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Understanding Performance-Enhancing Drug Use

DAVID WANG MD, MS

ABSTRACT—Performance-enhancing drug use is a prevalent problem in sports. It is a problem that has captured the world's attention as the media highlights story after story of athletes who have transformed their bodies over a short period of time, those who have simply defíed the aging process in an attempt to prolong a career and those whose ca- reers have been tarnished because of drug use. The baseball investigations and the Mitchell Report* of 2007 opened our eyes and gave us a glimpse of a secretive underground world. This "world" is much more intelligent and sophisticated than it is given credit for. It is the goal of this article to increase the awareness of the medical provider about the types of steroids and other medications used, the influence these substances have on the athletes, and how and why they use them.

DAVID WANG,MD,MS,EliteSportsMedidne, Connecticut Children's Medical Center.

D RUG use is an area in sports medicine that is crucial to recognize and is poorly studied, largely because the use of performance-enhancing substances

are illegal and therefore rarely, if ever, reported. It is an area difficult to gather scientific data about, but with the severity of consequences from the use of these substances it is imperative that the prudent practitioner is familiar enough with the substances and practices that red flags would be recognized and an open and honest discussion with the patient on the wrong path could occur.

During the course of a 20-year practice of sports medi- cine and I have encountered the use of these substances by athletes of all sorts. I have spent time in a smaller gym populated by serious bodybuilders and witnessed practices most would not know existed. Through con- versations with these bodybuilders, and I have learned of the countless steroids that are "stacked" and the myriad of other medications used to achieve their desired results or to manage side effects. The medical community is well aware of the existence of anabolic-androgenic steroids and human growth hormone ( H G H ) and their use for performance enhancement. However, most practitioners are often not well versed on the specific types of steroids and other medications that are used in combination with these ergogenic aids. It is the "other" medications that are responsible for much of the morbidity and mortal- ity within this population. When these athletes die it is often due to narcotic addiction and, to a much lesser degree, anabolic steroids and growth hormone use. Al- though the exact number of deaths is unknown, I have seen and heard of several. In my experience and I have witnessed or cared for several tragic deaths in training and competition. The number of deaths witnessed from drug use equals those observed from congenital heart disease and head injury.

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Initially our contact with an athlete can take place during the preparticipation screening examination. We typically designate a considerable amount of time to concussions, heart screening and musculoskeletal issues. In my experience of over a decade at the Divi- sion I collegiate level, the performance-enhancing drug questions are usually brief and almost always uniformly denied. It was a rare day when an athlete would admit to using creatine or glutamine. The acknowledgement that the use of performance-enhancing drugs in the athletic college population is not as high as in the weightlifting and body building populations and I am not suggesting that we decrease our diligence in screening for heart disease, concussions, and orthopaedic issues but rather increase our awareness of performance enhancing drug use. In my experience college athletes are at a lower risk of illegal ergogenic drug use than the time before or after college when the environment is less regulated. Collegiate athletes typically train under the guidance of the strength and conditioning coaches at their institution. However, while they may have decreased exposure to the "underworld" they should still be assessed for ergogenic drug use.

Athletes of various ages and levels often spend a significant portion of their-off season at the gym in a legitimate effort to enhance performance with hard work. It is in this environment where athletes can be exposed to performance-enhancing drug use. Athletes will witness first hand the massive muscle destroying workouts these bodybuilders and power lifters tolerate on a daily basis. They may begin to ask themselves, how did they get to be so strong and large? How do they endure these workouts? These lifters can have a profound effect on the athletes trying to emulate their strength gains. Perhaps after failed attempts with hard work to achieve the exponential strength increases, accelerated workout recovery, and the workout tolerance they have witnessed the athlete may turn to ergogenic aids.

The progression of drug use starts innocently enough with legal supplements and an aggressive weight-lifting regime. There are a multitude of supplements being used by athletes. Listed below is a selected list of the more common supplements used by athletes trying to improve their performance.

Legal Supplements

Protein powder supplementation has a recommended daily allowance of 0.8-0.9g/kg/day hut for increasing muscle mass it is 1.2-1.6g/kg/day. ̂ Vhey protein, which is a significant component of milk, contains leucine that is a branched chain amino acid that stimulates muscle protein synthesis. Whey protein is better absorbed than casein or soy proteins. Except in the case of renal insuffi-

ciency there are no significant medical issues with protein supplementation and they are generally considered safe.̂

Caffeine is felt to be beneficial for endurance as well as "stop and go" sports. The mechanism of action is unknown but alterations of the central nervous system may change perceptions of effort, and fatigue may be responsible for caffeine's ergogenic properties. Caffeine has also been shown to stimulate adrenaline and mobi- lize fat from adipose as well as muscle tissues. Benefits are felt to come from moderate doses of 2-3 mg/kg. As an example, a 250 ml can of Red Bull contains 80 mg caffeine, while a 375 ml can of Coca Cola has 49 mg of caffeine.^

