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Drugs in sport |
Summary
Drugs in sport are a concern for medical practitioners because of the implicit risks to the health of the athlete. There are also ethical concerns about cheating by artificially enhancing athletic performance. The International Olympic Committee has prepared an Olympic Movement Anti-Doping Code.1 This specifies prohibited substances, and prohibited methods of doping. Health professionals must be aware of the need to avoid giving 'banned' medications and the need to provide written notification when restricted substances are necessary. Sources of information about restricted substances include the Drugs in Sport Handbook2 published by the Australian Sports Drug Agency.
Key words: anabolic steroids, stimulants, growth hormone, doping
(Aust Prescr 2000;23:76-8)
Introduction
'Drugs in sport' receives daily attention in the media, the medicalliterature and in conversations across the country. In the twelve months 1998- 99, the Australian Sports Drugs Agency (ASDA) conducted 4801 dope tests across52 sports and events. Positive tests were recorded for drugs such as clenbuterol(a beta-agonist with anabolic properties), nandrolone and stanozolol (anabolicsteroids), frusemide, pseudoephedrine, prolintane (a stimulant used in thetreatment of attention deficit hyperactivity disorder) and cannabis. Sportingorganisations imposed sanctions on the offenders ranging from 'warning' to'life ban'.
The problem of using performance enhancing agents is not new. Anecdotal reportsgo back to ancient Greece when meat and wine were prescribed for better performancein the marathon. A death from stimulant (amphetamine) abuse by a cyclist wasreported in 1960.1,3 Cycling hasmore recently brought to light the problem of erythropoietin (EPO) abuse andthis is the focus of research (using red cell markers) at the Australian Instituteof Sport in Canberra and the Australian Sports Drugs Testing Laboratory inSydney. Similarly, swimmers were recently caught with human growth hormone(HGH), and the International Olympic Committee (IOC) has now funded an internationalstudy on the detection of HGH abuse by athletes.
The use of drugs such as DHEA (dehydroepiandrosterone), which is banned bythe IOC, and supplements such as creatine and hydroxymethylbutyrate (HMB),which are not banned, add to the ever increasing complexity of performanceenhancement in sport. This is a concern for the treating practitioner who maybe asked to assist an athlete.
Doping
Doping is the application of chemical substances with the deliberateintention or effect of altering performance.4 Itis opposed by the IOC and its member bodies and affiliates on ethical grounds(doping is cheating) and because doping poses a risk to the health of the athlete.
The IOC has produced a schedule which is updated annuallyand outlines the major classes of prohibited substances, prohibited methodsof doping, and classes of drugs subject to certain restrictions (seeTable 1). The prohibited substances include stimulants (e.g. ephedrineand amphetamine), narcotics, anabolic agents (e.g. testosterone and its relatedcompounds, including nandrolone and DHEA), diuretics, hormones (including HGHand EPO) and hormone analogues.
The difficulty for medical practitioners is recognising prohibited substancesin common usage and ensuring that their patients who are athletes do not inadvertentlytest positive to a dope test. By far the largest cause of 'inadvertent positives'is pseudoephedrine, which is available in many over-the-counter preparations.
Doctors and pharmacists can readily check any medication,to see whether or not it is permitted, by referring to the bimonthly issueof MIMS. Against each entry is a symbol which indicates if the drug can beused in sport or if certain restrictions apply. There is no symbol for thosesubstances which are totally banned. More information is available from ASDAor national sporting organisations.
International Olympic Committeeguide to classes of prohibited substances and methods of doping | |
Prohibited classes of substances | |
A. | Stimulants |
Prohibited methods | |
A. | Blood doping |
Classes of drugs subject to restrictions | |
A. | Alcohol |
Prohibited substances
Caffeine
Routine urine screening includes caffeine assay. A concentration above 12 microgram/mLis deemed a positive dope test. There are no acceptable excuses and athletesmust be warned that caffeine excretion can vary from individual to individual.Approximately six cups of brewed or percolated coffee (drunk rather rapidly)or 6 - 8 cans of a cola soft drink may put the athlete at risk of a positivetest.
Anabolic agents
The abuse of anabolic agents such as testosterone and its analogues, and ofHGH and human chorionic gonadotrophin (HCG), is unfortunately endemic. Blackmarket availability is widespread and athletes in sports which involve lifting,throwing, jumping and sprinting are particularly likely to be tempted. Thedangers of anabolic androgenic steroids lie in their hepatotoxicity (in the17 alpha-alkyl substituted forms), with resultant hepatitis, peliosis hepatisand risk of tumour. They can also virilise and produce permanent sequelae suchas deepening of the voice, gonadal atrophy and clitoral hypertrophy.5 Somebeta-agonists including clenbuterol and fenoterol are anabolic and are banned.
HGH abuse can produce acromegalic adverse effects and impairedglucose tolerance, while HCG is used to mimic the effect of testosterone. Polypeptideanabolic agents also include insulin, and because this drug is available withoutprescription it has become fashionable amongst body builders and strength-trainingathletes. Insulin injections are reportedly taken with high carbohydrate mealsand exercise to produce gains in muscle bulk and strength.
A urine test for testosterone is positive if the ratio of testosterone to epitestosteroneis greater than six. Testing for the polypeptide anabolics is still being developed.
Diuretics
Diuretics are banned. They are used by athletes to 'make weight'. Sports inwhich athletes are classed by weight include weightlifting, judo and boxing.Doping control checks routinely test for diuretics as the drugs can alsobe used to dilute the urine and mask prohibited drugs in the urine.
