Addictions Case Study: Part 3 - Treatment Plan

(Ksir, 2021)

Ksir, C. C. (2021-05-01). Drugs, Society, and Human Behavior, 18th Edition

Chapter 16

Performance-Enhancing Drugs

Why is there so much concern over drug use by athletes? Why not focus on drug use by clarinet players or automotive technicians? There are several answers to this question, some more compelling than others. First, well-known athletes are seen as role models for young people, portraying youth, strength, and health. When a famous athlete is reported to be using steroids or some other illicit substance, there is concern that impressionable young people will see drug use in a more positive light. This perspective acknowledges that it may be unfair to hold certain athletes to higher standards than those imposed on other members of our society. But it is argued that this is one of the many prices paid for in exchange for fame and celebrity.

Second, some of the drugs used by athletes are intended to give the user an advantage over the competition, an advantage that is clearly viewed as being unfair. Of course, wealthier athletes may have access to better training instruction, facilities, and equipment, which could give them an advantage over less well-off competitors. Yet, this is rarely considered in discussions of fairness in sports. Nonetheless, an unfair advantage is viewed as inconsistent with our tradition of fair play in sports.

Third, there is a concern that both the famous and the not-so-famous athletes who use drugs are endangering their health and perhaps their lives for the sake of a temporary burst of power or speed. Mind you, there are health hazards endemic to many sports. Consider the fact that many football players—from amateur to professional—sustain concussions during competition, and now, a growing number have developed premature cognitive and emotional problems such as dementia, Alzheimer’s, depression, and chronic traumatic encephalopathy (CTE). Thus, it seems hypocritical to ignore these risks as we consider potential harms caused by performing-enhancing drugs. These are just a few of the issues that we’d like you to keep in mind as you read this chapter.

Historical Use of Drugs in Athletics

Ancient Times

Although we tend to think of drug use by athletes as a recent phenomenon, the use of chemicals to enhance performance might be as old as sport itself. As with many early drugs, some of these concoctions seemed to make sense at the time but probably had only placebo value. We no longer think that the powdered hooves of an ass will make our feet fly as fast as that animal’s, but perhaps it was a belief in that powder that helped the ancient Egyptian competitor’s self-confidence. Also, if all the others are using it, why take chances?

The early Greek Olympians used various herbs and mushrooms that might have had some pharmacological actions as stimulants, and Aztec athletes used a cactus-based stimulant resembling strychnine. Athletic competitions probably developed in tribal societies as a means of training and preparing for war or for hunting, and various psychoactive plants were used by tribal peoples during battles and hunts, so it is not surprising that the drugs were also used in athletic contests from the beginning.

Early Use of Stimulants

During the 1800s and early 1900s, three types of stimulants were reported to be in use by athletes. Strychnine, which became famous as a rat poison, can at low doses act as a central nervous system stimulant. However, if the dose is too high, seizure activity will be produced in the brain. The resulting convulsions can paralyze respiration, leading to death. At least some boxers were reported to have used strychnine tablets. This might have made them more aggressive and kept them from tiring very quickly, but it was a dangerous way to do it. We’ll never know how many of those rugged heroes were killed in this way, but there must have been a few. Thomas Hicks won the marathon in the 1904 St. Louis Olympics, then collapsed and had to be revived. His race was partly fueled by a mixture of brandy and strychnine.1 Although the availability of amphetamines and other substances later made highly dangerous drugs such as strychnine less attractive, evidence indicates the occasional use of strychnine continues at the level of world competition even today. At the 2016 Rio de Janeiro Olympics, Kyrgyz weightlifter Izzat Artykov tested positive for strychnine and was stripped of his bronze medal.

Cocaine was also available in the 1800s, at first in the form of Mariani’s Coca Wine (used by the French cycling team), which was referred to in some advertisements as “wine for athletes.”2 When pure cocaine became available, athletes quickly adopted this more potent form. Many athletes used coffee as a mild stimulant, and some added pure caffeine to their coffee or took caffeine tablets. There were numerous reports of the suspected doping of swimmers, cyclists, boxers, runners, and other athletes during this period. Then, as now, some of the suspicions were raised by the losers, who might or might not have had any evidence of doping. Our use of the word dope for illicit drugs is derived from a Dutch word used in South Africa to refer to a cheap brandy, which was sometimes given to racing dogs or horses to slow them down. From this came the term for doping horses and then people, more often in an effort to improve rather than impair performance. Dogs and horses received all the substances used by humans, including coca wine and cocaine, before the days of testing for drugs.

