Addiction in sport: alcohol, betting and painkillers

“I don’t drink at all during the season. You know what the regime is like.”

The sentence is said with pride, and it is true. During the season he really doesn’t drink. But then the season ends, and with it come three weeks he doesn’t like to talk about. Or an injury comes, and with it tablets that were first prescribed for a knee and then started helping with something else as well — making the evenings calmer and quietening the thoughts about the future. Or there is a betting app on the phone, downloaded “just for fun” during long evenings in a hotel.

Addiction in sport is rarely talked about, and when it is, the conversation is mostly about doping. This post is not about doping. It is about three addictions that are more common in sport than you might expect, and that are even harder to talk about there than elsewhere: alcohol, gambling and painkillers. I write carefully, without names and without medical advice — from the perspective of psychotherapy, which I see as part of the help, not a substitute for a doctor.

Sport does not protect you from addiction

There is a firmly rooted belief that sport is the best medicine against addiction. For recreational exercise that is true in many ways. For competitive sport the picture is more complicated.

A review of the research published in 2006 by Matthew Martens and colleagues showed that student athletes in the United States drink more often and more riskily than their peers who don’t play sport. Even more telling is a 2011 study by Linda Cottler and colleagues among former professional American football players: more than half had taken strong opioid painkillers during their careers, and of those, around seven in ten had at some point taken them differently from how they were prescribed — more, for longer or for other reasons. The figure comes from one sport and one country, but it shows clearly how close injury and risk sit to each other.

The International Olympic Committee’s 2019 consensus statement on mental health in elite athletes (Reardon and colleagues) therefore lists among the issues to take seriously, alongside depression and anxiety, risky alcohol use, misuse of medication and gambling. Sport, then, is not a protection. It is an environment with risks of its own.

Alcohol: celebration and comfort

Alcohol is present in sport in ways we hardly notice any more. Champagne on the winners’ podium. The end-of-season dinner where it is “the done thing” to drink. A brewery as a sponsor. The beer after a recreational match that, for many people, is a more important part of the evening than the match itself.

Among elite athletes a pattern often appears that we might call drinking in bursts. Strict discipline during the season, then sudden, heavy drinking at the end of the season, after being dropped or after a defeat. Because there are no problems during the season, the person and those around them reassure themselves that everything is fine. But the question is not only how much you drink, but what the drinking is for. If alcohol is the only thing that truly lets you unwind after long months of tension, it is doing a job that something else should be doing.

In Slovenia alcohol has a particular place. I described how drinking becomes normalised in families in Alcohol in the Slovenian family: how it is normalised until it breaks. Sporting culture, with its celebrations and its “third halves”, fits neatly into that pattern.

Betting: the addiction that stays hidden for a long time

Gambling and sports betting are a special case in sport. An athlete knows sport better than the average punter, so they may feel that betting is not gambling for them but knowledge. This illusion of control is one of the well-described mechanisms that sustain gambling addiction.

The rules of many federations and clubs forbid athletes to bet on their own sport — for the sake of fair competition. But the ban does not cover other sports, casinos or online games. And the circumstances are often almost made for it: long evenings in hotels, boredom while travelling, money that is suddenly available, and a need for excitement that nothing else satisfies after a match.

Gambling addiction has no smell and doesn’t show in the body. That is why it stays hidden for a long time, even from those closest. I wrote about how it develops and why it is so insidious in Gambling: the addiction with no smell that stays invisible.

Painkillers: when help becomes a risk

Pain is an almost constant companion in sport. Playing through pain is seen as a virtue, and missing games through injury as a threat — to your place in the team, your contract, your identity. In that kind of environment painkillers are entirely ordinary, and in the vast majority of cases justified: a doctor prescribes them because they are needed.

The risk begins elsewhere. Some painkillers — opioids in particular — don’t only quieten physical pain. They also bring a sense of calm, warmth and distance from worries. For an athlete facing fear, loneliness and uncertainty after an injury, that can be very appealing. Pain and emotion are more closely linked in the brain than we tend to think; you can read more under the entry pain and emotions.

Here I need to be very clear: decisions about medication are made only with a doctor. Don’t change the dose yourself, don’t stop suddenly without advice, and don’t take tablets prescribed for someone else. With some medicines stopping suddenly can be dangerous — I explained why withdrawal deserves to be taken seriously in Withdrawal: why it deserves to be taken seriously. Your club doctor or GP also knows the anti-doping rules, so from that point of view too they are the right person to talk to.

I wrote more about how an injury can unsettle your mental balance in Injury and mental health: when your body stops you.

Why athletes in particular

Addiction is not a matter of weak will. Athletes are often people of exceptional willpower, and yet they are not protected. A few reasons why sport can be fertile ground:

• The reward system is used to peaks. Victory, a full arena, adrenaline — the brain gets used to strong stimuli. When they are gone, everyday life suddenly seems pale. I described what happens with dopamine and why this is not a matter of character in Addiction is not weak will: what happens to the reward system.
• Identity stands on one leg. As early as 1993, Britton Brewer and colleagues described athletic identity as a double-edged sword: it gives meaning, but when it is shaken — by injury, being dropped or the end of a career — a person no longer knows who they are. And emptiness looks for something to fill it.
• Structure disappears overnight. During the season every hour is planned. At the end of a career or during a long rehabilitation that structure is gone, and with it the external control.
• A culture of silence. Admitting a problem risks your place in the team. So problems are hidden until they become too big to hide.

