Analgesic Use in Sports: Results of a Systematic Literature Review

Results of a systematic literature review

Background: Consumption of medication to alleviate pain is widespread in Germany. Around 1.9 million men and women take analgesics every day; some 1.6 million persons are addicted to painkillers. Analgesic use is thought also to be common in sports, even in the absence of pain. The aim of this study was to assess the extent of painkiller use among athletes.

Methods: In line with the PRISMA criteria and the modified PICO(S) criteria, a systematic literature review was registered (Openscienceframework, https://doi.org/10.17605/OSF.IO/VQ94D) and carried out in PubMed and SURF. The publications identified (25 survey studies, 12 analyses of doping control forms, 18 reviews) were evaluated in standardized manner using the Newcastle‒Ottawa Scale (NOS) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews).

Results: Analgesic use is widespread in elite sports. The prevalence varies between 2.8% (professional tennis) and 54.2% (professional soccer). Pain medication is also taken prophylactically in the absence of symptoms in some non-elite competitive sports. In the heterogeneous field of amateur sports the data are sparse and there is no reliable evidence of wide-reaching consumption of painkillers. Among endurance athletes, 2.1% of over 50 000 persons stated that they used analgesics at least once each month in connection with sports.

Conclusion: Analgesic use has become a problem in many areas of professional/competitive sports, while the consumption of pain medication apparently remains rare in amateur sports. In view of the increasing harmful use of or even addiction to painkillers in society as a whole, there is a need for better education and, above all, restrictions on advertising.

Around 1.9 million people in Germany take painkillers every day (1). According to estimates based on data from the Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey), harmful consumption of painkillers (7.6%) is significantly higher than that of alcohol (2.8%) (1, 2, 3). Dependence on painkillers (3.2%) is reported to be close to dependence on alcohol (3.1%). According to a survey carried out by the Robert Koch Institute (RKI) in 2013/2014, 30% to 40% of respondents reported that physical pain was not a factor in their use of over-the-counter painkillers (4). According to findings of the 2021 Epidemiological Survey of Substance Abuse, the 30-day prevalence of nonopioid analgesic use in the German population is 47.4% (e28). Given the prevalence of harmful use of painkillers and painkiller dependence in society in general, Heinz and Liu (2019) called for more studies and systematic reviews to be carried out (5).

The use of analgesics is said to be widespread not only in the general population but also specifically in sport. Here, too, analgesics are apparently often consumed in the absence of symptoms (6, 7, 8). For example, according to studies based on data from doping control forms (DCFs), between 16.7% and 54.2% of professional football players take nonsteroidal anti-inflammatory drugs (NSAIDs) (9,10). Since doping controls are mandatory and the forms are more or less standardized, DCFs are well suited as a basis for estimating consumption of analgesics in elite-level and professional sports.

Media reports by the ARD Doping Editorial Team on excessive use of analgesics in football (11) led to a public hearing (on 27 January 2021) of experts in the German Bundestag Sports Committee on “Painkiller consumption in sport and society” (12). This revealed a heterogeneous and incomplete picture of the use of analgesics in sports, especially amateur sports. The aim of the present study was to achieve a more accurate assessment of the use of analgesics in sport.

Method

In accordance with the guidelines of the PRISMA (“preferred reporting items for systematic reviews and meta-analyses”) statement, a systematic, keyword-led search was carried out for publications dating from the year 2000 onwards on the use and abuse of analgesics in sport (13, 14). The literature search was conducted on 30 July 2021 on Medline and PubMed Central via PubMed, and on SURF (Sport And Research in Focus), the sport information portal of the German Federal Institute of Sport Science (Bundesinstitut für Sportwissenschaft, BISp) using the keywords listed in eTable 1. This was supplemented by a hand search. As a final step, the literature search was updated on 3 July 2022. The criteria for inclusion and exclusion of publications were determined according to a modified PICO(S) framework (eTable 2). The study protocol was registered as a “free registration” at the Open Science Framework (https://osf.io). Titles and abstracts in English, French, and German were selected by two independent review panels. The suitability of the full texts selected was checked by three authors independently. If their initial evaluations were discordant, consensus was reached through discussion.

eTable 1

Search strategy for the literature review

eTable 2

Inclusion/exclusion criteria: modified PICOS framework

The original and review articles selected were categorized according to, among other things:

• Target groups/sport groups in professional/elite sport, high-performance sport, and amateur sport;
• Data collection method (for example, doping control forms, surveys) ;
• Prevalence time periods for analgesic use;
• Whether they discussed adverse drug reactions and provided data on the analgesic group or substance class (eTable 3) .

eTable 3a

Studies of analgesic use in professional and elite sports (data collected from doping control forms)

eTable 3b

Survey studies on analgesic use in high-performance sport and amateur sport

eTable 3c

Review articles on analgesic use in sport

The main distinguishing features between the three sport groups were:

• Revenue (professional versus elite sport);
• Performance level (professional/elite sport versus high-performance sport);
• Time commitment and the performance concept (high-performance sport versus amateur sport).

