{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T03:45:01Z","timestamp":1790739901112,"version":"4.1.0"},"reference-count":131,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:00:00Z","timestamp":1770768000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmaceuticals"],"abstract":"<jats:p>Background: Analgesics are widely used in competitive sports, but their patterns of use and detection in anti-doping controls vary significantly across drug classes. This study examined a decade of Italian anti-doping reports with three aims: to describe trends involving non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and narcotics; to characterize the distribution of specific active ingredients; and to analyze the relative contribution of these classes to anti-doping violations, placing the findings within the regulatory framework. Methods: Data from national anti-doping reporting systems were analyzed from 2013 to the first half of 2023. Yearly data included tested athletes, athlete declarations of NSAID use, and laboratory analytical findings for prohibited substances (glucocorticoids and narcotics). NSAID prevalence was calculated relative to tested athletes, while glucocorticoid and narcotic findings were assessed as absolute counts and proportions of total violations. Temporal trends were assessed using the Cochran\u2013Armitage test. Results: NSAIDs consistently ranked as the most frequently reported medication, with nearly half of the tested athletes reporting their use and no significant linear trend in overall prevalence. However, a significant shift was observed within the NSAID class, with a marked decrease in declarations of COX-2 selective agents over time. Glucocorticoids accounted for a significant portion of prohibited substances, with fluctuating proportions (showing no significant linear trend), betamethasone being the most common active ingredient. Narcotics appeared only sporadically, although the use of non-prohibited opioids such as tramadol and codeine\u2014absent from official reports\u2014remains relevant for understanding analgesic practices. Conclusions: Analgesic use in Italian elite sports shows distinct patterns driven by therapeutic needs and anti-doping regulations. NSAIDs remain the primary choice for routine pain management, though the type of NSAID reported has shifted significantly. Glucocorticoids represent a notable share of prohibited findings with a fluctuating, rather than steadily increasing, pattern. Narcotics appear only sporadically in violation data. Ongoing monitoring will be crucial to understanding how evolving clinical practices and recent regulatory changes influence future detection trends and athlete health.<\/jats:p>","DOI":"10.3390\/ph19020298","type":"journal-article","created":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T11:13:15Z","timestamp":1770808395000},"page":"298","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Pain Management in Italian Elite Athletes: Trends in the Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Glucocorticoids, and Narcotics in Anti-Doping Reports (2013\u20132023)"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-5359-6301","authenticated-orcid":false,"given":"Mario","family":"Ruggiero","sequence":"first","affiliation":[{"name":"Department of Medical, Human Movement and Well-Being Sciences, University of Naples Parthenope, Via Medina 40, 80133 Napoli, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefania","family":"Santamaria","sequence":"additional","affiliation":[{"name":"Department of Medical, Human Movement and Well-Being Sciences, University of Naples Parthenope, Via Medina 40, 80133 Napoli, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pietro","family":"Montesano","sequence":"additional","affiliation":[{"name":"Department of Medical, Human Movement and Well-Being Sciences, University of Naples Parthenope, Via Medina 40, 80133 Napoli, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leopoldo","family":"Ferrante","sequence":"additional","affiliation":[{"name":"Department of Economics, Law, Cybersecurity and Sports Sciences, University of Naples Parthenope, 80035 Nola, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1025-6734","authenticated-orcid":false,"given":"Yuri","family":"Russo","sequence":"additional","affiliation":[{"name":"Department of Public Health and Sport Sciences, University of Exeter, Exeter EX1 2LU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5217-4710","authenticated-orcid":false,"given":"Filomena","family":"Mazzeo","sequence":"additional","affiliation":[{"name":"Department of Economics, Law, Cybersecurity and Sports Sciences, University of Naples Parthenope, 80035 Nola, Italy"},{"name":"Department of Law, Economics and Human Sciences (DiGiES), Mediterranea University of Reggio Calabria, Via dell\u2019Universit\u00e0, 25, 89124 Reggio Calabria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1230","DOI":"10.1016\/j.jpain.2010.07.002","article-title":"The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based Survey","volume":"11","author":"Johannes","year":"2010","journal-title":"J. Pain"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"700","DOI":"10.2522\/ptj.20100330","article-title":"Impact of Psychological Factors in the Experience of Pain","volume":"91","author":"Linton","year":"2011","journal-title":"Phys. Ther."