Cannabis Use and Sport: A Systematic Review

Influence of short-term chronic oral cannabidiol application on muscle recovery and performance after an intensive training protocol - a randomized double-blind crossover study

BACKGROUND

Rapid regeneration after intense exercise is essential for competitive athletes. Based on this assumption, supplementation strategies, focusing on food supplements, are increasing to improve the recovery processes. One such supplement is cannabidiol (CBD) which is gaining more attention in competitive sports. However, the evidence is still lacking and there are no data available about the effect of a short-term chronic application.

METHODS

A three-arm double-blind cross-over study was conducted to determine the effects of two different CBD products on performance, muscle damage and inflammatory processes in well-trained athletes. In total 17 subjects took successfully part in this study. Each subject underwent the six-day, high-intensity training protocol three times. After each training session, each subject took either a placebo or a CBD product (60 mg of oil or solubilisate). Between the intervention phases, at least four weeks of washout period was conducted. Before and after the training protocols the performance capacity in countermovement jump (CMJ), back squat (BS), bench press (BP) and 1-mile run were measured and biomarkers for muscle damage (creatine kinase, myoglobin), inflammatory processes (interleukin 6 and 10) and immune cell activity (ratios of neutrophil granulocytes, lymphocytes and, platelets) were analyzed. For statistical analyses, the current version of R and a linear mixed model was used.

RESULTS

It could identify different effects of the training protocol depending on performance level (advanced or highly advanced athletes) (p < .05). Regardless of the performance level, muscle damage and a reduction in performance could be induced by the training protocol. Only CBD oil was associated with a reduction in myoglobin concentration (p < .05) in advanced athletes. Concerning immune activity, a significant decrease in platelets lymphocyte ratios was observed in advanced athletes after placebo treatment (p < .05). CBD oil application showed a slight inhibitory effect (p < .10). Moreover, the reduction in performance differs between the performance levels. A significant decrease in CMJ was observed in advanced athletes and a decreasing trend in BS was observed in highly advanced athletes after placebo treatment (p < 0.10). Both CBD products do not affect performance parameters. For inflammatory parameters, no effects were observed.

CONCLUSION

It was found that the performance level of the subjects was a decisive factor and that they responded differently to the training protocol and the CBD application. However, no clear effects of either CBD product were found and further research is needed to identify the long-term effects of CBD application.

Cannabis Use Disorder Not Associated With Opioid Analgesic Use or Patient-Reported Outcomes After ACL Reconstruction: A Retrospective Matched-Cohort Analysis

BACKGROUND

The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD).

HYPOTHESIS

We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs.

STUDY DESIGN

Retrospective matched-cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

We identified patients with CUD who underwent primary ACLR at a single center and had minimum 3-month follow-up. Patients with CUD were propensity score matched 1:1 to non-CUD controls with respect to age, sex, and follow-up time. Total refills, days supply, and morphine milligram equivalents (MMEs) of opioid analgesics prescribed were calculated for up to 1 year postoperatively. Patient-Reported Outcome Information System (PROMIS) instruments were used to assess PROs. Opioid use and outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher's exact test. P values <0.05 were considered significant.

RESULTS

A total of 104 patients with CUD were matched to 104 controls. Both groups were majority male (65.4% male, 34.6% female). The CUD group had a mean age of 29.9 years and mean follow-up time of 16.1 months. There was no significant intergroup difference in opioid prescription rates (CUD 82.7% vs control 83.7%, P ≥ 0.99). Among patients prescribed opioids, there were no significant intergroup differences in total days supply (P = 0.67), total MMEs (P = 0.71), or MMEs per day (P = 0.65). There were no significant differences in pre- to postoperative improvement in PROMIS Pain Intensity (P = 0.51), Pain Interference (P = 0.81), Mobility (P = 0.90), Mental Health (P = 0.74), or Physical Health (P = 0.94).

CONCLUSION

There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference.

CLINICAL RELEVANCE

CUD does not appear to correlate with inferior outcomes after ACLR.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses

CONTEXT

Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health.

OBJECTIVE

To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes.

DATA SOURCES

PubMed and Scopus databases were searched on April 8, 2022.

STUDY SELECTION

Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis.

STUDY DESIGN

Umbrella review of SRs and MAs.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted.

RESULTS

A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance.

CONCLUSION

In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Cannabinoid Therapy in Athletics: A Review of Current Cannabis Research to Evaluate Potential Real-World Cannabinoid Applications in Sport

