The use and abuse of performance-enhancing substances in sport

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MJA Practice Essentials Series

John Orchard, Peter Fricker, Susan White, Louise Burke, Deborah Healey

Abstract

Anti-doping laws generally exist in order to provide a safe and fair environment for participation.

In particular these laws should prevent and protect athletes from subjecting themselves to health risks through the use of unsafe but performance-enhancing drugs.

Because of difficulties in proving intent to cheat, the World Anti-Doping Agency enforces a principle of strict liability with respect to positive tests for banned substances.

An area of major controversy with respect to liability is the ‘sports supplement’ industry, which is poorly regulated when compared to prescription drugs yet is a potential source of doping violations.

Medical practitioners can be found guilty of anti-doping violations if they traffic banned drugs or prescribe or assist athletes in taking banned substances.

Medical practitioners are also now required to complete paperwork (Therapeutic Use Exemption forms) to enable athletes to take banned substances which may be required on medical grounds for specific illnesses.  

Certain drugs have the potential to increase athletic performance. However, such drugs carry the risk of side effects, which may include death and life-long morbidity. For instance, a cyclist died from stimulant abuse in the 1960 Rome Olympics; anabolic steroids may cause death from cardiovascular disease and various cancers ¹ while many former female Eastern bloc athletes have also suffered from the permanent androgenising effects of these drugs, including infertility. Prohibitions on the use of dangerous performance-enhancing drugs have been introduced to almost all elite level sports over the past four decades. Anti-doping laws attempt to minimise the numbers of athletes engaging in doping, although the enforcement of anti-doping laws is, predictably, not 100% successful ^2-4 . Because of the perception that full enforcement of doping laws can not realistically be achieved, some commentators argue for a relaxation of doping laws to create an ‘open’ but arguably more ‘even’ playing field ². However, sport without anti-doping laws would disadvantage further those athletes who wanted to compete at an elite level without risking their health.   

The recently formed World Anti-Doping Agency (WADA) is responsible for developing and implementing uniform anti-doping standards worldwide (both with respect to lists of banned drugs and penalties for abusing them). The World Anti-Doping Code (“WADA Code”) was adopted after consultation with governments, sporting bodies, national anti-doping agencies and other relevant parties in 2003 by all Olympic Committees, many nations and many elite sports.

A substance can be included on WADA’s banned list if it meets two of the three major criteria defined by WADA, or if it is a potential masking agent. The three criteria are that the substance is performance-enhancing, that there are health risks to the athlete with use of the substance and/or that use of the substance violates the spirit of sport. The need for two out of the three criteria means that the WADA code can ban ‘social drugs’ such as marijuana (even though they are not performance enhancing) but can permit the use of a drug such as caffeine (even though low levels of this drugs are performance enhancing).

Anti-doping laws do not just relate to positive tests for prohibited substances. Refusing to submit to testing procedures, tampering with samples (before or after they are submitted), possession and/or trafficking illegal substances, and refusal to supply accurate regular whereabouts information to authorities (to allow for regular unannounced out of competition testing) can lead to doping infringements. Therefore, medical practitioners may also be subject to doping sanctions and suspended from involvement in elite sport.

The burden of proof in doping charges

With respect to the doping charge of “the presence of a prohibited substance or its metabolites or markers in an athlete’s bodily specimen”, an athlete is found guilty irrespective of whether there was a proven or even suspected intention to ingest the substance or cheat. Such strict liability does not necessarily apply to some other doping charges (e.g. trafficking illegal substances), in which various burdens of proof must be met.

WADA enforces the principle of strict liability because there is generally no reasonable doubt that a drug discovered within an athlete’s urine or blood sample (taken under a strict protocol) was present within the athlete’s system, yet it would be far too difficult, in the majority of cases, to prove intent to cheat beyond reasonable doubt.  Strict liability for doping offences is controversial, although the WADA Code does offer the athlete some opportunity to consider the unique circumstances of each case. If an athlete can prove no fault or negligence (in exceptional circumstances, such as a case of proven drink spiking) it is possible that suspensions can be downgraded or waived. These exceptional circumstances do not generally include cases where the athlete was given a prohibited substance by his or her personal physician or trainer without disclosure to the athlete ⁵ .

In cases in Australia even prior to the adoption of the WADA Code where an athlete has claimed inadvertent doping and his or her claims were verified, it has been rare to completely vindicate an athlete. There have been occurrences where medical practitioners have prescribed banned drugs for athletes for medical indications and have recorded the prescription in the notes, which have subsequently led to positive tests. Three case histories involving Australian professional cricket players are presented in Table 1 showing the response of drugs tribunals to the various explanations provided by the players.

