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This article shows some interesting things on reasons why drugs should be allowed in sports.

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The legalisation of drugs in sport may be fairer and safer

In 490 BC, the Persian Army landed on the plain of Marathon, 25 miles from Athens. The Athenians sent a messenger named Feidipides to Sparta to ask for help. He ran the 150 miles in two days. The Spartans were late. The Athenians attacked and, although outnumbered five to one, were victorious. Feidipides was sent to run back to Athens to report victory. On arrival, he screamed "We won" and dropped dead from exhaustion.

The marathon was run in the first modern Olympics in 1896, and in many ways the athletic ideal of modern athletes is inspired by the myth of the marathon. Their ideal is superhuman performance, at any cost.

DRUGS IN SPORT

Using drugs to cheat in sport is not new, but it is becoming more effective. In 1976, the East German swimming team won 11 out of 13 Olympic events, and later sued the government for giving them anabolic steroids. Yet despite the health risks, and despite the regulating bodies' attempts to eliminate drugs from sport, the use of illegal substances is widely known to be rife. It hardly raises an eyebrow now when some famous athlete fails a dope test.

In 1992, Vicky Rabinowicz interviewed small groups of athletes. She found that Olympic athletes, in general, believed that most successful athletes were using banned substances.

Much of the writing on the use of drugs in sport is focused on this kind of anecdotal evidence. There is very little rigorous, objective evidence because the athletes are doing something that is taboo, illegal, and sometimes highly dangerous. The anecdotal picture tells us that our attempts to eliminate drugs from sport have failed. In the absence of good evidence, we need an analytical argument to determine what we should do.

CONDEMNED TO CHEATING?

We are far from the days of amateur sporting competition. Elite athletes can earn tens of millions of dollars every year in prize money alone, and millions more in sponsorships and endorsements. The lure of success is great. But the penalties for cheating are small. A six month or one year ban from competition is a small penalty to pay for further years of multimillion dollar success.

The enormous rewards for the winner, the effectiveness of the drugs, and the low rate of testing all combine to create a cheating "game" that is irresistible to athletes. Kjetil Haugen investigated the suggestion that athletes face a kind of prisoner's dilemma regarding drugs. His game theoretic model shows that, unless the likelihood of athletes being caught doping was raised to unrealistically high levels, or the payoffs for winning were reduced to unrealistically low levels, athletes could all be predicted to cheat. The current situation for athletes ensures that this is likely, even though they are worse off as a whole if everyone takes drugs, than if nobody takes drugs.

Drugs such as erythropoietin (EPO) and growth hormone are natural chemicals in the body. As technology advances, drugs have become harder to detect because they mimic natural processes. In a few years, there will be many undetectable drugs. Haugen's analysis predicts the obvious: that when the risk of being caught is zero, athletes will all choose to cheat.

The goal of "cleaning" up the sport is unattainable. Further down the track the spectre of genetic enhancement looms dark and large.

THE SPIRIT OF SPORT

So is cheating here to stay? Drugs are against the rules. But we define the rules of sport. If we made drugs legal and freely available, there would be no cheating.

Would legal and freely available drugs violate this "spirit"? Would such a permissive rule be good for sport?

Human sport is different from sports involving other animals, such as horse or dog racing. The goal of a horse race is to find the fastest horse. Horses are lined up and flogged. The winner is the one with the best combination of biology, training, and rider. Basically, this is a test of biological potential. This was the old naturalistic Athenian vision of sport: find the strongest, fastest, or most skilled man.

Training aims to bring out this potential. Drugs that improve our natural potential are against the spirit of this model of sport. But this is not the only view of sport. Humans are not horses or dogs. We make choices and exercise our own judgment. We choose what kind of training to use and how to run our race. We can display courage, determination, and wisdom. We are not flogged by a jockey on our back but drive ourselves. It is this judgment that competitors exercise when they choose diet, training, and whether to take drugs. We can choose what kind of competitor to be, not just through training, but through biological manipulation. Human sport is different from animal sport because it is creative. Far from being against the spirit of sport, biological manipulation embodies the human spirit-the capacity to improve ourselves on the basis of reason and judgment. When we exercise our reason, we do what only humans do.

The result will be that the winner is not the person who was born with the best genetic potential to be strongest. Sport would be less of a genetic lottery. The winner will be the person with a combination of the genetic potential, training, psychology, and judgment. Olympic performance would be the result of human creativity and choice, not a very expensive horse race.

Classical musicians commonly use β blockers to control their stage fright. These drugs lower heart rate and blood pressure, reducing the physical effects of stress, and it has been shown that the quality of a musical performance is improved if the musician takes these drugs. Although elite classical music is arguably as competitive as elite sport, and the rewards are similar, there is no stigma attached to the use of these drugs. We do not think less of the violinist or pianist who uses them. If the audience judges the performance to be improved with drugs, then the drugs are enabling the musician to express him or herself more effectively. The competition between elite musicians has rules-you cannot mime the violin to a backing CD. But there is no rule against the use of chemical enhancements.

"You go to see Michael Jordan play for the same reason you went to see Astaire dance, Olivier act or the sun set over Canada. It's art. It should be painted, not photographed.It's not a game, it's a recital. He's not just a player, he's a virtuoso. Heifetz with a violin. Horowitz at the piano."

Indeed, it seems reasonable to suggest that the reasons we appreciate sport at its elite level have something to do with competition, but also a great deal to do with the appreciation of an extraordinary performance.

Clearly the application of this kind of creativity is limited by the rules of the sport. Riding a motorbike would not be a "creative" solution to winning the Tour de France, and there are good reasons for proscribing this in the rules. If motorbikes were allowed, it would still be a good sport, but it would no longer be a bicycle race.

We should not think that allowing cyclists to take EPO would turn the Tour de France into some kind of "drug race", any more than the various training methods available turn it into a "training race" or a "money race". Athletes train in different, creative ways, but ultimately they still ride similar bikes, on the same course. The skill of negotiating the steep winding descent will always be there.

UNFAIR?

People do well at sport as a result of the genetic lottery that happened to deal them a winning hand. Genetic tests are available to identify those with the greatest potential. If you have one version of the ACE gene, you will be better at long distance events. If you have another, you will be better at short distance events. Black Africans do better at short distance events because of biologically superior muscle type and bone structure. Sport discriminates against the genetically unfit. Sport is the province of the genetic elite (or freak).

The starkest example is the Finnish skier Eero Maentyranta. In 1964, he won three gold medals. Subsequently it was found he had a genetic mutation that meant that he "naturally" had 40-50% more red blood cells than average. Was it fair that he had significant advantage given to him by chance?

The ability to perform well in sporting events is determined by the ability to deliver oxygen to muscles. Oxygen is carried by red blood cells. The more red blood cells, the more oxygen you can carry. This in turn controls an athlete's performance in aerobic exercise. EPO is a natural hormone that stimulates red blood cell production, raising the packed cell volume (PCV)-the percentage of the blood comprised of red blood cells. EPO is produced in response to anaemia, haemorrhage, pregnancy, or living at altitude. Athletes began injecting recombinant human EPO in the 1970s, and it was officially banned in 1985.

In the early 1990s, after EPO doping gained popularity but before tests for its presence were available, several Dutch cyclists died in their sleep due to inexplicable cardiac arrest. This has been attributed to high levels of EPO doping. The risks from raising an athlete's PCV too high are real and serious.

In addition to trying to detect EPO directly, the International Cycling Union requires athletes to have a PCV no higher than 0.5. But 5% of people naturally have a PCV higher than 0.5. Athletes with a naturally high PCV cannot race unless doctors do a number of tests to show that their PCV is natural. Charles Wegelius was a British rider who was banned and then cleared in 2003. He had had his spleen removed in 1998 after an accident, and as the spleen removes red blood cells, its absence resulted in an increased PCV.

There are other ways to increase the number of red blood cells that are legal. Altitude training can push the PCV to dangerous, even fatal, levels. More recently, hypoxic air machines have been used to simulate altitude training. The body responds by releasing natural EPO and growing more blood cells, so that it can absorb more oxygen with every breath. The Hypoxico promotional material quotes Tim Seaman, a US athlete, who claims that the hypoxic air tent has "given my blood the legal 'boost' that it needs to be competitive at the world level."

There is one way to boost an athlete's number of red blood cells that is completely undetectable: autologous blood doping. In this process, athletes remove some blood, and reinject it after their body has made new blood to replace it. This method was popular before recombinant human EPO became available.

