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.
