Orthopedics

Interview 

Performance-enhancing Drug Use

Gary A. Green, MD

Abstract

In this issue of ORTHOPEDICS, Dr Gary Green discusses the dangers of performance-enhancing drug use by athletes and how orthopedists can help prevent their use.

Why is performance-enhancing drug use difficult to police?

Since the original ancient Greek Olympics, athletes have been trying to find magic potions to run faster and jump higher. The desire to go beyond the rules has existed for a while. Today’s athletes are expressing those same desires, but now have access to sophisticated methods that include genetic manipulation.

Would better, consistent testing and punishment deter its use?

Although no definitive studies have been done, surveys of athletes at all levels of competition have consistently supported sports drug testing and effective deterrents. Do these actually work? Since 2003, a strict drug testing program in Minor League Baseball has been in place and penalties have been increased to the point where a first-time positive test for anabolic steroids results in a 50-game suspension. This effectively derails a player’s career. As a result, the number of positive tests dropped dramatically. Although this is anecdotal “research,” strong penalties, effective testing, and a likelihood of being detected have been shown in surveys to reduce drug use.

What strategies can be used to prevent performance-enhancing drug use?

Gary A. Green, MD
Gary A. Green

I don’t believe that there is a single strategy to deter the use of ergogenic drugs. Each situation has to consider the level of play, incentives to use drugs, goals of the program, and resources available. In addition, each athlete is different. In general, athletes (and people) fall into 3 categories: those who will follow the rules no matter what, those who will follow the rules because they are afraid of being caught, and those who will break the rules regardless of the penalties. It would be an ideal world if all we had to do is educate athletes about performance-enhancing drugs; however, the incentives to use are so strong that drug testing with penalties is often needed in addition to good educational programs.

What are the harmful long-term effects?

Since the World Anti-Doping Agency has hundreds of drugs on their prohibited list, a discussion of all the adverse effects would require a much longer discussion. Many of the drugs on the list are powerful stimulants and hormones that can have both short- and long-term effects. Athletes often feel that if a little is good, then more is better and their feeling of invincibility encourages them to take higher doses. This attitude was succinctly expressed by Tour de France cyclist Tom Simpson who famously said, “If it takes 10 [pills] to kill you, I’ll take 9.” His words turned prophetic as he died of an amphetamine overdose while climbing during a stage of the 1967 Tour.

In addition, athletes often take these drugs in doses much greater than the recommended therapeutic amounts and combine several different drugs at once. Owing to this, it is not ethical to perform double-blind, placebo-controlled studies with the doses and combinations often used by athletes. In my work with the Drug Enforcement Agency, I have reviewed hundreds of patient files from doctors illegally prescribing performance-enhancing drugs like anabolic steroids, human growth hormone and other drugs. Despite the fact that these drugs were taken under “medical supervision,” there were a large number of serious adverse reactions.

Are the undesirable potential side effects that much worse than the dangers (ie, injury or death) of the sport itself?

It is important in sports to determine what defines that particular sport. Once that is done, then the acceptable risks can be considered. For example, sitting at a baseball game entails…

In this issue of ORTHOPEDICS, Dr Gary Green discusses the dangers of performance-enhancing drug use by athletes and how orthopedists can help prevent their use.

Why is performance-enhancing drug use difficult to police?

Since the original ancient Greek Olympics, athletes have been trying to find magic potions to run faster and jump higher. The desire to go beyond the rules has existed for a while. Today’s athletes are expressing those same desires, but now have access to sophisticated methods that include genetic manipulation.

Would better, consistent testing and punishment deter its use?

Although no definitive studies have been done, surveys of athletes at all levels of competition have consistently supported sports drug testing and effective deterrents. Do these actually work? Since 2003, a strict drug testing program in Minor League Baseball has been in place and penalties have been increased to the point where a first-time positive test for anabolic steroids results in a 50-game suspension. This effectively derails a player’s career. As a result, the number of positive tests dropped dramatically. Although this is anecdotal “research,” strong penalties, effective testing, and a likelihood of being detected have been shown in surveys to reduce drug use.

What strategies can be used to prevent performance-enhancing drug use?

Gary A. Green, MD
Gary A. Green

I don’t believe that there is a single strategy to deter the use of ergogenic drugs. Each situation has to consider the level of play, incentives to use drugs, goals of the program, and resources available. In addition, each athlete is different. In general, athletes (and people) fall into 3 categories: those who will follow the rules no matter what, those who will follow the rules because they are afraid of being caught, and those who will break the rules regardless of the penalties. It would be an ideal world if all we had to do is educate athletes about performance-enhancing drugs; however, the incentives to use are so strong that drug testing with penalties is often needed in addition to good educational programs.

What are the harmful long-term effects?

Since the World Anti-Doping Agency has hundreds of drugs on their prohibited list, a discussion of all the adverse effects would require a much longer discussion. Many of the drugs on the list are powerful stimulants and hormones that can have both short- and long-term effects. Athletes often feel that if a little is good, then more is better and their feeling of invincibility encourages them to take higher doses. This attitude was succinctly expressed by Tour de France cyclist Tom Simpson who famously said, “If it takes 10 [pills] to kill you, I’ll take 9.” His words turned prophetic as he died of an amphetamine overdose while climbing during a stage of the 1967 Tour.