"By allowing everyone to take performance enhancing drugs, we level the playing field."

There is no difference between elevating your blood count by altitude training, by using a hypoxic air machine, or by taking EPO. But the last is illegal. Some competitors have high PCVs and an advantage by luck. Some can afford hypoxic air machines. Is this fair? Nature is not fair. Ian Thorpe has enormous feet which give him an advantage that no other swimmer can get, no matter how much they exercise. Some gymnasts are more flexible, and some basketball players are seven feet tall. By allowing everyone to take performance enhancing drugs, we level the playing field. We remove the effects of genetic inequality. Far from being unfair, allowing performance enhancement promotes equality.

JUST FOR THE RICH?

Paradoxically, permitting drugs in sport could reduce economic discrimination. The cost of a hypoxic air machine and tent is about US$7000. Sending an athlete to a high altitude training location for months may be even more expensive. This arguably puts legal methods for raising an athlete's PCV beyond the reach of poorer athletes. It is the illegal forms that level the playing field in this regard.

One popular form of recombinant human EPO is called Epogen. At the time of writing, the American chain Walgreens offers Epogen for US$86 for 6000 international units (IU). The maintenance dose of EPO is typically 20 IU per kg body weight, once a week. An athlete who weighs 100 kg therefore needs 2000 IU a week, or 8600 IU a month. Epogen costs the athlete about US$122 a month. Even if the Epogen treatment begins four years before an event, it is still cheaper than the hypoxic air machine. There are limits on how much haemoglobin an athlete can produce, however much EPO they inject, so there is a natural cap on the amount of money they can spend on this method.

Meanwhile, in 2000, the cost of an in competition recombinant EPO test was about US$130 per sample. This test is significantly more complex than a simple PCV test, which would not distinguish exogenous or endogenous EPO. If monetary inequalities are a real concern in sport, then the enormous sums required to test every athlete could instead be spent on grants to provide EPO to poorer athletes, and PCV tests to ensure that athletes have not thickened their blood to unsafe levels.

UNSAFE?

Should there be any limits to drugs in sport?

There is one limit: safety. We do not want an Olympics in which people die before, during, or after competition. What matters is health and fitness to compete. Rather than testing for drugs, we should focus more on health and fitness to compete. Forget testing for EPO, monitor the PCV. We need to set a safe level of PCV. In the cycling world, that is 0.5. Anyone with a PCV above that level, whether through the use of drugs, training, or natural mutation, should be prevented from participating on safety grounds. If someone naturally has a PCV of 0.6 and is allowed to compete, then that risk is reasonable and everyone should be allowed to increase their PCV to 0.6. What matters is what is a safe concentration of growth hormone-not whether it is natural or artificial.

We need to take safety more seriously. In the 1960s, East German athletes underwent systematic government sanctioned prescription of anabolic steroids, and were awarded millions of dollars in compensation in 2002. Some of the female athletes had been compelled to change their sex because of the large quantities of testosterone they had been given.

We should permit drugs that are safe, and continue to ban and monitor drugs that are unsafe. There is another argument for this policy based on fairness: provided that a drug is safe, it is unfair to the honest athletes that they have to miss out on an advantage that the cheaters enjoy.

Taking EPO up to the safe level, say 0.5, is not a problem. This allows athletes to correct for natural inequality. There are of course some drugs that are harmful in themselves -for example, anabolic steroids. We should focus on detecting these because they are harmful not because they enhance performance.

Far from harming athletes, paradoxically, such a proposal may protect our athletes. There would be more rigorous and regular evaluation of an athlete's health and fitness to perform. Moreover, the current incentive is to develop undetectable drugs, with little concern for safety. If safe performance enhancement drugs were permitted, there would be greater pressure to develop safe drugs. Drugs would tend to become safer.

This is perhaps best illustrated by the case of American sailor Kevin Hall. Hall lost his testicles to cancer, meaning that he required testosterone injections to remain healthy. As testosterone is an anabolic steroid, he had to prove to four separate governing bodies that he was not using the substance to gain an advantage. Any tests that we do should be sensitive to the health of the athlete; to focus on the substances themselves is dogmatic.

Not only this, but health testing can help to mitigate the dangers inherent in sport.

Sometimes, the treatments for these conditions will raise the performance of an athlete beyond that which they could attain naturally. But safety should come first. If an archer requires β blockers to treat heart disease, we should not be concerned that this will give him or her an advantage over other archers. Or if an anaemic cyclist wants to take EPO, we should be most concerned with the treatment of the anaemia.

If we are serious about safety in sport, we should also be prepared to discuss changes to the rules and equipment involved in sports which are themselves inherently dangerous. Formula One motor racing, once the most deadly of sports, has not seen a driver death in over six years, largely because of radical changes in the safety engineering of the tracks and the cars. Meanwhile, professional boxing remains inherently dangerous; David Rickman died during a bout in March 2004, even though he passed a physical examination the day before.

CHILDREN

Linford Christie, who served a two year drug ban from athletics competition, said that athletics "is so corrupt now I wouldn't want my child doing it". But apart from the moral harms to children in competing in a corrupt sport, should we withhold them from professional sport for medical reasons?

The case where the athletes are too young to be fully autonomous is different for two important reasons. Firstly, children are much less capable of rejecting training methods and treatments that their coach wishes to use. Secondly, we think it is worth protecting the range of future options open to a child.

There is a serious ethical problem with allowing children to make any kind of choice that substantially closes off their options for future lifestyles and career choices. If we do not consider children competent for the purposes of allowing them to make choices that cause them harm, then we should not allow them to decide to direct all of their time to professional gymnastics at age 10. The modifications such a choice can make to a child's upbringing are as serious, and potentially as harmful, as many of the available performance enhancing drugs. Children who enter elite sport miss large parts of the education and socialisation that their peers receive, and are submitted to intense psychological pressure at an age when they are ill equipped to deal with it.

We argue that it is clear that children, who are not empowered to refuse harmful drugs, should not be given them by their coaches or parents. But the same principles that make this point obvious should also make it obvious that these children should not be involved in elite competitive sport in the first place. However, if children are allowed to train as professional athletes, then they should be allowed to take the same drugs, provided that they are no more dangerous than their training is.

Haugen's model showed that one of the biggest problems in fighting drug use was that the size of the rewards for winning could never be overshadowed by the penalties for being caught. With this in mind, we can begin to protect children by banning them from professional sport.

CLIMATE OF CHEATING

If we compare the medical harms of the entire worldwide doping problem, they would have to be much less than the worldwide harms stemming from civilian illicit drug use. And yet, per drug user, the amount of money spent on combating drugs in sport outweighs the amount spent on combating civilian drug use by orders of magnitude.

We can fairly assume that if medical harms and adherence to law were the only reasons we felt compelled to eradicate doping, then the monetary value we placed on cleaning up sport should be the same, per drug user, as the monetary value we place on eradicating recreational drug use. And yet it is not.

Because of this, it should be obvious that it is not medical harms that we think are primarily at stake, but harm to sport as a whole, a purported violation of its spirit. It is a problem for the credibility of elite sport, if everyone is cheating.

If it is this climate of cheating that is our primary concern, then we should aim to draft sporting rules to which athletes are willing to adhere.

PROHIBITION

It is one thing to argue that banning performance enhancing drugs has not been successful, or even that it will never be successful. But it should also be noted that the prohibition of a substance that is already in demand carries its own intrinsic harms.

Even when prohibition leads to a decrease in consumption, it often leads to the creation of a black market to supply the continuing demand, as it did in the Greenland study of alcohol rationing. Black markets supply a product that is by definition unregulated, meaning that the use is unregulated and the safety of the product is questionable.

The direct risks from prohibiting performance enhancing drugs in sport are similar, but probably much more pronounced. Athletes currently administer performance enhancing substances in doses that are commensurate with the amount of performance gain they wish to attain, rather than the dose that can be considered "safe". The athletic elite have near unlimited funds and the goal of near unlimited performance, a framework that results in the use of extremely unsafe doses. If athletes are excluded when their bodies are unsafe for competition, this kind of direct consequence from prohibition would be reduced.

THE PROBLEM OF STRICT LIABILITY

Lord Coe, a dual Olympic champion, has defended the doctrine of "strict liability", as it is currently applied to athletes who use a banned substance:

"...The rule of strict liability-under which athletes have to be solely and legally responsible for what they consume-must remain supreme. We cannot, without blinding reason and cause, move one millimetre from strict liability-if we do, the battle to save sport is lost."

