Drugs and Sport

A searchable database of prohibited drugs is available on the internet.¹

There are three reasons why sportsmen may take drugs.

• One is as medication for disease. A sportsman is entitled to treatment of a medical condition, as is anyone else but both the competitor and the doctor must be aware of the rules about banned substances. Failure to heed them can have very serious consequences. An athlete could receive either a temporary or permanent ban from competing in that sport. If the doctor is at fault, the potential for litigation is vast irrespective or whether the individual is an amateur or professional competitor.
• Another reason to take drugs is to enhance performance and in doing so to give an unfair advantage. The GMC's stance on this is unequivocal:
  

  GMC Guidance Doctors who prescribe or collude in the provision of drugs or treatment with the intention of improperly enhancing an individual's performance in sport would be contravening the GMC's guidance, and such actions would usually raise a question of a doctor's continued registration. This does not preclude the provision of any care or treatment where the doctor's intention is to protect or improve the patient's health.

• The third reason why sportsmen may take drugs is "recreational". Hence cannabis, that is not a performance enhancing drug, is a banned substance. The authorities say that it is necessary to take such steps as sportsmen are role models for young people and hence should not take illicit drugs. However, they do not suggest how young people would know that their heroes take drugs if they were not tested and positive results made public.

Nowadays all elite athletes competing at international level and professional sportsmen are liable to be tested as a matter of routine. However, testing may go down to much lower levels and include young competitors. Sometimes testing may be anticipated. It is common practice to test all who have won medals in major events and possibly a few others at random too. Elite athletes may also be visited by representatives from their governing body for out of season testing.

Some drugs are permissible when not competing but not during competition. Others, such as anabolic steroids are banned at all times.

Some drugs are banned in some sports but not others. Banned substances can include alcohol and caffeine above a certain level. Beta blockers would impair performance of an endurance athlete but suppression of tremor gives unfair advantage in shooting events. It may be possible to get guidance from the sport's website. A number of useful sites are listed at the end.

Drug testing does not apply simply to sports such as athletics and football but may include snooker, bridge and chess played at the highest levels.

If a doctor believes that there is a good reason why his patient needs a banned substance, it is possible to issue a Therapeutic Use Exemption (TUE) certificate. An example of one to be used for football is found at the FIFA website listed at the end. They may be temporary for a single spell of illness or of longer duration. They must be issued in good faith, stating that alternative medication is inappropriate. For example, if a snooker player has hypertension, does he really need a beta blocker?

The problems faced by a doctor may be mundane matters of treatment such as decongestants, analgesics and medication for asthma. As mentioned above, some drugs are permissible in some sports and not others. Some are permissible out of competition but not whilst competing.

Doctors need to be aware of the possibility that patients may use deceit to acquire prescriptions for substances that they know they should not have.

Analgesics

Athletes often suffer injuries and analgesics may be appropriate. NSAIDs are the group of choice and are always permissible as is paracetamol. Opiate related analgesics are more problematical. Codeine is not on the WADA list of banned substances and combinations such as cocodamol and coproxamol appear acceptable. It is the stronger narcotic agents that are banned. However, screening does not always differentiate adequately between the various narcotic or codeine related compounds and they are best avoided.

Sometimes an athlete will beg the doctor to give an injection into an injured part to permit competition. Pain is an important warning that something is wrong and if a significant injury is pain-free this is a dangerous situation. Look at the destruction of a Charcot joint. Steroid injections also weaken ligaments and must not be given into tendons or ligaments. If the athlete, now pain-free, sets off unrestrained and ruptures a tendon or ligament, the doctor has done him no favour. There are certainly many anecdotes about the dangers of steroid injections, not only in the lower limb but for conditions such as tennis elbow too.² A larger survey did find evidence of steroid injections predisposing to rupture of the Achilles tendon.³ Another study did not find that steroid injections put the Achilles tendon at risk but neither did they lead to an earlier return to sport.⁴ There is a shortage of good trials to ascertain the place of steroid injections in the treatment of tendon conditions.⁵

Diuretics

The main reason for wishing to use diuretics is to produce more dilute urine so that illicit substances are not detected. For this reason they are banned. They may also be used in sports with weight categories such as judo and weight lifting. The competitor can dehydrate, make the weight at the weigh-in and then rehydrate before the competition as even mild dehydration ebbs fitness significantly. Jockeys have used diuretics for many years. Masking substances to hide the use of illicit drugs include probenecid and this too is banned.