In addition, athletes often take these drugs in doses much greater than the recommended therapeutic amounts and combine several different drugs at once. Owing to this, it is not ethical to perform double-blind, placebo-controlled studies with the doses and combinations often used by athletes. In my work with the Drug Enforcement Agency, I have reviewed hundreds of patient files from doctors illegally prescribing performance-enhancing drugs like anabolic steroids, human growth hormone and other drugs. Despite the fact that these drugs were taken under “medical supervision,” there were a large number of serious adverse reactions.

Are the undesirable potential side effects that much worse than the dangers (ie, injury or death) of the sport itself?

It is important in sports to determine what defines that particular sport. Once that is done, then the acceptable risks can be considered. For example, sitting at a baseball game entails some risk of being struck by a batted baseball. However, a player who purposely throws a ball into the stands can be prosecuted for assault. Just because there is some risk in a sport, does not mean that additional risks are acceptable. Some drugs can alter a sport so dramatically as to change the nature of the sport. An example would be anabolic steroids in weight lifting. If they were completely allowed, the sport would soon become about who could take the most drugs, rather than who trained the hardest or was the best weight lifter. The recent debate about allowable suits in swimming is an example of a sport wrestling with the very definition of its game. The swimming federation ultimately decided that the essence of their sport was about who could swim the fastest, not who had the best suit.

In addition to the physical adverse effects, there is also the consequence of losing what society values about sports and the values of the competitors. If you compete in a sport where everyone is using performance-enhancing drugs, then you have 3 choices: compete at a disadvantage, quit the sport, or go against your principles and take the drugs. I would argue that all 3 are poor ethical choices.

There is a somewhat apocryphal study that is often quoted in which a majority of Olympic athletes surveyed said they would take a drug if it would guarantee them a gold medal, but they would die in 5 years. What is not reported is interviews with former East German female athletes who won gold medals in the 1970s and 1980s who were forced to take ergogenic drugs. Many of them have offered to return their medals and all say that they would trade their medals if they could have their health back. Many of them have experienced serious adverse effects, not only to themselves, but to their children.

What is the role of an orthopedist in the prevention of performance-enhancing drug use?

Everyone who deals with athletes is a “stakeholder” in the issue of performance-enhancing drugs and can influence athletes in a positive or negative role. For example, an orthopedist who sees a patient with an unusual tendon rupture, such as a psoas or triceps should consider anabolic steroid abuse. Team physicians need to be aware of medical complications of performance-enhancing drugs.

In addition, physicians need to police themselves. According to NCAA studies, approximately 15% of anabolic steroid users obtain them from a physician. There has been a proliferation of “anti-aging” clinics run by physicians that illegitimately prescribe drugs such as anabolic steroids and human growth hormone. These clinics are in fact well-disguised drug dealers. Physicians need to be part of the solution, not contribute to the problem. One of the most eloquent quotes on this matter was by Rica Reinisch who was a member of the East German 1980 Women’s swimming team who was given anabolic steroids. She said, “The coaches and doctors were our guardians, the people we trusted at sports school. I’ll never know how good I could have been [without drugs].” Doctors who either prescribe illegal drugs or turn a blind eye towards their use allow the problem to grow.

How do you convey to athletes that although they may see an increased performance over a short period of time, steroid use may eventually lead to serious injuries and even death?

Physicians are well-equipped to discuss health choices that patients make every day. Whether it is tobacco, alcohol, or performance-enhancing drug use, physicians are able to discuss the risks and benefits. For young athletes who lack perspective, long-term adverse effects have little deterrent effects. Instead, a discussion of short-term health effects, such as shrunken testicles and gynecomastia may have a better impact. In my experience, young athletes also respond to information regarding contamination and impurities in black market sources. In addition, a frank discussion of ethics in sports is warranted.

Is the banned use of performance-enhancing drugs a losing battle?

It depends on how you define “losing.” Although athletes who use these drugs receive the attention, studies consistently demonstrate that the vast majority of athletes, at all levels, respect the rules of the game and compete cleanly. One of the reasons I continue in this field is to support those who want to compete on a level playing field. Again, surveys have consistently demonstrated that the overwhelming majority of athletes support effective drug testing and do not want performance-enhancing drugs in their sport. Although that group does not get the media spotlight, they need to be supported.

I began this interview with the depressing fact that performance-enhancing drug use and cheating has been going on for thousands of years. That is true; however, the idea of competing fairly has also been present for thousands of years and is epitomized in a quote from the ancient Greek dramatist Sophocles, who wrote, “Rather fail with honor than succeed by fraud.”

Author

Dr Green is a clinical professor in the Division of Sports Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, serves as a consultant to Major League Baseball on performance-enhancing drugs, and is in private practice at the Pacific Palisades Medical Group, Pacific Palisades, California.

Dr Green has no relevant financial relationships to disclose.

DOI: 10.3928/01477447-20090728-39

10.3928/01477447-20090728-39

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