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The early ‘steroid
days’
Testing
improvements
World Anti-Doping
Agency
Recent
developments
When your patient
needs a prohibited
substance
Illicit drugs in
sport
The author
DR ANIK SHAWDON,
sports physician, Victorian Institute
of Sport, Melbourne Victory Football
Club and Australian Football League,
Melbourne, Victoria.
Drugs in sport
The story of drug cheating
DRUG use to enhance sporting performance has occurred since the
times of Ancient Greece, when early
Olympians used mushroom extracts,
plant seeds and other supplements
to improve their competitive ability.
The modern Olympic Games saw
the re-emergence of drug use in the
earliest Games, with substances such
as strychnine, amphetamines and
nicotinic acid.
The death of cyclist Knut Jensen in
the 1960 Rome Olympics followed
by that of cyclist Tommy Simpson
in the 1967 Tour de France, both
with amphetamines found at
autopsy, led the International
Olympic Committee (IOC) to
develop an anti-doping strategy
based primarily on athlete health and
welfare. The IOC established a list of
banned substances in 1968, with the
first testing at the Mexico City
Olympic Games.
Michelle Smith’s story
IN the 1996 Atlanta Olympic Games, relatively
unknown Irish swimmer Michelle Smith won
three gold medals and one bronze. This
represented a spectacular improvement in
performance and was considered by some to be
suspicious. Her husband, a discus champion,
had received a four-year sanction for a doping
violation.
After many attempts to conduct out-ofcompetition testing, testers finally caught up with
Smith at her home in 1998 for a drug test. The
results were quite shocking, including an alcohol
level that would generally be considered to be
fatal when consumed by a human being, as well
as the anabolic steroid, androstenedione. FINA*
concluded that Smith had been using anabolic
steroids and had used whisky as a masking
agent. She was suspended for four years.
*Fédération Internationale de Natation
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HOW TO TREAT Drugs in sport
The early ‘steroid days’
WITH developments in the pharmaceutical industry around the mid20th century, amphetamine and anabolic steroid use emerged as
increasingly important issues. While
use of these substances was associated with a variety of serious side
effects and deaths, the primary goal
of the IOC shifted from a concern
for athlete health to stopping ‘drug
cheating’.
In the early days, testing regimens
were limited in their ability to detect
prohibited substances, but as the test-
ing technology caught up with the
cheating strategies, numerous cases
of anabolic steroid use emerged in
the 1970s and 1980s. Notably, a
large group of East German swimmers in the 1976 Montreal
Olympics, and later Ben Johnson in
the 1988 Seoul Games were identified as having used anabolic steroids.
Despite these early gains, the testing technology lagged behind the
drug-cheating industry. Athletes were
able to avoid detection with various
strategies, including:
• Shifting to naturally occurring anabolic agents such as testosterone.
• Substitution of urine samples.
• Use of ‘washout drugs’ such as
diuretics.
• Ensuring drug taking was stopped
before significant events at which
there were known doping controls
in place.
• A shift to newer anabolic agents
such as some beta2 agonists (eg,
clenbuterol).
It is worth reading the Underground Steroid Handbook, published
in the US and available on the internet, which describes the various
drugs that can be used to cheat and
the different regimens of drug use.
The principles of pharmacological
cheating at this stage were based on a
sophisticated knowledge of pharmacology, rotating the use of different
drugs, and periods of ‘stacking’ (creating a synergistic effect using multiple anabolic drugs) to make significant strength gains.
The East Germans took this to a
new level in the 1970s and ’80s.
The scientific journal Chemistry
published parts of the East German
‘Stasi’ files, which documented the
cheating in that country. It is chilling reading to see how the government sanctioned the systematic poisoning of some of their very best
young people. The famous Australian sprinter Raelene Boyle, who
represented Australia at three
Olympic Games, winning three
silver medals, may have been right
in her claims that she was not
beaten fairly.
times (eg, anabolic agents). This list
is reviewed annually (now by the
World Anti-Doping Agency,
WADA) to keep abreast of the evolution in drug cheating.
Gradually improvements in laboratory technology and the testing procedures made ground on the cheating
athletes. Laboratories were able to
easily identify synthetic anabolic
agents such as stanozolol (Ben Johnson, Seoul) and then testosterone, by
looking at the various levels of
metabolites and their ratios.
Around this time there was a shift
to ‘methods’ of cheating such as
blood doping (red-cell transfusions)
and the use of peptide hormones
such as human growth hormone,
insulin-like growth factor (IGF-1)
and erythropoietin. It was a technology race in which drug cheats were
always a step ahead of the testing
agencies, albeit with the gap closing.
Testing improvements
AN important development in the
fight against drugs was the introduction of drug testing at non-competition times. Initially the IOC and
other sporting bodies were only
testing at competitions. This
allowed a window for athletes to
‘stack’ using anabolic agents, make
artificial strength gains and still test
clean at the time of their event.