The increasing legalization of Cannabis sativa plant products has sparked growing interest in their therapeutic applications. Prohibition laws established in 1937 hindered formal research on cannabis, a plant with cultural and medicinal roots dating back to 2700 BC in Chinese history. Despite regulatory hurdles, published research on cannabis has emerged; yet elite athletes remain an underrepresented population in these studies. Athletes, known for exploring diverse substances to optimize performance, are drawn to the potential benefits of cannabinoid therapy, with anecdotal reports suggesting positive effects on issues ranging from anxiety to brain injuries. This review aims to evaluate empirical published cannabis research with a specific focus on its potential applications in athletics. The changing legal landscape, especially the removal of cannabis from drug testing programs in leagues such as the National Basketball Association (NBA), and endorsements by Major League Baseball (MLB) for cannabinoid products and the National Football League (NFL) for cannabis research, reflects a shift in the acceptability of such substances in sports. However, stigma, confusion, and a lack of education persist, hindering a cohesive understanding among sports organizations, including business professionals, policymakers, coaches, and medical/training staff, in addition to athletes themselves. Adding to the confusion is the lack of consistency with cannabinoid regulations from sport to sport, within or out of competition, and with cannabis bioactive compounds. The need for this review is underscored by the evolving attitudes toward cannabinoids in professional sports and the potential therapeutic benefits or harms they may offer. By synthesizing current cannabis research, this review aims to provide a comprehensive understanding of the applications and implications of cannabinoid use in the realm of athletics.

Cannabis in combat sports: position statement of the Association of Ringside Physicians

and ARP Position Statement: Based on the available body of scientific evidence and with the goals of promoting safety of combat sports athletes and striving for the advancement of clean sport, the Association of Ringside Physicians recommends the following regarding cannabis:• Use of marijuana or synthetic cannabinoids by combat sports athletes is discouraged due to unproven benefits and many known adverse effects. Acute use can impair cognition and complex motor function, which likely leads to reduced performance in combat sports. Chronic use can increase risk for heart and lung disease, several cancers, schizophrenia, and can reduce testosterone in men and impair fertility. Benefits from cannabis in most contexts, including athletic performance, have not been proven.• Use of topical purified CBD is neither encouraged nor discouraged.• Since acute cannabis intoxication can impair complex cognitive and motor function, any athlete suspected of acute intoxication at the time of competition - based on clinical judgment - should be banned from that competition.• Wide-scale regulation of cannabis based on quantitative testing has limited usefulness in combat sports, for the following reasons:∘ Cannabis is not ergogenic and is likely ergolytic.∘ Concentrations in body fluids correlate poorly with clinical effects and timing of use.∘ Access to testing resources varies widely across sporting organizations.

Does a broad-spectrum cannabidiol supplement improve performance in a 10-min cycle ergometer performance-test?

Cannabidiol (CBD) is a non-intoxicating phytocannabinoid which has been proposed to possess anti-inflammatory and analgesic properties. Given the potential for perceptions of pain to limit exercise performance, the aim of the present study was to investigate if 3 weeks of daily CBD supplementation (150 mg day-1) improved performance in a 10-min performance-trial on a cycle ergometer. In a randomized, double-blind and placebo-controlled study, 22 healthy participants (n = 11 male and n = 11 female) completed two 10-min performance trials on a WattBike cycle ergometer interspersed with a 3-week supplementation period. Supplementation involved either 150 mg day-1 oral CBD or 150 mg day-1 of a visually identical placebo (PLA). During trials, ratings of perceived exertion (RPE [6-20]), heart rate (HR) and blood lactate (BLa) were collected every 2 min. Mean power (W) was also taken throughout the exercise at each time point. All data were analyzed using two-way ANOVAs. There were no significant differences (P > 0.05) between CBD or PLA groups for mean power (W) during the 10-min performance trial. There were also no significant differences (P > 0.05) in any of the physiological or perceptual parameters (HR, BLa and RPE) between conditions. Three weeks supplementation of a broad-spectrum CBD supplement did not improve performance via any change in RPE during a 10-min time trial on a cycle ergometer, and as such, this evidence does not support the claim that broad-spectrum CBD supplements could be performance-enhancing in this exercise modality.

Comprehensive analysis of prohibited substances and methods in sports: Unveiling trends, pharmacokinetics, and WADA evolution

This review systematically compiles sports-related drugs, substances, and methodologies based on the most frequently detected findings from prohibited lists published annually by the World Anti-Doping Agency (WADA) between 2003 and 2021. Aligned with structure of the 2023 prohibited list, it covers all proscribed items and details the pharmacokinetics and pharmacodynamics of five representatives from each section. Notably, it explores significant metabolites and metabolic pathways associated with these substances. Adverse analytical findings are summarized in tables for clarity, and the prevalence is visually represented through charts. The review includes a concise historical overview of doping and WADA's role, examining modifications in the prohibited list for an understanding of evolving anti-doping measures.

Cannabis containing THC impairs 20-min cycling time trial performance irrespective of the method of inhalation

