hon p.1 [100%]YAKUGAKU ZASSHI 131(12) 1761―1764 (2011)  2011 The Pharmaceutical Society of Japan

1761―Review―

Educational Opportunities and Anti-Doping Roles and Responsibilities for Pharmacists
Peter J. AMBROSE
Department of Clinical Pharmacy, School of Pharmacy, University of California,
San Francisco, CA, USA(Received August 31, 2011)
Drug use and abuse by athletes has become a common problem. Pharmacists can assist by managing the legitimate
medication needs of athletes to prevent them from accidentally using a banned substance. Pharmacists can also educate
athletes and the public about the health consequences of using performance-enhancing substances. Pharmacists can playa variety of roles to assist with anti-doping. Such roles include educating, advising, dispensing and monitoring medications and supplements; and working with anti-doping agencies. There are few established educational opportunities forpharmacists and pharmacy students. Educational programs in sports pharmacy and doping control need to be developedfor instruction in the classroom, for post-graduate training and for experiential programs. Classroom instruction should
include information about performance-enhancing substances and general principles of doping control. Student activities for an established advanced pharmacy practice experience include education on performance-enhancing substances
and assay technologies, preparing and providing presentations to athletes and others regarding these substances, performing literature research on drugs and dietary supplements used to improve athletic performance, writing a monograph on these substances, and participating in doping control programs.
Key words―doping control; pharmacy practice; pharmacy education; sports pharmacy

INTRODUCTION
The use and abuse of medications, dietary supplements and other substances by athletes has become acommon and problematic phenomenon. It is no longer a surprise when it is reported that an athlete tested
positive for a banned substance and is then penalized
for a doping violation. Athletes often seek a competitive advantage, and some resort to using performance-enhancing substances. This is not only true of elite
athletes, but has been reported in children, as well,
who likely do not understand the harm that many performance-enhancing substances can do to theirbodies.1) However, athletes also need medical careand have legitimate need for prescription and nonprescription medicines. This can become a potential
problem for them if a needed medication is banned
for their sport and sport-sanctioning organization,
particularly if they don't follow the appropriate policies and procedures. Further, athletes use dietary supplements for nutritional purposes, since they often
have special dietary requirements; and they may notrealize that a product contains banned ingredients.
e-mail: ambrosep＠pharmacy.ucsf.edu
This Review is based on the content of Symposia 36(S36) of the 131st Annual Meeting of the PharmaceuticalSociety of Japan.

Athletes who compete in sports with doping regulations are confronted with complicated rules andbanned substance lists. This creates a situation where
there is a signiˆcant risk of athletes innocently consuming banned substances, either by self medication
or even having been prescribed by a physician. One of
the most notorious examples of this occurred in the2000 Olympic Games in Sydney, Australia.1) In thisunfortunate case, a team physician made the mistakeof prescribing a common cold medication for an athlete, which then resulted in the athlete testing positive for the banned substance. It was generally agreed
that this was the result of a medication prescribing error and not intentional doping, however, it still resulted in the forfeiture of a gold medal.
ANTI-DOPING ROLES FOR PHARMACISTS
It seems obvious that pharmacists and the pharmacy profession should be utilized to educate and assist
athletes, coaches, athletic trainers, sports medicine
and team physicians, and the public in general. In
fact, the International Pharmaceutical Federation developed and approved a ``Statement of Professional
Standards'' on ``The Role of the Pharmacist in theFight against Doping in Sport,'' in 2005.2) In thisstatement, the Federation provides recommendations
for governments, pharmaceutical associations, phar-hon p.2 [100%]1762