To accommodate this the IOC,
in developing its “Prohibited List
of Drugs and Methods”, introduced the concept that some drugs
were only prohibited in event tests
(eg, stimulants) and others at all
World Anti-Doping Agency
IN 1999 the World Anti-Doping
Agency (WADA) was formed when
international sporting organisations
and national governments came
together and agreed to share
resources to develop a combined
anti-doping strategy. The WADA
Anti-Doping Code was introduced
on 1 January 2004. Essentially the
Code has:
• A definition of doping.
• An annually reviewed and
renewed list of prohibited substances and methods.
• A single sanctioning approach.
Nations and sporting organisations are required to sign up to the
code and be code compliant. WADA
has also established a comprehensive set of operating procedures and
standards for testing agencies and
laboratories to ensure that drug testing is conducted in a uniform and
effective manner throughout the
world. The criteria used by WADA
for determining which drugs or
methods are on the prohibited list
are summarised in the box, right.
Doping is considered to be contrary
to the “spirit of sport”, which is a
broad term used to cover qualities
such as “honour, fairness and
integrity”. In practice, it is the first
two criteria that are used.
The WADA prohibited list
WADA’s basis for determining what is on the prohibited list
Substances are placed on the prohibited list based on three criteria:
• The substance or method has the potential to enhance, or does enhance
performance in sport.
Classes of substance prohibited at
all times
• The substance or method has the potential to risk an athlete’s health.
Anabolic agents. These include
testosterone and its analogues, as
well as some beta2 agonists, which
have anabolic properties. These substances are used to mimic the effects
of endogenous male sex hormones,
including increased anabolism, especially of muscles, to enhance performance. They are still used extensively by body builders and in sports
in which power elements are important, such as lifting, throwing, jumping and sprinting.
Anabolic steroids are widely available on the black market. They are
hepatotoxic, and have androgenic
and virilising properties, including:
• Deepening of voice, body hair alterations and male-pattern baldness.
• The substance or method is deemed to violate the ‘spirit of sport’.
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| Australian Doctor | 30 September 2011
• Gonadal atrophy and clitoral
hypertrophy.
• Alterations in cholesterol ratios.
Increased aggression is also a
common side effect of these agents,
which is considered an additional
useful effect by some athletes.
The American College of Sports
Medicine acknowledges that anabolic agents, in the presence of
adequate diet, can contribute to
increases in body weight, often as
lean mass increases, and that the
gains in muscular strength
achieved through high-intensity
exercise and proper diet can be
further increased by the use of anawww.australiandoctor.com.au
bolic agents in some individuals.
Peptide hormones, growth factors
and related substances. These
include:
• Human growth hormone (hGH).
• Human chorionic gonadotrophin
(hCG).
• Insulin.
• Erythropoietin (EPO).
hGH has been on the list of prohibited substances since the increased
availability of the recombinant form
in the early 1990s. Like anabolic
steroids, hGH has a legitimate role
in medicine in the management of
growth hormone deficiencies, but it is
also misused by athletes.
Although its effectiveness in
enhancing physical performance is
unproven, the compound is used for
its potential anabolic effects, including an increased rate of protein synthesis and reduced catabolism. Side
effects include acromegaly and
impaired glucose tolerance.
The degree of similarity between
the endogenous and the recombinant forms, the normal pulsatile
secretion of endogenous hGH from
the pituitary, and marked interindividual variability of hGH levels
makes detection difficult. The
narrow detection window (because
of the short half-life of hGH in
blood) requires sophisticated testing methods.
hCG has similar actions to those
of endogenous luteinising hormone
and is used by athletes to increase
endogenous testosterone production. Therefore it has similar side
effects to those of testosterone supplementation.
A higher testosterone production
goes hand in hand with an elevated
oestrogen level (due to aromatisation of testosterone to oestrogen),
which can result in gynaecomastia.
Male athletes may thus combine
hCG with an anti-oestrogen such
as tamoxifen, which is usually used
in the treatment of breast cancer.
Male athletes also report more
frequent erections and increased
sexual desire. Other side effects of
hCG include:
• Acne.
• Fluid retention.
• Mood swings.
• Elevation of blood pressure.
In very young athletes hCG, like
anabolic steroids, can cause an
early stunting of growth due to
premature closure of epiphyseal
growth plates.
Insulin has powerful anabolic
properties in addition to its role in
glucose regulation, helping to drive
glucose and amino acids into
muscle cells, increasing glycogen
synthesis and lean muscle mass.
When combined with anabolic
steroids, insulin may also help prevent muscle catabolism.
The side effects of insulin are
well known, with insulin-related
hypoglycaemia a potentially lifethreatening outcome. Due to
insulin’s short half-life, detection
of its abuse is difficult.