Amphetamines

It isn’t clear when athletes first started using amphetamines for their stimulant effects, but it was probably not long after the drugs were introduced in the 1930s. Amphetamines were widely used throughout the world during World War II, and in the 1940s and 1950s there were reports of the use of these pep pills by professional soccer players in England and Italy. Boxers and cyclists also relied on this new synthetic energy source. More potent than caffeine, longer-lasting than cocaine, and safer than strychnine, it seemed for a while to be the ideal ergogenic (energy-producing) drug for both training and competition.

In 1952, the presence of syringes and broken ampules in the speed-skating locker room at the Oslo Winter Olympics indicated the presence of amphetamines in international competition. There were other reports from the 1952 summer games in Helsinki and the 1956 Melbourne Olympics. Several deaths during this period were attributed to overdoses of amphetamines or other drugs. By the time of the 1960 Rome games, amphetamine use had spread around the world and to most sports. On opening day a Danish cyclist died during time trials. An autopsy revealed that his death resulting from “sunstroke” was aided by the presence of amphetamines, which reduce blood flow to the skin, making it more difficult for the body to cool itself. Three other cyclists collapsed that day, and two were hospitalized.1 This and other examples of amphetamine abuse led to investigations and to antidoping laws in France and Belgium. Other nations, including the United States, seemed less concerned.

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International Drug Testing

Some sports, especially cycling, began to test competitors for drugs on a sporadic basis. Throughout the 1960s, some athletes refused to submit to tests or failed tests and were disqualified. These early testing efforts were not enough to prevent the death of cyclist Tommy Simpson, an ex-world champion, who died during the 1967 Tour de France. His death was seen on television, and weeks later it was reported that his body contained two types of amphetamines and that drugs had been found in his luggage. This caused the International Olympic Committee in 1968 to establish rules requiring the disqualification of any competitor who refuses to take a drug test or who is found guilty of using banned drugs. Beginning with fewer than 700 urine tests at the 1968 Mexico City Olympics, each subsequent international competition has had more testing, more disqualifications, and more controversy. More than 5,000 urine tests were performed at the 2012 London Olympics, but there were fewer disqualifications due to a drug-positive urine test than at the three previous games. The plan was to conduct even more tests during the 2016 Rio de Janeiro Olympics, but that wasn’t accomplished. According to a report from the World Anti-Doping Agency (WADA), the Rio 2016 management team suffered from “serious failings” that obstructed anti-doping operations. As a result, only 4,882 of the planned 5,380 tests were carried out.3

American Football

Most Americans did not seem to be very concerned about drug use by athletes until reports surfaced in the late 1960s and early 1970s that professional football players were using amphetamines during games. Before that, people might not have been very concerned about it even if they had known. Remember from Chapter 6 that the amphetamines underwent a major status change in the United States during the 1960s. For years an increasing number of Americans had used amphetamines to keep them awake, to provide extra energy, or to lose weight. They were seen by most people as legal, harmless pep pills. It was in that context that the physicians for professional football teams ordered large quantities of the drugs as a routine part of their supplies, and trainers dispensed them liberally.

At the end of the 1960s, amphetamines were widely considered to be drugs of abuse, dangerous drugs that could lead to violent behavior. In this context, revelations that many professionals were playing high made for sensational headlines. Several National Football League (NFL) players sued their teams for injuries received while playing under the influence of drugs, and the NFL officially banned the distribution of amphetamines by team physicians and trainers in 1971. Although the drugs were no longer condoned by the league, the NFL did little at that time to enforce the ban, except to request copies of each team’s orders for medical supplies. Athletes who wanted amphetamines still obtained and used them, often through a legal prescription from their own physicians. The attitude seemed to be that, if the players wanted to use pep pills and obtained them on their own, that was their business, but team physicians and trainers shouldn’t be using medications to push the athletes beyond their normal endurance.

