The work is punishing, the pressure extreme, and a replacement is always waiting in the wings. Is it any wonder athletes and substance abuse seem to go hand in hand? Drugs and alcohol are often used as a way to ignore pain, increase focus, boost energy, reduce stress, pump up before a game and unwind after. Misused, they can set a player on a downward spiral that can end a career or a life. Dr. Deborah Stote, a staff psychologist at Promises Austin, who also specializes in treating substance abuse in athletes, explained that several key factors appear to lead players to abuse drugs, but it all relates to the same mindset: \u201cstaying competitive by enhancing performance.\u201d The term \u201csubstances of abuse\u201d generally applies to drugs that are recreational, such as marijuana, cocaine and hallucinogens; controlled drugs such as Adderall or painkillers that are used without a prescription; and alcohol. Most professional sports organizations and NCAA-governed collegiate groups routinely test players for these, along with traditional performance enhancers such as steroids, and maintain substance abuse\/behavioral health programs that provide evaluation, education and treatment. Dealing with the Pain of the Game What causes an athlete to turn to substances of abuse? Pain control tops the list. Because of the physical demands of the sport, an athlete is bound to deal with injuries. \u201cPain medications can solve the immediate pain problem and allow the player to perform better or just keep playing despite injury,\u201d Dr. Stote said. That\u2019s vital for the player, whose career depends on getting back into the game. \u201cThere are always backups and competitors for any given position, and being out with an injury puts one\u2019s claim to a position at risk,\u201d she said. Problems start if the player uses the painkiller \u2013 often an opioid such as Vicodin or OxyContin \u2013 more often than prescribed or longer than needed. Opioid painkillers can be highly addictive and must be carefully managed to prevent dependence. What begins as legitimate use of what seems like a safe prescription medicine can quickly become a debilitating and potentially deadly habit. Athletes aren\u2019t the only group dealing with painkiller addiction. The U.S. is in the midst of a prescription drug abuse epidemic that has come about in large part because of the overprescription and misuse of opioid painkillers. Overdoses involving prescription painkillers now kill more Americans than those involving heroin and cocaine combined. And a National Survey on Drug Use and Health found that nearly 2 million Americans were dependent on or abusing prescription pain relievers. Chemically, these opiate painkillers are similar to heroin and can lead some to turn to heroin for a cheaper and easier high, helping to fuel a recent spike in heroin use. In short, painkillers have never been used more or to more devastating effect. In the ultracompetitive athletic community, where injuries are common and pressure to keep performing is extreme, players can be particularly vulnerable to painkiller abuse. Getting an Edge Another popular drug in the athletic community is one most commonly prescribed to hyperactive kids: Adderall. Medications used to treat Attention Deficit Hyperactivity Disorder (ADHD) can increase attention and alertness and help fight fatigue, which has appeal for athletes who seek every advantage to play at their best. \u201cThe uptick in athletes using ADHD medications like Adderall, Ritalin and Vyvanse to improve performance mimics the use of students in colleges and university, where roughly 30 percent use some form of stimulant medication to enhance their study, particularly during exams,\u201d Dr. Stote noted. Although almost all stimulants beyond coffee and Red Bull are on the banned substances list in the athletic world, a player can request a Therapeutic Use Exemption (TUE) that allows him or her to legally use the ADHD drugs. Baseball players, with their grueling schedules, seem particularly prone to use. Major League Baseball banned stimulants, including Adderall, at the end of the 2005 season. Since then almost 10 percent of its players have been cleared to receive an exemption allowing use. That\u2019s more than double the rate of ADHD in the U.S. adult population. Drugs like Adderall come with risks: They can be habit-forming and have negative side effects such as mood changes, fevers and seizures, especially if abused long-term. For some athletes, the risks can be seen as a price worth paying, even though the performance advantage is generally small. Reducing Stress The need to reduce stress can be another road to substance abuse. \u201cMostathletes play with a great deal of aggression to in order to compete,\u201d Dr. Stote said, \u201cbut athletes can also experience difficulty calming down after a game. Alcohol, marijuana, and anxiolytics serve the purpose of turning off the aggression.\u201d It\u2019s a play-hard, party-hard strategy often started in high school that persists into college and beyond. \u201cAfter sustained use, many are at risk to become dependent. For athletes with a heritability factor for addiction, or those also struggling with anxiety or depression, the risk of dependence is much greater,\u201d she said. Among the drug choices, alcohol is the No. 1 substance abused by athletes, from junior high players through the professional ranks.