essay on performance enhancing drugs in sports

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Performance-enhancing drugs in athletics: Research roundup

2015 roundup of research on the use of performance-enhancing drugs in athletics and academics as well as their potential health effects.

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by Leighton Walter Kille, The Journalist's Resource June 9, 2015

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Performance-enhancing drugs have a long history in sports, of course, but pharmacological research has led to a surge in the number of substances available, each with its own potential for misuse.

Given the potential financial rewards of athletic success, it’s no surprise that we’ve been witness to a seemingly endless procession of allegations and scandals. Sluggers Barry Bonds (steroids) and Alex Rodriguez (human growth hormone); cyclists Lance Armstrong (EPO),  Floyd Landis (testosterone) and Alberto Contador (clenbuterol); runners Tyson Gay (steroids) and Justin Gatlin (testosterone); and golfer Vijay Singh (IGF-1) are only some of the more prominent professionals implicated in such behavior. The complicity of medical professionals and shadowy labs is often involved, and a 2015 report from the International Cycling Union (UCI) found the sport’s own governing body bore significant responsibility.

Not surprisingly, hard numbers on rates of usage are difficult to come by, but anecdotal evidence isn’t lacking and anonymous surveys have provided some insight. Questionable use of medications and supplements have also been reported in the U.S. armed forces , fire and police departments , amateur athletics , and even high schools .

Below is a selection of studies on a range of issues related to performance-enhancing drugs. It has sections on their potential economic impacts, prevalence , health effects and athletes’ attitudes . For additional studies on these topics, you can search PubMed , which is the federal clearinghouse for all medical research. At bottom, we have also included some studies relating to cognitive-enhancing drugs and the related academic dimensions of this issue.

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“The Economics of Corruption in Sports: The Special Case of Doping” Dimant, Eugen; Deutscher, Christian. Edmond J. Safra Working Papers, No. 55, January 2015.

Abstract: “Corruption in general and doping in particular are ubiquitous in both amateur and professional sports and have taken the character of a systemic threat. In creating unfair advantages, doping distorts the level playing field in sporting competition. With higher stakes involved, such distortions create negative externalities not only on the individual level (lasting health damages, for example) but also frictions on the aggregate level (such as loss of media interest) and erode the principle of sports. In this paper, we provide a comprehensive literature overview of the individual’s incentive to dope, the concomitant detrimental effects and respective countermeasures. In explaining the athlete’s motivation to use performance enhancing drugs, we enrich the discussion by adapting insights from behavioral economics. These insights help to understand such an athlete’s decision beyond a clear-cut rationale but rather as a product of the interaction with the underlying environment. We stress that in order to ensure clean sports and fair competition, more sophisticated measurement methods have to be formulated, and the respective data made publicly available in order to facilitate more extensive studies in the future. So far, the lack of data is alarming, especially in the area of elite sports where the stakes are high and doping has a substantial influence.”

“The Frequency of Doping in Elite Sport: Results of a Replication Study” Pitsch, Werner; Emrich, Eike. International Review for the Sociology of Sport , October 2012, Vol. 47, No. 5, 559-580. doi: 10.1177/1012690211413969.

Abstract: “The difficulty of measuring the prevalence of doping in elite sport is a recurring topic in the scientific literature on doping. The Randomized Response Technique is a method for asking such embarrassing or even threatening questions while allowing the respondents to answer honestly. It was used to measure the prevalence of doping among German squad athletes by Pitsch et al. (2005, 2007). In a replication study with better sampling control, it was possible to replicate the general trend of the data from the 2005 study…. The paper-based survey resulted in a rate of 10.2% ‘honest dopers,’ irrespective of the disciplines, obtained with the question: ‘Have you ever knowingly used illicit drugs or methods in order to enhance your performance?’ By adding the rate of cheaters (24.7%), whose behaviour the researchers know nothing about, one can calculate the interval (10.2%, 34.9%), which should include the true rate of dopers throughout their career among German elite athletes. In contrast, this means that the larger proportion of athletes, namely, 65.2%, represents ‘honest non-dopers.’ In the 2008 season, this figure was 65%.”

“Growth Hormone Doping in Sports: A Critical Review of Use and Detection Strategies” Baumann, Gerhard P. Endocrine Reviews , April 2012, Vol. 33, No. 2 155-186. doi: 10.1210/er.2011-1035.

Abstract: “[Growth hormone] is believed to be widely employed in sports as a performance-enhancing substance. Its use in athletic competition is banned by the World Anti-Doping Agency, and athletes are required to submit to testing for GH exposure…. The scientific evidence for the [performance-enhancing characteristics] of GH is weak, a fact that is not widely appreciated in athletic circles or by the general public. Also insufficiently appreciated is the risk of serious health consequences associated with high-dose, prolonged GH use. This review discusses the GH biology relevant to GH doping; the virtues and limitations of detection tests in blood, urine, and saliva; secretagogue efficacy; IGF-I doping; and information about the effectiveness of GH as a performance-enhancing agent.”

“Supplements in Top-Level Track and Field Athletes” Tscholl, Philippe; Alonso, Juan M.; Dollé, Gabriel; Junge, Astrid; Dvorak, Jiri. American Journal of Sports Medicine , January 2010, Vol. 38, No. 1, 133-140. doi: 10.1177/0363546509344071.

Abstract: “Analysis of 3,887 doping control forms undertaken during 12 International Association of Athletics Federations World Championships and one out-of-competitions season in track and field. Results: There were 6,523 nutritional supplements (1.7 per athlete) and 3,237 medications (0.8 per athlete) reported. Nonsteroidal anti-inflammatory drugs (NSAIDs; 0.27 per athlete, n = 884), respiratory drugs (0.21 per athlete, n = 682), and alternative analgesics (0.13, n = 423) were used most frequently. Medication use increased with age (0.33 to 0.87 per athlete) and decreased with increasing duration of the event (from sprints to endurance events; 1.0 to 0.63 per athlete). African and Asian track and field athletes reported using significantly fewer supplements (0.85 vs. 1.93 per athlete) and medications (0.41 vs. 0.96 per athlete) than athletes from other continents. The final ranking in the championships was unrelated to the quantity of reported medications or supplements taken. Compared with middle-distance and long-distance runners, athletes in power and sprint disciplines reported using more NSAIDs, creatine, and amino acids, and fewer antimicrobial agents. Conclusion: The use of NSAIDs in track and field is less than that reported for team-sport events. However, nutritional supplements are used more than twice as often as they are in soccer and other multisport events; this inadvertently increases the risk of positive results of doping tests.”

“Alcohol, Tobacco, Illicit Drugs and Performance Enhancers: A Comparison of Use by College Student Athletes and Nonathletes” Yusko, David A.; et al. American Journal of Sports Medicine, August 2010. doi: 10.3200/JACH.57.3.281-290.

Abstract: Compares the prevalence and pattern of substance use in undergraduate student athletes and nonathletes from 2005-2006. Data was collected using questionnaires from male (n = 418) and female (n = 475) student athletes and nonathletes from 2005-2006 to assess prevalence, quantity, and frequency of alcohol and drug use, and to determine patterns of student athletes’ alcohol and drug use during their athletic season versus out of season. Male student athletes were found to be at high risk for heavy drinking and performance-enhancing drug use. Considerable in-season versus out-of-season substance use fluctuations were identified in male and female student athletes. Additional, and possibly alternative, factors are involved in a student athlete’s decision-making process regarding drug and alcohol use, which suggests that the development of prevention programs that are specifically designed to meet the unique needs of the college student athlete may be beneficial.”

Health effects

“Performance Enhancing Drug Abuse and Cardiovascular Risk in Athletes” Angell, Peter J.; Chester, Neil; Sculthorpe, Nick; Whyte, Greg; George, Keith; Somauroo, John. British Journal of Sports Medicine , July 2012. doi:10.1136/bjsports-2012-091186.

Abstract: “Despite continuing methodological developments to detect drug use and associated punishments for positive dope tests, there are still many athletes who choose to use performance- and image-enhancing drugs. Of primary concern to this review are the health consequences of drug use by athletes…. We will address current knowledge, controversies and emerging evidence in relation to cardiovascular (CV) health of athletes taking drugs. Further, we delimit our discussion to the CV consequences of anabolic steroids and stimulant (including amphetamines and cocaine) use. These drugs are reported in the majority of adverse findings in athlete drug screenings and thus are more likely to be relevant to the healthcare professionals responsible for the well-being of athletes.”

“Illicit Anabolic-Androgenic Steroid Use” Kanayama, Gen; Hudson, James I.; Pope Jr., Harrison G. Hormones and Behavior , Volume 58, Issue 1, June 2010, Pages 111-121. doi: 10.1016/j.yhbeh.2009.09.006.

Abstract: “The anabolic-androgenic steroids (AAS) are a family of hormones that includes testosterone and its derivatives. These substances have been used by elite athletes since the 1950s, but they did not become widespread drugs of abuse in the general population until the 1980s. Thus, knowledge of the medical and behavioral effects of illicit AAS use is still evolving. Surveys suggest that many millions of boys and men, primarily in Western countries, have abused AAS to enhance athletic performance or personal appearance. AAS use among girls and women is much less common. Taken in supraphysiologic doses, AAS show various long-term adverse medical effects, especially cardiovascular toxicity. Behavioral effects of AAS include hypomanic or manic symptoms, sometimes accompanied by aggression or violence, which usually occur while taking AAS, and depressive symptoms occurring during AAS withdrawal. However, these symptoms are idiosyncratic and afflict only a minority of illicit users; the mechanism of these idiosyncratic responses remains unclear. AAS users may also ingest a range of other illicit drugs, including both “body image” drugs to enhance physical appearance or performance, and classical drugs of abuse. In particular, AAS users appear particularly prone to opioid use. There may well be a biological basis for this association, since both human and animal data suggest that AAS and opioids may share similar brain mechanisms. Finally, AAS may cause a dependence syndrome in a substantial minority of users. AAS dependence may pose a growing public health problem in future years but remains little studied.”

“Adverse Health Effects of Anabolic-Androgenic Steroids” Van Amsterdama, Jan; Opperhuizena, Antoon; Hartgensb, Fred. Regulatory Toxicology and Pharmacology , Volume 57, Issue 1, June 2010, Pages 117-123. doi: 10.1016/j.yrtph.2010.02.001.

Abstract: “Anabolic-androgenic steroids (AAS) are synthetic drugs derived from testosterone. Illegally, these drugs are regularly self-administered by body builders and power lifters to enhance their sportive performance. Adverse side effects of AAS include sexual dysfunction, alterations of the cardiovascular system, psyche and behavior, and liver toxicity. However, severe side effects appear only following prolonged use of AAS at high dose and their occurrence is limited…. The overwhelming stereotype about AAS is that these compounds cause aggressive behavior in males. However, the underlying personality traits of a specific subgroup of the AAS abusers, who show aggression and hostility, may be relevant, as well. Use of AAS in combination with alcohol largely increases the risk of violence and aggression. The dependence liability of AAS is very low, and withdrawal effects are relatively mild. Based on the scores for acute and chronic adverse health effects, the prevalence of use, social harm and criminality, AAS were ranked among 19 illicit drugs as a group of drugs with a relatively low harm.”

“Effects of Growth Hormone Therapy on Exercise Performance in Men” Triay, Jessica M.; Ahmad, Bushra N. Trends in Urology & Men’s Health , July/August 2012, Vol. 3, Issue 4, 23-26. doi: 10.1002/tre.274.

Conclusions: “In the athletic arena, [growth hormone] doping is considered to be widespread and used in combination with other agents, and regimens vary depending on individual preferences and cost implications…. It must be recognised that the effects of GH administration in adults with a normal GH/IGF-1 axis are not comparable to those in GH deficiency and that the complexity of processes influencing GH release and peripheral actions means that overall performance should be considered as opposed to isolated effects. Although studies to date have been small in both subject numbers and treatment times, they have demonstrated measurable changes in GH and IGF-1 levels, as well as possible deleterious effects on exercise performance that should be taken seriously.”

“Performance-Enhancing Drugs on the Web: A Growing Public-Health Issue” Brennan, Brian P.; Kanayama, Gen; Pope Jr., Harrison G. American Journal on Addictions , March-April 2013, Vol. 22, Issue 2, 158-161. doi: 10.1111/j.1521-0391.2013.00311.x.

Abstract: “Today’s Internet provides extensive “underground” guidelines for obtaining and using illicit substances, including especially anabolic-androgenic steroids (AAS) and other appearance- and performance-enhancing drugs (APEDs). We attempted to qualitatively characterize APED-related Internet sites. We used relevant Internet search terms [and] found thousands of sites involving AAS and other APEDs. Most sites presented an unabashedly pro-drug position, often openly questioning the qualifications and motivations of mainstream medical practitioners. Offers of AAS and other APEDs for sale, together with medical advice of varying legitimacy, was widespread across sites. Importantly, many sites provided detailed guidelines for exotic forms of APED use, some likely associated with serious health risks, which are probably unknown to most practicing clinicians.”

“Doping in Sport: A Review of Elite Athletes’ Attitudes, Beliefs and Knowledge” Morente-Sánchez, Jaime; Zabala, Mikel. Sports Medicine , March 2013. doi: 10.1007/s40279-013-0037-x.

Abstract: “Although most athletes acknowledge that doping is cheating, unhealthy and risky because of sanctions, its effectiveness is also widely recognized. There is a general belief about the inefficacy of anti-doping programmes, and athletes criticise the way tests are carried out. Most athletes consider the severity of punishment is appropriate or not severe enough. There are some differences between sports, as team-based sports and sports requiring motor skills could be less influenced by doping practices than individual self-paced sports. However, anti-doping controls are less exhaustive in team sports. The use of banned substance also differs according to the demand of the specific sport. Coaches appear to be the main influence and source of information for athletes, whereas doctors and other specialists do not seem to act as principal advisors. Athletes are becoming increasingly familiar with anti-doping rules, but there is still a lack of knowledge that should be remedied using appropriate educational programmes. There is also a lack of information on dietary supplements and the side effects of [performance-enhancing substances].”