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Table 16.1 displays a partial list of the NFL’s prohibited substances. Even though more than two dozen substances comprise the table, it is far from comprehensive. Nevertheless, we hope the that our abbreviated table gives you a sense of the breadth of substances that are banned in the NFL. As can be seen, the current NFL policy prohibits all use of amphetamines, as well as many other substances, no matter where they are obtained. In special cases, players who require the use of a prohibited substance to treat a medical condition are sometimes granted a therapeutic-use exemption. For example, an athlete diagnosed with attention-deficit/hyperactivity disorder (ADHD) may be allowed to take amphetamine as part of his treatment regimen. Excluding marijuana use (see Drugs in the Media) and substance use in accordance with a therapeutic-use exemption, a positive drug test can be extremely costly to a player and his team. A first infraction that involves a stimulant or diuretic will result in the player being suspended without pay for two games. But a steroid positive test will lead to a six-game suspension. A second violation triggers a five-game suspension for stimulant or diuretic use and a 17-game suspension steroid use.

Steroids

During and after World War II, it was found that malnourished people could gain weight and build themselves up more rapidly if they were given the male hormone testosterone. The Soviets were the first to put this hormone to use on a wide scale to build up their athletes. An American team physician at the 1956 Olympics reported that the Soviet athletes were using straight testosterone, sometimes in excessive doses and with unfortunate side effects. Testosterone helps both females and males become more muscular, but its masculinizing effects on females and enlargement of the prostate gland in males are definite drawbacks. The American physician at the 1956 Olympics returned to the United States and helped develop and test anabolic steroids, which were quickly adopted by American weight lifters and bodybuilders.4

American and British athletes in events such as discus and shotput were the first to acknowledge publicly that they had used steroids, and there was evidence that steroid use was widespread during the 1960s in most track and field events. These drugs were not officially banned, nor were they tested for in international competition until the early 1970s, mainly because a sensitive urine test was not available until then. Of the 2,000 urine samples taken during the 1976 Olympics, fewer than 300 were tested for the presence of steroids, and 8 of those were positive.1 The first international athletes to be found guilty of taking steroids were a Bulgarian discus thrower, a Romanian shotputter, a Polish discus thrower, and weight lifters from several countries. By that time, it seemed that some Eastern European countries had adopted steroid use as a matter of tacit policy. When the East German swimming coach was asked during the 1976 Olympics why so many of their female swimmers had deep voices, the answer was, “We have come here to swim, not sing.”5

The BALCO Scandal

For years, rumors had circulated around Major League Baseball that certain players were using steroids—which had been banned since 1991—but the league did not test for them. When Barry Bonds came into the 2001 season looking bigger and stronger, and went on to hit a record 79 home runs, some speculated that he might have used steroids, but the rumors were always denied. In 2002, former player Ken Caminiti admitted to using steroids and claimed that “half” the Major League players were doing so. Then, in 2003, Major League Baseball instituted a limited testing program that subjected each player to one random test per year, but drug-positive tests were not punished. As a result, many regarded professional baseball testing as a sham.

In June 2003, an unidentified track coach delivered to the U.S. Anti-Doping Agency a syringe containing an “undetectable” steroid, naming the source as Victor Conte, founder of BALCO Laboratories. Analysis determined that the syringe contained tetrahydrogestrinone (THG), a steroid previously unknown to the agency that did not show up in agency tests. The BALCO investigation led to a raid on the laboratory and the discovery of other steroids and human growth hormone.6 Conte testified before a grand jury in San Francisco after being given immunity from prosecution and named a long list of Olympic and professional athletes who had been his clients, including Barry Bonds and many other professional baseball players. Bonds admitted to unknowingly taking steroids but has steadfastly denied intentionally using these drugs to enhance performance.

As a result of this and other developments, at the start of the 2006 season, Major League Baseball instituted more frequent testing and toughened penalties for drug policy violations. In addition, testing for amphetamines was included as part of the new policy for the first time (see the Myth Buster box). Under the current policy, each player is tested at least three times: once during the off-season, preseason, and regular season. Some players may also be subjected to additional random tests throughout the season. Table 16.2 summarizes the penalties associated with violations. Note that steroid violations are treated more harshly than amphetamine/stimulant violations. For example, the first steroid infraction results in an 80-game suspension, whereas a similar amphetamine infraction does not trigger a suspension.

