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Possible Reasons To Accept PED Use in Sports

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Possible Reasons To Accept PED Use in Sports

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The debate over athletes' use of steroids and other performance-enhancing drugs has taken on newfound urgency in recent months.

A report by former Sen. George Mitchell, released in December, mentioned dozens of baseball players as having used steroids and described their use as "widespread." Track star Marion Jones pleaded guilty to lying to investigators about steroid use in October. And last summer, several riders were dismissed from the Tour de France on charges of using banned substances.

Those who oppose the use of steroids and other performance-enhancing drugs say that the athletes who use them are breaking the rules and getting an unfair advantage over others. Opponents of the drugs say the athletes are endangering not only their own health, but also indirectly encouraging youngsters to do the same.

Others maintain that it is hypocritical for society to encourage consumers to seek drugs to treat all sorts of ailments and conditions but to disdain drug use for sports. They say the risk to athletes has been overstated and that the effort to keep them from using performance-enhancing drugs is bound to fail.

Six experts on steroids and other performance-enhancing drugs recently took on the issue in an Oxford-style debate, part of the series Intelligence Squared U.S. The debates are modeled on a program begun in London in 2002: Three experts argue in favor of a proposition and three argue against.

In the latest debate, held on Jan. 15, the formal proposition was, "We should accept performance-enhancing drugs in competitive sports."

As the debate began, it was announced that former Olympics sprinter Ben Johnson, who was scheduled to argue in favor of allowing drugs, had pulled out on the advice of his lawyer because of his involvement in a lawsuit. Johnson was stripped of his gold medal in the 1988 Olympics after testing positive for steroids.

In a vote before the debate, 18 percent of audience members supported the motion to accept performance-enhancing drugs in competitive sports, and 63 percent opposed it. Nineteen percent were undecided. After the debate, 37 percent of audience members agreed with the proposition. Fifty-nine percent opposed it, and 4 percent remained undecided.

The event was held at the Asia Society and Museum in New York City and moderated by longtime sportscaster Bob Costas, who hosts NBCs Football Night in America and HBOs Inside the NFL.

Highlights from the debate:

The Intelligence Squared U.S. series is produced in New York City by The Rosenkranz Foundation and for broadcast by WNYC.

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A panel of experts debates whether performance-enhancing drugs should be allowed in competitive sports. One group says efforts to ban drugs from sports is bound to fail. Another group contends drugs harm athletes and encourages abuse. It's the latest in the series Intelligence Squared U.S.

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It's seen all too often these days: the meteoric rise of an athletic superstar, with fans that marvel at his strength, quickness and agility - and then, in an instant, the accusations of drug abuse and the subsequent investigations, probations, suspensions, and even permanent bans from the sport bring that rise to a screeching halt. For sports fans, it's often an impossible thing to understand; why would a professional athlete with millions of dollars on the line risk using performance-enhancing drugs (PEDs)?

The upside of PED use, especially in the short term, could literally be a multi-million dollar windfall, whether it's making a roster, or signing a huge contract. As Jose Canseco said, "I don't recommend steroids for everyone...but for certain individuals, I truly believe, because I've experimented with it for so many years, that it can make an average athlete a super athlete. It can make a super athlete incredible." Ultimately, for certain athletes using performance enhancing drugs is a calculated risk. But to come to terms with a risk, athletes need to evaluate not only the upside and the downside, but also their probability of being caught.

It begs the question - are athletes who use PEDs slackers looking for an easy edge that can lead to extra money, or, are they simply rational gamblers?

How Prevalent is Drug Use in Sports?

In 2005, Major League Baseball introduced a new, stricter drug policy that significantly increased the severity of penalties for steroid and amphetamine use, signaling the end of the so-called "steroid era." In order to accurately judge the prevalence of drug use in sports, the graphics below use this new policy as a benchmark date and summarizes ten years' worth of suspension data across the National Football League and Major League Baseball, which have much higher incidence rates than any other sports.

In Major League Baseball, 47 players have been suspended for using banned substances (including steroids, HGH, testosterone, and amphetamines) since 2005, with penalties ranging from ten-day suspensions to 162 games (or the entire regular season) in the case of famed infielder Alex Rodriguez. Of the 47 suspensions, 12 were for a mere ten days, while 19 were for 50 games; only three were for 100 games or more.

