We're going to get started in a couple of minutes. Just settle in. You're in for quite a show, I think. Thank you. How's everyone doing out there? Woo! Are you ready? Are you not entertained? Are you ready to be entertained? All right, this is just an exciting and wonderful workshop. I'm so proud. This is the first time in AAAP's history that we are doing this on sports psychiatry and the blending and impact of what we as addiction psychiatrists can do. Welcome, everybody. Beautiful Saturday afternoon. Thank you for sharing your afternoon with us. We'll have plenty of time to enjoy the rest of the sunshine and the reception later. My name, again, is Dr. Timothy Fong. I'm a professor of psychiatry at UCLA. I'm also the president-elect of AAAP. I'm very excited about that. And, you know, hey, you know, you do what you gotta do. You do what you gotta do. So without a doubt, this came together with my friends and colleagues. So I'm gonna introduce my friends a little bit later, Dr. Eric Morris, Dr. Larry Westreich. But really, when we came about with this idea, it was to say, you know, what puts all Americans together? And that's sports. And I think about impact that sports has had on my life. I put some of the top moments of my life are all related to sports activity. When the Cubs won the World Series, when the Bears won the Super Bowl, when Hulk Hogan slammed Andre the Giant. These are things that are probably higher than the birth of our sons, right? Because that's what we love, sports. And the idea that us as psychiatrists have a role in that is absolutely, absolutely amazing. And really, that's what we wanted to do here today, is talk about the trends that we're seeing among athletes, give people a sense of the kind of work that the three of us do when it comes to sports and addiction psychiatry. And really for you to think about your own work. How many here in the room work with athletes? We have a good chunk. How many of you, and again, you may not even realize, because when you think about how do we define an athlete, it doesn't have to be a professional. It could be someone whose identity is around sports. I play a lot of tennis, I play a lot of pickleball, and that's a big part of my life. If I'm not able to do those well, I struggle. And I think those are the areas that we can think about. How many of you work with college-age students? So again, this is another perfect area where a lot of the things we're blending here today are about that. So with that, we had three short presentations. Dr. Morris is gonna talk about the typical substances used in athletes and how we as addiction psychiatrists can talk about that. Dr. Westright's gonna talk about performance-enhancing drugs in sports and the implications of what happens there. And I'm gonna talk about sports betting and impact on athletes. I do run the UCLA Gambling Studies Program, and it's really kind of an emerging area since the last six years in terms of gambling and sports. And then we're gonna get audience participation. We're talking about next steps where the academy can move forward with this, things that you all might wanna see to say, how could this be relevant to my day-in, day-out practice? With that, we're gonna get started. I'm so pleased to bring up to the podium Dr. Eric Morris. Now, I've known Eric, and we've known each other since we were in college at Northwestern. So believe it or not, we've known each other now over 30 years. It was our 30-year reunion last night at Northwestern. We came here instead of over there, and we have known each other a long time. We both went into psychiatry in the late 90s in part because of Sheldon Miller, former chair and former founding member of AAAP. And I'm so excited that we're actually sharing the podium together. So Eric, come on up. Don't share any stories about what we did in college and med school. That's for later. The podium is yours. Thank you. Thank you, thank you. Piggyback on what Tim was saying. I think one of the greatest moments of my life started, my son plays baseball, and we love baseball. And we were just watching ESPN one day, and I think it was an Oakland A's pitcher that had an immaculate inning. So an immaculate inning is three strikes, strikeouts. So nine pitches, all strikes, strikeout. And so one of his first pitching performances, I'm coaching the team, strike one, strike two, strike three. He strikes the first guy out. Next, hitter comes up, strike one, strike two, strike three. He strikes him out. Third hitter comes up, strike one, strike two, ball one, strike three. And I'm thinking, oh my God, he almost had an immaculate inning. So he comes, three strikeouts, everybody's, when he comes into the dugout, everybody's giving him a high five or a slap on his butt. And I'm kind of at the end of the dugout waiting for him to come over. And he says to me, I was one pitch away from an immaculate inning. I'm like, oh, this is definitely my son. And he had only seen that once before. So we never talked about it. So it was really something special. And I, you know, we're gonna talk about substance use in sports, but I really wanna start, well, let me, I don't have any conflicts. I'm not gonna talk really about any medications. We have a definition of sports psychiatry. So I was the president of the International Society for Sports Psychiatry from 2006 to 2010. So I've always had an interest in it. I go back to my residency days when I was in psychotherapy supervision. And I was working with a UNC soccer player, a women's player, which they really dominated the sport back then. And my psychotherapy supervisor was like, you seem much more interested in the soccer player than you do your other therapy cases. And I'm like, yeah. It's like, you should combine your interests. And that night I was flipping through a JAMA just randomly and saw a book review on the first textbook of sports psychiatry written by Dan Bagel and Bob Burton. And I'm like, well, this is weird because we were just talking about it today. So I sent in, I mailed, this was back before there was email. I mailed each one a letter just asking them, what do I do to become a sports psychiatrist? And Bob, who was actually on Northwestern, but I never met him, hand wrote me back a two page letter. And the first thing he suggested was joining the International Society for Sports Psychiatry. So if you're really interested in sports psychiatry, you should definitely join. You do not have to be a psychiatrist to join. And so I started working with UNC in my residency with the athletic department. And then I moved to Maryland to do an addiction fellowship at the University of Maryland, where I got to work with David McDuff, who allowed me to work with the Orioles and the Ravens. And I set up a sports psychiatry elective and stayed on at UMBC for three years. And then I went to the University of Maryland for two years. And then I moved to Raleigh for love, which never works out for me. And then, and so in Raleigh, there was NC State. So I show up at NC State, I call first, no one answers. I just show up and say, hey, I wanna work with you guys. And the sports medicine director was like, we've never had a sports psychiatrist before. I don't think we need you. So I emailed Debbie Yao, who's my athletic director at the University of Maryland. And I said, hey, can you send Lee Fowler, the athletic director at NC State an email, just saying that I'm good. And she didn't, she cc'd me on it, which was nice. And the next day I was working for NC State. And so I worked for NC State for 15 years. I also have worked with the United States Anti-Doping Agency for, I don't know, probably 15 years. PGA Tours since 2008. Our Olympic team, just volunteering my time as they need me. So, and I've represented sports psychiatry at the Joint Commission of Sports Medicine and Science since 2008. So that's kind of my background. It's always been like maybe 10 to 20% of what I do. My main job is I own and operate nine opioid treatment programs surrounding Raleigh. And I have a small private practice where I see athletes, but I also see non-athletes. Sports are good for you. There is no question that youth sports participation reduces the likelihood of you using substances. So, even though there may be some certain risk factors in certain sports for using certain substances, if you take anything away from my talk, it's all of our youth should be playing sports. They should learn teamwork. You know, there's studies that have shown that besides reducing obesity and health problems, it's also good for their academics, for their self-esteem, it reduces suicides, it reduces domestic violence, it reduces teenage pregnancies. I think there was a Nike ad about all of these things. Encouraging youth participation and to purchase Nike items. But there's no question that athletes tend to use substances less than the general population with certain exceptions, particularly performance-enhancing drugs, which Larry's gonna cover. And so, every couple of years, the NCAA does a survey study and all of the data is there on NCAA.org. If you're interested in getting the raw data, you can. I went on a few days before putting this talk together. And there's no question that when you compare it to other studies of age-matched folks that use is a lot less in college student athletes than it is in the general population, age-matched. So, what some of the most common substances being used, number one, it's cannabis. And it's up, it's higher. The highest is men's lacrosse. It's even higher in states where it's legal, which you kind of would expect. Binge drinking, 35% of student athletes admitted to binging within the past year. But that was down from 2009 when it was 55%. Prescription opioids are down. Tobacco, spit tobacco is down. Certainly baseball has the highest percentage. I think golf is up there, lacrosse. ADHD, stimulants, those percentages are down. But I think when you look at the data a little more carefully, you'll find that there's a large percentage of athletes that don't use anything at all. And then the folks who do use are probably using at a higher rate than the average person who