Pharmacologythe branch of science that deals with the action of drugs on the biological systemsSpecifically those that are used in medicine for diagnostic and therapeutic purposesUsed to achieve definite outcomes that improve quality of lifeVarious drugs and other substances are being used widely for performance enhancement or mood alteration

What is a drug?Chemical agent used in prevention, treatment, & diagnosis of disease

Ancient practice dating back to the Egyptians

Many are derived from natural sources

Drugs which have, in the past, come from nature are now produced synthetically

Administration of DrugsMust first enter the system and reach receptor tissue to be effectiveInternal administration

Inhalation (medication through respiratory tract)Intradermal (into the skin)Intramuscular (medication directly into muscle)Intranasal Intrathecal (medication injected into the spine)

Oral (most common form)Rectal (limited due to dosage regulation)Sublingual/buccal (dissolvable agents placed under tongueIntravaginal (placing drug device inside vagina)

Administration of DrugsMust first enter the system and reach receptor tissue to be effectiveExternal administration

Inunctions (oil based medication rubbed into skin)

Ointments (long lasting topical medication

Pastes (ointments with nonfat base

Plasters (thick ointment, counterirritant for pain & inflammation relief, increasing circulation)Transdermal patches (patch with slow release mechanism)

Solutions administered externally)

PharmacokineticsMethod by which drugs are absorbed, distributed, metabolized and eliminated from the body

Pharmacodynamics is the actions or effects of drugs on the body

Absorption of Drugs

Rate and extent determined by chemical characteristics of drug, dosage, and gastric emptying

Drug must dissolve before absorption.

BioavailabilityHow completely a drug is absorbed by the system is dependent on characteristics not dosage

Absorption rate dependent on dosage form

DistributionOnce absorbed, drug is transported through blood to target tissue

Volume of distribution: volume of fluid/plasma in which drug is dissolved and indicates extent of distribution of that drug

Efficacy: capability of producing therapeutic effect

Potency: dose of the drug required to produce a desired therapeutic effect

MetabolismBiotransformation of drug to water soluble compounds that can be excreted

Most takes place in liver, rest in blood and kidneys

Liver detoxifies active agents

Metabolites may be active or could be toxic.

ExcretionExcretion of drug or its metabolites is controlled by kidneys

Filtered through kidneys and usually excreted in the urine (some is reabsorbed)

May also be excreted in saliva, sweat and feces

Drug Half-LifeThe amount of time required for the plasma drug level to be reduced by one half measured in minutes, hours, or days depending on the drug

Drug steady stateThe amount taken is equal to the amount excreted

Drugs with long half-lives may take days or weeks to reach steady state

Effects of Physical Activity on Pharmokinetics

Exercise influences the amount of a drug that reaches the receptor site

Exercise decreases the absorption after oraladministration

Exercise increases absorption after intramuscularor subcutaneous administration due to the increased rate of blood flow

Legal Concerns in Administering Versus Dispensing Drugs

Administering is defined as a single dose of medication to be used by a patientDispensing constitutes providing a sufficient quantity to be used for multiple doses

By law, only licensed persons may prescribe or dispense prescription drugs for an athleteATC’s are not allowed to dispense medication unless allowed by state licensure

Administering Over the Counter DrugsATC may be allowed to administer a single dose of nonprescription medication

Rules relative to Secondary School

Oral medications vs. wound medication

Rules relative to College and

Professional AthletesATC must still use reasonable care and be prudent about types of medication provided

In all cases, actions should be performed under the supervision of a physician

Record keepingEstablish

Protocols that Address the legal

And safety Issues of your

Athletes

Log shouldContain method

Of administrationAnd dose of

Medication given

Obtain legal counselWork with Board Of Pharmacy, SHC

Physicians, to Avoid law Violations.

Be aware of LawsConcerning prescribing

Ordering, StorageDistribution, and

Dispensing.