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"981","DOI":"10.26603\/001c.37675","article-title":"Pain in Athletes: Current Knowledge and Challenges","volume":"17","author":"Alaiti","year":"2022","journal-title":"Int. J. Sports Phys. Ther."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Ruggiero, M., Vicidomini, A., Tafuri, D., Mazzeo, F., and Meccariello, R. (2025). Energy Homeostasis and Kisspeptin System, Roles of Exercise and Outcomes with a Focus on Male Reproductive Health. Endocrines, 6.","DOI":"10.3390\/endocrines6030043"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Siragy, T., Russo, Y., and Horsak, B. (2024). Mediolateral Margin of Stability Highlights Motor Strategies for Maintaining Dynamic Balance in Older Adults. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0313034"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.jneumeth.2018.10.006","article-title":"How Do Different Movement References Influence ERP Related to Gait Initiation? A Comparative Methods\u2019 Assessment","volume":"311","author":"Russo","year":"2019","journal-title":"J. Neurosci. Methods"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1136\/bjsports-2012-091524","article-title":"Development and Validation of a New Method for the Registration of Overuse Injuries in Sports Injury Epidemiology: The Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire","volume":"47","author":"Clarsen","year":"2013","journal-title":"Br. J. Sports Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1306","DOI":"10.1136\/bjsports-2015-095871","article-title":"Sports-Related Workload and Injury Risk: Simply Knowing the Risks Will Not Prevent Injuries: Narrative Review","volume":"50","author":"Drew","year":"2016","journal-title":"Br. J. Sports Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"100301","DOI":"10.1016\/j.peh.2024.100301","article-title":"Pain Management in Elite Sport: A Doping Problem, a Public Health Ethics Issue, or Both?","volume":"12","author":"Zandonai","year":"2024","journal-title":"Perform. Enhanc. Health"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1136\/bjsports-2017-097884","article-title":"International Olympic Committee Consensus Statement on Pain Management in Elite Athletes","volume":"51","author":"Hainline","year":"2017","journal-title":"Br. J. Sports Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1001\/journalofethics.2015.17.6.ecas3-1506","article-title":"Athlete Return-to-Play Decisions in Sports Medicine","volume":"17","author":"Tenforde","year":"2015","journal-title":"AMA J. Ethics"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"103094","DOI":"10.1016\/j.humov.2023.103094","article-title":"\u201cPosture First\u201d: Interaction between Posture and Locomotion in People with Low Back Pain during Unexpectedly Cued Modification of Gait Initiation Motor Command","volume":"89","author":"Rum","year":"2023","journal-title":"Human Mov. Sci."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"McNamee, M. (2014). Sport, Medicine, Ethics, Routledge. [1st ed.].","DOI":"10.4324\/9781315885971"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/1747-5341-9-4","article-title":"Performance Enhancement, Elite Athletes and Anti Doping Governance: Comparing Human Guinea Pigs in Pharmaceutical Research and Professional Sports","volume":"9","author":"Camporesi","year":"2014","journal-title":"Philos. Ethics Humanit. Med."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Ruggiero, M., Montesano, P., Ferrante, L., Mennitti, C., Scudiero, O., and Mazzeo, F. (2025). Unified Sports for Inclusive Education: Assessing Basketball\u2019s Role in Supporting Students with Special Educational Needs\u2014A Pilot Study. Disabilities, 5.","DOI":"10.3390\/disabilities5040102"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1170","DOI":"10.1136\/bjsm.2011.086124","article-title":"Ethical Practice and Sports Physician Protection: A Proposal","volume":"45","author":"Holm","year":"2011","journal-title":"Br. J. Sports Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/S1474-4422(14)70251-0","article-title":"Pharmacotherapy for Neuropathic Pain in Adults: A Systematic Review and Meta-Analysis","volume":"14","author":"Finnerup","year":"2015","journal-title":"Lancet Neurol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"m1315","DOI":"10.1136\/bmj.m1315","article-title":"Pregabalin and Gabapentin for Pain","volume":"369","author":"Mathieson","year":"2020","journal-title":"BMJ"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr6501e1","article-title":"CDC Guideline for Prescribing Opioids for Chronic Pain\u2014United States, 2016","volume":"65","author":"Dowell","year":"2016","journal-title":"MMWR Recomm. Rep."