The Battle over Testing

During the 1980s, public revelations of drug use by athletes became common and cocaine was often mentioned. Professional basketball, baseball, and football players in the United States were being sent into treatment centers for cocaine addiction, and several either dropped out or were kicked out of professional sports. Most amateur and professional sports organizations adopted longer and more complicated lists of banned substances and rules providing for more and more participants to be tested. For example, in 1986, the National Collegiate Athletic Association (NCAA) adopted a list of more than 3,000 brand-name drugs containing banned substances. All participants are to be tested during the championship contest and after all postseason football games. In many events around the world, all contestants must now be subjected to urine tests as a matter of routine.

Because of both the expense and the inconvenience, some have questioned the wisdom of trying to test every athlete for everything. Despite the enormous expense to which sports organizations have gone, the use of steroids, stimulants, and other performance-enhancing substances seems to be as great as ever. Both the extent of testing and the ingenuity of athletes trying to beat the tests continue to escalate. The BALCO scandal demonstrates that chemists will keep coming up with new ways to help the athletes avoid detection.

Stimulants as Performance Enhancers

The first question to be answered about the use of a drug to increase energy or otherwise enhance athletic performance is, Does it work? We might not worry so much about unfair competition if we didn’t feel that the use of a drug would really help the person using it. Also, if we could prove that these drugs were ineffective, then we could presumably convince young people not to take the risk of using drugs because there would be no gain to be had. But experiments can never prove that a drug has no effect—you might have done a hundred experiments and not used the right dose or the right test (peak output? endurance? accuracy?). The possibility always exists that someone will come along later with the right combination to demonstrate a beneficial effect. Therefore, be wary when someone tries to use scientific evidence to argue that a drug doesn’t work, has no effect, is not toxic, or is otherwise inactive.

We’ve had a pretty good idea of the effectiveness of the amphetamines since 1959, when Smith and Beecher published the results of a double-blind study comparing amphetamines and placebos in runners, swimmers, and weight throwers.7 They concluded that most of the athletes performed better under amphetamines, but the improvement was small (a few percentage points’ improvement). Several subsequent studies reported no differences or very small differences in performance, and some medical experts in the 1960s argued that amphetamines were essentially ineffective and there was no reason for people to use them. An excellent review of the literature put it all into perspective. The authors pointed out that it had been taking athletes an average of about 7 years for each 1 percent improvement in the world record speed for the mile run. If amphetamines produced even a 1 percent improvement, they could make an important difference at that level of competition. The study concluded that there is an amphetamine margin. It is usually small, amounting to a few percent under most circumstances. But even when that tiny, it can spell the difference between a gold medal and sixth place.8

Whether amphetamines or other stimulants increase physical ability (provide pep or energy) or produce their actions only through effects on the brain is an interesting question, which might not be answerable. Surely a person who feels more confident will train harder, compete with a winning attitude, try harder, and keep trying longer. With amphetamines, improvements have been seen both in events requiring brief, explosive power (shotput) and in events requiring endurance, such as distance running. In laboratory studies, increases have been found in isometric strength and in work output during endurance testing on a stationary bicycle (the subjects rode longer under amphetamine conditions). This endurance improvement could be due to the masking of fatigue effects, allowing a person to compete to utter exhaustion.

Caffeine has also been shown to improve muscular endurance and endurance performance under laboratory conditions. In one recent experiment, 350 to 400 mg of caffeine (approximately equivalent to three cups of brewed coffee) increased the number of sit-ups and push-ups by 6.3 and 8.2 percent, respectively.9 In the same experiment, participants were required to run for several minutes at a pace that progressively increased over time. On this measure of performance endurance, caffeine, compared with placebo, increased the distance covered by 11.9 percent. Small amounts of caffeine are acceptable in most sports, but a urine level above 15 μg/ml—approximately 6 to 8-oz cups of brewed coffee—will lead to disqualification in many competitions.

Apparently no controlled laboratory or field experiments have tested the performance-enhancing capabilities of cocaine. Despite the absence of empirical evidence, many athletes believed in its power, especially during the 1980s. Cocaine’s stimulant properties are generally similar to those of the amphetamines, so we can assume that cocaine would be effective under some circumstances. Given cocaine’s shorter duration of action, it would not be expected to improve endurance over a several-hour period as well as either amphetamines or caffeine.

