The NCAA Sport Science Institute convened a Doping, Drug Education and Drug Testing Task Force in July 2013 (for a list of task force members see 2013 Task Force Members ). The purpose of the task force was to provide a broad overview of doping, drug education and drug testing and to address collegiate-specific concerns. A series of three articles published via the Sport Science Institute Newsletter will summarize key task force findings. The first article will cover the historical background of doping and drug testing in sport, and include an overview of performance-enhancing drugs. A second article will review alcohol and recreational drug abuse. The final article will review the drug testing process and future considerations.
Doping refers to the use of performance-enhancing drugs, and has always been a part of sport; whenever there is a combination of competition and rules of engagement, there are competitors who seek an unfair competitive advantage, and this includes doping. In the 3rd century BC, Greeks ingested mushrooms to improve athletic performance. In the famed Circus Maximus, gladiators used stimulants to fight despite fatigue and injury. Modern day drug testing was first introduced in the 1968 Olympic Games. The World Anti-Doping Agency (WADA) was established in 1999 to promote, coordinate and monitor the fight against doping in sports.
The NCAA has been part of the modern day drug testing movement. Due to concern about the possibility of increasing drug abuse among college student-athletes, the NCAA established the Drug Education Committee in August 1970. At the 1971 Annual Convention, NCAA members passed a resolution condemning the use of nontherapeutic drugs in college sport, stating that such use was a violation of the NCAA’s principles of ethical conduct. In 1984, NCAA Convention delegates approved a resolution from the Pacific-10 Conference directing the NCAA Executive Committee to develop a testing program for NCAA Championships. The first postseason drug testing program for Divisions I, II and III was approved in 1986. This included testing for marijuana and allowed for medical exceptions for therapeutic drugs. In 1988, the Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS) assumed responsibility for NCAA drug education and testing programs. Year-round drug testing was introduced in 1989, and initially only included Division I football. With the intent of providing independent administration and transparency, the NCAA transferred the administration of drug testing programs to The National Center for Drug Free Sport, Inc. (Drug Free Sport) in 1999. Since then, Drug Free Sport has administered drug testing for all NCAA sports, with year-round (including summer) and championship drug testing.
Although it might seem self-evident to have a drug testing program in sport, we might take a step back and ask: “What’s wrong with drug use in sport?” Once we ask this question, we delve into practical ethics; good ethics begin with good facts, and must be within the conceptual framework of values and meaning in sport. With this in mind, the U.S. Anti-Doping Agency (USADA) conducted a survey across a large cross-section of America. As noted in Table 1, the top five values reinforced through sport are: honesty; fair play; respect for others; doing your best; and teamwork.
Table 1. Importance of Values to Reinforce Through Sport
Table 2 demonstrates that the top five perceptions of values most reinforced through sport are: competitiveness; winning; hard work; teamwork; and doing your best.
Table 2. Perceptions of Values Most Reinforced Through Sport
Interestingly, “fun” is the primary motivator for becoming involved in sport, for both the general population and for national governing body (NGB) sport participants (See Table 3).
Table 3. Top Motivators for Becoming Involved in Sport
And perhaps most importantly, the USADA survey found that the use of performance-enhancing substances is the most serious ethical issue facing sport today (See Table 4).
Table 4. Values & Ethics: Seriousness of Issues Facing Sport Today
How do we bring this back to doping in sport? Consider the many reasons we play sport:
· To learn values such as honesty, hard work, fair play, respect for others, and doing your best.
· To have fun and have companionship.
· For the drive of doing something well and mastering a skill.
· To develop character.
· To have glimpses of excellence in the harmony of the mind and body.
We must always balance values and ethics in sport with the fact that sport is also inherently and relentlessly competitive. At the margins of competition, some athletes, coaches or parents will do anything to gain a competitive advantage. With regard to doping in sport, there exists the possibility that a small advantage from performance-enhancing drug use may be greater than a slightly smaller advantage from talent and hard work alone. This means that when performance-enhancing drugs make a difference – and they can – clean athletes must choose among a few possibilities:
· Compete at a possible disadvantage.
· Take your talents elsewhere.
· Join in the cheating.
The point of doping control is to provide clean athletes a fair contest. Without doping control, there is the possibility that performance-enhancing drug use will not be contained, with never-ending pressure to use more drugs, higher dosages, and bizarre and dangerous combinations. This leads to an inevitable contagion to our youth. Just as we make decisions about the rules and equipment of sport to preserve a sport’s meaning, we also make decisions to deter doping in sport. Rules changes, equipment recommendations and doping control share the same common intent:
· Promotion of fairness.