is using who's not an athlete, if that makes sense. So, the folks who do use tend to use a lot more. They're risk takers. As an athlete, you have to be somewhat of a risk taker, especially if you're playing a contact sport. And you're not afraid of, you know, self-harm, and you're gonna take more risks. And you also have a higher metabolism, probably. So, it probably requires a higher dose to get an effect. In my experience in prescribing stimulants to student athletes, they tend to have a higher dose requirement than non-athletes that I see that are of the same age. So, I think a lot of those factors factor in. And, you know, comparing the use in a very similar survey of the American College of Health, and looking at the Monitoring the Future panel, there's no question that student athletes use less than their age-matched comparisons. You know, working at NC State for 15 years, we had a substance use prevention program. It was a drug testing program. But the idea behind the program was to reduce use. That was the goal. And there was no question that if you knew you were going to be tested, or there was a high likelihood of the fact that you were going to be tested, and there might be a consequence for using, I think that was a deterrent for a lot of our athletes. I don't know if we still, if NC State, I say we, I left NC State in 2021 during COVID. Cost-saving for them to let me go. And so they went back to using Student Health, which they did before I got there. And so I don't know that we still have a testing program. You know, I think there's a lot of reasons for them not to have that testing program. Now that there's NIL money, now that it's so easy to get into the transfer portal, you know, if you test positive and you have to see me, even though I'm really good looking, you may decide to go someplace else next year, where you get a clean slate. And maybe they don't drug test as much, or as well, or observe them, you know. So I think there's probably a lot of pressure in terms of retaining your athletes that you probably don't want to drug test them. And I think that has to be, you know, a factor. Yeah, it used to be you couldn't transfer unless you had permission to transfer by your coach. And you would never be able to transfer within your own conference. But now you're seeing athletes transfer within their own conference. You already know the playbook, you know the tendencies. So, and I do think that the money that student athletes get, and it's pretty significant, has a lot to do with why we may not be doing as much drug testing. A lot of times when I was meeting with athletes who test positive, so I was the, I was kind of the screening and the intervention arm. So anybody who tested positive had to see me. And, you know, main thing I was doing was screening for co-occurring illnesses and treating co-occurring illnesses. But also encouraging them not to use again. A lot of them didn't meet criteria for use disorder, but they were still meeting with me in a motivational interviewing, psychoeducational way. But one of the things we would talk about is do you have a desire to turn pro? And what would these positive tests, would they have an impact on your ability to get drafted? But now that some of the pro leagues have taken marijuana off their ban list, that's not as motivating anymore. So the more permissive attitudes of our pro leagues I think will increase the use on the college level. The NCAA only does tests in the championship rounds. So I've had a number of athletes who get to the semifinals and they tank, they lose on purpose because they know if they make it to the finals they're gonna be drug tested and they're gonna be embarrassed by having to give up their championship. So oftentimes back in the day I was motivating folks to not use so that they could actually win a national championship. And also for the NCAA the TUEs are all retrospective. So therapeutic use exemptions for Major League Baseball, for NFL, you have to do the paperwork, you have to get permission to use the stimulant or any other substance that's on the ban list. You have to demonstrate that there's a medical necessity and then you're allowed to use that substance. In the NCAA it's retrospective. So if you test positive for say a stimulant in the championship round then the NCAA will come back and say okay, give us the paperwork, why did they need that substance? So. it's important if you're working with an athlete and you're thinking about prescribing a controlled substance that you be familiar with band list, what's band. And so, it's on the ncaa.org website. But something like ProVigil, Modafinil is on the band list. So if you're going to prescribe it, you can still do it, again, the TUEs are retrospective. But you just need to document why you're doing it. And you need to make sure that documentation gets to the trainers, because they're the ones that are going to be submitting all the paperwork. But these are the classes of band lists. I have prescribed buprenorphine to some of my athletes who had opioid use disorder. I thought it was medically appropriate to do so. One of them had gotten tested, so our paperwork was requested by the NCAA. And it was approved. So I mean, you can prescribe whatever you need to prescribe, you just have to document. And obviously, if you're working with a professional athlete, you need to know what's on the band list. Certain sports are not testing for cannabis anymore. And then some of the other leagues that are, there may not be a consequence. So they're referring you on for an evaluation or for treatment, just to make sure that you're healthy, not that there's a consequence for testing positive. In my work with the PGA Tour, which I'm not allowed to talk about, they have raised, they have always matched the WADA, so the World Anti-Doping Agency's band list, and their nanograms per milliliter cutoffs. So right now, I think that's 450 nanograms per milliliter, which would be kind of a daily THC user, unless you binged right before your urine drug test. Alcohol, I think it is the most commonly used substance. It's always milliliter time. Alcohol and sports, I mean, it's hard to find a commercial break for a major sports event and not find some sort of beer commercial, or whiskey now, although betting, gambling, online gambling has really overtaken that. But it's important to think about the recruiting process in college. So you take a visit. These high school juniors, or even high school sophomores nowadays, they come to town, they're matched up with somebody who's already on the team, their job is to try to recruit you. If they like you, if they think you're good, they're gonna try to recruit you. And you're probably gonna go to some sort of off-campus party. Usually you go on the weekends because you're in school, high school. And you're gonna find that there's gonna be certain substances being used. The team wants to know, and the team culture, whether or not you're gonna keep your mouth shut if you're gonna use, depending on the substance. And there's also a part of rookie hazing, or freshman hazing. And so if I'm trying to prevent use, I have to work with the team. And some of my teams that I've worked with, we've developed with the athletes, we've developed team contracts on what's acceptable and what's not acceptable. And so there's a lot of cultural issues associated with that. And it's really something you have to be aware of on a cultural level. And of course, your coach is gonna have a lot to do with that. But I've had situations where 16, 17-year-old was left in front of a dorm intoxicated, poisoned, and had to go to the emergency room, and nobody stayed. I mean, they stayed, they called 911, but as soon as they didn't wanna be, you know, is she gonna, or is he gonna rat out the rest of the team? You know, those situations happen. And then they call me in, and I have to figure out what to do, right? So some of your interventions are gonna be on an individual level, but if you're really gonna be successful at it, you gotta work on a team level as well. Rarely have I needed any kind of meds to prescribe, but you know, if they meet use disorder criteria, of course, you're gonna follow the medical evidence and prescribe. You know, I always take a real careful history. I'm really looking for co-occurring illnesses. I always ask, what does that substance do for you? And is there, you know, in like a harm reduction way, is there something else we can do, whether it's behavioral or another prescription, to reduce your use? AA is often not an option for athletes, even though things are supposed to stay anonymous. I think when you have an elite athlete, I don't think most athletic directors, I don't think most GMs or owners want their athletes using 12-step. So you know, you gotta be familiar with motivational interviewing, you have to know how to use something other than 12-step facilitation as your main therapy approach. And the main thing that I focus on is your performance. And so I know that if you're working on a particular technique, you'll say free throw shooting. You know, take a thousand free throws. You're working on your release, all right? You go to bed, but before you go to bed, you decide to drink a lot of alcohol. You're not going to remember your muscles, your innate brain is not going to remember everything that you just practiced. All those hours that you put in, you're not going to be able to retrieve that memory the next day or in the next game. So I explain that to my athletes in a way so that, you know, they perform at a higher level, and I think that is, you know, really important. You know, cannabis, I think culturally we need to be very sensitive about this. And you know, there used to be, this was our, I don't know if it was just NC State or if it was the ACC or if it was the NCAA, quite honestly, but this used to be the consequences for testing positive, you know, when I first started, the nanogram cutoff was five nanograms per milliliter. So I was getting lots of referrals, and a lot of them were I smoked three weeks before the test, and I've only used three times in my entire life, you