Drug Abuse & Sport – Self-Medicating and First Aid Boxes: Avoiding Accidents
Over the first three parts of this series of articles we have discussed what makes a drug prohibited, how to get around a prohibition when one has a legitimate need for a drug, and why we separate drugs into the categories that we do.
To finish off, it seems fitting that we discuss what medications are acceptable according to the WADA and South African law, and some practical applications of this.
There are a lot of drugs which aren’t restricted according to the WADA standards. Many medications for chronic conditions, such as hypertension, diabetes mellitus, epilepsy, psychiatric conditions and so on, are not prohibited. And in the odd case that a drug is prohibited according to WADA and you need it for a chronic condition (such as with some anti-asthma medications or diuretics for hypertension), you can get a therapeutic use exemption. What I’m going to focus on here is drugs which you might think would be prohibited according to the WADA, but which are actually fine to use. Things you can mostly find over the counter in a pharmacy, and things which you would want to use in a sports setting. This boils down, mostly, to what is casually known as ‘anti-inflammatories’.
Anti-inflammatories is a generic term for a drug which, as the name suggests, reduces inflammation. These drugs for the most part can be divided into two sections: steroids (such as prednisone and methylprednisone), and non-steroidal anti-inflammatory drugs (NSAIDs). We’ll be focusing on the latter, as they seem to be the general exception to the WADA rules. The NSAIDs are a broad class of drugs that all act through a similar pharmacological mechanism and all have similar side effect profiles, though they have wildly varying potencies and some are more readily available than others. Regardless of how they work, these drugs all have the net effect of decreasing inflammation, and therefore decreasing pain. In addition, these drugs are not mentioned on the WADA prohibited list at all. If that seems incongruous, this is why: the WADA prohibited list does very specifically mention narcotic drugs such as morphine and its derivatives, for the express reason that they limit pain reception and that this can improve performance. So, what’s the difference between the opioid narcotics and the NSAIDs? Well, pharmacologically there’s a huge difference, and this translates into a large practical difference. Narcotic drugs work pretty quickly, and they block pain directly. NSAIDs work a lot more slowly, and a lot of what they do is preventing the production of new inflammatory mediators. This then eventually translates to a decrease in inflammation which has a corresponding effect on pain. This distinction is enough for the WADA to ignore NSAIDs, as they are unlikely to have a hugely game changing effect in professional sports, and they are legitimately useful for overcoming injury. As a last aside it should be noted that paracetamol (not an NSAID, but fairly close) is also not mentioned on the WADA prohibited list, and neither is codeine (an opioid analgesic, but one that produces a fairly low grade of pain relief compared to the prohibited narcotics).
Now that you know there are products which a sports person is allowed to use, what are you as a coach/manager/physio allowed to put in the first aid kit that is used when your team is playing? When somebody gets hurt and the first aid team runs onto the field, what medications are they allowed to have in that first aid kit that won’t contravene the WADA policy, or South African law? Well, to be blunt as well as brief…nothing. Yes, you didn’t misread that. NOTHING. As discussed above there are some applicable drugs which can be used for common injuries which aren’t a problem according to WADA policy. However, in this case, it’s our national law that represents the stumbling block. According to the Medicines and Related Substances Control Act 101 of 1965, no person is allowed to dispense a medication unless authorised to do so under the Pharmacy Act (53 of 1974). So unless the coach or first aider is also a registered pharmacist, or a pharmacy assistant perhaps, you’re not legally allowed to dispense medication to a patient. For the purposes of this article, the patient is quite clearly the person who is in need of the medical care (the injured party), and the person dispensing medication is the person physically handing medication to the patient. Under these restrictions, you shouldn’t have any actual medications in your first aid kit since legally speaking you can’t give them to the patient.
There is a good reason for this. Just like people will be allergic to all sorts of food stuffs, many people will be allergic to a particular drug, and if you as the coach/first aider give a medication to a person that induces an allergic or anaphylactic reaction, you can and will be held liable when that results in complications for the patient (complications potentially including death). You don’t know what the patient is and isn’t allergic to, they may not be in a fit state to tell you, and on top of that you don’t know what other medications they might already be using and how these will interact with whatever you want to give the patient. So for the safety of the injured party, and for your own legal safety, it’s better not to have any medication in your first aid kit.
That being said, a lot of websites will recommend that you keep things like antihistamines, ibuprofen and aspirin in first aid kits. Antihistamines can be associated with a lot of side effects that might not have long standing consequences, but if you give a patient chlorpheniramine (commonly known as Allergex®) and they experience drowsiness and end up having a car accident, a degree of the blame can be placed on you. If you give an injured patient ibuprofen and they have an allergic reaction, or it worsens a pre-existing complication, the blame is ultimately yours. If you give aspirin to a child complaining of a fever and a headache and they experience the rare but commonly fatal Reye’s syndrome as a result, that’s on you.
Now, while I quoted the Medicines and Related Substances Control Act above, there is technically a loophole. When a drug is registered for use in South Africa it receives a schedule. This schedule, ranging from 0 (the lowest) to 7 (the highest), determines where a drug can be sold, in what quantities, and by whom it can be prescribed and dispensed. Drugs which are schedule 0 can be sold by pretty much anyone in pharmacies, but can also be sold in other places. The most common example of this is seeing paracetamol (Panado®) being sold at petrol stations and shopping centres. Personally I don’t feel that having these medicines be readily available in uncontrolled settings is a good idea, but that’s a topic for an article on its own. Suffice it to say, you can buy paracetamol in a petrol station, and you could hypothetically put it in your first aid kit. But then you’d still need to know the patient’s medical history, their allergies, essentially their whole life story. So in the long run, it’s better to leave medicine out of first aid kits, so stick to bandages, wound disinfectants and related supplies. If an injury is severe enough to require an actual medication you’re better off referring the patient to the nearest EMS team, pharmacy or hospital. Save yourself the trouble of legal liability, and save your patient the risk of experiencing a severe adverse event that could have been avoided.