“Age and Gender Specific Variations in Attitudes to Performance Enhancing Drugs and Methods” Singhammer, John. Sport Science Review , December 2012. doi: 10.2478/v10237-012-0017-3.

Abstract: “Using a population-based cross-sectional sample of 1,703 Danish men and women aged 15-60 years, the present study examined age and gender variation in attitudes to performance enhancing drugs and methods…. Overall, participants held negative attitudes to drugs and methods enhancing predominantly cognitive-abilities-enhancing performance drugs and to appearance-modifying methods, but were positive to drugs for restoring physical functioning conditions. However, attitudes varied nonlinearly across age. Lenient attitudes peaked at around age 25 and subsequently decreased. Lenient attitudes to use of drugs against common disorders decreased in a linear fashion. No gender differences were observed and attitude did not vary with level of education, self-reported health or weekly hours of physical activity.”

“Drugs, Sweat and Gears: An Organizational Analysis of Performance Enhancing Drug Use in the 2010 Tour De France” Palmer, Donald; Yenkey, Christopher. University of California, Davis; University of Chicago. March 2013.

Abstract: “This paper seeks a more comprehensive explanation of wrongdoing in organizations by theorizing two under-explored causes: the criticality of a person’s role in their organization’s strategy-based structure, and social ties to known deviants within their organization and industry. We investigate how these factors might have influenced wrongdoing in the context of professional cyclists’ use of banned performance enhancing drugs (PEDs) in advance of the 2010 Tour de France….. We find substantial support for our prediction that actors who are more critical to the organization’s strategy-based structure are more likely to engage in wrongdoing. Further, we find that while undifferentiated social ties to known wrongdoers did not increase the likelihood of wrongdoing, ties to unpunished offenders increased the probability of wrongdoing and ties to severely punished offenders decreased it. These effects were robust to consideration of other known causes of wrongdoing: weak governance regimes and permissive cultural contexts, performance strain, and individual propensities to engage in wrongdoing.”

“Elite Athletes’ Estimates of the Prevalence of Illicit Drug Use: Evidence for the False Consensus Effect” Dunn, Matthew; Thomas, Johanna O.; Swift, Wendy; Burns, Lucinda. Drug and Alcohol Review , January 2012, Vol. 31, Issue 1, 27-32. doi: 10.1111/j.1465-3362.2011.00307.x.

Abstract: “The false consensus effect (FCE) is the tendency for people to assume that others share their attitudes and behaviours to a greater extent than they actually do…. The FCE was investigated among 974 elite Australian athletes who were classified according to their drug use history. Participants tended to report that there was a higher prevalence of drug use among athletes in general compared with athletes in their sport, and these estimates appeared to be influenced by participants’ drug-use history. While overestimation of drug use by participants was not common, this overestimation also appeared to be influenced by athletes’ drug use history.”

“The Role of Sports Physicians in Doping: A Note on Incentives” Korn, Evelyn; Robeck, Volker. Philipps-Universitat, Marburg, March 2013.

Abstract: “How to ban the fraudulent use of performance-enhancing drugs is an issue in all professional — and increasingly in amateur — sports. The main effort in enforcing a ‘clean sport’ has concentrated on proving an abuse of performance-enhancing drugs and on imposing sanctions on teams and athletes. An investigation started by Freiburg university hospital against two of its employees who had been working as physicians for a professional cycling team has drawn attention to another group of actors: physicians. It reveals a multi-layered contractual relations between sports teams, physicians, hospitals, and sports associations that provided string incentives for the two doctors to support the use performance-enhancing drugs. This paper argues that these misled incentives are not singular but a structural part of modern sports caused by cross effects between the labor market for sports medicine specialists (especially if they are researchers) and for professional athletes.”

“Socio-economic Determinants of Adolescent Use of Performance Enhancing Drugs” Humphreys, Brad R.; Ruseski, Jane E. Journal of Socio-Economics , April 2011, Vol. 40, Issue 2, 208-216. doi: 10.1016/j.socec.2011.01.008.

Abstract: “Evidence indicates that adolescents (athletes and non-athletes use performance enhancing drugs. We posit that adolescent athletes have different socio-economic incentives to use steroids than non-athletes. We examine adolescent steroid use using data from the Youth Risk Behavior Surveillance System. Multi-sport upperclassmen and black males have a higher probability of steroid use. Steroid use is associated with motivations to change physical appearance and experimentation with illicit substances. These results suggest there are different socio-economic motivations for adolescent steroid use and that steroid use is an important component of overall adolescent drug use.”

Cognitive-enhancing drugs

“Randomized Response Estimates for the 12-Month Prevalence of Cognitive-Enhancing Drug Use in University Students” Dietz, Pavel; et al. Pharmacotherapy , January 2013, Vol. 33, Issue 1, 44-50. doi: 10.1002/phar.1166.

Results: “An anonymous, specialized questionnaire that used the randomized response technique was distributed to students at the beginning of classes and was collected afterward. From the responses, we calculated the prevalence of students taking drugs only to improve their cognitive performance and not to treat underlying mental disorders such as attention-deficit-hyperactivity disorder, depression, and sleep disorders. The estimated 12-month prevalence of using cognitive-enhancing drugs was 20%. Prevalence varied by sex (male 23.7%, female 17.0%), field of study (highest in students studying sports-related fields, 25.4%), and semester (first semester 24.3%, beyond first semester 16.7%).”

“The Diversion and Misuse of Pharmaceutical Stimulants: What Do We Know and Why Should We Care?” Kaye, Sharlene; Darke, Shane. Addiction , February 2012, Vol. 107, Issue 3, 467-477. doi: 10.1111/j.1360-0443.2011.03720.x.

Results: “The evidence to date suggests that the prevalence of diversion and misuse of pharmaceutical stimulants varies across adolescent and young adult student populations, but is higher than that among the general population, with the highest prevalence found among adults with attention deficit-hyperactive disorder (ADHD) and users of other illicit drugs. Concerns that these practices have become more prevalent as a result of increased prescribing are not supported by large-scale population surveys…. Despite recognition of the abuse liability of these medications, there is a paucity of data on the prevalence, patterns and harms of diversion and misuse among populations where problematic use and abuse may be most likely to occur (e.g. adolescents, young adults, illicit drug users). Comprehensive investigations of diversion and misuse among these populations should be a major research priority, as should the assessment of abuse and dependence criteria among those identified as regular users.”

“Adderall Abuse on College Campuses: A Comprehensive Literature Review” Varga, Matthew D. Journal of Evidence-Based Social Work , 2012, Vol. 9, Issue 3. doi: 10.1080/15433714.2010.525402.

Abstract: “Prescription stimulant abuse has dramatically increased over the past 10 years, but the amount of research regarding college students and illicit prescription stimulant use is still very limited. This has important implications for college mental health professionals and higher education administrators. In this comprehensive literature review the author explores factors contributing to illicit use, self-medication, and recreational use of controlled prescription stimulants; discusses the potential consequences for those students abusing stimulants; and provides recommendations for educating, combating, and assisting students who illicitly use prescription stimulants on college campuses.”

“A Comparison of Attitudes Toward Cognitive Enhancement and Legalized Doping in Sport in a Community Sample of Australian Adults” Partridge, Brad; Lucke, Jayne; Hall, Wayne. AJOB Primary Research , November 2012. doi: 10.1080/21507716.2012.720639.

Abstract: “This article compares public attitudes toward the use of prescription drugs for cognitive enhancement with the use of performance enhancing drugs in sport. We explore attitudes toward the acceptability of both practices; the extent to which familiarity with cognitive enhancement is related to its perceived acceptability; and relationships between the acceptability of cognitive enhancement and legalized doping in sport. Of 1,265 [survey] participants, 7% agreed that cognitive enhancement is acceptable; 2.4% of the total sample said they had taken prescription drugs to enhance their concentration or alertness in the absence of a diagnosed disorder, and a further 8% said they knew someone who had done so. These participants were twice as likely to think cognitive enhancement was acceptable. Only 3.6% of participants agreed that people who play professional sport should be allowed to use performance-enhancing drugs if they wanted to. Participants who found cognitive enhancement acceptable were 9.5 times more likely to agree with legalized doping.”

Keywords: drugs, youth, sports, cheating, higher education, corruption, ADHD, research roundup

About The Author

Leighton Walter Kille

TOBIE SMITH, MD, MPH, Georgetown University Medical Center, Washington, District of Columbia

MATTHEW FEDORUK, PhD, AND AMY EICHNER, PhD, U.S. Anti-Doping Agency, Colorado Springs, Colorado

Am Fam Physician. 2021;103(4):203-204

Author disclosure: No relevant financial affiliations.

Family physicians may be surprised to learn the number of their patients who use performance-enhancing drugs, either deliberately to improve athletic performance or unknowingly through contaminated dietary supplements. Elite athletes account for only a small fraction of the approximately 3 million users of ergogenic drugs in the United States. 1 Sports organizations have broadened their efforts to detect and deter doping (i.e., the use of performance-enhancing drugs in competitive sports) at all levels of competition, resulting in a surprising number of positive doping test results in masters and recreational level athletes. 2 Recreational athletes who have been caught intentionally doping have reported many reasons for doing so, including keeping up with others in their age group in training and competition and for faster recovery from training and competitions so that they can continue to compete at a maximal level. 2 – 4

The prevalence of performance-enhancing drug use among athletes and the general public has led the World Health Organization to recognize the use of these drugs as a public health issue. 3 Over the past decade, the emergence of novel doping agents (particularly drugs aimed at boosting endogenous hormone levels and anabolic agents), increased acceptance of complementary and lifestyle medications, and increased contamination of dietary supplements have contributed to this growing public health concern.

The physical and psychological adverse effects of anabolic androgenic steroids (e.g., kidney and liver damage, acne, gynecomastia, suppression of normal testosterone production, aggression, depression) are well established. What physicians may not recognize are the potential adverse effects of novel, investigational drugs that are being used as doping agents. These include selective androgen receptor modulators (e.g., the investigational drugs ostarine [Enobosarm] and LGD-4033 [Ligandrol]), which have substantial anabolic effects on muscle and bone and significant potential for misuse in sports. These modulators are not approved for human use, and the adverse effects have not been well documented because they are still in clinical trials. Despite their experimental status, selective androgen receptor modulators have been found in dozens of dietary supplements and have caused more than 250 positive doping test results since 2010. 5 – 7 Growth hormone (GH) fragments (e.g., AOD-9604) and GH-releasing peptides, GH secretagogues (e.g., ibutamoren), metabolic modulators (e.g., meldonium), off-market drugs (e.g., sibutramine [Meridia]), and a handful of illegal designer stimulants (e.g., higenamine, 8 methylhexanamine, 9 octodrine 10 ) and other small molecules have also emerged on the doping stage. Consumers can easily buy all of these on the internet.

Even for the astute family physician, it can be difficult to identify patients who are using performance-enhancing drugs. Patients taking dietary supplements may be unintentionally ingesting performance-enhancing drugs because of contamination, and patients commonly do not disclose use of dietary supplements to their physicians. 11 Patients are less likely to disclose supplement use if the physician does not ask about it or if they believe that their physician is not knowledgeable about supplements. 11 Despite anti-doping agencies' warnings to elite athletes about supplement contamination risks, nonelite athletes are rarely educated about these risks.

Patients who are deliberately using performance-enhancing drugs may not disclose use because of shame, legality concerns, or lack of trust. In fact, users of performance-enhancing drugs often are not candid with their physicians about their use of these drugs. In one study, 56% of anabolic steroid users reported that they had never disclosed their use to their physician. 7 The adverse effects of many of the novel performance-enhancing drugs are not well documented or understood and thus may not trigger red flag findings on clinical history and physical examination that would alert a family physician to potential users of these drugs.

Patronage of wellness and antiaging clinics may also put recreational athletes at risk of inadvertent positive doping test results because treatments prescribed at these centers often include hormone replacement. Athletes can apply for a therapeutic use exemption for certain prescribed medications that are prohibited in competition (i.e., beta 2 agonists for asthma, glucocorticoids for inflammatory diseases, hormones for endocrine deficiencies); no exemptions are typically given for medications prescribed solely for symptom relief, antiaging purposes, or other purported health and wellness benefits (i.e., testosterone to treat “low” testosterone levels or nonspecific symptoms).

The family physician is a critical player in addressing the use of performance-enhancing drugs in recreational athletes of all ages. Family physicians should continue to be alert to signs of use of traditional performance-enhancing drugs, such as anabolic-androgenic steroids and stimulants, and also be aware of the emergence and accessibility of novel doping agents. In addition to the potential health risks of the performance-enhancing drug itself, harms of a positive doping test result can include the negative health and social impacts of sanctions prohibiting participation and the potential emotional damage related to being labeled a cheater.

Physicians should be aware of the competition status of athletic patients and consult the appropriate banned substances list (e.g., the World Anti-Doping Agency prohibited list) before prescribing medication and also understand the therapeutic use exemption process ( Table 1 ) . Family physicians should also be aware of the emergence of novel performance-enhancing drugs and their use among the general population; screen patients for use; and be prepared to discuss the safety, effectiveness, legality, and ethics of performance-enhancing drug use. 12

Pope HG, Kanayama G, Athey A, et al. The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates. Am J Addict. 2014;23(4):371-377.

Henning AD, Dimeo P. The complexities of anti-doping violations: a case study of sanctioned cases in all performance levels of USA cycling. Perform Enhanc Health. 2014;3(3–4):159-166.

Dreier F. Wider testing reveals doping among amateur cyclists, too. July 27, 2012. Accessed November 2, 2020. https://www.nytimes.com/2012/07/28/sports/cycling/doping-in-cycling-reaches-into-amateur-ranks.html

Henning AD, Dimeo P. The new front in the war on doping: amateur athletes. Int J Drug Policy. 2018;51:128-136.

Van Wagoner RM, Eichner A, Bhasin S, et al. Chemical composition and labeling of substances marketed as selective androgen receptor modulators and sold via the internet [published correction appears in JAMA . 2018; 319(7):724]. JAMA. 2017;318(20):2004-2010.