EPO is a naturally occurring
human hormone released by the
kidneys in response to hypoxaemia
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and anaemia. It has been commercially
available as recombinant human EPO
for almost 20 years.
While there are clear therapeutic
benefits for the use of EPO in the
management of some forms of
anaemia, athletes have also used the
drug as an ergogenic (performanceenhancing) aid to stimulate erythropoiesis and improve oxygen transfer.
EPO has replaced conventional ‘blood
doping’ (see below) as the drug of
choice to improve performance in
contests requiring maximal aerobic
potential.
The side effects of EPO are well
described and include increased blood
viscosity, potentially resulting in MI,
stroke or other vascular problems,
especially when combined with dehydration. Several deaths of athletes
appear to have been as a direct result
of abuse of EPO.
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The WADA prohibited list — summary*
Prohibited classes of substances at all times (in and out of competition)
Anabolic agents
Peptide hormones, growth factors and related substances
Hormone antagonists and modulators
Beta2 agonists
Diuretics and masking agents
Prohibited classes of substances in competition only
Stimulants
Narcotics
Cannabinoids
CRESTOR 20 mg
Glucocorticosteroids (by certain routes only)
vs placebo reduced the risk
Prohibited methods
of CV events by
Enhancement of oxygen transfer
Chemical and physical manipulation
*1,2
p<0.00001
Gene doping
Substances prohibited in particular sports
Hormone antagonists and modulators.
Also referred to as anti-oestrogenic substances, this group of drugs include
those that act to either decrease the synthesis of oestrogen in the body or to
block oestrogen receptors (eg, tamoxifen). These agents are most commonly
used therapeutically in the management
of breast cancer.
Male athletes may use tamoxifen in
conjunction with anabolic steroids to
try to counteract gynaecomastia or to
increase testosterone levels. Side effects
include hot flushes, gastrointestinal
anomalies, fluid retention and increased
risk of thrombosis.
Beta 2 agonists. At high doses some
beta2 agonists (eg, clenbuterol) have
anabolic properties. For this reason,
some beta2 agonists are prohibited on
the 2011 WADA list. However, when
taken by inhalation in accordance with
the manufacturers’ recommended therapeutic regimen, salbutamol and salmeterol are permitted.
Prohibited substances in this category include formoterol and eformoterol, commonly prescribed as
Foradile or as a component of Symbicort. In some cases an exemption may
be provided for an athlete to use these
products, based on specific medical circumstances and absence of appropriate alternatives (see page 34).
Diuretics and other masking agents.
Masking agents such as probenecid
may be used to reduce the excretion
rate of a prohibited substance (eg, an
anabolic steroid) in an attempt to
avoid its detection in a urine drug test.
Diuretics have been used by athletes
who need to ‘make weight’ for their
sport, such as weightlifting, judo, taekwondo, boxing and rowing, but also
by those who are trying to aid the
excretion of, or dilute a prohibited
substance in the urine.
Classes of substances prohibited in
competition
Stimulants. These include CNS stimulants, such as amphetamine, methylamphetamine, methylphenidate or
cocaine plus sympathomimetic agents
such as adrenaline, ephedrine and
pseudoephedrine. Amphetamines are
used widely in clinical practice in the
management of hyperkinetic syndromes (eg, ADHD). Athletes have
used this class of drugs to improve
alertness and reduce fatigue, with
some evidence that they also enhance
speed, power and concentration.
Narcotics. Narcotics are used in clinical
practice for the management of pain,
Alcohol (aeronautic, archery, automobile, karate, motorcycling, ninepin and tenpin
bowling, powerboating)
Beta blockers (aeronautic, archery, automobile, billiards and snooker, bobsleigh and
skeleton, boules, bridge, curling, darts, golf, motorcycling, modern pentathlon for
disciplines involving shooting, ninepin and tenpin bowling, powerboating, sailing for
match race helms only, shooting (also prohibited out of competition),
skiing/snowboarding in ski jumping, freestyle aerials/halfpipe and snowboard
halfpipe/big air, wrestling
*Minor revisions annually on 1 January
and while they have no ergogenic
effects, they may be used by athletes to
mask pain, and allow them to compete
with an injury.
Cannabinoids. Derivatives of the
cannabis plant are among the most
popular illicit drugs in the world, with
marked psychoactive properties. Their
use in sport is unlikely to be beneficial,
as there are negative effects on concentration and perception and also possible
negative effects on exercise performance itself. Athletes need to be aware
that in the chronic user, a positive drug
test may result for up to 90 days after
the last ingestion of the drug.
Glucocorticosteroids. Glucocorticosteroids are used in clinical practice for
their potent anti-inflammatory properties and are prohibited when administered by systemic means (oral, IV, IM or
rectal). Intra-articular, topical or inhaled
methods of administration are not prohibited.
