents and young adults, and they could involve activities such as regular team social outings and partnerships with local community organizations that offer substance-free activities.
Conclusion and Future Directions
Research has convincingly established that for some substances, particularly alcohol, athletes have higher levels of at-risk use than individuals not participating in athletics. Conversely, rates of use for many other types of drugs are lower among athletes than nonathletes. Nonetheless, it is important to focus on understanding and limiting drug use among athletes, considering the myriad negative effects of such use on this population at all competitive levels. Research in the general population has established several effective individual and environmental intervention strategies, and there is emerging evidence for the efficacy of many of these interventions specifically among athletes. One recommendation for future research is to examine strategies for disseminating different types of empirically supported interventions to athletes, particularly those that are low cost (e.g., personalized feedback interventions delivered electronically). A second research direction could involve examining the efficacy of environmental interventions at more local levels, such as team-specific strategies designed to limit alcohol and drug use. A third direction involves more research focused on substances besides alcohol, particularly in terms of intervention studies. Finally, researchers could consider exploring strategies for targeting/tailoring existing interventions to be more efficacious specifically among athletes. For example, one study found that personalized feedback tailored specifically for college athletes was more effective than feedback applicable to a general student population at reducing high-risk drinking (Martens, Kilmer, Beck, & Zamboanga, 2010). Tailoring other types of existing interventions may also yield enhanced effects among athletes.
- Barnes, M. J. (2014). Alcohol: Impacts on sports performance and recovery in male athletes. Sports Medicine, 44, 909–919.
- Barry, A. E., Howell, S. M., Riplinger, A., & Piazza-Gardner, A. K. (2015). Alcohol use among college athletes: do intercollegiate, club, or intramural student athletes drink differently? Substance Use & Misuse, 50, 302–307.
- Bower, B. L., & Martin, M. (1999). African American female basketball players: An examination of alcohol and drug behaviors. Journal of American College Health, 48, 129–133.
- Budney, A. J., Moore, B. A., Rocha, H. L., & Higgins, S. T. (2006). Clinical trial of abstinence-based vouchers and cognitive-behavioral therapy for cannabis dependence. Journal of Consulting and Clinical Psychology, 74, 307–316.
- Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843–861.
- Carey, K. B., Henson, J. M., Carey, M. P., & Maisto, S. A. (2009). Computer versus in-person intervention for students violating campus alcohol policy. Journal of Consulting and Clinical Psychology, 77, 74–87.
- Cimini, M. D., Monserrat, J. M., Sokolowski, K. L., Dewitt-Parker, J. Y., Rivero, E. M., & McElroy, L. A. (2015). Reducing high-risk drinking among student-athletes: The effects of a targeted athlete-specific brief intervention. Journal of American College Health, 63, 343–352.
- Clark, H. J., Camiré, M., Wade, T. J., & Cairney, J. (2015). Sport participation and its association with social and psychological factors known to predict substance use and abuse among youth: A scoping review of the literature. International Review of Sport and Exercise Psychology, 8, 224–250.
- Collins, T., & Vamplew, W. (2002). Mud, sweat, and beers: A cultural history of sport and Alcohol. New York: Berg.
- Coombs, R. H., & Ryan, F. J. (1990). Drug testing effectiveness in identifying and preventing drug use. The American Journal of Drug and Alcohol Abuse, 16, 173–184.
- Cronce, J. M., & Larimer, M. E. (2011). Individual-focused approaches to the prevention of college student drinking. Alcohol Research & Health, 34, 210–221.
- Curry, L. A., & Maniar, S. D. (2004). Academic course for enhancing student-athlete performance in sport. Sport Psychologist, 18, 297–316.
- de Hon, O., Kuipers, H., & van Bottenburg, M. (2015). Prevalence of doping use in elite sports: A review of numbers and methods. Sports Medicine, 45, 57–69.
- Diehl, K., Thiel, A., Zipfel, S., Mayer, J., Litaker, D. G., & Schneider, S. (2012). How healthy is the behavior of young athletes? A systematic literature review and meta-analyses. Journal of Sports Science & Medicine, 11, 201–220.
- Dietze, P. M., Fitzgerald, J. L., & Jenkinson, R. A. (2008). Drinking by professional Australian Football League (AFL) players: Prevalence and correlates of risk. Medical Journal of Australia, 189, 479–483.
- Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief alcohol screening and intervention for college students (BASICS): A harm reduction approach. New York: Guilford.
