The sports world can be represented as a continuum of rule-based play involving at least some physical activity and skills, ranging from improvised soccer on the school playground all the way to elite sports at Olympic level. Whereas recreational sports are often promoted for public health reasons, elite sports, affecting only a small fraction of the population, drives for maximization of performance at a potential health cost [1, 2]. Hence, recreational and elite athletes inhabit distinct socio-cultural, medical, and regulatory environments. Since the inception of the World Anti-Doping Agency (WADA) in 1999, an international regulatory framework restricts the use of various methods and substances in elite-level sports because they may enhance performance, represent a potential health risk and/or are against the ‘spirit of sport’ [3]. Since athletes can also have health issues necessitating treatment, exceptions can be made through so-called strictly regulated Therapeutic Use Exemptions (TUEs) [4]. Despite some regulatory restrictions, however, use of medication by recreational athletes, or outside of sports by gym and fitness goers is not uncommon and rather tolerated by society [5, 6]. In the present special issue of <i>Sports Psychiatry</i>, a series of articles discusses some of the socio-cultural, medical, and regulatory issues related to the similarities and differences of substance use between recreational and elite sports. Collectively these articles advocate for a more “health-based” approach, especially in recreational sport. In addition, instead of the current prohibitive zero-tolerance punitive environment created by the anti-doping movement for elite sport – which increasingly encroaches into recreational sport and the gym and fitness realm –, arguments are presented in favour of fostering individual physical and mental health and of promoting unstigmatized access to necessary treatment, including for those who tested positive for doping use.