Must maintainAdequate and

Up to date Medical

Information

Record KeepingATC’s must maintain accurate and up to datemedical records for each Athlete/Patient

NameComplaint Current medications Any known drug allergiesName of medication

Lot numberExpiration DateQuantity givenMethod of administrationDate and time of administration

Federally MandatedLabeling Requirements

Name of productName and address of manufacturer, packer or distributorNet contents of packageName of active ingredients and quantity of certain other ingredients

Name of any habit forming drug containedCautions and warnings to protect consumerAdequate directions for safe, effective useExpiration date and lot number

Legal Considerations

All drugs dispensed from the athletic training room must be properly labeled according to Federally mandated criteriaATC will have legal liability if drugs removed from original packaging and dispensed.

Safety in Use of Pharmaceuticals

1. No drug is completely safe and harmless.

2. Any drug can be potent and dangerous, with every individual reacting differently.

3. Athletes must be instructed on specific information regarding their medications (i.e. Frequency, with or without food,)

Drug Safety

Individual ResponsesATC must know their athlete’s in order to avoid potential adverse reactions

Individuals react differently to the same medications.different conditions cause altered effects of drugs.Drugs can change with improper storage or relative to how they are administered.Alcohol ingestion with medications should be avoided.Some medications can cause fluid depletion, further complicating illness, or make individuals sensitive to sunlight increasing risk of sunburn and allergic reactions

Alcohol is a CNS depressant and can increase or decrease effects of other drugs. Alcohol is used in many liquid preparations.Medication can potentially effect certain physiologic functions related to dehydration (sweating, urination, and the ability to control and regulate body temperature.Different diets may impact absorption rate

Medications for the Athletic Training Area

Buying MedicationPharmacist is a vital

resource.

assisting in selection of nonprescription drugs.suggesting less expensive generic drugs acting as a general advisor.

Proper StorageProper storage of medication is critical.

It must be kept in a locked cabinet.maintained in the original container.stored away from direct light, heat, damp places and extreme cold.

Athletes Traveling with Medications

Medication should not be stored in a bag/luggage but carried by the athlete taking itSufficient supply should be packaged in case of emergencyMake sure there is a source of medication while travelingTake copies of written prescriptionsKeep medication in original containerIf traveling internationally, understand restrictions of individual boundaries

Selected Therapeutic Drugs to Treat the Athlete

Widespread use in athletics and general society

Pharmaceutical labs develop compounds in vitro and then test, retest, and refine drugs in vivo before submitting it to the Food and Drug Administration (FDA)

Number of texts and databases are available for reference to determine appropriateness and effectiveness of medications for different conditions

INFECTION PREVENTIONLocal Antiseptics and DisinfectantsAntiseptics are substances that can be placed on living tissue for killing bacteria or inhibiting growthDisinfectants are used to combat microorganisms but should be applied to non-living objectsGermicides (generic name) designed to destroy bacteria, fungicides, sporicides and sanitizers

Antiseptics and DisinfectantsAlcohol

Most widely used skin antisepticEthyl alcohol and isopropyl alcohol are equally effectiveInexpensive and nonirritating, kill bacteria immediately with the exception of sporesNo long lasting germicidal action, can be used as an antiseptic or astringent70% solution can be used to disinfect instruments

PhenolEarly antiseptic and disinfectant in medical professionUsed to control disease organismsFound in various concentrations and emollientsDerivatives include, resorcinol, thymol, and common house cleaner Lysol

Antiseptics and Disinfectants

HalogensChlorine, bromine, fluoride (used for antiseptic effect)Iodophor or halogenated compounds create a much less irritating solution than tincture of iodineBetadine solution- excellent germicide, very effective for skin lesions, abrasions and lacerations

Oxidizing agentHydrogen peroxide is commonly used in the athletic training room.Readily decomposes in the presence of organic substances and has little use as an antiseptic.Cleanses infected cutaneous and mucous membranes.Dilute solution can be used to treat inflammatory mouth and throat conditions.

