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Mind, Body and Sport: Substance use and abuse

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness

By Brian Hainline, Lydia Bell and Mary Wilfert

The prevalence of mood-altering substances on campus – alcohol, marijuana, narcotics, stimulants, depressants, hallucinogens – has been tracked by campus prevention professionals for decades, evoking varying degrees of effort and success to reduce use and negative consequences.  

More recently, a keen understanding of the interplay between substance use and mental health brings two distinct fields – prevention specialists and treatment specialists – together to define more comprehensive and evidence-informed approaches to address these issues, including population-based environmental management, large screening events, and personalized assessment, feedback and intervention.

College students, including student-athletes, are susceptible to the college effect, in which heavy and frequent alcohol use increases when students arrive on campus, buying into the cultural myth that campus life is about alcohol abuse and drug use. Such beliefs result in an increase in negative impact on academic success, increased risk of sexual assault and other interpersonal violence, and other negative consequences.  

Student-athletes, compared with other students on campus, report higher rates of heavy episodic drinking, sometimes referred to as “binge drinking” (defined as four or more drinks for women and five or more for men). Even more disturbing is that one in five male student-athletes who use alcohol report drinking 10 or more drinks in an outing when they drink.

For marijuana, the good news is that fewer NCAA student-athletes report using marijuana than other students on campus. But the percentage of student-athletes who use marijuana has remained relatively flat over the last 10 years.  

And though alcohol and marijuana are the two most reported recreational drugs student-athletes use, the new illicit drug-use concern is the abuse of prescription stimulants and narcotics.

Substance abuse and mental health

There is no doubt that for many, substance abuse co-occurs with mental health issues. A 2004 Harvard University study described patterns of depression and alcohol abuse among young adults in college, and confirmed that “a substantial fraction of college youth are experiencing poor mental health – at any given time approximately 5 percent – and that these youth are at high risk for alcohol abuse, with depressed young women at highest risk.”  

The Harvard study noted the age of traditional students, 18-24, coincides with peak years for onset of common mental health problems among youth related to alcohol, tobacco and other drug use, depression and anxiety disorders and suicide.

The 2012 National Survey on Drug Use and Health of the Substance Abuse and Mental Health Services Administration identifies that 8.9 million adults have co-occurring mental and substance use disorders and recommends integrated treatment to improve outcomes.

Student-athlete substance use

Since 1985, the NCAA has conducted a quadrennial research study of substance use of college student-athletes, and collected survey data again in the spring of 2013 from more than 20,000 NCAA student-athletes from all three divisions and NCAA-sponsored championship sports.

Alcohol

Figures 3A and 3B present data about heavy episodic drinking and the negative consequences reported as a result of alcohol use.

When you drink alcohol, typically how many drinks do you have in one sitting? (Figure 3A)

Female Student-Athletes

  Division I Division II Division III
More than 4 drinks 31.9% 32.6% 37.8%
10+ drinks 2.4% 3.2% 3.3%

Male student-athletes

  Division I Division II Division III
More than 5 drinks 39.6% 39.6% 50.4%
10+ drinks 15.5% 16.8% 20.4%

 

It is particularly alarming that 30 percent of these student- athletes report experiencing blackouts, which are red flags for developing an alcohol addiction. In addition, more than 30 percent have done something they later regretted and more than 25 percent have been criticized for their drinking. 

