Drugs and sport

Chapter 4 Drugs and sport


The use of drugs to enhance sporting performance, and the fight by the authorities to try and detect those athletes seen as cheating by using performance-enhancing drugs, is a major problem within sport today. This is not just confined to professional sport but has consequences throughout the world of sport, both recreational and amateur, in that professional athletes often pave the way and set an example for recreational athletes. Despite increasing investment and technology aimed to detect drug abuse within the sport, the taking of drugs within professional sport is widespread1 and unfortunately, the authorities always seem to be one step behind the athletes.

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.

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.


The list of prohibited substances is produced by WADA every year and the reader is encouraged to read this list from the WADA website to at least become familiar with the different types of medications. It is beyond the scope of this book to discuss every form of medication but we will highlight the groups of drugs, their perceived effects, their side-effects and some common medications within this group to illustrate the size of the problem. It is important for each team physician, and the athletes themselves, to be 100% sure that every form of medication that they prescribe or take is not on the banned list. This is especially important for over-the-counter medications and for combinations of drugs that may contain small quantities of banned substances. It is also important to be aware that products that are ‘safe’ in one country may not be the same ‘safe’ products in another country. It is important to research all the ingredients of every product to be absolutely sure they are not on the banned list. One useful website for information to clarify whether a product is banned in or out of competition is the website www.didglobal.com and athletes should be encouraged to explore this website.

This list of prohibited substances and methods includes four categories, as follows:

Prohibited substances in and out of competition

Anabolic agents

Anabolic androgenic steroids occur naturally in the body and are secreted by the testes, ovaries and adrenal glands. They are responsible for the development of secondary sexual characteristics, however, testosterone promotes aggressive behaviour. Anabolic androgenic steroids (AASs) are derivatives of testosterone and many derivatives of testosterone have been used by athletes in the past (e.g. Androlone, stanozolol) and are banned. Athletes have used these drugs for strength events such as powerlifting, wrestling and sprinting and throwing in the track and field arena, but they are used widely and more worryingly, have drifted into the recreational field of sports and are known to be used by teenagers to develop muscle bulk.69

The drugs (or ‘gear’) are taken orally or intramuscularly either in a cyclical manner or taken via the two routes together (’stacking’) or in several preparations at once (’shot-gunning’). Occasionally a person may ‘short-gauge’ by injecting an individual muscle group specifically, as seen in bodybuilders. Most AASs are available on the internet or via gyms but there is a real problem in education of both professional and recreational athletes as to their short- and long-term effects.

The methods by which AASs affect the body are as follows:


The side-effects of anabolic steroids are extremely common. Most are reversible on cessation of the drug, however, some significant and some serious side-effects have been reported and some deaths are known. In one study, mortality among powerlifts because of steroid abuse was significantly higher than in a control population; 12.9% versus 3.1% and in another study, steroid use was shown to result in increased risk from violent death with impulsive, aggressive or depressive behaviour. This is often known as ‘roid rage’. There is also the risk of sharing infection if the drugs are administered intramuscularly and needles are shared. The risk of HIV, hepatitis and deep muscular abscess formation is well known among needle-sharers. The side-effects within both sexes include acne, alopecia, hypertension, irritability, mood swings with aggression and changes in libido. Among men, there is a reduced sperm count and reduction in testicular size as well as marked gynaecomastia. In women, there is hirsutism, menstrual irregularities, male pattern baldness and deepening of the voice, and in adolescents, there is increased body and facial hair, acne and premature closure of the epiphysis, resulting in stunted growth.

More specifically within the liver, in both sexes, abuse of anabolic steroids can cause liver disorders, including raised liver enzymes and hyperbilirubinaemia with biliary obstruction and jaundice, which can take up to 3 months to reverse. Similarly, the use of anabolic steroids can affect the cholesterol balance by raising the LDL and lowering the HDL/LDL ratio which is a risk factor towards heart disease and myocardial infarction.

Interestingly, cases of tumour formation in athletes using anabolic steroids, including Wilms tumour, prostate cancer and leukaemia have been reported, although a direct link has not been made. Blood pressure rises have also been associated with AAS intake and this, together with the cholesterol, puts the athlete at risk of coronary thrombosis. As mentioned above, acne formation together with sebaceous cysts and folliculitis is not uncommon among athletes taking anabolic steroids. Care should be taken when prescribing tetracycline or isotretinoin as treatment for these conditions, as these drugs may also aggravate pre-existing liver damage. Many of these side-effects are reversible on cessation of the drugs, however, it is important to educate the athletes of these side-effects and that they are putting themselves at risk of long-term problems.

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Jul 18, 2016 | Posted by in SPORT MEDICINE | Comments Off on Drugs and sport

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