The best reason for adhering to this rule is that, if coaches were made responsible for drugs that they had given to their athletes, then the coach would be banned or fined, and the athlete could still win the event. In this situation, other athletes would still be forced to take drugs in order to be competitive, even though the "cheat" had been caught.

But the doctrine of strict liability makes victims of athletes such as those of the East German swim team, who are competing in good faith but have been forced to take drugs. It also seems dogmatically punitive for athletes like British skier Alain Baxter, who accidentally inhaled a banned stimulant when he used the American version of a Vicks decongestant inhaler, without realising that it differed from the British model.

It seems that strict liability is unfair to athletes, but its absence is equally unfair. Our proposal solves this paradox-when we exclude athletes only on the basis of whether they are healthy enough to compete, the question of responsibility and liability becomes irrelevant. Accidental or unwitting consumption of a risky drug is still risky; the issue of good faith is irrelevant.

ALTERNATIVE STRATEGIES

Michael Ashenden proposes that we keep progressive logs of each athlete's PCV and hormone concentrations. Significant deviations from the expected value would require follow up testing. The Italian Cycling Federation decided in 2000 that all juniors would be tested to provide a baseline PCV and given a "Hematologic Passport".

Although this strategy is in many ways preferable to the prohibition of doping, it does nothing to correct the dangers facing an athlete who has an unsafe baseline PCV or testosterone concentration.

TEST FOR HEALTH, NOT DRUGS

The welfare of the athlete must be our primary concern. If a drug does not expose an athlete to excessive risk, we should allow it even if it enhances performance. We have two choices: to vainly try to turn the clock back, or to rethink who we are and what sport is, and to make a new 21st century Olympics. Not a super-Olympics but a more human Olympics. Our crusade against drugs in sport has failed. Rather than fearing drugs in sport, we should embrace them.

In 1998, the president of the International Olympic Committee, Juan-Antonio Samaranch, suggested that athletes be allowed to use non-harmful performance enhancing drugs. This view makes sense only if, by not using drugs, we are assured that athletes are not being harmed.

Performance enhancement is not against the spirit of sport; it is the spirit of sport. To choose to be better is to be human. Athletes should be the given this choice. Their welfare should be paramount. But taking drugs is not necessarily cheating. The legalisation of drugs in sport may be fairer and safer.

The legalisation of drugs in sport may be fairer and safer

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Why we should allow performance enhancing drugs in sport

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The legalisation of drugs in sport may be fairer and safer In 490 BC, the Persian Army landed on the plain of Marathon, 25 miles from Athens. The Athenians sent a messenger named Feidipides to Sparta to ask for help. He ran the 150 miles in two days. The Spartans were late.

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The Mayo Clinic is a very reliable source with all different kinds of information. It supports my claim but also puts other standpoints of whether or not it should be legal to use pain killers in sports.

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Performance-enhancing drugs and teen athletes

Performance-enhancing drugs can be tempting for teen athletes. Understand the warning signs and what you can do to keep your teen from using shortcuts to improve athletic performance.
By Mayo Clinic Staff
We're all familiar with famous athletes who've admitted to using performance-enhancing drugs. So it's no surprise that as many as 1 in 20 teenagers reports using steroids to increase muscle mass.

If you're the parent of a teen, talk with your teen about the dangers of performance-enhancing drugs. By explaining the consequences of using performance-enhancing drugs, you can help your teen steer clear.

Common performance-enhancing drugs

Among teens, common performance-enhancing drugs and supplements include:

Creatine. Creatine is a naturally occurring compound in the body that's also sold as an over-the-counter supplement. It's used to improve performance during high-intensity bursts of activity and to help increase muscle mass and strength.

Anabolic steroids. Anabolic steroids are synthetic versions of the hormone testosterone, used to build muscle and increase strength.

Steroid precursors. Steroid precursors, such as androstenedione ("andro") and dehydroepiandrosterone (DHEA), are substances that the body converts into anabolic steroids. They're used to increase muscle mass. Most steroid precursors are illegal without a prescription. DHEA, however, is still available in over-the-counter preparations.

Why it happens

Some teens experiment with performance-enhancing drugs as a way to cope with body image insecurities or to fit in with a group of peers. Others might be influenced by pressure to make a team or get a competitive edge. Factors that might increase the chances that a teen will use performance-enhancing drugs include:

Desire to gain muscle mass or strength

Negative body image or a tendency to compare one's appearance with others'

Pressure from parents, other adults or peers regarding weight or muscles

Hazards of performance-enhancing drugs

Steroids and their precursors can have severe, long-lasting health effects. In growing adolescents one of the major risks of using anabolic steroid precursors is the permanent stunting of height. Other side effects include:

Blood-clotting problems

High blood pressure and cholesterol

Liver problems

Mood swings

Reduced sperm production

Creatine can also cause nausea, abdominal pain and kidney damage.

Possible red flags of performance-enhancing drug use include:

Behavioral, emotional or psychological changes - particularly increased aggressiveness ("roid rage")

Changes in body build, including muscle growth, rapid weight gain and development of the upper body

Increased acne

Needle marks in the buttocks or thighs

Enlarged breasts, male-pattern baldness and shrinking of the testicles in boys

Smaller breasts, voice deepening and excessive growth of body hair in girls

What parents can do

To prevent your teen from using performance-enhancing drugs or supplements:

Discuss ethics and proper training. Remind your teen that using a performance-enhancing drug is cheating and also could lead to serious health problems. Explain that a healthy diet and rigorous training are the true and proven keys to athletic performance.

Be clear about your expectations. Tell your teen that you expect him or her to avoid performance-enhancing drugs. Set rules and explain the consequences of breaking them.

Get involved. Attend games and practices. Encourage your teen's coaches, school and sports organizations to discourage the use of performance-enhancing drugs. Reassure your teen of your love and support, regardless of his or her competitive performance.

Monitor your teen's purchases. Check the ingredients of any over-the-counter products your teen uses.

Help is available

If you suspect that your teen is using performance-enhancing drugs, talk to him or her. If your teen admits to using performance-enhancing drugs, encourage him or her to stop immediately. Make an appointment for your teen to see his or her doctor for a medical evaluation and counseling.

Consider informing your teen's coach, so he or she is aware of the problem. In addition, tell your teen that you're disappointed and enforce the consequences that you've established - such as quitting the team. Most importantly, emphasize the healthy alternatives to achieving his or her goals.

Don't put off talking with your teen about performance-enhancing drugs. Help your teen understand the risks, as well as healthier ways to support athletic performance and a good body image.

See more In-depth

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Performance-enhancing drugs and teen athletes

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Performance-enhancing drugs can be tempting for teen athletes. Understand the warning signs and what you can do to keep your teen from using shortcuts to improve athletic performance. By Mayo Clinic Staff We're all familiar with famous athletes who've admitted to using performance-enhancing drugs.

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NationWideChilderns, is a great website in the fact that it supports my claim in multiple ways. It has facts about the amount of deaths,what else can happen and also how to prevent things like that from happening in the future generations.

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Abuse of Drugs to Enhance Sports Performance: Winning at Any Cost

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Performance enhancing drugs can be regarded in four classes: androstenedione, creatine, anabolic steroids, and ephedra alkaloids.

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BMJ gives a lot of data on what performance enhancing drugs can do to an athlete, and the consequences of using them.

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Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician

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The use of performance-enhancing and social drugs by athletes raises a number of ethical and health concerns. The World Anti-Doping Agency was constituted to address both of these issues as well as publishing a list of, and testing for, banned substances in athletes.

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Len Bias was a professional basketball player in 1986. His career didnt last very long becuase he died two days after he was drafted. He died from going into cardiac arrythmia. This goes with my article becuase it shows what can happen to people who use drugs.

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This is a video I found on former NFL player Kyle Turley. He was kicked out of the NFL for using painkillers and marijuana products to help his performance. I picked this because it shows what can happen to an athletes career if they use performance enhancers.

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Painkillers in the NFL: Kyle Turley on Playing Numb

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This video is of Lance Armstrong admitting to "doping" in an interview with Oprah. Lance Armstrong was a cyclist who was a part of the biggest doping scandal. This goes with my claim because his career suffered because he tried to use drugs to make it better.