know. And so I do a little bit of education and say I hope we don't have to meet again when the next, because now you're in the positive testing pool, which increases the likelihood that you're going to be tested again. But oftentimes when folks did get penalized for continuing to test positive, it was rare, you know, breaking team rules or it was an injury, it was never released that they actually were losing games because they were testing positive for substance. And we talked about team culture and hazing and how recruiting to fit your team culture is important. So people who use THC are going to probably, you know, high school students that use THC are naturally going to gravitate towards teams that are also using THC. And I approach cannabis the same way as I really approach alcohol, other than maybe suggesting some N-acetylcysteine for THC withdrawal. But I don't know that this is being done anymore, quite honestly. And so I'll be here, I'll stay after, we're going to do Q&A at the end, or do we, yeah. And then at some point I'm going to the beach, I'm going to strap on my way too small Speedo, and so you can ask me questions that you have while I'm wearing the way too small Speedo if you want, if you see me on the beach. But if you go to the beach, please take your badge off. It's embarrassing for all of us. Thank you. Thank you, Eric. Appreciate it. Eric's so modest and really great, and again, he actually got me started in sports psychiatry as well, so please ask him a little bit more about that. So with that, we're going to move on to our second presenter, who's going to do about 25, 30 minutes on performance-enhancing drug in sport. I first met Dr. Westreich in 1997. I always tell this story. I was a fourth-year medical student. I got the medical student of the year award, AAAP, 1997. I have a photo, I didn't get a chance to put it in here, of me and him. It's black and white. It's that old. It was developed on film. And black hair for both of us. But Dr. Westreich has been a friend and a mentor for me, with me, now almost 25, 30 years. He's a former past president of AAAP. He's a private practice up in New York. He's a consultant for behavioral health and addiction, Major League Baseball. You already heard him about the forensic law and addiction symposium, and he's going to talk to us about performance-enhancing drugs in sport. Come on up, Larry. So I'm going to be talking about performance-enhancing drugs. Does this sound okay? Yes. Okay. And I'm so excited to be able to talk about it, because I never get to anymore. Usually, I get invited to talk about drugs of abuse or mental health with athletes. I started out with performance-enhancing drugs. You're not getting feedback? All right, I am. Is it... How's that? Is that okay? Yeah. Okay. And for a career path, I was hired in 2003 because I was an addiction psychiatrist and a forensic psychiatrist. There were steroid problems in baseball. You may have heard about them. And they were well aware that a congressional investigation was coming, and they wanted to clean it up. So I was hired with a number of other people to work on the steroid issue, which we did for the next several years. And I was indeed testified to the Mitchell Commission about that, which they expected to happen. But as often happens in consulting, I handed off the performance-enhancing drugs and steroids to other individuals, moved to drugs of abuse like cocaine, opiates, and stuff like that. About seven or eight years ago, the vice president of baseball, who I worked for, health, became aware that mental health is important for athletes also, as did many other sports. So I was... And he said, you're a psychiatrist, right? And so I was able to morph into working on mental health issues for baseball. I've worked with Tim and Eric very often in sports. By that, I mean I usually beg them to come and talk to our mental health professionals or to our athletes. So it's very much appreciated. We just worked together in Arizona a few weeks ago. So I started in performance-enhancing drugs, but I do that, I do drugs of abuse, I do mental health right now. This is David and Goliath. David kills Goliath with a little stone. And the guy in the performance-enhancing drug center, who pictures to me, the nerd there, says, David, could we talk to you for a minute? I don't have any conflicts of interest, and I'm aware of anything I say does not represent the commission of baseball. That's my personal opinion. I'm not going to get into what's going on politically right now with WADA and drug testing, other than to say, if you read the sports pages or the front pages, you'll see that this is very much an issue, and it has to do, more than just sport, has to do with international relations and serious issues that happen between countries. So I personally try to stay away from that. And I want to talk about why you test for performance-enhancing drugs in sport. And I talked about this yesterday in the presentation about workplace. But the first thing is the health and safety of the athletes. Steroids are dangerous. But the retort to that notion from, you know, maybe from athletes, maybe from others, are saying there's a lot of things that are dangerous that grown people do, like put their head by a 95-mile-an-hour fastball, or smash into a 300-pound lineman. And so, you know, we should be able to choose what we do that is dangerous. Fair point. The real reason, I think, is a fundamental fairness, having a level playing field, that athletes are competing against each other for their livelihood, are competing on the exact same basis, one with the other. And this is what athletes are comfortable with. Because we are sometimes told that the water list you mentioned of substances of abuse and performance-enhancing drugs is a little idiosyncratic, right? I mean, why are some substances on there and some not? And I'll probably get to some substances, but you wonder why they should be on the list. And the response is, it is idiosyncratic. But at least everyone's playing by the same rules. Athletes are role models for not only kids, but for adults. And as I said yesterday, the business necessity of professional sport necessitates keeping performance-enhancing drugs out. I am so excited to talk to you today that I've prepared about four or five hours of material. Tim said I had to stay at 25 minutes. So I'm just going to try to get to the stuff that's really interesting and we can have a good discussion about. I'm going to raise some questions. I'm going to talk a little bit about steroids. I'm going to talk a little bit about stimulants, which are both in the category of substances of abuse and performance-enhancing drugs. I'll talk a little bit about supplements. I'm going to talk about how philosophers think about performance-enhancing substances. I'm going to talk a little bit about therapeutic use exemptions. We've talked about that. And what I think are the challenges for the future. But the questions are, what's performance enhancement? I'll tell you, in sport, that is a dirty phrase, a dirty word. He's just enhancing his performance. But that's the whole point of sport. People are trying to do better than others. When someone says, well, you're just trying to get better by taking steroids, the athlete might say, of course I am. That's exactly what I'm doing. One thing I reacted to in what you said, which I agree with 100%, is about sports are good for us, which is true. Amongst young people, amongst adults, doing something that's focused and generative and productive is very helpful. That being said, professional athletes, at least, are not afraid of hurting themselves. They can be impulsive. And if they were afraid of hurting themselves, they wouldn't be standing by the fastball. So when I came into baseball, I had an education at NYU Addiction Psychiatry Fellowship, and I knew nothing about steroids or performance-enhancing drugs. And I made the point that education is what we need. We need to educate these players about how dangerous performance-enhancing drugs are, including steroids. And that thudded. It did not work. What works, as you pointed out, are sanctions. And there's a consequence if you use this substance, if you cheat and do something that is contrary to the values of our sport. So that's performance enhancement. What's a drug? What's a supplement? That's sort of a legal definition. What's a medication? What's the difference between treatment and enhancement? And I'm going to show you a chart, which I hope will demonstrate that. My overall is that this is a very fuzzy line between some of these ideas. So athletes have been trying to improve their performance from the ancient Greeks. They eat bull testicles probably for a good reason. The way sports doctors talk about medications and drugs is this way, and it's kind of funny if you're not used to it. Ergogenic improving performance, that makes sense, right? I mean, a drug can improve someone's athletic performance or their intellectual performance. What they call addiction is recreational use. Now those of us who treat addicts know it's not recreational. I mean, they're not having fun going to a party, but that's the way it's seen. And it's seen as self-medication, in quotes, or just an attempt to change consciousness. That's the other category. And then therapeutic, that's easy to understand, or they're using a medication to treat an underlying condition. So I have these categories of substances, and let's think about this with the notion that it's a good rubric for thinking about performance-enhancing drugs, but it's far from perfect, and these are fuzzy boundaries. What about heroin? Is it ergogenic? No. It doesn't improve your performance. Is it therapeutic? Is heroin therapeutic? History of it, and if you go to Great Britain, they have heroin prescription programs. You go to Canada, they are. So not in the U.S., but it can be therapeutic. Is it recreational, the way sports doctors talk about it? Yes. Tylenol is not ergogenic. It is therapeutic. It's not recreational. No one gets high from Tylenol. Testosterone is certainly ergogenic. It's therapeutic, sure, if