For years, athletes had another readily available stimulant in the form of ephedrine, either as a drug or in the form of ephedra extract. Ephedra (ma huang) was introduced in Chapter 6 as the herbal source of ephedrine, and it was the ephedrine molecule that was modified in the 1920s to produce amphetamine. When Olympic and NCAA officials developed lists of banned substances, ephedrine soon made its way onto the lists (except for people whose physicians said they suffered from asthma—ephedrine relaxes bronchial passages and is an ingredient in asthma medications). Professional sports organizations were at first less concerned about ephedrine, but eventually the NFL also banned it. Major League Baseball did not, and baseball players used it to provide extra energy, or in some cases to reduce weight, since ephedra was also found in many weight-control dietary supplements (Chapter 12). In 2003, Baltimore Orioles pitcher Steve Bechler died after collapsing during practice—his temperature rose to 108 degrees in the hospital before his death, which was attributed to heat stroke due to the ingestion of “significant amounts” of ephedrine from a dietary supplement.10 This widely publicized death finally gave the FDA enough political backing to ban ephedra and ephedrine in dietary supplements in 2004.

With all these and several other CNS stimulants banned by most sports associations, some athletes have continued to use them during training, to allow them to run, ride, or swim harder. They then do not use the drug for several days before the competition or during the competition, hoping that traces of the substance will not appear in the urine test. This might make sense, but no one knows whether training under one drug condition has an effect on competition under another condition. Also, overexertion under the influence of a fatigue-masking drug might be most dangerous during training, leading to muscle injury, a fall or another accident, or heat exhaustion.

Steroids

The male sex hormone testosterone has two major types of effects on the developing man. Androgenic effects are masculinizing actions: Initial growth of the penis and other male sex glands, deepening of the voice, and increased facial hair are examples. This steroid hormone also has anabolic effects. These include increased muscle mass, increases in the size of various internal organs, control of the distribution of body fat, increased protein synthesis, and increased calcium in the bones. In the 1950s, drug companies began to synthesize various steroids that have fewer of the androgenic effects and more of the anabolic effects than testosterone. These are referred to as anabolic steroids, although none of them is entirely free of some masculinizing effect.

There is no doubt that testosterone has a tremendous effect on muscle mass and strength during puberty, and experiments on castrated animals clearly show the muscle-developing ability of the synthetic anabolics.11 What had not been so clear is the effect of adding additional anabolic stimulation to adolescent or adult males who already have normal circulating levels of testosterone.

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For several decades there was a fair amount of controversy regarding whether these drugs are effective in increasing muscle size in healthy individuals or whether they improve athletic performance. The medical position was that they were not, whereas the lore around the locker room was that they would make anyone bigger, stronger, and more masculine-looking. A lot of people must have had more faith in the locker-room lore than in the official word. The 1992 Physician’s Desk Reference contained the following statement in boldface type: “Anabolic Steroids Have Not Been Shown to Enhance Athletic Ability.”

The medical position was based on evidence from research at the time. Findings from such studies suggested anabolic steroids produced little or no muscle-enhancing effects in healthy people. But, many athletes reported taking doses that were considerably larger than those tested in most clinical research studies; they also claimed to take doses that were much larger than those recommended for the treatment of a deficiency disorder.12 Thus, it was difficult to know whether the non-effect was due to the relatively low doses of anabolic steroids tested in clinical studies. The situation changed in 1996 with the publication of a landmark study by Bhasin and colleagues.13 These researchers administered large doses of testosterone (six times the dose used in replacement therapy) or placebo to healthy young men over the course of 10 weeks. They also controlled for potentially confounding variables such as the amount of exercise and nutritional intake. The data clearly showed that the combined effects of testosterone and exercise significantly increased muscle mass and strength compared with exercise alone. Several subsequent studies have replicated these findings.14

Steroids are known to enhance the natural process of muscle building. Key elements in building muscles are protein synthesis and cellular repair. Skeletal muscle is composed of long fiber chains containing proteins. Bundles of thousands of fibers make up the muscle itself. This structure is damaged when a person engages in a vigorous workout, causing microtrauma in the muscle fiber. The body naturally repairs this damage by healing the fibers. The result is a muscle that is larger and stronger than before, and with each additional workout the person adds bulk and strength. Steroids speed up the muscle repair and recovery process. Normally, it takes about 48 hours for muscles to repair themselves following a heavy workout. Steroids can shorten the repair and recovery process to only 24 hours, allowing the athlete to returning to heavy training more quickly.