Antifungal AgentsMedicine used to treat fungi (epidermophyton,

trichophyton, and candida albicans)1. Topical antifungals may be Over the counter

medications or Prescription. 2. Oral Antifungals are by prescription only and

must be ordered by a physician.3. Vaginal antifungals are available as Over the

counter medications or by Prescription.4. All prescription antifungals must be carefully

monitored.

AntibioticsMechanism of Action: Interferes with the necessary

metabolic processes of pathogenic microorganisms.1. Chemical agents that are produced by microorganisms.

2. Used topically or as systemic medication.

3. Indiscriminate use can produce hypersensitivity and prevent development of natural immunity or resistance to subsequent infections.

4. Must be prescribed and monitored by physician

Antibiotics

1. Bacitracin-topical antibacterial agent used alone or as a part of double or

triple antibacterial ointment.2. Erythromycin

-Broad spectrum antibiotic that includes mycoplasm and streptococcus as well as similar spectrum to Penicillin. May be used in patients allergic to Penicillin.

3. Penicillins and Cephalosporins-Most commonly prescribed broad spectrum antibiotic class

used for URI, skin infections (does not cover MRSA) 4. Sulfonamides

-Systemic antibiotic that can be used for UTI’s, ear infections, topically for eye infections, and persistent URI’s.

5. Tetracyclines-Broad spectrum systemic antibiotic that treat a variety of URI,

Chlamydia, lymes disease.6. Quinolones

- Newer broad spectrum antibiotic that treats more severe infections.

MRSA

•What is MRSA?

•Does your Athletic Department have a protocol for MRSA?

AsthmaUsed to treat chronic inflammatory lung disorder or exercise induced asthma.National Asthma Education and Prevention Program has established guidelines for diagnosis and treatmentGoals of asthma therapy are to prevent chronic and troublesome symptoms, maintain normal lung function, prevent exacerbation and provide adequate pharmacotherapy with minimal adverse effectsTreatment should not just be drug based

-monitor lung function with peak flow meter-eliminate asthma triggers-maintain healthy lifestyle with plenty of rest, exercise, and good eating habits, and hydration.

Pain Relief and Antiinflammatory

1. Excitatory effect on an individual impulse is depressed

2. Individual impulse is inhibited3. Perceived impulse is decreased.4. Anxiety created by pain or impending

pain is decreased.5. Anti-prostaglandin effects.

Counterirritants and Local Anesthetics1. Analgesics give relief by causing systemic and topical

analgesia.2. Application causes local increases in circulation,

redness, rise in skin temperature.3. Mild pain can often be reduced with counterirritants.

ExamplesLiniments (usually counterirritant or alcohol based)Analgesic balms (often counterirritant)Spray coolants (topical anesthetic-rapid freezing)Alcohol (coolness causes temporary analgesia)Menthol (analgesic counterirritant)Cold (constricts blood vessels to numb nerve endings)Local anesthetics (injected by physician)

Non-narcotic Analgesics and Antipyretics

Designed to suppress mild to moderate pain without drowsiness.

AcetaminophenTylenol - effective analgesic and antipyretic but has minimal anti-inflammatory activityDoes not irritate GI system and is often replacement for aspirin in non-inflammatory conditionsOver-ingestion can lead to liver damage

AspirinEffective analgesic and antipyretic with anti-inflammatory activity but may cause GI irritation and other side effects.

Non-steroidal Anti-inflammatory Drugs

Anti-inflammatory, antipyretic and analgesic properties.

Inhibit prostaglandin synthesis and effective or osteo and rheumatoid arthritis.

Used primarily to reduce pain, stiffness, swelling, redness, fever associated with localized inflammation.

Non-Steroidal Anti-inflammatory Drugs

Other ConsiderationsShould not be used in place of acetaminophen or aspirin for headaches or increased temperature.