Student-athlete drinking behavior — During the past 12 months (Figure 3B)

  Never Once Twice 3-5 times 6-9 times 10+ times
Had a hangover 36.7% 14.3% 11.5% 14.8% 7.4% 15.3%
Performed poorly on a test or important project 83.3% 6.9% 4.3% 3.3% 1.1% 1.1%
Been in trouble with police or other college authorities 91.0% 6.7% 1.5% .6% .1% .2%
Damaged property, pulled fire alarm, etc. 92.9% 3.2% 1.8% 1.2% .3% .5%
Gotten into an argument/fight 77.0% 9.6% 6.2% 4.5% 1.2% 1.5%
Gotten nauseated or vomited 48.5% 19.8% 13.0% 11.7% 3.7% 3.3%
Driven a car while under the influence 86.3% 5.5% 3.5% 2.4% .8% 1.5%
Missed a class 73.9% 7.9% 6.7% 6.7% 2.0% 2.7%
Performed poorly in practice or game 84.0% 6.6% 4.3% 3.2% .9% 1.0%
Have showed up late or missed practice or game 94.3% 3.0% 1.4% .8% .2% .3%
Been criticized by someone you know 74.6% 9.8% 6.6% 5.1% 1.5% 2.4%
Thought you might have a drinking or drug problem 94.4% 2.5% 1.2% .8% .4% .7%
Had a memory loss 70.0% 10.4% 7.0% 6.4% 2.9% 3.3%
Done something you later regretted 68.0% 12.0% 8.0% 6.6% 2.3% 3.1%
Been arrested for DWI/DUI 99.0% .7% .1% .1% .0% .1%
Tried unsuccessfully to stop using 96.7% 1.6% .7% .5% .2% .3%
Had feelings of depression, feeling sad for two weeks or longer 92.9% 3.7% 1.6% .9% .3% .6%
Been hurt or injured 87.7% 6.0% 3.5% 1.9% .3% .5%

These data also identify implications of use on both academic and athletics success, with more than 25 percent missing class and 16 percent performing poorly on a test or in practice due to use.

Marijuana

Another substance concern is the use of marijuana, which has remained fairly constant in this population over the past 10 years as noted in this table:

Marijuana use within the last 12 months

2005 2009 2013
21.2% 22.6% 21.9%

The college literature on marijuana use demonstrates strong links between use, especially chronic use, and cognitive deficits. Even for those who do not use regularly, marijuana use can impede concentration and attention, and interfere with student-athlete academic and athletics success.  

Student-athlete marijuana and grades

  Never used Used in last 30 days Used in last 12 months Used, but not in last 12 months
A (3.84 - 4.00) 10.5% 5.2% 5.8% 6.7%
A- (3.50 - 3.83) 19.8% 14.6% 16.1% 17.0%
B+ (3.17 - 3.49) 23.3% 20.7% 24.9% 23.0%
B (2.84 - 3.16) 21.4% 23.9% 23.2% 25.2%
B- (2.50 - 2.83) 13.5% 16.9% 15.3% 14.7%
C+ (2.17 - 2.49) 7.7% 11.8% 10.1% 9.1%
C (1.84 - 2.16) 2.9% 4.4% 3.6% 3.1%
C- (1.50 - 1.83) .6% 1.5% .8% .9%
D or below (< 1.50) .3% 1.0% .2% .3%

Depression and anxiety are the most commonly reported psychological issues reported by traditional-aged students, including student-athletes, and the peak age of onset for schizophrenia is in the teenage years and 20s.  

Marijuana use is implicated in exacerbating symptoms of anxiety, depression and schizophrenia, and those at risk of developing schizophrenia will have worsening symptoms if they use marijuana.

The NCAA study looked at marijuana use and grades, and found in the table above that those who have used in the last 30 days reported failing grades at three times the rate of those who don’t use. The table also notes that for those student-athletes who have never used, more than 30 percent report A grades compared with 20 percent of those who have used, either in the last 30 days or ever. (See Figure 3C)

prescription drug use. The following table notes that under 5 percent of NCAA student-athletes report prescribed ADHD stimulant medication use, similar to the estimates of ADHD in this population, but more than 5 percent report use without a prescription. The percentage of student-athletes prescribed narcotics for pain medication is higher than the general student body, which is understandable with injury and pain a part of competitive athletics, but use without prescription is of great concern given the potential for addiction to these medications. Whether this nonprescribed use is self-medication for inadequate response to sports injury is an area for further research. 