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This is Justin Gatlin he was an American sprinter who was banned for four years after he tested positive for testosterone usage. This supports my claim because Justin's career was ended after these failed drug tests.

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NCAA, uses a lot of information about the topic of Drug Abuse and Athletes.

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NCAA.org - The Official Site of the NCAA

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The prevalence of mood-altering substances on campus - alcohol, marijuana, narcotics, stimulants, depressants, hallucinogens - has been tracked by campus prevention professionals for decades, evoking varying degrees of effort and success to reduce use and negative consequences.

More recently, a keen understanding of the interplay between substance use and mental health brings two distinct fields - prevention specialists and treatment specialists - together to define more comprehensive and evidence-informed approaches to address these issues, including population-based environmental management, large screening events, and personalized assessment, feedback and intervention.

College students, including student-athletes, are susceptible to the college effect, in which heavy and frequent alcohol use increases when students arrive on campus, buying into the cultural myth that campus life is about alcohol abuse and drug use. Such beliefs result in an increase in negative impact on academic success, increased risk of sexual assault and other interpersonal violence, and other negative consequences.

Student-athletes, compared with other students on campus, report higher rates of heavy episodic drinking, sometimes referred to as "binge drinking" (defined as four or more drinks for women and five or more for men). Even more disturbing is that one in five male student-athletes who use alcohol report drinking 10 or more drinks in an outing when they drink.

For marijuana, the good news is that fewer NCAA student-athletes report using marijuana than other students on campus. But the percentage of student-athletes who use marijuana has remained relatively flat over the last 10 years.

And though alcohol and marijuana are the two most reported recreational drugs student-athletes use, the new illicit drug-use concern is the abuse of prescription stimulants and narcotics.

Substance abuse and mental health

There is no doubt that for many, substance abuse co-occurs with mental health issues. A 2004 Harvard University study described patterns of depression and alcohol abuse among young adults in college, and confirmed that "a substantial fraction of college youth are experiencing poor mental health - at any given time approximately 5 percent - and that these youth are at high risk for alcohol abuse, with depressed young women at highest risk."

The Harvard study noted the age of traditional students, 18-24, coincides with peak years for onset of common mental health problems among youth related to alcohol, tobacco and other drug use, depression and anxiety disorders and suicide.

The 2012 National Survey on Drug Use and Health of the Substance Abuse and Mental Health Services Administration identifies that 8.9 million adults have co-occurring mental and substance use disorders and recommends integrated treatment to improve outcomes.

Student-athlete substance use

Since 1985, the NCAA has conducted a quadrennial research study of substance use of college student-athletes, and collected survey data again in the spring of 2013 from more than 20,000 NCAA student-athletes from all three divisions and NCAA-sponsored championship sports.

Alcohol

Figures 3A and 3B present data about heavy episodic drinking and the negative consequences reported as a result of alcohol use.
When you drink alcohol, typically how many drinks do you have in one sitting? (Figure 3A)
Female Student-Athletes

Male student-athletes

It is particularly alarming that 30 percent of these student- athletes report experiencing blackouts, which are red flags for developing an alcohol addiction. In addition, more than 30 percent have done something they later regretted and more than 25 percent have been criticized for their drinking.
Student-athlete drinking behavior - During the past 12 months (Figure 3B)
These data also identify implications of use on both academic and athletics success, with more than 25 percent missing class and 16 percent performing poorly on a test or in practice due to use.

Marijuana

Another substance concern is the use of marijuana, which has remained fairly constant in this population over the past 10 years as noted in this table:
Marijuana use within the last 12 months
The college literature on marijuana use demonstrates strong links between use, especially chronic use, and cognitive deficits. Even for those who do not use regularly, marijuana use can impede concentration and attention, and interfere with student-athlete academic and athletics success.
Student-athlete marijuana and grades

Never used

Used in last 30 days

Used in last 12 months

Used, but not in last 12 months

Depression and anxiety are the most commonly reported psychological issues reported by traditional-aged students, including student-athletes, and the peak age of onset for schizophrenia is in the teenage years and 20s.

Marijuana use is implicated in exacerbating symptoms of anxiety, depression and schizophrenia, and those at risk of developing schizophrenia will have worsening symptoms if they use marijuana.

The NCAA study looked at marijuana use and grades, and found in the table above that those who have used in the last 30 days reported failing grades at three times the rate of those who don't use. The table also notes that for those student-athletes who have never used, more than 30 percent report A grades compared with 20 percent of those who have used, either in the last 30 days or ever. (See Figure 3C)

prescription drug use. The following table notes that under 5 percent of NCAA student-athletes report prescribed ADHD stimulant medication use, similar to the estimates of ADHD in this population, but more than 5 percent report use without a prescription. The percentage of student-athletes prescribed narcotics for pain medication is higher than the general student body, which is understandable with injury and pain a part of competitive athletics, but use without prescription is of great concern given the potential for addiction to these medications. Whether this nonprescribed use is self-medication for inadequate response to sports injury is an area for further research.

Prevention is a science!

The substance abuse prevention field has matured quickly since the 2002 publication of the National Institutes of Alcohol Abuse and Alcoholism. This report provided evidence of alcohol education and policy strategies that demonstrated an effect on use, strategies that held promise, and those that did not deliver.

Over the convening decade, prevention science has provided us greater insights into the kinds of campus efforts that support healthy choices, those that are ineffective, and even those that contribute to abuse.

The CDC's social-ecological model provides the framework for targeting our efforts, noting that individual behaviors are influenced by the individual's peer group, broader community and society. For the campus athletics culture, this translates into team, department and campus as a whole.

Understanding the process of behavior change, the role perception plays in use, the power of setting expectations, and the influence of environment and policy on individual choices is critical to effective alcohol abuse prevention. "Just say no" is not a method. Research has redirected our efforts toward more effective approaches to reduce substance abuse and its negative consequences, providing us evidence-informed strategies that affect behavior change, such as brief motivational interventions, correcting norms, engaging peers in intervention, and clear and consistent policy enforcement. As with any culture, educational efforts need to address student-athletes' motives, beliefs and expectations.

Athletics administrators will experience greater success in reducing substance abuse among their student-athletes when they partner with campus prevention specialists who have background and expertise in substance abuse prevention and mental health promotion.

The NCAA Division III and NASPA (Student Affairs Professionals in Higher Education) have entered into a collaborative project that intends to bring the best of prevention science to their constituents, administered in partnership between athletics and student affairs administrators, in a project called 360Proof. This effort combines personalized feedback process with campus support and intervention, relying on the very evidence-based strategies defined by these recent efforts.

The NCAA provides resources to help its membership address substance abuse prevention and promote mental health. The NCAA-sponsored APPLE Conferences (Promoting Student-Athlete Wellness and Substance Abuse Prevention) bring campus "prevention teams" composed of four to six members, including at least two student-athletes, through a strategic planning weekend that provides a framework to identify gaps in the institution's substance abuse efforts and walks them through the development of their institutional-specific plan to address those gaps.

The University of Virginia's Gordie Center for Substance Abuse Prevention ( www.virginia.edu/gordiecenter/apple) administers the program and houses the emerging support for "Coaches Assist," which recognizes the critical role coaches play in addressing student-athlete substance abuse.

The NCAA 2012 Student-Athlete Social Environment Study found that of the 21,000 student-athletes surveyed across all divisions and sports:

42 percent of men and 39 percent of women said they would turn to their parents first when seeking help/advice/support for substance use.

89 percent of student-athletes report coaches or others in the athletics department have talked to them about expectations regarding drinking and substance use, yet a quarter of men and a third of women would like them to talk more about it with their team.

85 percent of men and 93 percent of women would be likely or extremely likely to accompany a teammate home if he/she had a lot to drink.

79 percent of men and 93 percent of women would be likely or extremely likely to stop a teammate from driving if drinking.

The Step UP! Bystander Intervention Program ( www.stepupprogram.org) provides administrators with training materials to help student-athletes exercise leadership and to "step up" when a teammate or friend is engaged in potentially harmful or dangerous situations. Step UP! was developed from research that recognizes the desire of students to help a friend in distress but feel ill-equipped to do so safely and effectively. Step UP! training overcomes the bystander effect that sustains inertia, and takes students through the five-step process to recognize a problem and to take personal responsibility to help.

In the meantime, above all, athletics administrators must demonstrate leadership in recognizing the relationship of substance use, mental health and academic success by:

Viewing substance use prevention as critical to student success.

