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Cultural Drug Facts and Comparisons: Precautions for your traveling patient-athletes

Sports pharmacists offer advice in travel medicine, personalized for the patient-athlete or team physician, since the rules and regulations of the destination country are often different than the traveler’s home country. 

Import personal prescriptions or purchase local treatments

Carrying one’s own prescription medications and a limited supply of self-treatment medications offers the patient-athlete time to plan ahead and review with the pharmacist to verify the treatments selected are okay for a competitive athlete and okay to import into the destination country. Sports pharmacists review destination country travel rules for drug importation (including a review for what is illegal, such as traveling with cannabinoids), IOC travel recommendations to athletes, and consider alternatives or non-pharmaceutical options. Seeking therapeutic use exemptions when necessary for the patient-athlete is also vital in this planning process if going to a competitive event.

Purchasing locally, after arrival, can increase the risk for travelers unfamiliar with local medicine nomenclature, cultural medical practices, or the standard for government regulatory system for purity, labeling, and handling.

Precautionary advice for your traveling patient-athletes

Pharmacists should warn their patient-athletes about risks with sampling local medications or seeking self-treatment while abroad. Some medications that are prescription only in one country may be purchased directly from the pharmacist without a physician’s medical diagnosis in other countries. At times, the local drug name may be different from the registered International Non-Proprietary Name listed on the prohibited list as an example and may not be found in the athletes’ banned substance search engines. Similar or same brand names (registered, trademark, or label names) may have different ingredients in other countries.

Herbal therapies taken at the athlete’s own risk require additional research, since most cannot be checked against the prohibited substances lists, as only single chemicals are almost exclusively listed.

It is equally important for sports pharmacists to counsel their patient-athletes against the use of herbal products that may be a health risk or enhance performance to violate the spirit of sport. Without examples of herbal therapies on the prohibited substance list, pharmacists may do additional research on the mechanism of action, multi-ingredient product synergy or antagonism, and then weigh these findings against the risk that an herb (or herbal combination) is prohibited, mimics a prohibited substance effect, or may possibly be a health concern for a patient-athletes. Sports pharmacists should contact the local or world antidoping regulatory body for direction if they find an herb of high concern.

Complexity of mixed chemical constituents in herbal therapies

First hand knowledge of herbal products leads me to call for pharmacists to ask their patient-athletes directly, “What herbal products do you use or might you use?”

While in Zhejiang, China studying Chinese medicine and Mandarin, my herbal medicine professor taught me product identification and recipes. Traditional Chinese Medicine uses treatments to balance body energy as primary prevention, with the concept of synergy and antagonism woven deep in to selecting herbal combinations.

In the late 1990s, the chemical constituents were not yet well defined for individual herbal substances they way they are these days. Yet, three decades later, some of these may be candidates as prohibited substances, but await further evaluation by antidoping scientists. 

When used in a TCM herbal combination, the performance enhancing effects of one chemical may be diminished entirely by the selective addition of another herb. This is the yin-yang, the harmonious balance of Chinese medication that could negate the concern for doping or, instead, keep it under the radar.

 

 

Preprescribing – A great position for sports pharmacists on the team

Preprescribing: pharmacist involvement in drug selection after the diagnosis and prior to the decision for a prescription or supplement therapy.

Pharmacists recognize the variations between drugs, even small differences within the same class of drugs. Trained to identify the clinical significance of drug-interactions and the risks of adverse effects balanced with the proposed benefit of a prescription, we are specially-equipped to save time and headaches in the post-prescribing phase.

You’ve heard of prescribing and e-prescribing, perhaps even familiar with deprescribing, but how much do you think about preprescribing? A more valuable, time-saving role in which the pharmacist could be practicing. It’s a great place for sports pharmacists to practice.

Let’s first define preprescribing and put it into the cognitive services sector.

“Preprescribing” may be a term used in a hospital setting where pharmacists review medication orders after the prescriber decides on a medication and before it is verified for dispensing. Antibiotic stewardship has benefited from this process, where pharmacists select a more appropriate antibiotic after reviewing a patient’s full medical profile, based on a collaborative practice agreement. Insurance companies picked up on the term and used it for driving prescribing selection to their contract medications or “pre-prescribing prior authorization” requirements.

Preprescribing, in its most useful form, is integrated into the decision making process.

Ambulatory care settings and surgical centers that employ pharmacists for cognitive services and comprehensive documentation assistance already have preprescribing happening within patient care, through planning and shared decisions. Transitions of care programs employing pharmacists also practice preprescribing, even if the term isn’t used, to plan for the best outcomes.

If a medical team is a full “team” then this is a valuable position to put

a key player–the drug expert.

Preprescribing by sports pharmacists may include:

  • review the whole patient-athlete’s lifestyle and load, demographics, physiology, comorbidities/diagnoses with associated treatments (such as unintentional overlap of prescriptions from different specialists or with self-treatment)
  • consider non-pharmacological alternatives or a start-if scenario to avoid use of medications in patient-athletes, when appropriate
  • balancing the return to play schedule with medication use and, at times, patient-athlete advocacy for health first
  • assess potential ergolytic effects (decrease sport performance or potential risk of harm) and ways to avoid or minimize bothersome side effects, or recommending a different medication/treatment
  • review the clinical significance of drug-interactions (drugs, supplements/nutrients, herbals, CBD, etc)
  • evaluate the status in sport and recommend an effective alternative (even if not the drug of choice) that is not banned for the athlete or assist in documentation necessary to submit an application for a medical exemption
  • review the risks of dietary supplement use, benefit:risk balance and interactions (every choice, every time) to help reduce the risk
  • planning for international travel, assess the legal requirement for importing personal prescriptions

As a pharmacists reads through the bullet points above, many of these are key elements we consider for any patient in the preprescribing process, given time and access to the information.