Evaluation of publications and studies

The studies selected were independently assessed by three authors in a standardized manner for the quality of their methodology and their risk of bias using the Cochrane risk-of-bias tool (15). Cross-sectional cohort and survey studies were assessed using the Newcastle Ottawa Scale (NOS) with regard to selection of study participants, data collection, comparability of study groups, and quality of ascertainment of exposure (16).

Reviews, which ranged from the narrative to the selective or systematic, were reviewed using AMSTAR (“a measurement tool to assess systematic reviews”) (15). The criteria were: study design, study selection, data extraction, systematic literature search, study data/characteristics, consideration of the risk of bias in the primary studies, statistics, and potential conflicts of interest.

If the initial evaluations were discordant, consensus was reached through discussion. The study quality or the risk of bias in the study findings was not used as an exclusion criterion.

Results

Publication selection and study evaluation

Out of 6191 publications, after removal of duplicates 6083 studies remained for title screening (Figure). Of these, 128 studies were identified for abstract analysis and 96 were selected for full text analysis. Of these publications, 41 full texts were excluded, and 55 publications remained for content analysis (6, 7, 8, 9, 10, 12, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, e1, e2, e3, e4, e5, e6, e7, e8, e9, e10, e11, e12, e13, e14, e15, e16, e17, e18, e19, e20, e21, e22, e23, e24, e25).

Figure

PRISMA flow chart of the literature review: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SURF, sport information portal of the German Federal Institute of Sport Science

For the selected publications on the use of analgesics in sport, the NOS and AMSTAR assessment tools revealed varying degrees of representativeness, quality limitations, and risk of bias. eTable 4 lists studies based on doping control forms, all of which were rated using the NOS instrument at 7–8 stars out of a possible maximum of 9. In contrast to this, the risks of limited representativeness and bias are much higher in survey studies (eTable 5); here the study ratings ranged from 2 to 7 stars. According to AMSTAR, review articles primarily exhibit weak systematic methodology, lower quality, high risks of bias, and thus are more narrative in character (eTable 6).

eTable 4

Quality assessment of studies on analgesic use in professional and elite sport (data collection based on doping control forms)

eTable 5

Quality assessment of survey studies on analgesic use in high-performance and amateur sport

eTable 6

Quality assessment of review articles on analgesic use in sport

Use of analgesics in professional and elite sport

The 12 studies selected included 48 977 DCFs collected at World Championships, Olympic Games, competitive events, or during training (Table 1, eTable 3). The DCFs asked questions about the consumption of analgesics and dietary supplements during the 72 hours or 7 days before the dope test or competition. In elite sports, NSAID use varies greatly from sport to sport, ranging in the selected studies from 2.8% in professional tennis to 54.2% in professional football (10, e21). In the 2014 Football World Cup, per match 30.6% of players took NSAIDs (10). Trinks et al. (2021) determined a 33% level of analgesic use in the top German football leagues (Men’s Bundesliga, 2nd Men’s Bundesliga, Men’s 3rd League, Women’s Bundesliga, Junior Bundesliga) (e14). Olympic athletes in other sports reported average rates of NSAID use of 11.1% to 25.6% (26, e20). A Belgian–Dutch study reported rates of NSAID use ranging from 2.8% (tennis) to 31.1% (volleyball) (e21).

Table 1

Summary of detailed literature analysis*

Use of analgesics in high-performance sport

The 25 survey studies and 18 reviews evaluated mostly focus on endurance athletes (for example, half-marathon, marathon, ultramarathon) in the nonprofessional setting (Table 1, eTable 6). Compared to professional and elite sports, these studies suggest a lower level of analgesic consumption in high-performance sports. Nevertheless, among survey studies, which have a lower risk of bias than reviews, there are clear differences between individual studies: while a 60.3% rate of NSAID use was reported in participants in a 112-km ultramarathon event (e1), and a 60.5% rate on race day in a 161-km run (32), Rotunno et al. (e9) found rates of race-related painkiller use ranging from 3.1% (half-marathon) to 9.2% (56-km run) among over 75 000 endurance-trained participants.