Notice that roughly half of these suspensions are attributed to "undisclosed" substances. Under Section 5.C of the MLB's drug policy, the Commissioner's Office may issue a statement announcing the suspension of a player that includes the length of the suspension and the specific substances(s) and the category of prohibited substance that the player tested positive for or used, possessed, sold, or distributed. For first offenses, the Commissioner's Office often keeps the substance involved undisclosed, putting the onus on the player to withhold or share that information with fans.

Meanwhile, in the NFL, teams vary widely in the amount of drug-related suspensions enforced by the team. By comparison, only 3 games have been missed by Pittsburgh Steelers players due to suspension, while the Indianapolis Colts dwarf that number with 54 games missed. Suspensions related to substance abuse saw a sharp uptick in the NFL beginning in 2012, jumping to 82 suspensions in 2012 from 21 suspensions in 2011. Note that, in the map below, 'third strikes' are calculated as 16-game bans. This represents the minimum term for a third offense under the NFL's old policy, which was replaced in 2014.

While undisclosed substances make up the vast majority of violations, it's interesting to note that alcohol and marijuana are not far behind when it comes to substance abuse suspensions. However, alcohol-related suspensions are on the decline since 2006, while marijuana-related suspensions have remained fairly constant over the last ten years.

It's also important to remember that the data reflects positive tests - not violations committed. As Gwen Knapp at Sports on Earth argues, "even now, drug testing is a sieve. It is in every sport. The tests are probably useful in skimming off the worst abuse, requiring juiced athletes to moderate their doses - a pretty valuable effect, if you think about this clearly. The tests may even scare off some potential users, but they won't clean up a sport."

Drug-related suspensions, performance enhancing or otherwise, have become commonplace throughout the past ten years. But what physical advantages make the risk of suspension so tempting to athletes?

The Effects of Drugs on Athletic Performance

Simply put, many of the drugs athletes take illegally are designed to increase their athletic performance.

For example, steroids and related hormones (such as testosterone) are used to increase muscle mass and strength by promoting testosterone production. Steroids can also aid with recovery from workouts by reducing and helping heal the damage to muscles that occurs during workout sessions, enabling an athlete to work out harder and more often while minimizing the risk of overtraining. Some athletes may also value the aggressive feelings that steroid use can lead to, casually referred to as "roid rage."

Marijuana provides an interesting case for the leagues. The leagues tend to treat marijuana as a recreational drug; athletes, however, have cited it as a substance that helps with recovery and pain management. With the athletes' perspectives in mind, marijuana is grouped with amphetamines, anabolic agents, and other PEDs in the graphic below.

However, steroids and its related hormones have visible side effects, especially when taken at higher than medically safe doses. Men may experience prominent breasts, baldness, shrunken testicles, infertility, and impotence, as well as acne, an increased risk of tendinitis, liver abnormalities, high blood pressure, aggressive behaviors, psychiatric disorders, and more.

To combat these side effects of anabolic steroid use, many athletes turn to anti-estrogens, which mask many of the telltale signs of steroid use. Anti-estrogens block the body's estrogen receptors, allowing athletes to protect their physique while engaging in steroid use.

One murky area of today's drug landscape concerns Adderall and related drugs. Adderall is typically prescribed for ADHD and other related conditions as a way to help the patient focus, remain calm, and maintain concentration. However, studies have shown that Adderall and related drugs can help improve hand-eye coordination, acceleration, and strength, which athletes could benefit from in addition to improved focus and concentration.

Currently, Adderall is allowed with the proper exemptions and with a doctor's note; otherwise, it's banned by every major sporting drug policy, and it frequently causes positive results for amphetamine testing. Controversy surrounds Adderall because there's no official lab test to diagnose ADD and ADHD, meaning athletes can obtain it legally without much effort. In fact, as Seattle Seahawks cornerback Richard Sherman once famously proclaimed, "about half the league takes [Adderall]."

While the goals of taking drugs - improving performance or recovery time - are largely the same across sports, the policies of major sports all vary considerably regarding their testing methods and penalties.