This group of drugs produces euphoria and a range of other side effects,
including:
• Adrenal suppression.
• Fluid retention.
• Reduced immune function.
• Myopathy.
• Osteoporosis.
Despite the long list of adverse side
effects, athletes have used glucocorticosteroids to lessen pain and tiredness
as well as for their potential ergogenic
effects.
Prohibited methods
Enhancement of oxygen transfer. Techniques for enhancing oxygen transfer
to the tissues include:
• Blood doping — blood or red blood
cell products of any origin:
– autologous (from self)
– homologous (from another human)
– heterologous (from another
species).
• Artificial enhancement of uptake,
transport or delivery of oxygen by the
blood.
These techniques are prohibited.
The usual method of blood doping
by an athlete would be the withdrawal
of 1-2 units of blood 4-6 weeks before
competition, with re-infusion of the
blood 1-2 days before the competition.
In this time the red cell numbers would
have returned to normal, thus the reinfusion would ‘super-concentrate’ the
blood with red blood cells and improve
oxygen-carrying capacity.
Blood doping was first prohibited in
1984. The practice reduced substantially when recombinant EPO became
commercially available in the late
1980s. With improved technology for
detection of EPO, it is possible that
blood doping will increase again.
Chemical and physical manipulation.
This includes tampering with the
sample itself or the collection processes
of either urine or blood. The use of IV
infusions (except in the course of hospital admission or clinical investigation)
or sequential withdrawal, manipulation
and reinfusion of whole blood into the
circulatory system is also prohibited.
IV infusions have been used with the
intention of reducing haematocrit or
manipulating blood profiles in some
athletes.
Gene doping. Gene doping includes
the transfer of cells or genetic elements, or the use of cells, genetic elements or pharmacological agents to
modulate the expression of endogenous genes that have the capacity to
enhance athletic performance. Gene
doping is prohibited.
Until recently it was impossible to
prove that an athlete had undergone
gene doping, but late in 2010 a study
reported on a blood test that had been
developed to provide proof of doping
for up to 56 days for the commonly
used genes.1 According to the study
the test provides clear yes-or-no
answers based on whether or not
transgenic DNA is present in blood
samples. Transgenic DNA (tDNA) is
DNA that has been transferred into
the recipient’s body, often via viruses,
to create performance-enhancing substances such as EPO or substances that
improve muscle strength, such as
insulin-like growth factor 1. WADA is
currently undertaking a major review
of gene doping.
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HOW TO TREAT Drugs in sport
Recent developments
AFTER the Sydney Olympic
Games, a whistleblower informed
testing authorities of the wholesale
abuses that were going on with the
BALCO laboratory in San Francisco. This group was manufacturing and providing designer steroids
to athletes, including tetrahydrogestrinone (THG), that were difficult to detect because they disintegrated on metabolism. BALCO
also provided largely undetectable
peptide hormones, such as hGH
and EPO.
This led to a major US Government investigation, with a number
of elite athletes from a range of
sports implicated, in particular athletics and baseball. The most
famous ‘catch’ was the track athlete Marion Jones, who had won
a swag of medals at the 2000
Sydney Olympic Games. US Major
League Baseball effectively had no
meaningful anti-doping detection
strategy at all and the players had
developed a rampant drug-cheating culture.
More recently world cycling has
invested heavily in anti-doping
strategies and testing methodologies in an attempt to clean up the
sport. The cycling governing body
Union Cycliste Internationale
developed the ‘athlete passport’,
which effectively records key blood
and urine test results longitudinally
in individual cyclists. In this way
they are able to compare test
results from each individual cyclist
to that individual’s own normal
biological parameters, rather than
Common traps for the doctor treating athletes with a
prohibited drug
• Insulin for the treatment of diabetes
• Probenecid coadministered with antibiotics in the management of significant
infection
• Diuretics in the treatment of hypertension (eg, in masters-level athletes, who
are generally over 35 years old, without upper age restrictions, and motorracing drivers, in whom hypertension and other cardiovascular disease is
more common)
• Oral glucocorticosteroids in the treatment of respiratory and bowel conditions
• Adrenalin in the management of anaphylaxis
• Drug management with stimulants of ADHD in both children and adults
• HRT that includes testosterone or dehydroepiandrosterone (DHEA)
• Some inhaled asthma medications such as eformoterol and terbutaline
• Beta blockers in target sports such as bowls, shooting and archery
• Pseudoephedrine is currently prohibited in competition
NB: Annual modifications to the list occur on 1 January each year
relying on the blunter population
norms. This resulted in a quantum
leap in testing sensitivity and was
quickly picked up by other sports.
However, recent drug controversies that have occurred in the
world of competitive cycling indicates an ongoing problem with
abuses such as ‘micro dosing’ of
peptide hormones (laboratory
capability is limited due to a
narrow detection window related
to the hormone’s short half-life)
and blood doping. Even so the gap
has significantly closed in on drug
cheats and there is today a high
likelihood of eventually catching
an athlete using a prohibited substance or method.
