Many athletes self-medicate using various pharmacologic or nutritional substances in an effort to improve performance and speed recovery from injury. For example, over-the-counter anti-inflammatory medications are often used to limit pain and inflammation in an effort to reduce swelling, limit inflammation, and presumably speed healing from injury.

Other substances, some of which may be illegal, are used specifically in an effort to improve workload and performance.

Objective evaluations of ergogenic aids are often difficult to perform. Additionally, the scientific literature usually differs significantly from the advertising on many products (13).

There is no burden of proof on the manufacturer to prove efficacy or product content like there is for drugs (23).

Products may contain lower amounts of the product than those listed on the label, with some products having zero amount of the supposedly ergogenic substance, whereas others may be contaminated by the previous drug manufactured in the equipment (55).

Furthermore, the placebo effect can have a huge impact on the perceived benefits derived by the user.

Ergogenic aids can affect various aspects of physical fitness to improve performance. Six components of fitness that may be affected include aerobic fitness, anaerobic fitness, strength, body composition, psychological factors, and healing of injuries.

Aerobic metabolism uses oxygen, whereas anaerobic metabolism does not.

Aerobic fitness is the ability to produce work using aerobic metabolism, generally lasting longer than 1 minute and often lasting for hours, and is important especially in endurance events. It comprises two parts: maximal aerobic power and aerobic capacity.

Anaerobic fitness is important in activities generally lasting less than 1 minute and is fueled primarily through anaerobic metabolism.

Maximum strength, usually measured by the one-repetition maximum, refers to the amount of power that can be generated in a brief burst and is fueled by anaerobic metabolism.

Body composition can affect performance by increasing lean muscle mass. More muscle can perform more work, whereas decreasing body fat decreases the inert weight that has to be carried through space to the finish line.

Psychological factors may affect performance through various mind-body mechanisms including decreased perceptions of fatigue and pain.

Enhancing the healing of injuries and soreness promotes a more rapid return to training and maintenance of fitness.

Ergogenic aids can have side effects like any other substance.

Heart attacks, seizures, strokes, coma, and death have been attributed to the use of ergogenic products (13).

Injectable products carry the risk of disease transmission if needles are shared.

The athletic ideal is winning through natural training, which maximizes native ability and performance. However, this is often not the reality. Athletes are constantly caught in the dilemma of trying to keep up with what their competitors may be trying to do. Many athletes will try ergogenic aids even though the product has not been shown to work, has serious side effects, or is banned by the sport’s governing body ruling over the sport in which the athlete is competing.

In an attempt to keep the playing field level, various amateur and professional organizations have instituted drug policies. These policies are targeted toward substances that may be dangerous, illegal, and/or give an unfair competitive advantage. For example, the use of anabolic steroids had become so widespread by the 1964 Olympics that drug testing began at the 1968 Olympic Games in Mexico City, with the National Collegiate Athletic Association (NCAA) following in 1986.

The American College of Sports Medicine® (ACSM) and other organizations have taken a position on anabolic steroids stating that they are unethical, they have dangerous side effects, and their use should be deplored (2).

The Anabolic Steroids Control Act of 1991 made anabolic steroids a Schedule III controlled substance.

Anabolic steroids are not the only substances banned by sports governing bodies such as the International Olympic Committee (IOC), the World Anti-Doping Agency (WADA), and the NCAA. The IOC developed their list in 1967.

Because of many doping scandals, the U.S. Anti-Doping Agency (USADA) was formed in 2000 as an independent antidoping organization for Olympic sports in the United States. The list of substances banned by the IOC can be viewed on the WADA Web site at http://www.wada-ama.org/en/World-Anti-Doping-Program/ (72).

The NCAA has their list at http://www.ncaa.org/wps/wcm/connect/public/NCAA/Student-Athlete+Experience/NCAA+banned+drugs+list (48).

Because the lists are continually changing, physicians caring for athletes in these or other organizations should always consult them prior to writing a prescription or suggesting over-the-counter remedies.

Testing is usually done by analyzing urine samples through a number of methods, with most confirmatory tests done using gas chromatography/mass spectrometry. In the future, blood or hair samples may be used to detect banned substances. See Chapter 25, Drug Testing.

Further discussion of ethical considerations related to supplements, medications, and ergogenic aids can be found in Chapter 2, Ethical Considerations in Sports Medicine.

Specific ergogenic aids will be reviewed here regarding their efficacy, safety, and use in Olympic and NCAA competition. Table 71.1 gives an overview of many ergogenic aids, their effects on the six fitness components, and their safety.