How Policies Compare Across the Major Sports

The NFL's drug policy differs from the MLB's, which differs from the NBA's, and so on, although the leagues' different drug policies do have some common elements. For the major sporting leagues in the United States, the drug policy is generally determined by the league and negotiated during collective bargaining (the NCAA, interestingly, relies principally on the testing programs at their affiliated institutions, which vary widely; however, the NCAA typically makes several visits throughout the year to ensure policies are being upheld). Here's a glimpse at how drug policies stack up across major sports.

Banned Substances

In general, all major sporting leagues conduct urine tests for the following:

Steroids and related hormones

Anti-estrogens and masking agents

Stimulants

Diuretics

Oxygen-transfer enhancers

The NFL and MLB also test for "drugs of abuse" (recreational drugs, i.e., marijuana, cocaine, etc) and the NBA, similarly, tests for cocaine, opiates, PCP, LSD and marijuana.

Testing Policies

Prior to entering the league, only the NFL requires pre-employment testing for all players, although in the MLB, all players are subjected to testing within five days of reporting for spring training. The NBA, NHL, NCAA, and all other professional leagues do not require pre-employment testing.

The frequency with which players are tested also varies greatly among professional leagues. In the NFL, all players are tested at least once per year, and the policy allows for targeted testing. Ten players per team are randomly tested each week, which continues during the playoffs for teams in the postseason. There may also be up to six offseason tests per player.

In the NBA, all players are subject to four random tests per season, and the league conducts reasonable-cause testing. Similarly, in the NFL, players are tested up to three times per year at random. Surprisingly, in the MLB, players are only subject to the test within five days of reporting for spring training and one other test on a randomly selected date, in addition to random tests in and out of season.

Violations and Penalties

If a player in any professional sport violates the league's drug policy, they are immediately suspended, and the length of suspension (or ban) depends on how many times the player has violated the drug policy.

In the NFL, a first violation leads to a minimum four-game suspension, while a third violation calls for a minimum 12-month suspension as well as disqualification from the Pro Bowl and other honors for the year.

In the NBA, the first positive result for PEDs earns a 10-game suspension; the fourth violation results in disqualification from the league. If a first-year player tests positive for drugs of abuse, he earns a one year suspension with a chance of reinstatement after one year; all other players are suspended for at least two years. However, as we'll discuss more below, players who come forward with a drug abuse problem receive league-paid treatment.

In the MLB, which strengthened its drug penalties in 2005, a player's first PED violation leads to a 50 game suspension without pay. A second violation leads to a 100 game suspension without pay, and a third violation leads to a lifetime ban. However, violations of drugs of abuse are treated clinically first, rather than through suspension.

Substance Abuse Programs

The professional leagues' approaches to their substance abuse programs vary as well. In the NFL, upon testing positive for a banned PED, the player is notified and the sample (which is split in half during the original phase of testing) is re-tested. Mandatory physical examinations are conducted to rule out naturally occurring high levels of chemicals (such as testosterone), and psychological examinations may also be conducted in case of suspected addition. The burden of proof is placed on the league during an appeals process.

In the NBA, meanwhile, the approach is much more recovery-focused. Players who come forward with their drug problems receive league-funded counseling from the Life Extension Institute, a 24-hour counseling center funded jointly by the NBA and the NBPA.

The MLB's approach takes a middle ground. Any player testing positive for a drug of abuse or found to possess such a drug must submit to an initial evaluation by medical personnel, who then determine whether or not a treatment program is necessary. The treatment program is agreed upon by medical personnel and the player, who can complete treatment as either an inpatient or an outpatient. Players who refuse to comply with the treatment program or who test positive for drugs of abuse after their evaluation and commitment to the treatment board may find themselves suspended or subject to other discipline.

How Policies Have Changed Over Time

Out of the major professional sports, the MLB has perhaps the most interesting history of drug policies. In January of 2005, under pressure from Congress, the MLB and its players announced a new drug agreement, in which first offenses earned a 10-day suspension and fourth violations earned a one-year ban.

However, later that year, players and owners revised that agreement to say that first violations resulted in a 50-game suspension, second violations resulted in 100-game bans, and third violations earned lifetime bans. In 2011, players and owners agreed to have blood testing for HGH during spring training in 2012, and blood testing has since been implemented during the regular season.