Table 1 - Case histories involving Australian cricket players

Type of drug	Circumstance	Penalty	Rationale
Probenecid (potential masking agent)	Treated for an abscess by a medical practitioner who was unaware that the player was subject to drug testing. Given probenecid to enhance penicillin action.	Suspended for one month and fined $2000	Because there was a clear indication for probenecid and because the drug was not performance enhancing (but classified as a masking agent), a more lenient verdict (but not a finding of innocence because the definition of guilt in the code is the presence of a substance) was given. The player admitted to failing to notify the doctor that he was subject to drug testing
Nandrolone (anabolic steroid)	Was prescribed injectable nandrolone to assist in the recovery from a chronic back condition when not playing professional cricket, although the drug was detected after he returned to professional play.	18 months suspension.	Very little sympathy was extended to the player for the explanation that he was prescribed an anabolic steroid for medical indications, as the drug was clearly performance enhancing and the indication for the drug was dubious.
Diuretic (masking agent)	Took a diuretic (prescribed for another person) for weight loss	12 months suspension.	Controversial case as he was given a severe penalty but less than the maximum available, suggesting that the tribunal offered some ‘discount’ for his explanation and the fact that the drug was a masking agent rather than performance enhancing; however he was still found liable for the positive test

Responsibilities of treating medical practitioners

A case in which a GP prescribed a professional player probenecid, which resulted in a doping violation (Table 1), in particular highlights the need for every medical practitioner, whether interested in sports medicine or not, to be aware that doping laws exist for athletes. Athletes are also responsible for informing every treating medical practitioner that they are subject to doping restrictions. Doctors unfamiliar with drugs on the most recent banned list must check with Australian Sports Drug Agency (ASDA) (via the Drugs in Sport hotline 1800 020506 or the ASDA website http://www.asda.org.au/index.htm), before prescribing. To date, there has been no reported litigation involving athletes and their medical practitioners for prescribing banned drugs which led to suspensions. In scenarios where a doctor was either unaware of the ‘testable’ status of an athlete or where a drug was administered as part of emergency treatment it is unlikely that a doctor would be considered negligent for prescribing a banned drug. However, where a patient asked a doctor to check the legal status of a drug and an error was made, then a doctor may be held responsible for this mistake. With respect to prescribing drugs for athletes, a similar principle applies to that of treating pregnant women: ‘if in doubt about the status of a drug, check it or do not use it’. Practitioners are also advised to have some system of notifying on a patient’s file whether he or she is subject to sports drug testing.

Success in policing of anti-doping laws

  Many of the women’s track world records still stand from the 1980s and were set in a period where both drug testing programs and the ability to detect anabolic steroids were nowhere near as advanced as they are today. It is impossible to be certain that a specific world record was only achieved with doping (other than cases where confessions were made). However, that world-class standards have dropped in women’s track events over the past 15 years is probably attributable to the decreased use of performance enhancing agents over that time, with the relative success of current anti-doping measures.

The fact that the majority of records in men’s track events and in other disciplines such as swimming and cycling have been broken since the 1980s can be explained with a variety of hypotheses, including that the relative performance advantage in these events for using anabolic steroids is not as great as for women’s track events. There is an expectation that world records will gradually improve over time as training advances are made.

It has been recently been revealed that, for example, many athletes from East Germany in the 1970s and 1980s were regularly prescribed anabolic steroids, yet calls by some commentators to have retrospective changes to the record books have not been heeded. This is a sensible outcome, as it is perhaps counter-productive to re-write history many years after the event. If an athlete wins an event under the drug-testing regimen of the day, any later declaration that he or she was able to beat the system of the time does not necessarily mean that he or she was the only athlete in that event doing so. It may also be helpful for improving the approach towards drugs in sport that athletes can confess years after an event, without being restricted by the potential retrospective erasing of results.

Blood doping and EPO – should direct or indirect testing be used?

Blood doping (using blood transfusions, either donor blood or one’s own stored blood) to enhance performance in endurance events has probably now been superseded by erythropoietin (EPO). EPO increases red blood cell indices, such as haemoglobin concentration, and hence endurance performance. In certain sports, the ‘average’ haemoglobin levels of competitors have increased significantly in recent years, which is highly suspicious of blood doping or EPO use ^{2 3} . EPO is considered a very difficult drug to detect: it exists naturally within the body and has a short half-life of a few hours while its effects on red blood cell counts last for over a month.  Thus, rather than relying solely on direct EPO detection, athletes in sports such as cycling and cross-country skiing (where EPO abuse is thought to have been common) are banned from competing if red blood cell indices are raised beyond certain levels (possibly consistent with but not definitive of EPO use). These tests are done just prior to competition and exclusion from that event is based on the potential risk to health.