Apart from running, individual studies are available for football (e8, e13), basketball (e11), diving (29), mountain biking (24), and triathlon (7, 28, 30), among others. Here, NSAID consumption on race day ranges from 10% of participants in an ultra mountain bike race (24) to 47.4% in a triathlon competition (30).

Use of analgesics in amateur sport

In contrast to the study and data situation for professional and elite sports, in the heterogeneous amateur sports sector there is a lack of original studies and reviews giving a comprehensive and valid picture of the prevalence of painkiller use (Table 1, eTables 5–6).

Apart from some single studies, the literature predominantly reports figures from running or endurance sports (eTable 3). These sometimes originate from individual events and differ significantly as to the figures cited for painkiller consumption. According to Brune et al. (2009), for example, 61% of respondents took analgesics before the start of the Bonn half-marathon/marathon (6), whereas in the study by Mahn et al. (2018), which analyzed data from runners in the Hannover marathon, only 17% stated that they had ever taken painkillers before a marathon race (40).

In contrast, the results of Rüther et al. (2018) (e10) and of Leyk and Rüther (2021) (12) are based on data collected at more than 100 running events in the period from 2016 to 2020. More than 96% of the over 50 000 respondents selected the response options “never” or “rarely” when asked about the frequency of their use of pain medication in connection with sports (Table 2). 2.1% of the athletes reported taking painkillers at least once a month, mainly for musculoskeletal complaints.

Table 2

Frequency of analgesic use by athletes (n = 54 184)

To summarize, the systematic literature review concluded that there is no scientifically robust evidence for widespread use of analgesics in amateur sport (12, e10).

Discussion

Important limitations of this systematic literature review arise from the different forms of data collection used in the studies, the study types, and the heterogeneous study populations. The risks of limited representativeness and of bias are evaluated in eTables 4–6. In addition, significantly fewer studies are available for the wide and highly diverse field of amateur sport than for professional/elite and high-performance sport. It is virtually impossible to assess any changes over time in painkiller consumption.

The results of the systematic literature review show that the use of analgesics is widespread in professional/elite sport and, to some extent, also in ambitious high-performance sport. Both studies based on DCFs and survey studies show that in top-level national and international football, for example, about one in two and one in three players, respectively, regularly take painkillers (10, 11, e14, e26). Analgesic consumption varies obviously from sport to sport (eTable 3).

However, using analgesics does not necessarily mean misusing them, nor does it necessarily mean that they are being used in connection with the sport being practiced. DCFs give no information about any disease-related, sport-related, or prophylactic reasons for use. Even some survey studies did not ask whether the painkiller use was related to the sporting activity (eTable 3) (17, 18, 20, 28, 32, 34, e8, e13). On the other hand, studies that specifically asked about why painkillers were taken show that they were being used prophylactically (6, 7, 8). This is well seen in endurance sports: The longer and more grueling a competition, the more frequently painkillers are taken in the runup to it. In ultra-endurance sport, this may be the case in 60.3% to 70% of all competitors (32, 35, e1). Even in the match-playing sports, analgesic use in the absence of symptoms cannot be ruled out (e11, e25). According to Schneider et al. (2019), 5% of high-performance players take analgesics in order to prevent pain. Apart from prophylactic use, up to 84% of young high-performance basketballers still report occasionally using analgesics (e11).

Findings on analgesic consumption in professional/elite sport cannot be simply extrapolated to the field of amateur sport. However, in regard to ambitious amateur sport there is a gray area, such as in endurance or ultra-endurance sports, where participants take analgesics more often. The extent of training and the energy expenditure of these amateurs are quite comparable to those of professional/elite athletes in ball sports or athletics (for example, in sprinting/throwing disciplines).

The results of the literature review show that there is no reliable evidence of widespread analgesic abuse in amateur sport. There is a lack of solid data from original studies and reviews on this question. Only two selective studies, whose data were collected as part of a large running event and which show methodological ambiguities, conclude that analgesics are widely used in endurance sports (up to 61%) (6, 38). This is in contrast to the findings of a South African study of over 70 000 runners, where the use of analgesics ranged from 3.6% of participants in a half-marathon to 16.4% in a 56-km race (e9).