In March of 2014, players and owners announced that PED penalties would increase to 80 games for a first violation and 162 games (or a full season, including the postseason) for a second violation; all suspensions are without pay.

In 2007, the NFL announced stricter anti-doping policies, increasing the number of players tested and the number of random off-season tests; four years later, the NFL became the first major American sports league to approve blood testing for HGH, a policy which was finally implemented in 2014.

The NBA's drug policy has remained relatively constant over the years. The NHL first instituted a drug-testing policy for PEDs in 2005.

Conclusion

What causes an athlete to assume the risk of taking drugs? For an NBA player, maybe it's knowing that he can always come clean, so to speak, and get free treatment. For an NFL wide receiver, maybe it's the possibility that an easily obtained Adderall prescription could improve his reflexes. For an MLB player, maybe it's the fact that random tests are few and far between. Whatever the case, it's clear that positive drug tests are much more prevalent in today's sports than they were even ten years ago.

Many sports fans tend to take the black-and-white view of athletes and PEDs: professional athletes who take PEDs are labeled as poor decision makers, while athletes who reject PEDs are supporting the purity of the sport. However, athletes and PEDs actually lie more in a grey area. Given the profound effects that PEDs can have on your body, and the fact that marginal improvements in performance can be rewarded with multi-million dollar contracts, professional athletes who take PEDs might be more accurately labeled as calculated risk-takers - especially if their sport's drug testing policies are lax.

It's easy to ask (and answer) the question of why so many athletes get caught using PEDs. Instead, maybe we should begin asking ourselves - why so few?

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Exploring Topics in Sports: Why Do Athletes Risk Using Performance Enhancing Drugs?

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Exploring Topics in Sports: Why Do Athletes Risk Using Performance Enhancing Drugs?

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This video explains the side effects for using PED.

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Side Effects of Performance Enhancing Drugs (PED)

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I chose this picture because it shows the ways you can inject a PED.

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I chose this because it shows the changes more in depth

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I chose this picture because it shows how it changes your body.

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I also chose this because it shows you have to inject it into a vain like any other drug.

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I chose this picture cause it shows the effects on your body when using a Performance Enhancer.

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This article supported the reasons not to use for better performance

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Usain Bolt (centre) won the highly anticipated men's 100m event at the World Athletics Championships in Beijing. EPA/Hu Wong

The World Athletics Championships are currently in full flow. There was a collective sigh of relief earlier this week when Usain Bolt triumphed in the blue-riband men's 100m event over Justin Gatlin, who has previously served two bans for taking performance-enhancing drugs. Three other athletes in the final - Mike Rodgers, Tyson Gay and Asafa Powell - had also received previous bans for doping.

Almost everyone seems to be in agreement that performance-enhancing drugs are a blight on competitive sport. Two major claims underpin the aversion to this use of drugs. The first is that it is cheating. The second is that performance-enhancing drugs threaten the health of athletes.

But is either claim persuasive?

Using drugs is unfair

The problem is not that athletes try to gain an advantage over their competitors by enhancing their performance. We praise them for doing so, and it is the main goal that athletes set for themselves.

The complaint is not against performance enhancement, but the method by which it is achieved. The real concern behind the cheating claim is that athletes who use drugs are gaining an unfair advantage by accessing something not available to those who follow the rules. Those who use drugs prosper at the expense of those who play fair.

But things are murkier than they seem. How interested are we in fairness in sport? Athletes try to enhance their performance in many ways: coaches, psychologists, dietitians, massage therapists, training at high altitude, skin-tight swimsuits. All of these are used to gain an advantage, which is often unfair because, like drugs, they are available to some - wealthy athletes rather than cheats - but not to everyone.

The Tour de France, a sporting event well known for drug use, would not suddenly become a level contest if drug use disappeared. The race winner has his performance enhanced by the quality of his team. The Tour would only be a true test of individual riders if teams were banned.

Performance is also unfairly enhanced when governments fund athletes. Australia spent more than A$300 million to prepare athletes for the last Olympics. One of the major reasons for the British squad's success at the London Olympics was the large amount of financial support for the team.