Establishing an environment that is supportive of student success and deters excessive drinking/drug use.

Working with campus and community constituents and experts to implement a comprehensive program of evidence-based strategies.

Brian Hainline began his tenure as the NCAA's chief medical officer in January 2013. As the first person to hold that position in the organization, Hainline oversees the newly created NCAA Sport Science Institute, a national center to promote and develop safety, excellence, and wellness in college student-athletes, and to foster lifelong physical and mental development. The NCAA Sport Science Institute works collaboratively with member institutions and centers of excellence across the United States. A graduate of Notre Dame and Chicago's Pritzker School of Medicine, Hainline completed his neurology residency at The New York Hospital-Cornell. He was chief medical officer of the US Open Tennis Championships for 16 years, and then served as chief medical officer of the United States Tennis Association before moving to the NCAA. Mary Wilfert is an associate director in the NCAA Sport Science Institute. Since 1999, she has administered the NCAA drug-education and drug-testing programs and worked to promote policies and develop resources for student-athlete healthy life choices. She serves as primary liaison to the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, the governing body charged with providing leadership on health and safety recommendations to the NCAA membership. Wilfert has worked in the health education field for more than 30 years to empower individuals to make informed choices for lifelong health and success. Lydia Bell is the associate director of research for academic performance at the NCAA. In this role, Bell assists in all aspects of development and analysis of research on current and former student-athlete academic performance and well-being. Before joining the NCAA, she was an assistant professor of practice and director of Project SOAR in the Center for the Study of Higher Education at the University of Arizona. She received her Ph.D. in language, reading and culture and M.A. in higher education from Arizona, and an A.B. in government and legal studies and sociology from Bowdoin College.

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Mind, Body and Sport: Substance use and abuse

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The prevalence of mood-altering substances on campus - alcohol, marijuana, narcotics, stimulants, depressants, hallucinogens - has been tracked by campus prevention professionals for decades, evoking varying degrees of effort and success to reduce use and negative consequences.

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Abstract

Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the history of doping in athletes, the effects of different classes of substances used for doping, side effects of doping, the role of anti-doping organizations, and treatment of affected athletes. Doping goes back to ancient times, prior to the development of organized sports. Performance-enhancing drugs have continued to evolve, with "advances" in doping strategies driven by improved drug testing detection methods and advances in scientific research that can lead to the discovery and use of substances that may later be banned. Many sports organizations have come to ban the use of performance-enhancing drugs and have very strict consequences for people caught using them. There is variable evidence for the performance-enhancing effects and side effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

Keywords: doping, athletes, steroids, drug abuse, mental illness

Introduction

Doping, defined as use of drugs or other substances for performance enhancement, has become an important topic in virtually every sport 1 and has been discovered in athletes of all ages and at every level of competition. 2- 4 See Table 1 for rates of use of a variety of substances, whether doping agents or recreational substances, among different populations of athletes as reported in various recent research studies. 5- 10 Of note, self-reports are generally felt likely to yield under-reported figures. 5 Importantly, performance-enhancing drugs (PEDs) are not restricted to illegal drugs or prescription medications, such as anabolic steroids. 11 They include dietary supplements and a variety of compounds that are available at grocery and health food stores and online. 12

Table 1

Substance

Athlete population

Percentage of athletes using substance

Alcohol

College athletes (self report)

75%-93% for male athletes; 71%-93% for female athletes over past year 6
85% over past year 7

College athletes (self report)

0.2%-5% for males depending on sport; 0.0%-1.6% for females depending on sport over past year 7, 8

Professional football players (self report)

9% used at some point in career 8

Competitive power lifters (self report)

67% used at some point in career 8

College baseball players (self report)

40%-50% over past year 10

Professional baseball players (self report)

35%-40% over past year 10

Professional football players (self report)

20%-30% over past year 10

Drug abuse in the athlete population may involve doping in an effort to gain a competitive advantage. Alternatively, it may involve use of substances such as alcohol or marijuana without the intent of performance enhancement, since athletes may develop substance use disorders just as any nonathlete may.

Athletes may turn to substances to cope with numerous stressors, including pressure to perform, injuries, physical pain, and retirement from a life of sport (which happens much earlier than retirement from most other careers). 13 Additionally, athletes may be significantly less likely to receive treatment for underlying mental illnesses such as depression. 14 Athletes receive comprehensive treatment and rehabilitation for physical injuries, but this may be less often the case for mental illness, because of their sometimes viewing mental illness as a sign of weakness. 14 Untreated mental illness is often associated with substance use, perhaps in an effort to self-treat. Alternatively, substances of abuse may cause mental illness. 15

We will especially focus on doping in this review, which specifically aims to serve as a single paper that provides a broad overview of the history of doping in athletes, the effects of different classes of drugs used for doping, side effects of doping, the role of anti-doping organizations, and the treatment of affected athletes.

Materials and methods

For this review, we identified studies through a MEDLINE search. Search terms included the following, individually and in combination: "doping", "athletes", "steroids", "drug abuse", "mental illness", "drug testing", "anti-doping", "psychiatry", "sports", "depression", "substance abuse", "substance dependence", "addiction", "history", "side effects", "drug testing", "treatment", "androgens", "testosterone", "growth hormone", "growth factors", "stimulants", "supplements", "erythropoietin", "alcohol", "marijuana", "narcotics", "nicotine", "Beta agonists", "Beta blockers", "diuretics", "masking agents", "gene doping", "National Collegiate Athletic Association", and "World Anti-Doping Agency". We restricted results to the English language and used no date restrictions. We retrieved all papers discussing drug abuse in athletes. We reviewed the findings of each article, and reviewed the references of each paper for additional papers that had been missed in the initial search and that might include findings relevant to the scope of our review. Ultimately, 67 manuscripts or chapters were felt relevant and representative for inclusion among those referenced in this paper.

History of doping in athletes

The belief that doping is only a recent phenomenon that has arisen solely from increasing financial rewards offered to modern day elite athletes is incorrect. 16 In fact, doping is older than organized sports. Ancient Greek Olympic athletes dating back to the third century BC used various brandy and wine concoctions and ate hallucinogenic mushrooms and sesame seeds to enhance performance. Various plants were used to improve speed and endurance, while others were taken to mask pain, allowing injured athletes to continue competing. 17- 19 Yet, even in ancient times, doping was considered unethical. In ancient Greece, for example, identified cheaters were sold into slavery. 1

The modern era of doping dates to the early 1900s, with the illegal drugging of racehorses. Its use in the Olympics was first reported in 1904. Up until the 1920s, mixtures of strychnine, heroin, cocaine, and caffeine were not uncommonly used by higher level athletes. 16

By 1930, use of PEDs in the Tour de France was an accepted practice, and when the race changed to national teams that were to be paid by the organizers, the rule book distributed to riders by the organizer reminded them that drugs were not among items with which they would be provided. 20

In the 1950s, the Soviet Olympic team began experimenting with testosterone supplementation to increase strength and power. 16 This was part of a government-sponsored program of performance enhancement by national team trainers and sports medicine doctors without knowledge of the short-term or long-term negative consequences. Additionally, when the Berlin Wall fell, the East German government's program of giving PEDs to young elite athletes was made public. 1 Many in the sporting world had long questioned the remarkable success of the East German athletes, particularly the females, and their rapid rise to dominance in the Olympics. Young female athletes experienced more performance enhancement than did male athletes. Unfortunately, they also suffered significant and delayed side effects, including reports of early death in three athletes. 19

The specific substances used to illegally enhance performance have continued to evolve. 21 The "advances" in doping strategies have been driven, in part, by improved drug testing detection methods. 21 To avoid detection, various parties have developed ever more complicated doping techniques. 21 Further, new doping strategies may result from advances in scientific research that can lead to the discovery and use of substances that may later be banned. Over the past 150 years, no sport has had more high-profile doping allegations than cycling. 16 However, few sports have been without athletes found to be doping.

Many sports organizations have come to ban the use of PEDs and have very strict rules and consequences for people who are caught using them. The International Association of Athletics Federations was the first international governing body of sport to take the situation seriously. 22 In 1928, they banned participants from doping, 22 but with little in the way of testing available, they had to rely on the word of athletes that they were not doping. It was not until 1966 that the Federation Internationale de Football Association and Union Cycliste Internationale joined the International Association of Athletics Federations in the fight against drugs, closely followed by the International Olympic Committee (IOC) the following year. 23

The first actual drug testing of athletes occurred at the 1966 European Championships, and 2 years later the IOC implemented their first drug tests at both the Summer and Winter Olympics. 24 Anabolic steroids became even more prevalent during the 1970s, and after a method of detection was found, they were added to the IOC's prohibited substances list in 1976. This resulted in a marked increase in the number of doping-related disqualifications in the late 1970s, 24 notably in strength-related sports, such as throwing events and weightlifting.