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Secondulfo, C., Mazzeo, F., Pastorino, G.M.G., Vicidomini, A., Meccariello, R., and Operto, F.F. (2024). Opioid and Cannabinoid Systems in Pain: Emerging Molecular Mechanisms and Use in Clinical Practice, Health, and Fitness. Int. J. Mol. Sci., 25.","DOI":"10.3390\/ijms25179407"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Ruggiero, M., Motti, M.L., Meccariello, R., and Mazzeo, F. (2025). Resveratrol and Physical Activity: A Successful Combination for the Maintenance of Health and Wellbeing?. Nutrients, 17.","DOI":"10.3390\/nu17050837"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Motti, M.L., Tafuri, D., Donini, L., Masucci, M.T., De Falco, V., and Mazzeo, F. (2022). The Role of Nutrients in Prevention, Treatment and Post-Coronavirus Disease-2019 (COVID-19). Nutrients, 14.","DOI":"10.3390\/nu14051000"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"106569","DOI":"10.1016\/j.rmed.2021.106569","article-title":"Controversy Surrounding the Sputnik V Vaccine","volume":"187","author":"Cazzola","year":"2021","journal-title":"Respir. Med."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Ruggiero, M., Mercurio, N., Ferrante, L., Scudiero, O., and Mazzeo, F. (2026). Craft Non-Alcoholic and Low-Alcohol Beer (NABLAB): Perceived Role as Functional Foods Among Italian Consumers and a Focus on Benefits for Well-Being and Physical Activity. Nutrients, 18.","DOI":"10.3390\/nu18010033"},{"key":"ref_25","unstructured":"WADA (2025, December 30). The Prohibited List 2025. Available online: https:\/\/www.wada-ama.org\/en\/prohibited-list."},{"key":"ref_26","first-page":"1669","article-title":"Development of Doping in Sports: Overview and Analysis","volume":"18","author":"Mazzeo","year":"2018","journal-title":"J. Phys. Educ. Sport"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"52","DOI":"10.2174\/187152312803476255","article-title":"Clinical Pharmacology of Non-Steroidal Anti-Inflammatory Drugs: A Review","volume":"11","author":"Bacchi","year":"2012","journal-title":"Anti-Inflamm. Anti-Allergy Agents Med. Chem."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1136\/bjsm.2009.059980","article-title":"Non-Steroidal Anti-Inflammatory Drugs in Sports Medicine: Guidelines for Practical but Sensible Use","volume":"43","author":"Paoloni","year":"2009","journal-title":"Br. J. Sports Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"113598","DOI":"10.1016\/j.fct.2022.113598","article-title":"Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): A Current Insight into Its Molecular Mechanism Eliciting Organ Toxicities","volume":"172","author":"Panchal","year":"2023","journal-title":"Food Chem. Toxicol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1007\/s12325-011-0100-7","article-title":"5-Lipoxygenase Metabolic Contributions to NSAID-Induced Organ Toxicity","volume":"29","author":"Burnett","year":"2012","journal-title":"Adv. Ther."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1016\/j.therap.2018.11.002","article-title":"Pharmacoepidemiology of Non-Steroidal Anti-Inflammatory Drugs","volume":"74","author":"Moore","year":"2019","journal-title":"Therapies"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"S29","DOI":"10.1194\/jlr.R800042-JLR200","article-title":"Cyclooxygenases: Structural and Functional Insights","volume":"50","author":"Rouzer","year":"2009","journal-title":"J. Lipid Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1949","DOI":"10.3390\/ph3061949","article-title":"Non-Steroidal Anti-Inflammatory Drugs and Brain Inflammation: Effects on Microglial Functions","volume":"3","author":"Bernardo","year":"2010","journal-title":"Pharmaceuticals"},{"key":"ref_34","first-page":"i4857","article-title":"Non-Steroidal Anti-Inflammatory Drugs and Risk of Heart Failure in Four European Countries: Nested Case-Control Study","volume":"354","author":"Scotti","year":"2016","journal-title":"BMJ"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Dhanjal, J.K., Sreenidhi, A.K., Bafna, K., Katiyar, S.P., Goyal, S., Grover, A., and Sundar, D. (2015). Computational Structure-Based De Novo Design of Hypothetical Inhibitors against the Anti- Inflammatory Target COX-2. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0134691"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1021\/acs.biochem.7b01019","article-title":"Molecular Mechanisms in the Selectivity of Nonsteroidal Anti-Inflammatory Drugs","volume":"57","author":"Shamsudin","year":"2018","journal-title":"Biochemistry"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"143","DOI":"10.14336\/AD.2017.0306","article-title":"A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly","volume":"9","author":"Wongrakpanich","year":"2018","journal-title":"Aging Dis."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"105","DOI":"10.2147\/JPR.S75160","article-title":"New Insights into the Use of Currently Available Non-Steroidal Anti-Inflammatory Drugs","volume":"8","author":"Brune","year":"2015","journal-title":"J. Pain Res."