Glycoprotein and polypeptidehormones
A recent addition to the banned list of hormones is EPO. This injectable recombinanthormone promotes red cell production by the bone marrow and thus enhances aerobic(endurance) activity in athletes - hence its infamous popularity amongst competitiveroad cyclists. It carries a risk of thrombosis and has been implicated in anumber of deaths amongst cyclists.
A test for EPO is currently being developed in Australia andit is the fervent wish of officials and honest competitors that the test beintroduced at the Sydney Olympic Games.
Prohibited methods
There are a number of prohibited methods which are used for performance enhancement.These include blood doping (using homologous or autologous blood), the useof masking agents such as probenecid (which blocks the renal excretion oftestosterone), providing substitute urine samples for testing and chemicalmanipulation of urine to be tested. Dope tests therefore screen for maskingagents and analyse a range of chemical and physical properties of urine todetect manipulation of the sample.
Restricted use
The IOC also specifies a list of drugs subject to certain restrictions.Alcohol, for example, may be banned in certain sports, as are marijuana andbeta blockers, because of specific pharmacological effects which may assistperformance. For example beta blockers control tremor and heart rate, so theymay be useful in target sports, such as shooting.
Local anaesthetics (excluding cocaine) are permitted for localand intra-articular use only, and written notification is requested by somesports at the time of competition. Similarly corticosteroids are permitted only fortopical application, by inhalation for the treatment of asthma, or by localor intra-articular injection (including depot formulations).
Another important restriction is the use of beta-agonists. Only salbutamol,salmeterol and terbutaline are permitted and they can only be used for thetreatment of asthma if they are given by inhaler. The sporting authoritiesrequire written notification of the athlete's asthma.
Permitted use of 'banned drugs'
In Australia, the Australian Sports Drugs Medical Advisory Committee(ASDMAC) has been empowered by Parliament to provide advice to national sportingbodies on the therapeutic use of IOC 'banned' drugs. If an athlete suffersulcerative colitis, for example, and requires corticosteroid therapy, the treatingmedical practitioner may write to ASDMAC and seek adviceon this therapy. All medical details must be provided, with the athlete's permission.ASDMAC, in consultation with the relevant national sporting organisation, cangrant permission for medication to be used in stated doses for particular conditionsfor a period of time. During this time sanctions will not be imposed if theathlete tests positive. The decision on whether or not to 'approve' therapeuticuse is based on the necessity for such treatment to maintain health, the absenceof alternatives in therapy and the decision that no unfair gains in sportsperformance may be obtained by using such medication in prescribed doses. Itshould be recognised that ASDMAC 'approval' currently applies within Australiaonly and 'approval' to use outside Australia must be obtained either directlyfrom the IOC (where Olympic Games are concerned) or from the appropriate nationalsporting body in the country of competition.
If there is any doubt, it is better for the athlete not totake the medication in question. If medication is necessary, the athlete shouldwithdraw from competition.
Dope testing
Drug testing in Australia is conducted by the ASDA. The testing is strictlycontrolled to ensure that the athlete is guaranteed security, privacy and fairness.Guidelines cover notification of the athlete selected for testing, chaperoningand supervision while a urine sample is obtained, sealing of specimens, securedelivery of the sample to the IOC-accredited laboratory, sample analysis andnotification of results.
There is a detailed process for appeals and hearings, shouldsanctions by a sporting organisation be considered. The penalties are severefor drug abuse, trafficking, doping and using prohibited methods. In many sportsa second offence for anabolic steroid abuse results in a life ban from therelevant sport.
Supplements
There are countless enterprises in Australia touting supplements, vitamins,amino acids and herbal extracts to promote health and improved performance.Some supplements such as creatine and amino acids are not 'banned' but thepurity of such products must be guaranteed before the athlete is safe fromtesting positive. The truly risky area is that of herbal extracts and compounds.Some include ephedra which is banned, and the botanic (or Chinese) name maynot help the unwary. Similarly guarana contains caffeine, which is 'banned'above a level of 12 microgram/mL in urine.
Caution must also be exercised when buying any product overthe internet, for the same concerns apply with respect to content and purity.What you buy may not necessarily be what you get, and you may get more thanyou bargained for.
Conclusion
Health professionals should not become involved in doping or prohibitedprocedures which are intended to enhance sporting performance. They also needto be aware that in treating an athlete's medical condition they can unwittinglyprescribe a banned or restricted substance. Inappropriate prescriptions canprejudice an athlete's career, so checking that a drug is permitted beforeprescribing it is recommended.
Australian Sports Drugs Medical Advisory Committee
PO Box 345
CURTIN ACT 2605
References
1. Olympic Movement Anti-Doping Code. Lausanne:International Olympic Committee; 1999. http://www.nodoping.org
2. Drugs in Sport Handbook. Canberra: AustralianSports Drug Agency; 2000. http://www.ausport.gov.au/asda
3. Wadler GI. Drug use update. Med Clin NorthAm 1994;78:439-55.
4. Williams JGP. Doping of athletes. PhysEduc 1963;55:39-41.
5. Conway AJ, Handelsman DJ, Lording DW, StuckeyB, Zajac JD. Use, misuse and abuse of androgens: The Endocrine Society of Australiaconsensus guidelines for androgen prescribing. Med J Aust 2000; 172:220-4.
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