Herein, we examine the human exercise response following cannabis inhalation, taking into consideration varied cannabinoid concentrations and different inhalation methods. A semirandomized crossover study design was used, with measures of perceived exertion and physiological responses to submaximal and maximal exercise. Participants (n = 14, 9 males 5 females) completed exercise after 1) smoking Δ-9-tetrahydrocannabinol (THC)-predominant cannabis (S-THC), 2) inhaling aerosol (vaporizing) from THC-predominant cannabis (V-THC), 3) inhaling aerosol from cannabidiol (CBD)-predominant cannabis (V-CBD), or 4) under control conditions. All exercise was performed on a cycle ergometer, with submaximal testing performed at 100 W followed by an evaluation of maximal exercise performance using an all-out 20-min time trial. Metabolism was characterized via the analysis of expired gases while subjective ratings of perceived exertion (RPE) were reported. During submaximal cycling, heart rate was higher during S-THC and V-THC compared with both control and V-CBD (all P < 0.02). During maximal exercise, V̇e was lower in V-THC compared with control, S-THC, and V-CBD (all P < 0.03), as was S-THC compared with control (P < 0.05). Both V̇o2 and RPE were similar between conditions during maximal exercise (both P > 0.1). Mean power output during the 20-min time trial was significantly lower in the S-THC and V-THC conditions compared with both control and V-CBD (all P < 0.04). Cannabis containing THC alters the physiological response to maximal and submaximal exercise, largely independent of the inhalation method. THC-containing cannabis negatively impacts vigorous exercise performance during a sustained 20-min effort, likely due to physiological and psychotropic effects. Inhalation of cannabis devoid of THC and primarily containing CBD has little physiological effect on the exercise response or performance.NEW & NOTEWORTHY Inhalation of cannabis containing THC alters physiological responses to both submaximal and maximal exercise and reduces mean power output during a 20-min time trial, regardless of whether it is inhaled as smoke or aerosol. In contrast, cannabis devoid of THC and predominantly containing CBD has no effect on physiological responses to exercise or performance.

Cannabis Use in Adolescent and Young Adult Athletes: A Clinical Review

CONTEXT

Cannabis use among the general population has increased over time, in part due to decriminalization of use and greater social acceptance of cannabis use. These changes have contributed to increased availability of cannabis products, thus raising the likelihood that a subset of adolescent and young adult athletes will use cannabis. Therefore, it is imperative that clinicians and other providers working with young athletes have a thorough understanding of the impact cannabis can have on the athletic performance and overall health of a young athlete.

EVIDENCE ACQUISITION

PubMed (Medline), CINAHL, PsycINFO, and SportDiscus databases were used to perform a literature search of articles published between January 1, 2010 and December 31, 2022. Additional articles were reviewed based on references obtained from initial articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Survey studies suggest that up to 1 in 4 athletes have used cannabis at least once in the last year. Age, sex, race, sexual orientation, level of competition, and country of residence of an athlete all contribute to differing rates of cannabis use among athletes. The scientific literature does not support using cannabis for athletic performance, and multiple studies have demonstrated notable impairments in objective athletic performance measures. Cannabis use can also negatively impact an athlete's overall health via cardiovascular, gastrointestinal, and mental health symptoms and disorders.

CONCLUSION

Cannabis use among adolescent and young adult athletes is common, and rates of use are influenced by many different factors. Current evidence suggests that cannabis use can worsen sport performance, negatively impact an athlete's general health, and contribute to negative mental health outcomes.

Substance Misuse in Elite Athletes: Early Detection, Brief Intervention and Referral to Treatment

Sports medicine physicians and athletic trainers regularly encounter athletes who misuse substances that put them at risk for adverse health, social, interpersonal, academic, psychological, and performance effects. The three most encountered substances are alcohol (binge drinking), cannabis (marijuana), and tobacco/nicotine vaping. Early detection using self-report screening instruments, adverse consequences questionnaires, and urine testing are reviewed. Brief interventions that involve personalized feedback, goal setting, support system involvement, psychoeducation, contingency management, and/or motivational interviewing are highlighted. Lack of response to brief intervention or progression to a substance use disorder should prompt the consideration of referral to a substance specialty level of care.

Physician Perceptions of Cannabidiol (CBD) and Cannabis in Sports Medicine and Performance

Objectives

There is growing evidence regarding cannabinoid use in sports medicine and performance, especially cannabidiol (CBD). This study aims to determine if sports medicine physicians are recommending cannabinoids for therapeutic purposes, as well as analyze perceptions of cannabinoids within sports medicine and performance.

Methods

Physician members of the American Medical Society for Sports Medicine (AMSSM) completed an anonymous survey on demographics, CBD and Cannabis recommendations, as well as attitudes toward cannabinoid products within sports medicine. Factors associated with CBD and cannabis recommendations as well as perceptual differences were found using multivariate regression modelling.

Results

Responses from 333 physicians were recorded. The following groups were less likely to agree with allowing cannabis for recreational purposes: female gender (coeff. = 0.79 (0.33-1.25), p=0.001), increasing age (coeff. = 0.04 (0.02, 0.07), p  <  0.001), and rural respondents (compared to baseline urban, coeff. = 1.16 (0.36, 1.95), p=0.004). Similarly, these three factors were associated with a higher likelihood of disagreeing with WADA removing cannabis from the prohibited substance list and with the NCAA allowing CBD use by collegiate athletes (p ≤ 0.045). CBD was less likely to be recommended by pediatricians, rural physicians, and academic physicians (p ≤ 0.030). Male physicians and younger physicians were less likely to identify cannabis as performance-enhancing (p ≤ 0.042).

Conclusions

Sports medicine physicians have varying views on cannabinoids. While sports medicine physicians generally have favorable attitudes toward CBD and cannabis, these perceptions appear to be significantly affected by age, practice type, and gender.

