Nearly half of tested Italian elite athletes declared an anti-inflammatory drug

Anti-doping programmes exist to catch prohibited substances. A side effect is that they generate one of the few systematic records of what elite athletes take that is entirely permitted. A study published in Pharmaceuticals on 11 February works that record for a decade of Italian data, and the picture it produces is of a population managing pain pharmacologically at rates far above the general public — legally, consistently, and without much sign of change [s1].

The analysis draws on the annual anti-doping reports published within the Italian Ministry of Health's Reporting System Doping Antidoping Archives, covering athletes tested at events organised by the national federations, associated disciplines and sports promotion bodies, from 2013 to the first half of 2023 [s1].

The numbers

Across the period, 9,882 athletes underwent doping tests, an annual average of 898.36 [s1]. Of those, 4,292 declared use of a non-steroidal anti-inflammatory drug at the time of testing — an annual average of 45.34% [s1].

Anti-doping analyses identified 430 prohibited substances over the period, an annual average of 39.09 cases [s1]. Within that total, glucocorticoid findings amounted to 51 cases, an annual average of 0.50% of tested athletes, while narcotic findings numbered three, an annual average of 0.03% [s1]. Expressed as a share of all prohibited-substance findings, glucocorticoids averaged 12.97% and narcotics 0.91% [s1].

Temporal trends were tested with the Cochran–Armitage test. There was no evidence of a linear trend in the overall proportion of tested athletes self-reporting any NSAID use (χ²(1) = 0.207, p = 0.649) [s1]. Nor was there evidence of a linear trend in the proportion with an adverse analytical finding for glucocorticoids (χ²(1) = 0.008, p = 0.927) [s1].

What did change was which anti-inflammatory. The proportion of tested athletes reporting COX-2 selective agents showed a significant decreasing linear trend (χ²(1) = 10.083, p = 0.002), while non-selective NSAIDs showed no trend (χ²(1) = 1.881, p = 0.170) [s1]. Among athletes who reported any NSAID use, the share reporting a COX-2 selective drug also decreased significantly (χ²(1) = 10.665, p = 0.001), meaning non-selective agents came to dominate the NSAID-using group [s1].

By active ingredient, ketoprofen and ibuprofen appear consistently among the most frequently reported non-selective agents, followed by diclofenac and nimesulide, with celecoxib and etoricoxib showing lower but stable frequencies among the selective agents [s1]. Among glucocorticoid findings, betamethasone was the most frequently detected, followed by prednisolone and prednisone, with sporadic findings of methylprednisolone and triamcinolone [s1]. Only two narcotics appeared at all across the decade: methadone and oxycodone [s1].

Why the comparison between classes is not what it looks like

The paper's most important methodological point is one it states about itself. NSAID data reflect athlete declarations — voluntary reports of a permitted medication. Glucocorticoid and narcotic data reflect adverse analytical findings — instances where in-competition rules were broken [s1]. These are not comparable measures of use, and the authors say so: the dataset cannot yield a single estimate of total analgesic prevalence [s1].

The consequence is that the low narcotic numbers do not mean athletes are not taking opioids. Codeine and tramadol do not appear in the findings tables because they are not on the WADA Prohibited List and therefore cannot generate a violation [s1]. The authors note explicitly that use of non-prohibited opioids such as tramadol and codeine remains relevant for understanding analgesic practices and is absent from official reports [s1].

Two further limits. The data capture only substances detected during official testing, not therapeutic use outside the in-competition window [s1]. And the series stops at the first half of 2023, which means the effect of WADA's 2022 regulatory change — the prohibition of all injectable glucocorticoid routes in competition — cannot yet be assessed from it [s1].

The clinical context

The reason nearly half of a tested population declares an anti-inflammatory is not mysterious. The paper cites epidemiological estimates putting musculoskeletal pain prevalence in athletes at 30% to over 60%, depending on sport, training load and assessment method, and daily NSAID use among elite athletes at 25–35% against 1–4% in the general population [s1].

NSAIDs are permitted because current evidence indicates they do not enhance performance [s1]. The authors argue that this regulatory permission supports not only therapeutic use but routine or prophylactic administration before training and competition — while noting the documented risks of gastrointestinal, renal and cardiovascular adverse effects, and evidence that NSAIDs may impair healing in specific musculoskeletal injuries [s1].

Glucocorticoids sit on the other side of the line. They are prohibited in competition on the basis of documented performance-enhancing potential, with WADA operating washout periods and urinary reporting levels rather than an outright therapeutic ban [s1]. Their risks in athletes include tendon rupture and cartilage damage [s1].

A registry review published in Drug Design, Development and Therapy on 2 February gives a parallel view from the trial side. Analysing 426 adult sport-injury trials registered on ClinicalTrials.gov as of 13 March 2025, the authors identified 20 pharmacological agents; NSAIDs and local anaesthetics were the predominant classes, most agents were permitted under WADA rules when used by appropriate routes, and systemic corticosteroids were restricted during competition [s2]. Their conclusion — that route-specific prescribing is the operative concern — mirrors what the Italian findings show, where the substance detected matters less than how it was given and when [s2].

What to watch

Whether Italian reports covering 2023 onward show any detectable shift in glucocorticoid findings following the 2022 injectable ban, which the authors identify as the open question their data cannot answer [s1]. And whether anti-doping reporting systems ever begin capturing permitted opioids, without which the analgesic picture in elite sport stays structurally incomplete [s1].

Sources

1. [s1] Pain Management in Italian Elite Athletes: Trends in the Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Glucocorticoids, and Narcotics in Anti-Doping Reports (2013-2023). Pharmaceuticals, published online 11 February 2026. https://doi.org/10.3390/ph19020298
2. [s2] Pharmacological Interventions in the Management of Sports Injuries: A Review of Clinical Use, Dosage Forms, and Anti-Doping Considerations. Drug Design, Development and Therapy, 2 February 2026. https://doi.org/10.2147/dddt.s587793