The end of a career is a particularly vulnerable time. I wrote about how your sense of who you are changes in When the career ends: who you are when you’re no longer an athlete.

A conversation that is hard to start

The hardest step is often the first conversation. This is what it might look like between two teammates after training (a composite, not a real person):

“Hey, have you got a minute?”
“Yeah, what is it?”
“I don’t know how to say this. For the last few weeks I’ve seen you take something before training. And at night you’re always on your phone, on those betting sites.”
“What’s it to you? I’ve got it all under control.”
“Maybe you have. It’s just … if you haven’t, you can tell me. I won’t go to the coach. I just want you to know I’ve noticed.”
(a long silence) “My knee still hurts. And I can’t sleep without it.”

The teammate in this conversation doesn’t diagnose, threaten or preach. He says what he has noticed and leaves room. That is often all it takes for the wall to crack for the first time. If you are the one who is worried, it also helps to know where support ends and enabling begins — that is the subject of When your partner is addicted: where support ends and enabling begins.

Warning signs

With addiction, what matters is not only the quantity but above all your relationship with the substance or behaviour. A few questions that may help:

• Do you need alcohol, a bet or a tablet to calm down, fall asleep or get through?
• Have you already tried to cut down and not managed it?
• Are you hiding anything from your partner, family, coach or doctor?
• Are you taking medication for longer, in larger doses or for other reasons than it was prescribed?
• Have you increased your bets to cover your losses?
• Do you feel you couldn’t get through the season, rehabilitation or the end of your career without it?

If you nodded at several of these questions, that is not yet a diagnosis. But it is a good reason to talk to a doctor. You will find more questions that say more than quantity alone in Am I an addict? Questions that say more than quantity, and a short explanation of the concept under the entry addiction.

Exercise: a week of honest observation

This exercise doesn’t require you to change anything. It only asks you to look honestly for one week. Start today.

1. Every evening, write down three things: what you drank, bet or took (and how much), when it happened and where you were. No corrections and no comments.
2. Next to each note, add one word for the feeling you had just before: boredom, tension, pain, loneliness, celebration, fear.
3. At the end of the week, look for a pattern. Does the same feeling keep coming back? The same place — the hotel, the bus, home after a defeat? The same time of day?
4. Choose one person and tell them what you have noticed. Not the coach, if that doesn’t feel safe, but someone you trust: your partner, a friend, your doctor.
5. If medication is involved, book an appointment with your doctor and show them your notes. Agree together on how to go on. Don’t change anything on your own.

Your notes are not evidence against you. They are a map that shows what the substance or the betting is replacing in your life — and therefore where to look for a different kind of help.

Where to find help in Slovenia

Addiction is a health problem and is best addressed from several sides at once. The first port of call is almost always your GP or club doctor, who can assess your physical condition, help you handle medication safely and, if needed, refer you on — to a psychiatrist or to specialised addiction treatment programmes. For alcohol and other addictions, self-help groups also help many people; I summarised what the research says about them in Alcoholics Anonymous and other programmes: what the research says.

Where does psychotherapy fit in? Not at the start, when your physical health is at risk, but alongside treatment. In therapy we look at what the substance or the betting does in your life: whether it soothes the fear of being dropped, fills the emptiness after the season, or quietens a grief that cannot be spoken about in the dressing room. In relational family therapy, in which I am training, we often see that addiction leans on old patterns from the family — on how distress was dealt with at home and what it was allowed to feel. And addiction never affects just one person; that is why it sometimes makes sense to invite a partner or family into therapy too. I also work with English-speaking clients, in person in Ljubljana.

If you are unsure whether you need a doctor, a psychiatrist, a sport psychologist or a psychotherapist, start with the doctor. They can assess what is needed first and point you onwards. You don’t have to know everything in advance — it is enough to take the first step.

If in your distress thoughts of not wanting to live appear, call the crisis line Klic v duševni stiski on 01 520 99 00 (in Slovenia, every day from 7 p.m. to 7 a.m.) or the Samaritans’ confidential line on 116 123 (in Slovenia, every day, 24 hours). In the case of poisoning or another emergency, call 112.

Where this post does not apply

Not every glass is an addiction. Most athletes who drink more than usual at the end of the season are not addicted. Most people who take painkillers as their doctor instructs stop without difficulty once treatment ends. The aim of this post is not to make you see illness in every celebration.

Medication is not the enemy. Pain needs treating, and medicines prescribed by a doctor have their place. A fear of medication that leads someone to suffer needlessly or to self-medicate in the wrong way can be just as harmful.

Doping is a different story. The use of substances to enhance performance has its own causes and its own rules, and this post does not cover it.

Psychotherapy is not the first port of call when the body is at risk. If, when you stop drinking or taking medication, you experience shaking, sweating, restlessness, confusion or severe physical symptoms, you need a doctor straight away, not a therapist. A sport psychologist is not the right first port of call for addiction either — their field is performance. I am not a sport psychologist; but I can be part of the team that helps you understand what happened and how to live on.

What to remember

• Sport does not protect you from addiction — alcohol, betting and painkillers are more common in sport than you might expect.
• What matters more than quantity is what the substance or the bet is for: what it soothes, what it covers, what it replaces.
• Moments of injury, being dropped and the end of a career, when identity is shaken, are particularly vulnerable.
• Decisions about medication are made only with a doctor: no changing doses on your own and no sudden stopping.
• Help works best when several people work together — a doctor, a psychiatrist, a psychotherapist and those close to you.