Individuals with nasal polyps, associated bronchospasm or history of anaphylaxis should not receive NSAID’s.

Can cause GI reactions, headache, dizziness, depression, or tinnitus.

Taken in conjunction with increased alcohol use may produce stomach irritation or GI ulceration.

Nonsteroidal Anti-inflammatory Drugs

Acetylsalicylic Acid (Aspirin)\

Widely used analgesic, anti-inflammatory, antipyretic and may be overused thus an abused drug.Helps reduce pain, fever and inflammation.Adverse reactions generally GI related.Over-ingestion can lead to tinnitus and dizziness..Reye’s syndrome can develop if given to adolescents.Allergic reactions result in anaphylaxis -- asthmatics may be at risk for reactions.Should be avoided within 12 hours of contact sports as it prolongs clotting time.

Non Steroidal Anti-inflammatory Drug

Over the CounterAspirinAdvil

Aleve Ketoprofen

PrescriptionMotrin Anaprox NaprosynFeldeneMobicOrudusCelebrex

CorticosteroidsUsed primarily for chronic inflammation of musculoskeletal and joint problemsProlonged use can create complications

Fluid and electrolyte disturbancesMusculoskeletal and joint impairmentDermatological problemsNeurological impairmentEndocrine dysfunctionOphthalmic conditionsMetabolic impairment

Cortisone is primarily injectedCan have negative effect on ligaments and tendons

Also administered through iontophoresis and phonophoresis

Drugs that Produce Skeletal Muscle Relaxation

Used to eliminate muscle guarding and spasm

cause drowsiness

Do not appear to be superior analgesics or sedatives in either acute or chronic conditions

Examples: Methocarbamol (Robaxin) , Carisoprodol (Soma), Cyclopentolate (Flexeril)

Most derived from opium or are synthetic opiatesDepress pain impulse and respiratory centerExamples include:

CodeineHydrocodone (Vicodin)Propoxyphene (Darvon)Meperidine (Demerol)Morphine

Narcotic Analgesics

Gastrointestinal Disorders

stomach upsetflugas formationacute or chronic hyperaciditydiarrhea or constipation

Drugs used to treat Gastrointestinal DisordersRelief of acid indigestion, heart burn, peptic ulcers

AntacidsSodium bicarbonate or baking soda are popularAntacids with magnesium tend to have laxative effectThose with aluminum and calcium cause constipationOveruse can cause electrolyte imbalance

Histamine-2 BlockersReduce stomach acid output by blocking histamine on certain stomach cellsUsed to treat peptic and gastric ulcers and GI hypersecretory conditionsDrug examples include Cimetidine (Tagamet) and ranitidine (Zantac)

Drugs used to treat Gastrointestinal Disorders

Anti-emeticsUsed to treat nausea and vomitingWorking Locally

Work on mucosal lining of stomach (may be more placebo) Pepto Bismol

Working Centrally (require Rx)Affect brain, making it less sensitive to nerve impulses from inner ear and stomachVariety of medications available, but may cause drowsiness. Phenergan, Tigan, Compazine

Drugs used to treat Gastrointestinal Disorders

Anti-flatulents SimethiconeProvide relief from flatulence (gas)Inhibit gas formation and aid in expulsion

Cathartics (laxatives)Must be under direct supervision of physician

Constipation may be symptomatic of serious diseaseIndiscriminate use may render athlete unable to have normal bowel movementsMay cause electrolyte imbalance

Anti-diarrheal ImodiumDiarrhea tends to be a symptom, not a diseaseResult of emotional stress, allergies, adverse drug reactions, odifferent intestinal problems

Colds and AllergiesSymptomatic Treatment

Nasal DecongestantsTopicalOral

ExpectorantsWater is a natural expectorant.Guaifenesin

AntihistaminesTopical (Rx only)Oral (OTC and Rx)

AntitussivesNon narcotic is DMNarcotic contains codeine or hydrocodone.