A randomized, double-blind, placebo-controlled, repeated-dose pilot study of the safety, tolerability, and preliminary effects of a cannabidiol (CBD)- and cannabigerol (CBG)-based beverage powder to support recovery from delayed onset muscle soreness (DOMS)

BACKGROUND

Cannabinoid-containing products are marketed to athletes as promoting recovery, in spite of a lack of data on their safety and effects. This randomized, double-blind, placebo-controlled, repeated-dose pilot study tested the safety, tolerability, and preliminary effects on recovery of a formulation containing cannabidiol (CBD; 35 mg), cannabigerol (CBG; 50 mg), beta caryophyllene (BCP; 25 mg), branched-chain amino acids (BCAAs; 3.8 g), and magnesium citrate (420 mg).

METHODS

Exercise-trained individuals (N = 40) underwent an experimental induction of delayed onset muscle soreness (DOMS) and completed follow-up visits 24-, 48-, and 72-hours post-DOMS. Participants were randomized to active or placebo formulation, and consumed the formulation twice per day for 3.5 days.

RESULTS

There was one adverse event (AE) in the active group (diarrhea) and two AEs in placebo (dry mouth; eye rash/swollen eye). There was 100% self-reported compliance with formulation consumption across the two groups. For the primary outcome of interest, the estimate of effect for ratings of average soreness/discomfort 72 hours post-DOMS between active and placebo groups was -1.33 (85% confidence interval = -2.55, -0.10), suggesting moderate evidence of a treatment difference. The estimate of effect for the outcome of ratings of interference of soreness, discomfort, or stiffness on daily activities at work or home 48 hours post-DOMS was -1.82 (95% confidence interval = -3.64, -0.01), indicating a treatment difference of potential clinical importance. There was no significant effect between active and placebo groups on objective measures of recovery, sleep quality, or mood disturbance.

CONCLUSIONS

The tested formulation reduced interference of DOMS on daily activities, demonstrating its improvement on a functional aspect of recovery.

Cannabis use for exercise recovery in trained individuals: a survey study

BACKGROUND

Cannabis use, be it either cannabidiol (CBD) use and/or delta-9-tetrahydrocannabinol (THC) use, shows promise to enhance exercise recovery. The present study aimed to determine if individuals are using CBD and/or THC as a means of recovery from aerobic and/or resistance exercise, as well as additional modalities that might be used to aid in recovery.

METHODS

Following consent, 111 participants (Mean ± SD: Age: 31 ± 13 years) completed an anonymous survey. All participants were regularly using cannabis (CBD and/or THC) as well as were currently exercising. Questions pertained to level of cannabis use, methods used for consumption of cannabis, exercise habits, exercise recovery strategies, and demographics.

RESULTS

Eighty-five percent of participants reported participating in aerobic training. In addition, 85% of participants also reported regular participation in resistance exercise. Seventy-two percent of participants participated in both aerobic and resistance exercise. Ninety-three percent of participants felt that CBD use assisted them with recovery from exercise, while 87% of participants felt the same regarding THC use.

CONCLUSIONS

Individuals who habitually use cannabis, CBD or THC, and regularly engage in exercise do feel that cannabis assists them with exercise recovery. More data are necessary to understand the role of cannabis in exercise recovery as well as perceived ergogenic benefits of cannabis by individuals who both regularly participate in exercise and habitually use cannabis.

Regular Use of Cannabis in Female Athletes Is Associated With a Reduction in Early Anaerobic Power Production

ABSTRACT

Lisano, JK, Flores, VA, Kisiolek, JN, and Stewart, LK. Regular use of cannabis in female athletes is associated with a reduction in early anaerobic power production. J Strength Cond Res 37(3): 616-622, 2023-Despite a growing number of claims related to the ability of cannabis use to affect health and performance, there is limited research available, especially in female athletes. This cross-sectional study aimed to determine whether chronic cannabis use in physically active female athletes is related to altered health and performance. Healthy, physically active, female cannabis users (CU: n = 12) and noncannabis users (NU: n = 12) with an average age of 23.8 ± 3.7 years and 19.3 ± 4.2% body fat completed athletic performance and health assessments. Significance was set at alpha = 0.05. The age of onset of regular cannabis use was 20.1 ± 2.8 years in CU with an average duration of cannabis use of 5.8 ± 3.1 years. There were no differences between groups with respect to body size, body composition, pulmonary function, cardiorespiratory function, or muscular strength. Cannabis users produced significantly less power in the first 2 stages of the Wingate assessment, but CU experienced significantly less anaerobic fatigue. Although body composition and cardiovascular fitness were comparable, average C-reactive protein concentration classified CU with higher risk for cardiovascular disease (CVD). Athletes and coaches who rely heavily on anaerobic performance should consider these findings because they indicate that regular cannabis use may affect early power production and CVD risk.

Influence of Mild Traumatic Brain Injury History and Mental Health Status on Alcohol and Cannabis Use in University Athletes

OBJECTIVE

This study examined the relationship between mild traumatic brain injury (mTBI) history, mental health, and sex with single and polysubstance use in university athletes.

