4. The use and misuse of performance-enhancing substances in sport

Certain drugs have the potential to increase athletic performance, but they carry the risk of side effects, which may include death and life-long morbidity. Examples include a cyclist dying from stimulant misuse during the 1960 Rome Olympics, and deaths from cardiovascular disease and various cancers resulting from use of anabolic steroids,1 as well as the permanent androgenising effects of these drugs, including infertility, which affect many female Eastern bloc former athletes. Prohibitions on the use of dangerous performance-enhancing drugs have been introduced in almost all elite-level sports over the past 4 decades. Antidoping laws attempt to minimise the numbers of athletes engaging in doping, although the enforcement of antidoping laws is, predictably, not 100% successful.2-4 Because there is a perception that it is impossible to fully enforce antidoping laws, some commentators argue that these laws be relaxed to create an “open” but arguably more “even” playing field.4 However, sport without antidoping 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 antidoping standards worldwide (both with respect to lists of banned drugs and penalties for misusing them). The World Anti-Doping Code (“WADA Code”) was adopted after consultation with governments, sporting bodies, national antidoping agencies and other relevant parties in 2003 by all Olympic Committees, many nations and many elite sports associations.

A substance can be included on the World Anti-Doping Code Prohibited 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 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).

Antidoping 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, doctors who may potentially prescribe or otherwise assist athletes in taking banned drugs may also be subject to doping sanctions and suspended from involvement in elite sport.

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 strict protocols; see Box 1) was present within the athlete’s system, while it would be far too difficult, in most cases, to prove intent to cheat beyond reasonable doubt. Strict liability for doping offences is controversial, although the WADA Code does allow consideration of 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 before 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 the 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 Box 2 showing the response of drugs tribunals to the various explanations provided by the players.

The case in Box 2, in which a general practitioner prescribed probenecid for a professional player, which resulted in a doping violation, 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 the Australian Sports Drug Agency (ASDA, via their hotline [1800 020 506] or their website <http://www.asda.org.au/>), before prescribing. To date, there has been no reported litigation involving athletes taking action against 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, if a patient asked a doctor to check the legal status of a drug and an error was made, then the doctor may be held responsible for this mistake. When 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 recording on a patient’s file whether he or she is subject to sports drug testing.

Blood doping (transfusions of 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. In certain sports, the “average” haemoglobin levels of competitors have increased significantly in recent years, which is highly suggestive 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 detecting EPO directly, athletes in sports such as cycling and cross-country skiing (where EPO misuse is thought to have been common) are banned from competing if their red blood cell indices are raised beyond certain levels (possibly consistent with, but not definitive of, EPO use). These tests are done just before competition and exclusion from that event is based on the potential risk to health.

While seen by some as a sensible method of minimising harm,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, wheelchair athletes with spinal cord injuries who have high blood pressure before an event are prevented from competing at the Paralympics, without prospective suspension, as the elevated blood pressure may be self-induced (illegal “boosting” to improve performance) or the result of a concurrent medical condition.

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 Box 3) with the proviso that they may be used for certain medical indications, which require that the relevant body is notified before their use. Under the WADA Code, prospective approval to take a banned drug through the therapeutic use exemption (TUE) process for a documented medical condition is currently provided if:

• the condition poses significant impairment to health; and

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

• 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. However, incorrect lodgement of paperwork can 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 3 months in late 2004 for testing positive to a corticosteroid, injected by a doctor for a wrist injury.

Less commonly-exempted drugs (with greater potential for misuse and performance enhancement) must be assessed by an expert panel. In Australia, these requests for TUEs are handled by an independent panel called the Australian Sports Drug Medical Advisory Committee (see http://www.asdmac.org.au). 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 committee. 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 help elevate 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 have conditions for which anabolic steroids are indicated, because of the known beneficial effects on performance.12

The legality 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, but pseudoephedrine has been recently removed from the banned list (Box 3). The most contentious TUE decisions with respect to stimulants are for conditions such as narcolepsy and attention deficit hyperactivity disorder (ADHD). While these conditions improve markedly with stimulant medication,13 a recent review cautioned against awarding TUEs for stimulants on the basis that symptoms are difficult to verify “objectively”, making it possible for athletes to allege having symptoms of narcolepsy and ADHD to gain access to performance enhancing stimulants.8

While most over-the-counter supplements are considered “legal” within anti-doping codes, some controversies exist because 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.14 For instance, certain athletes taking bicarbonate/citrate, creatine and/or caffeine can exercise at higher work rates or for longer before experiencing fatigue.10,15,16 WADA has taken a pragmatic approach, considering that such ingredients occur naturally in food, and that manufactured products simply represent a practical way for athletes to consume a desired dose.

By contrast, the WADA Code bans prohormones, including androstenedione, dehydroepiandrosterone, and 19-norandrostenedione, which can be converted in the body to testosterone or the anabolic steroid nandrolone.17 Over recent years there has been controversy relating to their legality in professional baseball in the United States. Since the Dietary Supplement Health and Education Act (1994) was passed in the United States, products containing prohormones have been marketed as over-the-counter dietary supplements there. Even in countries like Australia where prohormones do not 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 prohormones generally leads to positive results from urinary drug screening tests,18-20 which means that none of the anabolic steroid prohormones can be considered “safe” for athletes who are subject to testing, yet certain individuals may still test negative for anabolic steroids after taking low doses of prohormones. Over recent years, many athletes who have tested positive for low levels of the anabolic steroid nandrolone have claimed that they took only apparently “legal” supplements. Several studies from overseas have suggested that up to 10%–15% of supplements may contain contaminated substances.18,21 Clearly, there are problems with the supplement industry worldwide, and solutions must include self-regulation of manufacturing processes to ensure uncontaminated and accurately labelled products, appropriate government regulations, and product testing and certification programs for athletes.

Another confusion about prohormone 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 prohormone supplementation is that there is little evidence of improved muscle size or strength above the gains achieved through resistance training.14 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.22