Substance Use and Performance: How Best to Support Athlete Patients

Substance use affects the body, mind, and ultimately performance. Alcohol, cannabis, nicotine, stimulants, and other drugs are sometimes used to cope with stress, pain, travel demands, or performance pressure. While they may offer short-term relief, these substances can interfere with recovery, disrupt sleep, impair focus and coordination, and negatively affect long-term health.

Research shows, for example, that alcohol can meaningfully slow muscle recovery by interfering with muscle protein synthesis, with some studies showing reductions in recovery-related processes of 20% to 30% under certain conditions.¹ Cannabis use has been associated with reduced reaction time, balance, and coordination.² Even substances that may seem performance-enhancing, such as anabolic steroids or stimulants, carry serious risks. Steroid use has been linked to markedly increased rates of cardiovascular disease, including cardiomyopathy, arrhythmias, and premature heart attacks, and can also contribute to mood changes such as irritability, aggression, anxiety, and depression.^3-4

Athletes are often viewed as low risk for substance misuse because of their discipline, fitness, and resilience. Substance use is common in sports. About 28% of college athletes report binge drinking, and approximately 1 in 5 report misusing prescription pain medication after an injury.⁵

What Counts as Substance Use?

Substance use includes alcohol, nicotine, cannabis, nonprescribed or misused medications, illicit drugs, and performance-enhancing substances. With athletes, these generally fall into 3 categories:

Recreational substances: Alcohol, cannabis, vaping, nicotine, and party drugs may feel socially accepted or routine, but they can still affect sleep, recovery, mental health, and long-term performance.

Misused prescription medications: This includes pain medications, sedatives, or stimulants taken in higher doses, more frequently, or in ways different from how they were prescribed. Misuse can increase the risk of dependence and may mask symptoms that need medical attention, such as an injury or sleep disorder.

Performance-enhancing substances and supplements: Anabolic steroids, testosterone boosters, stimulants, and some supplements or “pre-workout” products may contain unregulated or mislabeled ingredients. Unlike medications, most supplements are not approved by the US Food and Drug Administration for safety or effectiveness. Some have led to positive drug tests even when athletes believed they were using legal products. Athletes should always review supplements with their health care or sports medicine team.

How Does Substance Use Affect the Athlete?

Substance use can affect multiple areas of an athlete’s life. Below are examples from research on how substances may impact physical performance, mental health, and social functioning.

Reduced sleep quality: Although substances like alcohol may make it easier to fall asleep, research shows that even a few drinks can reduce sleep quality and REM sleep, which are critical for recovery, learning, and emotional regulation.⁶

Increased injury risk and slower recovery: Alcohol use after resistance training has been shown to increase cortisol and decrease testosterone levels and muscle protein synthesis, potentially slowing recovery and increasing injury risk over time.^1,7

Greater risk of anxiety, depression, or dependence: Substances can disrupt the brain’s natural reward and stress systems. Over time, this may increase vulnerability to anxiety, low mood, irritability, and reliance on substances to manage stress or emotions.⁸

Impaired coordination, reaction time, and balance: Some substances directly affect neuromuscular control. For example, cannabis has been shown to impair movement speed, balance, and coordination, particularly during periods of acute intoxication.²

What Are Risk Factors for Substance Misuse in Athletes?

Research highlights several factors that may increase risk, including:

1. Injuries that require pain management
2. High performance expectations from coaches, teammates, or fans
3. Team cultures where substance use is normalized
4. Social pressure inside and outside of sport
5. Identity is tied almost entirely to athletic performance

Recognizing these risk factors can help athletes identify early warning signs and seek support sooner.

Tips to Offer Athletes That Protect Health and Performance

Build stress-management skills: Techniques such as breathing exercises, grounding strategies, focus cues, and constructive self-talk can help manage pressure and improve consistency under stress.

Communicate honestly about pain and injuries: Open communication with athletic trainers and medical staff is critical. Hiding pain or self-medicating can increase the risk of long-term injury and dependence.

Build a strong support network: Teammates, coaches, athletic trainers, family members, and mental health professionals can help athletes navigate pressure, setbacks, and transitions.

Know the early warning signs: Early warning signs may include using alcohol or cannabis to fall asleep, taking more medication than prescribed, needing substances to “get going” or “wind down,” missing training or school, or hiding use from others.

Psychiatric Assessment

As mental health professionals, you can confidentially help athletes:

• Understand the level of support they may need.
• Identify whether use is connected to pain, stress, injury, sleep, or performance demands.
• Create a plan to reduce or stop substance use safely.
• Monitor and manage withdrawal symptoms, if relevant.

Takeaway

Substance use is more common in sports than many people realize, but awareness, education, and care make a difference. By understanding how substances affect the body and mind, recognizing early warning signs, and leaning on trusted supports, athletes can protect both their health and their long-term success in sport. You, as mental health clinicians, can support their journey.

You can refer athletes patients looking for more information on supporting mental health and well-being to this resource: https://www.athletesforhope.org/center-for-athlete-wellbeing/

Dr Rader is a behavioral geneticist, neuroscientist, and postdoctoral associate at the Institute for Behavioral Genetics.

Dr Mirhom is past president of the New York County Psychiatric Society, an assistant professor of Psychiatry at Columbia University, a Forbes contributor, and Chief Wellbeing Officer at Athletes for Hope.

References

1. Parr EB, Camera DM, Areta JL, et al. Alcohol ingestion impairs maximal post-exercise rates of myofibrillar protein synthesis following a single bout of concurrent training.PLoS One. 2014;9(2):e88384.

2. Hitchcock LN, Tracy BL, Bryan AD, et al. Acute effects of cannabis concentrate on motor control and speed: smartphone-based mobile assessment.Front Psychiatry. 2021;11:623672.

3. Gestsdottir S, Kristjansdottir H, Sigurdsson H, et al. Prevalence, mental health and substance use of anabolic steroid users: a population-based study on young individuals. Scand J Public Health. 2021;49(5):555-562.

4. Windfeld-Mathiasen J, Heerfordt IM, Dalhoff KP, et al. Cardiovascular disease in anabolic androgenic steroid users. Circulation. 2025;151(12):828-834.

5. Johnson G. Student-athletes report drop in binge drinking, use of narcotic pain medication and spit tobacco. National Collegiate Athletic Association. January 9, 2024. Accessed February 11, 2026. https://www.ncaa.org/news/2024/1/9/media-center-student-athletes-report-drop-in-binge-drinking-use-of-narcotic-pain-medication-and-spit-tobacco.aspx

6. Gardiner C, Weakley J, Burke LM, et al. The effect of alcohol on subsequent sleep in healthy adults: a systematic review and meta-analysis.Sleep Med Rev. 2025;80:102030.

7. Lakićević N. The effects of alcohol consumption on recovery following resistance exercise: a systematic review.J Funct Morphol Kinesiol. 2019;4(3):41.

8. Avdija A. Substance use and stress-induced cognitive impairment: the causes of anxiety and depression among college students.J Drug Educ. 2022;51(3-4):70-81.