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Performance-enhancing drugs keep winning the race against testing

    “The drug problem has always been with us, and it always will be. Athletes have always used performance-enhancing substances... It’s human nature to try to obtain every possible advantage for success. If there were a drug available that would dramatically increase the ability of university faculty to get grants, you'd better believe they'd be injecting their butts with it in front of Old Main.”— Charles Yesalis, M.P.H. leading expert on performance enhancing drugs
    The history of athletes using performance-enhancing drugs (PEDs) goes back at least 2000 years, when ancient Greek athletes used mushrooms and opioids during athletic competition, including the first Olympic Games. There are reports of European cyclists using a variety of stimulants during the late 19th century. In the 20th century, German physicians discovered the first injectable anabolic steroids, and these drugs may have been administered to Nazi troops during World War II. After the war, use of these drugs took off in both amateur and professional sporting events.
    The situation became a reflection of the Cold War—their use a symbol of the political competition between the East and West. Soviet weightlifters achieved great success in the 1950s using anabolic steroids. While the first Olympic drug testing was established in 1968, the world’s attention was drawn to the incredible performances of East German female swimmers in the 1970s. Many of these young women were selected by the government from an early age, taken from their families, and received intensive training and sophisticated chemical regimens, leaving them with terrible physical and psychological complications years later. Some are infertile or have given birth to deformed children. Others have developed male sex characteristics and at least one developed so many male sex characteristics she underwent a sex change operation. When East Germany collapsed, their unfortunate stories were revealed and the world took note of the drug problem in sports.
    Meanwhile in the West, European cyclists used amphetamines routinely in the 1960s. In the United States, PEDs made their way into professional sports. In 1970, former New York Yankees pitcher Jim Bouton wrote Ball Four, a best-seller about his life in baseball, describing widespread use of amphetamines, known as “greenies.” Gradually, medical advances made PEDs more accessible to professional athletes and drug testing could not keep pace with the drug explosion.
    In the last two decades, drug use has proliferated. Top Olympians including Marion Jones and Ben Johnson tested positive for banned compounds, calling their world-class performances into question. Johnson, once “the world’s fastest man,” had his world record 100-yard dash time thrown out and was temporarily banned from his sport. Jones, among America’s top Olympians, was stripped of five Olympic medals and went to jail for events revolving around her use of illegal PEDs.
    Following his career, former Oakland Athletics outfielder Jose Canseco publicly charged steroid use was widespread in baseball. His accusations were first viewed skeptically, but as baseball performances reached new heights, some players confessed to using drugs, lending his claims credibility. In 2005, Congress held public hearings and players including Mark McGwire and Sammy Sosa, hailed as heroes only several years before, were unconvincing in their denials of steroid use. It’s been recently disclosed that stars including Alex Rodriguez, Barry Bonds, Andy Pettite, Manny Ramirez and David Ortiz have all tested positive for PED.
    Meantime, the abuse of PEDs has crept into college and high school athletics. Surveys indicate more than one million American children between the ages of 12 and 17 have taken PEDs (including creatine, which falls into a special category). It would be naive to believe the success of professional athletes who have used PEDs has not influenced younger athletes. Since testing is expensive and sometimes impractical at the lower levels, no one knows how serious the problem is. However, the accessibility of these drugs through the internet and other channels makes PEDs a serious public health issue at all levels of sports.
    What are we talking about when we say PEDs? The term is all- encompassing and nonspecific. It includes some legal drugs and othersthat are illegal. Some of the drugs are injected, some taken orally and others used in skin patches. It includes naturally occurring substances, synthetic compounds, drugs used for other legitimate purposes, nutritional supplements and drugs used not for performance, but to mask or counter the effects of other drugs. This is why it is hard to draw absolute medical conclusions about what drugs athletes ingest.
    Many athletes distrust the scientific community on the issue of PEDs. Much of the early scientific literature stated unequivocally that certain commonly used compounds like anabolic steroids did not improve performance and routinely caused dramatic side-effects. This ran directly counter to the underground athletic community experience and had the effect of discrediting the medical literature. Athletes and their trainers experimented with multiple drug combinations and dosing regimens that were based outside mainstream pharmacology. This information was eventually transmitted by word of mouth to others who modified what they heard and created their own regimens. Physicians were generally unaware of how the compounds were being used and rarely performed tests reflecting real-life situations. Even today, reliable knowledge about the benefits and dangers of PEDs remains hard to come by in the medical literature. There is a small cadre of experts working diligently to answer these questions, but there’s an ongoing development of new drugs and methods of administration.
    A complete discussion of the medical effects of PEDs is beyond the scope of this article, but the following is based on the current state of medical knowledge about commonly used compounds:

