Performance-Enhancing Drugs: A New Reality in Sports?
Doping violates the spirit of sports and is dangerous.
Doping violates the spirit of sports and is dangerous.
A-Rod … Lance Armstrong … These athletes made headline news because they covertly used pharmaceuticals to improve performance, commonly known as doping.1 A-Rod and Lance aren’t alone. They just represent the most recent and very public scandals. By doping, athletes violate the World Anti-Doping Agency’s (WADA’s) regulation forbidding use of pharmaceutical products in competitive sports. WADA’s World Anti-Doping Code includes drug lists describing what is not acceptable—and what is—in a number of sports. The National Collegiate Athletic Association (NCAA) also publishes a list of banned performance-enhancing substances (PESs) annually.2 Table 1 enumerates some reasons why athletes ignore the rules.
Sports: Our Obsession, Athletes’ Angst
Sponsors and fans routinely spend millions of dollars on sports and the hoopla that surrounds it—advertising, parties, and items that carry a favorite team’s brand. Winning athletes are rewarded with recognition, scholarships, and lucrative contracts; second place is often considered “first loser.”6 Coaches’ jobs depend on a team’s success.7-9 Consequently, athletes and coaches will risk a great deal to obtain a competitive edge and enhance performance.
How much will they risk? Sports Illustrated interviewed a cohort of elite Olympic athletes, asking, “If you were given a performance-enhancing substance, you would not be caught, and you would win, would you take it?”
Ninety-eight percent of athletes answered yes. When they changed the question to, “If you were given a performance-enhancing substance, and you would not be caught, win all competitions for 5 years, then die, would you take it?” More than 50% still said yes.10,11
Doping is controversial mainly because the medical community has not defined where restoration of normative function ends and performance enhancement begins. Those opposed to doping contend that it undermines the traditional principle of a level playing field and creates unnecessary health risks. Supporters maintain that medical practitioners’ concerns about long-term health effects are unwarranted and that athletes who are informed about possible adverse effects should be able to make an informed decision.5,12
Testing: A Cat-and-Mouse Game
Six of 10 Olympic athletes use PESs.13 To address possible doping, WADA tests the first 5 athletes who finish any event, and 2 others randomly. The agency also holds blood samples for 8 years and retests them as new technologies become available.13 In contrast, professional sports in the United States avoid extensive antidoping programs—players’ unions and collective bargaining agreements prevent extensive testing.14,15
Antidoping programs rely on testing, The ability to detect drug misuse is limited: many athletes know the pharmacokinetics and pharmacology of the drugs they take better than a third-year pharmacy student does. They time their doses and use masking agents to circumvent detection.12
Doping is not limited to professional sports. Increasingly, public health officials are concerned that amateur and recreational athletes are also doping.4,16,17 Some of these athletes are children.1,16,18 Ironically, male college athletes who use PESs are also more likely to use social/recreational drugs, despite personal and anecdotal evidence clearly showing their negative effects on athletic performance.19 And like professional athletes, they are likely to engage in “stacking,” the sports world’s word for polypharmacy with PESs.20
Increasing oxygen delivery to active muscles—especially by increasing the number of red blood cells—is the most effective way to increase aerobic performance.3 For this reason, blood doping and using erythropoietin products are common among cyclists and other endurance athletes. Online Table 2 describes the drugs and techniques that athletes use illicitly most often. Anabolic steroids are the most commonly abused substances, and many athletes receive dosing recommendations from coaches, other athletes, online discussion groups, and Internet vendors.5 Some receive the drugs without their knowledge or consent; coaches may give athletes supplements without revealing that they contain drugs.21 Many websites imply that steroids are safe, often claiming that unskilled physicians, biased researchers, and government bureaucrats inflate their dangers.5
Table 2: Frequently Abused Performance-Enhancing Substances
Drugs and Notes
Amphetamines (intensify alertness, concentration, and self-confidence)
- Long-term administration associated with growth retardation in adolescents and myocardial pathology
- High chronic doses may lead to persistent personality changes (eg, amphetamine psychosis)
Cannabinoids (recreational relaxation, stress relief)
- Marijuana, hashish
- Modafinal and adrafinil
- Marketed as having low abuse liability and fewer side effects (eg, insomnia, anxiety, agitation)
Hormones and related substances
- hGH, testosterone
- Some athletes believe that hGH is as effective as anabolic steroids for stimulating skeletal muscle growth and promoting rapid recovery after intensive training, with fewer side effects
Narcotics (eg, morphine, oxycodone) and analgesics
- Used for pain relief
- Nonmedical use of prescription opioids is highest in high-injury sports
- Many professional athletes remain addicted to opioid analgesics after leaving their sport
Stimulants (eg, amphetamines, ephedrine, cocaine)
- Stimulants are often used by student athletes in high-contact sports to boost energy for handling academic commitments and remaining eligible for competition
Archery, billiards, pistol shooting
Beta-blockers (reduce tremor)
- In endurance sports, beta-blockers adversely affect performance
- Clenbuterol is also used as an anorectic
- Inhaled beta-blockers may be allowed
Endurance sports, especially track and field and cycling
Oxygen enhancement (eg, blood doping, erythropoiesis
- Traditionally, athletes saved and reinfused their own red blood cells
- Sleep chambers that mimic high—altitude environments are used to stimulate red blood cell production
- Erythropoietin is abused
Endurance sports, weight lifting
Glucocorticosteroids (allowed externally, but not internally; generally called steroids) and anabolic—androgenic steroids
- Help decrease inflammation
- Increase muscle mass and alter appearance
- Needle sharing of injectable steroids increases risk for infection with HIV or hepatitis
- A new trend to avoid apprehension is to purchase cattle implants that contain anabolic drugs and estrogen, and then extract the estrogen using directions available on the Internet
Wrestling, gymnastics, horse racing (for the jockey)
Diuretics (weight loss or fluid retention)
- Used to meet weight-class limits
- Modify urine excretion rate of prohibited drugs
- Overcome fluid retention as a consequence of anabolic steroid use
hGH = human growth hormone.