DESIGN

Observational study.

SETTING

University in Ontario, Canada.

PARTICIPANTS

Participants were identified from a dataset of 416 university athletes ages 18 to 21. Participants were classified based on their substance use habits and, 153 met criteria for the nonsubstance group, 195 for the alcohol use (AU) only group, and 64 polysubstance use group [ie, a combined substance use (AU+) group].

INDEPENDENT VARIABLES

Athletes received baseline assessments and completed self-reported questions regarding alcohol, cannabis, or other recreational substance use, the Patient Health Questionnaire-9, self-reported mTBI history, and self-reported anxiety, and/or panic disorder endorsement information.

MAIN OUTCOME MEASURES

Comparison of mTBI history and mental health status between individuals in the alcohol only or polysubstance use group.

RESULTS

Mild traumatic brain injury history was a significant predictor of AU ( P < 0.001) and AU+ ( P < 0.001). Anxiety endorsement was also a significant predictor of polysubstance use ( P < 0.001) and there was a small but nonsignificant association of polysubstance use in men ( P = 0.057).

CONCLUSIONS

University athletes who experience mTBI are more likely to engage in single or polysubstance use and athletes who experience anxiety are more likely to engage in polysubstance use. Consideration of mTBI history and mental health may inform clinical concussion management for identifying potential high-risk behavior such as polysubstance use in university athletes and tailoring intervention strategies (eg, incorporating education about substance use).

Edible marijuana and cycle ergometer exercise

Purpose: There is extensive public and scientific interest in the influence of cannabis and the psychoactive cannabinoid, delta-9-tetrahydrocannabinol (THC), on exercise performance. Unfortunately, recent, up-to-date studies are lacking. The aim of the current study was to address the hypothesis that ingestion of edible marijuana, prior to exercise, would have unfavorable effects on the physiological response to exercise and on exercise performance. Methods: 17 Healthy adult male and female habitual exercisers, who were regular users of cannabis products, were screened for study participation. 10 were enrolled, and data from 9 [8 males, 1 female, aged 25±3 years, with peak oxygen uptake of 56.5±11.7 ml/kg/min (mean ± SD)] were retained. Participation included two exercise sessions, each preceded by self-administration and ingestion of either edible marijuana (containing 10 mg THC) or placebo. Cardio-respiratory responses (via indirect calorimetry) to stationary cycle ergometer exercise (8 min at 50, 100 and 150 W) were recorded before completion of a 20-min Functional Threshold Power test (FTP²⁰) and a sprint test involving maximal effort until volitional fatigue. Results: Edible marijuana increased the concentration of circulating THC and THC metabolites, and evoked sensations of intoxication and altered psychoactive state. Cardio-respiratory responses to staged cycle ergometer exercise were normal and were unaffected by edible marijuana. Compared with placebo, edible marijuana did not influence FTP²⁰ (Placebo 253±75 vs THC: 251±72 W (mean±SD); p > 0.45) or peak power output during the sprint test (Placebo: 710±201 vs. THC: 732±136 W; p = 0.864). Conclusion: 10 mg of THC, when ingested prior to exercise by regular exercisers and habitual users of cannabis, had little effect on the physiological response to standardized cycle ergometer exercise, and was neither ergogenic nor ergolytic.

Substance Use and Addiction in Athletes: The Case for Neuromodulation and Beyond

Substance use, misuse and use disorders continue to be major problems in society as a whole and athletes are certainly not exempt. Substance use has surrounded sports since ancient times and the pressures associated with competition sometimes can increase the likelihood of use and subsequent misuse. The addiction field as a whole has very few answers to how to prevent and secondarily treat substance use disorders and the treatments overall do not necessarily agree with the role of being an athlete. With concerns for side effects that may affect performance coupled with organizational rules and high rates of recidivism in the general population, newer treatments must be investigated. Prevention strategies must continue to be improved and more systems need to be in place to find and treat any underlying causes leading to these behaviors. This review attempts to highlight some of the data regarding the field of substance misuse and addiction in the athletic population as well as explore possible future directions for treatment including Neuromodulation methods and Ketamine. There is a need for more rigorous, high-quality studies to look at addiction as a whole and in particular how to approach this vulnerable subset of the population.

How and why adults use cannabis during physical activity

BACKGROUND

With increased legalization of cannabis, users are combining cannabis with exercise. The purpose of this study is to understand how and why people use cannabis when participating in physical activity.

METHODS

A convenience sample of cannabis users participated in an anonymous online survey created by the authors regarding exercise habits while under the influence of cannabis, perceived benefits, unanticipated experiences related to cannabis and exercise, and demographics.

RESULTS

One hundred thirty-one respondents (18-55 years) were eligible and began the survey. Nearly 60 physical activities under the influence of cannabis were reported. The most frequently reported modes of exercise included hiking (60%), yoga (58%), and aerobic machines (50%). The primary reasons for using cannabis before exercise were "helping to focus/concentrate" (66%), "helping enjoy the exercise experience" (65%), and "enhancing mind-body-spirit connection" (65%). Thirty-three participants reported "yes" or "maybe" regarding having an experience they "didn't anticipate or desire while exercising under the influence of cannabis."