you have a true testosterone deficiency. It's not usually seen as recreational, depending how you define recreation, I guess. Adderall is certainly ergogenic. It's certainly therapeutic. And we all know that people use it as a substance of abuse to change their consciousness. What about beta-blockers? I saw the answer to this question in your slide, but we'll see if people were reading your slides carefully. Beta-blockers are ergogenic. They help with sports performance. Yes. Did you read the slide? Did you know that? So why would a beta-blocker be helpful in riflery? Does anyone know the answer to that question? There's one other sport it's good in. I know you know. Well, maybe, but why is it only banned in the Olympics for biathlon and archery? Biathlon and archery, banned in the Olympics. No. Heart rate. The athletes wait to shoot between their heartbeats, because if your heartbeat makes their gun go like this, I'm told. And so they strategically wait between their heartbeats to shoot the gun or do whatever they do in archery. And so it's a competitive advantage to use inderail. And this is well known in their sport. That's why it's banned. For them only. Is it therapeutic? Yeah. Is it recreational? No. Hydrochlorothiazide. It's not ergogenic, as far as I know. Is it therapeutic? Yes. It's not recreational. Banned in every major sport. Why? Exactly. You know, it's a loop diuretic, and it will cause urine drug screens to be negative. And as you pointed out, you can get an exemption for it. If the athlete absolutely needs it, then they can get the paperwork done and take hydrochlorothiazide. Although, one question is why a 22-year-old would need hydrochlorothiazide? Another question. Cannabis? Yeah, it's a mess. Is it ergogenic? I don't think so, but that's arguable. Is it therapeutic? Maybe. And is it recreational? Yes. So my point here is showing you these categories and saying, don't be convinced by these categories. What about this? What about illegal versus prescription only? Let's look at Adderall, for instance. It's not illegal. It's by prescription only. It's banned in all the major professional sports. I believe it's banned by NCAA and Olympics also, unless you have an exemption for it. And can it be dangerous? Yeah. I mean, in addiction it can be dangerous, or withdrawal can be dangerous. So these are the categories that we think about these substances in. When I get to therapeutic exemptions, I want to respond to something you said, which I thought was great. But I want to talk about attitude. And I would include elite athletes in all these attitudinal perspectives. But people who are paid to do this sport, and their livelihood is based on it, and who have been doing it since they were six, and it's the only thing they're good at, sometimes have this kind of an attitude, even more than those of us who are weakened warriors. This is a, I don't know if it's a study, but it's a survey of 198 Olympic athletes. Say I told you you had a drug that was so fantastic that if you took it once, you would win every competition you would enter, from the decathlon to the Mr. Universe contest for the next five years. It has a drawback. It would kill you five years after you took it. Would you still take it? They asked 198 athletes. What percentage said they'd be willing to die in five years to have all these victories? 52%. And, again, that is not contrary to my experience of people willing to take chances to do things that might be physically harmful to them, because they're already doing that on the playing field. And I think, you know, elite sports sequester people who are willing to do that sort of thing, including taking drugs that enhance their performance. Tom Simpson, who is a pro bicyclist, famously said, this is the attitude I love, if it takes ten pills to kill you, I'll take nine. And this is his memorial on the Tour de France where he died of dehydration with a normal amphetamine on board. So this is obviously what we're trying to prevent and we're trying to work against. So I'll talk about steroids. They're all derivatives of testosterone. You could as well take testosterone or take anabolic steroids. They're both oral and injectable anabolic steroids. Arguably, the oral ones are more dangerous to liver. They're not corticosteroids. I don't need to tell you that, but I need to tell the athletes that if they're worried about things are getting injected into their joint spaces or onto their skin. This is the molecule. You can see the metabolism of testosterone very simply. Cholesterol is broken up, DHEA, to androstenedione, to testosterone. And excess testosterone in the body is metabolized to female hormones, which is the reason that male athletes get gynecomastia when they use anabolic steroids. These are progesterone estradiol. You can see the similarity and it's no secret why this would happen. There are medical uses of anabolic steroids. Bone pain from severe osteoporosis, bad anemia, metastatic breast cancer, real nutritional wasting syndromes, hereditary angioedema, true hormone deficiency in males. And the reason I put this up there is to make the point that these aren't bad medications, but they're inappropriate for someone who doesn't need them for these indications. And I argue no elite athlete has these indications, otherwise they wouldn't be an elite athlete. I think that in this audience you'll understand we've made a mistake. We made a mistake in drug education at least 15 or 20 years ago by trying to give the message of how dangerous anabolic steroids were, that basically you'll drop dead if you take anabolic steroids. But it's like giving the message you'll drop dead if you smoke a joint. Everyone knows it's not true. And then when we come to something like fentanyl or we come to something that like some of the more serious anabolic steroids, we give that message, it's not well received. So we have to always acknowledge there are uses for these medications. And specifically when talking about side effects, we have to be very clear about the ones that are common, the ones that are catastrophic, and the ones that you may never see. What we learned when we started testing for anabolic steroids in at least baseball players was that we were mistaken in thinking that only the ones who were really jacked up were the ones who were taking anabolic steroids. It was actually other individuals who were taking relatively small amounts for healing usually of shoulder injuries. And not an unreasonable medical procedure to do it that way, just banned. And those individuals who were taking it at relatively low levels, arguably appropriately medically, were not experiencing many side effects. But the side effects that you will see if you see an anabolic steroid user, and I would just say that my own experience when I came to baseball and learned about steroids was that I suddenly started recognizing people using steroids. Before that, someone would come into my office and I would just say, gee, he goes to the gym a lot. I mean, he's a big fella. And not unreasonably because I had no experience with anabolic steroids. When I started recognizing it, then actually my private practice, I saw plenty of people unrelated to any sports who were taking anabolic steroids. What you will see often, certainly if someone looks like the Hulk, I mean, that's your clue. I mean, they're probably taking anabolic steroids. On the other hand, if you see things like gynecomastia, if you see things like increased aggression for no apparent reason, back acne, liver dysfunction by seeing elevated liver function tests, heart disease in a relatively young person, that can be early signs of anabolic steroid use. And I would be very aware of it. So this is the message that we give to athletes. But we're well aware that most of them, if they take it at relatively low levels, won't experience any of these side effects. So that's why we have to do testing. I'm going to get to in a second the people who do experience these side effects, which are high school and college students who go to Gold's Gym and some doofus tells them what the dosage of anabolic steroids is, which is double or triple or quadruple what any pro athlete would take. And they really hurt themselves. And I'll tell you how that happens. And this is the slide. And I showed this yesterday because it's really worrisome. These are 12th graders who take anabolic steroids. These are the Michigan data. Thankfully, the rate has come down. I don't know if it's because of education or because of cultural ethos or whatever the reason is. But fewer high school students take anabolic steroids. But some do. And enough do that. At least in 2015, when I calculated, it was about 61,000 12th graders. And frankly, I'm more worried about them than I am about professional athletes. Because professional athletes usually have good advice about taking it. I'm not advocating for that. I'm just saying that they have a doctor telling them how to take these medications safely. High school kids don't. And they have the same effects everyone does. But what is very typical are student athletes who take very high dosages of anabolic steroids and then must stop abruptly because mommy and daddy catch them or because the coach catches them or because, you know, you mentioned a championship testing only in the state where I live, in New Jersey, the state athletic association, in their wisdom, only tests for performance enhancing drugs at the championship level. So if you get to the championship, then they test you for drugs. So the kids say, well, I got to stop now, you know? And that decrease can lead to profound withdrawal, can lead to really serious problems with mood swings, increased aggression or irritability, withdrawing from family members. A very typical scenario is a, you know, high school senior or junior who stops abruptly taking steroids for some reason or other, gets a profound depression, and now has no sexual functioning. And so if you're an 18 or 19-year-old male who a doctor says, you don't have no sexual functioning right now, and there's about a 5 to 10% chance that your sexual functioning won't return, which