The results of our own survey do not suggest that analgesics are widely used in amateur sport at present (12, e10): only 1.7% of participants took painkillers “one to several times per month” and 0.4% “weekly” or “daily” in connection with their sporting activities. Further analysis showed that health reasons predominated for the use of painkillers.

This brings the discussion to another aspect of the use of analgesics in sport, and that is the question of whether and to what extent analgesic use is indicated to enable exercise and training. For example, analgesics can certainly be beneficial in patients undergoing medical exercise therapy. However, adverse effects of analgesics can be made worse by physical activity, not only in patients under medical exercise therapy, but also in healthy athletes. For example, higher levels of exercise lead to a reduction in glomerular filtration rate in the kidney. Taking anti-inflammatory drugs increases the risk of chronic kidney disease and acute kidney failure.

Especially when it comes to preventive use of analgesics, it should be remembered that these substances suppress important warning signs (pain, infection-related raised temperature, etc.), thereby increasing the risk of serious illness (6, 8, 19, e12, e22, e23). Table 3 lists observed symptoms and diseases that have been reported in the literature to be connected with analgesic use in sport.

Table 3a

Symptoms and diseases associated with analgesic use in sport (excluding musculoskeletal system)

Table 3b

Symptoms and diseases of the musculoskeletal system associated with analgesic use in sport

Given the widespread use of analgesics in society and in different parts of the world of sport, it is also worth noting at this point how omnipresent painkiller advertising is on television, in the print media, and, increasingly, in internet forums and through influencers. People are promised, among other things, appropriate and rapidly effective solutions for various types of pain. This can help to lead to a state of affairs where many people are careless about their use of painkillers, which in the form of nonprescription (over-the-counter) analgesics are easily accessible (e27). The freedom to self-medicate has been created by the law, which has obliged pharmaceutical manufacturers to provide comprehensive information in the form of package inserts. However, survey results show that important information about adverse drug effects and recommendations for use are still not well known (4). In addition to more targeted information, advertising restrictions could help to reduce the harmful use of painkillers in sport and in society at large (5).

Acknowledgments

Our thanks go to our IT specialist, Michael Trunzler, for his excellent programming work in the ActIv project. We thank Matthias Krapick, medical documentalist, for his valuable contributions to the systematic literature search, data preparation, and manuscript preparation.

Conflict of interest statement
Dr. Vits holds shares in Sanofi S. A. and Zur Rose Group AG.

The other authors declare that they have no conflict of interest.

Manuscript received on 25 April 2022, revised version accepted on 4 January 2023.

Corresponding author
Prof. Dr. med. Dr. Sportwiss. Dieter Leyk
Deutsche Sporthochschule Köln
Forschungsgruppe Leistungsepidemiologie
Am Sportpark Müngersdorf 6, 50933 Köln, Germany

Cite this as:
Leyk D, Rüther T, Hartmann N, Vits E, Staudt M, Hoffmann MA: Analgesic use in sports—results of a systematic literature review. Dtsch Arztebl Int 2023; 120: 155–61. DOI: 10.3238/arztebl.m2023.0003

►Supplementary material
eReferences, eTables:
www.aerzteblatt.de/m2023.0003

References

1. Atzendorf J, Rauschert C, Seitz N-N, Lochbühler K, Kraus L: The use of alcohol, tobacco, illegal drugs and medicines: an estimate of consumption and substance-related disorders in Germany. Dtsch Arztebl 2019; 116: 577–84.

2. Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM): International classification of diseases for mortality and morbidity statistics (ICD-11 MMS). Entwurfsfassung: ICD-11 MMS 2022.

3. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF): S3-Leitlinie Medikamentenbezogene Störungen (AWMF-Register-Nr.: 038–025). www.awmf.org/uploads/tx_szleitlinien/038-025l_S3_Medikamtenbezogene-Stoerungen_2021-01.pdf (last accessed on 21 April 2022).

4. Robert Koch-Institut: Anwendung rezeptfreier Analgetika in Deutschland. Eine Befragungsstudie zum Anwendungsverhalten, zur Kenntnis von Anwendungsinformationen und Bewertung eines möglichen Packungsaufdrucks in der erwachsenen Allgemeinbevölkerung. Berlin: Robert Koch-Institut 2015.