U.S. Anti-Doping Agency. Supplement 411: realize, recognize, reduce. High-risk supplement list; 2019. Accessed April 24, 2020. https://www.supplement411.org

World Anti-Doping Agency. Anti-doping testing figures report. December 20, 2019. Accessed April 24, 2020. https://www.wada-ama.org/en/resources/laboratories/anti-doping-testing-figures-report

Cohen PA, Travis JC, Keizers PHJ, et al. The stimulant higenamine in weight loss and sports supplements. Clin Toxicol (Phila). 2019;57(2):125-130.

Eliason MJ, Eichner A, Cancio A, et al. Case reports: death of active duty soldiers following ingestion of dietary supplements containing 1,3-dimethylamylamine (DMAA). Mil Med. 2012;177(12):1455-1459.

Cohen PA, Travis JC, Keizers PHJ, et al. Four experimental stimulants found in sports and weight loss supplements: 2-amino-6-methylheptane (octodrine), 1,4-dimethylamylamine (1,4-DMAA), 1,3-dimethylamylamine (1,3-DMAA) and 1,3-dimethylbutylamine (1,3-DMBA). Clin Toxicol (Phila). 2018;56(6):421-426.

Guzman JR, Paterniti DA, Liu Y, et al. Factors related to disclosure and nondisclosure of dietary supplements in primary care, integrative medicine, and naturopathic medicine. J Fam Med Dis Prev. 2019;5(4) ):10.23937/2469-5793/1510109.

Jenkinson DM, Harbert AJ. Supplements and sports. Am Fam Physician. 2008;78(9):1039-1046. Accessed November 2, 2020. https://www.aafp.org/afp/2008/1101/p1039.html

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Why are we so opposed to performance-enhancing drugs in sport?

Associate Professor in Political Science and International Relations, The University of Western Australia

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The World Athletics Championships are currently in full flow. There was a collective sigh of relief earlier this week when Usain Bolt triumphed in the blue-riband men’s 100m event over Justin Gatlin , who has previously served two bans for taking performance-enhancing drugs. Three other athletes in the final – Mike Rodgers, Tyson Gay and Asafa Powell – had also received previous bans for doping.

Almost everyone seems to be in agreement that performance-enhancing drugs are a blight on competitive sport. Two major claims underpin the aversion to this use of drugs. The first is that it is cheating. The second is that performance-enhancing drugs threaten the health of athletes.

But is either claim persuasive?

Using drugs is unfair

The problem is not that athletes try to gain an advantage over their competitors by enhancing their performance. We praise them for doing so, and it is the main goal that athletes set for themselves.

The complaint is not against performance enhancement, but the method by which it is achieved. The real concern behind the cheating claim is that athletes who use drugs are gaining an unfair advantage by accessing something not available to those who follow the rules. Those who use drugs prosper at the expense of those who play fair.

But things are murkier than they seem. How interested are we in fairness in sport? Athletes try to enhance their performance in many ways: coaches, psychologists, dietitians, massage therapists, training at high altitude, skin-tight swimsuits. All of these are used to gain an advantage, which is often unfair because, like drugs, they are available to some – wealthy athletes rather than cheats – but not to everyone.

The Tour de France, a sporting event well known for drug use, would not suddenly become a level contest if drug use disappeared. The race winner has his performance enhanced by the quality of his team. The Tour would only be a true test of individual riders if teams were banned.

Performance is also unfairly enhanced when governments fund athletes. Australia spent more than A$300 million to prepare athletes for the last Olympics. One of the major reasons for the British squad’s success at the London Olympics was the large amount of financial support for the team.

The advantage gained through financial support might be different to that gained by drug use because it is not achieved through underhand means. But, if fairness is our goal, the source of the disadvantage is secondary.

So, if our objection to drugs is that they create an unfair advantage, consistency demands we apply the same standard to many other aspects of athletic competition. There seems to be no reasonable justification for drawing a line in the sand that places drug use on one side and the above-mentioned performance enhancers on the other.

Given that drugs are significantly cheaper than psychologists, permitting their use might actually level out the playing field for poorer athletes. Finally, if fairness is our major concern we can easily solve the problem by lifting the prohibition – thus making drugs available to all athletes.

Performance-enhancing drugs and harm

The second objection is that drug use, unlike coaches and massage therapists, causes harm. Removing the prohibition might make things fairer but it would come at a heavy price.

In response to this objection, ethicist Julian Savulescu has argued that performance-enhancing drugs are not particularly dangerous, and if their use was no longer clandestine they would be safer still. It is difficult to know whether allowing drug use would lead to greater harm to athletes, but for the sake of argument let’s assume Savulescu is wrong and accept that drug use is risky.

Is harm prevention a reasonable justification for limiting drug use in sport? One thing to bear in mind is that the very act of participating in many sporting activities is dangerous. Climbing, boxing, mixed martial arts, rugby, AFL, NFL, cricket, horse riding and many other sports can cause significant physical harms and sometimes result in death. There is no rush to ban people from climbing Mount Everest even though it is far more dangerous than taking EPO.

The NFL in America recently agreed to pay US$750 million to compensate for head injuries sustained by former players. Still, NFL athletes are allowed to collide with great force every week. It is certainly not obvious that performance-enhancing drugs cause more damage than high-impact sports.

I have not suggested that drug use should be permissible in sport because there might be persuasive arguments for proscription I have not addressed. For example, one might argue that using drugs is an attempt to win in the “wrong way”. If so, we need to know why using other performance enhancers like caddies in golf or high-tech equipment is winning in the “right way”.

But, the two claims most often used for prohibiting performance-enhancing drugs do not seem to provide sufficient grounds for a ban unless one is willing also to prohibit many other aspects of sport in the name of fairness and harm prevention.

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The Spotlight on Steroids and Sports

Should we accept steroid use in sports.

Jeffrey Katz

The Edited Broadcast of the Debate

Fans hold up a sign during a 2004 game between the New York Mets and the San Francisco Giants. Giants slugger Barry Bonds has long been accused of steroid use. Al Bello/Getty Images hide caption

Fans hold up a sign during a 2004 game between the New York Mets and the San Francisco Giants. Giants slugger Barry Bonds has long been accused of steroid use.

Hear the Full Debate

The unedited debate (1 hour, 52 minutes), read bios of the debate panelists.

Produced for broadcast by WNYC, New York.

The next debate , on the proposition "America Should Be the World's Policeman," takes place Feb. 12.

The debate over athletes' use of steroids and other performance-enhancing drugs has taken on newfound urgency in recent months.

A report by former Sen. George Mitchell, released in December, mentioned dozens of baseball players as having used steroids and described their use as "widespread." Track star Marion Jones pleaded guilty to lying to investigators about steroid use in October. And last summer, several riders were dismissed from the Tour de France on charges of using banned substances.

Those who oppose the use of steroids and other performance-enhancing drugs say that the athletes who use them are breaking the rules and getting an unfair advantage over others. Opponents of the drugs say the athletes are endangering not only their own health, but also indirectly encouraging youngsters to do the same.

Others maintain that it is hypocritical for society to encourage consumers to seek drugs to treat all sorts of ailments and conditions but to disdain drug use for sports. They say the risk to athletes has been overstated and that the effort to keep them from using performance-enhancing drugs is bound to fail.

Six experts on steroids and other performance-enhancing drugs recently took on the issue in an Oxford-style debate, part of the series Intelligence Squared U.S. The debates are modeled on a program begun in London in 2002: Three experts argue in favor of a proposition and three argue against.

In the latest debate, held on Jan. 15, the formal proposition was, "We should accept performance-enhancing drugs in competitive sports."

As the debate began, it was announced that former Olympics sprinter Ben Johnson, who was scheduled to argue in favor of allowing drugs, had pulled out on the advice of his lawyer because of his involvement in a lawsuit. Johnson was stripped of his gold medal in the 1988 Olympics after testing positive for steroids.

In a vote before the debate, 18 percent of audience members supported the motion to accept performance-enhancing drugs in competitive sports, and 63 percent opposed it. Nineteen percent were undecided. After the debate, 37 percent of audience members agreed with the proposition. Fifty-nine percent opposed it, and 4 percent remained undecided.

The event was held at the Asia Society and Museum in New York City and moderated by longtime sportscaster Bob Costas, who hosts NBCs Football Night in America and HBOs Inside the NFL.

Highlights from the debate:

FOR THE MOTION

Radley Balko , a senior editor and investigative journalist for Reason magazine, says: "So what is this debate really all about? I'd suggest it's about paternalism, and it's about control. We have a full-blown moral panic on our hands here, and it's over a set of substances that, for whatever reason, has attracted the ire of the people who have made it their job to tell us what is and isn't good for us. Our society has an oddly schizophrenic relationship with pharmaceuticals and medical technology. If something could be said to be natural, we tend to be OK with it. If it's lab-made or synthetic, we tend to be leery. But even synthetic drugs and man-made technology seem to be OK if the aim is to make sick people better or broken people whole again."

Excerpt of Balko's argument.

Norman Fost , professor of pediatrics and bioethics at the University of Wisconsin, says: "I ask you in the audience to quickly name, in your own minds, a single elite athlete who's had a stroke or a heart attack while playing sports. It's hard to come up with one. Anabolic steroids do have undesirable side effects: acne, baldness, voice changes ... infertility. But sport itself is far more dangerous, and we don't prohibit it. The number of deaths from playing professional football and college football are 50 to 100 times higher than even the wild exaggerations about steroids. More people have died playing baseball than have died of steroid use."

Excerpts of Fost's argument

Julian Savulescu , professor of practical ethics at the University of Oxford, says: "To say that we should reduce drugs in sport or eliminate them because they increase performance, is simply like saying that we should eliminate alcohol from parties because it increases sociability. So our proposal is that we allow a modest approach. ... Our proposal is enforceable, it frees up the limited resources to focus on drugs that may be affecting children, which we grant should not have access to drugs ... As we've argued, performance enhancement is not against the spirit of sport, it's been a part of sport through its whole history, and to be human is to be better, or at least to try to be better."

Excerpts of Savulescu's argument

Against the motion.

George Michael , a sportscaster and creator of the program Sports Machine , says: "I am not willing to pay the price for legalizing steroids and performance-enhancing drugs, because I've seen too often what it can do. I don't want to go to the cemetery and tell all the athletes who are dead there, 'Hey guys, soon you'll have a lot more of your friends coming, because we're going to legalize this stuff.' The only good news out of it? They wouldn't hear the news. Because they're all dead."

Excerpts of Michael's argument

Dale Murphy , a former Major League Baseball outfielder who started the iWon't Cheat Foundation to help rid sports of drugs, says: "We need better testing, harsher punishments and people will decide not to get involved with performance-enhancing drugs. Gambling in baseball is the perfect example. The culture of professional baseball players is the one thing they know, and one thing they learn from the minute they sign a professional contract, is that if you gamble on the game in any way, shape or form, your career will be over."

Excerpts of Murphy's argument.

Richard Pound , chairman of the World Anti-Doping Agency and a partner in the Canadian law firm Stikeman Elliott, says: "The use of performance-enhancing drugs is not accidental; it is planned and deliberate with the sole objective of getting an unfair advantage. I don't want my kids, or your kids, or anybody's kids to have to turn themselves into chemical stockpiles just because there are cheaters out there who don't care what they promised when they started to participate. I don't want my kids in the hands of a coach who would encourage, condone or allow the use of drugs among his or her athletes."

Excerpts of Pound's argument.

The Intelligence Squared U.S. series is produced in New York City by The Rosenkranz Foundation and for broadcast by WNYC.

The Evolution of Performance-Enhancing Drug Use in Sport

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This chapter traces the emergence of the major classes of performance-enhancing drugs (PEDs) used in sport such as stimulants and steroids and also techniques that have potential to enhance performance such as gene doping. Trends in use of PEDs are examined along with progress in adapting anti-doping regulations and developing methods to identify PEDs. The chapter also examines the relationship between PED consumption in elite sport and use by non-elite athletes, especially young athletes, and gym users.

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Houlihan, B. (2022). The Evolution of Performance-Enhancing Drug Use in Sport. In: Rabin, O., Corazza, O. (eds) Emerging Drugs in Sport. Springer, Cham. https://doi.org/10.1007/978-3-030-79293-0_1

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Performance-Enhancing Drugs

Christopher dandoy.

* Pediatric Hematology/Oncology, Fellow, Cincinnati Children’s Hospital, Cincinnati, OH.

Rani S. Gereige

† Clinical Professor of Pediatrics–Florida International University, Miami Children’s Hospital, Miami, FL.

Educational Gap

Performance-enhancing drug (PED) use by children and teenagers rose sharply in the past decade. One study shows 3.3% of high school students admit anabolic steroid use; another finds 8% of girls and 12% of boys report using products to improve appearance, muscle mass, or strength. Pediatrics clinicians must monitor PED usage trends, screen perceptively, and offer anticipatory guidance.

After completing this article, readers should be able to:

• Recognize the signs and symptoms of the use of anabolic steroids and growth hormone.
• Know how to diagnose the use of anabolic steroids and growth hormone by data collection (history, physical examination, and laboratory evaluation).
• Know the side effects of anabolic steroids.

Introduction

The use of performance-enhancing drugs (PEDs) by preteenagers and teenagers has increased tremendously over the past decade. This trend is driven by multiple factors, including the decrease in the age of participation in competitive sports; the increase in popularity of team/competitive sports; the focus of the media on thinness in females and muscular bodies in males; pressure from parents and coaches; the age-related characteristics of taking risks and feeling invincible; and the availability of various PEDs in many forms and shapes.

The pediatric clinician must be aware of the use of performance-enhancing substances by pediatric patients; be prepared to identify risk factors, signs, and symptoms; ask screening questions; and offer anticipatory guidance related to their use. Table 1 lists the common classes of PEDs. This review will focus on a select group of commonly used PEDs. The reader should know that anabolic steroids are synthetic substances derived from testosterone and are also called anabolic-androgenic steroids (AASs) or just “steroids.” Steroid precursors also are used as performance-enhancing agents.

