Many athletes distrust the scientific community on the issue of PEDs. Much of the early scientific literature stated unequivocally that certain commonly used compounds like anabolic steroids did not improve performance and routinely caused dramatic side effects. This ran directly counter to the underground athletic community experience and had the effect of discrediting the medical literature. Athletes and their trainers experimented with multiple drug combinations and dosing regimens that were based outside mainstream pharmacology. This information was eventually transmitted by word of mouth to others, who modified what they heard and created their own regimens. Physicians were generally unaware of how the compounds were being used and rarely performed tests reflecting real-life situations. Even today, reliable knowledge about the benefits and dangers of PEDs remains hard to come by in the medical literature. There is a small cadre of experts working diligently to answer these questions, but there’s an ongoing development of new drugs and methods of administration.
The following discussion is an admittedly incomplete overview of the medical effects of PEDs and is based on the current status of medical knowledge about commonly used compounds.
Anabolic Steroids
These PEDs are derivatives of the male hormone testosterone. Anabolic refers to their ability to stimulate protein synthesis and increase muscle mass. Not all steroids are anabolic. Anabolic steroids should not be confused with corticosteroids such as prednisone, which are commonly used in sports. Corticosteroids are generally injected into injured tissue to suppress short-term inflammation. While their use is sometimes controversial in the management of injury, corticosteroids are generally not considered PEDs.
Anabolic steroids include injectable drugs such as testosterone and nandrolone and oral drugs such as stanozolol. These drugs can be used for short periods of time or in on-off cycles of six to twelve weeks, a process known as stacking. Occasionally athletes will increase the dose significantly during a stacking cycle—this is known as pyramiding. Anabolic steroids basically build muscle mass, increasing size and strength, although users must train and eat properly to realize the greatest effect. Their benefit is obvious for power sports, such as weight lifting, wrestling, and football, but they may also benefit those who require bursts of energy, such as sprinters. For baseball players they have the obvious benefits of increasing strength, bat speed, and probably throwing velocity. It’s possible they increase hand-eye coordination. There are other less measurable, but just as practical, competitive effects, such as increasing confidence and aggression. These are potent drugs with significant side effects, and a number of studies suggest they may be addictive, though the potential for addiction is a matter of debate.
In children they are especially dangerous since they accelerate the maturation process and result in growth plate closure and shortened adult height. In both children and adults, muscle growth may outstrip tendon and ligament support and result in increased injuries. In adults potential complications include cardiovascular disease (hypertension, accelerated atherosclerosis, heart attacks, heart failure), liver problems (hepatitis, liver tumors), endocrine problems (high blood sugar, decreased sexual characteristics and sperm production in men, masculinization in women), acne, and psychological changes (depression, irritability).
The exact incidence of complications is unknown since it is difficult to test these drugs under actual conditions. In addition since long-term experience is limited, it’s unknown what happens in later life to young athletes using these drugs. Another important complication is the consequence of needle injection. Those who inject steroids are susceptible to serious and well-documented complications, including bacterial and chemical skin abscesses, viral hepatitis, HIV infection, and other serious blood infections.
Anabolic steroids are currently classified as Schedule III—they can only be obtained with a prescription. Possession of anabolic steroids without a prescription carries legal penalties, and unlawful distribution is a more serious legal offense. The International Olympic Committee (IOC) and most professional sports leagues in North America and Europe ban their use.
Steroid Precursors or Prohormones
These are hormones produced in the body that are ultimately converted to testosterone. Two common precursors are dehydroepiandrosterone (DHEA) and androstenedione (the drug baseball player Mark McGwire admitted taking). These drugs have no specific medical indication and technically are not anabolic steroids. Because they are converted to anabolic steroids in the body, they have similar effects and side effects, though they are relatively less potent than actual anabolic steroids. Since they were classified differently than anabolic steroids for many years, they were popular ingredients in nutritional supplements. However, the federal government has reclassified these drugs in the same category as anabolic steroids, and there are penalties at the federal level for possession and distribution. Androstenedione was a popular supplement in Major League Baseball until it was banned in 2004. It’s also banned by the IOC, National Football League (NFL), and National Collegiate Athletic Association (NCAA).
Human Growth Hormone
Human growth hormone (HGH) is a naturally occurring hormone of the pituitary gland. It is used to treat patients with certain growth disorders who are deficient in its production and is used in some specific chronic diseases. It is a popular PED today because it can’t be detected by most routine testing procedures. Its effects on normal subjects are unclear although there are reports it increases strength and decreases body fat. Former Chicago White Sox pitcher Jim Parque admitted to injecting HGH after an injury while an active major leaguer. (It was not banned at the time.) His experience is instructive; he describes that it did not make him stronger but allowed him to train harder because it shortened recovery time between workouts. The capacity for drugs such as HGH to permit users longer, more rigorous training sessions and to shorten recovery time after workouts should not be underestimated. That is an important, albeit indirect, factor in performance enhancement.
