"Anything worth winning is worth cheating for."

I used to speedskate in pack style races.  For a while one of my competitors would come to the line and make that statement just before we all took off.  Most of us thought that it was hilarious.  One day I was intentionally sandbagging, and told several people that I was really fatigued and did not anticipate that I would be very competitive.  When the gun went off I broke for the first turn as fast as everyone else.  They gave me a hard time for sandbagging after that race and I reminded them: "Anything worth winning is worth cheating for."

That brings me to the recent Lance Armstrong saga.  The Oprah interview followed by endless opinion pieces and man on the street interviews focused on the emotional response to his doping confessions.  That has continued this week with a skewering by comedians, indignant responses by journalists, endless analyses of his interviews, the looming threat of ongoing legal action, and the expected outrage from the process of being lied to.  But I wonder if there is not a lot more going on that just cheating and lying. 

A little context is important.  Bicycle racing has been associated with cheating for decades.  Most people don't realize it but one of the most widely used antipsychotics,  haloperidol was invented as an antidote to amphetamines by Paul Janssen in response to the following observation he made in the 1950s:

“Even when he was pulled off his bike and congratulated by a reporter, he tried to continue cycling” Janssen said. It was obvious, he added, that “finding a treatment for amphetamine intoxication would provide a cure for paranoid schizophrenia”.  Ivan Oransky.  The Lancet - 17 January 2004 ( Vol. 363, Issue 9404, Page 251 )

Haloperidol was invented in 1959.  A British cyclist allegedly under the influence of amphetamines died in 1967 during the Tour de France while ascending Mt. Ventoux.

Over the intervening decades doping has become more sophisticated and the anti-doping authorities have become more sophisticated.  Epo was probably introduced to cycling as early as the 1980s.  There were 18 deaths of young professional cyclists in the late 1980s and 8 additional deaths since 1993.  The commonest compounds in the news that are thought to give a competitive advantage include testosterone and testosterone derivatives and the cytokine - erythropoietin or Epo for short.  Erythropoietin the primary regulator of human red blood cell production, survival, and differentiation of bone marrow derived blood cells.  It has been known for some time that is also has potential performance enhancing characteristics in elite athletes:

“Administration of Epo, by increasing haemoglobin and haematocrit, increases the oxygen carrying capacity of the blood, thereby improving the athlete’s endurance.  The use of Epo in this manner can be dangerous, increasing the risk of heart failure, strokes and thrombosis.  A number of high profile cases have been reported in the press, including in 1998, the arrest on drugs charges of the doctors of the Tour de France cycling Team, Festina.   One of the Festina riders ……has only recently returned to competition after a ban after admitting to regularly taking Epo.”  The Cytokine Handbook. Volume 2, p 1267.

Testosterone and its derivatives referred to as anabolic steroids first appeared in 1954. The use of anabolic steroids or anabolic androgenic steroids (AAS) has increased significantly across the population over the past 20 years.  In the 1990s about 1% of high school students used these compounds.  This increased to 3% recently with as many as 10% of 15-19 year old boys (4).  Pope, et al (5) reviewed the evidence that AAS use resulted in addiction and came up with a figure of 30% across seven studies with the qualifier that selection bias may be a factor.  The most recent review of the evidence (6,7) indicates that AAS are widely abused and that most AAS users are engaged in polypharmacy.