Classes of Commonly Used Performance-Enhancing Drugs

Epidemiology

Over the past 25 years, there has been an explosion in youth sports participation, resulting in a dramatic increase in the total number of athletes under age 18 years. It is estimated that more than 30 million children and adolescents are participating in organized sports today. Title IX, which was passed in 1972, promoted equal numbers of male and female college athletes and increased the number of female athletes. In 1972, there were ∼25,000 female high school athletes, in comparison to 3 million in 2000. ( 1 ) This number has been stable at 3 million in 2007, according to Title IX data.

With the increase in number of childhood athletes, the stress to perform at a high level has increased. Parents, coaches, and the players themselves are constantly pushing themselves to perform. This drive to be successful in athletic competition often is a positive one, resulting in increased self-confidence, a drive for hard work, and cooperation among peers. This drive, however, can turn negative when competition and winning is “at all costs.” When athletes lose sight of the meaning of fair competition by taking performance-enhancing substances, they put their future health at risk and compromise their ability to practice sportsmanship.

There are many historic examples of athletes over the last century who relied on PEDs to improve their performance. During the original Olympic Games, cash awards were given to the winners of the games. At that time, the use of performance-enhancers was widely accepted. Athletes would consume large amounts of meat and herbs with the belief that it would give them a competitive edge. They would also consume a type of opium juice called “doop”; this term was the origin of the word “doping.”( 2 )

Gladiators of Roman times used to ingest strychnine to avoid injury and to decrease fatigue. During the 1950s, the Soviet Union dominated power lifting by providing their wrestlers testosterone injections. In the 1960s, Sports Illustrated documented the use of amphetamines, tranquilizers, cocaine, and other drugs by professional athletes. ( 3 ) In 1988, Ben Johnson turned in a record-breaking performance in the 100-m dash but was stripped of his title after he tested positive for the anabolic steroid stanozol. ( 4 )

Recently, over concerns about the medical complications of performance-enhancing substances and the potential influence professional athletes have on children’s performance in sports and sports-related behavior, athletes are being monitored for use of substances that enhance performance. Despite this focus, athletes in baseball, cycling, football, and basketball continue to test positive for PEDs on a frequent basis.

Risk Factors

Specific factors place the adolescent at increased risk for use of performance-enhancing substances. Adolescents, by their nature, are particularly vulnerable to risk-taking behaviors and experimentation. Teenagers often feel invincible and lack insight into long-term complications. Among athletes who use PEDs, those who play football, baseball, and basketball, who wrestle, and who are involved in gymnastics and weight training are at increased risk. ( 5 )

Some adolescents not involved in sports use performance-enhancing substances. At risk are the teenagers who are preoccupied with appearance or are focused on weight building or performance in the gym. Project EAT-II, a longitudinal study in which the authors reviewed eating, activity, and weight in 2,500 adolescents over a 5-year period of time, revealed that 1.4% of girls and 1.7% of boys reported having used anabolic steroids in the past year. The two variables that were predictors of steroid use in males were (a) having an ideal body size that is larger than one’s current body size and (b) self-report of healthy weight control behaviors. In girls, the two predictors of steroid use were (a) low satisfaction with weight and (b) high BMI. ( 6 ) Other factors that have been predictors of steroid use in adolescents include peer pressure, media influence, and parental pressures with regard to weight and muscles. Adolescents with a history of depression, those who have a negative body image, and teenagers who have a tendency to compare their own bodies to those who are known users of steroids are at increased risk of using as well. ( 7 )( 8 )

The pediatrician who cares for adolescents also must consider the media and its effects on adolescents taking performance-enhancing substances. Field et al ( 9 ) found that 8% of girls and 12% of boys reported using some type of product to improve appearance, gain muscle mass, or improve strength. Adolescents who reported that they wanted an improved physical appearance were more likely to use performance-enhancing substances. Also, girls who wanted to lose weight were more likely to use some type of PED.

Studies have revealed that males who read men’s, teenager, fashion, or health and fitness magazines were twice as likely to use a performance-enhancing substance to improve strength. Females wanting to look more like women in the media were more likely to use products that enhance their physiques. Adolescents who lift weights or play football were more likely to use creatine, amino acids, dehydroepiandosterone (DHEA), growth hormone, or anabolic steroids.

Anabolic Agents

Anabolic-androgenic steroids, physiologic effects.

As mentioned, AASs are synthetic derivatives of testosterone that have been modified to maximize anabolic effects. These testosterone derivatives have several general effects: they promote an increased nitrogen concentration in muscle, which in turn promotes an anabolic state; the agents inhibit the binding of catabolic glucocorticoids to muscle, preserving muscle mass and prohibiting muscle breakdown; and AASs have an effect on aggression, promoting athletes to train and push themselves harder. When combined with strength training, AASs increase fat-free mass and muscle strength. Strength gains can be substantial, with increase of strength to 5% to 20%. Clinical trials testing aerobic activity have not demonstrated significant improvements. With use of anabolic steroids, muscle mass increases through muscle hypertrophy as well as an increased number of muscle fibers. ( 10 )( 11 )( 12 )( 13 )( 14 )

Prevalence of Use

The National Youth Risk Behavior Surveillance System, conducted every 2 years, surveys ∼16,500 9th- through 12th-graders in private and public schools regarding priority health-risk behaviors. In relation to steroid use, the survey asks if the teenager “ever took steroid pills or shots without a doctor’s prescription one or more time during their life.” The incidence from 1991 to 2003 grew from 2.7% to 6.1%. That number has revealed a decrease from its peak in 2003 to 3.3% in 2009. Boy respondents (4.4%) were more likely than girls (2.2%) to have used steroids at least once. Race was not a contributing factor to steroid use. ( 15 )

Monitoring the Future is a long-term study of adolescents and adults based at the University of Michigan Institute for Social Research. Each year, the survey investigates substance abuse and use in ∼50,000 8th-, 10th-, and 12th-grade students. In 2010, the survey revealed the annual male adolescent prevalence rates for steroid use of 0.7% for 8th-graders, 1.3% for 10th-graders, and 2.5% for 12th-graders. The annual female adolescent prevalence is 0.3% in 8th-graders, 0.5% in 10th-graders, and 0.3% for 12th-graders.

Since 1993, perceived risk and disapproval were asked of the adolescents. Between 1998 and 2000, there was a sharp decline in perceived risk of steroid use. This decline could be related to the use of performance-enhancing substances by professional athletes. There has been a small rise in perceived risk of steroid use; however, the perceived risk still remains at 59%. Fewer adolescents perceive steroids as “fairly easy or very easy” to get since 2003. Finally, more adolescents disapprove of steroid use since 2003 as well. ( 16 )

Administration

Steroids can be injected, taken orally, or absorbed transdermally. Injectable forms of steroids are more potent and last longer. Oral anabolic steroids are converted in the liver into active testosterone. Anabolic steroids often are “stacked,” which means taking multiple steroids at the same time, and taken in 4- to 12-week cycles. The doses often are in a “pyramid” sequence with the largest dose at the middle of the cycle. The doses often are 50 to 100 times what would be needed to maintain the normal physiologic level of testosterone. A large market has developed creating “designer steroids” that are modified to evade detection.

Testing for exogenous testosterone can be accomplished by determining the urinary ratio of testosterone glucuronide to epitestosterone glucuronide. The ratio is normally 1–3:1. When someone is taking anabolic steroids, endogenous testosterone glucuronide and epitestosterone glucuronide are suppressed, leaving just the exogenous testosterone. A testosterone to epitestosterone ration of more than 4:1 is considered positive. Another way to monitor for exogenous testosterone is to obtain urine testosterone and luteinizing hormone. Because exogenous testosterone suppresses luteinizing hormone, this ratio is high (more than 30) in those taking anabolic steroids. ( 17 )

Adverse Effects

There are many adverse effects of anabolic steroids, and some can be serious and lifelong. These symptoms are prominent with the use of AASs as well as steroid precursors. Table 2 highlights the major adverse effects.

Adverse Effects of Androgenic-Anabolic Steroids and Steroid Precursors

The Anabolic Steroid Control Act of 1990 made AAS a schedule III controlled substance. The Anti-Drug Abuse Act of 1988 made AAS illegal to use for anything other than disease treatment.

Steroid Precursors

Anabolic steroid precursors or prohormones have gained popularity as PEDs in the past 15 years. These substances were first marketed and sold over the counter, promoting increased endogenous testosterone and thus promoting lean body mass. In the late 1990s and early part of this past decade, there was an explosion of the use of steroid precursors. These steroid precursors include, but are not limited to, the following: androstenedione (also known as “andro”), androstenediol, norandrostenedione, norandrostenediol, and DHEA. ( 18 )

Most androgenic steroids in humans are derived from DHEA, which is secreted from the adrenal cortex. DHEA is converted to androstenedione and androstenediol, which is then converted to testosterone. Steroid precursors were produced and distributed in hopes that these substances would increase free testosterone. The effects that are hoped for are often not seen because these precursors bind poorly to androgen receptors. Multiple studies have been done with steroid precursors; most of them have revealed increases in androstenedione and estradiol but little to no increase in serum testosterone. There have been no studies revealing increased muscle mass or improved athletic performance. ( 19 )

Although these steroids have minimal desired effects, they still have many of the negative effects of anabolic steroids ( Table 2 ). In female athletes, these substances have an androgenizing influence, including general virilization and male pattern baldness. Males can experience gynecomastia, acne, and testicular atrophy. In both genders, decreased high-density lipoproteins, increased lipids, and stunted growth can result. Finally, these substances can downregulate endogenous testosterone over time. ( 20 )( 21 )

In 2005, androstenedione was classified as a schedule III controlled substance. DHEA continues to remain an over-the-counter nutritional supplement. Unfortunately, the Dietary Supplement Health and Education Act of 1994 allows many steroid precursors to be sold over the counter with minimal regulation.

Nutritional Supplements

Nutritional supplements have become increasingly popular among adolescents in the past 18 years. In 1993, the Proxmire Amendment limited jurisdiction of the Food and Drug Administration over nutritional supplements. This decision severely limited federal regulation. From that point forward, there was a market explosion. Dietary supplements can be found in health food stores, supermarkets, and even the corner gas station. The easy availability and advertising campaigns directed at young athletes have lead to a high rate of use among adolescents.

There are hundreds of nutritional supplements and more are being produced each year. These products undergo little human testing and no testing in children and adolescents, which can be potentially dangerous. ( 22 ) Currently, most nutritional supplements are not recommended for consumption by those under age 18 years.

Creatine is the most popular nutritional supplement, accounting for $400 million in sales annually. Despite recommendations against creatine use in adolescents under age 18 years, its use is still common. In 2001, Metzl et al ( 23 ) questioned 1,103 adolescents and found creatine use in 5.6% of them. Those that used creatine were in each grade level from 6th to 12th, and improved sports performance was cited as the goal in 75% of these cases.

Creatine is a nonessential amino acid that is made in the liver, pancreas, and kidneys and helps create adenosine triphosphate. Creatine can be found in meat, milk, and fish among other foods, and the total daily requirement is 2 g per day. Often, athletes use two to three times this amount when using creatine for improved sports performance.

Creatine has been shown to improve performance in short, high intensity exercises, including weight lifting. There are smaller benefits found in performances of longer duration. Creatine-related adverse effects include weight gain, water retention, gastrointestinal cramping, fatigue, and diarrhea. ( 12 )

Human Growth Hormone

Human growth hormone (hGH) is an endogenous hormone produced in the pituitary gland. In children and adults, the main reason hGH is given is to treat growth hormone deficiency and short stature in order to increase linear growth. However, hGH has been used by sports competitors for performance-enhancement since the 1970s. Recently, the use of hGH by professional athletes has received attention in the media from players in the National Football League to Major League Baseball. The reason this drug has been popular among athletes is because it is difficult to detect.

Studies evaluating growth hormone in healthy individuals reveal that endogenous growth hormone does increase lean body mass and decreases fat mass. However, growth hormone has little effect on strength and athletic performance and might worsen exercise capacity by increasing exercise-induced lactate levels. ( 24 ) Adverse effects such as diabetes, cardiomyopathy, hepatitis, and renal failure have occurred with the use of high-dose growth hormone. Also, participants in studies evaluating the effects of growth hormone often complained of soft tissue edema, joint pain, carpal tunnel syndrome, and increased fatigue. ( 25 )

Currently, hGH is on the World Anti-Doping Agency banned substance list. Blood tests currently exist for its detection; however, there is only a small window of opportunity for its detection. Currently, there are two methods of detection in the blood. The “markers” method looks for alterations in the ratios of serum proteins that exogenous hGH would alter. The “isoform” method looks for alterations in the growth hormone structure. ( 26 )

Erythropoietin

Erythropoietin (EPO) has gained notoriety recently as a PED used by cyclists and endurance athletes. EPO administration leads to increased production of red blood cells, which in turns leads to increased oxygen delivery to muscles. Unfortunately, this rise in hematocrit can create complications, including dehydration and increased viscosity and sluggishness of blood, which can lead to stroke and pulmonary emboli. Detection of EPO can be done through urine sample electrophoresis. ( 27 )( 28 )

Stimulants such as ephedrine and caffeine are used by adolescent athletes for their ergogenic effects. ( 29 ) Stimulants are an attractive ergogenic option because they are widely available, easily accessible, and difficult to detect. Stimulants reduce the perception of fatigue and increase time to exhaustion. They improve alertness, as well as neurocognitive and aerobic performance.

Ephedrine is available in cough and cold remedies over the counter. Ephedra was banned by the Food and Drug Administration in 2004 due to its numerous adverse effects, such as hypertension, weight loss, insomnia, anxiety, tremors, headaches, arrhythmias, strokes, and psychosis. The drug has been implicated in several deaths in athletes. Since its ban, ephedra was replaced by other sympathomimetics that have similar effects.

Caffeine is used in beverages, soft drinks, and pill forms. Guarana is a plant extract sold in drinks and energy shots. Guarana seeds contain 9,100 to 76,000 ppm of caffeine. Caffeine use for performance-enhancement has been reported in 27% of adolescent athletes in the United States. Caffeine produces ergogenic effects at a dose as low as 250 mg (3.0–3.5 mg/kg). Caffeine does not seem to be useful for sprints or short bursts of activity but may be effective for prolonged sports containing short bursts, such as tennis and team sports.