     These PEDs are derivatives of the male hormone testosterone. Anabolic refers to their ability to stimulate protein synthesis and increase muscle mass.  Not all steroids are anabolic. Anabolic steroids should not be confused with corticosteroids such as prednisone, which are commonly used in sports. Corticosteroids are generally injected into injured tissue to suppress short-term inflammation. While their use is sometimes controversial in the management of injury, corticosteroids are not considered PEDs.
    Anabolic steroids include injectable drugs such as testosterone and nandrolone and oral drugs such as stanozolol. These drugs can be used for short periods of time or in on-off cycles of 6 to 12 weeks, a process known as stacking. Occasionally athletes will increase the dose significantly during a stacking cycle—this is known as pyramiding. Anabolic steroids basically build muscle mass, increasing size and strength, although users must train and eat properly to realize the greatest effect. Their benefit is obvious for power sports, such as weight lifting, wrestling and football, but they may also benefit those who require bursts of energy, such as sprinters. For baseball players, they have the obvious benefits of increasing strength, bat speed and probably throwing velocity. It’s possible they increase hand-eye coordination. There are other less measurable, but just as practical, competitive effects such as increasing confidence and aggression.     These are potent drugs with significant side-effects and a number of studies suggest they may be addictive, though the potential for addiction is a matter of debate. In children, they are especially dangerous since they accelerate the maturation process and result in growth plate closure and shortened adult height. In both children and adults, muscle growth may outstrip tendon and ligament support and result in increased injuries. In adults, potential complications include cardiovascular disease (hypertension, accelerated atherosclerosis, heart attacks, heart failure), liver problems (hepatitis, liver tumors), endocrine problems (high blood sugar, decreased sexual characteristics and sperm production in men, masculinization in women), acne and psychological changes (depression, irritability). The exact incidence of complications is unknown since it is difficult to test these drugs under actual conditions. In addition, since long-term experience is limited, it’s unknown what happens in later life to young athletes using these drugs.     Another important complication is the consequence of needle injection. Those who inject steroids are susceptible to serious and well-documented complications including bacterial and chemical skin abscesses, viral hepatitis, HIV infection and serious blood infections.
    Anabolic steroids are currently classified as Schedule III—they can only be obtained with a prescription. Possession of anabolic steroids without a prescription carries legal penalties and unlawful distribution is a more serious legal offense. The International Olympic Committee (IOC) and most professional sports leagues in North America and Europe ban their use.
   These are hormones produced in the body ultimately converted to testosterone. Two common precursors are DHEA and androstenedione (the drug baseball player Mark McGwire admitted taking). These drugs have no specific medical indication and technically are not anabolic steroids. Because they are converted to anabolic steroids in the body, they have similar effects and side effects, though they are relatively less potent than actual anabolic steroids. Since they were classified differently than anabolic steroids for many years, they were popular ingredients in nutritional supplements. However, the Federal Government has reclassified these drugs in the same category as anabolic steroids and there are penalties at the federal level for possession and distribution. Androstenedione was a popular supplement in Major League Baseball until it was banned in 2004. It’s also banned by the IOC, NFL and NCAA.

