Sport goes beyond a measure of athletic excellence and the winning of trophies and medals. Sport is an integral thread in the fabric of society and enriches our daily lives. Most of us have a favourite sport we play or follow with a passion be it soccer, rugby, swimming, cycling, athletics, winter sports or our national games of hurling, football and handball. The character and team spirit displayed by the Irish football squad in the face of disappointment and adversity has ignited the country this month and national pride has soared and spread once again "like a prairie fire". Sport also teaches us about honest endeavour, commitment and fair play; ethics we can extrapolate to all walks of life.
The most honourable among us are perhaps those who have competed in sport and hold true its finest principles. True winners are those who achieve their goals through talent, skill, training, motivation and rising to all the challenges their sports present. Increasingly, however, a "win at all costs" ethos that undermines the very integrity of sport has entered the arena and a new game is at stake, the dangerous and sometimes deadly game of doping.
Doping in sport is not a new phenomenon; athletes have taken performance-enhancing agents since the beginning of time. The legendary Arthurian knights supposedly drank magical potions from the cup of Merlin. Our own Celtic tales describe the use of strengthening potions to aid valour in battle and the druids' use of narcotics is well documented by historians. The berserkers', a class of ancient Norse warriors who fought frenziedly, "berserk" behaviour was attributed to a deliberate diet of wild mushrooms. The Ancient Olympics in Greece were riddled with corruption and doping to the extent that the games had to be dissolved.
In Ancient Rome, gladiators drank herbal infusions to strengthen them before chariot races and going into battle. Almost two millenia later, the first documented report in the medical literature was published in 1865 in the British Medical Journal, citing expulsion of a swimmer from an Amsterdam canal race, for taking an unnamed performance-enhancing drug.2 The first doping death occurred in 1886 in cycling.
In the early 1900s, the most popular doping agent was a cocktail of alcohol and strychnine. The use of strychnine was superseded by amphetamine, following its development in the 1930s. In 1960, the Danish cyclist, Kurt Jensen, died after overdosing on amphetamine in an attempt to seek competitive advantage and the search for control measures began. Methods of anti-doping control were first pioneered in the 1960s, by Arnold Beckett, an academic pharmacist with a specialist interest in sports pharmacy, based at Kings College London (formerly Chelsea College). It was however the televised death of the British cyclist Tommy Simpson, while under the influence of amphetamine during the 1967 Tour de France, that proved the catalyst for implementation of official anti-doping control systems and the banning of amphetamine in international sport. Cycling has long since been a harbinger for systematic doping and as one top cyclist explained "it is impossible to finish in the top five of a Tour de France without doping". In 1968, the International Olympic Committee (IOC) published the first banned list of drugs and implemented the first formal drug testing programme at the Montreal Olympics.
In the last three decades a number of names have joined the cheaters' hall of fame including Ben Johnson (stanozolol), Dan Mitchell (testosterone), Lindford Christie (nandrolone), Olga Yegorova (erythropoetin) and Andrea Raducan (pseudoephedrine), to name a few. Johnson was abusing stanazolol and other agents for years with the help of fringe practitioners, before testing positive at the Seoul Olympics in 1988. In the UK, many were shocked by the Lindford Christie saga, however he first tested positive in 1988, at the start of his career, for the banned stimulant pseudoephedrine; not surprisingly he has now lost the contract for whiter than white whites. It was the Irish swimmer Michelle Smith de Bruin who brought the reality of doping home to our own doorstep; while the country was divided in 1998 as to whether she was a sporting Jenny or a bold deceiver, the IOC confirmed that there was "Whiskey in the Jar" and the amount therein defied all possible human consumption. The doping scourge has continued into the new millennium. Alain Baxter came from 63rd in the world to attain a bronze medal in this year's Winter Olympics at Salt Lake City, only to be stripped of his medal after a positive test that could only have been attained had the nasal spray implicated been swallowed whole. Only recently, another scandal hit the headlines adding to the disrepute of cycling when Stefano Garzelli tested positive for probenecid; five of his team were either arrested, indicted or "disappeared" during police investigations.
