The International Olympic Committee (IOC)² defines drug doping as ‘the use of a substance or method which is potentially harmful to an athlete’s health, or is capable of enhancing their performance, or the presence in the athlete’s body of a prohibited substance, or evidence of the use thereof, or evidence of the use of a prohibited method’.

It is interesting to point out that in the IOC’s definition, the first and most important aspect is to protect the athlete from the harmful effects of drugs. Obviously it is important to prevent the cheats from gaining improved performance; however, the overriding issue is to protect the athletes from being harmed by potentially dangerous drugs, when their insight into these effects may be clouded by the goal to achieve better performances.

Historically, performance-enhancing drugs date back many years, even to ancient times when Greeks, Romans and Egyptians used potions and herbal mixtures to try and improve performance. Doping was evidenced in the nineteenth century when stimulants were used, both for athletes and for military troops to help performance. A series of cyclists tragically died in both the Olympic events and the Tour de France, most notably Kurt Yensen in 1960 and Tommy Simpson in 1967. The IOC set up a medical commission in 1967 and started drug testing in the 1968 Mexico Olympics.

Anabolic steroids in the form of testosterone can be dated back to the 1920s and again were used in the Second World War by German troops, to enhance their aggressive nature. In the world of sport it was first alleged to be used in the 1950s in power events, such as lifting, throwing and wrestling. In the 1970s the IOC started testing for anabolic steroids. The most notable athlete who was found positive for this was Ben Johnson in the 1988 Seoul Olympics. In the late 1980s the set-up of the Australian Sports Drug Agency spread the net from in-competition testing to out-of-competition testing and random drug testing on athletes. At the same time, it became apparent that athletes were using other forms of doping, such as re-infusing blood and later in the 1990s, using erythropoietin (EPO) to enhance oxygen carrying capacity. Blood doping was banned by the IOC in 1986; in the Sydney Olympics EPO was detected for the first time.

In 1999, the World Anti-Doping Agency (WADA)³ was established under the initiative of the IOC and now represents the world authority and regulatory body on drug doping. On 1 January every year, it issues a complete list of prohibited drugs, with alterations from the previous year. It is important for the athlete as well as the team physician and sports physician to be familiar with any alterations that occur to this list.

So why do we test for drug doping?

This is done for three main reasons: first, to deter athletes from being tempted to take drugs that can not only cause the side-effects, but can have a serious implication on their short and long-term health. Second, it is performed to deter any cheating. The ethos of competitive sport is that it is performed on a baseline of equal opportunity and training benefit, rather than the ability to take drugs to enhance performance. Third, it performs as a reminder to athletes of the doping regulations, to ensure they avoid the inadvertent use of banned drugs.

Why do athletes take drugs?

With the knowledge that WADA is out there to detect medication abuse, and that there is both in- and out-of-competition testing that can occur at any time, and that it can be harmful to your health, why do athletes take the risk of taking performance-enhancing drugs? There is little evidence behind the reasons for this; however the following reasons may represent the multifactorial issues involved.

1. To succeed at all costs. For a professional athlete, the opportunity of reaching their goal and achieving greatness in their sporting activity, can override any other issue within their life, both short and long term. A survey was performed, just on Olympic athletes, in which the athletes were asked if they would take a banned but undetectable performance-enhancing drug that would ensure their success in competitions over the next 5 years, if they were offered the drug. Despite being fully informed of its dangers including its eventually leading to premature death, 60% said they would have no hesitation in taking the drug.⁴ This highlights the short-term goals that these athletes have to the detriment of any long-term consequences. One could call this a higher level of focus, but this may give some insight into why some athletes take banned medication to achieve their goals.

2. The knowledge that other athletes or their competitors are also taking medication. At the top level of sport the difference between winning and losing is so fine, that if you think or believe that your competitors are taking any form of ergogenic drugs, that you will have less chance of winning.

3. Expectation from others. There may be pressure from peers, coaches or parents to take medication to produce ‘your best performance’, so as to not let anybody else down.

4. Financial rewards and security. If taking medications means you win your goal and therefore receive financial rewards and security for your family and future, then there may be increased pressure to take these medications.

5. Lack of knowledge and education. This should not be an issue due to the increased awareness that athletes have and the access via the internet and other agencies to ask advice on medication, however, in some countries where access to legal and medication advice may be limited, ignorance may be a cause, although not a genuine reason.

It is likely that a combination of the above explains why athletes take banned medications. Ignorance, however, is no excuse, either from the athlete or his advising physician. However, the athlete needs to be made aware that at the end of the day it is he, and he alone, that is responsible for ingesting or taking any medication that may be banned. Likewise it is he, and he alone, who has to explain how medication got into his body, and it is he, and he alone, that will suffer the resulting consequences.

Getting access to banned drugs is not difficult from either the internet or from colleagues. The ingestion of anabolic steroids among bodybuilders is not uncommon,⁵ often as a result of dissatisfaction with body image in a similar way that anorexia can affect young females. The attraction of increased muscle tone and power to offset personality deficiencies can be attractive and the ‘stacking’ of medication, when two drugs are given together via different routes, either orally or intramuscularly, or the ‘shot-gunning’ of drugs when several preparations are taken at once, is practised. The practice of ‘short-gauge’, when injecting an individual muscle is performed to enhance that particular muscle definition, can result in ruptures of the collagen fibres and tendon tearing. Unfortunately, ‘plateauing’ occurs when there is failure to get further gain from taking medication, and the temptation then is to increase the dose, which unfortunately only results in further side-effects. As a result of this, ‘cycling’ is performed and drugs are taken for anything from 4–18 months with a 2–3 month rest period. Unfortunately, dependence, be it physical or psychological, can occur. It is important to tell athletes that there are no safe anabolic steroids.