Stimulants

The problem of stimulants in sport reached public attention in 1960 when the Danish cyclist Knut Jenson died in the Rome Olympics and it transpired that he had been taking amphetamines. The problem for doctors is not amphetamines that have few indications but decongestants that may be requested or bought over the counter to clear the airways of an athlete with a cold. Substances containing phenylephedrine and pseudoephedrine should be avoided. Ephedrine is permitted up to 10μg/L. This probably means that 0.5% ephedrine nose drops are safe. Saline nose drops are certainly safe but less effective. If a pharmacological agent is required, an anticholinergic such as ipratropium spray may be used.

Beta agonists are banned substances but they may be used if delivered by inhaler to a patient with asthma and a TUE is issued.

Corticosteroids are also banned but if anyone needs them, the wisdom of competing at top level needs to be questioned. A TUE may be issued. Topical steroids are permitted.

Enhancement of Oxygen Transfer

For endurance events, a high haematocrit enhances performance. There are 3 ways to achieve this:

• Training at altitude in a low PO₂ stimulates endogenous erythropoietin.
• Recombinant erythropoietin is effective, especially if combined with supplementary iron.
• Blood doping means removal of a unit of blood, perhaps 4 to 6 weeks before competition, the body replaces the lost blood and shortly before competition the blood is transfused.

Of these 3 techniques, only altitude training is legal although it is probably the most expensive and arguably the most dangerous.

There is no satisfactory way of detecting blood doping by autologous transfusion.⁶ Techniques are being developed to detect recombinant EPO⁷ and may already be used.

Substances to enhance oxygen uptake and haemoglobin substitutes are also banned.

Anabolic steroids

Anabolic steroids are a generic term for male hormones. They may be used for hypogonadism or diseases such as aplastic anaemia but such people are unlikely to compete at an elite level. In the 1970s athletes would take synthetic androgens such as nandrolone and these are easy to detect without any controversy. A much more difficult problem is when an endogenous substance such as testosterone is taken. The ratio of testosterone to dihydroepiandrosterone (DHEA) is usually about 1:1 or 2:1. A similar ratio is expected in women. If it is over 4:1 then exogenous testosterone is likely. Some men appear to have naturally high ratios but a radiocarbon test can detect synthetic testosterone.

New ways are being developed⁸ to detect metabolites of androstenedione, testosterone and dihydrotestosterone abuse.

In the 1970s the abuse of anabolic steroids by East European female, as well as male competitors was legendary. In the 1990s the Chinese women's swimming team were extremely muscular, all had acne and pictures showed a shadow suggesting the need to shave a male distribution of pubic hair. Their world champion at breast stroke had a style so poor that she risked disqualification but she powered her way to victory, and was nick-named "the dump truck".

Female hormones also have anabolic effects, although not as marked as male hormones. Athletes who return to training after pregnancy often find that they are stronger than they were before. Oral contraceptives are permitted substances and may well be most desirable. They tend to reduce menstrual loss and hence any tendency to iron deficiency. As well as making menstruation more tolerable, they can be used to adjust its timing so that the competitor is not pre-menstrual or menstruating during an important event. Their great value as a contraceptive is also to be appreciated. After having been selected to run the London Marathon, the commonest cause for failing to start is pregnancy.

Other banned substances include tibolone, that has some anabolic effects and anti-oestrogens including the SERMs and aromatase inhibitors. If there are genuine reasons to prescribe such drugs, a TUE can be issued.

The chemicals that we tend to think of as anabolic or male hormones are by no means the only ones with anabolic properties and hence other hormones may also be abused. In 1989 the Medical Commission of the International Olympic Committee (IOC) introduced the new doping class of peptide hormones and analogues, which include human chorionic gonadotrophin (hCG) and related compounds, ACTH, human growth hormone (hGH), all the releasing factors of these listed hormones, and erythropoietin (Epo). Both hCG and luteinizing hormone (LH) may be used to enhance the endogenous production of testosterone⁹ by artificial means.