The pharmacy department at Kings College remains a focus for drug testing and now houses one of the world's leading drug testing laboratories; headed by Professor David Cowan, it is the only IOC accredited anti-doping control laboratory in the UK, and it is to this laboratory all Irish urine samples are sent for analysis.
It is not just athletes who are involved in the doping games, however. Coaches, managers, team doctors and fringe practitioners have all been implicated. Eric Rykaert, medical officer of the Festina cycling team, was prosecuted for possession of erythropoetin in 1999. The Australian swimming team coach for the 2000 Sydney Olympics, Gennadi Touretski was found in possession of stanozolol; interestingly this discovery was made following the arrest of two heroin addicts who burgled his home. But perhaps the most sinister of all, is the publication last year of the book "Faust's Gold" which takes an in-depth look at the systematic doping machine implemented by the German Democratic Republic (GDR) in the 1970s.
The GDR regime involved the state, sports federation officials, coaches and sports physicians and activities were encouraged by the secret police. Many of the athletes were given performance enhancing agents without their knowledge; 142 former female athletes experienced androgenic changes, infertility and delivery of abnormal offspring as a result of involuntary drug abuse and are currently seeking compensation in the courts; an initial payment of 2 million euro has been paid by the German parliament. Heidi Krieger, the GDR shot-putter had so many testosterone injections that she opted for a gender change and now lives as Andreas Krieger. It is estimated that as many as 10,000 athletes were processed through the GDR doping machine. The former state sports physician Manfred Hoeppner, and the Head of the GDR Sports Federation, Manfred Ewald (1961 - 1988), received a 22 month sentence in 1999 for unlawful use of drugs.
However, it is not only the East Germans who were involved in such dubious practices. The US cycling team bought into the practice of blood doping and during the 1984 Los Angeles (LA) games, a professor of medicine, no less, supervised the transfusion of non cross-matched blood from families of cyclists in an LA hotel room;
hardly an aseptic environment.4 In the same games, 86 athletes tested positive for anabolic steroids; interestingly 9 of these positive test results disappeared from the laboratory.
Doping not only contravenes the spirit of fair competition, it can be seriously detrimental to health. Elite athletes who turn to doping take the greatest risks which seem to pale in contrast to their burning desire for gold. Anabolic steroids affect cardiovascular and mental health and are associated with an increased risk of neoplasms.5,6 Dietary supplements containing ephedra alkaloids have been linked to serious health risks including hypertension, tachycardia, stroke, seizures and death.7 This finding has lead to the recall of ephedra containing supplements in the USA and Canada. Deaths under the influence of drugs and combinations thereof are not uncommon in sport. The peptide hormones or so-called "sports-designer drugs" are thought to be the most dangerous, although the combination of amphetamines, anabolic steroids or antihypertensives combined with intense exertion in athletes are just as hazardous. America's dream girl Florence Griffith Joyner, "Flo-Jo", and the Cuban runner Chelimo both died from cardiovascular events at 38 years of age. Natural causes or doping? We will never know. President Bill Clinton said of Flo-Jo " we were dazzled by her speed, humbled by her talent and captivated by her style".
Accurate data on the prevalence of doping is difficult to accrue as it is not financially feasible to screen all athletes. Selection for doping is usually random e.g. medal winners, team captains, goal scorers, the number on a shirt or bib, or athletes who show a sudden or unexpected improvement in personal bests and world placings. The true incidence of doping tends to be more widespread than anti-doping control data would suggest. Several surveys have revealed alarming statistics.8 In a British Olympic Survey in 1996, 48% of athletes agreed doping was a problem; of these 86% stated it was most prevalent in track and field events. In 1989, an Australian Senate Standing Committee Report concluded that 70% of athletes who had competed internationally had taken drugs. One study found that men and women participating in sport are more likely to abuse drugs towards the end of their career.