macists, and pharmaceutical manufactures. In particular, it encourages pharmaceutical associations toparticipate with anti-doping agencies and to provide
basic and continuing education to pharmacists about
doping and the health consequences. Further, theFederation recommends that pharmacists be familiar
with the World Anti-Doping Agency's Code, and toprovide information to assist athletes and others tounderstand which medicines are listed in that code.
The general objectives of doping control are to ensure fair and equitable competition, and to protect
the health and safety of all the athletes. Thus, theroles for pharmacists should parallel this objective
and include educating, advising, dispensing andmonitoring medications and supplements, and working with anti-doping agencies. Further, pharmacists
can help prevent athletes from accidentally using abanned substance. Educational needs should be basedon these new roles, and opportunities should be created to meet these needs.
To advise and counsel athletes that have legitimate
medication needs, pharmacists must be intimatelyfamiliar with the banned substance lists for various
sports and sports organizations. Coaches, athletic
trainers and physicians also need help in understanding the banned substance lists. This can help prevent
athletes from accidentally taking a banned substance.
This is particularly true for dietary supplements,
where the listed ingredients may hide banned substances by using herbal and botanical names. However, even if the pharmacist is not an expert, the pharmacist can advise athletes to contact their sportsgoverning organization and inquire about the banned
status of a particular medication. Such organizations
have a mechanism for athletes to obtain this information and the pharmacist can assist the athlete withthis. Often, the major sports organizations have interactive websites and telephone services where athletes
can check their medications and supplements to determine if they are banned or permitted.3) Pharmacists
can assist with this, particularly in helping with drug
names and other ingredients.
Pharmacists can educate athletes and the public
about the dangers of doping and the consequences
these substances can cause. This can be done at alllevels of competition, including school children.
Pharmacists can also serve as doping control o‹cers
and work with the various sports-governing agencies,
such as the Japan Anti-Doping Agency. Medication

Vol. 131 (2011)

and supplement histories are often obtained, and thepharmacist is very knowledgeable about these. Sports
organizations may also consult with pharmacists
regarding their policy of which medications to ban or
permit, since pharmacists have considerable knowledge of pharmacology.
EDUCATIONAL OPPORTUNITIESSports pharmacy and anti-doping roles for pharmacists are relatively new and emerging ˆelds. Thus,
there are few established educational programs in existence. Pharmacists that wish to practice in theseroles will need to be pioneers and will need to seek opportunities to learn and to be involved. For the future, we need to create curricula and practice models
for pharmacy students. This includes instruction in
the classroom, experiential training, and post-graduate training. Pharmacists that are involved in these
activities can serve as instructors, role models andmentors.
A fundamental component of a curriculum to prepare pharmacists to practice in anti-doping roles
should include information on substances that areused for performance enhancement. This would contain information on the pharmacology and the proposed mechanism of action of these substances, andhow they aŠect athletic performance. Pharmacists
should learn skills on how to evaluate data to support
or dispute claims that are made of performance-enhancing substances. This is particularly important for
dietary supplements, where advertisements are notorious for making bold and unsubstantiated claims andfor which there is little scientiˆc research.
Communication skills are also very important.
Pharmacists will be consulting with physicians andscientists, as well as athletes of all ages who may havelittle technical knowledge. Advising and educating athletes and the public will require the ability to communicate at their level of understanding to provide
unbiased and factual information. To build andmaintain credibility, both the positive and negativeeŠects of performance-enhancing substances should
be discussed.
Pharmacists should learn about the general principles of doping control and the rules and regulations
regarding banned substances. For example, somedrugs may be banned only during competition, whileothers are banned at all times. For some medications,
therapeutic use exemptions may be available, but re-hon p.3 [100%]

No. 121763

quire documentation and following a speciˆc process.
Thus, familiarity with the policies and banned substance lists for the major sports organizations is required. It is also beneˆcial for pharmacists to understand the process of sample collection (blood and urine) for doping control. The exact process may vary
for the diŠerent sports organizations, however, thegeneral principles are similar. Having expertise in thisarea would allow pharmacists to be doping controlo‹cers where they perform the specimen collections,which may include obtaining histories of the recent
use of medications and dietary supplements.4) Although a thorough understanding of assay techniquesand drug detection is not required, knowledge ofgeneral principles of these technologies is helpful for
pharmacists to understand the full picture of doping
control.
Many of the above topics can be taught in the classroom with lectures and perhaps some laboratory exposure. However, experiential practice provides anopportunity for the pharmacy student to actually use
the knowledge and skills learned. In the USA, there
are few opportunities for advanced pharmacy practice experiences (APPEs) in sports pharmacy anddoping control. In 2006, an APPE in sports pharmacy was created for senior pharmacy students at the
University of California, San Francisco.5) This sixweek clerkship has been oŠered once a year sincethen, with 69 students per session. The preceptor forthis APPE has participated in the drug testing andTable 1.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