In the past 20 years, growth hormone (GH) has been considered as a performance-enhancing drug in the world of sport and there is not yet an approved method for detecting its abuse. Because resting or random measurements of plasma GH concentrations per se are meaningless, new methods have been devised to evaluate plasma levels of GH-sensitive substances¹⁰ that are more stable, and hence detectable, than the hormone itself.

Growth hormone and insulin seem to work together to control blood glucose but the role of insulin is much more profound than just glucose homeostasis.¹¹ Insulin may be used to counter the hyperglycaemic effects of GH but it is also abused by body builders¹² and there are reports of severe hypoglycaemia as a result. The legal classification of insulin has been changed from P to POM so that it can no longer be bought over the counter in the presence of a pharmacist but requires a prescription.

Sometimes when an athlete is found to have taken a banned substance he or she admits to the fault but very often they deny ever knowingly having taken a banned substance. Cynics are unsurprised but often the athletes seem very genuine.

Elite athletes are not "normal" people and so reference ranges for physiological substances need to be determined on their peers. A cyclist who may be burning 9,000 calories a day during competition is not a normal subject. Sprinters tend to be very muscular and have a low body fat content. Fat is important in the metabolism of steroid hormones. The people who set such standards are sufficiently well versed in sports medicine and exercise physiology that they set their standards by the normal for the group that they examine. Nevertheless, if they say that their reference range will include 99% of all those active athletes who are not taking banned substances, then 1 in 100 will fall outside that range.

Most top athletes use dietary supplements¹³ and the contents of these may not be as vigorously controlled as may be hoped. Contaminants that have been identified include a variety of anabolic androgenic steroids including testosterone and nandrolone as well as the pro-hormones of these compounds, ephedrine and caffeine. This contamination may be the result of poor manufacturing practice, but there is some evidence of deliberate adulteration of products. The principle of strict liability that applies in sport means that innocent ingestion of prohibited substances is not an acceptable excuse, and athletes testing positive are liable to penalties. Although it is undoubtedly the case that some athletes are guilty of deliberate cheating, some positive tests are likely to be the result of inadvertent ingestion of prohibited substances present in otherwise innocuous dietary supplements.¹⁴ The beneficial effects of creatine have been shown in a number of studies.¹⁵ Creatine, ginseng and a number of other substances raise the question of when does a dietary supplement become a drug? Some people like to use herbal products in the belief that they are beneficial but not pharmacological. Some may even have been contaminated with pharmaceutical products as with the contamination of Chinese treatments for eczema with corticosteroids.¹⁶

The position of the GMC with regard to aiding and abetting drug abuse in sport is clear. However, a doctor may be faced by a patient who admits to using anabolic steroids. He does not enter competitions and so is not tested. He wants the doctor to monitor his LFTs as an early warning of any damage. What is the position? He will continue to take the steroids whether the doctor cooperates or not. It would be reasonable to warn him of the dangers and to check LFTS and lipids. This is not endorsing his action any more than a needle exchange encourages intravenous drug abuse. He may also benefit from the needle exchange. It is a damage limitation exercise that can be justified.

There is a constant battle between those seeking new techniques to detect illicit use of performance enhancing substances and those who wish to circumvent the rules. Testing is vigorous and can be unannounced and the penalties for being discovered are severe. Nevertheless there are, and always will be, those who attempt to use illicit ways of enhancing performance to get the necessary slight edge that is required to win. From time to time illegal substances are discovered. In British sport this should not be seen as evidence of widespread abuse of drugs but evidence that a vigorous and effective system of monitoring is in place. It is in countries such as China where there are never any reported cases that there is cause for concern.

Some would argue that the only way to get a "level playing field" is to lift all bans on drugs and let us push human endurance to the limit. Records have tumbled with new technologies going back to spikes and starting blocks and including modern running shoes and fibreglass poles for vaulting. Let pharmacological technology reach the edge. This is a false argument as the banned substances are not without significant risk. It cannot even be argued that the athlete is free to make his own choice as if the opposition use drugs to gain advantage, he will have to do the same to be able to compete.