Drugs to Control Bleeding

Vasoconstrictorsadministered externally at sites of profuse bleedingEpinephrine commonly usedImmediate acting. Often used in instances of epistaxis (nosebleed)

Hemostatic AgentsDrugs that immediately inhibit bleeding (under investigation)Thrombin

AnticoagulantsHeparin

Prolongs clotting time but will not dissolve clot once formedControls extension of a thrombus already present

CoumadinGiven orally, they can be used to slow clotting time in certain vascular disorders

Drugs that Affect the Rate of Heat Illness

Some drugs may alter the body’s ability to thermoregulate

1. Anticholinergics and antihistamines (decrease sweating mechanism)

2. Sympathomimetic amines (may predispose athlete to heat stroke)

3. Phenothiazines (impacts hot/cold temp. regulation)4. Diuretics (alters volume expansion and cutaneous

vasodilation)

ATC must be aware of potential risk of medications relative to heat illnesses

Be Prepared for Anaphylaxis

–When life is at risk and time is critical due to an allergic reaction.

–Epipen Auto Injector stops an allergic reaction fast.

–Gives you time to get your Athlete/Patient emergency care.

Substance Abuse Has No PlaceIn Athletics

1. Athletic trainer must be knowledgeable about substance abuse in athletic population and should be able to recognize signs that athlete may be engaged in substance abuse.

2. Drug use and performance enhancing agents in athletics.

3. Use and abuse of substances can have a profound effect on performance

Ergogenic AidsPerformance Enhancing Substances

Drugs, Devices, Substances, or Procedures intended to improve athletic performance.

Some are naturally occuring, easily available and legal

Some are manufactured, illegal, and/or banned by Sporting organizations

StimulantsAmphetamines and Cocaine

Increase alertness, self confidence, and a feeling of energy

Most widely used for performance enhancement

Short term and long term side effects may be of concern.

SympathomimethicsMental stimulation, increased blood flow, and feeling of energy.

Often found in cold, allergy, and asthma meds.

Anabolic SteroidsTake Steroids May have Deleterious

and Irreversible Effects to HealthIncrease muscle mass, weight, growth, and bone maturation.Available as oral and injectable dosage forms

Methods of Dosing: -Cycling -Stacking -Pyramiding.

Designer SteroidsAndro, THG, Clen, and DHEA are some of the

commonly known Designer Steroid Supplements

Each has potential serious health risks.

Minimal Scientific evidence to prove benefit.

Banned by most Sports Organizations

CreatineResearch has shown some positive effects, however more study is needed for long term safety/benefits

Be aware of the Tips and Cautions

Creatine supplements are not regulated, what you buy is not necessarily what you get!

Human Growth Hormone

Increased use by athletes because it is more difficult to detect in testingLike anabolic steroids, it is associated with serious and irreversible side effects.

Blood DopingBlood Reinjection

Can significantly improve performance

Unethical and Dangerous

Risks involve allergic reactions, kidney damage, fever, jaundice, metabolic shock due to overload.

Caffeine and other legal Drugs to Monitor

CaffeineFound in coffee, tea, cocoa, and soft drinks and is a CNS stimulant, diuretic, and stimulates gastric secretions.Habitual user that ceases use may go through withdrawal

Believed to act as ergogenic aid during prolonged activity

Banned by USOC as stimulant in high doses (12 mcg/ml)

Caffeine and other legal Drugs to Monitor

Narcotic Analgesic DrugsUsed for management of moderate/severe painRisk physical and psychological dependency

Beta BlockersRelax blood vessels, slows heart rate and decreases cardiac output and heart contractility

DiureticsUsed for variety of cardiovascular and respiratory conditionsIn sports, misused for weight loss and decreasing concentration in urine

Recreational Substance Abuse Among Athletes

It occurs among athletesDesire to experiment, temporarily escape, be part of the groupCan be abused and habit formingDrug used for non-medical reasons with the intent of getting high, or altering mood or behavior