While the fight against stimulants and steroids was producing results, 24 the main front in the anti-doping war was rapidly shifting to blood doping. 25 This removal and subsequent reinfusion of an athlete's blood in order to increase the level of oxygen-carrying hemoglobin has been practiced since the 1970s. 25 The IOC banned blood doping in 1986. 25 Other ways of increasing the level of hemoglobin were being tried, however. One of these was erythropoietin. 25 Erythropoietin was included in the IOC's list of prohibited substances in 1990, but the fight against erythropoietin was long hampered by the lack of a reliable testing method. An erythropoietin detection test was first implemented at the 2000 Olympic Games. 25

In the 1970s and 1980s, there were suspicions of state-sponsored doping practices in some countries. The former German Democratic Republic substantiated these suspicions. 25 The most prominent doping case of the 1980s concerned Ben Johnson, the 100 meter dash champion who tested positive for the anabolic steroid stanozolol at the 1988 Olympic Games in Seoul. 25 In the 1990s, there was a noticeable correlation between more effective test methods and a drop in top results in some sports. 25

In 1998, police found a large number of prohibited substances, including ampoules of erythropoietin, in a raid during the Tour de France. 25, 26 The scandal led to a major reappraisal of the role of public authorities in anti-doping affairs. As early as 1963, France had been the first country to enact anti-doping legislation. Other countries followed suit, but international cooperation in anti-doping affairs was long restricted to the Council of Europe. In the 1980s, there was a marked increase in cooperation between international sports authorities and various governmental agencies. Before 1998, debate was still taking place in several discrete forums (IOC, sports federations, individual governments), resulting in differing definitions, policies, and sanctions. Athletes who had received doping sanctions were sometimes taking these sanctions, with their lawyers, to civil courts and sometimes were successful in having the sanctions overturned. The Tour de France scandal highlighted the need for an independent, nonjudicial international agency that would set unified standards for anti-doping work and coordinate the efforts of sports organizations and public authorities. The IOC took the initiative and convened the First World Conference on Doping in Sport in Lausanne in February 1999. Following the proposal of the Conference, the World Anti-Doping Agency (WADA) was established later in 1999.

Performance-enhancing effects of substances used by athletes

There is a research base demonstrating that many doping agents are in fact performance-enhancing. However, some substances (eg, selective androgen receptor modulators, antiestrogens, and aromatase inhibitors), used in an effort to enhance performance, have little data to back up their effectiveness for such a purpose. Note that the studies cited in this paper are chosen as being historically important or representative of the bulk of the research on the topic, and the broad overview provided in this paper does not aim to cite all evidence on the effects of these substances. Additionally, research on this topic is limited by the difficulty in performing ethical studies due to the high doses of doping agents used, potential side effects, and lack of information on actual practice.

Androgens

Androgens include exogenous testosterone, synthetic androgens (eg, danazol, nandrolone, stanozolol), androgen precursors (eg, androstenedione, dehydroepiandrosterone), selective androgen receptor modulators, and other forms of androgen stimulation. The latter categories of substances have been used by athletes in an attempt to increase endogenous testosterone in a way that may circumvent the ban enforced on natural or synthetic androgens by WADA.

Amounts of testosterone above those normally found in the human body have been shown to increase muscle strength and mass. For example, a representative randomized, double-blind study involved 43 men being randomized to four different groups: testosterone enanthate 600 mg once per week with strength training exercise; placebo with strength training exercise; testosterone enanthate 600 mg once per week with no exercise; and placebo with no exercise. This was a critical study in demonstrating that administration of testosterone increased muscle strength and fat-free mass in all recipients, and even moreso in those who exercised. 27 A second study from the same investigators 5 years later further demonstrated a dose-response relationship between testosterone and strength. 28 Another double-blind trial of exogenous testosterone involved 61 males randomized to five different doses of testosterone enanthate, ranging from 25 mg to 600 mg, along with treatment with a gonadotropin-releasing hormone agonist to suppress endogenous testosterone secretion. That study demonstrated findings similar to the previous one, in showing a dose-dependent increase in leg power and leg press strength, which correlated with serum total testosterone concentrations. 29

Androgen precursors include androstenedione and dehydroepiandrosterone (DHEA). We found no evidence that androstenedione increases muscle strength. 30 DHEA is available as a nutritional supplement that is widely advertised in body building magazines as a substance that will improve strength. However, results from placebo-controlled studies of DHEA in males have been mixed. 30, 31 One study involved 40 trained males being given DHEA 100 mg per day, androstenedione, or placebo, with no resulting differences in muscle mass or fat-free mass between groups. 30 A second study involved nine males and ten females randomized to receive DHEA 100 mg daily or placebo for 6 months, who were then crossed over to the other group for a further 6 months. The males but not females showed increased knee and lumbar back strength during DHEA treatment. 31

Selective androgen receptor modulators are not approved for use in humans in any country, but athletes are able to obtain these substances on the Internet. 32 No studies were found looking at the effects of selective androgen receptor modulators on muscle strength or mass in humans.

Other forms of androgen stimulation include exogenous human chorionic gonadotropin, antiestrogens such as tamoxifen, clomiphene, and raloxifene, and aromatase inhibitors such as testolactone, letrozole, and anastrozole. These substances may result in increased serum testosterone. 33 However, we found minimal research demonstrating an effect on muscle strength. 34 While androgens of different forms have been shown to improve muscle strength and mass, they have not been shown to improve whole body endurance per se. 35

Growth hormone and growth factors

Growth hormone and growth factors are also banned by WADA. Research shows recombinant human growth hormone to increase muscle mass and decrease adipose tissue. One representative study randomized male recreational athletes to growth hormone 2 mg/day subcutaneously, testosterone 250 mg weekly intramuscularly, a combination of the two treatments, or placebo. 36 Female recreational athletes were randomized to growth hormone 2 mg daily or placebo. In both males and females, growth hormone was associated with significantly decreased fat mass, increased lean body mass, and improved sprint capacity (although with no change in strength, power, or endurance). Sprint capacity improvement was even greater when growth hormone and testosterone were coadministered to males.

Growth factors include insulin-like growth factor and insulin. They are presumed to have similar effects to growth hormone, but have not been studied in athletes. 37 Athletes use these substances because of their apparent anabolic effect on muscle. 37

Stimulants

Stimulants include amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, dimethylamylamine, cocaine, fenfluramine, pemoline, selegiline, sibutramine, strychnine, and modafinil. Research has shown stimulants to improve endurance, increase anaerobic performance, decrease feelings of fatigue, improve reaction time, increase alertness, and cause weight loss. 38 Of note, while WADA bans stimulants as a class, it does allow use of caffeine. Energy beverages now often include a variety of stimulants and other additives including not only caffeine, but also the amino acids taurine and L-carnitine, glucuronolactone, ginkgo biloba, ginseng, and others. 39 Caffeine content can be up to 500 mg per can or bottle. The potential performance benefits of the other ingredients in energy beverages are unclear. For example, taurine may improve exercise capacity by attenuating exercise-induced DNA damage, but the amounts found in popular beverages are probably far below the amounts needed to be of performance-enhancing benefit. 39

Of note, the number of athletes, especially at top levels of competition, reported to be using stimulant medications has markedly increased in recent years. In the USA, the National Collegiate Athletic Association acknowledged that the number of student athletes testing positive for stimulant medications has increased three-fold in recent years. 40 There has also been concern about inappropriate use of stimulants in major league baseball in the USA. According to a report released in January 2009, 106 players representing 8% of major league baseline players obtained therapeutic use exemptions for stimulants in 2008, which was a large increase from 28 players in 2006. 41 Therapeutic use exemptions allow athletes to take otherwise banned and performance-enhancing substances if their physician attests that they should for medical reasons.