Doping is not just a symptom of elite competition, it is also prevalent in amateur sports and school sports. In France, the incidence of deliberate doping in amateur sport is 5-15%.10 In 1993, the Canadian Centre for Drug-Free Sport estimated that 83,000 children between the ages of 11 and 18 years had used anabolic steroids in the previous 12 months.4 In a more recent American study, prevalence of anabolic steroid use in teenagers was 4-12% for boys and 0.5-2% for girls; in addition to school sports performance, males used anabolics to enhance physical appearance.11 In France, the incidence of adolescent doping is estimated at 3-5%, males again more commonly implicated.10
The scale of drug use in body builders is thought to significantly exceed that of the elite athlete.12 Body builders use combinations of domestic, foreign and veterinary medicines to create "successful training programmes".12 In an American study, 54% of male body builders were abusing anabolic steroids.2 Androgenic anabolic changes are particularly marked in the female body builder who would otherwise only be exposed to trace levels of testosterone.
The most commonly abused group of drugs are stimulants, followed by anabolic steroids.2 Alcohol is one of the most widely used drugs in the athletic population as a whole; it is implicated in sports injury and poor physiological performance and should be avoided by the serious athlete.13
Athletes may obtain banned medicines from physicians, pharmacists, retail outlets, health and lifestyle magazines, gymnasiums, coaches, family members, fellow athletes, the internet and the black market. Many GPs may prescribe unwittingly for what they trust is a genuine complaint.10, 14 & 16 With the banning of amphetamine, those prone to doping turned to over-the-counter (OTC) medicines containing ephedrine, pseudoephedrine, phenylephrine and phenylpropanolamine, available for purchase in community pharmacies. Banned drugs, including anabolic steroids, are widely advertised in lifestyle magazines and gymnasiums and there are no controls on mail order and internet sales.
Family members are another source of banned medicines. Diuretics are banned in all sports and beta-blockers in control sports e.g. archery, shooting, bobsleigh. Both types of antihypertensives are the most widely prescribed in Ireland by very nature of their evidence base; they are also used for treatment of heart-failure. Parents of children on high-tech medical treatment are selling paediatric supplies of hormones and methylphenidate on the black market. A particular problem for some UK Childrens' Hospitals is the sale of supplies of human growth hormone (HGH) to the highest bidder, leaving children to go without much needed treatment. And what about the spouses? CJ Hunter, estranged husband of American sprinter Marion Jones, tested positive for nandrolone while Mr de Bruin was banned for using testosterone some years prior to his wife's ban.
Insulin dependent diabetics are selling penfills; the average price of an insulin actrapid penfill on the black market is estimated at £60 stg, with unused aliquots being sold on with the added risk of sharing needles and potential HIV and hepatitis C infection. Dr Rob Dawson, a GP in Rowlands Gill (near Newcastle), has set up a confidential needle exchange system for body builders and athletes; about 10% of his clinic abuse insulin and most get their supplies from "friends who are diabetics.17
Most of the high-tech drugs end up on the black market. Human growth hormone first appeared in the underground doping literature in 1982; 1575 vials were stolen and sold on the black market immediately prior to the Sydney Olympics in 2000 and a 1000 human pituitaries were discovered in an organ jar in a flat in Moscow.18
The advent of gas chromatography and mass spectrometry in the early 1980s transformed the success of drug testing. The main problem now for anti-doping control tests, is that although analytical tests are becoming increasingly sophisticated, the athletes who cheat are "at least one step ahead".18 The interface between science and law is evident in recent sports arbitration decisions.20, 21 One such example is the Yegorova and erythropoetin case. It is clear that testing procedures and application of the rule of strict liability alone will not win the war against drugs. Operational inconsistencies exist between countries and sports federations and progress is hampered by lack of international collaboration.22 New strategies are needed based on educational and psychological approaches.23, 24 Moreover the new age of gene transfer technology (GTT) will gradually render dope testing control systems obsolete; GTT will increase muscle growth by as much as 28%.4 Doping is a major ethical, educational, financial, health and management problem and governments have a poor track record in controlling its spread.25
Whereas some athletes use drugs to seek a competitive advantage others may feel pressurised into taking something if they are to level the playing field. Whether deliberate or inadvertent is irrelevant, as the IOC and National Sports Councils apply the rule of strict liability. It is essential therefore that athletes have a means of checking all medicines they are taking or are considering purchasing. Players need to know what they can and cannot take and also the medicines that require prior notification such as inhalers for asthma. There is a need for collaborative education of the athletes, medical officers, coaches and managers.