Psychological vs. Physical Dependence

Psychological dependence is the drive to repeat the ingestion to produce pleasure or avoid discomfortPhysical dependence is the state of drug adaptation that manifests self in form of tolerance When cease consumption abruptly unpleasant withdrawal occurs

Tobacco UseNicotine is the addictive chemical in tobaccoone of the most toxic drugs

Cigarettes, cigars & pipes are increasingly rare in athletics, but Smokeless tobacco and passive exposure to others continues to be an ongoing problemSeriously impacts performance for those that are highly sensitiveSmokeless Tobacco possesses serious health risk

More addictive habit w/out exposure to tar and carbon monoxide

Alcohol UseMost widely used and abused substance with

athletesAbsorption affected by quantity and rate of consumption, concentration and amount of food in stomach.

oxidized by liver at 2/3 ounce/ hour

If excess is in blood stream.1% - lose motor function.2%-.5% symptoms become more profound and

Alcohol Use Athlete abusing alcohol may exhibit the followingMood and attitude changes

Missed practices

Isolation

Fighting or inappropriate outburst of violence

Changes in appearance

Hostility

Complaints from family

Changes in peer group

Drug UseMarijuana (carcinogenic drug)Formerly most abused drug in Western societyCan lead to respiratory disease, lowered sperm count and testosterone levels, limited immune functioning and cell metabolismCauses increased pulse rate and can cause decrease in strengthPsychologically causes diminution of self-awareness and judgment, slower thinking and short attention spanMay remain in the body and brain for weeks and months resulting in cumulative deleterious effects

Drug UseCocaine

CNS stimulant w/ short duration effects (intense)Produces immediate feeling of euphoria, excitement, etc.Long term use results in psychological tolerance and dependenceOverdose can lead to:

Tachycardia, hypertension, extra heartbeats, coronary vasoconstriction, strokes, pulmonary edema, aortic rupture and sudden death

Sudden stimulation w/ crack can cause cardiac or respiratory failureCan be taken in many forms including snorted, intravenously or smoked (freebased)

Be Prepared for a Drug Overdose

Call 911Call Poison ControlMonitor Vital Signs

Start CPR if Necessary

The following history would be helpful if it is possible to obtain:– Is the patient conscious?– Is the patient breathing? – What is the age of the patient? – What symptoms are the patient

experiencing?– What drug(s) were taken try to

locate the drug's container? – How much of the drug was

taken? – When was the drug taken? – Was the drug taken with

alcohol or any other drugs or chemicals?

Drug Testing in Athletics

Purpose: Identify individuals who have problems with drug abuse and ensure health and fair

practices of athletesControversial topicNCAA and USOC routinely test

Began at the Olympics in 1968 and has since expanded nationally (USOC and NCAA) and internationally

Mandatory and random testing occurs at both levels

The Drug TestNCAA requires all athletes to sign a consent form agreeing to participate in testing throughout the year.

USOC tests randomly throughout the year and before USOC sanctioned events.

During the test, the athlete provides identification, and 2 samples under direct supervision; One for testing and confirmation, second for reconfirmation.

If positive… the athlete is subject to sanctions!

Sanctions for Positive TestsNCAA

First time positive in NCAA results in minimum one year suspension; will undergo random testing throughout the yearMust test negative prior to reinstatementHowever, additional positives can result in lifetime disqualification from NCAA

USOCSanctions range from 3 months - 24 months depending on the drug for a first time offense

Lifetime ban for subsequent positive tests

Banned SubstancesNCAA and USOC have a banned substance list for athletesAthletic trainers working with athletes who may be tested for drugs by NCAA or athletes governed by USOC should be familiar with the lists of banned drugs and substances.

4600 medications including ergogenic drugs, recreational drugs, as well as OTC or prescribed medications are on the list of banned substances.

USOC is more extensive than NCAA because it is also subject to IOC rules