Active Voice: The Team/Sports Medicine Physician and Drug Abuse By Gary I. Wadler, M.D., FACSM Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM. Gary Wadler, M.D., FACSM practices internal medicine and sports medicine in Manhasset, New York, and he is a Clinical Associate Professor of Medicine at the Hofstra North Shore-LIJ School of Medicine. He has served as medical advisor to the White House Office of National Drug Control Policy and recently served as chairman of the World Anti-Doping Agency (WADA) Prohibited List and Methods Committee. Dr. Wadler is an expert on sport and substance abuse and has provided medical leadership and served as a policy advisor on these matters at the highest levels nationally and internationally for many years. This commentary appeared in a recent issue of the Professionals Against Doping in Sports (PADS) e-newsletter. To sign up for this quarterly e-newsletter, visit www.nodope.org. Unlike community-based physicians, team/sports medicine physicians are well positioned to observe athletes in varied settings and conditions over an extended period of time. Consequently, they may observe changes in behavior, mood, performance, appearance and interpersonal relationships (e.g., arguments with teammates and inappropriate challenges to authority figures). The drug-abusing athlete may routinely show up late or early to practice and exhibit an increase in injuries or an excessive reliance on medication. All these might suggest substance abuse. Together with a physical examination and a properly timed and administered drug testing protocol, a diagnosis of substance abuse can be established. Key to diagnosing substance abuse is a focused history. However, first physicians must be aware of their own personal preexisting attitudes, prejudices and insecurities regarding drug abuse, and they must avoid letting these become barriers to effective assessment and management. Even one’s tone of voice may reflect underlying attitudes which may serve as a barrier to effective communication. The history should be obtained in a setting where privacy and confidentiality are absolutely assured. This takes on additional importance in organized athletics, since the athlete may view any suspicion of drug abuse as jeopardizing his or her athletic career. As an ice-breaker, initially the history might center on the use of legal substances, such as cigarettes and caffeine. A discussion about the perceived effects of these substances on behavior and performance can open the door to a discussion about the effects of other substances on behavior and performance. From nicotine and caffeine, the discussion can gradually shift to alcohol. From there, a discussion about illicit drug can begin, starting with marijuana. Since this exchange may deal with the use of other illegal drugs, or of illegally obtained legal drugs, it is especially important to be consistent in emphasizing the health aspects associated with the abuse of these substances. Since so much of athlete’s substance abuse relates to attempts to enhance performance, there should be a discussion of this matter in addition to any discussion about recreational drug abuse. As many athletes believe that physicians are poorly informed about the effects of drugs on athletic performance, athletes are often reluctant to discuss this subject with physicians. Essential to any effective communication between the physician and athlete is the requirement that the team/sports medicine physician knows about and is comfortable with the subject of substance abuse in sports.