The side effects of HGH can be serious and include diabetes, heart disease, arthritis, and skeletal abnormalities, including jaw prominence and skull enlargement. Until recently most HGH was collected from cadavers, and use of the drug carried the risk of viral disease transmission. Today HGH is made synthetically, eliminating this danger and making it more accessible to patients and athletes. HGH is legal with a prescription, but distribution without a prescription can lead to a fine and/or prison term. Many “HGH creams and sprays” are available through the Internet, but they are most likely worthless since the body can only use HGH when it is injected.
Blood Doping
Blood doping is a technique especially popular with competitive cyclists and long-distance runners. It involves increasing the number of oxygen-carrying red blood cells in the body in order to increase aerobic performance. Formerly, athletes would store their own blood and receive it as transfusions near the time of competition. Today the same effect can be obtained through the administration of erythropoietin (EPO), an agent that stimulates red blood cell production (used in patients with chronic renal failure who are anemic). Recently it has been demonstrated that in certain types of brain injury, EPO has protective effects that are independent of its red blood cell stimulation. The mechanism of this “neuroprotective” effect is uncertain, and it may also play a role in the benefits that athletes realize by using EPO.
EPO is difficult to detect with current testing. Blood doping, while it increases aerobic capability, is extremely dangerous. Increasing the number of red blood cells in the body essentially makes blood thicker and can result in heart attacks, strokes, and sudden death. These complications are more common in athletes who become dehydrated. Since 1987 the deaths of at least eighteen Belgian and Dutch cyclists have been attributed to EPO. Interestingly training at high altitudes for long periods of time, while controversial, can result in the same effect as blood doping—that is, increasing red blood cell numbers and aerobic potential by stimulating
the natural production of EPO.
Stimulants
The use of stimulants as PEDs ranges from caffeine to ephedrine and its derivatives to amphetamines. Unlike hormones, these drugs don’t increase strength or aerobic capabilities. They can be effective because they reduce the sense of fatigue, increase alertness, heighten euphoria, and lessen the sensation of pain.
Caffeine is the most commonly used drug by athletes. In moderation it may increase endurance and improve performance. When used excessively, it may interfere with athletic performance and cause dehydration. Olympic and NCAA competition permit caffeine up to certain levels (roughly the amount in six cups of coffee over twenty-four hours). Higher levels are banned. Ephedrine and its derivatives are commonly used asthma drugs that have been used as PEDs. They stimulate the nervous system, although their effect on athletic performance is unclear. (Bodybuilders claim they increase energy, metabolism, and training drive and help mobilize body fat.) In 2003 an ephedrine derivative was linked to the death of Steve Bechler, a prospective pitcher for the Baltimore Orioles.
Most studies have demonstrated little athletic benefit to these drugs. A number of deaths and cardiovascular complications have been reported with the use of ephedrine and related compounds, especially in hot weather. Ephedrine-like compounds represent a lucrative export industry from China. Compounds such as ma huang and similar dietary supplements have been touted to improve muscle tone and energy levels, although there is little documentation. Ephedrine and its derivatives remain legal in the United States under certain conditions; however, the Food and Drug Administration (FDA) has banned many supplements containing ephedrine.
The IOC, NCAA, and NFL have all banned ephedrine-containing compounds. Amphetamines were once a popular drug of abuse in sports, especially in baseball because of the grueling daily schedule. Amphetamine derivatives have some therapeutic uses in conditions such as attention deficit disorder. They are also used as recreational drugs, as well as reportedly by students as a study aid and in the military by pilots on long missions. The dangers of amphetamines are well known, and their use was banned in Major League Baseball in 2006.
Other Drugs
Certain drugs with legitimate therapeutic uses are also used either as PEDs or to mask the signs and symptoms of the drugs mentioned above. Inderal, a beta blocker, is a commonly used cardiovascular agent that also decreases hand tremor and reduces anxiety by blocking the effects of adrenalin. It is used in such sports as archery and riflery. (Musicians, singers, and public speakers also employ it because it minimizes stage fright.) It has been banned by the IOC because of the advantage it confers by reducing tremors.
Diuretics are used for rapid weight loss and occasionally as masking agents in an attempt to beat drug tests by diluting the urine. Therapeutic hormones such as clomiphene and human chorionic gonadotropin (HCG) have been used to stimulate recovery after anabolic steroid cycling.
Creatine and Other Supplements
Dietary supplements, products containing substances such as vitamins, minerals, botanicals, and amino acids, are meant to supplement normal oral intake. Creatine may be the most widely used supplement in the United States. In 2000 creatine accounted for more than $400 million in sales. Creatine is a naturally occurring compound stored in skeletal muscle. It is essentially muscle protein and is available by eating meat or fish. It’s then synthesized and stored in the body. Creatine supplements are basically larger, more concentrated amounts of this muscle protein.
Creatine is taken to increase muscle mass and enhance performance. The compound has been studied in different types of athletic activity, and there are indications it improves performance in certain types of high-intensity exercise, especially running and jumping. This effect has not been seen in all types of aerobic activity and may depend on factors including the athlete’s body mass and training regimen. Creatine appears to increase weight and decrease body fat in the short term, although much of the weight increase may be due to water retention. Also it is unclear whether short-term increases in muscle mass are an anabolic effect or the result of increased training.