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1097\/FPC.0000000000000186","article-title":"CYP2C9 Variants as a Risk Modifier of NSAID-Related Gastrointestinal Bleeding: A Case\u2013Control Study","volume":"26","author":"Figueiras","year":"2016","journal-title":"Pharmacogenet. Genom."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1007\/s40272-013-0031-7","article-title":"Clinical Pharmacology of Indomethacin in Preterm Infants: Implications in Patent Ductus Arteriosus Closure","volume":"15","author":"Pacifici","year":"2013","journal-title":"Pediatr. Drugs"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1016\/j.pharmthera.2012.12.007","article-title":"Cytochrome P450 Enzymes in Drug Metabolism: Regulation of Gene Expression, Enzyme Activities, and Impact of Genetic Variation","volume":"138","author":"Zanger","year":"2013","journal-title":"Pharmacol. Ther."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"E715","DOI":"10.1073\/pnas.1715035115","article-title":"Ibuprofen Alters Human Testicular Physiology to Produce a State of Compensated Hypogonadism","volume":"115","author":"Kristensen","year":"2018","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"4S","DOI":"10.1016\/S0002-9343(00)00627-6","article-title":"Nonsteroidal Anti-Inflammatory Drug Prescribing: Past, Present, and Future","volume":"110","author":"Jones","year":"2001","journal-title":"Am. J. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1097\/00042752-199701000-00002","article-title":"Efficacy of Naproxen Sodium for Exercise-Induced Dysfunction Muscle Injury and Soreness","volume":"7","author":"Dudley","year":"1997","journal-title":"Clin. J. Sport Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"963","DOI":"10.1359\/jbmr.2002.17.6.963","article-title":"Cyclo-Oxygenase 2 Function Is Essential for Bone Fracture Healing","volume":"17","author":"Simon","year":"2002","journal-title":"J. Bone Miner. Res."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1016\/S0002-9440(10)61199-6","article-title":"NS-398, a Cyclooxygenase-2-Specific Inhibitor, Delays Skeletal Muscle Healing by Decreasing Regeneration and Promoting Fibrosis","volume":"167","author":"Shen","year":"2005","journal-title":"Am. J. Pathol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"C475","DOI":"10.1152\/ajpcell.00088.2004","article-title":"The COX-2 Pathway Is Essential during Early Stages of Skeletal Muscle Regeneration","volume":"287","author":"Bondesen","year":"2004","journal-title":"Am. J. Physiol. Cell Physiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1164\/rccm.201210-1853PP","article-title":"Inhaled Corticosteroids in Lung Diseases","volume":"187","author":"Raissy","year":"2013","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1097\/JSM.0000000000000603","article-title":"Injectable Corticosteroids in Sport","volume":"28","author":"Olafsen","year":"2018","journal-title":"Clin. J. Sport Med."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1055\/s-0036-1594286","article-title":"Injectable Corticosteroids: Take Precautions and Use Caution","volume":"20","author":"Freire","year":"2016","journal-title":"Semin. Musculoskelet. Radiol."},{"key":"ref_51","first-page":"203","article-title":"Steroids: Pharmacology, Complications, and Practice Delivery Issues","volume":"14","author":"Kaye","year":"2014","journal-title":"Ochsner J."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"655","DOI":"10.4187\/respcare.06314","article-title":"Clinical Pharmacology of Corticosteroids","volume":"63","author":"Williams","year":"2018","journal-title":"Respir. Care"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1111\/bcp.12637","article-title":"Inhaled Corticosteroids: Potency, Dose Equivalence and Therapeutic Index","volume":"80","year":"2015","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1039","DOI":"10.1007\/s12098-008-0208-1","article-title":"Corticosteroid Physiology and Principles of Therapy","volume":"75","author":"Gupta","year":"2008","journal-title":"Indian J. Pediatr."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.steroids.2016.09.008","article-title":"Glucocorticoid Administration in Athletes: Performance, Metabolism and Detection","volume":"115","author":"Collomp","year":"2016","journal-title":"Steroids"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1016\/j.mce.2008.05.014","article-title":"Stimulation of Human Omental Adipose Tissue Lipolysis by Growth Hormone plus Dexamethasone","volume":"295","author":"Fain","year":"2008","journal-title":"Mol. Cell. Endocrinol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1055\/s-0030-1269919","article-title":"Short-Term Glucocorticoid Intake and Metabolic Responses During Long-Lasting Exercise","volume":"43","author":"Thomasson","year":"2011","journal-title":"Horm. Metab. Res."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"121","DOI":"10.3810\/psm.2010.10.1817","article-title":"Evidence on Ergogenic Action of Glucocorticoids as a Doping Agent Risk","volume":"38","author":"Duclos","year":"2010","journal-title":"Physician Sportsmed."