Nutritional supplements

Nutritional supplements include vitamins, minerals, herbs, extracts, and metabolites. 39 Importantly, the purity of these substances cannot be guaranteed, such that they may contain banned substances without the athlete or manufacturer being aware. Studies have shown that many nutritional supplements purchased online and in retail stores are contaminated with banned steroids and stimulants. 42 Thus, athletes could end up failing doping tests without intentionally having ingested banned substances. 42 Creatine is not currently on the WADA banned list and is the most popular nutritional supplement for performance enhancement. 3 Studies demonstrate increased maximum power output and lean body mass from creatine. 43, 44 As such, some allowable nutritional supplements may have ergogenic effects, but may have insufficient evidence supporting their ergogenic properties to rise to the level of being banned.

Methods to increase oxygen transport

Substances athletes use to increase oxygen transport include blood transfusions, erythropoiesis-stimulating agents such as recombinant human erythropoietin and darbepoetin alfa, hypoxia mimetics that stimulate endogenous erythropoietin production such as desferrioxamine and cobalt, and artificial oxygen carriers. Transfusions and erythropoiesis-stimulating agents have been shown to increase aerobic power and physical exercise tolerance. 45 However, the ergogenic effects of the other agents are debatable. 45

Other recreational drugs

Other recreational drugs that may be used in an attempt to enhance performance include alcohol, cannabinoids, narcotics, and nicotine. 13 WADA does not currently ban nicotine but bans cannabinoids and narcotics. Alcohol is banned in six sports during competition only. All of these substances may be used by athletes to reduce anxiety, which may be a form of performance enhancement, but we found little research looking at actual performance enhancement from these agents. Narcotics are used to decrease pain while practicing or playing. Nicotine may enhance weight loss and improve attention. 46

Beta agonists

There is debate as to whether beta-2 adrenergic agonists, for example, albuterol, formoterol, and salmeterol, are ergogenic. 47 There is anecdotal evidence of improvements in swimmers who use these substances prior to racing. 48 Additionally, oral beta agonists may increase skeletal muscle, inhibit breakdown of protein, and decrease body fat. 48 However, there is some evidence suggesting that swimmers may have a relatively high prevalence of airway hyperresponsiveness due to hours spent breathing byproducts of chlorine, such that beta agonists may be needed to restore normal, not enhanced, lung function. 49

Beta blockers

Beta blockers such as propranolol result in a decreased heart rate, reduction in hand tremor, and anxiolysis. These effects may be performance-enhancing in sports in which it is beneficial to have increased steadiness, such as archery, shooting, and billiards. 48

Other prescription drugs

Diuretics and other masking agents may be used as doping agents. 12 Diuretics can result in rapid weight loss such that they may be used for a performance advantage in sports with weight classes, such as wrestling and boxing. 12 Diuretics may also be used to hasten urinary excretion of other PEDs, thereby decreasing the chances that athletes will test positive for other banned substances that they may be using. 12 Masking agents in general conceal prohibited substances in urine or other body samples, and include diuretics, epitestosterone (to normalize urine testosterone to epitestosterone ratios), probenecid, 5-alpha reductase inhibitors, and plasma expanders (eg, glycerol, intravenous administration of albumin, dextra, and mannitol). 50

Glucocorticoids are sometimes used by athletes in an attempt to enhance performance because of their anti-inflammatory and analgesic properties. 12 However, there is minimal research to show any performance benefits of this class of drugs.

Athletes may also use phosphodiesterase-5 inhibitors in an attempt to attain increased oxygenation and exercise capacity, since they have vasodilatory effects. 51 However, again, little research exists to support a performance benefit from these substances.

Psychiatric medications, including antidepressants, anxiolytics, antipsychotics, and anticonvulsants, are generally not on the WADA banned list. 14 Bupropion is an antidepressant that is on the WADA 2014 monitoring list, meaning WADA is monitoring for any concerning trends of inappropriate use. One small study of nine males suggested that bupropion, when used acutely in warm environments, may allow athletes to push themselves to higher body temperature and heart rates without perceiving greater effort. 52 Otherwise, there is very minimal evidence that any of these classes of psychiatric medications enhance performance. 14

Nondrug performance-enhancing measures

Gene doping is a concerning potential method of nondrug performance enhancement and is banned by WADA. The potential to directly affect strength and endurance through gene manipulation has been demonstrated in laboratory mice, but no human athletes thus far have been found to be using this method. 16

Additionally, athletes may legally attempt to improve physical performance in a number of nondrug ways. 53 These have varying degrees of research into their effectiveness and safety, and include hypoxia induction techniques. 53 For example, athletes may train at high altitudes, which can result in erythrocytosis. Some studies suggest that a high-low method of sleeping at high altitude followed by training at low altitude is a better training strategy than training or sleeping at either high or low altitudes alone. 54 Some athletes have tried sleeping at simulated high altitude by using low oxygen tents. Athletes may also make dietary changes to try to increase hemoglobin levels. 55, 56

Side effects of substances used by athletes

It is presumed that most if not all doping agents have potential short-term and/or long-term side effects. Unfortunately, given the high doses of these agents used by athletes, it is difficult to confirm such effects. It would be unethical to give dosages as high as those used by athletes for performance enhancement effects to participants in research studies. 16 Knowledge about side effects may be gleaned from empirical observation, reports of admitted users, and effects in patients prescribed such agents for medical conditions. Table 2 lists the potential side effects of various forms of doping. 57- 59

Table 2

Substance/method

Potential side effects

Androgens (eg, testosterone, danazol, nandrolone, stanozolol)

* Reproductive: diminished spermatogenesis and gynecomastia in men, decreased fertility, decreased testicular size, possible benign prostatic hypertrophy or prostate cancer
* Cardiovascular: decreased high-density lipoprotein cholesterol, increased low-density lipoprotein cholesterol
* Hepatic: hepatotoxicity
* Neuropsychiatric: depression, mania, psychosis, aggression
* Other: hastened epiphyseal closure in adolescents, acne, hirsutism, temporal hair recession, clitoromegaly, voice deepening, and oligomenorrhea/amenorrhea in women, infections (abscesses at injection sites, septic arthritis, and hepatitis/human immunodeficiency virus from sharing needles), tendon rupture

Growth hormone and growth factors (eg, insulin-like growth factor, insulin)

* I nsulin resistance, hyperglycemia, diabetes mellitus, cardiomegaly, hastened epiphyseal closure in adolescents, myopathy, hypertension, edema, carpal tunnel syndrome

Stimulants (eg, amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, cocaine)

* Hypertension, tachycardia, myocardial infarction, stroke, heat stroke, weight loss, rhabdomyolysis, headache, nausea, tremor, insomnia, anxiety/panic attacks, agitation, aggression, psychosis

Methods to increase oxygen transport (eg, blood transfusions, recombinant human erythropoietin, darbepoetin alfa)

* Myocardial infarction, stroke, deep vein thrombosis/pulmonary embolism, hypertension, antibody-mediated anemia

Nutritional supplements (eg, vitamins, minerals, herbs, extracts, metabolites)

* Depends on the components
* Creatine: acute interstitial nephritis, more rapid progression of chronic kidney disease 57, 58

Other recreational drugs

* Alcohol: sedation, decreased concentration and coordination
* Cannabinoids: reduced alertness, impaired short-term memory, psychomotor retardation, dysphoria, anxiety, psychosis 59
* Narcotics: physical dependence, nausea/vomiting, constipation, decreased concentration and coordination, fatigue
* Nicotine: chronic use associated with cardiovascular disease, chronic obstructive lung disease, and many types of cancer

Beta agonists (eg, albuterol, formoterol, salmeterol))

* Tachycardia, arrhythmias, hypokalemia, hyperglycemia, tremor

Beta blockers (eg, propranolol)

* Bradycardia, increased airway resistance, decreased endurance

Other prescription drugs

* Diuretics and other masking agents: dizziness, muscle cramps, rash, gout, renal insufficiency, electrolyte imbalances, gynecomastia (spironolactone)
* Glucocorticoids: hyperglycemia, fluid retention, depression, mania, psychosis, chronic use may result in reduced muscle mass/weakness, osteoporosis, diabetes mellitus, hypertension, weight gain, central obesity, and cataracts

Gene doping

* Unknown

Anti-doping organizations, drug testing in athletes, and rules

Drug testing typically occurs only in organized, competitive sports. At the college level, organizations such as the National Collegiate Athletic Association 60 and individual member institutions conduct standard drug testing programs and enforce penalties for positive tests.