DISCUSSION

Participants' reasons for exercising with cannabis span the physiological, psychological, neuromotor, and even spiritual domains. However, some reported an undesired experience when pairing cannabis with exercise. While this was an online survey with a small sample size, our results agree with and contribute to the growing research investigating cannabis use and physical activity participation.

CONCLUSION

We found considerable heterogeneity in types of physical activity participation under the influence of cannabis, as well as perceived benefits of use. This study provides directions to further explore the risks and benefits of combining cannabis with physical activity.

Do varsity college athletes have a greater likelihood of risky alcohol and cannabis use than non-athletes? Results from a National Survey in Brazil

OBJECTIVE

We examined the prevalence of risky alcohol and cannabis use among Brazilian varsity college athletes and whether this group had a greater likelihood of risky use than non-athletes.

METHODS

In 2009, Brazilian college students (n=12,711) were recruited for a national stratified random survey. Their sociodemographic characteristics, mental health, substance use, and participation in varsity sports were assessed. Binary logistic regression models were used to examine the association between varsity athlete status and moderate to high-risk alcohol and cannabis use.

RESULTS

Among varsity athletes, 67.6 and 10.7% reported risky alcohol and cannabis use, respectively. Varsity athletes had greater odds of risky alcohol consumption than non-athletes (aOR = 2.02, 95%CI 1.08-3.78). Varsity athletes also had greater odds of risky cannabis use than non-athletes in unadjusted analyses (OR = 2.57, 95%CI 1.05-6.28), although this relationship was attenuated after covariate adjustment.

CONCLUSIONS

Among college students in Brazil, varsity athletes had a higher prevalence of risky alcohol and cannabis use than non-athletes. The rates were considerably higher than those observed among samples of U.S. college athletes. Future research should examine the use of these substances among varsity college athletes in other middle-income countries since these findings will likely guide prevention and treatment efforts.

Cannabis, cannabidiol and tetrahydrocannabinol in sport: An overview

The World Antidoping Agency now allows cannabidiol (CBD) to be taken in elite sport but has retained all other cannabinoids on its banned list. This, together with liberalisation of cannabis laws have led to an increasing interest in its use in sport. This includes commercial sponsorship of sporting events and highlights the need for accurate information to be readily available to athletes and their advisers. This narrative review confirms that CBD and tetrahydrocannabinol (THC) do not enhance performance. CBD possesses anti-inflammatory and analgesic properties which have not been adequately evaluated in the area of sport. Some formulations of CBD contain THC or other cannabinoids that may result in a positive drug test. This article is protected by copyright. All rights reserved.

COVID-19 Lockdown 2020 Changed Patterns of Alcohol and Cannabis Use in Swiss Elite Athletes and Bodybuilders: Results From an Online Survey

Objectives: During the COVID-19 pandemic, increased patterns of substance use have been reported in the general population. However, whether this also applies to athletes is not yet clear. This study aimed to detect changes in alcohol consumption and cannabis use in elite athletes and bodybuilders during the first COVID-19 lockdown in Switzerland. Methods: Between April 25 and May 25, 2020, a cross-sectional online survey was conducted among bodybuilders and Swiss elite athletes who were active in Olympic sports and disciplines approved by the International Olympic Committee (IOC) on at least the national level. The collected data included information on alcohol and cannabis use during the last month (lockdown) and in the year before COVID-19 lockdown (pre-lockdown), daily training times, existential fears on a scale from 1 to 100, Patient Health Questionnaire-9 for depression (PHQ-9), Insomnia Severity Index (ISI), and State-Trait Anxiety Inventory (STAI). Results: N = 275 athletes (elite athletes: n = 193; bodybuilders: n = 82) was included in this study. Both pre-lockdown and during lockdown, more bodybuilders used cannabis (both time points: p < 0.001) than elite athletes, and more elite athletes drank alcohol (pre-lockdown: p = 0.005, lockdown: p = 0.002) compared to bodybuilders. During lockdown, fewer athletes drank alcohol compared to before, but those who continued drinking did so on more days per week (p < 0.001, Eta2 = 0.13). Elite athletes were more likely to increase their drinking with 17.7 vs. 8.2% in bodybuilders. When compared to pre-lockdown measures, the number of athletes using cannabis did not change during lockdown. Only three of 203 elite athletes reported using cannabis during lockdown; this contrasts with 16 of 85 bodybuilders. In a multivariate regression model, existential fears and a lower ISI score were significant predictors for increased alcohol consumption during the lockdown in the entire sample. In a model based on elite athletes only, male sex and a lower ISI score predicted increased alcohol consumption. In a bodybuilder-based model, predictors of increased alcohol consumption were existential fears and trait anxiety. Conclusion: We suggest identifying athletes who are at risk for increased alcohol and cannabis use; we suggest this to be able to professionally support them during stressful times, such as the COVID-19 pandemic.