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"895","DOI":"10.1139\/H07-064","article-title":"Cortisol and GH: Odd and Controversial Ideas","volume":"32","author":"Duclos","year":"2007","journal-title":"Appl. Physiol. Nutr. Metab."},{"key":"ref_60","first-page":"55","article-title":"How Do Glucocorticoids Influence Stress Responses? Integrating Permissive, Suppressive, Stimulatory, and Preparative Actions","volume":"21","author":"Sapolsky","year":"2000","journal-title":"Endocr. Rev."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1249\/00149619-200412000-00005","article-title":"Injections and Return to Play","volume":"3","author":"Dietzel","year":"2004","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1097\/01.jsm.0000179233.17885.18","article-title":"Complications Associated with the Use of Corticosteroids in the Treatment of Athletic Injuries","volume":"15","author":"Nichols","year":"2005","journal-title":"Clin. J. Sport Med."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1136\/bjsports-2020-103512","article-title":"A Novel Approach to Improve Detection of Glucocorticoid Doping in Sport with New Guidance for Physicians Prescribing for Athletes","volume":"55","author":"Ventura","year":"2021","journal-title":"Br. J. Sports Med."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Mazzeo, F., Meccariello, R., and Guatteo, E. (2023). Molecular and Epigenetic Aspects of Opioid Receptors in Drug Addiction and Pain Management in Sport. IJMS, 24.","DOI":"10.3390\/ijms24097831"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1146\/annurev-neuro-080317-061522","article-title":"Endogenous and Exogenous Opioids in Pain","volume":"41","author":"Corder","year":"2018","journal-title":"Annu. Rev. Neurosci."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1111\/bph.12618","article-title":"The Role of \u03b4-Opioid Receptors in Learning and Memory Underlying the Development of Addiction","volume":"172","author":"Klenowski","year":"2015","journal-title":"Br. J. Pharmacol."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1002\/jlcr.3005","article-title":"Positron Emission Tomography Radioligands for the Opioid System","volume":"56","author":"Dannals","year":"2013","journal-title":"J. Label. Comp. Radiopharm."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1124\/pr.114.008979","article-title":"Molecular Pharmacology of \u03b4-Opioid Receptors","volume":"68","author":"Gendron","year":"2016","journal-title":"Pharmacol. Rev."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1016\/j.cell.2022.12.026","article-title":"Structures of the Entire Human Opioid Receptor Family","volume":"186","author":"Wang","year":"2023","journal-title":"Cell"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1200\/EDBK_180469","article-title":"Pain and Opioids in Cancer Care: Benefits, Risks, and Alternatives","volume":"37","author":"Bennett","year":"2017","journal-title":"Am. Soc. Clin. Oncol. Educ. Book"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1277","DOI":"10.1212\/WNL.0000000000000839","article-title":"Opioids for Chronic Noncancer Pain: A Position Paper of the American Academy of Neurology","volume":"83","author":"Franklin","year":"2014","journal-title":"Neurology"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1097\/JSM.0000000000000604","article-title":"Analgesic Management of Pain in Elite Athletes: A Systematic Review","volume":"28","author":"Harle","year":"2018","journal-title":"Clin. J. Sport Med."},{"key":"ref_73","first-page":"CD007789","article-title":"Oral Non-Steroidal Anti-Inflammatory Drugs versus Other Oral Analgesic Agents for Acute Soft Tissue Injury","volume":"8","author":"Jones","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_74","unstructured":"WADA (2025, December 30). International Standard for Therapeutic Use Exemptions (ISTUE). Available online: https:\/\/www.wada-ama.org\/en\/resources\/world-anti-doping-code-and-international-standards\/international-standard-therapeutic-use#resource-download."},{"key":"ref_75","unstructured":"Ministero Della Salute (2025, December 30). Archivio Reporting System Doping Antidoping, Available online: https:\/\/www.salute.gov.it\/new\/it\/tema\/doping\/archivio-reporting-system-doping-antidoping\/."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1016\/j.jsams.2022.08.018","article-title":"Prevalence, Frequency, Adverse Events, and Reasons for Analgesic Use in Youth Athletes: A Systematic Review and Meta-Analysis of 44,381 Athletes","volume":"25","author":"Pedersen","year":"2022","journal-title":"J. Sci. Med. Sport"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1136\/bjsports-2015-094784","article-title":"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","volume":"49","author":"Tscholl","year":"2015","journal-title":"Br. J. Sports Med."