With the development of the testing technology alongside the broad
platform of drug testing of elite
athletes across all sports, many relatively low-level and poorly
informed athletes have been inadvertently caught doping when there
was clearly no real intent to cheat.
The testing for cannabinoids is a
case in point, as it has no performance-enhancing effects in sport and
a very low excretion rate. Elite athletes usually have access to highquality drug education but not all
athletes have had adequate access
to this. Common examples of inadvertent positive drug tests are for
use of:
• Cannabinoids.
• Pseudoephedrine.
• Cocaine and ecstasy.
• Probenecid.
• Narcotics.
What to do if your patient requires a prohibited substance
THE WADA Code has provision
for circumstances in which an athlete is allowed to take a prohibited
medication for the reasonable treatment of a medical condition. For
Australian athletes, the Australian
Sports Drugs Medical Advisory
Committee (ASDMAC) can provide therapeutic use exemptions
(TUEs) to allow use of otherwise
prohibited drugs.
For example, an athlete who suffers from active inflammatory
bowel disease almost certainly
would be granted an exemption to
use oral corticosteroids provided
that full medical details of the diagnosis and treatment options have
been provided. ASDMAC will base
their determinations on:
• Necessity of treatment.
• Absence of alternative therapeutic
options.
• A reasonable trial of a permitted
alternative drug.
• Absence of unfair gains in sporting performance from the therapeutic doses of the medication in
question.
A TUE is for a limited time, after
which a repeat application is
required, and they may have conditions regarding their use.
Supplements
The Australian healthcare industry
is inundated with the use of alternative medicines such as supplements and herbal products. There
are countless enterprises in Australia touting supplements, vitamins, amino acids and herbal
34
| Australian Doctor | 30 September 2011
Supplements that are
not manufactured in
Australia have up to a
20% risk of
containing a
prohibited substance.
Instructions for contacting ASDMAC
The URL of the Australian Sports Drugs Medical Advisory Committee is
www.asdmac.gov.au, and their phone number is 02 6222 4232. Therapeutic
use exemption (TUE) application forms can be downloaded from this site and
there are useful fact sheets regarding common therapeutic issues that require a
TUE. Applications should accompanied by a separate letter providing adequate
clinical material regarding the diagnosis and management of the athlete’s
condition. Attach useful investigation reports such as blood tests, imaging and
biopsies. Sometimes ASDMAC will seek a second opinion from a renowned
specialist of the condition the athlete has if there is doubt about aspects of the
application. Members of the committee are all medical practitioners and can
usually be contacted to discuss urgent TUE-related matters.
extracts to promote health and
improved performance. Supplements can assist athletes to achieve
peak performance. However, poor
regulation of the supplement industry allows athletes to be bombarded with marketing hype that
exaggerates or invents unproven
benefits arising from their use.
Supplements and herbal products
are very high risk in that they are the
cause of many inadvertent positive
drug tests. Supplements that are not
manufactured in Australia have up
to a 20% risk of containing a prohibited substance, either as an intended
www.australiandoctor.com.au
additive (labelled or not) or due to
contamination in the manufacturing
process. Some countries such as the
US, Netherlands, New Zealand,
China and Bulgaria, to name a few,
have by Australian standards unregulated manufacturing, in which the
inadvertent risk is higher.
Even with Australia’s strong regulatory environment, supplements
need to be managed extremely
carefully by athletes because the
sourcing of bulk supplies from outside of this country is a common
practice.
Athletes should absolutely never
purchase supplements or drugs
over the internet. An Australian
triathlete accepted a two-year sanction, imposed by Triathlon Australia, for attempted use of anabolic steroids, which resulted from
a failed attempt by the triathlete to
import anabolic steroids from
Thailand, purchased on the web.
Investigations into the attempted
importation began when a package addressed to the triathlete was
intercepted by Customs and Border
Protection in March 2008. The
package was examined and found
to contain the prohibited anabolic
steroid methandienone (Dianabol)
disguised as financial statements.
The package was seized and the
Australian Sports Anti-doping
Authority was notified as part of
the joint agreement between the
two agencies in relation to illegal
importations of performance- and
image-enhancing drugs.
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HOW TO TREAT Drugs in sport
Illicit drugs in sport
THE WADA code prohibits the use
of narcotics, stimulants and
cannabinoids “in competition”, but
not “at all times”. A number of
Australian national sporting organisations (including the Australian
Football League, National Rugby
League and Cricket Australia) have
introduced an “illicit drugs policy”
to complement that of their
WADA-compliant codes. Given that
many of these substances are not
performance enhancing when taken
away from competition but do have
negative health effects, these sports
considered that they should be prohibited at all times rather than
simply during competition.
