MJ A P R A C TI C E E S S EN T I A L S — S P O R T S ME D I C I N E
spo
medicin
rts
4. The use and misuse of performance-enhancing
substances in sport
John W Orchard, Peter A Fricker, Susan L White, Louise M Burke and Deborah J Healey
e
Doctors need to know if a patient is an athlete subject to drug testing, and to be aware of the
legal situation surrounding drugs they prescribe such patients
C
ertain drugs have the potential to increase athletic performance, but they carry the risk of side effects, which may
include death and life-long morbidity. Examples include a
cyclist dying from stimulant misuse during the 1960 Rome Olympics, The
and Medical
deaths from
cardiovascular
disease0025and various cancers
Journal
of Australia ISSN:
1
resulting
from
use
of
anabolic
steroids,
as
well
as the permanent
729X 6 February 2006 184 3 132-136
androgenising
effects Journal
of these ofdrugs,
including
©The Medical
Australia
2006 infertility, which
affect www.mja.com.au
many female Eastern bloc former athletes. Prohibitions on the
Practiceperformance-enhancing
Essentials — Sports Medicine
use ofMJA
dangerous
drugs have been introduced in almost all elite-level sports over the past 4 decades.
Antidoping laws attempt to minimise the numbers of athletes
engaging in doping, although the enforcement of antidoping laws is,
ABSTRACT
• Antidoping laws generally exist in order to provide a safe
and fair environment for participation in sport.
• These laws should prevent and protect athletes from
subjecting themselves to health risks through the use
of unsafe, but performance-enhancing drugs.
• Because of difficulties in proving intent to cheat, the World
Anti-Doping Agency enforces a principle of strict liability for
positive test results for banned substances.
• An area of major controversy with respect to liability is the
“sports supplement” industry, which is poorly regulated when
compared with prescription drugs yet is a potential source of
doping violations.
• Medical practitioners can be found guilty of anti-doping
violations if they traffic banned drugs, prescribe these to
athletes or otherwise assist athletes in taking banned
substances.
• Medical practitioners are also now required to complete
paperwork (therapeutic use exemption forms) to enable
athletes to take banned substances which are required
on medical grounds for specific illnesses.
MJA 2006; 184: 132–136
SERIES EDITORS: JOHN ORCHARD AND PETER BRUKNER
Sports Medicine at Sydney University, University of Sydney,
Sydney, NSW.
John W Orchard, PhD, FACSP, FACSM, Sports Physician.
University of New South Wales, Sydney, NSW.
Deborah J Healey, LLM, Senior Lecturer, Faculty of Law.
Australian Institute of Sport, Canberra, ACT.
Peter A Fricker, OAM, MB BS, FACSP, Director; Louise M Burke, PhD,
APD, FACSM, Head, Department of Sports Nutrition.
Olympic Park Sports Medicine Centre, Melbourne, VIC.
Susan L White, MB BS. FACSP, Sports Physician.
Reprints will not be available from the authors. Correspondence:
Dr John W Orchard, Sports Medicine at Sydney University, University of
Sydney, Corner Western Avenue and Physics Road, Sydney, NSW 2006.
johnorchard@msn.com.au
132
predictably, not 100% successful.2-4 Because there is a perception
that it is impossible to fully enforce antidoping laws, some commentators argue that these laws be relaxed to create an “open” but
arguably more “even” playing field.4 However, sport without antidoping laws would disadvantage further those athletes who wanted
to compete at an elite level without risking their health.
The recently formed World Anti-Doping Agency (WADA) is
responsible for developing and implementing uniform antidoping
standards worldwide (both with respect to lists of banned drugs
and penalties for misusing them). The World Anti-Doping Code
(“WADA Code”) was adopted after consultation with governments,
sporting bodies, national antidoping agencies and other relevant
parties in 2003 by all Olympic Committees, many nations and
many elite sports associations.
A substance can be included on the World Anti-Doping Code
Prohibited List if it meets two of the three major criteria defined by
WADA, or if it is a potential masking agent. The three criteria are
that the substance is performance-enhancing, that there are health
risks to the athlete with use of the substance and that use of the
substance violates the spirit of sport. The need for two out of the
three criteria means that the WADA Code can ban “social drugs”
such as marijuana (even though they are not performance-enhancing) but can permit the use of a drug such as caffeine (even though
low levels of this drugs are performance-enhancing).