The actual effects of performance enhancing drugs are very difficult to evaluate largely because of the secrecy surrounding their use and the inability to investigate them on an systematic basis.  As I hear stories about what has been used a lot of it does not seem to make any sense.  For example, there was the famous incident where a Tour de France cyclist tested positive for testosterone after gaining 4 minutes on the field.  In the subsequent discussion he said initially that alcohol may have been the reason but eventually acknowledged using a testosterone patch.  The stage occurred well into the race and it made no sense to me why he thought that testosterone would be effective overnight.  An alternative explanation is that he was using more testosterone and the testing done was not accurate .  I have also heard recent comments on taking “hydrocortisone pills.”  I don’t understand how anyone would expect a glucocorticoid to lead to performance enhancing effects when it has a catabolic effect on muscle tissue.  There is some more clear cut documentation showing potential performance advantages from anabolic steroids, but much of it is anecdotal with little attention paid to minimum doses.  In fact some of the literature describes a natural tendency for escalation and uncontrolled use – a hallmark of addiction.  The literature on AAS use and whether or not they do enhance performance is varied.  The original literature originated in secret classified documents from the German Democratic Republic (GDR) and their Olympic efforts from 1966 through the late 1980s.  In over 150 documents, specific programs and dosing regimens were noted on thousands of athletes and hundreds of physicians and scientists.  An observation of the performance enhancing effects from this paper: 

“Performances could be improved with the support of these drugs within 4 years as follows: Shot-put (men) 2.5-4 m,  Shot-put (women) 4.5-5 m, Discuss throw (men) 10-12 m. Discuss throw (women)11-20m, Hammer throw 6-10 m, Javelin throw(women) 8-15 m, 400 m (women) 7-10 sec, 800 m (women) 5-10 sec, 1500 m (women) 7-10 sec….”

Without access to the original documents it is difficult to say exactly how carefully this was studied but I doubt that it was an A-B-A design with comparisons to placebo.  Nonetheless, if all of the performance enhancement was due to AAS, it would provide a clear advantage in events decided by meters or seconds and could potentially move an athlete from very good to world class.  Subsequent controlled studies like the first study (8) of the anabolic effects of supraphysiological doses of testosterone documented increases in both muscle diameter and strength during the administration of 10 weeks of testosterone injections.  They also commented that the widespread use of AAS at the time (1996) was unsubstantiated.  The authors documented strength increases of 22 – 38% during that experiment.

Another interesting document (3) of the widespread use of AAS by athletes and people interested in the body building aspects of these drugs was based on a hearing on the matter where doctors prescribing steroids were questioned.  The initial focus of this article was the 1988 disqualification of Ben Johnson after he won the 100 m event in the Olympics in Seoul, South Korea.  The physician in that case described a 5 year program of AAS use.  An estimated 20% of AAS were prescribed by physicians and one of the physicians in the report estimated that the size of his practice was 2000 patients and he thought there were 70 other physicians in the Los Angeles area prescribing these drugs.  At the time AAS use in international track and field competition and a “drug free athlete was considered a losing athlete.”

The politics and limited memory of the scope of this problem is also interesting.  Armstrong responded to the rhetoric of the officials who went after him and described his doping operation as the largest and most sophisticated.  A cycling team would not seem large compared with estimates of one million AAS users in the 1990s, 300 thousand of them active in any given year.  From previous estimates that number may be three times as large right now and chances are that many of these people are also using growth hormone and other polypharmaceutical approaches that they believe will enhance their performance.

The bottom line for me is that Lance Armstrong used performance enhancing drugs by his own admission.  Like practically all users of these drugs he lied about using them.  He used the legal system and his resources to his advantage to defend his positions.  None of this is very surprising given a culture that has used performance enhancing drugs for decades and one that is expanding to the use of cognitive enhancers (9).  So be irate with him if you want, but there is clearly a large segment of the population that practices performance enhancement and the population is also expanding into enhancers for intellectual performance as well as athletic performance.  It is not likely that either of these practices will be going away any time soon.

 

George Dawson, MD, DFAPA

1.  Lewis JL, Lotze GM (2003) Haemopoietic cytokines. In: The Cytokine Handbook, vol. 2 (Thompson AW, L. M., ed), p 1267 London: Academic Press.

2.  Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clin Chem 1997;43:1262-1279.

3.  Breo DL.  Of MDs and muscles--lessons from two 'retired steroid doctors'. JAMA. 1990 Mar 23-30;263(12):1697, 1699, 1703-5. PubMed PMID: 2407878.