Prevention is a science!  

The substance abuse prevention field has matured quickly since the 2002 publication of the National Institutes of Alcohol Abuse and Alcoholism. This report provided evidence of alcohol education and policy strategies that demonstrated an effect on use, strategies that held promise, and those that did not deliver.

Over the convening decade, prevention science has provided us greater insights into the kinds of campus efforts that support healthy choices, those that are ineffective, and even those that contribute to abuse.

The CDC’s social-ecological model provides the framework for targeting our efforts, noting that individual behaviors are influenced by the individual’s peer group, broader community and society. For the campus athletics culture, this translates into team, department and campus as a whole.

Understanding the process of behavior change, the role perception plays in use, the power of setting expectations, and the influence of environment and policy on individual choices is critical to effective alcohol abuse prevention.  "Just say no" is not a method.  Research has redirected our efforts toward more effective approaches to reduce substance abuse and its negative consequences, providing us evidence-informed strategies that affect behavior change, such as brief motivational interventions, correcting norms, engaging peers in intervention, and clear and consistent policy enforcement. As with any culture, educational efforts need to address student-athletes’ motives, beliefs and expectations.

Athletics administrators will experience greater success in reducing substance abuse among their student-athletes when they partner with campus prevention specialists who have background and expertise in substance abuse prevention and mental health promotion.  

The NCAA Division III and NASPA (Student Affairs Professionals in Higher Education) have entered into a collaborative project that intends to bring the best of prevention science to their constituents, administered in partnership between athletics and student affairs administrators, in a project called 360Proof. This effort combines personalized feedback process with campus support and intervention, relying on the very evidence-based strategies defined by these recent efforts.  

The NCAA provides resources to help its membership address substance abuse prevention and promote mental health. The NCAA-sponsored APPLE Conferences (Promoting Student-Athlete Wellness and Substance Abuse Prevention) bring campus "prevention teams" composed of four to six members, including at least two student-athletes, through a strategic planning weekend that provides a framework to identify gaps in the institution’s substance abuse efforts and walks them through the development of their institutional-specific plan to address those gaps.  

The University of Virginia’s Gordie Center for Substance Abuse Prevention (www.virginia.edu/gordiecenter/apple) administers the program and houses the emerging support for "Coaches Assist," which recognizes the critical role coaches play in addressing student-athlete substance abuse.

The NCAA 2012 Student-Athlete Social Environment Study found that of the 21,000 student-athletes surveyed across all divisions and sports:

  • 42 percent of men and 39 percent of women said they would turn to their parents first when seeking help/advice/support for substance use.
  • 89 percent of student-athletes report coaches or others in the athletics department have talked to them about expectations regarding drinking and substance use, yet a quarter of men and a third of women would like them to talk more about it with their team.
  • 85 percent of men and 93 percent of women would be likely or extremely likely to accompany a teammate home if he/she had a lot to drink.
  • 79 percent of men and 93 percent of women would be likely or extremely likely to stop a teammate from driving if drinking.

The Step UP! Bystander Intervention Program (www.stepupprogram.org) provides administrators with training materials to help student-athletes exercise leadership and to "step up" when a teammate or friend is engaged in potentially harmful or dangerous situations. Step UP! was developed from research that recognizes the desire of students to help a friend in distress but feel ill-equipped to do so safely and effectively. Step UP! training overcomes the bystander effect that sustains  inertia, and takes students through the five-step process to recognize a problem and to take personal responsibility to help.

In the meantime, above all, athletics administrators must demonstrate leadership in recognizing the relationship of substance use, mental health and academic success by:

  • Viewing substance use prevention as critical to student success.
  • Establishing an environment that is supportive of student success and deters excessive drinking/drug use.
  • Working with campus and community constituents and experts to implement a comprehensive program of evidence-based strategies.