General Approach

The general approach to dealing with PED use in the young athlete is similar to the approach to any other type of substance abuse. In fact, PEDs have been considered gateway drugs because teenagers and preteenagers who engage in the use of PEDs, marketed legally or illegally, are more likely to exhibit risk-taking behavior in other ways and to engage in the use of other substances of abuse (opioids, narcotics, and cocaine, etc). The clinician should maintain a high degree of suspicion and look for “red flags” in the history and physical examination.

The psychosocial history should include, in addition to inquiring about the use of alcohol, smoking, and drugs, asking about the use of PEDs in all shapes and forms, including nutritional supplements. The clinician should inquire about sources of PEDs, motives behind their use, the patient’s understanding of the effects and adverse effects of the PEDs being used, and the use of PEDs by peers, which is a strong predictor of use. It is important to remember that not all PED users are involved in athletic activities and the motive might be to enhance looks.

Physical Examination

The clinician must look for red flags on physical examination that might point to the effects and adverse effects of PEDs. Sudden increases in muscle mass and lean weight over a short period of time, facial and body acne at a time that is asynchronous with when acne is expected to develop in a teenager, stretch marks, even mood changes and anger outbursts in boys and signs of virilization in girls, all raise suspicion for AAS use. Coarse features and rapid growth suggest hGH use.

Anticipatory Guidance and the Role of the Clinician

The clinician must include questions about the use of PEDs in the psychosocial history on all youth, regardless of their involvement in sports. Education and discussion should begin early (elementary school) before the youth becomes a user. The following are a few tips for the clinician to address PED use in teenagers and preteenagers:

• Maintain an opened dialogue
• Understand the motive behind the use of PEDs
• Educate the athlete against the use of banned/illegal ergogenics
• Tell the youth what is known and not known about these substances
• Discuss the adverse effects and dangers
• Be aware that drug testing has not proven to be a deterrent alone
• Promote balanced meals, good nutrition, and training
• Discuss safe alternatives
• Know that occasionally, tests that reveal a low sperm count in AAS users can motivate the user to stop using AASs
• Clinicians should screen for anabolic steroid use because there is evidence that, based on results of the National Youth Risk Behavior Surveillance System, 3.3% of 9th- to 12th-graders admit to using steroids in the past. ( 15 )
• It is an established fact that adolescents are vulnerable to risk-taking behaviors and experimentation, feel invincible, and lack insight into long-term complications. ( 2 )
• Based on epidemiologic data, among all athletes who use performance-enhancing drugs, athletes who play football, wrestle, are involved in gymnastics, play baseball and basketball, and participate in weight training are at increased risk of use. ( 15 )( 23 )
• Based on strong evidence, the predictors of steroid use in boys are desire for an ideal body size that is larger than one’s current body size and self-report of healthy weight control behaviors, whereas in girls, predictors of steroid use are low satisfaction of weight and high BMI. ( 3 )
• Strong evidence suggests that risk factors for steroid use include: peer pressure, media exposure, parental pressure, a history of depression, a negative body image, and a tendency to compare one’s own body with those who are known users of steroids. ( 3 )( 4 )( 5 )( 15 )

Author Disclosure

Drs Dandoy and Gereige have disclosed no financial relationships relevant to this article. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.

Suggested Reading

• Gomez J; American Academy of Pediatrics Committee on Sports Medicine and Fitness. Use of performance-enhancing substances . Pediatrics . 2005; 115 ( 4 ):1103–1106 [ PubMed ] [ Google Scholar ]
• Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes . Pediatrics . 2006; 117 ( 3 ):e577–e589 [ PubMed ] [ Google Scholar ]
• Metzl JD. Performance-enhancing drug use in the young athlete . Pediatr Ann . 2002; 31 ( 1 ):27–32 [ PubMed ] [ Google Scholar ]

Performance-Enhancing Drugs and Substances Use in Sports Report

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Introduction

History of doping behavior, causes of doping and its effects on competition, sociological perspectives and models explaining doping behavior, works cited.

The emergence of sports competitions such as athletics and biking instigated the use of performance-enhancing substances to increase the probability of winning. It was not until 1968 that the testing of athletes for the use performance-enhancing drugs began. As a result, doping has been banned by enacting stiff penalties to deal with the problem. Nevertheless, with the most competitive sports attracting high incentives and coveted awards, the problem has only intensified in recent years as the users focus on gaining a competitive edge.

The ideology of doping promotes unfairness. To tackle the menace, the International Olympic Committee (IOC) and World Anti-doping Agency (WADA) prepare and update a list of the banned substances annually. Sports participants commonly use tranquilizers, steroids, liquor, and diuretics, among other stimulants to boost their performances. Other drugs, such as peptide and antagonistic hormones, together with their modulators, are also frequently used amongst players (Kisaalita and Michael 44).

The motives and objectives of doping in sports are guided by the personality traits and behavior of the people involved. The public expects individuals to apply socially accepted methods to achieve success. Deviating from this expectation attracts a penalty from the society that prescribes the norms and values that govern various sports activities. For this reason, the IOC and WADA have stringent prescriptions concerning the behavior of the participants in sports. Breaking the rules is deemed as deviance. As a result, various types of punishments are applicable to drug users.

During the late nineteenth and early twentieth centuries, cycling gained popularity as the game extended the limits of the human body (Kisaalita and Michael 45). Since then, riders have been shown to use all sorts of stimulants such as strychnine and amphetamines, especially in tough races that are characterized by long and exhaustive cycling hours. Substantial evidence reveals that bike cycling is commonly faced with the use of performance-enhancing drugs (PED).

Such competitions attract high-end prizes, among other incentives that comprise the fundamental reasons for doping. There have been sporting scandals pertaining to performance drugs since the 1990s. For example, on the eve of Tour de France in 1998, a team assistant for the top-ranked Festina team was intercepted along the French and Belgian border, transiting a truckload of performance-enhancing products. This scandal sparked a massive crackdown and robust anti-doping campaign in the world of sports. The society was highly blamed for failing to nurture ethical and responsible completion practices. Doping is a shared problem that arose from socialization processes. Research has found that the culprits of PED acquire unacceptable practices from peers in either school and/or street competitions, among other places. The IOC, among other anti-doping campaigners, posits that tackling the addressing at such places is a sound move towards alleviation of the menace. The consequences of doping are inevitably undesirable.

Besides causing unfair competition, some of the drugs can have very harmful effects on the health of the users. Numerous researchers have affirmed that some sports allow the use of performance-enhancing substances as part of their set norms and culture. In such cases, failure to use them is termed as deviance. For instance, sports that allow the use of PED include basketball, bodybuilding, cycling, & Olympics. However, the use of such substances outside sports is considered non-conformity.

This risky behavior has contributed significantly to the widespread use of PED in many competitions. Nevertheless, athletes across a range of sports have opposed the sporting ethic with a view of neutralizing deviant behavior in sports. Some of the motivations for the use of PED include self-fulfilling accounts and denial of injuries. A study that was conducted to investigate professional cyclists and elites revealed that the use of PEDs was once perceived as a rite of passage to professional competitions or group initiations.

However, this conception changed after the Festina Affair. Today, the practice is seen as an individualized choice and affair (Kisaalita and Michael 48). Cyclists were also failed to condemn the act as they claimed that the use of PED was a personal choice. It was uncovered that doping among professionals and elites was acceptable but condemned among amateurs. Given the diversity of cycling cultures, doping is viewed differently in diverse parts of the world. However, as far as international laws and rules of the game, such as the Olympics are concerned, the use of performance-enhancing substances is a criminal practice that attracts lawful punishment. For the purpose of this paper, the social constructs and beliefs utilized by the users of PEDs have been discussed with the aim of providing an insight into the practice.

Studies on cyclist attitudes have uncovered the socio-cultural perspectives under which doping happens. Some of the identified key attitudes and values among elite cyclists include endurance, perseverance, and competitiveness. Such cultural values have given rise to the increasing use of PEDs in cycling and other sports in contemporary sports competitions. Socialization has played a key role in the emergence of the doping culture. Researchers have used various sociological perspectives to explain doping practices in athletics due to the shifting social trends in the modern sport, including the integration of technology into sports performance and a sub-cultural tradition of use of performance-enhancing substances (Kisaalita and Michael 44).

People who use PEDs adopt neutralization strategies to justify their deviant behaviors, including denial of responsibility and injury and criticism of condemners. Numerous researches have revealed that the behavior is common among doping culprits in the present-day sports. In addition, various subcultures and settings of neutralization that contribute to the practice exist. The above justifications of doping protect then victims from prosecution and condemnation.

Several models of doping behaviors have also attempted to explain the complexity of drugging justifications. For instance, the Drugs in Sports Deterrence Model (DSDM) highlight the role of decision-making processes involved in PED use and the contributions of other determinants (Kisaalita and Michael 46). Moreover, drug compliance in sports models puts forward several factors presumed as important advantages for doping practices, including threat and benefits appraisal, personal morality, legitimacy, personal self-esteem, drug availability, and reference group opinion, among others (Kisaalita and Michael 45).

As aforementioned, the use of performance-enhancing drugs and substances is not a new phenomenon as it gained popularity as early as the nineteenth century. Many factors leverage the use of PEDs in sports based on the behavioral attributes and attitudes of users. Regardless of the cultural perceptions that individuals possess regarding the use of PEDs, their outcome is unfair competition since users gain a competitive advantage over non-users. Despite various sports governing bodies intensifying anti-doping campaigns by outlining penal repercussions, the practice poses a significant challenge since users are gradually adopting advanced methods of doping. Nonetheless, it is the role of society to change the negative trend of using unfair means to achieve success in sports.

Kisaalita, Nkaku and Michael Robinson. Attitudes and Motivations of Competitive Cyclists Regarding Use of Banned and Legal Performance Enhancers. Journal of Sports Science & Medicine 13.1(2014): 44-50. Print.

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Home — Essay Samples — Nursing & Health — Performance Enhancing Drugs — Performance Enhancing Drugs in Sports: the Steroid Debate

Performance Enhancing Drugs in Sports: The Steroid Debate

• Categories: Doping Performance Enhancing Drugs Steroids in Sports

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Words: 2180 |

11 min read

Published: May 24, 2022

Words: 2180 | Pages: 5 | 11 min read

Works Cited

• Barry, A. (2013). The steroids era: Lessons from the game's most infamous era. Baseball Research Journal, 42(2), 71-77.
• Daneshvar, D. H., Baugh, C. M., Nowinski, C. J., McKee, A. C., Stern, R. A., & Cantu, R. C. (2011). Helmets and mouthguards: The role of personal equipment in preventing sport-related concussions. Clinics in Sports Medicine, 30(1), 145-163.
• Dimeo, P. (2007). A history of drug use in sport 1876-1976: Beyond good and evil. Routledge.
• Gurney, B. (2003). Steroids in sports: The end of baseball’s steroid era. Fordham Intellectual Property, Media & Entertainment Law Journal, 13(2), 735-757.
• Harvard University. (2012). Doping in sport: Understand the risks. Harvard Men's Health Watch, 17(2), 1-3.
• Karkazis, K., & Jordan-Young, R. (2018). Debating sex and gender in sports: Human rights and fairness. Science, 359(6378), 1011-1012.
• Sjöqvist, F. (2008). Anabolic steroids and doping in sports: A critical writer's view. Scandinavian Journal of Medicine & Science in Sports, 18(3), 278-279.
• Sports and Drugs. (n.d.). In National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/publications/drugfacts/sports-drugs
• Tannenbaum, A., & Rasmussen, N. (2018). Anabolic-androgenic steroid use among Canadian high school students. Psychology of Sport and Exercise, 36, 29-35.
• World Anti-Doping Agency. (2021). The World Anti-Doping Code. Retrieved from https://www.wada-ama.org/en/what-we-do/the-code

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Should Performance-Enhancing Drugs and Technologies Be Allowed in Sports?

• History of Performance-Enhancing Drugs and Technologies in Sports

Sports “ain’t never been clean,” says Charles Yesalis, former  Pennsylvania State University  professor and long-time performance-enhancing drug researcher.