is what the data show, that's a problem. And, you know, do I get to, well, I want to talk about treatment a little bit. Not only for professional athletes, but for athletes in general who must abruptly stop anabolic steroid use. I've done that treatment. My part is the psychiatric side. I try to treat the anxiety and depression that's there, try to, you know, very aggressively with medications, usually holding hands with an endocrinologist. You know, 95% of the testosterone in the male body is produced by the testes, 5% by the adrenal glands. The testicular function shuts down when exogenous testosterone comes on board, and as I said, 5 to 10% of the time, it just doesn't come back. And so the endocrinologist can replete that with testosterone, but it's, at least to my observation, it's not that easy, and it's quite a long-term thing. Yes? That's a good question. I don't know the answer to that. In my experience, it's been at least like a year. I mean, it's not a couple times taking steroids is going to shut down your testicular function. So it's usually it's the big hulks who have no testicular function. Well, that's a really good question. How do you test for anabolic steroids? If you test for testosterone levels, you'll get all over the place. What you do is do something called the testosterone-epitestosterone ratio, and there is a ratio in your body and my body which is always the same of testosterone to epitestosterone. Unless you're getting exogenous testosterone, where it will be elevated to 6, 10, 20. It usually should be around one or so. But anyway, it stays the same for you and for me. So that way, if you test with that test, you can test for any anabolic steroid use, any testosterone use, because I can't test for all the steroids that are out there, because it's not an infinite list, but it's very long. And people are actively trying to fool the testers by putting in new compounds. We can test at TE level, which is what we do. Mark McGuire, who remembers Mark McGuire? This wasn't the bottle, but he famously had a bottle. What's that? I don't doubt it. But he had the bottle of androstenedione in his locker, and a news photographer took a picture of it, and everyone said, but that just metabolized the testosterone, and that's not fair. And he truthfully said, well, androstenedione is not banned, nor is it illegal at the time. Maybe unwise to have it in his locker, but both those things were true at the time. And now it's banned. I think it's illegal, but it's certainly banned. I was talking about treatment. This is something that you need to work with an endocrinologist in treating young people. My experience is almost all males. I'm embarrassed to say that I don't have much experience at all with female athletes, so when I'm asked those questions, I just kind of don't answer. So I want to move a little bit to supplements that people use, and start with human growth hormone. It's not really a supplement, but it is a medication that's perfectly appropriate in the ways that it's prescribed by endocrinologists. These are the indications for human growth hormone. Children who have documented growth hormone deficiency, Turner syndrome, Prader-Willi syndrome, if you remember med school, you can recognize these syndromes at about 100 yards. They're not athletes. Adults with documented growth hormone deficiency, this is the only medication you can't prescribe off-label. It's written in the federal register that these are the only indications for prescribing growth, human growth hormone. So that's really cool, except a lot of people prescribe human growth hormone. I was going to actually this conference a few years ago, and I'm sitting in the airplane, and I see this advertisement. Clearly, someone's prescribing either human growth hormone or testosterone. Didn't exactly say it, so I was like, well, maybe I'm just imagining things. I saw this on the next page, grow young with human growth hormone. So there are plenty of anti-aging clinics who prescribe this kind of stuff, and who are, I would argue, purveying substances which are really dangerous, number one, because the substances themselves can be dangerous, number two, because someone who appears to have a testosterone deficiency or human growth hormone deficiency might have something else, and they need a full evaluation by an endocrinologist, which is the point we make to our athletes. Not only is this banned, and you're going to get in trouble, but it's dangerous for you. If you don't have sexual function, and you're 25 years old, the doctor needs to find the reason for that and get it treated, as opposed to you going to a mall in South Florida and getting an injection of testosterone. I'm a little bitter, okay. This is what it says in the Federal Register. We had the head of the DEA come and talk to us about something else, and I asked him, why are all these clinics there if it's clearly illegal, and everyone knows it is. The response was that I was correct about the law, but that they just have other fish to fry. It's not high in the list of things to worry about where there's a clinic with a licensed doctor in it who's prescribing medications. He might be accused of malpractice, but the DEA is not necessarily after him. I want to talk about other nutritional supplements in training. These are a number that are used. This is a really good paper written by colleagues of mine at baseball talking about performance-enhancing drugs and dietary supplements. Not commenting at all about what's happening politically right now, but just supplements even before the second Trump administration, they're the Wild West. FDA-approved medications, when you go to CVS and get them, you're probably going to get exactly what it says on the label. You're certainly going to get what it says on the label. When you get a supplement, not so. We've had plenty of athletes who have gone to Vitamin Shoppe, GNC, and come back and taken something they bought off the counter, had a positive for steroids, and they said, I just bought this at GNC. We said, well, too bad. First of all, it's in your body. It's your responsibility. Then we've gone to GNC, and on two occasions, we bought what they said they bought and tested it. Antibiotic steroids. We have in place, and NFL uses the same company. I work for the umpires, too. This is the umpires' policy, but it's the same for players. We have a group of almost 1,000 supplements that players can use that we can guarantee, because we had this company go and check, that they're not contaminated with something else, and that exactly what's in the supplement bottle is the supplement you're getting. We are very carefully not saying these are helpful to you. I don't think most of them are, but they're not contaminated. It is an affirmative defense to a positive drug test to say, I only use NSF supplements. They have to have this label on them. It says NSF certified for sport. Our athletes can use it. NFL athletes use it. That being said, I found out recently that in the Dominican Republic, where you have 30 academies, someone has started making these labels and just putting them on bottles. I guess it keeps you young. Drugs of use in sport, we already talked about that. There are medical uses of supplements, of stimulants. Let's talk about stimulants. I talked a little bit about therapeutic use exemptions yesterday. Eric talked about them. There are plenty of medical uses for stimulants. The one that's most common, obviously, is ADHD. Some athletes have ADHD. It would be fundamentally unfair for us to say, because you're playing this sport, you can't take a medication that you need. The message I give to athletes, we give to athletes, is that there are substantial side effects to stimulant medications, but there are substantial benefits also. You need to have that decided upon. As Eric alluded to, we have a really sophisticated process overseen by Tim Willans at Harvard, Francis Levin from Columbia, and Len Adler from NYU, where we send our players to a certain group of ADHD specialists to make a diagnosis. We're right most of the time. It's not a biological diagnosis, so people have to make a clinical assessment. A lot of people are using Adderall. Data is showing that the shorter-acting stimulant medications are relatively more abusable. I'm saying that very carefully, because I think that's true. I also think it's true, as a clinician, that some patients need shorter-acting stimulant medications, longer-acting and shorter-acting on top. Just to show you a little dirty laundry, sports doctors say, well, let's just let people take long-acting medications. Some sports do do that. I think Olympics does that. We don't so far, but we try to push people towards the longer-acting stimulants. This is where medical knowledge of our clinicians comes into place. You have to decide if someone's trying to get shorter-acting because they're trying to get high, or they genuinely need that attention boost in the afternoon to do what they need to do. I know it's miserable. Yeah Right I theory runs into practice a lot Right no, it's true And I talked about this yesterday This is what you talked about therapeutic use exemptions where somebody should be allowed to take the medication that they're prescribed But we don't want them to cheat and and it's a clinical assessment. It's a classical Demonstration of dual agency. I'm obligated to the player to be because I'm a doctor I'm obligated to my employer who was trying to maintain a level playing field and You know in those circumstances the only thing that you can do is be rigorously honest about what you are doing What who you will be informing and what exactly is going on? I mean, you know, these are the kinds of things that end up in hearings these end up in court cases There's an agent will say my player has ADD. He deserves to get this medication And you know actually most of the time people are well-intentioned and genuinely think that but but we have to hold to our own protocols I Talked about TVs yesterday Wizenator, I won't talk about drug testing. I talked about that yesterday Let's see So, you know what's happening right now