Thus, the bottom line is that anabolic steroids increase muscle size and strength. They can help an individual train harder and recover more quickly. Many athletes, sports writers, and fans had arrived at this conclusion decades ago, long before it was accepted by the scientific and medical communities. By the way, that FDA disclaimer about anabolic steroids is no longer required.

Sex, Gender, and Testosterone

Because females usually have considerably lower amounts of testosterone than males (see Table 16.3), there are a few unique considerations for female athletes and anabolic steroids that we need to address. For example, should women with high levels of endogenous testosterone be permitted to compete against other female athletes? Caster Semenya, Olympic champion from South Africa, and Dutee Chand, a sprinter from India, drew intense media scrutiny in the months leading up to the 2016 Rio Olympics for precisely this question. Both identify their gender as woman. But, in the past, these female athletes have been subjected to humiliating sex tests and barred from competition because of their “masculine” appearance and naturally occurring testosterone levels that exceed guidelines for their sex. Currently, the testosterone eligibility threshold for female athletes is arbitrarily set at 144 ng/dl (5 nmol/l), which is just over twice the average high-end level for adult female nonathletes and well below levels for average male nonathletes. This issue becomes increasingly complex when average testosterone levels for elite athletes only are examined. There is considerable overlap of the range of testosterone levels between the sexes.15 In addition, the growing participation of transgender athletes adds further complexity to this issue. What seems clear, however, is that current eligibility requirements that limit female participation in athletic events that are based on “normal” testosterone concentrations aren’t scientific, nor are they unsustainable. Besides, these biological differences are minuscule compared with levels produced from taking performance-enhancing substances.

Psychological Effects of Steroids

The reported psychological effects of steroids, including a stimulant-like high and increased aggressiveness, might be beneficial for increasing the amount of work done during training and for increasing the intensity of effort during competition. However, there are also concerns that these psychological effects might produce great problems, especially at high doses. One concern is that a psychological dependence seems to develop in some users, who feel great when they are on the steroids but become depressed when they are off them. Many users take the drugs in cycles, and their mood swings can interfere with their social relationships and other life functions.

There has been a great deal of discussion about “roid rage,” a kind of manic rage that has been reported by some steroid users. We should be careful about attributing instances of violence to a drug on the basis of uncontrolled retrospective reports, especially when the perpetrator of a violent crime might be looking for an excuse.16

Adverse Effects on the Body

There are many concerns about the effects of steroid use on the body. In young users who have not attained their full height, steroids can cause premature closing of the growth plates of the long bones, thus limiting their adult height. For all users, the risk of peliosis hepatitis (bloody cysts in the liver) and the changes in blood lipids possibly leading to atherosclerosis, high blood pressure, and heart disease are potentially serious concerns. Acne and baldness are reported, as are atrophy of the testes and breast enlargement in males using anabolic steroids.

There are also considerations for females who use anabolic steroids. Because females usually have only trace amounts of testosterone produced by the adrenals, the addition of even relatively small doses of anabolic steroids can have dramatic effects, in terms of both muscle growth and masculinization. Some of the side effects, such as mild acne, decreased breast size, and fluid retention, are reversible. The enlargement of the clitoris might be reversible if steroid use is stopped soon after it is noticed. Other effects, such as increased facial hair and deepening of the voice, might be irreversible.17

Regulation

As we found in Chapter 2, when a drug is perceived to produce dependence, violent behavior, and toxic side effects, society may feel justified in trying to restrict the drug’s availability. In 1988, congressional hearings were held on the notion of placing anabolic steroids on the list of controlled substances. Evidence was presented that a large black market had developed for these drugs, amounting to perhaps $100 million per year. In addition, there was concern that adolescent boys, many of whom were not athletic at all, had begun to use steroids in the belief that they would quickly become more muscular and “macho” looking. Predictably, in 1990, U.S. Congress passed the Steroid Trafficking Act, which reclassified anabolic steroids as Schedule III controlled substances, requiring more record-keeping and limited prescription refills. The Anabolic Steroid Control Acts of 2004 and 2014 expanded the list of controlled and banned anabolic steroid-related compounds.