Quality of Life and a Surveillant Endocannabinoid System

The endocannabinoid system (ECS) is an important brain modulatory network. ECS regulates brain homeostasis throughout development, from progenitor fate decision to neuro- and gliogenesis, synaptogenesis, brain plasticity and circuit repair, up to learning, memory, fear, protection, and death. It is a major player in the hypothalamic-peripheral system-adipose tissue in the regulation of food intake, energy storage, nutritional status, and adipose tissue mass, consequently affecting obesity. Loss of ECS control might affect mood disorders (anxiety, hyperactivity, psychosis, and depression), lead to drug abuse, and impact neurodegenerative (Alzheimer's, Parkinson, Huntington, Multiple, and Amyotrophic Lateral Sclerosis) and neurodevelopmental (autism spectrum) disorders. Practice of regular physical and/or mind-body mindfulness and meditative activities have been shown to modulate endocannabinoid (eCB) levels, in addition to other players as brain-derived neurotrophic factor (BDNF). ECS is involved in pain, inflammation, metabolic and cardiovascular dysfunctions, general immune responses (asthma, allergy, and arthritis) and tumor expansion, both/either in the brain and/or in the periphery. The reason for such a vast impact is the fact that arachidonic acid, a precursor of eCBs, is present in every membrane cell of the body and on demand eCBs synthesis is regulated by electrical activity and calcium shifts. Novel lipid (lipoxins and resolvins) or peptide (hemopressin) players of the ECS also operate as regulators of physiological allostasis. Indeed, the presence of cannabinoid receptors in intracellular organelles as mitochondria or lysosomes, or in nuclear targets as PPARγ might impact energy consumption, metabolism and cell death. To live a better life implies in a vigilant ECS, through healthy diet selection (based on a balanced omega-3 and -6 polyunsaturated fatty acids), weekly exercises and meditation therapy, all of which regulating eCBs levels, surrounded by a constructive social network. Cannabidiol, a diet supplement has been a major player with anti-inflammatory, anxiolytic, antidepressant, and antioxidant activities. Cognitive challenges and emotional intelligence might strengthen the ECS, which is built on a variety of synapses that modify human behavior. As therapeutically concerned, the ECS is essential for maintaining homeostasis and cannabinoids are promising tools to control innumerous targets.

Cannabis and Athletic Performance

Cannabis is widely used for both recreational and medicinal purposes on a global scale. There is accumulating interest in the use of cannabis and its constituents for athletic recovery, and in some instances, performance. Amidst speculation of potential beneficial applications, the effects of cannabis and its two most abundant constituents, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), remain largely un-investigated. The purpose of this review is to critically evaluate the literature describing the effects of whole cannabis, THC, and CBD, on athletic performance and recovery. While investigations of whole cannabis and THC have generally shown either null or detrimental effects on exercise performance in strength and aerobic-type activities, studies of sufficient rigor and validity to conclusively declare ergogenic or ergolytic potential in athletes are lacking. The ability of cannabis and THC to perturb cardiovascular homeostasis warrants further investigation regarding mechanisms by which performance may be affected across different exercise modalities and energetic demands. In contrast to cannabis and THC, CBD has largely been scrutinized for its potential to aid in recovery. The beneficial effects of CBD on sleep quality, pain, and mild traumatic brain injury may be of particular interest to certain athletes. However, research in each of these respective areas has yet to be thoroughly investigated in athletic populations. Elucidating the effects of whole cannabis, THC, and CBD is pertinent for both researchers and practitioners given the widespread use of these products, and their potential to interact with athletes' performance and recovery.

Substance Use and Its Impact on Athlete Health and Performance

The pressure to gain mass, power, explosiveness, and endurance and to obtain a performance edge continues to a part of sports. Anabolic agents, including selective androgen receptor modulators along with peptides, hormones, and metabolic modulators, continues to evolve. Methods to promote transcription to modify gene expression are a part of the evolution. In order to monitor and improve doping detection, the Athlete Biological Passport has been created. This article provides an up-to-date review of alcohol, anabolic androgens and related agents, stimulants, opioids, and cannabis and related compounds and their effects on athlete health and performance.

Effects of Cannabidiol Supplementation on Skeletal Muscle Regeneration after Intensive Resistance Training

Cannabidiol supplements (CBD) are increasingly consumed by athletes to improve regeneration. However, the evidence for the pro-regenerative effects of CBD in sports is quite limited. Therefore, our aim was to investigate the effects of a single CBD supplementation in a six-arm placebo-controlled crossover study after resistance training on performance and muscle damage. Before and after the resistance training, one-repetition maximum in the back squat (1RM BS), countermovement jump (CMJ), and blood serum concentrations of creatine kinase (CK) and myoglobin (Myo) were measured in healthy, well-trained participants. 16 out of 21 participants completed the study and were included in the analysis. In 1RM BS, a significant decrease was observed after 24 h (p < 0.01) but not after 48 and 72 h. A significant group difference was detected after 72 h (p < 0.05; ES = 0.371). In CMJ, no significant changes were observed. The CK and Myo concentrations increased significantly after 24 h (CK: p < 0.001; Myo: p < 0.01), 48 h (CK: p < 0.001; Myo: p < 0.01) and 72 h (CK: p < 0.001; Myo: p < 0.001). After 72 h, significant group differences were observed for both muscle damage biomarkers (CK: p < 0.05 ES = 0.24; Myo: p < 0.05; ES = 0.21). The results show small but significant effects on muscle damage and recovery of squat performance after 72 h. However, more data are required for clearer statements concerning potential pro-regenerative effects of CBD supplementation after resistance training.