Elite athletes competing at international and national levels are subject to standardized anti-doping guidelines under the auspices of WADA and related national organizations. WADA is the international independent agency that publishes the World Anti-Doping Code, which is the document harmonizing anti-doping policies in all sports and all countries. 61 The Code was first adopted in 2003 and became effective in 2004. The Code sets forth specific anti-doping rules and principles that are to be followed by the anti-doping organizations responsible for adopting, implementing, or enforcing anti-doping rules within their authority, including the IOC, International Paralympic Committee, international sport federations (for example, the International Cycling Union), major event organizations, and national anti-doping organizations (for example, the US Anti-Doping Agency).

WADA revises and publishes its list of banned substances approximately annually. It specifies those banned substances and methods that are prohibited at all times (both in-competition and out-of-competition) because of their potential to enhance performance in future competitions or their masking potential, and those substances and methods that are prohibited in-competition only. The list may be expanded by WADA for a particular sport.

WADA has also taken the lead in the development of the athlete biological passport concept. 61 WADA's athlete biological passport operating guidelines took effect in 2009. The fundamental principle of the athlete biological passport is based on the monitoring of selected parameters over time that indirectly reveal the effect of doping, as opposed to the traditional direct detection of doping by analytical means. This concept gained momentum as a result of questions raised during the 2006 Olympic Winter Games surrounding suspensions of athletes by their federations following health checks that reported high hemoglobin levels. An athlete's passport purports to establish individual baseline hormone/blood levels, which are monitored over time for significant changes. A positive test result would consist of too dramatic a change from the established individual baseline. This approach is intended to protect athletes from false-positive tests resulting from naturally occurring high levels of endogenous substances, while catching those attempting to cheat by using naturally occurring substances.

In the event that an athlete and his or her medical providers feel it necessary, for documented medical reasons, that he or she continue to take a banned substance, WADA may consider granting a therapeutic use exemption, a concept mentioned earlier. A therapeutic use exemption must be on file before an athlete tests positive for the substance allowed by that therapeutic use exemption.

Treatment of affected athletes, including counseling and psychiatric support

The first level of addressing the problem of drug abuse by athletes is prevention. 13 Drug screening is used in higher-level athletics both to deter athletes from using drugs and to punish and offer opportunities for rehabilitation to those who are found to have done so. Didactic education is another method aimed at prevention. 62 On the one hand, some authors and clinicians feel that among the most effective preventive strategies for drug abuse in sports is frequent, accurate, very closely observed, truly random urine drug testing. 13, 63 However, some view drug testing as ineffective at preventing use of PEDs. 64 The argument for the latter is that these interventions target doping behavior rather than athlete attitudes. Athletes ultimately focus on their performance, and thus may view doping as rational behavior. 63 Moreover, knowledge of the potentially dangerous consequences from doping imparted via didactic education does not necessarily dissuade athletes. For example, in 1997, Bamberger and Yaeger surveyed 198 Olympic athletes. When asked if they would use PEDs under the hypothetical conditions of knowing they would not be caught and knowing their use would result in victory, 195 of 198 responded "yes". Moreover, if the caveat was added that they would die within 5 years, 61% of the athletes still said they would use them. 65

There is little research available to guide counseling and psychiatric approaches to treatment of athletes who abuse drugs. 64 However, motivational interviewing approaches have been suggested for athletes with drug abuse or doping problems, since athletes may often present in the precontemplation stage of change. 13, 64 Important elements of motivational interviewing include: 64

1. Developing discrepancies between where the athlete wants to go in life after sport and the impact that continued use of the substance might have on those goals. During this process, the provider helps athletes to clarify conflict among their values, motives, interest, and behaviors.

2. Rolling with resistance. When resistance inevitably occurs, providers should avoid arguing with athletes, as that can exacerbate resistance to change. The provider may "agree to disagree" on certain points with some athletes. Providers may propose or "wonder about" certain alternative viewpoints or actions, but they do not impose or insist upon them.

3. Encouragement of self-efficacy. Athletes may need to shift their viewpoint from one of being willing to do whatever it takes to win, to acknowledging that they would use PEDs only if ultimately incapable of succeeding without them (with the hope that athletes will never get to that point). If an athlete is physically dependent on a drug, then additional strategies may be needed. These may include pharmacologic interventions such as naltrexone, acamprosate, or disulfiram for alcohol dependence, or buprenorphine for opiate dependence. 13 Additionally, providers should assess for comorbid mental illness, since co-occurrence of physical dependence and mental illness is commonplace. 13 Any underlying mental illness should be treated. 13 A recent review paper on the epidemiology of mental illness in athletes noted that some mental illnesses such as depression are probably as common in athletes as nonathletes. 14 Twelve-step facilitation, cognitive behavioral therapy, and network therapy are also approaches that may be helpful for athletes who are abusing drugs, although studies are preliminary. 10, 13, 66

Conclusion and suggestions

Drug abuse in athletes is a significant problem that has many potential underlying causes. The drive to be the best in sport dates to ancient times, as does the use of performance-enhancing substances. With the ever-mounting pressures faced by athletes, it is not surprising that drug abuse by athletes exists across essentially all sports and age groups.

Suggestions for those undertaking research and clinical work with athletes include:

1. If providers become aware of an athlete using PEDs, they should educate the athlete about the potential risks of continued use, regardless of any evidence that suggests this may not be influential for all athletes. Providers should encourage discontinuation of the abused substance(s).

2. There is great variance in drug testing programs in different sports and at different levels of competition. 13 More high-quality, prospective, randomized trials should be undertaken to determine the deterrent efficacy of various types of PED screening programs, and changes should be made to those types of screening programs found to be ineffective. 8

3. Physicians, trainers, coaches, parents, and others in the athlete entourage need to be well trained in recognizing the signs and symptoms of drug abuse, including changes in physical health and behaviors ( Table 3 ).

Table 3

Substance

Common signs and symptoms of use

Alcohol

Sedation, decreased concentration and coordination, disinhibition, slurred speech, vomiting

Anabolic steroids

Acne, rapid muscle gain, irritability, gynecomastia and hair loss in males, deepening of voice and facial hair in females, visible injection sites and cysts

Cannabinoids

Bloodshot eyes, increased appetite, slowed responses, cough, lack of motivation, paranoia

Opiates

Constricted pupils, sedation, slowed responses, slurred speech, constipation

Stimulants

Dilated pupils, anxiety, jitteriness, increased heart rate and blood pressure, loss of appetite, tics

4. The efficacy of education about PED use as a preventative measure needs further study. Early integration of well designed prevention curricula into sports programs may be beneficial. 8 However, as alluded to earlier, at least one preliminary study suggests that educational programs that solely emphasize the negative effects of PEDs may be ineffective for young athletes. 67

5. Mental health professionals should be included in the network of team doctors and other health care providers readily available to athletes. Psychiatrists are often helpful in developing strong drug prevention policies that emphasize education and treatment and not just sanctions. 13 Mental health care professionals should have a year-round presence with the athletes and teams with whom they are working so as to build trust. 13

6. Screening for and treatment of underlying mental illnesses such as depression that may contribute to self-treatment with drugs by athletes should be increased. The effectiveness of this screening should be studied.

7. Athletes who are using drugs are often skeptical of the medical field. This may be partly with good reason, as many health care professionals are unfamiliar with the mentality of athletes or common drug abuse patterns in this population. Accordingly, referral networks or team assistance programs consisting of health care professionals familiar with these issues should be established for athletes and teams. 62 The effectiveness of these models should be studied.

8. Research should examine differences in treatment approaches that may be needed for athletes who have been using drugs for a shorter versus longer period of time.

Trainers, coaches, and health care providers should provide evidence-based, safe alternatives to PED use, including optimal nutrition, weight-training strategies, and psychological approaches to improving performance, all of which may help with athletes' confidence in their natural abilities.

Footnotes

Disclosure
The authors report no conflicts of interest in this work.

References

46. Bailey JA, Averbuch RN, Gold MS. Cosmetic psychiatry: from Viagra to MPH. Directions in Psychiatry. 2009;29:1-13. [ Google Scholar]

64. Johnson MB, Sacks DN, Edmonds WA. Counseling athletes who use performance-enhancing drugs: a new conceptual framework linked to clinical practice. J Soc Behav Health Sci. 2010;4:1-29. [ Google Scholar]

Articles from Substance Abuse and Rehabilitation are provided here courtesy of Dove Press

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Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such ...

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Drugs will end up getting athletes kicked off and ineligible to play on sports team.