The advantage gained through financial support might be different to that gained by drug use because it is not achieved through underhand means. But, if fairness is our goal, the source of the disadvantage is secondary.

So, if our objection to drugs is that they create an unfair advantage, consistency demands we apply the same standard to many other aspects of athletic competition. There seems to be no reasonable justification for drawing a line in the sand that places drug use on one side and the above-mentioned performance enhancers on the other.

Given that drugs are significantly cheaper than psychologists, permitting their use might actually level out the playing field for poorer athletes. Finally, if fairness is our major concern we can easily solve the problem by lifting the prohibition - thus making drugs available to all athletes.

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Performance-enhancing drugs and harm

The second objection is that drug use, unlike coaches and massage therapists, causes harm. Removing the prohibition might make things fairer but it would come at a heavy price.

In response to this objection, ethicist Julian Savulescu has argued that performance-enhancing drugs are not particularly dangerous, and if their use was no longer clandestine they would be safer still. It is difficult to know whether allowing drug use would lead to greater harm to athletes, but for the sake of argument let's assume Savulescu is wrong and accept that drug use is risky.

Is harm prevention a reasonable justification for limiting drug use in sport? One thing to bear in mind is that the very act of participating in many sporting activities is dangerous. Climbing, boxing, mixed martial arts, rugby, AFL, NFL, cricket, horse riding and many other sports can cause significant physical harms and sometimes result in death. There is no rush to ban people from climbing Mount Everest even though it is far more dangerous than taking EPO.

The NFL in America recently agreed to pay US$750 million to compensate for head injuries sustained by former players. Still, NFL athletes are allowed to collide with great force every week. It is certainly not obvious that performance-enhancing drugs cause more damage than high-impact sports.

I have not suggested that drug use should be permissible in sport because there might be persuasive arguments for proscription I have not addressed. For example, one might argue that using drugs is an attempt to win in the "wrong way". If so, we need to know why using other performance enhancers like caddies in golf or high-tech equipment is winning in the "right way".

But, the two claims most often used for prohibiting performance-enhancing drugs do not seem to provide sufficient grounds for a ban unless one is willing also to prohibit many other aspects of sport in the name of fairness and harm prevention.

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Why are we so opposed to performance-enhancing drugs in sport?

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The World Athletics Championships are currently in full flow. There was a collective sigh of relief earlier this week when Usain Bolt triumphed in the blue-riband men's 100m event over Justin Gatlin, who has previously served two bans for taking performance-enhancing drugs.

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I selected this article since it shows the long term effects and risks of using PED. It describes how much of a risk a certain drug puts you at for the future and the present.

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Where Families Find Answers on Substance Use | Partnership for Drug-Free Kids

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Performance-Enhancing Drugs Can Have Severe Long-Term Impact on Health: Expert

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Performance-enhancing drugs, which led to the suspension of 13 Major League Baseball players this week, can have severe long-term health effects, an expert tells Fox News.

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I chose this article be cause it shows the risks of using performance enhancers, but it also describes reasons athletes or even regular every day citizens may use them.

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The Society for Cardiovascular Angiography and Interventions

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Use of performance-enhancing drugs (PEDs), also known as "doping," isn't just a problem among elite athletes like Lance Armstrong. Unfortunately, PED use is widespread in high schools, colleges, and gyms across the United States. Many young people may feel pressured - by their peers or by their own ambitions - to use these drugs to improve their competitive performance, lose weight, or improve their own body image. Doping may raise the risk for a number of serious health-related problems, including increased risk of heart-related death and long-term cardiovascular damage.

Read on to learn more about PEDs and strategies for discouraging doping.

What Are Performance-Enhancing Drugs?

The most commonly used PEDs are anabolic androgenic steroids, which are known for their ability to build and strengthen muscle as well as reduce body fat.

Other common PEDs include:

Human growth hormone (HGH). Athletes and other young adults may use this drug to improve performance and increase muscle.

Human chorionic gonadotropin (HCG). Some men may use this hormone as a PED to increase testosterone if, as a result of anabolic steroid use, their bodies have stopped making high enough concentrations of testosterone naturally.

Erythropoietin (EPO). Endurance athletes may use this as a PED to increase the number of red blood cells in the body, thereby increasing oxygen in the bloodstream.