In addition, due to the half-life
of some of these products, taking
them ‘out of competition’ may still
produce a match-day positive test
result. The fact that many are illegal
reinforces the need for the prohibition.
The illicit drug policies of these
organisations are based on a medical model rather than a pure sanctioning approach, allowing for one
or two positive results before sanctions and public disclosure. This
model is in contrast to the WADA
sanctioning approach and is consistent with the Federal Government’s harm-minimisation strategy.
After an initial positive test out of
competition, the player is advised
by the national sporting organisation’s medical officer and is offered
counselling, if clinically indicated,
depending on the circumstances of
the positive test. In some cases an
athlete may have simply made a
poor decision as a one-off event, or
at the other extreme may be selfmedicating a psychological or psychiatric condition with illicit drugs.
The management of each situation
therefore depends on the individual
and their clinical circumstances.
Given the high media profile of
many athletes, confidentiality at the
outset is paramount.
The AFL illicit drugs policy has
resulted in significantly fewer positives each year, in the face of significantly greater numbers of tests,
including over holiday periods
(table 1). This indicates success of
the policy in terms of general health
and achieving player behaviour
change.
Recent high-profile cases
Alberto Contador, the 2010 Tour de
France winner, tested positive to
minute doses of clenbuterol in a drugs
Table 1: AFL illicit drugs test results
Year
Total detections
2nd positives
Test numbers
Detection %
2005
19
3
472
4.03
2006
9
0
486
1.85
2007
14
3
1152
1.2
2008
12
2
1220
0.98
2009
14
2
1568
0.89
2010
6
1
1654
0.36
Alberto Contador, after his suspension was overturned.
Wendell Sailor playing rugby union for Australia in 2004.
test taken during the Tour. He was
subsequently issued with a one-year
suspension, which was overturned on
appeal. The basis of the overturn was
that there have been a number of
reports of meat contaminated with
clenbuterol.
The German Sports University laboratory in Cologne (WADA accredited) recently published a paper showing that more than 75% of visitors to
China had detectable amounts of
clenbuterol, presumably from food
contamination, most likely from the
misuse of the drug as a growth promoter in stock breeding. This case is
currently being reviewed by WADA.
Australia has not been without it
drug controversies involving elite
athletes.
Caffeine. At the 1988 Seoul
Games, pentathlete Alex Watson
tested positive for caffeine by
exceeding a threshold urine level
of 12g/mL. He claimed that his
sources of caffeine were supple-
Author’s case study
AN 18-year-old elite road cyclist
attended the clinic for information on whether his asthma medication was ‘allowed’ in his sport.
He had had asthma since childhood, but not controlled on salmeterol and Ventolin. His usual
GP had given him formoterol
(combined with budesonide in the
product Symbicort) with good
results.
Formoterol is prohibited on the
current WADA list, and a TUE was
required to allow the cyclist to use
this formulation. An application
was made to the Australian Sports
Drug Medical Advisory Commit-
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| Australian Doctor | 30 September 2011
tee (ASDMAC), including spirometry, but the reversible FEV1 after
beta2 agonist was only 8%, which
was not deemed acceptable to the
committee. They required a challenge test to confirm the diagnosis.
A subsequent eucapnic voluntary
hyperpnoea test, which is widely
considered the gold-standard test
for diagnosing exercise-induced
asthma, demonstrated an 18%
reversible drop in FEV1, which was
acceptable to the committee, who
approved use of the formoterol for
four years. Both the athlete and the
doctor were provided with notice
of the TUE.
ments, coffee and cola consumed
on the day of competition.
The problem with caffeine is that,
while it is mildly ergogenic and therefore performance enhancing, it is
widely available in foods and beverages. The IOC and then WADA
removed caffeine from the prohibited
list, presumably for these reasons.
WADA does, however, maintain a
monitoring program that assesses the
use of caffeine by athletes. If at some
future time its use becomes excessive,
it may be placed back onto the prohibited list, as has happened with
pseudoephedrine.
Cocaine. In 2006, Australian
Rugby Union player Wendell
Sailor tested positive for cocaine
in a match-day test. He claimed
he used the illicit substance at a
nightclub a few days earlier and
that only trace amounts were
detected in his urine and therefore did not result in any performance enhancement. This was a
plausible explanation but highlights the risk of elite athletes
using illicit substances when they
are also subject to extremely sensitive drug testing looking for performance-enhancing substances.
Sailor received a two-year suspension and had his contract terminated.
Former Australian Rugby Union
chief executive Gary Flowers stated,
“The use of any illegal drug is contrary to the ethical concepts of sportsmanship, fair play, good medical
practice and is potentially harmful
to the health of the individual. We
also reject the arguments of those
who claim we have no right to be
testing for so-called ‘recreational
drugs’. There is no such thing as
recreational drugs. These drugs are
illegal, they are harmful to the people
using them and they are not acceptable for use by our sportsmen and
women. Australian Rugby will not
accept people in their playing ranks
who are not good role models for
the children of Australia.”