5. Heinz A, Liu S: Addiction to legal drugs and medicines in Germany. Dtsch Arztebl Int 2019; 116: 575–6

6. Brune K, Niederweis, Kaufmann A, Küster-Kaufmann M: Analgetikamissbrauch bei Marathonläufern. Jeder Zweite nimmt vor dem Start ein Schmerzmittel. MMW Fortschr Med 2009; 151: 39–42.

7. Seifarth S, Dietz P, Disch AC, Engelhardt M, Zwingenberger S: The prevalence of legal performance-enhancing substance use and potential cognitive and or physical doping in German recreational triathletes, assessed via the randomised response technique. Sports 2019; 7: 241.

8. Graf-Baumann T: Missbrauch im Sport nimmt zu.„Ohne Schmerzmittel läuft nichts“. MMW Fortschr Med 2013; 155: 62–4.

9. Tscholl P, Feddermann N, Junge A, Dvorak J: The use and abuse of painkillers in international soccer: data from 6 FIFA tournaments for female and youth players. Am J Sports Med 2009; 37: 260–5.

10. Vaso M, Weber A, Tscholl PM, Junge A, Dvorak J: Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey. BMJ Open 2015; 5: e007608.

11. CORRECTIV, ARD Dopingredaktion: Pillenkick. Schmerzmittelmissbrauch im Fußball. https://correctiv.org/top-stories/2020/06/08/pillenkick/ (last accessed on 5 April 2022).

12. Leyk D, Rüther R: Schmerzmittelkonsum im Sport und in der Gesellschaft. Ausgewählte Fakten zur öffentlichen Anhörung des Sportausschusses des Deutschen Bundestages am 27.01.2021. www.bundestag.de/resource/blob/818272/cf51d57bc44da349429bd368106e3cc1/20210127-Leyk-data.pdf (last accessed on 14 February 2023).

13. Liberati A, Altman DG, Tetzlaff J, et al.: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Br Med J 2009; 339: 1–27.

14. Ziegler A, Antes G, König I: Bevorzugte Report Items für systematische Übersichten und Meta-Analysen: Das PRISMA-Statement. Dtsch med Wochenschr 2011; 136: e9–e15.

15. Schmucker C, Nothacker M, Möhler R, Kopp I, Meerpohl J: Bewertung des Verzerrungsrisikos von systematischen Übersichtsarbeiten: ein Manual für die Leitlinienerstellung. 2017. www.cochrane.de/de/review-bewertung-manual (last accessed on 1 February 2023).

16. Schmucker C, Nothacker M, Rücker G, Muche-Borowski C, Kopp I, Meerpohl J: Bewertung des Biasrisikos (Risiko systematischer Fehler) in klinischen Studien: ein Manual für die Leitlinienerstellung. 2016. www.cochrane.de/sites/cochrane.de/files/uploads/manual_biasbewertung.pdf (last accessed on 1 February 2023).

17. Aavikko A, Helenius I, Vasankari T, Alaranta A: Physician-prescribed medication use by the Finnish paralympic and olympic athletes. Clin J Sport Med 2013; 23: 478–82. .

18. Alaranta A, Alaranta H, Heliövaara M, Airaksinen M, Helenius I: Ample use of physician-prescribed medications in Finnish elite athletes. Int J Sports Med 2006; 27: 919–25.

19. Alaranta A, Alaranta H, Helenius I: Use of prescription drugs in athletes. Sports Med 2008; 38: 449–63.

20. Broman D, Ahmed OH, Tscholl PM, Weiler R: Medication and supplement use in disability Football World Championships. PM R 2017; 9: 990–7.

21. Brune K, Niederweis U, Krämer BK: Unheilige Alianz zum Schaden der Niere. Dtsch Arztebl 2008; 105: 1894–7.

22. Brune K, Niederweis U, Küster M, Renner B: Laien- und Leistungssport: Geht nichts mehr ohne Schmerzmittel? Dtsch Arztebl 2009; 106: 2302–4

23. Brune K, Niederweis U, Küster-Kaufmann M: Schmerzmittel – fataler Einsatz im Breitensport. DAZ 2009; 149: 68–73.

24. Chlíbková D, Ronzhina M, Nikolaidis PT, Rosemann T, Knechtle B: Non-steroidal anti-inflammatory drug consumption in a multi-stage and a 24-h mountain bike competition. Front Physiol 2018; 9: 1–8.

25. Ciocca M: Medication and supplement use by athletes. Clin Sports Med 2005; 24: 719–38, x-xi.

26. Corrigan B, Kazlauskas R: Medication use in athletes selected for doping control at the Sydney Olympics (2000). Clin J Sport Med 2003; 13: 33–40.