Stimulants. Amphetamines - including attention deficit- hyperactivity disorder (ADHD) medications - can function as PEDs when they are used to enhance mental performance and physical functioning.

Testosterone. Commonly used in conjunction with other PEDs, testosterone is particularly easy to abuse because it is applied to skin rather than injected.

Who Uses Performance-Enhancing Drugs?

Because of several highly publicized cases of doping among professional athletes, we tend to think of PEDs as a problem unique to professional sports. However, studies and news reports have revealed that athletes at less competitive levels - including high school and college-level sports - may feel pressured to dope to improve their chances of winning at their sport or being recruited.

Some teenage girls and young women may use PEDs for weight loss, while teenage boys and young men may use them to build muscle to improve their body image.

Research has found that more than one million Americans now use anabolic steroids, and that 5 percent of boys and 2 percent of girls in high school admit use of PEDs.

What Are the Cardiovascular Risks of Performance-Enhancing Drugs?

Different types of PEDs will carry different risks. More research is needed, but use of anabolic steroids seems to increase the risk of potentially fatal conditions, including heart attack and heart rhythm problems. Various PEDs can also raise blood pressure, and anabolic steroids can raise "bad" cholesterol while lowering "good" cholesterol levels, contributing to long-term heart disease. Among those at greatest risk are young athletes who have hypertrophic cardiomyopathy - typically an inherited thickening of the heart muscle. Anabolic steroids, which have also been shown to thicken the main pumping chamber of the heart, could worsen hypertrophic cardiomyopathy. While more research is necessary, it appears that in some cases use of PEDs in people with congenital (present at birth) heart disease can further increase the risk of sudden cardiac death. An important takeaway is that not all young athletes who have a congenital heart defect know that they do. Congenital heart disease can be diagnosed at any point in the life span, including well into adulthood. While sudden cardiac death is extremely rare in young athletes, discouraging use of PEDs may be one way to keep its occurrence as low as possible.

What Can I Do to Discourage Use of Performance-Enhancing Drugs?

If you are active in the lives of teens and young adults, you can help address the problem of doping fi rst by being aware of the problem yourself and communicating about it with other adults. Share with other parents, guardians, teachers, coaches, and so on, that student athletes at all levels may be taking the drugs, and that non-athletes (male and female) may be taking PEDs to try to improve their appearance.

Next, try to talk with the young people in your life about PEDs. Make them aware that use of performance-enhancing drugs may be dangerous to their short- and long-term health.

Signs to Watch For

Physical changes. PEDs may cause changes that are sudden and pronounced. Look for drastic changes in appearance, such as big gains in muscle in boys or breast enlargement; increased acne in boys and girls; and quick weight loss, excess body hair growth, and a deepening voice in girls.

Excessive concern about athletic performance. When taken to extremes, this may be a warning sign. Has the teen or young adult expressed feelings of extreme pressure to win? Has he or she made sudden gains in athletic performance that training alone can't quite explain?

Excessive concern about appearance. Has the teen or young adult expressed feelings of being too weak or overweight, accompanied by sudden physical changes?

Drastic emotional changes. Anabolic steroids can cause emotional changes, including angry outbursts referred to as "'roid rage." Though more research is necessary, there may also be a link between steroid use and depression and suicide.

Unaccounted-for expenditures. While news reports suggest PEDs can be easy to obtain and relatively cheap, you may still notice that your teen is spending money that isn't fully accounted for.

None of the above. Teens and young adults who are taking PEDs may not obviously exhibit any of the signs mentioned above, making use of the drugs diffi cult to identify. When you discuss drug and alcohol use with a teen or young adult, consider also mentioning the risks involved in using PEDs.

What Should I Do If I Have Other Questions?

Ask them. Get in touch with your healthcare provider and ask all of your questions. Any time you have health questions, the conversations you have with your doctor are the key to successful results. Ask every question you have.

To download the PDF of this information, click here.