Inadvertent doping is a particular concern for amateur associations who perhaps are not as geared towards education of members in anti-doping. The on-going controversy between the Gaelic Athletic Association (GAA) and the Irish Sports Council is one such example. The plethora of OTCs available in Ireland that contain banned ingredients is a therapeutic minefield and the risk of inadvertent exposure is considerable, not to mention the danger to reputation of both player and association.26
The IOC medical code states that "doping consists of the administration of substances belonging to prohibited classes of pharmacological agents or the use of various prohibited methods or both". The IOC banned list contains three categories: prohibited classes of substances, prohibited methods and classes of substances subject to certain restrictions.27 The full IOC list is not straightforward and includes the unhelpful clause "and related substances" in each substance category.
Table 1 IOC banned list of substances and prohibited methods
* banned in males only ** permitted topically and by inhalation with prior written notification
Each class listed in Table 1 has been reviewed at length in a previous publication in terms of performance enhancing potential and detriment to health.16 Substances in the banned list may be restricted according to route, sport and governing body regulations. For example, steroid inhalers and beta-agonist inhalers are mostly permitted with prior written notification but are banned orally. Bambuterol, fenoterol and reproterol are banned completely, regardless of route, as is the vetinerary beta-agonist clenbuterol. Similarly, steroids are permitted with notification by intraarticular administration but are banned intramuscularly or intravenously. Beta-blockers are banned in control sports only e.g. archery, shooting, bobsleigh, snooker, darts, synchronised swimming. Alcohol is banned in sports such as motor-racing and shooting where performance of skilled tasks may be affected to detriment of both competitors and spectators.
Blood doping is now passé and has been superseded by erythropoetin (EPO) and its analogue darbopoetin which surfaced in cross-country ski-ing at the 2002 Winter Olympics. These hormones are abused in endurance sports such as cross-country events and cycling and although new tests have been developed, detection of EPO remains difficult. Indeed problems with recently developed laboratory tests for EPO have undermined confidence in IOC accredited laboratories. A unique identifier for HGH has also been elucidated but requires more work and financial support to standardise the test. 18 Given the lack of a specific test and claims of human growth hormone performance benefits, abuse has markedly increased. The side-effect profile of HGH is particularly grim, the first presentation being acromegalic features. One of the first elite athletes to admit to the abuse of HGH was Ben Johnston.18 A relatively new addition to the fraudulent armamentarium are the artificial oxygen carriers such as haemoglobin solutions and perfluorocarbon emulsions, both of which have potentially lethal side-effects.28
It can be difficult to interpret and apply the IOC list and guidelines to prescribed medicines. Each medicine needs to be evaluated in its own right and status in sport clarified. Permitted routes of administration can be particularly confusing e.g. nasal steroids are permitted whereas inhaled steroids require notification. A problem unique to Ireland is the brand name variance that exists north and south of the border e.g. Klacid and Klaricid are the same antibiotic. It is not always banned drugs that are abused. Permitted anti-inflammatory agents such as NSAIDs are sometimes taken to not only alleviate pain and swelling but to allow the athlete to continue despite injury. The masking of pain may exacerbate injury. A Swiss study into the use of medications before sporting events showed a prevalence of NSAID use of 5-10%.29 Also many drugs that are permitted in sport may impair performance such as sedatives and some antidepressants. Sample analysis may be hampered by legitimate medicines. The widely prescribed antibiotic trimethoprim is one of the most common drugs to interfere with the testing matrix.21
Stimulants remain the most commonly abused class of drugs in competitive sport. The main problem with OTCs is the risk of inadvertent exposure for clean athletes. There are numerous OTCs containing banned ingredients available on the Irish and UK market and Table 2 lists just a few examples. The problem is compounded by regular changes in presentations, product withdrawals and new products coming onto the market. In addition, many names sound similar causing confusion not only for athletes but also health-care professionals; Table 3 lists some examples where mistakes may easily occur. Again, the north-south product variance that exists poses a major problem. Identical brand names with indistinguishable packaging do not always contain reciprocal ingredients; a classical example is Lemsip which is permitted in the Rebuplic of Ireland whereas the same product name with almost identical packaging in N.Ireland contains phenylephrine.