And by “never,” Yesalis means  never . Research suggests that the first  Olympians  were  openly  doping. “The ancient  Olympic  champions were professionals who competed for huge cash prizes as well as olive wreaths, lived on the public  dole  and were sometimes recruited by competing cities seeking status. Most forms of what we would call cheating were perfectly acceptable to them, save for game-fixing. There is evidence that they gorged themselves on meat — not a normal dietary staple of the Greeks — and experimented with herbal medications in an effort to enhance their performances,” explains sports journalist Sally Jenkins. Read more history…

Pro & Con Arguments

Pro 1 PED use is so prevalent that banning it only disadvantages those not doping and hinders the forward progress of sport. “But everyone else is doing it” might not be an argument a teenager is going to win with a parent, but in the case of professional athletes and PEDs, the argument is one that the sporting world should accept. As sports editor Matt Glover explains, “Some might argue that performance-enhancing drugs (PEDs) are cheating or unfair. I beg to differ. I believe it would truly even the playing field because some countries (like Russia …) already are doping, while clean athletes are punished for being clean. There is a prisoners’ dilemma for athletes, with the dominant strategy being to cheat. This penalizes those who have the moral character or fortitude to not cheat, while rewarding others who did cheat.” [ 7 ] “The solution,” Glover asserts, “is not more draconian testing policies, but rather an abolition of these policies and a level playing field where athletes are able to make informed decisions about their bodies. This would ensure all athletes that wanted to use PEDs could, rather than those that can circumvent testing either with new drugs or through sheer luck (as not all athletes are tested).” [ 7 ] The “spirit of sport” evolves in tandem with the evolution of the actual sports and society at large. Torbjörn Tännsjö, professor of practical philosophy at Stockholm University, notes that paying athletes was once considered highly problematic. Sport evolved to pay athletes for their talents, and it can similarly evolve to allow PEDs, because as Tännsjö concludes, there is no overriding “moral virtue” in “exhibiting natural strength.” [ 8 ] Glorifying “natural” playing in sports only encourages more injuries and, thus, short careers. This hinders the advancement of sport and competition. Read More

Pro 2 PEDs help athletes to recover from injuries and to endure the rigors of sport. Professional athletes are almost guaranteed to be injured at some point during their career. A 2021 survey found 62.5 injuries per 100 players in the MLB, NBA, NFL, and NHL from 2007 through 2019. While a similar study of women’s professional sports injuries was not available, on average, female athletes are prone to even more injuries because of anatomical differences like wider pelvises and weaker knees. [ 9 ] [ 10 ] Quite a few drugs, including steroids and growth hormone, that are regularly banned by sports organizations are useful medical treatments, especially for sports injury recovery. Research is showing that short-term anabolic androgenic steroid use during surgery may help people recover after ACL (the anterior cruciate ligament that stabilizes the knee) surgery and total joint replacement surgery (in which a human joint is replaced with a prosthesis). The drugs may also “augment the biological healing environment” for muscle injuries, fractures, and rotator cuff repair. In other words, though many PEDs, such as anabolic steroids, have gotten a “renegade” reputation, there are some with useful, “ethical clinical applications.” [ 11 ] [ 12 ] “If an [athlete’s] injury is severe enough to sideline a patient for a month or so, there’s a good chance that there will be long-term consequences of that injury that will extend many years, sometimes decades, into their later life. In patients with ACL tears, for example, even after surgery and rehab, muscles in their injured leg are often around 30 percent weaker than they were before the injury. Over time, this weakness slowly erodes the cartilage in the knee. My lab is currently investigating the possibility that growth hormone — a banned substance by WADA — could help address this weakness in an FDA-approved clinical trial,” explains Christopher Mendias, assistant professor at the University of Michigan. [ 13 ] Mendias asserts that, unlike the popular news stories of unscrupulous medical drug dealers, “the vast majority of sports medicine clinicians and researchers are interested in finding ways to help restore injured athletes back to their pre-injury levels and not to engage in therapies that give athletes advantages that go above and beyond what they could achieve through approved training techniques and practices.” [ 13 ] “If a player can reach his full fitness level two to three weeks faster, then [PED use] makes sense. It’s not about players being brought up to 120, 150 or even 180 per cent [of their previous capacity and skill level]. It’s about getting players to their usual level as soon as possible,” argues Bernd Schuster, a former German professional footballer. [ 14 ] Read More

Pro 3 PEDs can be regulated and safely used. Professional athletes are adults who deserve bodily autonomy, meaning the right to do with their own bodies as they choose. Banning PEDs, which are otherwise legal drugs, treats adult athletes like children. [ 15 ] “It’s time to head in the opposite direction: legalizing performance enhancing drugs (PEDs)…. If steroid use for professional athletes is permitted, they will be able to legally obtain physical enhancement drugs which have been regulated, and are therefore possibly safe to use,” says columnist Maeve Juday. [ 16 ] “We do not want an Olympics in which people die before, during, or after competition,” from taking banned drugs, say professors Julian Savulescu, Bennett Foddy, and M. Clayton. “What matters is health and fitness to compete. Rather than testing for drugs, we should focus more on health and fitness to compete.” [ 17 ] “We should permit drugs that are safe and continue to ban and monitor drugs that are unsafe. There is another argument for this policy based on fairness: provided that a drug is safe, it is unfair to the honest athletes that they have to miss out on an advantage that the cheaters enjoy,” the three professors argue. “Far from harming athletes, paradoxically, such a proposal may protect our athletes. There would be more rigorous and regular evaluation of an athlete’s health and fitness to perform. Moreover, the current incentive is to develop undetectable drugs, with little concern for safety. If safe performance enhancement drugs were permitted, there would be greater pressure to develop safe drugs. Drugs would tend to become safer.” [ 17 ] Further, the treatment of medical conditions would not be stigmatized and private medical conditions would not have to be divulged publicly because the treatment is a “banned” drug. For example, “if an archer requires β [beta] blockers to treat heart disease, we should not be concerned that this will give him or her an advantage over other archers. Or if an anaemic cyclist wants to take EPO [ erythropoietin ], we should be most concerned with the treatment of the anaemia.” Ultimately, taking a health-centered approach, rather than a prohibitive approach to drugs, will safeguard the athletes, and thus the sport. [ 17 ] The same applies to so-called “techno-doping.” As journalist and bioethicist Alex Pearlman explains, “Supporters of using enhancing technologies in sports counter that people with disabilities already rely on increasingly high-tech assistive devices in everyday life. They point out that enhancements would not worsen an already inherently unjust situation. On the contrary—more attention to assistive devices might have the fringe benefit of going a long way toward alleviating ableist supremacy and getting more technology to people who need it.” [ 6 ] Read More

Con 1 PEDs violate the spirit and integrity of sport. “Sports are designed to test a specific cluster of skills and capacities, including physical, psychological, tactical and technical abilities. Performance-enhancing drugs elevate the importance of certain physical attributes, such as strength and stamina. Lifting the ban on drugs would alter the nature of sports by increasing the significance of this sub-set of physical attributes at the expense of other physical attributes, such as coordination and agility, as well as non-physical attributes such as strategic skill, mental resilience, and technical proficiency,” explains John William Devine, lecturer in sports ethics at Swansea University. [ 15 ] We are “designing people for sport. We are treating human beings like pieces of meat. We create them for this activity. If commercialism pushes this so strongly, we lose the core values about celebrating human effort and the joy of the effort and the love of the game,” says Angela Schneider, professor of kinesiology at Western University. Designer athletes, so to speak, make “sport… a perversion and a circus.” [ 18 ] The World Anti-Doping Agency (WADA) lays out this dynamic: “Anti-doping programs seek to preserve what is intrinsically valuable about sport. This intrinsic value is often referred to as ‘the spirit of sport.’ It is the essence of Olympism, the pursuit of human excellence through the dedicated perfection of each person’s talents. It is how we play true. The spirit of sport is the celebration of the human spirit, body and mind, and is reflected in values we find in and through sport, including Ethics, fairplay and honesty; health; excellence in performance; character and education; fun and joy; teamwork; dedication and commitment; respect for rules and laws; respect for self and other Participants; courage; community and solidarity.” [ 19 ] In the 2004 Summer Olympics, Ukraine’s Yuriy Bilonoh earned the gold medal in the shot put. In 2013, that gold medal was awarded to American Adam Nelson “during a rushed meeting with an IOC official outside Burger King at the Atlanta Airport.” Bilonoh’s steroid use had been confirmed via drug tests and, thus, Nelson won the gold medal almost a decade after competing, without the glory or affirmation of the top place on the medal stand and without an estimated $2.5 million in income that would have come had he been awarded gold while actually at the Olympics. [ 20 ] “The thing that makes sports fantastic is watching competition on a level playing field. Throw PEDs in the mix, and it becomes not about how good you are, but how good your doctor is,” says Nelson. Moreover, Nelson only won the gold medal because Bilonoh was drug-tested. Not all athletes in all sports are tested, meaning some who dope keep their ill-gotten awards, throwing into question every win by every athlete who has not been tested. [ 20 ] Read More

Con 2 Despite any benefit in injury recovery, PEDs are dangerous drugs that can still yield an unfair competitive advantage. Even if a PED is originally used for injury or surgery recovery, the drugs’ effects can be addictive and lead to more long-term use and unfair advantage in competition. While PEDs may seem like the quick ticket to athletic glory, they are deadly. They can shorten not only an athlete’s career but their lifespan as well. We only have to look at bodybuilding, a sport that has historically encouraged PED use, for proof of this fact. Bodybuilders “stack various steroids and other muscle-building drugs, then add in compounds intended to burn fat, blunt appetite or sap water from below the skin,” explain journalists Bonnie Berkowitz and William Neff . “They might counteract the worst side effects with another arsenal of medications, vitamins and supplements. The result can be outlandish physiques that appear indestructible but are often quite fragile.” These drug combinations essentially send their bodies into survival mode: their bodies believe death is near and every bodily process slows to try to stay alive. [ 21 ] PED use can result in weak hearts with overly thick walls that cannot pump blood effectively, high cholesterol, blood clots, heart attacks, and strokes, not to mention a complete shutdown of the reproductive system and severe mental alterations, including “roid rage,” mood disorders, depression, psychosis, and suicide, among other disorders. [ 21 ] Former champion bodybuilder and California Governor Arnold Schwarzenegger says bodybuilding is “the most dangerous sport in the world. In MMA fighters, you’ve had four guys die in the last ten years. In bodybuilding you’ve had 14 guys [die] over the last ten years. So it just shows you how dangerous it is to take some of those medications and things that those guys take.” [ 22 ] The sports themselves are brutal enough, as seen in boxing and football and the rise of chronic traumatic encephalopathy (CTE), a degenerative brain disease typically associated with repetitive trauma to the head. CTE can cause headaches, depression, increased irritability, decreased ability to concentrate, loss of short-term memory, and suicidal behavior, leading to headline-making tragedies as well as numerous lawsuits. Why would the sporting world want to compound such serious medical and mental afflictions by now allowing PEDs? [ 23 ] Moreover, as PED use gets more and more “cutting edge,” the dangers rise significantly. Jon Mannah was an Australian National Rugby League player when he died of Hodgkin lymphoma in 2013. The disease was in remission until his team’s “sports scientist” began giving him (and other players) peptides, a less-used variety of PED with little to no scientific study behind its use. His cancer returned, and he died at age 23. [ 24 ] Read More

Con 3 Allowing PEDs will increase youth drug use and other unhealthy activities. A review of 52 studies of 187,288 people aged 10-21 years old, as well as an additional 894 adults, found that, on average, kids first use PEDs when they are 14 years old, with some using the drugs as early as nine. [ 25 ] The same study found that kids who use PEDs are more likely to participate in other dangerous behaviors such as substance abuse (including alcohol, marijuana, and heroin), driving drunk, not wearing a seatbelt, riding with a drunk driver, and sexual promiscuity. Whether one bad habit directly fed another is not the point—all are signs and symptoms of dangerous behavior that should not be condoned or encouraged. [ 25 ] While athletic performance is often a driver for PED use, a correlation between male body image and PED use has also been noted “There is increasing concern regarding a rise in body dissatisfaction in young males particularly around masculinity. Individuals develop an unhealthy obsession with muscle growth and definition and are at risk of over-exercising as well as utilising medications including anabolic agents to achieve their goals,” says Laura Lallenec, physician and medical advisor for the Australian government. [ 26 ] Athletes, like it or not, are role models for children, especially as social media increases access to famous players. Their behavior, good and bad—and especially their use of PEDs—can spur similar actions among their youthful fans. Teddy Bridgewater, self-professed “Neighborhood Hope Dealer” and a former NFL quarterback, posted about this dynamic on Instagram: “Kids don’t be fooled. You can play ball, do the right thing and they still gonna accept you. Look at me, I’m far from perfect but I chose the ball route but I can still go to the hood and post up and it’s all love. I still keep the same 3 dudes around me. My people accept me for making all the right decisions and not falling victim or being tricked by the false image you see on IG [Instagram] from a lot of ball players.” [ 27 ] Read More

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Should athletes be allowed to use performance enhancing drugs?

• Related content
• Peer review
• Julian Savulescu , Uehiro chair in practical ethics 1 ,
• Leon Creaney , consultant in sport and exercise medicine 2 ,
• Anna Vondy , ST6 emergency medicine 3
• 1 University of Oxford, Oxford, UK
• 2 Trauma and Orthopaedics, University Hospital Birmingham, Birmingham, UK
• 3 Emergency Department, Royal Liverpool University Hospital, Merseyside, UK
• Correspondence to: J Savulescu julian.savulescu{at}philosophy.ox.ac.uk , L Creaney leon.creaney{at}uhb.nhs.uk

Stories about illegal doping in sport are a regular occurrence. Julian Savulescu argues that rather than banning performance enhancing drugs we should regulate their use, but Leon Creaney and Anna Vondy say this would lead to escalating use and call for tougher enforcement

Yes— Julian Savulescu

The zero tolerance ban on doping has failed. The second fastest runner ever, the American Tyson Gay, recently tested positive for a banned substance, along with Jamaican sprinters Asafa Powell and Sherone Simpson. There is evidence of widespread doping across many sports including athletics, tennis, and cycling. 1 Recent evidence from Germany suggests doping is rife in football. 2 Despite apparent advances in the “war on doping,” our success in detecting drug misuse is limited. In 2000, the first tests for erythropoietin were introduced. 3 Yet in 2012, the US Anti-Doping Agency expert Larry Bowers said that a negative test cannot be equated with the absence of doping. 4

According to Hermann and Henneberg, “Using typical values of detectability . . . the probability of detecting a cheater who uses doping methods every week is only 2.9% per test.” 5 It is time for a different approach.

Human nature

It appears we reached the limits of human performance in sprinting about 15 years ago. Starting with Ben Johnson in 1988, only 10 men have ever run under 9.8 sec. Only two (including Usain Bolt) are currently untainted by doping.

To keep improving, to keep beating records, to continue to train at the peak of fitness, to recover from the injury that modern training inevitably inflicts, athletes need enhanced physiology. We have exhausted human potential. But to be human is to be better, and doping is not going to go away.

Regulation could improve safety

The strongest argument against doping is safety. Since there have been no scientific tests of the effects of doping …

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Article contents

Alcohol abuse and drug use in sport and performance.