education program for the National Collegiate Athletic Association (NCAA) since 1986; and has
served as a doping control o‹cer at the Olympic
Games in Atlanta (1996), Sydney (2000) and Beijing(2008).
The objectives of the APPE are listed in Table 1.
There are a variety of activities that the students engage in to achieve these objectives. They are given lectures about performance-enhancing substances, andare then assigned to groups of 23 students for themto prepare their own presentations. In the process, thestudents learn about these substances more in depth.
Then, throughout the six weeks, the students givepresentations at local colleges to athletes, athletic
trainer students, athletic trainers, and in kinesiology
classes as guest lecturers. All the students in the
APPE attend each of the presentations with the preceptor.
Students also gain drug information experience byresearching the answers to questions by NCAA athletes and personnel who inquire about the banned
status of substances. This is conducted with the National Center for Drug Free Sport (NCDFS), which
manages the drug testing and education program for
the NCAA.6) In addition, each student is assigned toresearch and write a monograph on a speciˆc drug or
dietary supplement, which is provided to the NCDFS
to post on their website. Each student shares andreads their monograph to the preceptor and the otherstudents for feedback, critique and suggestions before

Learning Objectives for an Advanced Pharmacy Practice Experience in Sports Pharmacy

Demonstrate three ways that pharmacists can participate in doping control or drug education programs in sports.
Explain and defend the two primary purposes of doping control in sports to mixed audiences.
List and describe ˆve classes of drugs that are commonly used by athletes as ergogenic aids.
Counsel athletes on why banned drug lists can be problematic for them if they compete for more than one sports－governingorganization.
Explain three reasons to athletes why dietary supplements are a particular concern for them since they are subject to drug testing.
Obtain relevant medication histories from athletes during a drug-testing event.
Conduct sample collections, describing in detail the proper procedures and techniques for drug testing.
Select appropriate assay procedures commonly employed in doping control, and compare and contrast the advantages anddisadvantages of each.
Given a list of medications, determine if each is banned, restricted or permitted by a speciˆc sports-governing agency (e.g.,
NCAA, USADA, NFL, etc.) and advise athletes accordingly.
Present a topic relevant to sports pharmacy to instructor and fellow students and/or other audiences (e.g., high school students, college athletes, athletic drug trainers).
Prepare a monograph on a drug or dietary supplement on its use or abuse in sports, suitable for publication.

NCAA＝National Collegiate Athletic Association, USADA ＝United States Anti-Doping Agency, NFL＝National Football League.

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Vol. 131 (2011)

they ˆnalize the monograph.
The APPE students are also taught the basics ofdrug assays and techniques to detect doping. Students
then visit and tour a laboratory accredited by theWorld Anti-Doping Agency and the Anti-Doping
Research Institute, Inc.7) Students are also taught
how to perform urine specimen collections, and they
participate with their preceptor in several real collections for the NCAA's drug testing program at local
universities and championships. The process and protocol are very technical to protect the integrity of thespecimen, and requires the students to test the specimens for adequate volume, pH and speciˆc gravity
before accepting the specimen for shipment to thelaboratory. Students also blind the samples fromlaboratory personnel with code numbers, as per policy.
CONCLUSION
Pharmacists are needed to assist athletes in their
medication needs, and to join in the cause against
doping. There are many roles that they can serve inthis regard, which include counseling athletes, advising physicians and athletic personnel, educating the
public on the eŠects of performance-enhancing substances, and participating in the anti-doping programs of sports organizations. Currently, there arefew established educational opportunities for pharmacists and pharmacy students. Examples of topics
that should be included in such educational programs
are presented, including a unique APPE in sports
pharmacy.
REFERENCES
1)
2)

3)

4)
5)
6)

7)

Ambrose P. J., J. Am. Pharm. Assoc., 44, 501
516 (2004).
FIP statement of professional standards. ``The
role of the pharmacist in the ˆght against doping in sport.'':〈http://www.ˆp.org/www/
uploads / database _ ˆle.php?id ＝ 208&table _ id＝〉, cited 11 July, 2011.
Ambrose P. J., Tsourounis C., Olander R.,
Uryasz F., Sports Health: A Multidisciplinary
Approach, 2, 1218 (2010).
Ambrose P. J., Am. J. Health Syst. Pharm.,
54, 10531057 (1997).
Ambrose P. J., Am. J. Pharm. Educ., 72, Article 19: 18 (2008).
The National Center for Drug Free Sport,
Inc.,〈http://www.drugfreesport.com/〉, cited
10 July, 2011.
Anti-Doping Research, Inc.,〈http://www.antidopingresearch.org / index.php 〉, cited 11
July, 2011.