ADHD IN ELITE ATHLETES: PHARMACOLOGICAL TREATMENT, TUE AND STIMULANT MISUSE RISK

Abstract

Background. Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition that frequently persists into adolescence and adulthood, affecting attention regulation, impulsivity, emotional control, sleep and overall functioning. In elite/competitive sport, these domains are tightly linked to training adherence, tactical decision-making, injury risk and recovery. Pharmacotherapy is one of the most effective evidence-based treatments for ADHD, yet in high-performance sport it must be implemented within additional constraints: potential cardiovascular and sleep-related adverse effects under heavy training load, elevated risk of non-medical use and diversion of prescription stimulants in athlete-adjacent environments and anti-doping regulations that may require a Therapeutic Use Exemption (TUE) for prohibited stimulant medications.

Aim: To summarize evidence and practical guidance on pharmacological treatment of ADHD in elite/competitive athletes with specific focus on medication selection and monitoring under high training demands, TUE and anti-doping compliance, and prevention and management of stimulant misuse/diversion risk.

Materials and Methods: A narrative literature review was conducted using a structured search strategy in PubMed/MEDLINE, supplemented by targeted retrieval of relevant World Anti-Doping Agency (WADA) TUE/ISTUE documents. The search covered the period from January 2011 to January 2026. The final search was executed on 16 February 2026. Eligible publications included original research, systematic reviews/meta-analyses, and regulatory guidance addressing ADHD pharmacotherapy, athlete contexts, TUE/anti-doping implications, and/or stimulant misuse/diversion.

Results: The evidence supports that core pharmacotherapy principles for ADHD are broadly similar in athletes and non-athletes; however, elite sport requires additional implementation safeguards. Stimulants remain highly effective for symptom control but warrant careful monitoring of heart rate/blood pressure, sleep, appetite/energy availability, and anxiety—particularly during titration and high-load training periods. Non-stimulants (e.g., atomoxetine; selected cases guanfacine) may be appropriate when stimulants are not tolerated, contraindicated or when misuse/diversion risk is high. In tested sport, clinically necessary stimulant use often necessitates early, well-documented TUE planning to avoid inconsistencies between prescribing and regulatory submissions. Misuse and diversion are most commonly documented in young adult and collegiate settings, where sport-relevant drivers such as performance pressure, peer “sharing,” and weight-control motives may be present; this highlights the need for proactive education, secure storage, and structured follow-up.

Conclusions: ADHD pharmacotherapy can be appropriate and beneficial in elite athletes, but it must be embedded in a sport-specific framework that integrates safety monitoring, stable competition-period planning, anti-doping/TUE documentation, and misuse/diversion risk mitigation. High-quality athlete-specific comparative studies - particularly stimulant versus non-stimulant strategies using objective outcomes - remain a key research priority.