Antidoping laws do not just relate to positive tests for prohibited
substances. Refusing to submit to testing procedures, tampering
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1 Samples for drug testing must be collected according
to a rigorous protocol to prove that detected
substances were definitely found within an athlete's
system
with samples (before or after they are submitted), possession and/
or trafficking illegal substances, and refusal to supply accurate
regular whereabouts information to authorities (to allow for
regular unannounced out of competition testing) can lead to
doping infringements. Therefore, doctors who may potentially
prescribe or otherwise assist athletes in taking banned drugs may
also be subject to doping sanctions and suspended from involvement in elite sport.
The burden of proof in doping charges
With respect to the doping charge of “the presence of a prohibited
substance or its metabolites or markers in an athlete’s bodily
specimen”, an athlete is found guilty irrespective of whether there
was a proven or even suspected intention to ingest the substance
or cheat. Such strict liability does not necessarily apply to some
other doping charges (eg, trafficking illegal substances), in which
various burdens of proof must be met.
WADA enforces the principle of strict liability because there is
generally no reasonable doubt that a drug discovered within an
athlete’s urine or blood sample (taken under strict protocols; see
Box 1) was present within the athlete’s system, while it would be
far too difficult, in most cases, to prove intent to cheat beyond
reasonable doubt. Strict liability for doping offences is controversial, although the WADA Code does allow consideration of the
unique circumstances of each case. If an athlete can prove no fault
or negligence (in exceptional circumstances, such as a case of proven
drink spiking) it is possible that suspensions can be downgraded
or waived. These exceptional circumstances do not generally
include cases where the athlete was given a prohibited substance
by his or her personal physician or trainer without disclosure to
the athlete.5
In cases in Australia, even before the adoption of the WADA
Code, where an athlete has claimed inadvertent doping and his or
her claims were verified, it has been rare to completely vindicate
the athlete. There have been occurrences where medical practitioners have prescribed banned drugs for athletes for medical
indications and have recorded the prescription in the notes, which
have subsequently led to positive tests. Three case histories
involving Australian professional cricket players are presented in
Box 2 showing the response of drugs tribunals to the various
explanations provided by the players.
Responsibilities of treating medical practitioners
The case in Box 2, in which a general practitioner prescribed
probenecid for a professional player, which resulted in a doping
violation, highlights the need for every medical practitioner,
whether interested in sports medicine or not, to be aware that
doping laws exist for athletes. Athletes are also responsible for
informing every treating medical practitioner that they are subject
to doping restrictions. Doctors unfamiliar with drugs on the most
recent banned list must check with the Australian Sports Drug
Agency (ASDA, via their hotline [1800 020 506] or their website
<http://www.asda.org.au/>), before prescribing. To date, there has
been no reported litigation involving athletes taking action against
medical practitioners for prescribing banned drugs which led to
suspensions. In scenarios where a doctor was either unaware of the
“testable” status of an athlete or where a drug was administered as
part of emergency treatment, it is unlikely that a doctor would be
considered negligent for prescribing a banned drug. However, if a
patient asked a doctor to check the legal status of a drug and an
error was made, then the doctor may be held responsible for this
2 Case histories involving Australian cricket players
Drug
Circumstance
Probenecid
(potential
masking
agent)
Patient treated for an abscess by a medical
practitioner who was unaware that the player
was subject to drug testing. Given probenecid
to enhance penicillin action
1-month
suspension
and
$2000 fine
Penalty
Rationale
Because there was a clear indication for probenecid and because
the drug was not performance-enhancing (but classified as a
masking agent), leniency was exercised (but the player was not
found innocent because the definition of guilt in the code is the
presence of a substance). The player admitted to failing to notify
the doctor that he was subject to drug testing
Nandrolone
(anabolic
steroid)
Patient was prescribed injectable nandrolone
to assist in the recovery from a chronic back
condition when not playing professional
cricket, although the drug was detected after
he returned to professional play
18-month
suspension
Very little sympathy was extended to the player for the