Other Hormonal Manipulations

Whereas the anabolic steroids have been in wide use, other treatments have been experimented with on a more limited basis. Female sex hormones have been used to feminize males, so that they could compete in women’s events. The women’s gold medal sprinter in the 1964 Olympics was shown by chromosome testing to have been a man, and he had to return the medal. Hormone receptor–blocking drugs have probably been used to delay puberty in female gymnasts. In females, puberty shifts the center of gravity lower in the body and changes body proportions in ways that adversely affect performance in some gymnastic events. Smaller females appear to be more graceful, spin faster on the uneven bars, and generally have the advantage, which is why top female gymnasts are usually in their teens.

We have certainly not seen the end of growth-promoting hormonal treatments. Human growth hormone, which is released from the pituitary gland, can potentially increase the height and weight of an individual to gigantic proportions, especially if administered during childhood and adolescence. In rare instances, the excessive production of this hormone creates giants well over 7 feet tall. These pituitary giants usually die at an early age because their internal organs continue to grow. However, administration of a few doses of this hormone at the right time might produce a more controlled increase in body size. Likewise, the growth-hormone-releasing hormone, and some of the cellular intermediary hormones by which growth hormone exerts its effects, might work to enhance growth. It is difficult to test for the presence of these substances. Despite the possible dangers, the lure of an otherwise capable basketball player growing a couple of inches taller or of a football player being 30 pounds heavier has no doubt caused many young athletes to experiment with these substances. Studies have shown that growth hormone increases lean body mass but may not improve strength in healthy individuals.19 However, there is limited evidence showing that growth hormone treatment increased leg muscle strength in healthy males over 50 years old.20

Erythropoietin (EPO)

In June 2020, when many people around the globe were sheltering in place due to the COVID-19 pandemic, ESPN broadcast a 4-hour long documentary on Lance Armstrong. Armstrong, a professional cyclist, was forced to retire from the sport after being diagnosed with the most advanced stage III testicular cancer. The cancer had advanced to his brain, and his chances for survival were bleak. But remarkably, Armstrong recovered, returned to cycling, and won the Tour de France an unprecedented seven consecutive times. Rumors swirled around him during this period. Competitors, teammates, and others charged that he was doping. For years, Armstrong met such accusations with intense denials sometimes involving legal retaliations.

Ultimately, as the ESPN documentary shows, the truth was uncovered. Turns out, Armstrong had been using performance-enhancing substances, including human growth hormone, for most of his career, even before his cancer diagnosis. According to Armstrong, however, erythropoietin (EPO) was the substance that enhanced his performance the most.

EPO is hormone produced in our kidneys. Its major functions are to stimulate bone marrow cells to make more red blood cells and regulate the concentration of red blood cells in the blood. Red blood cells transport oxygen to cells in the body, including muscles cells. This enables them to function more effectively. Thus, it isn’t difficult to understand why athletes might want to increase the number of red blood cells in their bodies. By doing so, it would increase the amount of oxygen that gets to the muscles, thereby boosting performance. That is why, Armstrong and others willingly received injections of EPO, which, by the way, had been placed on the International Olympic Committee’s list of banned substances in 1990. Plus, because EPO is an endogenous substance, it took approximately 10 years to develop a valid test that could differentiate between endogenous and exogenous EPO.

High doses of EPO administered chronically can cause the body to produce excessive amounts of red blood cells, which lead to blood clots heart attack, and stroke. This dosing regimen can also stimulate the production of antibodies directed against EPO, which can lead to anemia.

Beta-2 Agonists

At the beginning of the 1992 Olympics, the leader of the British team was disqualified because of the detection of a new drug. Clenbuterol was developed as a treatment for asthma and is a relative of several other bronchodilators that are found in prescription inhalers. These drugs have sympathomimetic effects on the bronchi of the lungs but are designed to be more specific than older sympathomimetics, such as ephedrine or the amphetamines (see Chapter 6). Their specificity comes from a selective stimulation of the beta-2 subtype of adrenergic receptors. Research with cows had revealed an increase in muscle mass, and speculation was beginning that this might represent a new type of nonsteroidal anabolic agent. Apparently someone in the United Kingdom was keeping an eye on the animal research literature and decided to try the anabolic actions on at least one Olympic athlete. Presumably it was hoped that such a new drug would not be tested for, but the Olympic officials were also well informed and ready, at least for clenbuterol. Human studies have shown some increases in strength of selected muscle types and improvements in endurance performance with clenbuterol or a similar beta-2 agonist.21