there is a Unfortunate resurgence of advertising to teenagers on tik-tok about steroids and they are a very malleable Population and so there is has been a bump up Probably not even reflected in the Michigan data yet of Teenagers using anabolic steroids because they're easy to get if you got a credit card and a you know Internet connection you can get anabolic steroids we had a good talk from Consumer protection branch of the FDA about them going after stimulants are going after them at least as of two months ago we're going after them hard because They were getting all kinds of different substances snuck in under stimulants under supplements Yeah, they're going after these cases, so these are some references if you're interested, I'll make my slides available Also, anyone's welcome to look at them and I'm looking forward to the discussion. Thanks everyone I'm bonded by sports, so I'll go from there. All right, thank you so much, Larry. All right, so again, hopefully you're starting to get a vision and say, how does this apply to me as a psychiatrist? Again, if you're working with athletes, these are tried and true principles. If you're not working with athletes, I can tell you that athletes need addiction psychiatrists. We see a lot of the folks who provide care for athletes are family medicine doctors, sports medicine doctors, or psychologists. But none of them have the training we do as addiction psychiatrists. So that's our call here today, is that for you to say, how do I make this relevant to my world? And if I'm interested in building this world, do kind of like what Eric did, which is to reach out and say, hey, I'm an addiction psychiatrist that can do things that addiction medicine docs cannot do and family medicine docs cannot do. I'm going to talk now about what I do at UCLA Gambling Studies Program. As an example, we built the Gambling Studies Program in 2005. What followed really were then opportunities in sport because of the work we were doing with gambling. So number one, this is it. For athletes and really anyone, you do not have to have a gambling problem to experience problems from gambling. How many of you in this room in the last 12 months have had a patient with a gambling disorder? Isn't that amazing? About 10 years ago, we would have asked that question. It would have been like two or three. So I always start with a case. And this highlights what we're doing with gambling and athletes. The perils that they see. This is a 24-year-old baseball player. During 2020 spring training, COVID hit. He was a very prized top 100 prospect, was looking to make the major club. Pandemic hit, season placed on hold, unsure if he was ever going to play again. Went back to his home state where there was mobile sports gambling, nothing to do. Out of boredom, starts gambling on sports. Says, I don't know when we're coming back. I don't even know if I'm going to be a professional player again. Just need a little bit of money. I'm bored. I'm curious. By the end of the year, he'd spent about $1,000. Not a huge amount, but a significant amount. And then he got upset when he didn't get paid off a bet. So he asked the state commissioner or the gambling operator, hey, this gambling company didn't pay me out. I need to get paid. The state gambling regulator looked at his name, cross-referenced it to a database he had of professional athletes, and it matched. He then notified Major League Baseball, this is a player on your roster who's gambling. Immediately, he was placed on administrative leave for 18 months. Now, that's a long time. Pandemic, career, he's young, $1,000, not a huge amount. Then they make their way to come see me. Hey, let's get the gambling experts to see what we have. I evaluate him, and it turns out that he did bet on baseball games, because he said, I didn't think I was a baseball player anymore. I didn't think I was ever going to go back to the major leagues. He said, yeah, I did think about gambling as a way to solve problems, boredom, curiosity, a way to make money. That's not really what it's supposed to be for. I didn't think of it as a form of entertainment. That's not really right. It's not really something else. And there were harmful consequences due to his continued pattern of gambling. So it was pretty clear that here was a guy that very clearly had gambling disorder, didn't quite know what he had, didn't affect his play, wasn't affecting, he didn't throw the game, because there were no games. But he did things that, at base value, didn't make a lot of sense. Why would he take these risks? If he showed up in your office, what would you tell him? If you weren't working with a major league baseball, and he was saying these things to you, do you have a duty to report him to his boss, that sort of thing? What could we have said had been done earlier? I can tell you all the way to the end, the outcome was he never got back into baseball. 18 months, all his career eventually stalled out. I don't know what he's doing now, but it was very clear he did have a gambling issue. So we have a lot of those stories like that, and why does that matter? Because over the next five or 10 years, you are going to see more and more of these cases show up into your own offices, regardless of whether you work with athletes or not. So right now, after the last election, we have 40 states in America that have legalized sports betting by phone or by brick and mortar. Can you imagine that? Just in six years, we've gone from having just two states to 40 states. So we've made this a normalized behavior. For athletes, it's really three areas I think about, and it's really true for any person, but particularly for athletes. Number one, we are, of course, concerned about athletes that develop addiction gambling disorder. Number two, we're worried about athletes and their relationship with gambling that could interfere with the integrity of sports. And lastly, we're seeing, unfortunately, more and more athletes that are experiencing harassment online and in real life because of gambling, the surge of gambling demand. So we're talking about athletes that are getting threats on their body, threats on their families, or messaging, or requests, frankly, venmo from crazed fans that say, I lost a bet. You please venmo me the bet that you made me lose. So again, things that you never would have thought of before. So again, just in that culture, the acceptability of gambling is gone. It is not taboo. It is part of the water. It's part of the air that we breathe now. You imagine the elementary kid school, the high school kid who only knows sports books and FanDuel and DraftKings and betting as part of the sport. We have a lot of folks who are getting interested in sports and not viewing sports for the enjoyment of sports, but viewing it as a financial tool to make money. The access is 24-7. That means we don't go to the casino. The casino comes to you 24-7. And think about a lot of the athletes that we work with, how much time they have on their hands. It's really remarkable. We work with G League and NBA players. And I have a patient of mine whose day doesn't start to 1 PM every day. 1 PM, that means he wakes up at 7 AM and he's in a hotel because he's trying to make it to the big leagues. That means he has six, seven hours every morning. Doesn't even have a car. Tremendous amounts of boredom. Tremendous amount of time on the road. Again, this idea of making money quickly. So the average salary in the G League and the NBA is about less than $100,000. The average WNBA player makes $50,000, $60,000. So although you see large salaries in professional athletes, some of the rookies still only make a couple hundred thousand. So oftentimes, they'll think of gambling as a way of making money quickly to alleviate the peer and family pressure that they have. So a lot of athletes, even in college, are like, I need to make money now to help my mom or dad who sacrificed so much for me to become an athlete. So it makes an easy synergy when you have a world where people are celebrating gambling, when there's role models on gambling, constant people are talking about gambling. Of course, it's a natural feel for an athlete to get into it. So tremendous areas now of opportunities to have research and study on this area. We have more and more. Basically, what we know is that globally, the prevalence rates of gambling disorder in athletes is higher than non-athletes, particularly in student athletes, that 18 to 24-year-old group. We're not so sure in professional athletes. In part because it's hard to do research with professional athletes, very tough to get cooperation to the leagues and things like that. We do see a solid signal of more male than female athletes having a risk for gambling disorder. And in which sports? Surprisingly, of all the sports, golf. Golf is the highest risk for gambling disorder, in part because of the culture of golf and gambling that's always been embedded in that, followed by other sports, of course, including football and basketball and things like that. So NCDAA also does a survey like they do for substances. We were part of this for the gambling thing. And again, you'll see over from 2004 onward up to 2016, again, roughly around 1% of male athletes gambling disorder. And for females, less than 0.1%, very tiny. The 2020 survey was not done because of COVID. They're doing that survey this year. But again, did you know that there are over 700,000 student athletes in college? That is a massive number. So 1% is not insignificant. Those are the ones that we are trying to reach, for sure. All right, so again, the personality traits to consider about why someone who's an athlete would go gamble, they're competitive, they're impulsive, they're risk-taking, they have a hard time dealing with loss, they're obsessional, detailed, they have strong confidence. I had a tennis pro with a gambling disorder who was like, I played against these men and women. I know this game. And even though it had been 10 years since he played, he's like, I know the insider. I can tell when a player isn't going to win. And all that's a cognitive distortion. So you put all that