explanation that he was prescribed an anabolic steroid for
medical indications, as the drug was clearly performanceenhancing and the indication for the drug was dubious
Diuretic
(masking
agent)
Patient took a diuretic (prescribed for another
person) for weight loss
12-month
suspension
Controversial case as the player was given a severe, but not
maximum, penalty, suggesting that the tribunal offered some
“discount” for his explanation and the fact that the drug was a
masking agent rather than performance-enhancing; however, he
◆
was still found liable for the positive test
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3 Evidence base* for the status of certain drugs on the World Anti-Doping Code Prohibited List 2005
Drug category
Common therapeutic use(s)
Current status
Rationale for current status
β2-agonists
Asthma
Banned, but an abbreviated
TUE form acceptable for
exemption for inhaled use
Oral salbutamol in high doses enhances performance
(Level 2 evidence)7
Corticosteroids
Asthma (oral/inhalers); certain
injuries (local injections)
Banned, but therapeutic
exemptions may be granted
Suspected of being taken indiscriminately in ultraendurance events during competition to induce a sense
of euphoria and perhaps to mask pain (controversial Level
4 evidence); no anabolic effects
Anabolic steroids
Very rare (eg, after surgery for
pituitary tumour)
Banned. Need full TUE from
medical panel for exemption,
which would only be granted in
extreme cases
Performance-enhancing and dangerous when misused
(Level 1 evidence)1
Amphetamines
Attention deficit hyperactivity
disorder, narcolepsy
Banned. Need full TUE from
medical panel for exemption
Controversial category, as very likely to be performanceenhancing and unsafe in high doses (Level 4 evidence).
Therapeutic uses are genuine but hard to diagnose
objectively8
Finasteride
Hair loss; prostate disorders
Recently banned as a masking
agent. Need full TUE from
medical panel for exemption
Potential masking agent
Pseudoephedrine
Very common component of
over-the-counter cold and flu
medications
Has recently been removed from No performance-enhancing effects from a standard dose
the banned list
(Level 2 evidence)9
Caffeine
No medical use, but common in All restrictions on caffeine have
many foods
recently been removed
Impractical to ban and a fairly safe drug, despite some
potential performance benefits (Level 1 evidence)10
Local anaesthetic
injections
Suturing of wounds; minimising Legal
pain from an injury
No advantage conferred over uninjured athletes (Level 4
evidence); impractical to enforce ban11
* Evidence rated according to National Health and Medical Research Council levels of evidence.6 TUE = therapeutic use exemption.
mistake. When prescribing drugs for athletes, a similar principle
applies to that of treating pregnant women: “if in doubt about the
status of a drug, check it or do not use it”. Practitioners are also
advised to have some system of recording on a patient’s file
whether he or she is subject to sports drug testing.
Success in policing of antidoping laws
Many of the women’s track world records from the 1980s still
stand. They were set in a period where both drug testing programs
and the ability to detect anabolic steroids were nowhere near as
advanced as they are today. It is impossible to be certain that a
specific world record was only achieved with doping (other than
cases where confessions were made). However, the fact that worldclass standards have dropped in women’s track events over the past
15 years is probably attributable to the decreased use of performance-enhancing agents over that time, as antidoping measures
have become more successful.
The fact that most records in men’s track events and in other
disciplines such as swimming and cycling have been broken since
the 1980s can be explained with a variety of hypotheses, including
that the relative performance advantage in these events for using
anabolic steroids is not as great as for women’s track events. There
is an expectation that world records will gradually improve over
time as training advances are made.
It has recently been revealed that many athletes from East
Germany in the 1970s and 1980s were regularly prescribed anabolic
steroids, yet calls by some commentators to have retrospective
changes made to the record books have not been heeded. This is
sensible, as it is perhaps counterproductive to rewrite history many
134
◆
years after the event. If an athlete wins an event under the drugtesting regimen of the day, any later declaration that he or she was
able to beat the system of the time does not necessarily mean that he
or she was the only athlete in that event doing so. It may also be
helpful for improving the approach towards drugs in sport that
athletes can confess years after an event, without the threat of
[potential] retrospective erasing of results.
Blood doping and erythropoietin: should direct or
indirect testing be used?