- Doumas, D. M., Haustveit, T., & Coll, K. M. (2010). Reducing heavy drinking among first year intercollegiate athletes: A randomized controlled trial of web-based normative feedback. Journal of Applied Sport Psychology, 22, 247–261.
- Dunn, M., Thomas, J. O., Swift, W., & Burns, L. (2011). Recreational substance use among elite Australian athletes. Drug and Alcohol Review, 30, 63–68.
- Dunn, M., Thomas, J. O., Swift, W., Burns, L., & Mattick, R. P. (2010). Drug testing in sport: The attitudes and experiences of elite athletes. International Journal of Drug Policy, 21, 330–332.
- Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry, 165, 179–187.
- Fromme, K., & Corbin, W. (2004). Prevention of heavy drinking and associated negative consequences among mandated and voluntary college students. Journal of Consulting and Clinical Psychology, 72, 1038–1049.
- Goldberg, L., Elliot, D. L., MacKinnon, D. P., Moe, E., Kuehl, K. S., Nohre, L., & Lockwood, C. M. (2003). Drug testing athletes to prevent substance abuse: Background and pilot study results of the SATURN (Student Athlete Testing Using Random Notification) study. Journal of Adolescent Health, 32, 16–25.
- Holland, A., & Andre, T. (1994). Athletic participation and the social status of adolescent males and females. Youth & Society, 25, 388–407.
- Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. Journal of Consulting and Clinical Psychology, 79, 433–440.
- Johnston, L. D., O’Malley, P. M., Bachman, J., Schulenberg, J. E., & Miech, R. A. (2015). Monitoring the Future national survey results on drug use, 1975–2014: Volume 2, College students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan.
- Kingsland, M., Wolfenden, L., Tindall, J., Rowland, B. C., Lecathelinais, C., Gillham, K. E., . . . , McElduff, P. (2015). Tackling risky alcohol consumption in sport: A cluster randomised controlled trial of an alcohol management intervention with community football clubs. Journal of Epidemiology and Community Health. Advance Online Publication.
- Kwan, M., Bobko, S., Faulkner, G., Donnelly, P., & Cairney, J. (2014). Sport participation and alcohol and illicit drug use in adolescents and young adults: A systematic review of longitudinal studies. Addictive Behaviors, 39, 497–506.
- Larimer, M. E., & Cronce, J. M. (2007). Identification, prevention, and treatment revisited: Individual-focused college drinking prevention strategies 1999–2006. Addictive Behaviors, 32, 2439–2468.
- Leichliter, J. S., Meilman, P. W., Presley, C. A., & Cashin, J. R. (1998). Alcohol use and related consequences among students with varying levels of involvement in college athletics. Journal of American College Health, 46, 257–262.
- Lisha, N. E., & Sussman, S. (2010). Relationship of high school and college sports participation with alcohol, tobacco, and illicit drug use: A review. Addictive Behaviors, 35, 399–407.
- Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137–160.
- Marcello, R. J., Danish, S. J., & Stolberg, A. L. (1989). An evaluation of strategies developed to prevent substance abuse among student-athletes. Sport Psychologist, 3, 196–211.
- Martens, M. P., Dams-O’Connor, K., & Duffy-Paiement, C. (2006). Comparing off-season with in-season alcohol consumption among intercollegiate athletes. Journal of Sport and Exercise Psychology, 28, 502–510.
- Martens, M. P., Kilmer, J. R., Beck, N. C., & Zamboanga, B. L. (2010). The efficacy of a targeted personalized drinking feedback intervention among intercollegiate athletes: A randomized controlled trial. Psychology of Addictive Behaviors, 24, 660–669.
- Martens, M. P., Smith, A. E., & Murphy, J. G. (2013). The efficacy of single-component brief motivational interventions among at-risk college drinkers. Journal of Consulting and Clinical Psychology, 81, 691–701.
- Mays, D., DePadilla, L., Thompson, N. J., Kushner, H. I., & Windle, M. (2010). Sports participation and problem alcohol use: A multi-wave national sample of adolescents. American Journal of Preventive Medicine, 38, 491–498.
- Meilman, P. W. & Fleming, R. L. (1990). A substance abuse prevention program for student-athletes. Journal of College Student Development, 31, 477–479.
- Middleton, J. C., Hahn, R. A., Kuzara, J. L., Elder, R., Brewer, R., Chattopadhyay, S . . . , Lawrence, B. Task Force on Community and Preventive Services (2010). Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 39, 575–589.