Diuretics. Shane Warne had a
diuretic (Moduretic) detected in a
urine drug test. He stated at the
time that he used the drug for cosmetic purposes. On reviewing his
steroid profile over a number of
tests it was clear he had not been
attempting to mask a use of anabolic agents with the diuretic.
However, he still received a 12month ban from cricket.
Reference
1. Beiter T, et al. Direct and longterm detection of gene doping in
conventional blood samples.
Gene Therapy 2011; 18:225-31.
Online resources
• Australian Sports Drugs Medical
Advisory Committee (ASDMAC):
www.asdmac.gov.au
• World Anti-Doping Agency:
www.wada-ama.org
• Australian Sports Anti-Doping
Authority: www.asada.gov.au
• Australian Institute of Sport —
information on supplement use in
athletes:
www.ausport.gov.au/ais/nutrition/
supplements
Summary
ATHLETES are subject to drug
testing, both in and out of competition. The rules are based on an
attempt to create a ‘level playing
field’ in sport and the protection of
the athlete’s health and wellbeing.
All athletes should be aware of
the WADA prohibited list, which is
updated annually on 1 January, and
when they seek medical advice,
doctors should inform them if
drugs they are prescribed are subject to drug testing.
GPs can do their best to minimise
their patients’ risk of a positive test
by using the MIMS notification of
medications that are prohibited in
sport and by understanding the
principles of the prohibited list.
However, under the World AntiDoping Code strict liability principle, athletes are ultimately responsible for any substance found in their
body, regardless of how it got there
and for what purpose.
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HOW TO TREAT Drugs in sport
GP’s contribution
DR GED FOLEY
Mosman, NSW
JD, a 28-year-old semi-professional
body builder, presented with a
painful swelling in the left gluteal
region. He initially stated that this
had arisen spontaneously.
On examination, he was found
to have a large abscess in the right
buttock. The abscess was incised
and drained and a swab of the
abscess contents was sent for culture; this subsequently grew a community-acquired MRSA. JD was
treated with the appropriate antibiotics.
On direct questioning, JD admitted that he had injected anabolic
steroids, obtained from a fellow
competitor and sourced from overseas. The precise composition and
nature of the preparation was
unknown to him. He said he had
been using these drugs intermittently for several months. He also
admitted that he was uncertain
about the sterility of the needle
used for injection, as the drug had
been administered by his colleague.
scribe a prohibited substance?
Any competitive athlete is potentially subject to drug testing by
ASADA at any time. This includes
those competing at state, national or
international level, as well as those
who are deemed to ‘have the potential’ to do so, irrespective of age. If
there is any question about whether a
patient is subject to drug testing, it is
wise to err on the side of caution, and
if possible contact ASADA directly
to clarify the position.
Routine examination, apart from
increased muscle mass, was
normal.
JD was counselled about the
risks of anabolic steroids and the
use of non-sterile injection equipment. Routine haematology, biochemistry, HIV, hepatitis B and C
serology were negative. He was
counselled about using barrier contraception until repeat testing for
HIV and hepatitis were negative.
Over the subsequent two weeks,
JD returned for re-dressing of the
abscess until this healed. Subsequent repeat HIV and hepatitis
serology was negative.
Questions for the author
On a later visit, JD mentioned his
wife’s desire to become pregnant. Is
there any impact of anabolic steroids
on male fertility or spermatogenesis?
One of the many side effects of
high doses of anabolic steroids is
hypogonadotrophic hypogonadism,
with subsequent oligo- or azoospermia and increased numbers of abnormal sperm cells. This results in
reduced male fertility. It appears that
the effects may not be permanent
and that in many cases sperm counts
return towards normal levels some
months after total cessation of anabolic steroid use.
JD was evasive about how long he
had been using prohibited substances
for. What long-term side effects
should he be monitored for?
Anabolic steroids are hepatotoxic
and can be associated with increased
plasma levels of liver enzymes and
an increased frequency of benign and
malignant liver tumours. Liver failure
is a rare but significant long-term side
effect. Gynaecomastia is another
long-term side effect that is usually
permanent.
Adverse effects on blood pressure
and cholesterol ratios usually nor-
How to Treat Quiz
malise with time after stopping
steroid use, but long-term use of anabolic steroids may be associated with
left ventricular hypertrophy and
impaired diastolic function. One
long-term side effect of anabolic
steroids is permanent stunting of
growth when used in adolescents.
What age does a competitor have
to be (and at what level of competition) for us to become concerned
about seeking permission to pre-
JD did not participate at an elite
level and his drug use was likely to
go undetected. Is there any research
about how prevalent the use of
prohibited substances is outside the
elite sporting level?