While seen by some as a sensible method of harm minimisation ⁴ , “banning” according to haematological indices means that the principle of strict liability cannot be adhered to. Medical conditions, such as polycythaemia rubra vera, can cause similar haematological changes. Thus, affected athletes are not subject to doping sanctions, but are merely designated ‘unfit’ to participate in the current competition. Similarly spinal cord injured wheelchair athletes with high blood pressure prior to an event are prevented from competing at the Paralympics, without prospective suspension, as this may be self-induced (illegal ‘boosting’ to improve performance) or due to a concurrent medical condition.

Therapeutic Use Exemptions (TUEs)

Table 2 – Evidence base for the status of certain drugs on 2005 WADA list

Drug category	Common therapeutic use(s)	Current status (WADA)	Rationale for current status
β2-agonists	Asthma	Banned, but an abbreviated ‘TUE’ form acceptable for exemption for inhaled use	Oral salbutamol in high doses is performance-enhancing (level 2) 6 .
Corticosteroids	Asthma (oral/inhalers); certain injuries (local injections)	Banned, but therapeutic exemptions may be granted	Suspected of being taken indiscriminately in ultra-endurance events during competition to induce a sense of euphoria and perhaps to mask pain (controversial level 4 evidence); no anabolic effects.
Anabolic steroids	Very rare (e.g. post-surgery for pituitary tumour)	Banned. Need full TUE from medical panel for exemption, which would only be granted in extreme cases.	Performance-enhancing and dangerous when abused (level 1-2) 1 .
Amphetamines	Attention Deficit Hyperactivity Disorder (ADHD), narcolepsy	Banned. Need full TUE from medical panel for exemption.	Controversial category, as very likely to be performance-enhancing and unsafe in high doses (level 4). Therapeutic uses are genuine but hard to objectively diagnose 7
Finasteride	Hair loss; prostate disorders	Recently banned as a masking agent. Need full TUE from medical panel for exemption.	Potential masking agent.
Pseudoephedrine	Very common component of over-the-counter cold and flu medications	Has recently been removed from the banned list.	No performance-enhancing effects from a standard dose (Level 2) 8 .
Caffeine	No medical use, but common in many foods	All restrictions on caffeine have recently been removed.	Impractical to ban and a fairly safe drug, despite some potential performance benefits (level 1) 9 .
Local anaesthetic injections	Suturing of wounds; minimising pain from an injury	Legal	No advantage conferred over uninjured athletes (level 4); impractical to enforce ban 10 .

The WADA Code has a process for granting exemptions for the legitimate medical use of banned substances. All applications must be prospective and registered (except in emergency situations). Some medications are banned (see Table 2) with the proviso that they may be used for certain medical indications, which require notification prior to their use. Prospective approval to take a banned drug via a TUE (Therapeutic Use Exemption) process for a documented medical condition is currently provided (under the WADA Code) if:

1        the condition poses significant impairment to health, and

2        there is no additional enhancement of performance (other than return to normal state of health following treatment of the legitimate medical condition), and

3        no reasonable therapeutic alternative exists to treat the condition 

The TUE process is generally simple for specific commonly-exempted drugs (inhaled β₂ agonists for the treatment of asthma and non-systemic glucocorticosteroids) with automatic approval being considered "granted" once a correctly lodged form is received by the relevant national or international sporting body. There is however the threat that incorrect lodgement of paperwork could result in a guilty verdict under the principle of strict liability. This has already occurred in the case of an Austrian tennis player who was banned for three months in late 2004 for testing positive to a corticosteroid, injected by a doctor for a wrist injury.

Less commonly-exempted drugs (with a greater potential for abuse and performance enhancement) must be assessed by an expert panel. These requests for TUEs are handled in Australia by an independent panel called ASDMAC (the Australian Sports Drug Medical Advisory Committee). The web address www.asdmac.org.au is most useful for information on the process and for application forms. Medical practitioners can also ring for advice, particularly in emergency situations, and may be able to speak directly to one of the medical practitioners on the board. TUEs are commonly granted for the use of oral glucocorticosteroids to treat severe asthma or inflammatory bowel disease. All applications require full documentation including specialist opinions and results of investigations. A TUE would never be granted to facilitate the elevation of a slightly ‘below normal’ testosterone level in an otherwise healthy adult. It has been noted that athletes will go to extraordinary lengths to appear to be suffering from conditions where anabolic steroids are indicated, because of the known beneficial effects on performance ¹¹ .