Is creatine dangerous? The answer is unclear. While there are anecdotal reports of significant problems, current literature seems to indicate that when creatine is taken in recommended doses, there is no definitive evidence of serious harm. This doesn’t mean there is no risk or that the product can be deemed completely safe. In addition little is known about possible long-term effects of chronic creatine use. At present, creatine, if taken, is best used under the auspices of a qualified trainer or physician familiar with the compound.
Other supplements abound, especially those containing supernormal amounts of basic dietary amino acids. While there are often glowing claims that these supplements improve performance and release endogenous hormones, the vast majority of these claims are unsubstantiated and probably have no validity. Many supplements offer nothing more than a high-priced, well-balanced diet. They may be safe but are probably ineffective and are very expensive. It should be remembered that the FDA can’t rigorously examine every product on the market, and there may be counterfeit products (especially through the Internet or imported from abroad) prepared in an unsterile manner or tainted with substances such as anabolic steroids. This may be a source of positive drug tests for athletes uncertain of what is in the products they use. Ultimately, athletes are responsible for what they put in their bodies.
This is only a partial list of the PEDs and supplements currently available. But new designer drugs are being developed constantly. Little is known of these new drugs—even those designing these drugs are often working by trial and error.
Charles Yesalis, an expert on drug use in athletes, has observed that it is human nature for individuals to seek every advantage in competition, and athletes are among the most competitive individuals. The race is always on to look for better drugs and ways to beat testing. The tests will improve, but testers will always remain one step behind users—the entire exercise resembles a high-tech game of cops and robbers. All too often we extol the virtues of, rather than condemn, athletes who use these drugs.
We put undue emphasis on winning at all costs and transmit this to our athletes, who believe they must use these drugs to succeed. This is especially dangerous in the case of children, who feel the pressure even more acutely than adults and are at the greatest risk from these drugs. As one world-class cyclist so aptly put it, “What goes around comes around eventually. It can be 10 years, 15 years; it all comes out in the wash and where are you? A gold medal isn’t as gold anymore.”
39
A PILL NOT IN THE BEST INTERESTS OF HEALTHY STUDENTS
* * *
Canst thou not minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuffed bosom of that perilous stuff
Which weighs upon the heart?
—WILLIAM SHAKESPEARE, MACBETH
SHOULD DOCTORS PRESCRIBE powerful stimulant drugs to improve the grades of underperforming but otherwise healthy schoolchildren? According to the New York Times, a pediatrician in Georgia, Dr. Michael Anderson, provides Adderall to low-income children in Cherokee County, north of Atlanta, to help them do better in school. Anderson told the Times, “I don’t have a whole lot of choice. We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”
Adderall is an amphetamine used to treat attention deficit hyperactivity disorder (ADHD). However, as the Times article suggests, pediatricians and pediatric psychiatrists have observed the growing practice of prescribing Adderall and other psychotropic drugs to enhance school performance in children who do not carry a diagnosis of ADHD. Essentially, bad school grades have become a treatable disease for doctors. As Anderson said of his prescribing, “People who are getting A’s and B’s, I won’t give it to them.�
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The practice of physicians “medicalizing,” or creating a disease out of disapproved behavior, has a long history. The ancient Greeks believed women exhibited specific emotional disorders that originated in the womb. For centuries the medical community was complicit in preventing women from assuming their full role in society by diagnosing them with “hysteria” (from the Greek for “uterus”).
In the antebellum South, slaves who ran away from their masters were often diagnosed with “drapetomania,” a “disease” that caused them to run away. Until 1973 the American Psychiatric Association classified homosexuality as a mental disorder. In defense of Anderson, his motives, while not defensible, are understandable. He and others are frustrated by low-income students trapped in failing schools and by the perceived societal neglect of those students’ social and emotional needs.
Other trends also are at work here. Drugs are a lucrative shortcut. Performance-enhancing drugs in sports are ubiquitous (see Armstrong, Lance). Pharmaceutical companies seek to expand the indications for the use of their drugs (“off-labeling”) to increase their profits. They pressure patients and doctors with aggressive marketing. Some physicians feel they have no option but to respond with the most accessible weapon at their disposal—the prescription pad.
Make no mistake, however; the attempt to improve healthy students’ grades with Adderall, a practice fraught with danger, should be unequivocally condemned. Adderall is reasonably safe in the short-term treatment of ADHD, but it can have serious and occasionally life-threatening neurologic and cardiovascular side effects. In addition the effects of Adderall on the developing central nervous system and the consequences of long-term use are poorly understood. Widespread prescription of the drug, especially when there is no known “correct” dose for poor school performance, would inevitably result in healthy children experiencing devastating side effects. The nature of Adderall as a stimulant also creates the potential in users for abuse and addiction; it is a widely sought drug on the black market.
The Doctor Will See You Now Page 13