Potential Role of Cannabidiol on Sports Recovery: A Narrative Review

The use of cannabidiol (CBD) among athletes is becoming extensive and frequent. This could be due to the elimination of CBD from the list of prohibited substances by federations and international institutions of sport. The legalization and resulting production, and commercialization of CBD, could increase its intake in sports professionals. This commercialization of cannabinoids has fueled a race to study their properties, benefits, and risks for health and performance in athletes. Although there is evidence that suggests some beneficial properties such as anxiolytics, antidepressants, anti-inflammatory, and antioxidants among others, the evidence presented so far is neither clear nor conclusive. There are significant gaps in knowledge of the physiological pathways that explain the role of CBD in sports performance. This mini-review examines evidence suggesting that CBD has the potential to be used as a part of the strategies to recover from fatigue and muscle damage related to physical and cognitive exertion in sports.

The relationships between marijuana use and exercise among young and middle-aged adults

As decriminalization, increased access, and decreased perception of risk spurs the popularity of medical and recreational marijuana, more information is needed on possible links between marijuana use and social determinants of health. The goal of this study was to assess the relationships between marijuana use and exercise. Data sources included the two most recent waves of the National Longitudinal Study of Adolescent to Adult Health (Wave IV, 2008-2009; N = 14,784 and Wave V, 2016-2018; N = 12,043). The exercise variables included any form of exercise/sport during the past 7 days and the number of days participating in each of 7 types of exercise/sport. Marijuana-use variables comprised any current use and frequency of use during the past 30 days. Both fixed-effects and random-effects models were estimated with numerous control variables, along with binary and count measures of exercise. Results show that, particularly for fixed-effects models, marijuana use is not significantly related to exercise, counter to conventional wisdom that marijuana users are less likely to be active. Indeed, the only significant estimates suggest a positive relationship, even among heavier users during the past 30 days. These findings are at odds with much of the existing literature, which generally shows a negative relationship between marijuana use and exercise. As additional states legalize the medicinal and recreational use of marijuana, perhaps its impact on exercise, one of the leading social determinants of health, is not necessarily a primary concern.

Chronic cannabis consumption and physical exercise performance in healthy adults: a systematic review

OBJECTIVE

The effects of chronic cannabis consumption on physiological parameters of athletic performance are investigated to determine whether chronic cannabis consumption negatively affects athletic performance; improves performance, potentially via enhanced recovery; or has no effect at all.

METHODS

A systematic review of the literature (cross-sectional, longitudinal, and intervention studies) concerning the effects of cannabis consumption on sports performance outcomes, e.g. VO2Max (maximal oxygen uptake), PWC (physical work capacity) up to January 2020 was conducted using the PubMed, CINAHL, Medline, PsycArticles, PsycInfo, SPORTDiscus, Psychology and Behavioural Sciences Collection, and Health Source: Nursing/Academic Edition databases. After screening and additional forward searching, four articles were found to fit the inclusion criteria.

RESULTS

Resting heart rate was the only physiological measure that significantly differed between groups, and only in one of the four studies included herein. The strongest predictors of athletic performance (VO2Max and PWC) were not found to be significantly different between groups in any of the included studies. Chronic cannabis consumption had no significant effect on athletic performance. The included studies did not assess other elements, such as recovery or endurance.

CONCLUSION

No evidence exists for ergogenic or ergolytic effects from chronic cannabis consumption. In some sports, advantages may plausibly be conveyed by psychotropic enhancement or pain reduction. Further research (particularly longitudinal or interventional studies) is required to determine whether cannabis, or constituents thereof, may provide indirect supplemental benefits to athletes.

Understanding the Medical Chemistry of the Cannabis Plant is Critical to Guiding Real World Clinical Evidence

While cannabis has been consumed for thousands of years, the medical-legal landscape surrounding its use has dramatically evolved over the past decades. Patients are turning to cannabis as a therapeutic option for several medical conditions. Given the surge in interest over the past decades there exists a major gap in the literature with respect to understanding the products that are currently being consumed by patients. The current perspective highlights the lack of relevance within the current literature towards understanding the medical chemistry of the products being consumed. The cannabis industry must rigorously invest into understanding what people are consuming from a chemical composition standpoint. This will inform what compounds in addition to Δ⁹-tetrahydrocannabinol and cannabidiol may be producing physiologic/therapeutic effects from plant based extracts. Only through real-world evidence and a formalized, granular data collection process within which we know the chemical inputs for patients already using or beginning to use medical cannabis, we can come closer to the ability to provide targeted clinical decision making and design future appropriate randomized controlled trials.