There is limited information
about the prevalence of steroid use
in the population, as most products
are not sourced through medical
circles. The use of anabolic steroids
appears to have increased in the
past two decades, with the largest
group of users being recreational
weightlifters and body builders who
are using the drugs for the purposes
of increasing muscle mass and their
effects on body appearance.
More recently there have been
reports of anabolic steroids being
used by ‘recreational drug’ users in
attempts to counteract the cachectic
and anorexic side effects of these
psychotropic agents.
INSTRUCTIONS
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by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.
Drugs in sport — 30 September 2011
1. Which TWO statements are correct?
a) ‘Stacking’ is a means of drug cheating in
which multiple anabolic drugs are used for a
limited period for a synergistic effect but to
avoid detection
b) Drug testing is usually only done just before
and during competition
c) The World Anti-Doping Agency (WADA) has
deemed that some drugs are only prohibited
in event tests (eg, stimulants) and others at
all times (eg, anabolic agents)
d) Blood doping refers to tampering with blood
test samples to avoid drug detection
2. Which TWO statements are correct?
a) Substances are placed on the WADA
prohibited list if the substance or method
enhances, or has the potential to enhance,
performance in sport
b) The risk to an athlete’s health is not taken
into account when placing a drug on the
WADA prohibited list
c) Anabolic agents include testosterone and its
analogues, and certain beta2 agonists
d) Anabolic agents tend to be used to increase
endurance and aerobic capacity in sports
3. Which THREE of the following are side
effects of anabolic steroids?
a) Deepening of voice in women
b) Body hair alterations and male-pattern
baldness
c) Testicular hypertrophy
d) Hepatotoxicity
4. Which TWO statements are correct?
a) Peptide hormones used for performance
enhancement include human growth
hormone (hGH), human chorionic
gonadotrophin (hCG), insulin and
erythropoietin (EPO)
b) hGH decreases the rate of protein synthesis
and increases protein catabolism
c) Hypoglycaemia is a side effect of hGH
d) Insulin has anabolic effects by increasing
muscle glycogen and lean muscle mass,
and preventing muscle catabolism
5. Which TWO statements regarding
difficulties in the detection of exogenous
hGH are correct?
a) The endogenous and the exogenous forms
are very similar
b) Secretion of hGH from the pituitary is
constant
c) There is little inter-individual variability of
endogenous hGH levels
d) There is a narrow detection window
because of the short half-life of hGH in
blood
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6. Which TWO statements are correct?
a) hCG is used by athletes to block the
synthesis of oestrogen
b) Male athletes may combine hCG with an antioestrogen such as tamoxifen to prevent
gynaecomastia
c) Side effects of hCG include acne, fluid
retention, mood swings and elevation of
blood pressure
d) In very young athletes, hCG and anabolic
steroids can cause excessive tallness due to
stimulation of unfused epiphyseal growth
plates
7. Which THREE statements are correct?
a) EPO stimulates erythropoiesis and improves
aerobic capacity
b) EPO improves performance in contests
requiring maximal power (strength)
c) The side effects of EPO include increased
blood viscosity, with an increased risk of MI,
stroke or other vascular problems
d) Clenbuterol is a beta2 agonist with anabolic
effects
8. Which TWO statements are correct?
a) Inhaled salbutamol and salmeterol in
therapeutic doses are prohibited in sport
b) Probenecid increases the excretion rate
of a prohibited substance, reducing
blood levels of prohibited agents
c) Diuretics have been used by athletes who
need to ‘make weight’ for weightlifting, judo,
taekwondo or boxing
d) Diuretics have been used to aid the
excretion of a prohibited substance or to
dilute it in the urine
9. Which TWO statements are correct?
a) Amphetamines may improve speed, power
and concentration
b) Narcotics mask pain and allow athletes to
compete with an injury
c) Cannabinoids do not enhance performance
and so are not prohibited in sport
d) Cannabinoids tend to be cleared from the
body quickly
10. Which TWO statements are correct?
a) Intra-articular, topical or inhaled
glucocorticoids are prohibited in sport
b) Caffeine is prohibited during competitions
c) Gene doping refers to the transfer of DNA
into the recipient’s body, often via viruses, to
create substances such as EPO or insulinlike growth factor 1
d) The ‘athlete passport’ of blood and urine
tests allows comparison of results over time
in one athlete, rather than depending on
population normal ranges
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2011-13 triennium. You can
complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or
fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Giovanna Zingarelli
Co-ordinator: Julian McAllan
Quiz: Dr Giovanna Zingarelli
NEXT WEEK The next How to Treat delves into the world of infant feeding and nutrition. The author is Dr Jacqui Dalby-Payne, senior staff specialist in general paediatrics, and member of the
multidisciplinary feeding team, The Children’s Hospital at Westmead, NSW.
38
| Australian Doctor | 30 September 2011
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