Many athletes do not realise that caffeine is also banned in sport; a level greater than 12 micrograms/ml constitutes an offence. Many of the OTC analgesics contain caffeine as do beverages, sports drinks and dietary supplements.
Nutritional supplements are totally unregulated and are aggressively marketed to athletes. Content and quality cannot always be easily ascertained and many are deliberately or inadvertently adulterated. In addition, many are contaminated with heavy metals such as mercury, arsenic and lead.16 Asian herbal medicines have been found to contain not only toxic heavy metals but also undeclared prescription drugs.30 Of all the nutritional supplements flooding the worldwide market the IOC has only taken a stance on banning three herbal preparations: ephedrine, Ma Huang (Chinese ephedra), and Guarana and greater direction is needed.
The labelling of such preparations does not always reflect their actual content and so platitudes such as "always read the label" no longer apply. For example, ginseng has been used as an energy booster; ginseng root does not contain prohibited substances, but products carrying the name ginseng have tested positive for ephedrine. In one study, brands of OTC androgenic-anabolic supplements did not comply with labelling requirements; one product contained 77% more steroid than the label stated and another contained 10mg undeclared testosterone.31 Analysis of 75 supplements purchased over the internet found that 7 contained undeclared hormones and 2 contained ephedrine and caffeine.32 The most compelling evidence is from a recent study commissioned by the International Olympic Committee (IOC), 94 out of 634 "legal supplements" purchased in 13 countries contained banned substances; 64 containing testosterone, 23 nandrolone and 7 both steroid hormones.33 Capsules were more commonly contaminated than tablet formulations. In the same study, one batch of creatine was cross-contaminated with 7 different banned hormones. How many of our Irish sports population use creatine?
The supplement culture in sport needs to be addressed. Knowledge of nutritional supplements and recommended daily allowances is generally poor; endorsements of products by top athletes for financial gain aggravates the problem. Hypervitaminosis is common. At the Sydney Olympic games, 2167 athletes out of 2758 tested declared a medicine or supplement. Of these, 542 athletes were taking more than 6-7 preparations a day and one athlete was taking 26 different preparations.34
Performance enhancement may be attained fairly through good dietary nutrition and effective training and recovery programmes. The role of protein is often overestimated. Fatigue is often due to either dehydration or depletion of carbohydrate stores or both.35 The role of carbohydrate and fluid intake has been overlooked. A rich carbohydrate diet after each exercise session will promote endurance and recovery. Athletes require good dietary advice from early on in their career and this should be part of undergraduate sports curriculae; coaches require a parallel education in dietetics.
The need for education
Athletes suffer the same cross-section of chronic diseases e.g. asthma, diabetes and common ailments e.g. headache, cold, 'flu, hay-fever, as the general population and so a balance is needed to have a range of medicines that may be used for treatment of all conditions while maintaining a level playing field. All athletes are aware of the risks of taking medicines near or during competition and for their own benefit should always ensure that the medicines they are taking are permitted by their governing body, as regulations may vary from sport to sport.
Some athletes avoid all medicines completely at the risk of testing positive, a choice that may ultimately impair performance due to continuation of symptoms. Similarly, some permitted substances may have side-effects that impair performance. The plethora of OTCs containing banned ingredients, the similarity between brand names (see Table 3) and the north-south product variance that exists is a hazard for athletes. In particular, the nutritional alchemy that has descended on modern day sports renders the risk of a positive drug test much higher. Athletes require quality information in an easy to digest manner in order to make valued judgements on the use of medicines in sport.