Glutamine is a common amino acid found in muscles. It is a legal supplement that is felt to build muscles but this has not been proven in studies to date. Studies have yet to demonstrate any improvement in athletic perfor- mance."*

Creatine is a naturally occurring amino acid found in skeletal muscle as well as other tissues. The vast major- ity of creatine is in the skeletal muscle and is used for rephosphorylation of adenosine diphosphate (ADP) hack to adenosine triphosphate (ATP) so that more energy can be created. Creatine is used to increase energy availability in the muscles. Studies on athletic performance have not shown a conclusive benefit from creatine supplementa- tion. Side effects include water-weight gain, muscle cramps, and gastrointestinal cramping.^ Except in the case of renal insufficiency there are no other significant medical issues reported. The use of creatine supplementa- tion has been felt to portend a higher risk to future ana- bolic steroid use. Creatine supplement use plus exposure to steroid users in the gym can increase the possibility of future anabolic steroid use.*

Weight Modifying

Diuretics are one of the commonly used weight loss medications. By increasing urine production they are able to dilute the urine and consequently are used as a masking agent to prevent the detection of performance-enhancing drugs. They are also used in an effort to decrease weight in those sports with weight classes.

In my conversations with bodybuilders one of the interesting medications that was mentioned for cutting weight was 2,4-dinitrophenol (DNP). D N P uncouples oxidative phosphorylation in the mitochondria and therefore energy from other sources such as fat must be used. This weight-loss medication has not been used since the 1930s as causes nausea, vomiting, and hyperthermia. D N P has been used to make dyes, wood preservatives, and pesticides.

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Prohormones

There are a variety of prohormones available that claim to increase the levels of testosterone by increasing sub- strate but none of these claims have been substantiated. Dihydroepiandrosterone (DHEA) is one of the over the counter prohormones that is a precursor of testosterone. It appears that D H E A does not promote fat loss or muscle gain or augment adaptations to resistance training in healthy men.^ This supplement is still classified as an anabolic-androgenic steroid by the World Anti-Doping Agency and is banned from use in athletic competition.

Anabolic Steroids

Anabolic-androgenic steroids are commonly used to increase muscle mass and improve strength. This is not done without consequence. The side effects are numerous and involve multiple systems within the body. Beginning with the cardiovascular system an increased risk of heart disease is attributable to many factors. The lipid profile can be changed with a lowering of high-density lipo- protein (HDL) and elevation of low-density lipoprotein (LDL) cholestérols. As body mass increases the cardiac workload is intensified. Hypertension and left ventricular hypertrophy have been seen in this population.'

One of the most commonly used steroids is testos- terone not only because of its availability but that it is often combined with other steroids. Testosterone occurs in natural and synthetic forms. Steroids derived from natural testosterone have less liver toxicity but have an unfavorable side-effect profile due to the conversion of testosterone to dihydrotestosterone (DHT) in the skin and prostate. Side effects seen from increased levels of D H T are prostatic enlargement, acne, and male- patterned baldness. For this reason. Prosear (5-alpha- reductase inhibitor) is often taken to prevent the conver- sion of testosterone to D H T . Synthetic testosterone is not converted to D H T . However, both types of testosterone can be aromatized to estrogen. This conversion to estro- gen can be blocked by mixed estrogen agonist/antagonist medications such as Clomid or Nolvadex and Cytadren. Estrogen has the unwanted side effects of water reten- tion, gynecomastia, and adds to the suppression of the hypothalamic pituitary axis.

Several oral steroid medications can lead to liver dis- ease. The 17-alpha-alkylated steroids are the most toxic to the liver. Liver abnormalities include; cholestasis, peliosis hepatic, heptaocellular adenomas, and even hepatic rupture have been reported.'

Long-term steroid use in body builders can also result in focal segmental glomerulosclerosis. The mechanism that has been postulated is secondary to increased muscle mass therefore the kidneys are subjected to an increased workload and a decline in kidney function.'"

Further side effects of long-term steroid use are: increase in rage and aggression; increased muscle mass which causes the collagen in the tendons to develop a disorganized pattern making the tendons more suscep- tible to injury; and secondary to the increased body mass sleep apnea can also occur."

Testosterone is the most commonly used steroid. Because it can be "stacked" with other steroids and used to replace natural testosterone that is suppressed by the other anabolic androgenic steroids. Users combine vari- ous types of steroids together to increase desired results and to mitigate different side effects. Table 1 illustrates some of the different steroids used, their intended use, and the most prevalent adverse effects they are known to cause.

Although anabolic androgenic steroids are the most commonly used of the ergogenic illegal drugs, there are other drugs used in the pursuit of strength and perfor- mance enhancement.