We hope you will also use this website to learn more about your cardiovascular health and treatment options. SecondsCount.org was developed by the Society for Cardiovascular Angiography and Interventions (SCAI), the medical society for interventional cardiologists. Learn more about interventional cardiologists.
This website and the information contained herein does not, and is not intended to, constitute comprehensive professional medical services or treatment of any kind. This website and the information contained herein is not intended or designed to provide medical diagnosis or medical advice and must be considered as an educational service only.
References

1. Angell PJ, Chester N, Sculthorpe N., et al. Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. Br J Sports Med 2012; 46:i78-i84.

2. Higgins JP, Heshmat A, Higgins CL. Androgen abuse and increased cardiac risk. South Med J. 2012; 105(12):670-674.

3. Jones G, Jacobson G. The secret edge: steroids in high school. Dallas Morning News. 2005. http://www.dallasnews.com/sharedcontent/dws/spe/2005/steroids/index.html. Accessed January 21, 2013.

4. Martin C. Steroid use among high school girls on rise. Stamford Advocate. August 30, 2012. http://www.stamfordadvocate.com/sports/article/Steroid-use-among-high-school-girls-on-rise-3829152.php. Accessed January 21, 2013.

5. Szalavitz M. Performance-enhancing drugs O.K. in school, but not in sports, students say. Time. May 9, 2012. http://healthland.time.com/2012/05/09/performance-enhancing-drugs-o-k-in-school-but-not-in-sports-students-say/ Accessed January 24, 2013.

6. United States Anti-Doping Agency. Effects of steroids, doping and performance-enhancing drugs. United States Anti-Doping Agency. http://www.usada.org/effects-peds/ Accessed January 24, 2013.

7. World Anti-Doping Agency. 2013. World Anti-Doping Agency. http://www.wada-ama.org/ Accessed January 24, 2013.

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Performance-Enhancing Drugs & The Heart: Do You & Your Teens Know the Dangers of Doping?

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Use of performance-enhancing drugs (PEDs), also known as "doping," isn't just a problem among elite athletes like Lance Armstrong. Unfortunately, PED use is widespread in high schools, colleges, and gyms across the United States.

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This explains everything you need to know about athletes using drugs.

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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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NCAA´s Addresses Amount of Students Using PED.

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NCAA´s Addresses Amount of Students Using PED.

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I chose this because it describes and shows the amount of students using substances in College Football in the three divisions ( D1, D2, D3).

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NCAA.org - The Official Site of the NCAA

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The 2017 NCAA Student-Athlete Substance Use Survey, developed by the NCAA's research staff, provides the latest insights into the use of drugs, alcohol and tobacco by student-athletes. The study, released in June 2018, shows college athletes continue to make healthier decisions in many areas than their peers in the general student body.

The Student-Athlete Substance Use Survey has been conducted every four years since 1985 to assess the health and well-being trends among student-athletes. The report helps inform NCAA policy-makers with both current and historical information concerning levels of student-athlete drug and alcohol use. The study also analyzes why student-athletes do or do not use specific substances, when they started to use drugs, and their attitudes regarding drug use and drug testing.

The latest survey, based on the responses of approximately 23,000 student-athletes in all three divisions, indicates college athletes are using marijuana and amphetamines at a lower rate than the nonathlete college population. The percentage of student-athletes who reported drinking alcohol in the last year also showed a slight decrease from the previous survey in 2013, continuing a trend of a reduction in binge drinking since 2009. The most recent study also shows a significant decrease in the use of narcotic pain medication use with a prescription.

For more information on the Student-Athlete Substance Use Survey, view the full survey results or read the executive summary to see the most significant findings researchers identified. For questions regarding the survey instrument or the study procedures, contact Markie Cook at 317/917-6195 or mcook@ncaa.org. For questions related to Institutional Review Board issues or survey administration issues, contact Michael Miranda at 317/917-6304 or mmiranda@ncaa.org.

# data[].attributes.attachment_link.title
NCAA Student-Athlete Substance Use Study

# data[].attributes.attachment_link.description
The 2017 NCAA Student-Athlete Substance Use Survey, developed by the NCAA's research staff, provides the latest insights into the use of drugs, alcohol and tobacco by student-athletes. The study, released in June 2018, shows college athletes continue to make healthier decisions in many areas than their peers in the general student body.

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"Doping" - administer drugs in order to inhibit or enhance sporting performance.

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The Disturbing Truth About Doping in Sports