27. Didier S, Vauthier J-C, Gambier N, Renaud P, Chenuel B, Poussel M: Substance use and misuse in a mountain ultramarathon new insight into ultrarunners population? Res Sports Med 2017; 25: 244–51.

28. Dietz P, Dalaker R, Letzel S, Ulrich R, Simon P: Analgesics use in competitive triathletes its relationship to doping and on predicting its usage. J Sports Sci 2016; 34: 1965–9.

29. Dowse MSL, Cridge C, Smerdon G: The use of drugs by UK recreational divers: prescribed and over-the-counter medications. Diving Hyperb Med 2011; 41: 16–21

30. Gorski T, Cadore EL, Pinto SS, et al.: Use of NSAIDs in triathletes: prevalence, level of awareness and reasons for use. Br J Sports Med 2011; 45: 85–90.

31. Harle CA, Danielson EC, Derman W, et al.: Analgesic management of pain in elite athletes: a systematic review. Clin J Sport Med 2018; 28: 417–26.

32. Hoffman MD, Fogard K: Factors related to successful completion of a 161-km ultramarathon. Int J Sports Physiol Perform 2011; 6: 25–37.

33. Holgado D, Hopker J, Sanabria D, Zabala M: Analgesics and sport performance: beyond the pain-modulating effects. PM R 2018; 10: 72–82.

34. Holmes N, Cronholm PF, Duffy AJ, Webner D: Nonsteroidal anti-inflammatory drug use in collegiate football players. Clin J Sport Med 2013; 23: 283–6.

35. Joslin J, Lloyd JB, Kotlyar T, Wojcik SM: NSAID and other analgesic use by endurance runners during training, competition and recovery. S Afr J Sports Med 2013; 25: 101.

36. Kavukcu E, Burgazlı KM: Preventive health perspective in sports medicine: the trend at the use of medications and nutritional supplements during 5 years period between 2003 and 2008 in football. Balkan Med J 2013; 30: 74–9.

37. Koes B, van Ochten J, van Middelkoop M: NSAIDs use in athletes. Dansk Sportmedicin 2018; 22: 25–30.

38. Küster M, Renner B, Oppel P, Niederweis U, Brune K: Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study. BMJ Open 2013; 3.

39. Lai-Cheung-Kit I, Lemarchand B, Bouscaren N, Gaüzère B-A: Consommation des anti-inflammatoires non stéroïdiens lors de la préparation au Grand Raid 2016 à La Réunion. Science & Sports 2019; 34: 244–58.

40. Mahn A, Flöricke F, Sieg L, et al.: Consumption of analgesics before a marathon and effects on incidence of adverse events: the Hannover marathon study. IJAR 2018; 6: 1430–41.

e1. Martínez S, Aguiló A, Moreno C, Lozano L, Tauler P: Use of non-steroidal anti-inflammatory drugs among participants in a mountain ultramarathon event. Sports 2017; 5: 11.

e2. Müller-Platz C, Symanzik T, Lütkehermölle R, Müller RK, Boos C: Doping und Arzneimittelmissbrauch im Freizeit- und Breitensport. Internistische Praxis 2011; 51: 173–91.

e3. Niederberger E, Geisslinger G: Analgetika im Breitensport. Pharmakon 2016; 4: 31–5.

e4. Oester C, Weber A, Vaso M: Retrospective study of the use of medication and supplements during the 2018 FIFA World Cup Russia. BMJ Open Sport Exerc Med 2019; 5: e000609.

e5. Pardet N, Lemarchand B, Gaüzère B-A: Ultra-trailers’ consumption of medicines and dietary supplements, about the grand raid 2015 // La prise de médicaments et de compléments alimentaires chez l’ultra-trailer compétiteur durant la préparation du Grand Raid 2015 de l’île de La Réunion. Science & Sports 2017; 32: 344–54.

e6. Pedrinelli A, Ejnisman L, Fagotti L, Dvorak J, Tscholl PM: Medications and nutritional supplements in athletes during the 2000, 2004, 2008, and 2012 FIFA Futsal World Cups. Biomed Res Int 2015; 2015: 1–7.

e7. Rosenbloom CJ, Morley FL, Ahmed I, Cox AR: Oral non-steroidal anti-inflammatory drug use in recreational runners participating in Parkrun UK: prevalence of use and awareness of risk. Int J Pharm Pract 2020; 28: 561–8.