Blood doping (transfusions of either donor blood or one’s own
stored blood) to enhance performance in endurance events has
probably now been superseded by erythropoietin (EPO). EPO
increases red blood cell indices, such as haemoglobin concentration, and hence endurance. In certain sports, the “average” haemoglobin levels of competitors have increased significantly in recent
years, which is highly suggestive of blood doping or EPO use.2,3
EPO is considered a very difficult drug to detect: it exists naturally
within the body and has a short half-life of a few hours, while its
effects on red blood cell counts last for over a month. Thus, rather
than relying solely on detecting EPO directly, athletes in sports
such as cycling and cross-country skiing (where EPO misuse is
thought to have been common) are banned from competing if their
red blood cell indices are raised beyond certain levels (possibly
consistent with, but not definitive of, EPO use). These tests are
done just before competition and exclusion from that event is
based on the potential risk to health.
While seen by some as a sensible method of minimising harm,4
“banning” according to haematological indices means that the
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principle of strict liability
cannot be adhered to.
Medical conditions, such
as polycythaemia rubra
vera, can cause similar haematological changes. Thus,
affected athletes are not
subject to doping sanctions, but are merely designated “unfit” to participate
in the current competition.
Similarly, wheelchair athletes with spinal cord injuries who have high blood
pressure before an event
are prevented from competing at the Paralympics,
without prospective suspension, as the elevated
blood pressure may be selfinduced (illegal “boosting”
to improve performance) or the result of a concurrent medical
condition.
Therapeutic use exemptions (TUEs)
The WADA Code has a process for granting exemptions for the
legitimate medical use of banned substances. All applications must
be prospective and registered (except in emergency situations).
Some medications are banned (see Box 3) with the proviso that
they may be used for certain medical indications, which require
that the relevant body is notified before their use. Under the
WADA Code, prospective approval to take a banned drug through
the therapeutic use exemption (TUE) process for a documented
medical condition is currently provided if:
• the condition poses significant impairment to health; and
• there is no additional enhancement of performance (other than
return to normal state of health following treatment of the
legitimate medical condition); and
• no reasonable therapeutic alternative exists to treat the condition.
The TUE process is generally simple for specific commonlyexempted drugs (inhaled β2-agonists for the treatment of asthma
and non-systemic glucocorticosteroids) with automatic approval
being considered “granted” once a correctly lodged form is
received by the relevant national or international sporting body.
However, incorrect lodgement of paperwork can result in a guilty
verdict under the principle of strict liability. This has already
occurred in the case of an Austrian tennis player who was banned
for 3 months in late 2004 for testing positive to a corticosteroid,
injected by a doctor for a wrist injury.
Less commonly-exempted drugs (with greater potential for
misuse and performance enhancement) must be assessed by an
expert panel. In Australia, these requests for TUEs are handled by
an independent panel called the Australian Sports Drug Medical
Advisory Committee (see http://www.asdmac.org.au). Medical
practitioners can also ring for advice, particularly in emergency
situations, and may be able to speak directly to one of the medical
practitioners on the committee. TUEs are commonly granted for
the use of oral glucocorticosteroids to treat severe asthma or
inflammatory bowel disease. All applications require full docu-
mentation, including specialist opinions and results
of investigations. A TUE
would never be granted to
help elevate a slightly
“below normal” testosterone level in an otherwise
healthy adult. It has been
noted that athletes will go
to extraordinary lengths to
appear to have conditions
for which anabolic steroids are indicated, because
of the known beneficial
effects on performance.12
The legality of the various stimulants presents a
further area of controversy.
A Romanian gymnast was
stripped of a gold medal at
the Sydney Olympics after
testing positive for pseudoephedrine, which was banned at the
time, but pseudoephedrine has been recently removed from the
banned list (Box 3). The most contentious TUE decisions with
respect to stimulants are for conditions such as narcolepsy and
attention deficit hyperactivity disorder (ADHD). While these
conditions improve markedly with stimulant medication,13 a
recent review cautioned against awarding TUEs for stimulants on
the basis that symptoms are difficult to verify “objectively”, making
it possible for athletes to allege having symptoms of narcolepsy
and ADHD to gain access to performance enhancing stimulants.8
The use of “legal” supplements
While most over-the-counter supplements are considered “legal”
within anti-doping codes, some controversies exist because they
may enhance athletic performance. While there is no scientific
evidence to support the benefits claimed for most products, there
is substantial proof that some can enhance specific performance
outcomes when used according to specific protocols.14 For
instance, certain athletes taking bicarbonate/citrate, creatine and/
or caffeine can exercise at higher work rates or for longer before
experiencing fatigue.10,15,16 WADA has taken a pragmatic
approach, considering that such ingredients occur naturally in
food, and that manufactured products simply represent a practical
way for athletes to consume a desired dose.