Creatine

One widely used substance among bodybuilders has been creatine, a natural substance found in meat and fish. This legal product is sold as a food supplement. There is clear evidence that creatine helps regenerate ATP, which provides the energy for muscle contractions. Users of creatine tend to gain some weight, some of which is water weight. There is considerable evidence that the use of creatine can not only athletic performance, but it is also helpful in preventing and reducing injury severity, facilitating rehabilitation from injuries, and enhancing athletes ability to tolerate demanding training regimens.22

Getting “Cut”

If getting “cut,” “ripped,” and “shredded” sounds like something you’d want to avoid, then you’re probably not into bodybuilding. These terms refer to the appearance of someone who is both muscular and lean. Because amateur wrestlers compete in weight classes and they need to be strong, they have always had the problem of eating well to build strength and train hard, but then needing to “cut” weight before the weigh-ins for matches. Jockeys have had a similar problem. Over the years, some of these athletes have engaged in fairly extreme methods to achieve short-term weight reduction, such as purging, taking diuretic drugs to lose water weight, and exercising in a heated environment or wearing nonporous clothing to maximize sweating. The entire list of weight-control drugs mentioned in Chapters 6 and 12 have been used as well, ranging from amphetamine to ephedrine to caffeine.

Increasingly, bodybuilders are seeking the look of someone who is both strong and lean, with lots of muscle definition. That appearance is referred to as looking “cut,” probably derived from the idea of cutting weight or cutting fat, but perhaps also carrying the connotation of “sculpted.” A more extreme version of looking cut is looking “ripped,” or sometimes “shredded.” These are the males and females whose every muscle fiber and vein can be seen through the skin, perhaps with a body fat percentage down to an unhealthy 5 to 7 percent (8 to 19 percent is considered ideal for a healthy male, while the healthy range for females is 21 to 33 percent). They also are using drugs and nutritional supplements to help achieve this appearance. Steroids increase muscle mass, but they don’t produce this kind of lean definition. A brisk market has developed in dietary supplements containing the word ripped in their name, such as “Ripped Fuel” and “Ripped Fast.” For many years these products relied mainly on ephedra as the main active ingredient. Once ephedra was banned, these profitable products did not go away. They simply changed their formulas and kept making the same claims about being “fat burners” and promising incredible results. They contain a bewildering variety of plant extracts, many of which contain caffeine in unknown amounts (e.g., guarana extract, green tea extract, and coffee bean extract).

Remember that these dietary supplements do not have to be demonstrated to be effective, and the beneficial claims have not been evaluated by the FDA (or anyone else). If an included ingredient should turn out to be dangerous, it might take a long time for this to come to the attention of the FDA, and it would then take a long time for the agency to build a case to remove the ingredient from the market (it took 10 years for ephedra). No such product has ever been shown to actually be a “fat burner,” so it’s unlikely that these are either. If you buy them, the closest you’ll get to being “ripped” as a result is probably feeling “ripped off” when the magic pill doesn’t deliver what you hoped.

Summary

· Performance-enhancing drugs have been used by athletes throughout history.

· Athletic use of stimulants appears to have increased and spread to most sports with the use of amphetamines during the 1950s and 1960s.

· Amphetamines and caffeine have both been shown to increase work output and to mask the effects of fatigue.

· Anabolic steroids are capable of increasing muscle mass and strength.

· Anabolic steroids can also produce a variety of dangerous and sometimes irreversible side effects.

· EPO stimulates bone marrow cells to make more red blood cells, which transport oxygen to muscle cells enabling them to function more effectively.

· Creatine is a legally available nutritional supplement that can improve exercise performance.

Review Questions

1. What was the first type of stimulant drug reported to be used by boxers and other athletes in the 1800s?

2. What was the first type of drug known to be widely used in international competition and that led to the first Olympic urine-testing programs?

3. When and in what country were the selective anabolic steroids first developed?

4. Do amphetamines and caffeine actually enhance athletic performance? If so, how much?

5. Describe the basic process of building muscles and how steroids affect this process.

6. What muscle effect do we know for certain that anabolic steroids can produce in healthy males?

7. What specific effect of anabolic steroids might be of concern to young users and to females?

8. How does EPO work to improve athletic performance?

9. How does creatine increase strength?