together, what is that implication for you as a clinician to say, hey, if I'm working with athletes, I have to look at some of their personality traits that might uniquely position themselves to develop increased risk for gambling disorder. Unfortunately, our treatments are not as advanced as they are for other areas of addiction. We don't have an FDA approved medication, although we will use naltrexone and acetylcysteine and a variety of other things that might work a little bit, like lithium for bipolar spectrum type gamblers. But again, the standards of biological treatment for gambling disorder are treating the co-occurring disorder and encouraging sleep and healthy nutrition. We have brief interventions that work. We have psychotherapy models and there's no one form of psychotherapy that's better than another. They all work pretty well for gambling disorder. Of course we have gamblers anonymous. But how can you possibly use that for an athlete? How difficult is that for an athlete to walk into a room or log onto a Zoom and he or she's face is plastered and even though it's supposed to be anonymous, not really, really safe. So we have to figure out other ways to get a safe treatment space for athletes. So the treatment principles I have for gambling disorder, again, similarly, if I prescribe medications because of their metabolism, sometimes we also see side effects magnified because every little side effect will affect performance. Dry mouth, just a few pounds of weight gain is definitely a concern. These are the things that they tell us. So we miss a lot, of course, with the gambling disorder, the ADHD, mood disorders and PTSD. And again, we have so many athletes that struggle with how do I know I can trust you? So one of the things about sports psychiatry is you're not working necessarily in isolation. You're working with teams and coaches and trainers and agents and everyone's got an agenda and everyone's got an opinion. So that is a new skill for us as psychiatrists to figure out how do we navigate those lanes so that we can communicate with folks in a thoughtful, meaningful way. There are some athletes that I honor their wishes and I never tell a soul about what's happening, but those treatment outcomes are never nearly as successful as when we bring it in. So I oftentimes say to folks, gambling is now part of the athletic training experience, just like sleep, nutrition, what you put in your body, how much you exercise aerobically and aerobically, things like that. All right, so resources and things for you to think about. Number one, we do have now telehealth programs for gambling disorder across the nation. So no longer do you have to be in person. This is a company I work with that provides mental health therapy. They can do it 24 hours a day in hotel rooms, on the room, things like that. We also have lived experience speakers where they come out and they talk to teams and talk to them about gambling, not scared straight stuff, but just giving them good information about gambling and athletes. And now we have an app you can download. This is good not only for non-athletes as well as a gambling recovery app. In this app, you get markers, you can track craving, you get modules, you get access to non-12-step groups, you get a lot of good supportive tools for recovery. All right, and then one of the questions we have, again, is how do we address gambling disorders in athletes moving forward? In other words, what type of sports bet are the most dangerous for athletes? So for years and years, there were only a few kinds of sports bets you can make. Now, does anyone not know, who does not know what a same game parlay is? A few people. So a same game parlay is a type of sports bet where I'll put, let's say, $5 down and I need five things to happen inside that same game. I need player A to have 10 points or more, I need player B to have 20 points or more, I need player C to have less than eight rebounds. And if all these things happen, my $5 wager can suddenly become $25 or $100. It's like a lottery ticket, a low-cost investment for a larger reward. Well, it turns out that in all those mobile sports betting apps, the same game parlays are about 70% of their business. This is really a popular form. So in other words, this isn't the traditional forms of sports betting, where you pick team A versus team B. This is the lottery. And because of that, we see a much higher rate of return of money for gambling companies than you do with traditional forms of sports betting. We mentioned golf being at the greatest risk. But again, that's going to change as you get more and more bets and changing the culture of sports betting. And again, at what stage should an athlete hear about this? A lot of the athletes know about Pete Rose, even though they never even knew him or saw him play. But his name still resonates throughout the halls of athletes from as soon as he can start playing baseball. And then who's really responsible for doing this work to get that information to athletes about proper healthy gambling and the risks of gambling? So in an area I thought was really interesting in mental health-wise that we don't think about enough, if you're working with athletes, this question of maintaining integrity of sports. And the reason why we value sports so much is why? Because it's undetermined. It's supposed to be based on merit. And if it's unfair, it's unsafe, it's not something I would want. But I've always thought about this. I'm a big fan of professional wrestling. It was never formed as a form of sport, right? Turned into sports entertainment. It's predetermined sports entertainment. Now, if we knew that baseball, football, and soccer, and all the sports we love to watch, it was predetermined, would it still be as popular? In all the movies we watch, it's predetermined, right? So the real question is, why is it so important for us to maintain the purity of sport? I think it's because we love sports so much. We want to see it settled, basically person versus person based on merit, not on outcome. When you get a lot of conspiracy theories heightened because of the gambling. So you get a lot of this stuff online, oh, NBA's rigged, scoring is up because of gambling. No one wants the Chiefs to lose, and that's all because of gambling, and it's all rigged. You create these misinformation myths that you as a psychiatrist have to identify with patients and athletes that are struggling with either gambling disorder or athletes themselves. So, I'll finish this with the sports gambling harassment, and again, how many of you have worked with patients who've experienced harassment online? Who've said, you know what, one of the things that's driving my depression, my anxiety, my distress, is because I've been targeted by harassment online. So this is relevant not just to athletes, but to any of our patients who might be a part of this. And here's an example of an unintended consequence of legalizing sports betting. That over the last six years, a significant rise in harassment and abuse, digital comments, digital sports media, harassment, direct messaging, in-person threats, I'm gonna kill you, I'm gonna kill your family, I'm gonna blow up your car. Now, I've never been harassed, thankfully, by my patients. I've never been harassed by the public, but I can't imagine what that must feel like. Whenever I get a negative critical evaluation on a lecture from the medical student, I hurt, I don't like that. I take that seriously, but I can't imagine having that repeated. That's a form of trauma. That's a form of abuse. And for us as psychiatrists, we had to do that. So we had to develop better tools on how to help any individual who was struggling dealing with it, but particularly for athletes that have this issue. As an example, you can hear highlighted, this was a survey, NCAA, saying that in sports with high volume, we're talking about nearly most of the sports, over 54,000 comments flagged by potential abuse, abuse things that are happening. One in three high-profile athletes have received abusive message related to someone else's betting interests. So as an example, for us as psychiatrists to be paying attention to these trends in culture. And so when we see a rise in something that can create mental health distress, that's our job, to come up with tools and strategies to help with people. And the reason makes sense. Anytime you put a lot of money combined with fandom and passion and competition and anonymity, which is what mobile sports betting get, then of course, that's what you're gonna get people reacting really, really quickly. It's very hard to police this, very hard to enforce this, very hard to stop this. So this is definitely an area I'm worried about moving forward with athletes. So a few things for us to think about moving forward for athletes. Again, if you're working with athletes saying, listen, I'm adding in gambling behavior as part of my screening and basic assessment tools. I'm adding in gambling activity as part of what we're gonna do in our treatments and assessments. If you're working with an actual team to say, let's talk about gambling policies more, let's educate staff and trainers and coaches that we actually have that. I've been doing this bit more and more with hospitals. For instance, how many of you have gambling policies in your workplace that are in writing? Probably, well, majorly baseball. But it's amazing to me how many hospitals do not. At UCLA Health, we do not have a gambling policy. And I sat down with the heads, I said, why don't we put that in motion? They're like, really? You really think that's gonna be a thing? I said, we have alcohol policies, we have tobacco policies, we have substance use in the workplace policies. This is an addictive behavior. This is an activity that can potentially create all sorts of fraught problems. We need to have workplace policies related to gambling. In other words, when that nurse in the overnight shift is playing Candy Crush or slots overnight, to me, that is a violation of workplace policy. It's the same thing for athletes. All right, same thing with integrity, the idea that when