e8. Rossi FW, Napolitano F, Pucino V, et al.: Drug use and abuse and the risk of adverse events in soccer players: results from a survey in Italian second league players. Eur Ann Allergy Clin Immunol 2021; 53: 37–42.

e9. Rotunno A, Schwellnus MP, Swanevelder S, Jordaan E, van Janse Rensburg DC, Derman W: Novel factors associated with analgesic and anti-inflammatory medication use in distance runners: pre-race screening among 76 654 race entrants-SAFER Study VI. Clin J Sport Med 2018; 28: 427–34.

e10. Rüther T, Witzki A, Schomaker R, Löllgen H, Rohde U, Leyk D: Konsum von NEM und Schmerzmitteln bei Läufern – Ergebnisse des „Bleib-gesund-und-werde-fit“-Surveys. Dtsch Z Sportmed 2018; 69: 179 (Abstract).

e11. Schneider S, Sauer J, Berrsche G, Löbel C, Sommer DK, Schmitt H: [Joint pain and consumption of analgesics among young elite athletes nationwide data from youth basketball]. Schmerz 2019; 33: 57–65.

e12. Seidel EJ: Medikamentenmissbrauch bei Läufern und die Folgen. Manuelle Medizin 2015; 53: 205–8.

e13. Taioli E: Use of permitted drugs in Italian professional soccer players. Br J Sports Med 2007; 41: 439–41.

e14. Trinks S, Scheiff AB, Knipp M, Gotzmann A: Declaration of analgesics on doping control forms in German football leagues during five seasons. Dtsch Z Sportmed 2021; 72: 67–74.

e15. Tscholl P, Junge A, Dvorak J: The use of medication and nutritional supplements during FIFA World Cups 2002 and 2006. Br J Sports Med 2008; 42: 725–30.

e16. Tscholl P, Alonso JM, Dollé G, Junge A, Dvorak J: The use of drugs and nutritional supplements in top-level track and field athletes. Am J Sports Med 2010; 38: 133–40.

e17. Tscholl PM: Der Einsatz von nicht-steroidalen Antirheumatika (NSAR) im Spitzensport. Dtsch Z Sportmed 2014; 65: 34–7.

e18. Tscholl PM, Vaso M, Weber A, Dvorak J: High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. Br J Sports Med 2015; 49: 580–2.

e19. Tscholl PM, Dvorak J: Abuse of medication during international football competition in 2010—lesson not learned. Br J Sports Med 2012; 46: 1140–1.

e20. Tsitsimpikou C, Tsiokanos A, Tsarouhas K, et al.: Medication use by athletes at the Athens 2004 Summer Olympic Games. Clin J Sport Med 2009; 19: 33–8.

e21. van Thuyne W, Delbeke FT: Declared use of medication in sports. Clin J Sport Med 2008; 18: 143–7.

e22. Warden SJ: Prophylactic misuse and recommended use of non-steroidal anti-inflammatory drugs by athletes. Br J Sports Med 2009; 43: 548–9.

e23. Warden SJ: Prophylactic use of NSAIDs by athletes: a risk/benefit assessment. Physician Sportsmed 2010; 38: 132–8.

e24. Whatmough S, Mears S, Kipps C: The use of non-steroidal anti-inflammatories (NSAIDs) at the 2016 London marathon. Br J Sports Med 2017; 51: 408.

e25. Berrsche G, Schmitt H: Schmerzprävalenzen und Analgetikakonsum bei Nachwuchsleistungsportlern – ein aktueller narrativer Überblick. Dtsch Z Sportmed 2022; 73: 93–7.

e26. Seppelt H, Löer W, Sachse J: Neue Studie im Profifußball: Schmerzmittel bei jeder dritten Dopingkontrolle. https://correctiv.org/aktuelles/fussballdoping/2021/03/08/neue-studie-im-profifussball-schmerzmittel-bei-jeder-dritten-dopingkontrolle/ (last accessed on 1 February 2023).

e27. Schmitt H: Wieviel Schmerz ist erlaubt? Dtsch Z Sportmed 2022; 73.

e28. Rauschert C, Möckl J, Seitz NN, Wilms N, Olderbak S, Kraus L: The use of psychoactive substances in Germany—findings from the Epidemiological Survey of Substance Abuse 2021. Dtsch Arztebl Int 2022; 119: 527–34