 

Brian Hainline began his tenure as the NCAA’s chief medical officer in January 2013. As the first person to hold that position in the organization, Hainline oversees the newly created NCAA Sport Science Institute, a national center to promote and develop safety, excellence, and wellness in college student-athletes, and to foster lifelong physical and mental development. The NCAA Sport Science Institute works collaboratively with member institutions and centers of excellence across the United States. A graduate of Notre Dame and Chicago’s Pritzker School of Medicine, Hainline completed his neurology residency at The New York Hospital-Cornell. He was chief medical officer of the US Open Tennis Championships for 16 years, and then served as chief medical officer of the United States Tennis Association before moving to the NCAA.

 

Mary Wilfert is an associate director in the NCAA Sport Science Institute. Since 1999, she has administered the NCAA drug-education and drug-testing programs and worked to promote policies and develop resources for student-athlete healthy life choices. She serves as primary liaison to the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, the governing body charged with providing leadership on health and safety recommendations to the NCAA membership. Wilfert has worked in the health education field for more than 30 years to empower individuals to make informed choices for lifelong health and success.

 

Lydia Bell is the associate director of research for academic performance at the NCAA. In this role, Bell assists in all aspects of development and analysis of research on current and former student-athlete academic performance and well-being. Before joining the NCAA, she was an assistant professor of practice and director of Project SOAR in the Center for the Study of Higher Education at the University of Arizona. She received her Ph.D. in language, reading and culture and M.A. in higher education from Arizona, and an A.B. in government and legal studies and sociology from Bowdoin College.

Signs and symptoms

Not all student-athletes with substance use problems consume alcohol or drugs in settings where the signs are easily visible; some may choose to consume these substances alone so as to avoid drawing attention to these signs.  

Alcohol

  • Being irresponsible regarding commitments or responsibilities to school, sport and relationships
  • Consuming alcohol in situations that are dangerous to themselves and others

Stimulant-type substances (Amphetamines, cocaine, ephedrine and medication for ADHD)

  • Shakiness
  • Rapid speech or movements, difficulty sitting still
  • Difficulty concentrating
  • Lack of appetite
  • Sleep disturbance
  • Irritability

Marijuana

  • Red eyes
  • Lethargy
  • Apathy

Athletics consequences

Alcohol: Alcohol is a central nervous system depressant. It can decrease concentration, coordination, reaction time, strength, power and endurance. It can also inhibit the body’s absorption of nutrients. The effects of heavy alcohol consumption can last for days.

Stimulant-type substances (Amphetamines, cocaine, ephedrine and medication for ADHD): The individual may become nervous or jittery, which can negatively affect any skill requiring fine motor coordination and concentration. Performance can also be negatively affected by increased heart rate, blood pressure, heat production and body temperature.

Marijuana: The effects of marijuana on sport performance are much like those of alcohol. It can slow reaction time, impair both motor and eye-hand coordination, and affect time perception.

What can you do?

Approaching a student-athlete with a suspected substance-abuse problem is somewhat different from approaching a student-athlete regarding symptoms of depression or anxiety. Student-athletes with depression and/or anxiety may be more receptive and motivated for assistance. Student-athletes with substance-related difficulties may be less receptive to assistance for the following reasons:

  • They may be using the substance in order to not feel bad
  • They may be dependent on their substance
  • They may be in denial that they have a substance-use problem
  • They may fear punishment for illegal activities
  • They may fear stigma associated with admitting a substance-use problem

Given these issues, approaching a student-athlete with a substance-use problem can be difficult. They may deny the problem and resist your efforts to assist them. It is probably best not to argue with them or try to convince them. Simply tell them that you are concerned, and that the only way to know for sure if there is a problem is for them to be evaluated by a professional with expertise in this area. Make the referral and follow up to make sure the referral was accepted and completed.

Questions for reflection

How do you model or discuss alcohol use with student-athletes?

At what point would you consider substance use a problem in need of treatment?

How would you distinguish between casual substance use and problematic substance use?