we have sports that are really integrity, that we have public trust, that's gonna raise just the joy that everyone has around it. But, and right now, there's a lot of software tracking these sorts of things, and a lot of things that we can look at moving forward. And harassment, I have no idea how to stop harassment. No one does. But we do know that there's certain things that are happening. When there's single player prop bets, meaning bets just on the one player to do something in that game, we do see that's where you see a much higher related evidence of harassment. And again, it doesn't matter whether you win or you lose, because always, someone is gonna be winning or losing based on your number. We now know that we have even bets that go down to the pitch. For instance, you can bet, is this pitch gonna be 90 miles an hour or more or less? So you can see how the harassment can come down. You can have a great game, but you could still have lost money for a gambler who said, you know what, in the fourth inning, in the fifth pitch, I bet $100,000 on it, and you threw it under 90 miles an hour, you piece of crap. So that's the level of harassment that we're seeing. So if you're working with anyone, again, who's experiencing harassment, we feel really strongly that the authorities need to be involved, because without taking legal action, it's just gonna continue on moving forward. We also encourage athletes not to engage with a harasser, and you'd be surprised at how many athletes do, because they are competitive, they're impulsive, they wanna respond quickly, that's just a recipe for disaster. So I think about this, gambling is part of the athletic training experience. It affects body, brain, mind, spirit, and even recreationally, athletes are set to a different set of rules than the rest of us. You know, I was just speaking to some of our UCLA athletes, they said, there really is no reason for you to do this while you're in college, you can wait until you're older. And a couple of them said, well, that's just not fair. I said, I recognize that, but it's also part of the privilege of you being a UCLA athlete to have the benefits. And then they began to realize, oh, you know what, I don't have to do this right now. But he was under the impression that he had to gamble right now, because he was worried about missing out on all the other gambling activities there. All right, so our website here for our resources, our team at UCLA that does this, this is my QR code. I'm very proud of this, it took me quite a while to make this. So if you wanna scan it, you get me right into your phone and send me a text or contact. And then I asked my 19 year old son, hey, can you make a QR code for me? He's like, dad, all you gotta do is go to LinkedIn, go to your profile, go to the upper corner, right click, and it'll generate a QR code for yourself. So the young people do know something. All right, so with that, we wanted to stop there. Let me use the mic. We have questions. We'll have Eric, Larry, and myself up, come up here if you have questions, comments related to sports, you wanna know more about what we do or about what this field is like. And again, I wanna highlight, by being a addiction psychiatrist first, that's what opened up these opportunities in sport. And I think Eric and Larry would highlight that. So that's the value we see in this organization and go from there. All right. Thank you. And that was pretty cool to see a feature on. I'm Shubh Bhargavan, I'm an addiction psychiatrist in Wisconsin. My question is to you, Dr. Westerreich, specifically. Towards the end of your presentation, you started talking about, I think, energy drinks and supplements. And I just wanted to get more, could you expand on that? Because I have actually seen that by testing, quantitative testing, for there were lots of patients who did not disclose they were taking illicit stimulants. But there were instances they really did not have any reason to not disclose. And we were starting to see like prescription stimulants showing up in urine drug testing when they were clearly admitting to using various kinds of energy drinks and things like that. So I don't know if that's what you were referring to, but I'm curious about if this is something you've seen. Yeah, no, it is. And you sort of hit on a sort of complicated area. Because energy drinks are sort of in the middle. Anything you buy at GNC that says supplement on it is something that we would ban, say you should only use certified for sport. I think if you go to CVS and buy yourself a bottle of over-the-counter Tylenol, you're gonna be safe. Energy drinks are kind of in the middle. Red Bull, Monster, other things, you just have a lot of caffeine in them. Some have guarana in them. And what we have settled this is by putting those on our NSF list. So on our list of things you can use are energy drinks like Red Bull is on our list. And you can buy those, have a little stamp on them, you're gonna be safe. But what happens when a guy goes into CVS, buys himself an energy drink, and it's contaminated? I don't have a great answer for that. I mean, other than saying, you should probably be using only things that are on the NSF list. Because energy drinks are not well modified. They're not well regulated. So, yeah, so it's a problem. Right, that's exactly right. The name for that. Thank you. Introduce yourself, please. My name's Sarah, I'm a medical student from UM. As you guys mentioned, it's very highly advertised, all the mobile sports betting and stuff. And I wanted to ask if you think there's a role that this organization, or how to play a role in cutting back on the advertising and limiting the amount of advertising for sports betting. So you're touching a really sore subject because gambling advertising is supposed to be regulated. By definition, all gambling that is regulated, there are state rules that are put into it. But rare has it been that they've actually enforced it. So unlike alcohol, tobacco, cannabis, and guns that have very tight regulations for advertising, they haven't done that. So the power of that has to come from the governments. It has to be enforced both at the state level, at the local level, and potentially at the federal level. Unfortunately now, what we've done is gone the opposite, is that we've promoted now gambling activity as a super positive thing, as an amazing thing, as a way of just blowing up. And so to take that away is very, very difficult because there's just too much money in it right now. And until you get a consolidation of people saying, this is really bad for young people, I think we're gonna be in for a lot of trouble. So if people have asked me, well, what should we be saying on advertising there? Well, I think what's very simple, you should be telling the truth. This is not a reliable way of making money. This is meant to make your life better. And right now, a lot of the basic messaging that they also have even in problem gambling messaging is, I think, off. It's like, oh, just play until the fun stops or make a plan and stick to it. Well, that's not quite right either. So again, it starts with studying the impact of advertising, and we know it just promotes and drives people engagement. But more than anything else, like cannabis, it diminishes perception of risk and harm. And anytime you do that with advertising, that's when you're gonna get people to say, it's no big deal. It is no big deal for a vast majority of people who engage in it, but for that one to 2% of the population to develop harm, it is not, it is devastating. So we'll take one more, and then we're gonna wrap, and please introduce yourself. Sure. My name is Ben Chia. means we are going to be examined by all kinds of entities. So we wanted to have a program in place that was defensible. So we have these three experts who oversee a panel of other ADD experts, who are the only ones we allow to diagnose ADD. And we did that specifically because of our experience with the Mitchell Commission. We knew that people could, we have to publish these numbers every December in the newspaper, actually, what our percentage of people who use stimulants is. And so I think we have a creditable policy, as I implied. We're right most of the time, not all the time. But I think it's different on the. And I'll say, again, two things on that. I work with our UCLA sports athletes, and a lot of times they'll come say, I got ADD doc. I say, how do you know? Oh, I can't focus. My grades aren't great. I can't concentrate. Do you have NP testing? No. Show me the evidence. I just can't focus. I have trouble learning the playbook. Then you get collateral information, and the athlete's showing up on time, practices hard, goes to everything. And they're clearly just wanting to get it for that. And that's a really difficult part, because I've had cases that test your ethical boundaries. When the coaches or trainer are like, hey, can you give them something? I'm like, no, we can't. That's not appropriate. And then I thought about, well, how is it really performance enhancing? And I had a baseball player once who told me, once he got on Adderall, he was able to pick up the spin of the ball better. And he was able to sit and stand in the center field and not let his mind wander. So therefore, he cut down on errors. That's how it was performance enhancing. I had a tennis player who said, you know what? I had just as confidence that I wasn't going to miss. That's performance enhancing. I play golf. It's the same thing. Golf is 99% confidence. And when I'm just a little bit more confident, I can hit that six iron on 220. Or if I get a little bit of the yips, I shank it. Anyway, we want to thank everyone for your attention. It's time for the area meetings. Eric and Larry, come up here. We've got to do a photo. We've got to do a photo. And then we'll hang out for a few more minutes. Kristen can take the photo.

sports psychiatry

addiction psychiatry

Dr. Timothy Fong

Dr. Eric Morris

substance use

team culture

performance-enhancing drugs

anabolic steroids

drug testing

gambling addiction

mental health

sports betting

workplace policies