Education of prescribersGPs, hospital physicians and medical officers should be aware of medicines permitted, restricted and prohibited in sport, in accordance with IOC guidelines. The BNF, also used by physicians in Ireland, includes a reference section on drugs in sport. Nonetheless, prescribers' knowledge of drugs that are prohibited by the IOC is generally poor. In a survey of GPs in West Sussex, only one third were aware of the prescribing guidelines for sport in the BNF and general knowledge of banned substances was highly variable.34 In the same survey 20% of GPs said that they had been asked to prescribe anabolic agents for non-medical conditions.34 Moreover, GPs, including those specialising in sports medicine are increasingly wary of advising on drugs in sport as it is an area fraught with litigation.
Sports' medicines information sources are limited. IOC lists and governing bodies are not helpful for the GP who has a patient waiting in the surgery. Access to accurate, up-to-date, quality sports' medicines information at the point of prescribing is much needed in Ireland. Incorporation of compiled lists of permitted and prohibited medicines into prescribing handbooks and computerised prescribing support systems would prove invaluable in aiding good prescribing for the sports population. To truly address the problem, pharmaceutical legislation needs to change and a sport specification should be included in data sheets, SPCs and pharmaceutical packaging.
The British Medical Association (BMA) launched a new report on the 11 April 2002 on the use of drugs in sport.8 The comprehensive document "Drugs in Sport: The Pressure to Perform" highlights problems in the UK and makes a number of recommendations to combat doping, as summarised in Table 5. Interestingly, none of the suggestions include more funding for testing laboratories. What is particularly visionary about the report is that it is the first body to acknowledge the importance of rehabilitation and education of suspended athletes in the hope of returning and contributing to clean sport.
Clause 9 of the pharmacy contract obliges pharmacists to ensure that medicines are appropriately indicated, effective, safe and acceptable to patients. In addition, to managing prescribing risk, community pharmacists must ensure that OTC medicines are appropriate for patients. Self-medication for management of common ailments is commonplace. Pharmacists have a unique knowledge of pharmacology and therapeutics and are ideally placed to advise on permitted substances in sport and permitted routes of administration. To do so however, they must also have a good working knowledge and ready access to up-to-date and accurate quality information. Sports is a special population and warrants the same knowledge as drugs in pregnancy, lactation, elderly and children. In a recent training programme, only 9 out of 70 pharmacists and qualified assistants were aware of the BNF drugs in sport section.37 The remainder said that they would use it as reference source in future.
Pharmacists working in the hospital sector need to be vigilant in regard to the increasing numbers of high- tech drugs being sold on the black market. Systems need to be developed for closer stock control in pharmacies and monitoring of hospital supplies to out-patient clinics, particularly of insulin, human growth hormone, erythropoetin and methylphenidate.
It is increasingly apparent that technological solutions will not curb what are essentially behavioural problems. Some success has been achieved in schools with team centred education and health education based interventions.38, 39 There are several examples of novel pharmacy input into clean sport. Hospital pharmacists at one Manchester Hospital have been compiling a drug formulary for the forthcoming Commonwealth games, to be hosted in the City in the summer. Similarly, the Commonwealth village has opened a dedicated pharmacy, employing staff trained in anti-doping information, from which all athletes must obtain their medicines.
Despite the development of advanced drug testing systems, doping in sport, both deliberate and inadvertent, is on the increase in both elite, amateur and school sports. Doping in sport not only contravenes the spirit of fair competition it can be seriously detrimental to athletes' health. Whereas some take drugs to seek deliberate advantage, others feel pressurised into considering doping as the only viable option to level the playing field. Others inadvertently take prohibited substances due to a lack of awareness. A particular problem is the risk of today's supplement culture to accidental exposure and a positive drug test. An effective anti-doping program must incorporate educational components in addition to testing. Education needs to be collaborative and pro-active and include athletes, coaches, managers, governing bodies, and health-care professionals. The increasing problem of drug abuse in junior sports warrants special attention. Simplification and standardisation of procedures, policies and educational strategies is needed at international level. Pharmaceutical legislation needs to change to accommodate safety of medicines in sport. To date, governments have poured too much money into technology and establishment of rigorous drug testing methods without addressing the educational needs of sportsmen and women and youth cultures. Technological advances cannot address what is essentially a behavioural problem.
Orla Sheehan MRPharmS, MPSI, MMedSci and Brendan Quinn B Pharm Hons MPSI
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