4.  Lukas SE. (2009) The pharmacology of anabolic steroids.  In:  Principles of Addiction Medicine, Fourth Edition, p 252, Philadelphia: Lippincott, Williams, and Wilkins.

5.  Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG Jr. Treatment of anabolic-androgenic steroid dependence: Emerging evidence and its implications.  Drug Alcohol Depend. 2010 Jun 1;109(1-3).

6.  Kersey RD, Elliot DL, Goldberg L, Kanayama G, Leone JE, Pavlovich M, Pope HG Jr. National Athletic Trainers' Association position statement: anabolic-androgenic steroids. J Athl Train. 2012 Sep-Oct;47(5):567-88.

7.  Kanayama G, Pope HG Jr. Illicit use of androgens and other hormones: recent advances. Curr Opin Endocrinol Diabetes Obes. 2012 Jun;19(3):211-9.

8.  Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, Phillips J, Bunnell TJ, Tricker R, Shirazi A, Casaburi R. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996 Jul 4;335(1):1-7.

9.  Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, Farah MJ. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008 Dec 11;456(7223):702-5.

Lance Armstrong and parallels with physician discipline

I read the headlines in the paper today "Armstrong stripped of seven Tour titles."  I had just read his personal position on Facebook.  For those who have not followed this issue, the US Anti Doping Agency (USADA) has been trying to say that Armstrong violated doping regulations by using banned substances despite a significant amount of objective evidence in his favor.  The objective evidence in his favor was to such a degree that the Department of Justice dropped a 2 year investigation of him.  The USADA is not a branch of law enforcement branch but it does have the power to ban athletes, ban them for life, and apparently remove any awards that they have won in a retrospective manner even though they were under intense scrutiny at the time.  In my reading the USADA also apparently believes that their test results are infallible which makes their spin on those results even more confusing.  As Armstrong points out - during competition he had to submit for testing 24/7 at at no time did the USADA say that he had a positive test result or pull him from competition.  I am not going to review the pros and cons of the decision - only to say that at this point it has been politicized and a stunning amount of objective evidence has been ignored.  My interest in the process is how it resembles similar processes that are conducted against physicians.

The "disruptive physician" concept seems to have been the driving force behind a lot of these initiatives.   Disruptive physicians to me would be physicians who have not violated the medical practice statutes in their states.  They would be basically physicians that somebody doesn't like because of their behavior or personality.  The Joint Commission has a position statement:

"Intimidating and disruptive behaviors including overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks were quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, and impatience with questions or it overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated."

They go on to cite research suggesting that these behaviors are widespread as high as 40% in some settings. The research is survey research and there are no concerns about its potential quality or biases. My concern and working in a number of medical settings for the past 30 years is that I have witnessed it exactly once. An attending physician personally verbally attacked me several times after he learned I was going to be a psychiatrist at least until I outguessed him on the correct diagnosis of acute abdominal pain.  I think that behavior would clearly qualify.

On the other hand, I have become aware of many physicians being disciplined and even losing their jobs over trivial situations in the workplace. Apparently the threshold for a complaint against a physician is that the complainant feels as if they were "disrespected".  In today's healthcare environment that complaint plus a personal dislike from a department chairman is enough to get you fired or at least live a miserable existence until you decide to quit.  That is true irrespective of the number of people who would testify on your behalf, service to the department, patient satisfaction ratings,  ratings by residents and medical students, and other professional accomplishments.  If you are a physician these days all it takes is the subjective opinion from someone who does not know you or your personal motivation or reasons for doing things to file a complaint and potentially destroy your career. Even if you are not fired outright, there could be a lingering process of accumulating demerits and reviews by other physicians who are not sympathetic to your plight before you are ultimately let go.

At least Lance Armstrong can say that a ton of objective evidence was ignored in order to make this decision. The decision against a physician can be based on a single subjective complaint irrespective of how reliable or credible the complainant is and what sort of evidence exists.

That is all it takes to be a disruptive physician.

George Dawson, MD. DFAPA