The "Other Drugs"

Human growth hormone (HGH) is a medication that is used to repair tissue and stimulate growth. Many of the desired effects of H G H are achieved through insulin growth factor 1 (IGF-1). IGF-1 is stimulated by H G H and is produced in the liver. IGF-1 like H G H is used for its anabolic effects such as protein synthesis and for • the formation of new muscle cells. Side effects of H G H may include carpal tunnel syndrome, hypertension, and acromegely.'^ Although not proven there are concerns that use of H G H may promote cancers.'^

Insulin is one of the medications that was mentioned to me in my conversations with these lifters. It is used after workouts to optimize muscle growth. Insulin stimulates protein formation and absorption. It also promotes fat synthesis and is often combined with an anabolic ste- roid and/or thyroid hormone to combat this side effect. Insulin is difficult and dangerous to used as one miscal- culation can result in death. I talked to one power lifter who told me of his nearly fatal use of insulin where he became unconscious secondary to hypoglycemia, and if his girlfriend had not been there to call the ambulance he may not have survived.

All of the medications are not enough without an in- tensive weight-lifting program. Due to excessive lifting, pain and injury are natural consequences. In an effort to push past the pain-lifters may use narcotic medications during or after their workouts. Nubain, which is an opioid agonist-antagonist, can be used during workouts for pain while medications like Vicodin, Percocet, or MS Contin are used after workouts. These tend to cause significant health and physiological issues as they are addicting. I have heard of deaths secondary to fentanyl patches due

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Table 1

Name

Anavar (oxyandrolone)

Winstrol (stanozolol)

Trenbolone

Deca-Durabolin (nandrolone)

Dianabol (methandrostenolone)

Equipoise (boldenone undecylenate)

Androl (oxymetholone)

Primobolan (methenolone)

Route

Oral

Oral, Injection

Injection Cutting fat

Oral, Injection

Injection

Oral

Oral, Injection

Desired Result

Cutting fat

Increase muscle mass and muscle hardness

Increase muscle mass

Increase stamina and red-cell mass

Increase muscle mass and red cell-mass

Increase strength

Side Effects

Hepatotoxic

Hepatotoxic Increases LDL and decreases HDL

Hepatotoxic Increases prolactin

Decreases thyroid hormone

Bloating Water retention

Aromatizes to estrogen Suppression of natural testosterone

Masculinization

Hepatotoxic Hypertension

Typical HPA suppression

Hepatotoxic Hirsutism

Water retention

Minimal side effects (choice for women)

to these addictions. Those that have used Nubain report it can allow one to -workout through the pain much more effectively than the pure opioid agonists.

In general, medications acquired from the medical community tend to have the highest quality and are the most sought after. I have been told of physicians, oral surgeons, and chiropractors who have prescribed or sold steroids, growth hormone, and narcotics to the body builders who I encountered in my gym. In addition these steroid users are quite adept at controlling and misleading the medical professionals they come in contact with. For instance, some steroid users bring their female dog to the veterinarian to stop them from going into heat. The veterinarian prescribes Cheque drops (mibolerone) for the dog but instead the athlete will use the steroid him/ herself. Needless to say these medications are acquired without the providers understanding of their ultimate use. Unfortunately some medical providers are aware of the intended use of the medications. These medical professionals who knowingly have prescribed these medi- cations have faced serious consequences when writing prescriptions without conducting physical examinaions or understanding their intended use.

Within the gym setting there are liflers who may pro- vide these medications to others as a source of income. Along with obtaining medication from the health-care

community these athletes can acquire medication from China, Mexico, and over the Internet. One of the in- teresting tricks of the business is the sale of steroids in weight-lifting and body-building magazines. The prod- ucts in these magazines have similar names to known steroids but their chemical compositions are slightly different. Due to the chemical composition differences, these products can be sold in the United States but they are not effective.

The medical doping literature attempts to scare ath- letes from using these substances due to the fact that they could result in a positive drug test, even months after use. While a failed drug test is a concern to many athletes, the users of these substances know exactly how long the substance will be in their bodies. Steroids can be either water-soluble (oral) while others are fat-soluble (injection). Athletes can switch to fast-acting water-based steroids closer to drug-testing time to avoid the posi- tive test. Even though the athletes do try to control the amount of steroids in their system around competition time they still have tested positive for banned substances in their respective sports. There are many examples of athletes who have used various ergogenic aids and have been stripped of Olympic medals, their names erased from the record books, and have had their successes tarnished because they were achieved using these drugs.

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As medical providers we must be aware of what our athletes could potentially be taking to aid in their performance or to achieve a desired look. Although, many of these athletes are not part oí the. popular sports medicine population these athletes deserve and require attentive sports medicine care. They have a higher risk of mortality due to the numerous medications being used with minimal, if any, direction. Hopefully, education will help some of these athletes avoid potentially lethal practices. An increased understanding of their world and the types of aides they are using will allow us to have the credibility necessary to educate our patients. With open and honest communication with our patients we will better recognize a chance to intervene, reduce dangerous complications, or even save a life.

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