},{"key":"ref_78","first-page":"795","article-title":"Improvement in Soccer Learning and Methodology for Young Athletes","volume":"19","author":"Montesano","year":"2019","journal-title":"J. Phys. Educ. Sport"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1186\/s40798-020-00247-w","article-title":"Effect of Non-Steroidal Anti-Inflammatory Drugs on Sport Performance Indices in Healthy People: A Meta-Analysis of Randomized Controlled Trials","volume":"6","author":"Cornu","year":"2020","journal-title":"Sports Med. Open"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1080\/00913847.2023.2220439","article-title":"Is Physical Performance Affected by Non-Steroidal Anti-Inflammatory Drugs Use? A Systematic Review and Meta-Analysis","volume":"52","author":"Pereira","year":"2024","journal-title":"Physician Sportsmed."},{"key":"ref_81","first-page":"e37080","article-title":"Effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Gastroprotective NSAIDs on the Gastrointestinal Tract: A Narrative Review","volume":"15","author":"Sohail","year":"2023","journal-title":"Cureus"},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1016\/j.semarthrit.2008.08.001","article-title":"Nonsteroidal Anti-Inflammatory Drugs: Adverse Effects and Their Prevention","volume":"39","author":"Vonkeman","year":"2010","journal-title":"Semin. Arthritis Rheum."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1007\/s11894-008-0089-5","article-title":"Adverse Effects of Nonsteroidal Anti-Inflammatory Drugs on the Colon","volume":"10","author":"Ballinger","year":"2008","journal-title":"Curr. Gastroenterol. Rep."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/S0002-9343(99)00365-4","article-title":"Profile and Mechanisms of Gastrointestinal and Other Side Effects of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)","volume":"107","author":"Rainsford","year":"1999","journal-title":"Am. J. Med."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"3","DOI":"10.21037\/aoj-23-58","article-title":"The Effect of Nonsteroidal Anti-Inflammatory Drug Use on Soft Tissue and Bone Healing in the Knee: A Systematic Review","volume":"9","author":"Solaiman","year":"2024","journal-title":"Ann. Jt."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1023\/B:INFL.0000041130.58342.15","article-title":"NSAID-Induced Gastrointestinal Damage: The Biochemical Consequences of the \u201cion Trapping\u201d Hypothesis","volume":"8","author":"Sigthorsson","year":"2000","journal-title":"Inflammopharmacology"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"1421","DOI":"10.1211\/jpp.58.10.0001","article-title":"NSAID Injury to the Gastrointestinal Tract: Evidence That NSAIDs Interact with Phospholipids to Weaken the Hydrophobic Surface Barrier and Induce the Formation of Unstable Pores in Membranes","volume":"58","author":"Lichtenberger","year":"2006","journal-title":"J. Pharm. Pharmacol."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1016\/j.freeradbiomed.2013.07.027","article-title":"Nonsteroidal Anti-Inflammatory Drug Induces Proinflammatory Damage in Gastric Mucosa through NF-\u03baB Activation and Neutrophil Infiltration: Anti-Inflammatory Role of Heme Oxygenase-1 against Nonsteroidal Anti-Inflammatory Drug","volume":"65","author":"Bindu","year":"2013","journal-title":"Free Radic. Biol. Med."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1002\/eji.201445222","article-title":"NSAIDs: Learning New Tricks from Old Drugs","volume":"45","year":"2015","journal-title":"Eur. J. Immunol."},{"key":"ref_90","doi-asserted-by":"crossref","unstructured":"Coxib and traditional NSAID Trialists\u2019 (CNT) Collaboration, Bhala, N., Emberson, J., Merhi, A., Abramson, S., Arber, N., Baron, J.A., Bombardier, C., Cannon, C., and Farkouh, M.E. (2013). Vascular and Upper Gastrointestinal Effects of Non-Steroidal Anti-Inflammatory Drugs: Meta-Analyses of Individual Participant Data from Randomised Trials. Lancet, 382, 769\u2013779.","DOI":"10.1016\/S0140-6736(13)60900-9"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"114147","DOI":"10.1016\/j.bcp.2020.114147","article-title":"Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Organ Damage: A Current Perspective","volume":"180","author":"Bindu","year":"2020","journal-title":"Biochem. Pharmacol."},{"key":"ref_92","doi-asserted-by":"crossref","unstructured":"Bensman, A. (2020). Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Systemic Use: The Risk of Renal Failure. Front. Pediatr., 7.","DOI":"10.3389\/fped.2019.00517"},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"536962","DOI":"10.1155\/2015\/536962","article-title":"NSAIDs and Cardiovascular Diseases: Role of Reactive Oxygen Species","volume":"2015","author":"Ghosh","year":"2015","journal-title":"Oxidative Med. Cell. Longev."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"k3426","DOI":"10.1136\/bmj.k3426","article-title":"Diclofenac Use and Cardiovascular Risks: Series of Nationwide Cohort Studies","volume":"362","author":"Schmidt","year":"2018","journal-title":"BMJ"},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.addbeh.2017.02.008","article-title":"Identification of Non-Steroidal Anti-Inflammatory Drug Use Disorder: A Case Report","volume":"70","author":"Godersky","year":"2017","journal-title":"Addict. Behav."