3 Ways to Address Doping Among Athletes

With the Summer Olympics finished and the athletes home again, this seems like a good time to talk about doping, or the use of performance-enhancing drugs (PEDs). Although we hear about it mostly in reference to major sports, doping occurs in all sports and at most levels of competition.

Retail health providers may—and probably do—see weekend warrior-type athletes, competitive military members, and youths who aspire to sports scholarships who are doping. What are the clues, and do clinicians have a role in intervention?

Traditionally, most people think “steroids” when they think about doping, but steroids are just the tip of the doping iceberg. Performance enhancement isn’t the sole reason athletes dope. Some self-treat undiagnosed mental illness, stress, injuries, or pain, while others strive to improve their appearances. TheTabledescribes substances that are often abused in sports.

TABLE:SUBSTANCES OFTEN ABUSED IN SPORTS

Doping Approach

Most Likely Sport

Examples

Analgesics

All

· Acetaminophen, ibuprofen, aspirin

· Used to decrease pain and avoid being benched or side-lined

Androgens

Strength- or endurance-based sports

· Exogenous testosterone, synthetic androgens (eg, danazol, nandrolone, stanozolol), androgen precursors (eg, androstenedione, dehydroepiandrosterone), selective androgen receptor modulators

Beta agonists

Swimmers

· Albuterol, formoterol, and salmeterol

· May decrease airway hyper-responsiveness due to hours spent breathing byproducts of chlorine

Beta blockers

Sports requiring steadiness (archery, shooting, golf)

· Usually propranolol

· Decreases heart rate, reduces hand tremor, and decreases anxiety

· In endurance sports like cycling or long-distance running, beta blockers adversely affect performance

Bupropion

Sports played in the heat

· May allow athletes to push themselves to higher body temperatures and heart rates without perceiving greater effort

Diuretics

Sports with weight limits (wresting, boxing)

· Reduces weight

· May also be used to clear urine of the metabolites of drugs of abuse or overcome steroid-induced fluid retention

Glucocorticoids

Sports that cause pain and inflammation

· Perceived to relieve pain, although no studies support this claim in athletic injuries

Growth hormone and growth factors

All sports

· Growth hormone, insulin-like growth factor, and insulin

· Use is surging among teens, with more than 10% reporting having tried growth hormone

Methods to increase oxygen transport

Sports that require aerobic power and physical exercise tolerance

· Blood transfusions, erythropoiesis-stimulating agents (such as recombinant human erythropoietin and darbepoetin alfa), hypoxia mimetics that stimulate endogenous erythropoietin production (such as desferrioxamine and cobalt), and artificial oxygen carriers

Nutritional supplements

A desire for increased power and leaner

body mass

· Creatine

· Can cause nausea, abdominal pain, and kidney damage

Stimulants

Strength- or endurance-based sports

· Amphetamine, D-methamphetamine, fenfluramine, pemoline, methylphenidate, ephedrine, pseudoephedrine, dimethylamylamine, cocaine, selegiline, sibutramine, strychnine, and modafinil

· Use in student athletes has tripled recently

Once athletes begin self-medication to improve performance or deal with activity-induced symptoms, many of them develop a casual attitude about drugs. They may subscribe to the “more is better” philosophy and use several PEDs, or try other medications or substances to treat the PEDs’ adverse effects. They may also seek relief from other conditions. Patients at risk for sports doping may visit the retail health clinic for an acute minor illness, or in an attempt to gain access to drugs they perceive they need.

Addressing drug abuse in athletes requires a 3-step approach:

1. Heighten your awareness of the problem.

Often, health care providers are detectives of sorts. Like the best investigators, they often pick up clues during casual conversation (eg, What do you do for a living? What are your hobbies and interests?). Also, be aware of community trends. Your local news will comment if doping is a growing problem in your community.

The following are some red flags in reasons given for requesting PEDs:

· The athlete plays a year-round sport, because it’s difficult to stay in top shape competitively for more than 3 or 4 months.

· The athlete plays on a team coached by a coach who’s been associated with doping before.

· The athlete asks for prescriptions for drugs not usually used in healthy, athletic people (eg, diuretics, beta blockers).

· The athlete uses muscle-building, weight-loss, sexual enhancement, and “energy” supplements recommended by a coach or teammate, but has no idea what’s in them or indicates that it’s a

secret formula.

· The athlete seems secretive about his or her supplement use or general health.

· The athlete reports changes in his or her physical appearance, especially enlarged or smaller breasts, changes in voice, changes in hair growth, or shrinking testicles.

· The athlete exhibits or experiences unexplained health problems including aggression or emotional volatility, abnormal liver enzymes, elevated blood pressure, acne, sexual dysfunction,

insomnia, seizure, tremor, or arrhythmia.

· The athlete has needle marks on the buttocks or thighs.

2. Talk about the problem, even if in general terms.

Remove the stigma, and talk openly. Say, “I've heard that some athletes in the area are using supplements to improve performance. What have you heard?” That may open the door to discussion.

Discuss your concerns with the athlete (and his or her parents, if younger than 18 years), and help them find assistance and support if necessary. Encourage parents to stay involved and attend all games and practices. Use motivational interviewing to encourage athletes to use good diet and appropriate training to develop prowess.

3. Take the opportunity to educate athletes about doping’s potential harms.

The many real-world events in the news lately can be jumping points to educate athletes about potential health consequences and legal problems associated with doping. Patients may be less receptive if you use words like “cheating” and “unethical.”

With so much pressure to win, athletes may go to great lengths to have even small advantages. Let’s redirect the focus to the real wins: lifelong good health.