Patient-athletes get the bonus of having more targeted discussions about status in sports and the risks to them in their unique career.

Hey Sports Pharmacists, consider offering your services in the preprescribing process. It improves patient care and primary adherence, but also could nearly eliminate those post-prescribing headaches.

 

Sports Pharmacy Consulting for Drugs Banned In-Competition

When substances are prohibited in-competition only, consult a sports pharmacist.

When certain drug use (including prescriptions, Over-The-Counter drugs, illicit drugs or dietary supplements) is okay outside of an event and not allowed during an event period, this is referred to as “Prohibited In-Competition Only” by WADA. It can vary by sport and competition; so, look closely at the details with your patient-athlete. This may be unlike NCAA Banned Substances List or Professional sports lists of banned substances.

As pharmacists know, human beings metabolize medications at different rates, and even personal lifestyle choices and demographic changes will affect clearance rates within an individual. The time it takes for a substance to become undetectable in a sample of an athlete has to be considered with the same confounding factors. That is why expert pharmacists (or other expert antidoping healthcare providers) would provide directions to individuals, instead of publishing guidelines for athletes on clearance.

Athletes must avoid many drugs and other substances during the In-Competition period, such as stimulants, psychoactive drugs, and certain uses of steroidal anti-inflammatories (glucocorticoids / corticosteroids). The American public learned about the marijuana anti-doping rule violation by a star athlete just prior to the Tokyo 2020 Olympics. Our first thought, in jest, was, “Well, that athlete didn’t ask a sports pharmacist how long it would take to clear from the body.”

That athlete’s story is a much more complex case involving personal tragedy, self-treatment, and a possible misunderstanding of the definition of Out-of-Competition use or clearance of a substance. Determining cannabis clearance from the body requires an in depth use history and transparency from the user about the Cannabis spp., route, frequency of use, along with the most recent use and all the standard Comprehensive Medication List work up done by a pharmacist. Yet, this substance clearance is still seemingly unpredictable in some users. We almost exclusively warn elite athletes that using marijuana is at the risk of testing positive at any event, and that warning should include use of some CBD products.

One category of substances prohibited by WADA In-Competition Only that will soon have more detailed guidance for healthcare providers working with athletes is glucocorticoids (also called corticosteroids). For 2022, WADA will provide additional guidance on clearance of glucocorticoids as changes come again to this category of substances. All injectable glucocorticoids will be prohibited in competition.

Please read about the washout periods described in “A novel approach to improve detection of glucocorticoid doping in sport with new guidance for physicians prescribing for athletes” published prior to the 2022 WADA Prohibited List changes.

Several patient-athlete advocacy groups and international federations of sport applaud the change to ban the use of all injectable corticosteroids during or leading up to events. Union Cycliste Internationale may be one of the most well-recognized organizations supporting this change to the prohibited list, which puts the health of the athlete ahead of the win-at-all-costs mentality. Pharmacists can quickly get on board with this patient-athlete advocacy step!

Other categories of prohibited substances are much less likely to have such specific guidance any time soon. With that, pharmacist role in interpreting pharmacokinetic factors related to individual patient-athletes remains vital to avoiding accidental doping with prescriptions and over-the-counter products (or recreational, decriminalized drug use) prohibited in-competition.

Interview

Interview with Sports Pharmacists: Ashley Anderson

Clinical pharmacist, Ashley Anderson, works primarily as a hospital pharmacist on most workdays, keeping her clinical skills current by staffing ICU, L&D, ED, and Med/Surg, but has also carved out a special place for her passion of working in anti-doping, preventing inadvertent doping, educating other healthcare providers about sports pharmacy and acting as a preceptor for pharmacy students.

Ashley began working in 2006 for the athlete’s Drug Reference Line, a phone call service originally started with a single pharmacist’s passion for athletes health while he (Jeff Podraza) was interning at the OTC. This call line was later hosted by USADA for their stakeholders. The early days of this position demanded self-directed research, mentoring, networking, and advanced self-training in prohibited substances, the nuances of prescription and non-prescription use / misuse / abuse, specialty pharmacotherapy, exercise pharmacokinetics, regulations, and dietary supplements.

She completed the IOC Drugs in Sport Certification program in February 2019 with the inaugural class.

Currently, Ashley, is involved with the International Sports Pharmacists Network, LLC., provides consultant services on the clinical application of sports pharmacists’ training and educating patients and healthcare professionals one-on-one.

Ashley mentions that she practices pharmacy to look at the whole person’s response to medication. Her goal is to help people wean off medications that are no longer necessary (deprescribing), and she views many medications as a bridge to return to health. Nutrition, maintenance of one’s microbiome, mindfulness and exercise are the first-line treatments, as Ashley notes that only a small subgroup of people need to take supplements– a high risk to patient-athletes because they are unregulated products.