The legal status of the various stimulants presents a further area of controversy. A Romanian gymnast was stripped of a gold medal at the Sydney Olympics after testing positive for pseudoephedrine, which was banned at the time of this event there. However, pseudoephdrine has been recently removed from the banned list (Table 2). The most contentious TUE decisions with respect to stimulants are for conditions such as narcolepsy and ADHD (Attention Deficit Hyperactivity Disorder). While these conditions are markedly improved with stimulant medication, ¹² a recent review cautioned against the awarding of TUEs for stimulants on the basis that symptoms are difficult to ‘objectively’ verify and therefore narcolepsy and ADHD symptoms may be alleged by athletes wishing to gain access to performance enhancing stimulants ⁷.

The use of “legal” supplements

While most over-the-counter supplements are considered “legal” within anti-doping codes, some controversies exist as they may enhance athletic performance.  While there is no scientific evidence to support the benefits claimed for most products, there is substantial proof that some can enhance specific performance outcomes, when used according to specific protocols ¹³ . For instance, certain athletes taking bicarbonate/citrate, creatine and/or caffeine can exercise at higher work-rates or for longer duration before experiencing fatigue ^{9 14 15} . WADA has taken a pragmatic approach, considering that such ingredients occur naturally in food and manufactured products simply represent a practical way for athletes to consume a desired dose.

By contrast, the WADA code bans pro-hormones, including androstenedione, DHEA, and 19-norandrostenedione, which can be converted in the body to testosterone or the anabolic steroid nandrolone ¹⁶ . Over recent years there has been controversy relating to their legality in professional baseball in the USA . Since the Dietary Supplement Health and Education Act (1994) was passed in the United States , products containing pro-hormones have been marketed as over-the-counter dietary supplements there. Even in countries like Australia where they don’t enjoy this liberalised status, they may be available to athletes through internet or mail-order sales.

There is conflicting data about whether the use of pro-hormones generally leads to positive results from urinary drug screening tests ^17-19 , meaning that none of the anabolic steroid pro-hormones can be considered ‘safe’ for athletes who are subject to testing to use, yet certain individuals may still test negative for anabolic steroids after taking low doses of pro-hormones. Over recent years, many athletes who have tested positive for low levels of the anabolic steroid nandrolone have claimed that their performance aids were limited to apparently ‘legal’ supplements. Several studies from overseas have suggested that up to 10-15% of supplements may contain contaminated substances ^{17 20} . Clearly, there are problems with the supplement industry world-wide, and solutions must include self-regulation of manufacturing processes to ensure uncontaminated and accurately labeled products, appropriate government regulations, and product testing and certification programs for athletes.

Another confusion about pro-hormone supplements lies with their ability to enhance sports performance in young adults with normal endogenous production of steroids.  The present consensus from acute and chronic studies of pro-hormone supplementation is that there is little evidence of improved muscle size or strength above the gains achieved through resistance training ¹³ .  Although it is tempting to say that these products “don’t work”, the treatment doses used in studies are conservative in comparison to the doses recommended and used by some athletes ²¹ .

Testing for ‘social’ drugs that are not performance-enhancing

Major controversy also surrounds testing for non-performance-enhancing but illegal drugs, which athletes may take for social (or recreational) purposes. The banning of stimulants, such as cocaine, when competing is universally accepted. The dilemma lies in whether stimulant drugs should be tested out-of-competition (where presumably they convey no performance advantage) and whether drugs such as marijuana, which are illegal but unlikely to confer any performance advantage, should be tested for and potentially lead to disqualification. The argument offered by WADA is that these drugs affect the health of the athlete, and that taking of drugs inappropriately is against the spirit of sport.

It may be considered an invasion of privacy to test for non-performance-enhancing drugs out of athletic competition. However, it is hard to argue in defence of athletes who choose to break not only anti-doping but also criminal laws by using illicit social drugs. It may be more appropriate that these athletes receive counselling, and perhaps shorter suspensions, than other athletes found using drugs that would confer upon them an unfair performance advantage.

Conclusion

Doping authorities are further ahead than they have ever been, but awareness that doping is prevalent in sport is also greater than it has ever been. With current anti-doping policies, authorities greatly attenuate a major problem in sport (the widespread use of dangerous substances) which would occur under a scenario without anti-doping laws. However the difficulties with enforcing prohibitions lead to many areas of controversy. It is planned that subtle ongoing changes will be made to the WADA code, making it necessary for all medical practitioners who treat athletes to know how to check up to date lists of legal drugs and substances.

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