• Matthew P. Martens Matthew P. Martens University of Missouri
• https://doi.org/10.1093/acrefore/9780190236557.013.168
• Published online: 28 June 2017

Issues associated with athletics, alcohol abuse, and drug use continue to be salient aspects of popular culture. These issues include high-profile athletes experiencing public incidents as a direct or indirect result of alcohol and/or drug use, the role that performance-enhancing drugs play in impacting outcomes across a variety of professional and amateur contests, and the public-health effects alcohol abuse and drug use can have among athletes at all competitive levels. For some substances, like alcohol abuse, certain groups of athletes may be particularly at-risk relative to peers who are not athletes. For other substances, participating in athletics may serve as a protective factor. Unique considerations are associated with understanding alcohol abuse and drug use in sport. These include performance considerations (e.g., choosing to use or not use a certain substance due to concerns about its impact on athletic ability), the cultural context of different types of sporting environments that might facilitate or inhibit alcohol and/or drug use, and various internal personality characteristics and traits that may draw one toward both athletic activity and substance use. Fortunately, there are several effective strategies for preventing and reducing alcohol abuse and drug use, some of which have been tested specifically among athlete populations. If such strategies were widely disseminated, they would have the potential to make a significant impact on problems associated with alcohol abuse and drug use in sport and athletics.

Introduction

Alcohol and drugs are a pervasive part of many sports, and in many ways they are inextricably linked. These links include issues such as ubiquitous alcohol advertising and sponsorship in many sports, frequent scandals involving performance-enhancing drugs (e.g., anabolic steroids and human growth hormone), and high-profile incidents among nationally known athletes that involve excessive alcohol and/or drug use. Scholarship on alcohol abuse, drug use, and sport has increased substantially, providing a more complete understanding of the phenomenon. Alcohol use among athletes has received more attention in the research literature than use of other substances, which is not surprising considering that it is abused more than drugs like marijuana, cocaine, and amphetamines. Three primary topics related to alcohol and other drug use are discussed in this article. First, rates of alcohol abuse and drug use among different groups of athletes are addressed. When possible, comparisons with relevant nonathletes norms are discussed. Second, several unique considerations associated with understanding alcohol abuse and drug use specifically among athletes are presented. Third, prevention and intervention strategies that have promise for reducing alcohol abuse and drug use in sport are explored. Finally, suggestions are provided for future directions among scholars and practitioners interested in this topic.

Prevalence of Substance Abuse in Sport

Although few studies have examined prevalence rates of alcohol abuse or other formal alcohol use disorders among athletes, several studies have examined rates of binge drinking or other indicators of at-risk alcohol consumption. Research has generally shown that younger adolescents participating in sport are more likely than those not participating in sport to report excessive alcohol use (Kwan, Bobko, Faulkner, Donnelly, & Cairney, 2014 ), although this relationship may differ depending upon other contextual factors. For example, one study of more than 8,000 high school students in the United States found that participating in sports was associated with an overall increase in problematic alcohol use over time, but only for adolescents who did not participate in other extracurricular activities like academic or music clubs (Mays, DePadilla, Thompson, Kushner, & Windle, 2010 ). Another study of more than 3,000 Norwegian adolescents found that sports participation was associated with increased likelihood of future alcohol intoxication, but only for those participating in team sports (Wichstrøm & Wichstrøm, 2009 ). Several large studies from the 1990s and early 2000s showed that college athletes in the United States were more likely than those not participating in formal athletics to report high-risk drinking and experience alcohol-related problems (Leichliter, Meilman, Presley, & Cashin, 1998 ; Nelson & Wechsler, 2001 ; Wechsler, Davenport, Dowdall, Grossman, & Zanakos, 1997 ). In these studies, more than 50% of college athletes reported at least one binge-drinking episode (typically defined as five or more drinks for men and four or more drinks for women in a single sitting) and more than 25% reported three or more binge-drinking episodes in the preceding two weeks. Comparison rates for those not participating in formal athletics were 38%–43% for at least one binge-drinking episode and 16%–21% for at least three binge-drinking episodes. College athletes were also more likely than nonathletes to report a host of academic, legal, and interpersonal difficulties associated with their alcohol use. A more recent study showed that college athletes at all competitive levels (intramural, club, and varsity) engaged in binge-drinking episodes more frequently than nonathletes (Barry, Howell, Riplinger, & Piazza-Gardner, 2015 ). Comparatively fewer studies have been conducted among older adults participating in organized sports, although evidence suggests both amateur and elite adult athletes in certain sports may drink more than the general adult population and/or at hazardous levels (Dietze, Fitzgerald, & Jenkinson, 2008 ; Kerry S O’Brien, Blackie, & Hunter, 2005 ; O’Farrell, Allwright, Kenny, Roddy, & Eldin, 2010 ). Together, the existing research suggests that, in general, those who participate in sport are at-risk for excessive alcohol use and related negative consequences.

Recreational Drugs

In contrast to the literature on alcohol abuse, research on recreational drug use and sport suggests that those participating in athletics may be less likely than others to use a variety of substances (Lisha & Sussman, 2010 ). A meta-analysis of 17 studies examining drug use among adolescents found that those participating in sport were significantly less likely than those not participating in sport to report cannabis use (Diehl et al., 2012 ). Another systematic review of longitudinal studies among adolescents found that athletic participation was inversely associated with the use of drugs other than cannabis (Kwan et al., 2014 ). Research among college athletes in the United States has also found that athletes were less likely than nonathletes to report marijuana use (Wechsler et al., 1997 ), and rates of other drug use among this group are generally lower than population norms (Johnston, O’Malley, Bachman, Schulenberg, & Miech, 2015 ; Rexroat, 2014 ). Finally, the limited research on illicit drug use among elite athletes at both the adult and adolescent level also suggests lower prevalence rates relative to the general adult population (Dunn, Thomas, Swift, & Burns, 2011 ; Peretti-Watel et al., 2003 ).

Performance-Enhancing Drugs

Drug use in sport is often most associated with a variety of substances designed to improve athletic performance (e.g., anabolic steroids, human growth hormone). Many of these substances are illegal without a prescription and/or banned by sporting agencies. Several high-profile incidents have involved athletes being punished for the use of the substances, such as Ben Johnson losing the 100-meter track gold medal in the 1988 Olympics for steroid use, Lance Armstrong being stripped of seven Tour de France cycling titles for performance-enhancing drug use, and a number of top athletes in United States receiving suspensions for steroid or other performance-enhancing drug use. Such incidents may create the impression that performance-enhancing drug use is rampant in athletics, but the research evidence is equivocal. A meta-analysis of nine studies found an overall positive association between adolescent sports participation and anabolic steroid use (Diehl et al., 2012 ). In contrast, a study of more than 16,000 high school students in the United States reported no differences in steroid use between those who did and did not participate in athletics (Miller, Barnes, Sabo, Melnick, & Farrell, 2002 ). A 2013 study of approximately 21,000 college athletes in the United States indicated that only 0.4% of the sample used anabolic steroids in the preceding 12 months (Rexroat, 2014 ). In comparison, a national study of college students reported an annual prevalence rate of 0.5% (Johnston et al., 2015 ).

Rates of performance-enhancing drug use may be higher among elite athletes, where the stakes and incentives for optimal performance are quite high. A recent review of the literature concluded that the “doping” rate among elite athletes was between 14% and 39%, although there was considerable variation among different types of sports and hard data on the question is lacking (de Hon, Kuipers, & van Bottenburg, 2015 ). These estimates are consistent with several anecdotal reports in the popular press estimating that performance-enhancing drug use rates are relatively high among elite adult athletes, particular in certain sports (e.g., American football or track and field).

The Sporting Context, Alcohol Abuse, and Drug Use

Research has generally shown that, particularly among adolescents, sport participation is associated with positive psychosocial outcomes (Clark, Camiré, Wade, & Cairney, 2015 ). This finding extends to prevalence rates of some substances (e.g., cannabis and other illicit drugs), where sport participation has been shown to be a protective factor. Yet, for other substances (e.g., alcohol) sport participation serves as a risk factor. Such contradictory findings illustrate the importance of understanding the roles various sport-related factors play in either promoting or inhibiting alcohol abuse and drug use. It is also important to explore such factors considering the ethical issues inherent in the use of some substances in sport (i.e., performance-enhancing drugs) and the degree to which the use of other substances can lead to unique negative consequences for athletes (e.g., failed drug tests, negative publicity, poor sporting performance). Several factors that are somewhat unique to the sporting context are discussed.

The Cultural Context of Alcohol and Sport

Despite the potential negative effects of alcohol use on athletic performance (Barnes, 2014 ), in many countries alcohol and sport are inextricably linked. Alcohol beverage companies throughout the world serve as major sponsors for leagues, teams, and in some cases even individual athletes (Collins & Vamplew, 2002 ). There are several mechanisms by which these associations might translate to individual drinking behavior. One involves an indirect association: athletes, most of whom have likely been following sport from a young age, have strongly ingrained ideas associating athletic participation with alcohol consumption. A second is a more direct association, where athletes receive free or discounted alcohol products due to sponsorship from a beverage company. Two studies of athletes in Australia and New Zealand, ranging from club to national level, revealed positive associations between alcohol sponsorship and individual alcohol consumption (O’Brien & Kypri, 2008 ; O’Brien, Miller, Kolt, Martens, & Webber, 2011 ).

Another cultural aspect of sport that may relate to drinking behavior involves popularity and prestige. Athletes, particularly those who are successful and well-known, are often afforded higher social status than their peers, which can lead to significant social opportunities (Holland & Andre, 1994 ; Tricker, Cook, & McGuire, 1989 ). At the adolescent and collegiate level, successful athletes may find that they are regularly invited to social gatherings where alcohol or other drugs are provided. Athletes old enough to go to bars, clubs, and other public establishments may find that other patrons are eager to socialize with them, including purchasing their drinks. Additionally, a club or bar owner may provide free drinks to athletes of a certain stature to encourage their patronage. Basic behavioral economics principles indicate that the likelihood of substance use will increase with lower price and greater availability (Murphy, Correia, & Barnett, 2007 ). Thus, athletes who may be at-risk for developing a substance abuse problem may often find it relatively easy to be in social settings where alcohol and drugs are readily available.

Performance-Related Considerations

Athletes have clear incentives to perform at an optimal level in their sport. The reward value of such incentives generally increase as athletes progress to more elite competitive levels, culminating in major awards, international recognition, educational opportunities in the form of university scholarships, and the opportunity to make one’s (often well-compensated) livelihood in sport. Thus, some athletes will be tempted to use substances that have the potential to make them stronger and faster, thereby improving their athletic performance. Indeed several studies among athletes at varying competitive levels have shown that the primary reason athletes choose to use performance-enhancing substances is to improve their athletic performance (Miller, Barnes, Sabo, Melnick, & Farrell, 2002 ; Rexroat, 2014 ). Conversely, concerns about the impacts certain substances can have on athletic performance may serve as an important deterrent among athletes. Research among college students in the United States suggests that concerns about athletic performance is an important reason they choose not to use certain substances, although factors such as health-related concerns and lack of desire to experience the substance’s effects seem to be more salient factors (Rexroat, 2014 ). Addressing the role certain substances can play in inhibiting athletic performance could be a potentially useful component of interventions designed to prevent and reduce drug use among athletes.

Seasonal Effects

A unique aspect of many athletes’ lives involves the yearly rhythms surrounding their competitive season. Although many athletes train year-round, they have defined periods when their athletic performance is more salient and relevant. For example, the formal competitive season for a college football player in the United States runs from August (the start of official practice) through December or January (depending upon the date of the final game). These athletes may have other obligations throughout the year, such as spring practice and off-season workouts, but they are not participating in formal competitions. Athletes who limit alcohol and drug use due to performance-related concerns may choose to increase their use outside of these formal competitive seasons. Several research studies have shown that transitioning from in- to off-season serves as a risk factor for heavy drinking among athletes. Studies among college athletes in the United States found heavier alcohol consumption outside of their athletic season, including one longitudinal study that reported average drinking rates doubled during the off season (Bower & Martin, 1999 ; Martens, Dams-O’Connor, & Duffy-Paiement, 2006 ; Thombs, 2000 ). Another study of professional Australian Football League players showed a dramatic increase in risky drinking between pre-season and in-season time periods versus the off season (Dietze et al., 2008 ). The use of other substances may follow a similar pattern, and suggests the need for targeted intervention/prevention efforts for athletes transitioning out of their competitive seasons.

Drug Testing

Formal testing for the presence of certain drugs, particularly during an athlete’s competitive season, is another factor that almost certainly impacts drug use among these groups. Elite athletes at the international level are regularly tested for both performance-enhancing and illicit drug use, as are athletes in many major professional sports leagues and major amateur organizations (e.g., college athletes at National Collegiate Athletic Association member institutions). Several studies have shown that drug testing serves as a deterrent to banned substances (Coombs & Ryan, 1990 ; Dunn, Thomas, Swift, Burns, & Mattick, 2010 ), and may partially account for relatively low prevalence rates of certain illegal drugs. However, one study among adolescents in the United States showed that randomized testing reduced drug use but increased other risk factors for use, such as perceived norms and less risky beliefs about drug use (Goldberg et al., 2003 ). Further, if athletes are aware of their testing schedule, they may be able to organize their use around times when it would not trigger a positive test. Fear of a positive drug test almost certainly inhibits short-term drug use for some athletes, but the degree to which drug testing provides a more general impact on the substance use habits of athletes is more difficult to determine.

Ethical Considerations

A final sport-related contextual factor to address when considering substance use among athletes is ethical issues related to performance-enhancing drug use. This consideration is almost wholly unique to the athletic environment, as it is one of the only arenas where an individual may be incentivized to take a substance that would allow him or her to be physically superior to a specified opponent. Health or societal concerns regarding substance use can be applied across almost any group, but sport is unique in that use of certain substances may undermine the core foundation of the entity. Virtually all sports are based on the notion that each competitor agrees to a specified set of rules and regulations, which in many instances involve the types of drugs and other performance-enhancing techniques that are allowable. For example, in many professional sports leagues, athletes are allowed to take certain narcotic painkillers, but cannot take anabolic steroids or human growth hormone. Sporting organizations are motivated to ensure that athletes do not use drugs that are banned by their governing body, as it is important that they convey to the public that they are attempting to enforce the ideal of all athletes playing by the same rules. Further, sporting organizations are also motivated for their athletes to be perceived as living up to some sort of ideal (e.g., serving as a “role model” for children), which is why use of certain substances that have no performance benefits still results in suspension and other punishments. Many athletes therefore find themselves in situations regarding drug use that seem arbitrary, and at times hypocritical, in terms of the substances they can ingest. For example, they may be suspended for using a substance legal in several countries and states in the United States (cannabis), but they are allowed to use narcotic painkillers in an effort to facilitate their return to the practice or competitive arena.