    HGH is a naturally occurring hormone of the pituitary gland. It is used to treat patients with certain growth disorders who are deficient in its production and is used in some specific chronic diseases. It is a popular PED today because it can’t be detected by most current testing procedures. Its effects on normal subjects are unclear although there are reports it increases strength and decreases body fat. Recently, former White Sox pitcher Jim Parque admitted to injecting HGH after an injury while an active major leaguer (it was not banned at the time). His experience is instructive; he describes it did not make him stronger, but allowed him to train harder because it shortened recovery time between workouts. The capacity for drugs such as HGH to permit users longer, more rigorous training sessions and to shorten recovery time after workouts should not be underestimated. That is an important, albeit indirect, factor in performance enhancement.
    The side effects of HGH can be serious and include diabetes, heart disease, arthritis and skeletal abnormalities, including jaw prominence and skull enlargement. Until recently, most HGH was collected from cadavers and use of the drug carried the risk of viral disease transmission. Today, HGH is made synthetically, eliminating this danger and making it more accessible to patients and athletes. HGH is legal with a prescription but distribution without a prescription can lead to a fine and/or prison term. Many “HGH creams and sprays” are available through the internet, but they are most likely worthless since the body can only use HGH when it is injected.

    Blood doping is a technique especially popular with competitive cyclists and long distance runners. It involves increasing the number of oxygen-carrying red blood cells in the body in order to increase aerobic performance. Formerly, athletes would store their own blood and receive it as transfusions near the time of competition. Today, the same effect can be obtained through the administration of erythropoietin (EPO), an agent that stimulates red blood cell production (used in patients with chronic renal failure who are anemic).
    EPO is difficult to detect with current testing. Blood doping, while it increases aerobic capability, is extremely dangerous. Increasing the number of red blood cells in the body essentially makes blood thicker and can result in heart attacks, strokes and sudden death. These complications are more common in athletes who become dehydrated. Since 1987, the deaths of at least 18 Belgian and Dutch cyclists have been attributed to EPO. Interestingly, training at high altitudes for long periods of time, while controversial, can result in the same effect as blood doping, i.e. increasing red blood cell numbers and aerobic potential by stimulating the natural production of EPO.  

    The use of stimulants as PEDs ranges from caffeine to ephedrine and its derivatives to amphetamines. Unlike hormones, these drugs don’t increase strength or aerobic capabilities. They can be effective because they reduce the sense of fatigue, increase alertness, heighten euphoria and lessen the sensation of pain.     Caffeine is the most commonly used drug by athletes. In moderation, it may increase endurance and improve performance. When used excessively, it may interfere with athletic performance and cause dehydration. Olympic and NCAA competition permit caffeine up to certain levels (roughly the amount in six cups of coffee over 24 hours). Higher levels are banned.
    Ephedrine and its derivatives are commonly used asthma drugs that have been used as PEDs. They stimulate the nervous system although their effect on athletic performance is unclear. Most studies have demonstrated little athletic benefit to these drugs. A number of deaths and cardiovascular complications have been reported with the use of ephedrine and related compounds, especially in hot weather. Ephedrine-like compounds represent a lucrative export industry from China. Compounds such as ma huang and similar dietary supplements have been touted to improve muscle tone and energy levels although there is little documentation. Ephedrine and its derivatives remain legal in the United States under certain conditions, however the FDA has banned many supplements containing ephedrine. The IOC, NCAA and NFL have all banned ephedrine-containing compounds.
    Amphetamines were once a popular drug of abuse in sports, especially in baseball because of the grueling daily schedule. Amphetamine derivatives have some therapeutic uses in conditions such as attention deficit disorder. They are also used as recreational drugs, as well as reportedly being used by students as a study aid and in the military by pilots on long missions. The dangers of amphetamines are well known, and their use was banned in Major League Baseball in 2006.  

