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Invited Commentary

Managing Medications in the Training Room and on the Sidelines

Young, Craig C. MD, FACSM1,2; Higgs, Jessica D. MD3; Chang, Cindy J. MD, FACSM2,4

Author Information
Current Sports Medicine Reports: July 2020 - Volume 19 - Issue 7 - p 249-250
doi: 10.1249/JSR.0000000000000727
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Medications are often indicated for the treatment of many sport-specific problems, as well as general medical issues in athletes. Ready accessibility of medications is convenient for athletes and allows medical personnel to monitor medication use. On sidelines and at mass participation events, it is optimal to have medications available that could treat medical emergencies, such as anaphylaxis and severe asthma attacks (1). It is important to recognize, however, that ready accessibility of medications also can carry significant risks, both medical and legal. All medications, especially prescription medications, need to be properly administered, dispensed, and stored to minimize the risk of medicolegal problems and ensure compliance with state and federal licensing guidelines, laws, and practice acts (2). Lawsuits filed by former athletes alleging inappropriate practice related to medications by team physicians, as well as recent investigations by the United States Drug Enforcement Agency (DEA) into medication use in training rooms highlight the importance of awareness and compliance with appropriate guidelines regarding medication availability in the sport or training room setting.

Once a decision has been made to have medications available at an athletic clinical setting or venue, planning should include considerations for the following: storage, packaging and labeling, administration, dispensing, inventory control and disposal, emergency protocols, traveling (if applicable), as well as appropriate documentation of all of these aspects. Team physicians should write protocols to ensure proper administration, dispensing, and storage of both over-the-counter (OTC) and prescription medications (2,3). In addition to compliance with applicable licensure guidelines and laws, it is essential to ensure that any medication provision complies with rules relevant to athlete drug testing and specific policies of a given sports organization or school. Additional considerations should be given to developing protocols for pain medication to minimize risks of abuse, addiction, and diversion. Providers also need to remember that federal law requires any facility that receives, stores, administers, or dispenses controlled substances to maintain a valid DEA registration.

All medication should be stored in a dry, environmentally controlled space. All prescription medications must be stored in a locked space accessible only by appropriate personnel. All medication, even OTC, must be appropriately packaged and labeled. Teams may want to consider a pharmacy service which provides individually packaged and labeled medications along with inventory control sheets to minimize administrative work. Unit dosing is the preferred method of dispensing OTC medications; repackaging them may lead to concerns of accountability and contamination, as well as potential liability under federal and local laws (2).

Be aware that state regulations may differ for drug administration and drug dosing. Drug administration refers to giving a single dose of medication for immediate use. Drug dispensing includes preparing, labeling, or providing multiple doses of a medication for future use (4). Most states do not allow athletic trainers to dispense prescription medications even with standing orders or with permission from the supervising physician (2). Dispensing of OTC medications by athletic trainers may be allowed in some states. Documentation of medications that have been administered or dispensed should be recorded in both the patient's medical chart and the facility records. Records should include date, patient name, medication, quantity, and name of administering/dispensing personnel. Records need to be kept for a minimum of 2 years (or longer in some states). Records and inventory should be audited on a regular basis, and appropriate protocols should be designed for disposal of expired medications since many will be considered hazardous waste (2).

Event physicians can minimize administrative issues by arranging (if an option) for an appropriate level emergency responder (e.g., paramedics, emergency medical technicians, ambulance crew) to be available to provide and administer emergency medications on site. Most states will allow athletic trainers to administer emergency medications, such as epinephrine autoinjectors or naloxone.

Traveling with a team may create additional issues, particularly if state or national borders are crossed. The passage of the Sports Medicine Licensure Clarity Act of 2017 allows team physicians to practice medicine when traveling with their teams, but it does not specifically allow teams to travel with medications. At the time of this publication, the Medical Controlled Substances Transportation Act of 2017, which would allow physicians to travel with controlled substances out of state for up to 72 hours with appropriate documentation and registration, has been passed by the U.S. House of Representatives, but has not yet passed in the U.S. Senate.

Teams traveling internationally will need to be mindful of customs regulations in both the United States and the host country. Individuals carrying legal personal prescription medication should be aware of the proper protocols for the countries that they are visiting. Typically, at a minimum, a copy of the prescription needs to be available. There is frequently a requirement for the medication to be transported in the original container. For individuals with multiple medications, it may be worthwhile (at least from a space-saving perspective) to utilize pharmacy services which can combine daily medications into individual packets. It also is important to remember that although a prescription medication may be legal in the United States, the same medication may be illegal in other countries, even if the visitor holds a valid prescription in their home country. For example, any medications that contain amphetamines, such as those used to treat attention deficit disorder (e.g., Adderall and Vyvanse), are illegal in Japan. Possession of this type of medication, even with a valid prescription from the United States, may result in arrest and jail time (5,6). Larger volumes of medications intended for the team (e.g., stock bottles of ibuprofen or acetaminophen), as well as personal medications prescribed for quantities beyond specific amounts (typically 30 days), will often need special permission or customs declarations and forms. Failure to obtain appropriate permission in advance may lead to potential serious legal complications (5,6).

In summary, while having prescription and OTC medications available at training and competition venues can increase convenience for and compliance by athletes, and even occasionally constitute a lifesaving intervention, this availability is fraught with multiple administrative issues. To minimize the risk of medicolegal problems, it is critical that proper protocols are written in compliance with state and federal licensing, laws and practice acts, and with policies established by sports organizations and schools.

The authors declare no conflict of interest and do not have any financial disclosures.

References

1. Herring SA, Bergfeld JA, Boyajian-O’Neill LA, et al. Mass participation event management for the team physician: a consensus statement. Med. Sci. Sports Exerc. 2004; 36:2004–8.
2. Chang CJ, Weston T, Higgs JD, et al. Inter-association consensus statement: the management of medications by the sports medicine team. J. Athl. Train. 2018; 53:1103–12.
3. Herring SA, Kibler WB, Putukian M, et al. Team physician consensus statement: 2013 update. Med. Sci. Sports Exerc. 2013; 45:1618–22.
4. Parsons J, editor. 2017–2018 NCAA Sports Medicine Handbook. 26th ed. Indianapolis (IN): National Collegiate Athletic Association; 2017.
5. ACCESSIBLEJAPAN. Bringing medicine to Japan. [cited 2020 January 15]. Available from: https://www.accessible-japan.com/bringing-medicine-to-japan/.
6. U.S. Embassy & Consulates in Japan. Bringing Over-the-Counter Medicine and Prescriptions into Japan. [cited 2020 January 15]. Available from: https://jp.usembassy.gov/u-s-citizen-services/doctors/importing-medication/.
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