- Miller, K. E., Barnes, G. M., Sabo, D., Melnick, M. J., & Farrell, M. P. (2002). A comparison of health risk behavior in adolescent users of anabolic-androgenic steroids, by gender and athlete status. Sociology of Sport Journal, 19, 385–402.
- Miller, K. E., Barnes, G. M., Sabo, D. F., Melnick, M. J., & Farrell, M. P. (2002). Anabolic-androgenic steroid use and other adolescent problem behaviors: Rethinking the male athlete assumption. Sociological Perspectives, 45, 467–489.
- Miller, M. B., Leffingwell, T., Claborn, K., Meier, E., Walters, S., & Neighbors, C. (2013). Personalized feedback interventions for college alcohol misuse: An update of Walters & Neighbors (2005). Psychology of Addictive Behaviors, 27, 909–920.
- Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American psychologist, 64, 527–537.
- Murphy, J., & Dennhardt, A. (2016). The behavioral economics of young adult substance abuse. Preventive Medicine. Advance Online Publication.
- Murphy, J. G., Correia, C. J., & Barnett, N. P. (2007). Behavioral economic approaches to reduce college student drinking. Addictive Behaviors, 32, 2573–2585.
- Nelson, T. F., & Wechsler, H. (2001). Alcohol and college athletes. Medicine & Science in Sports & Exercise, 33, 43–47.
- O’Brien, K. S., Blackie, J. M., & Hunter, J. A. (2005). Hazardous drinking in elite New Zealand sportspeople. Alcohol and Alcoholism, 40, 239–241.
- O’Brien, K. S., & Kypri, K. (2008). Alcohol industry sponsorship and hazardous drinking among sportspeople. Addiction, 103, 1961–1966.
- O’Brien, K. S., Miller, P. G., Kolt, G. S., Martens, M. P., & Webber, A. (2011). Alcohol industry and non-alcohol industry sponsorship of sportspeople and drinking. Alcohol and Alcoholism, 46, 210–213.
- O’Farrell, A. M., Allwright, S. P., Kenny, S. C., Roddy, G., & Eldin, N. (2010). Alcohol use among amateur sportsmen in Ireland. BMC Research Notes, 3, 313.
- Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-step and cognitive-behavioral treatment of substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, 65, 230–240.
- Peretti-Watel, P., Guagliardo, V., Verger, P., Pruvost, J., Mignon, P., & Obadia, Y. (2003). Sporting activity and drug use: Alcohol, cigarette and cannabis use among elite student athletes. Addiction, 98, 1249–1256.
- Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29.
- Rexroat, M. (2014). NCAA National Study of Substance Use Habits of College Student-Athletes.
- Rowland, B., Allen, F., & Toumbourou, J. W. (2012). Impact of alcohol harm reduction strategies in community sports clubs: Pilot evaluation of the Good Sports program. Health Psychology, 31, 323–333.
- Task Force on Community Preventive Services (2010). Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 39, 590–604.
- Thombs, D. L. (2000). A test of the perceived norms model to explain drinking patterns among university student athletes. Journal of American College Health, 49, 75–83.
- Toomey, T. L., Lenk, K. M., & Wagenaar, A. C. (2007). Environmental policies to reduce college drinking: An update of research findings. Journal of Studies on Alcohol and Drugs, 68, 208–219.
- Tricker, R., Cook, D. L., & McGuire, R. (1989). Issues related to drug abuse in college athletics: Athletes at risk. Sport Psychologist, 3, 155–165.
- Vuchinich, R. E., & Tucker, J. A. (1988). Contributions from behavioral theories of choice to an analysis of alcohol abuse. Journal of Abnormal Psychology, 97, 181–195.
- Wagenaar, A. C., & Toomey, T. L. (2002). Effects of minimum drinking age laws: review and analyses of the literature from 1960 to 2000. Journal of Studies on Alcohol, Supplement 14, 206–225.
- Wechsler, H., Davenport, A. E., Dowdall, G. W., Grossman, S. J., & Zanakos, S. I. (1997). Binge drinking, tobacco, and illicit drug use and involvement in college athletics: A survey of students at 140 American colleges. Journal of American College Health, 45, 195–200.
- Wichstrøm, T., & Wichstrøm, L. (2009). Does sports participation during adolescence prevent later alcohol, tobacco and cannabis use? Addiction, 104, 138–149.
- Wyrick, D. L., Fearnow-Kenney, M., & Milroy, J. (2009). Drug and alcohol prevention for NCAA student-athletes: Division II pilot study final report. Greensboro, NC: Prevention Strategies.