Adapted from references 3-5, 18, 22-25.
High Doses, Serious Sequelae
PESs have many harmful consequences that many athletes experience. Pharmacists must keep in mind that athletes may use these drugs at doses well beyond those used in therapeutic settings. Some serious consequences can result, including irreversible androgenic/anabolic effects, toxic hepatitis, withdrawal, dependence, body dysmorphic disorders, depression, aggression, the unmasking or acceleration of cancer growth, diabetes mellitus, dyslipidemias, cardiomyopathy, and nephrotoxicity. Steroids are associated with recurrent hepatitis, cholestasis, hemorrhage, or hepatoma in some individuals. Additionally, products obtained from illicit sources may contain toxic contaminants.20
Health care professionals need to fully understand the complexity of PESs (eg, their physiologic and psychotropic properties, individual characteristics, different drugs and doses), acknowledging that each athlete’s biology is unique. Pharmacists should be aware that Internet information can strongly influence vulnerable athletes’ decisions. PESs offer temporary glory or improved appearance, but their long-term effects are considerable and dangerous.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy with interests in medical history and how society views and addresses issues related to prescription drugs.
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- NCAA banned drug classes 2012. National Collegiate Athletic Association website. www.ncaa.org/health-and-safety/policy/drug-testing. Accessed January 15, 2014.
- Sawka MN, Joyner MJ, Miles DS, Robertson RJ, Spriet LL, Young AJ. American College of Sports Medicine position stand: the use of blood doping as an ergogenic aid. Med Sci Sports Exerc. 1996;28:i-viii.
- Angell PJ, Chester N, Sculthorpe N, Whyte G, George K, Somauroo J. Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. Br J Sports Med. 2012;46(suppl 1):i78-i84.
- Brennan BP, Kanayama G, Pope HG Jr. Performance-enhancing drugs on the web: a growing public-health issue. Am J Addict. 2013;22:158-161.
- Popik B. Second place is the first loser. www.barrypopik.com/index.php/new_york_city/entry/second_place_is_the_first_loser_sports_adage/. Accessed January 14, 2014.
- Coaches fall. Crain’s Detroit Business. January 2, 2006. General OneFile website. Accessed January 15, 2014.
- Shuit DP. Sideline business: part 2 of 2. Workforce Management. August 1, 2005. General OneFile website. Accessed January 15, 2014.
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- Baron DA, Martin DM, Abol Magd S. Doping in sports and its spread to at-risk populations: an international review. World Psychiatry. 2007;6:118-123.
- Bamberger M, Yaeger D. Over the edge. Sports Illustrated. 1997;14:62-70.
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- Botrè F, Wu M, Boghosian T. Preparation and accreditation of anti-doping laboratories for the Olympic Games. Bioanalysis. 2012;4:1623-1631.
- Furst Wolf R. Conflicting anti-doping laws in professional sports: collective bargaining agreements v. state law. Seattle U L Rev. 2011;34:1606.
- Washutka DM. Collective bargaining agreements in professional sports: the proper forum for establishing performance-enhancing drug testing policies. Pepp Disp Resol LJ. 2007;8. http://digitalcommons.pepperdine.edu/drlj/vol8/iss1/5. Accessed January 15, 2014.
- Laure P, Binsinger C. Doping prevalence among preadolescent athletes: a 4-year follow-up. Br J Sports Med. 2007;41:660-663.
- Stubbe JH, Chorus AM, Frank LE, de Hon O, van der Heijden PG. Prevalence of use of performance enhancing drugs by fitness centre members [published online September 9, 2013]. Drug Test Anal.
- Veliz P, Boyd C, McCabe SE. Adolescent athletic participation and nonmedical Adderall use: an exploratory analysis of a performance-enhancing drug. J Stud Alcohol Drugs. 2013;74:714-719.
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- Perera NJ, Steinbeck KS, Shackel N. The adverse health consequences of the use of multiple performance-enhancing substances: a deadly cocktail. J Clin Endocrinol Metab. 2013;98:4613-4618.
- Prakash K. Performance enhancing drugs in sports and the role of doctors: are there guidelines? Indian J Med Ethics. 2013;10:115-117.
- Cacic DL, Hervig T, Seghatchian J. Blood doping: the flip side of transfusion and transfusion alternatives. Transfus Apher Sci. 2013;49:90-94.
- Dunn M, McKay FH, Iversen J. Steroid users and the unique challenge they pose to needle and syringe program workers. Drug Alcohol Rev. 2014;33:71-77.
- Hope VD, McVeigh J, Marongiu A, et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open. 2013;3:e003207.
- Veliz PT, Boyd C, McCabe SE. Playing through pain: sports participation and nonmedical use of opioid medications among adolescents. Am J Public Health. 2013;103:e28-e30.