Intervention and Prevention Strategies for Alcohol Abuse and Drug Use

A number of effective intervention and prevention strategies for alcohol abuse and drug use have been identified. This section of the chapter will address those strategies that have been well-studied and have the strongest empirical support. When possible, research that has examined these approaches specifically among athletes is presented here. Most of these studies focus on alcohol use, but in some cases their findings may translate to other substances.

Motivational Enhancement Interventions

The term “motivational enhancement” refers to a group of interventions, often sharing similar characteristics, which are designed to enhance an individual’s motivation to change a target behavior(s). Most of these interventions are founded in motivational interviewing, which is a theoretical and therapeutic approach that helps clients resolve ambiguity about behavior change (Miller & Rose, 2009 ). Motivational interviewing-based approaches are designed to help individuals identify their own reasons for change and support specific efforts toward change. A common feature of motivational enhancement interventions is personalized feedback, where the individual receives personalized information about the behavior in question. Theoretically, this feedback helps increase internal discrepancies in the individual that subsequently result in behavior change. Popular components of this feedback include personalized social norms information (i.e., how the individual’s drinking behavior and perception of “typical” drinking among a specific reference groups compares to actual drinking norms), typical drinking levels (e.g., estimated blood alcohol concentration on a heavy drinking occasion) and risks associated with such levels, and a summary of problems associated with the behavior in question (e.g., specific negative consequences experienced over the past 30 days as a result of alcohol consumption). These interventions also sometimes include an alcohol skills training component (Dimeff, Baer, Kivlahan, & Marlatt, 1999 ).

Overall, there is considerable empirical support for the efficacy of motivational enhancement interventions. Several meta-analyses have shown that brief (1–2 sessions) in-person interventions are effective at reducing at-risk alcohol and drug use (Burke, Arkowitz, & Menchola, 2003 ; Jensen et al., 2011 ; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010 ). Further, interventions that provide personalized feedback in the absence of individual clinician contact have also been shown to be efficacious at impacting substance use (Miller et al., 2013 ). A handful of studies have examined the efficacy of motivational enhancing interventions specifically among athletes, with promising results. For example, in one study, Martens and colleagues ( 2010 ) found that a personalized feedback-only intervention was effective among a sample of college athletes at reducing peak blood alcohol concentration. Another study by Doumas et al. ( 2010 ) found that a feedback-only intervention was effective among high-risk drinkers at reducing average weekly drinking, drinking to intoxication, and peak number of drinks consumed on a single occasion. Finally, a recent study by Cimini et al. ( 2015 ) provided similar support for the efficacy of a single-session in-person motivational enhancement intervention. Together, these findings suggest that brief, motivational enhancement interventions have considerable potential in reducing harmful alcohol consumption among athletes.

Alcohol and Drug Skills Training Programs

Another class of interventions involve those designed to teach individuals specific skills and strategies that are used to reduce alcohol and drug use and limit the likelihood of experiencing substance-related problems. Most of these programs have focused on alcohol use, and their specific content can vary widely and include both alcohol-specific topics and general lifestyle factors (Larimer & Cronce, 2007 ). The delivery of these types of programs can also vary considerably, including individually in the context of a motivational interviewing-based session (Martens, Smith, & Murphy, 2013 ), in a group format (Fromme & Corbin, 2004 ), or via a computer without personal contact (Carey, Henson, Carey, & Maisto, 2009 ). Overall, empirical support for these types of programs has been mixed, which is not surprising considering the diversity of approaches (Cronce & Larimer, 2011 ).

Only a few studies have examined the efficacy of alcohol skills programs specifically among athletes. One early study found no effects for a single session program delivered in a group setting that included general educational information about alcohol and other drugs, stress management, and strategies to alleviate peer pressure associated with substance use (Marcello, Danish, & Stolberg, 1989 ). This study was limited by factors such as a low sample size and high dropout rate. Other skills programs are presented in the literature, but they have either not been formally evaluated (Curry & Maniar, 2004 ; Meilman & Fleming, 1990 ) or have not been subjected to peer review (Wyrick et al., 2009 ). Considering that many sporting entities mandate that their athletes receive some degree of education/training on alcohol and drug-related issues, implementing skills-based programs that have shown evidence of efficacy in the general population could have a significant impact on the alcohol and drug use habits of athletes at a variety of competitive levels.

Contingency Management

One of the most efficacious strategies for intervening with individuals experiencing alcohol and drug disorders is contingency management, with one meta-analysis indicating that it had the strongest effects of any psychosocial intervention in terms of treating substance use disorders (Dutra et al., 2008 ). Contingency management interventions are based on basic operant behavior principles, where target behavior is reinforced and therefore likely to increase. For example, patients in a contingency management program for a drug-use disorder may receive a cash payment or voucher each time they provide a negative urine sample. The level of reinforcement often increases over time, with consecutive instances of the target behavior yielding escalating rewards (Budney, Moore, Rocha, & Higgins, 2006 ). Theoretically, the individual will initially engage in the behavior (e.g., being abstinent from alcohol or drugs) to receive the tangible reward associated with the intervention. Over time, the individual will begin to experience other reinforcers that naturally occur due to decreased substance use, such as better relationships and job performance. Ideally, these reinforcers will be powerful enough to cause the individual to continue to engage in the target behavior even after the contingency management intervention has ended. For example, an athlete in a contingency management program whose sport performance improves after ceasing drug use may be likely to continue to refrain from drug use even when he or she no longer receives the financial incentives associated with the program.

To date no studies have been published that examined the efficacy of contingency management interventions specifically among athletes. Due to the fact that many sporting organizations already routinely test athletes for various substances, implementing such a program in certain athletic settings may be somewhat easier than the typical outpatient or inpatient clinic. Indeed, many organizations already have a punishment-related system affiliated with drug testing (e.g., suspensions for positive drug tests); a contingency management system would involve the reverse of this, where athletes received incentives for negative drug tests. Such a program would likely be most appropriate for athletes who have been experiencing fairly significant alcohol and drug problems and are attempting to eliminate their use of the substances.

Twelve-Step Programs

Twelve-step programs are likely the mode of alcohol and drug abuse intervention most familiar to the general public. They are most frequently affiliated with Alcoholics Anonymous or Narcotics Anonymous (AA/NA). AA or NA programs have historically been the most common route for individuals to engage in a 12-step program, but there are examples of individual interventions designed to facilitate the 12-step process (e.g., Project MATCH Research Group, 1997 ). Twelve-step programs conceptualize addiction as a disease, and therefore complete abstinence is the desired outcome. “Working” a 12-step program involves a series of steps, which include behaviors such as admitting that one is powerless over addiction (Step 1), asking God or a higher power to remove shortcomings (Step 7), and carrying the 12-step message to other alcoholics/addicts (Step 12).

There is evidence to suggest that 12-step programs are as efficacious as other interventions/treatments (Ouimette, Finney, & Moos, 1997 ; Project MATCH Research Group, 1997 ). However, it can be difficult to examine the efficacy of individual 12-step programs; by definition, they are usually anonymous and assignment to appropriate control conditions is logistically challenging. No published studies have examined the efficacy of 12-step programs among athletes, although numerous athletes have undoubtedly participated in such programs. If an athlete has a significant alcohol abuse and/or drug use problem and is open to abstinence as a treatment goal, then encouraging them to consider a 12-step program would be appropriate.

Environmental Interventions

Environmental interventions to refer to a broad class of interventions designed to impact behavior by changing the external environment in such a way as to inhibit alcohol and drug use. The interventions addressed thus far in this chapter are individual interventions, in that they are designed to change thoughts, behaviors, and emotions of specific individuals who receive the intervention. In contrast, environmental interventions are not necessarily targeted to specific individuals but are designed to create a context that disincentivizes alcohol and drug use among all of those in the environment. Most of these interventions have focused on alcohol use because it is a legal substance readily available in most communities. An example of a well-known environmental intervention involved raising the drinking age in the United States from 18 to 21, which resulted in a decrease in alcohol consumption and traffic crashes (Wagenaar & Toomey, 2002 ).

Many environmental interventions involve attempts to create policies or rules that limit access to alcohol, such as restricting times when alcohol can be sold or outlawing drink discounts or other specials that might encourage heavy alcohol use (Toomey, Lenk, & Wagenaar, 2007 ). Other interventions focus on creating, publicizing, and enforcing rules against alcohol and drug use (e.g., alcohol-free dormitories on college campuses). A number of studies have shown that environmental interventions can be efficacious at impacting the target behavior (see Middleton et al., 2010 ; Task Force on Community Preventive Services, 2010 ; Toomey et al., 2007 ), but they can also pose unique challenges. Implementing environmental interventions often requires considerable coordination among a variety of parties, some of whom actually benefit from substance use. For example, if a group of bar owners believed that drink specials yielded more patrons and greater profits, it might be challenging to convince them to outlaw such specials in an attempt to limit heavy drinking.

Another means of conceptualizing environmental interventions for alcohol and drug abuse is behavioral economics theory, which posits that the decision to use substances is related to availability and price of both the substances themselves and alternative sources of reinforcement (Vuchinich & Tucker, 1988 ). For example, all else being equal, adolescent alcohol use would theoretically be lower in a community that had numerous alcohol-free social activities available that were reinforcing to young people than a community that did not have such alternative activities. Behavioral economic theory also posits that alcohol and drug use will be lower when individuals are orientated toward future rewards incompatible with substance use, such as successful educational and vocational outcomes (Murphy & Dennhardt, 2016 ). Therefore, environmental interventions that promote such a future-based orientation may result in diminished desire to obtain short-term reinforcement from alcohol and drug use.

To date, only one large controlled trial has examined the efficacy of an environmental alcohol intervention among athletes. In this study, the researchers evaluated the efficacy of the Good Sports program (Rowland, Allen, & Toumbourou, 2012 ), which was implemented at community football clubs in Australia. This program includes a variety of environmental interventions grouped across three accreditation levels. An example of a level 1 intervention strategy is serving alcoholic drinks only in standard drink amounts, an example of a level 2 strategy is not serving shots of liquor, and an example of a level 3 is having and distributing a written alcohol policy to club members. An initial study showed that clubs with higher accreditation levels reported less alcohol use than clubs with lower accreditation levels (Rowland et al., 2012 ). Subsequently, researchers conducted a trial where 88 football clubs were randomized to the intervention or control condition. After the intervention, participants in the intervention condition reported less risky alcohol use than those in the control condition (Kingsland et al., 2015 ).

Considering these promising findings, as well as the overall support for different types of environmental interventions in other populations, athletic organizations should consider contextual strategies designed to limit alcohol and other drug use. Many large organizations have clear rules and policies built into their larger systems, such as suspensions for positive drug tests or alcohol-related arrests. Individual teams, clubs, or schools/universities could build more specific, targeted policies into their systems. For example, a high school or adolescent sporting club might ask team members to sign a pledge to refrain from alcohol and drug use, whereas a collegiate or adult club might ask team members to pledge to limit their alcohol consumption in some way. Consistent with behavioral economic theories, organizations could also promote social activities that do not involve substance use. Such strategies may be particularly useful among adolescents and young adults, and they could involve activities such as regular team social outings and partnerships with local community organizations that offer substance-free activities.

Conclusion and Future Directions

Research has convincingly established that for some substances, particularly alcohol, athletes have higher levels of at-risk use than individuals not participating in athletics. Conversely, rates of use for many other types of drugs are lower among athletes than nonathletes. Nonetheless, it is important to focus on understanding and limiting drug use among athletes, considering the myriad negative effects of such use on this population at all competitive levels. Research in the general population has established several effective individual and environmental intervention strategies, and there is emerging evidence for the efficacy of many of these interventions specifically among athletes. One recommendation for future research is to examine strategies for disseminating different types of empirically supported interventions to athletes, particularly those that are low cost (e.g., personalized feedback interventions delivered electronically). A second research direction could involve examining the efficacy of environmental interventions at more local levels, such as team-specific strategies designed to limit alcohol and drug use. A third direction involves more research focused on substances besides alcohol, particularly in terms of intervention studies. Finally, researchers could consider exploring strategies for targeting/tailoring existing interventions to be more efficacious specifically among athletes. For example, one study found that personalized feedback tailored specifically for college athletes was more effective than feedback applicable to a general student population at reducing high-risk drinking (Martens, Kilmer, Beck, & Zamboanga, 2010 ). Tailoring other types of existing interventions may also yield enhanced effects among athletes.

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Thesis Statement of "Performance Enhancing Drugs in Sport"

EF_Team2 1 / 1704   May 30, 2007   #2 Greetings! I think you have a good start on your thesis statement, but it is a run-on sentence. I might suggest a couple of small changes: Because athletes are in the public eye, their actions can affect the children and adults for whom they serve as role models. Therefore, athletes who use performance-enhancing drugs should face consequences for the use of these illegal substances. I hope this helps! Thanks, Sarah, EssayForum.com

OP traci107 1 / 1   May 30, 2007   #3 Thank you!!!!!!!!!!!!

Zem7 - / 2   Feb 4, 2008   #4 Help with my thesis for Performance - Enhancing Drugs and Athletes I need some help making my thisis more arguable, and maybe worded a litte better. This is what i have right now: Due to the use of performance - enhancing drugs by professional athletes there has been increased use at the high school level, their athletics as well as academics are suffering because of the focus on the drugs athletes are using and the negative effects that they cause. Any suggestions would be great!

EF_Team2 1 / 1704   Feb 4, 2008   #5 Greetings! I'd be happy to help! First off, your thesis is a run-on sentence. The first sentence should end at "level." Let's see if we can make it a little tighter: "Both athletics and academics at the high school level are suffering as students continually see news of their sports heroes' use of performance-enhancing drugs." You would then go on to explain the connection. There are many ways you could write the thesis; just remember to keep it succinct and to the point. I hope this helps! Thanks, Sarah, EssayForum.com

Zem7 - / 2   Feb 5, 2008   #6 Thats great! Thanks