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Performance effects and sport regulation of cannabis use

This is an excerpt from Clinical Pharmacology in Athletic Training by Michelle A. Cleary,Thomas E. Abdenour & Mike Pavlovich.

The performance-enhancing effects of a substance are determined if the substance has “medical or other scientific evidence, pharmacological effect, or experience that the substance or method, alone or in combination with other substances or methods, has the potential to enhance or enhances sport performance.”²⁶ Although cannabis does not have any overt performance-enhancing benefits, the 2021 World Anti-Doping Agency (WADA) prohibits its use during competition. According to WADA’s Prohibited List (an international standard antidoping code; also discussed in chapter 19), substances of abuse are identified as such because they are frequently abused in society outside of the context of sport. The following are designated substances of abuse: cocaine, diamorphine (heroin), methylenedioxymethamphetamine (MDMA, or Ecstasy), and tetrahydrocannabinol (THC).^45,48 Players in the National Football League (NFL) have enlisted their management to lift the ban on CBD to avoid deterring individual players from using medical marijuana. An argument presented by the players is that when treating severe pain secondary to playing football their choice is either to use an opioid or marijuana; therefore, medical marijuana should be made an available option.⁵ The league has taken a listening and learning posture of collection and analysis of scientific data.

The International Olympic Committee (IOC) consensus statement on pain in elite athletes concludes that further research and increased consistency in measures and methods across studies are needed. There is a need to better understand the incidence and prevalence of analgesic medication use in sport and the benefits and risks of various pharmacological and nonpharmacological treatments, and their combinations, for specific pain presentations. The IOC discussion about pain management in athletes does not include information about cannabis, although they do have protocols for use of steroid injections, anticonvulsants, antidepressants, and opioids. Due to the paucity of research into the efficacy of cannabinoid treatment for pain in athletes, the IOC consensus statement concluded that current evidence does not justify the use of cannabinoids for pain management in elite athletes.⁴⁹

Cannabis use in athletes has been primarily studied in adolescent, elite, and collegiate athletes from an antidoping or antiabuse perspective. A review of cannabis use in elite athletes concluded that there was no evidence for use of cannabis as a performance-enhancing drug and that cannabis may play a role in pain management and concussion-related symptoms.^45,49 There is an apparent paradox in considering the effects of cannabis on athletic performance. Despite evidence that recreational cannabis use may acutely impair psychomotor skills and cognitive function, there is a perception among some athletes that cannabis use may have beneficial effects.⁴⁵ The literature is scant, and the illegal or prohibited status of cannabis worldwide has limited the ability to generate high-quality data on the patterns and prevalence of cannabis use among elite athletes.⁴⁵

Sport-regulating agencies are endeavoring to use published scientific data to achieve the most objective judgment on the potential of substances or methods used for performance enhancement, doping practices, or unfair sportsmanship. When developing recommendations, athletics policymakers should assemble a diverse team of experts in the field of sports medicine, pharmacology, toxicology, doping, analytical chemistry, endocrinology, and hematology.²⁶ Historically, prohibition of recreational cannabis use has long been the dominant policy model for sport organizations. Consequently, a growing number of organizations have implemented cannabis policy reforms. As U.S. states and other countries continue to legalize and decriminalize approaches for the use and supply of cannabis,¹⁶ athletics policies and recommendations must continue to evolve and be refined.

Clinical Recommendations

Good-quality evidence indicates that substantial risk of adverse health outcomes may result from cannabis use. This risk may be reduced by informed behavioral choices among users and sound advice from ATs and other sports medicine practitioners. The evidence-based recommendations, education, and intervention tools inform patients about choices on the use of cannabis. However, it is important that institutions and athletics departments systematically communicate support in order for key recommendations to be effective. As legalization continues to evolve, policymakers must actively review and implement new recommendations toward reducing health risks related to cannabis use.¹⁶ When working with patients who are considering using medical cannabis or cannabis-based medicines, ATs should have a thorough dialogue with the patient and in consultation with the prescriber and may consider a written treatment agreement (figure 20.2). Since ATs and other sports medicine clinicians may be placed in a position to advise on cannabis as a medicine, they should provide patients with information regarding the benefits and risks of use, as well as responsible medicinal use.

Evidence-based recommendations may reduce the risk of adverse health outcomes from cannabis use, especially in young users. Therefore, it is prudent to use good-quality evidence to develop recommendations to lower the risk of cannabis use. Based on a systematic review of current evidence, experts have developed 10 major recommendations for lower-risk cannabis use:^16,23

1. The most effective way to avoid health risks related to cannabis use is abstinence.
2. Avoid early-age initiation of cannabis use (i.e., nothing before the age of 16 years).
3. Choose products with a low ratio (percentage) of THC or balanced THC:CBD ratio cannabis products.
4. Abstain from using synthetic cannabinoids (refer to section on Synthetic Cannabinoids).
5. Avoid combusted cannabis inhalation and give preference to nonsmoking use methods.
6. Avoid deep inhalation and other risky inhalation practices.
7. Avoid high-frequency (e.g., daily or near-daily) cannabis use.
8. Abstain from driving while under the influence of cannabis.
9. Members of populations at higher risk for health problems related to cannabis use should avoid use altogether.
10. Avoid combining previously mentioned risk behaviors (e.g., early initiation and high-frequency use).

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