    Certain drugs with legitimate therapeutic uses are also used either as PEDs or to mask the signs and symptoms of the drugs mentioned above.
    Inderal, a beta blocker, is a commonly used cardiovascular agent that also decreases hand tremor and reduces anxiety by blocking the effects of adrenalin. It is used in such sports as archery and riflery. (Musicians, singers and people giving speeches also employ it because it minimizes stage fright.) It has been banned by the IOC because of the advantage it confers.
    Diuretics are used for rapid weight loss and occasionally as masking agents in an attempt to beat drug tests by diluting the urine. Therapeutic hormones such as clomiphene and human chorionic gonadotropin (HCG) have been used to stimulate recovery after anabolic steroid cycling.  

    Dietary supplements, products containing substances such as vitamins, minerals, botanicals and amino acids, are meant to supplement normal oral intake.
    Creatine may be the most widely used supplement in the United States. In 2000, creatine accounted for more than $400 million in sales. Creatine is a naturally occurring compound stored in skeletal muscle. It is essentially muscle protein and is available by eating meat or fish. It’s then synthesized and stored in the body. Creatine supplements are basically larger, more concentrated amounts of this muscle protein. Creatine is taken to increase muscle mass and enhance performance. The compound has been studied in different types of athletic activity and there are indications it improves performance in certain types of high intensity exercise, especially running and jumping. This effect has not been seen in all types of aerobic activity and may depend on factors including the athlete’s body habitus and training regimen. Creatine appears to increase weight and decrease body fat in the short term, although much of the weight increase may be due to water retention. Also, it is unclear whether short-term increases in muscle mass are an anabolic effect or the result of increased training.
    Is creatine dangerous? The answer is unclear. There are common side effects including cramping, gastrointestinal disturbances and dehydration (creatine should be supplemented with vigorous water intake). While there are anecdotal reports of more severe problems, current literature seems to indicate  when creatine is taken in recommended doses, there is no definitive evidence of serious harm. This doesn’t mean there is no risk or that the product can be deemed completely safe. In addition, little is known about possible long- term effects of chronic creatine use.  At present, creatine, if taken, is best used under the auspices of a qualified trainer or physician familiar with the compound.
    Other supplements abound, especially those containing supernormal amounts of basic dietary amino acids.  While there are often glowing claims these supplements improve performance and release endogenous hormones, the vast majority of these claims are unsubstantiated and probably have no validity. Many supplements offer nothing more than a high-priced, well-balanced diet. They may be safe, but are probably ineffective, and are very expensive. It should be remembered that the FDA can’t rigorously examine every product on the market and there may be counterfeit products (especially through the Internet or imported from abroad), prepared in an unsterile manner or tainted with substances such as anabolic steroids. This may be a source of positive drug tests for athletes uncertain of what is in the products they use. Ultimately, athletes are responsible for what they put in their bodies.
    This is only a partial list of the PEDs and supplements currently available. But new designer drugs are being developed constantly. Little is known of these new drugs—even those designing these drugs are often working by trial and error.
    Charles Yesalis, an expert on drug use in athletes, has observed it is human nature for individuals to seek every advantage in competition, and athletes are among the most competitive individuals. The race is always on to look for better drugs and ways to beat testing. The tests will improve, but testers will always remain one step behind users—the entire exercise resembles a high-tech game of cops and robbers.
    All too often we extol the virtues of, rather than condemn, athletes who use these drugs. We put undue emphasis on winning at all costs and transmit this to our athletes who believe they must use these drugs to succeed. This is especially dangerous in the case of children, who feel the pressure even more acutely than adults and are at the greatest risk from these drugs. As one world-class cyclist so aptly put it, “What goes around comes around eventually. It can be 10 years, 15 years; it all comes out in the wash and where are you? A gold medal isn’t as gold anymore.”

Published: October 11, 2009
Issue: November 2009 Sports Issue