By contrast, the WADA Code bans prohormones, including
androstenedione, dehydroepiandrosterone, and 19-norandrostenedione, which can be converted in the body to testosterone or the
anabolic steroid nandrolone.17 Over recent years there has been
controversy relating to their legality in professional baseball in the
United States. Since the Dietary Supplement Health and Education
Act (1994) was passed in the United States, products containing
prohormones have been marketed as over-the-counter dietary
supplements there. Even in countries like Australia where prohormones do not enjoy this liberalised status, they may be available to
athletes through Internet or mail-order sales.
There is conflicting data about whether the use of prohormones
generally leads to positive results from urinary drug screening
tests,18-20 which means that none of the anabolic steroid prohormones can be considered “safe” for athletes who are subject to
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testing, yet certain individuals may still test negative for anabolic
steroids after taking low doses of prohormones. Over recent years,
many athletes who have tested positive for low levels of the
anabolic steroid nandrolone have claimed that they took only
apparently “legal” supplements. Several studies from overseas have
suggested that up to 10%–15% of supplements may contain
contaminated substances.18,21 Clearly, there are problems with the
supplement industry worldwide, and solutions must include selfregulation of manufacturing processes to ensure uncontaminated
and accurately labelled products, appropriate government regulations, and product testing and certification programs for athletes.
Another confusion about prohormone supplements lies with
their ability to enhance sports performance in young adults with
normal endogenous production of steroids. The present consensus
from acute and chronic studies of prohormone supplementation is
that there is little evidence of improved muscle size or strength
above the gains achieved through resistance training.14 Although it
is tempting to say that these products “don’t work”, the treatment
doses used in studies are conservative in comparison to the doses
recommended and used by some athletes.22
Testing for “social” drugs that are not
performance-enhancing
Major controversy also surrounds testing for illegal drugs that do
not enhance performance, but which athletes may take for social
(or recreational) purposes. The banning of stimulants, such as
cocaine, when competing is universally accepted. The dilemma
lies in whether stimulant drugs should be tested out-of-competition (where presumably they convey no performance advantage)
and whether drugs such as marijuana, which are illegal but
unlikely to confer any performance advantage, should be tested for
and potentially lead to disqualification. The argument offered by
WADA is that these drugs affect the health of the athlete, and that
taking of drugs inappropriately is against the spirit of sport.
It may be considered an invasion of privacy to test for nonperformance-enhancing drugs outside periods of athletic competition. However, it is hard to argue in defence of athletes who choose
to break not only antidoping, but also criminal laws by using illicit
social drugs. It may be more appropriate that these athletes receive
counselling, and perhaps shorter suspensions, than other athletes
found using drugs that would confer an unfair performance
advantage.
Conclusion
Doping authorities are further ahead than they have ever been, but
awareness that doping is prevalent in sport is also greater than it
has ever been. With current antidoping policies, authorities greatly
decrease the widespread use of dangerous substances in sport.
However the difficulties with enforcing prohibitions lead to many
areas of controversy. It is planned that subtle ongoing changes will
be made to the WADA Code, making it necessary for all medical
practitioners who treat athletes to know how to check up-to-date
lists of legal drugs and substances.
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3 Stray-Gundersen J, Videman T, Penttila I, Lereim I. Abnormal hematologic profiles in elite cross-country skiers: blood doping or? Clin J Sport
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4 Savulescu J, Foddy B, Clayton M. Why we should allow performance
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Competing interests
Susan White is a member of the Australian Sports Drug Medical Advisory
Committee (ASDMAC). Peter Fricker was a member of ASDMAC while
writing this article, but has since resigned after accepting the position of
Director of the Australian Institute of Sport.
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