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1016\/j.jsams.2024.11.010","article-title":"The Use of Pain Killers (NSAIDs) in Athletes: How Large Is the Risk?","volume":"28","author":"Fitzpatrick","year":"2025","journal-title":"J. Sci. Med. Sport"},{"key":"ref_97","doi-asserted-by":"crossref","unstructured":"Ruggiero, M., Ferrante, L., Tafuri, D., Meccariello, R., and Mazzeo, F. (2025). Trends in Antidepressant, Anxiolytic, and Cannabinoid Use Among Italian Elite Athletes (2011\u20132023): A Longitudinal Anti-Doping Analysis. Sports, 13.","DOI":"10.3390\/sports13070233"},{"key":"ref_98","unstructured":"WADA (2025, December 30). Prohibited List 2022. Available online: https:\/\/www.wada-ama.org\/sites\/default\/files\/2022-01\/2022list_final_en_0.pdf."},{"key":"ref_99","unstructured":"WADA (2025, December 30). Prohibited List 2026. Available online: https:\/\/www.wada-ama.org\/sites\/default\/files\/2025-09\/2026list_en_final_clean_september_2025.pdf."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1186\/1710-1492-9-30","article-title":"A Practical Guide to the Monitoring and Management of the Complications of Systemic Corticosteroid Therapy","volume":"9","author":"Liu","year":"2013","journal-title":"Allergy Asthma Clin. Immunol."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"j1415","DOI":"10.1136\/bmj.j1415","article-title":"Short Term Use of Oral Corticosteroids and Related Harms among Adults in the United States: Population Based Cohort Study","volume":"357","author":"Waljee","year":"2017","journal-title":"BMJ"},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1002\/pmrj.12042","article-title":"Systemic Absorption and Side Effects of Locally Injected Glucocorticoids","volume":"11","author":"Stout","year":"2019","journal-title":"PM R"},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"e2","DOI":"10.2106\/JBJS.RVW.16.00004","article-title":"Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections","volume":"4","author":"Honcharuk","year":"2016","journal-title":"JBJS Rev."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"101169","DOI":"10.1016\/j.asmr.2025.101169","article-title":"Risks of Intra-Articular Hip Corticosteroid Injections Include Rapidly Progressive Osteoarthritis and Femoral Head Collapse in Patients With and Without Pre-Existing Osteoarthritis: A Systematic Review","volume":"7","author":"Parry","year":"2025","journal-title":"Arthrosc. Sports Med. Rehabil."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1016\/0163-7258(93)90049-J","article-title":"Clinical Pharmacology of Corticosteroids in Bronchial Asthma","volume":"58","author":"Lipworth","year":"1993","journal-title":"Pharmacol. Ther."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"66","DOI":"10.12659\/AOT.906164","article-title":"Pharmacokinetic Drug-Drug Interactions Between Immunosuppressant and Anti-Infective Agents: Antimetabolites and Corticosteroids","volume":"23","author":"Satyanarayana","year":"2018","journal-title":"Ann. Transplant."},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"534","DOI":"10.1177\/1941738120933542","article-title":"Opioid Use in Athletes: A Systematic Review","volume":"12","author":"Ekhtiari","year":"2020","journal-title":"Sports Health"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"100415","DOI":"10.1016\/j.apunsm.2023.100415","article-title":"Use of Analgesics in Professional Soccer Players: A Systematic Review","volume":"58","author":"Zandonai","year":"2023","journal-title":"Apunt. Sports Med."},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"866","DOI":"10.1111\/bcp.16333","article-title":"Ten-year Analgesic Utilization Patterns and Economic Implications in Portugal","volume":"91","author":"Duarte","year":"2025","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"567","DOI":"10.15585\/mmwr.mm7325a1","article-title":"Treatment for Opioid Use Disorder: Population Estimates\u2014United States, 2022","volume":"73","author":"Dowell","year":"2024","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_111","doi-asserted-by":"crossref","unstructured":"Zandonai, T., Escorial, M., and Peir\u00f3, A.M. (2021). Codeine and Tramadol Use in Athletes: A Potential for Abuse. Front. Pharmacol., 12.","DOI":"10.3389\/fphar.2021.661781"},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"1483","DOI":"10.1001\/jama.2021.14306","article-title":"Tramadol, Codeine, and Risk of Adverse Outcomes","volume":"326","author":"Kim","year":"2021","journal-title":"JAMA"},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1016\/j.jsams.2017.10.032","article-title":"Tramadol Effects on Physical Performance and Sustained Attention during a 20-Min Indoor Cycling Time-Trial: A Randomised Controlled Trial","volume":"21","author":"Holgado","year":"2018","journal-title":"J. Sci. Med. Sport"},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"1169","DOI":"10.1249\/MSS.0000000000002217","article-title":"Tramadol Does Not Improve Performance or Impair Motor Function in Trained Cyclists","volume":"52","author":"Bejder","year":"2020","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"115","DOI":"10.12996\/gmj.2024.4219","article-title":"Examining the Effects of Tramadol, on the WADA Prohibited List, on Sports Performance","volume":"36","year":"2025","journal-title":"Gazi Med. J."},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/j.biopha.2015.01.022","article-title":"Tramadol Hydrochloride: Pharmacokinetics, Pharmacodynamics, Adverse Side Effects, Co-Administration of Drugs and New Drug Delivery Systems","volume":"70","author":"Vazzana","year":"2015","journal-title":"Biomed. Pharmacother."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/j.biopsych.2019.06.027","article-title":"Epigenetic Mechanisms of Opioid Addiction","volume":"87","author":"Browne","year":"2020","journal-title":"Biol. Psychiatry"},{"key":"ref_118","doi-asserted-by":"crossref","first-page":"105069","DOI":"10.1016\/j.neuint.2021.105069","article-title":"Epigenetics of Addiction","volume":"147","author":"Cadet","year":"2021","journal-title":"Neurochem. Int."},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"108215","DOI":"10.1016\/j.pharmthera.2022.108215","article-title":"MicroRNAs in Drug Addiction: Current Status and Future Perspectives","volume":"236","author":"Zhao","year":"2022","journal-title":"Pharmacol. Ther."},{"key":"ref_120","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1097\/AJP.0b013e31816b2f26","article-title":"Efficacy of Opioids for Chronic Pain: A Review of the Evidence","volume":"24","author":"Ballantyne","year":"2008","journal-title":"Clin. J. Pain"},{"key":"ref_121","doi-asserted-by":"crossref","unstructured":"Paul, A.K., Smith, C.M., Rahmatullah, M., Nissapatorn, V., Wilairatana, P., Spetea, M., Gueven, N., and Dietis, N. (2021). Opioid Analgesia and Opioid-Induced Adverse Effects: A Review. Pharmaceuticals, 14.","DOI":"10.3390\/ph14111091"},{"key":"ref_122","doi-asserted-by":"crossref","first-page":"2788","DOI":"10.1523\/JNEUROSCI.4331-05.2006","article-title":"Properties and Opioid Inhibition of Mesolimbic Dopamine Neurons Vary According to Target Location","volume":"26","author":"Ford","year":"2006","journal-title":"J. Neurosci."},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1016\/0165-6147(92)90060-J","article-title":"Drugs of Abuse: Anatomy, Pharmacology and Function of Reward Pathways","volume":"13","author":"Koob","year":"1992","journal-title":"Trends Pharmacol. Sci."},{"key":"ref_124","doi-asserted-by":"crossref","unstructured":"D\u2019Errico, A., Nasso, R., Ruggiero, M., Rullo, R., De Vendittis, E., Masullo, M., Mazzeo, F., and Arcone, R. (2026). Polyphenol-Enriched Extracts from Leaves of Mediterranean Plants as Natural Inhibitors of Monoamine Oxidase (MAO)-A and MAO-B Enzymes. Nutrients, 18.","DOI":"10.3390\/nu18010022"},{"key":"ref_125","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1002\/ana.10465","article-title":"\u03bc Opioid Receptors and Analgesia at the Site of a Peripheral Nerve Injury","volume":"53","author":"Truong","year":"2003","journal-title":"Ann. Neurol."},{"key":"ref_126","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1038\/ajgsup.2014.5","article-title":"Molecular Physiology of Enteric Opioid Receptors","volume":"2","author":"Galligan","year":"2014","journal-title":"Am. J. Gastroenterol. Suppl."},{"key":"ref_127","doi-asserted-by":"crossref","first-page":"237","DOI":"10.36076\/ppj.2008\/11\/237","article-title":"Variations in Opioid Responsiveness","volume":"11","author":"Smith","year":"2008","journal-title":"Pain Physician"},{"key":"ref_128","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1002\/phar.1986","article-title":"Review of Opioid Pharmacogenetics and Considerations for Pain Management","volume":"37","author":"Hamadeh","year":"2017","journal-title":"Pharmacotherapy"},{"key":"ref_129","doi-asserted-by":"crossref","first-page":"888","DOI":"10.1002\/cpt.2149","article-title":"Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2D6, OPRM1, and COMT Genotypes and Select Opioid Therapy","volume":"110","author":"Crews","year":"2021","journal-title":"Clin. Pharmacol. Ther."},{"key":"ref_130","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/S0140-6736(21)01653-6","article-title":"A Time of Crisis for the Opioid Epidemic in the USA","volume":"398","author":"Lancet","year":"2021","journal-title":"Lancet"},{"key":"ref_131","unstructured":"Hoffman, B. (2026, February 06). 22 Years for Angels Employee Who Gave Drugs to Pitcher. New York Times 2022. Available online: https:\/\/go.gale.com\/ps\/i.do?p=AONE&u=anon~3b5cb372&id=GALE%7CA721916795&v=2.1&it=r&sid=googleScholar&asid=c5a4e510."}],"container-title":["Pharmaceuticals"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8247\/19\/2\/298\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T11:25:50Z","timestamp":1770809150000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8247\/19\/2\/298"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,11]]},"references-count":131,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["ph19020298"],"URL":"https:\/\/doi.org\/10.3390\/ph19020298","relation":{},"ISSN":["1424-8247"],"issn-type":[{"value":"1424-8247","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,11]]}}}