· Prevention of harm.
· Preservation of meaning.
In addition to doping control having an ethics-based foundation, we might also consider that doping control in sport is a public health issue. Because of the relentlessly competitive structure of sport, without doping control there could exist an uncontrolled, massive pharmaceutical experiment that would indeed be a public health risk. If some athletes are willing to resort to anything to win at all costs, then the intrinsic value of sport is undermined, with potential serious health and social costs. Doping control allows athletes to compete while celebrating excellence in mind, body and spirit. For doping control to be truly successful, we must enlist all of our athletes in the cause.
Performance-enhancing drugs (PEDs) are drugs that allow an athlete to attain an otherwise unreachable level of performance. PEDs work through some combination of:
· Muscle or skeletal growth.
· Increased work potential, either through hastened recovery or diminishing fatigue.
· Increased focus or aggression.
PEDs also include drugs that may mask the detection of other PEDs.
PEDs include the following:
· Anabolic agents: Drugs that promote the storage of protein and the growth of tissue. Examples include:
o Testosterone and anabolic-androgenic steroids: Anabolic-androgenic steroids, often called anabolic steroids, mimic the effects of testosterone.. Testosterone is a hormone that is produced in the body of males and females, although in much higher levels for males. Testosterone is responsible for the development of primary male sexual characteristics in utero, and a surge in testosterone production during puberty leads to the development of secondary male characteristics. Within this class of drugs, one cannot separate the anabolic effects (muscle building and improved recovery) from the androgenic effects (increased secondary male characteristics). From a doping perspective, athletes ingest or inject testosterone and related anabolic steroids for:
· Increased muscle growth and muscle strength, coupled with weight gain.
· Hastened recovery.
· Increased aggressiveness.
o Human Growth Hormone (hGH): Human growth hormone is produced within the body, and is responsible for proper organ growth and development. Physiological effects of hGH include the incorporation of amino acids into protein muscle; the stimulation of glucose uptake in muscle; antilipolytic effects in adipose tissue (e.g., the breakdown of fat). Like testosterone and other anabolic steroids, hGH can be delivered as a performance-enhancing drug by way of an injection. When taken as an exogenous substance for doping, hGH may lead to:
· A synergistic effect with testosterone, (e.g., an increase in the anabolic effects of testosterone).
· Breakdown of excessive fat and weight loss.
o Human Chorionic Gonadotropin (hCG): Human chorionic gonadotropin is produced within the body and is primarily responsible for stimulating the body’s normal production of testosterone. When delivered by way of an injection for doping, hCG may lead to excessive testosterone production, thereby leading to similar effects of other anabolic steroids. Some athletes will also use hCG to prevent testicular atrophy, which can develop with prolonged use of anabolic steroids.
o Clenbuterol: Although banned in the United States, clenbuterol is a drug that is used in some countries to treat asthma and related conditions.. Like other inhaled asthma drugs, clenbuterol is a bronchodilator, meaning that the airways become less constricted. Clenbuterol also has a combination of anabolic properties (improves muscle mass) and fat-burning properties (lean muscle), and is therefore considered an anabolic agent. It is noteworthy that clenbuterol is often given to animals in an attempt to produce lean meat. Clenbuterol is used as a doping agent because of its potential anabolic properties.
o Selective Androgen Receptor Modulators (SARMs): SARMs are drugs that bind to receptors in the body with the intent of increasing anabolic potential (e.g., muscle building and hastened recovery) while avoiding androgenic effects (e.g., the secondary male characteristic effects of testosterone and other anabolic-androgenic steroids). SARMs are reputedly becoming popular as doping agents within the athletic community because of their more selective anabolic effects. Examples of SARMs include andarine S-4 and enobosarm, with others in various stages of development.
o Other Anabolic Agents: There are other hormones and peptides that are normally produced in the body to stimulate the production of hormones that may have anabolic properties. Because these agents can be produced exogenously, athletes may inject them as doping agents. Examples include gonadotropin releasing hormone, growth hormone releasing peptide and clomiphene (also classified as an anti-estrogen drug).
o Supplements that contain anabolic agents: In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA), which eliminated broad U.S. Food and Drug Administration (FDA) oversight of supplements. Supplements include herbs, plant derivatives and extracts, and are often taken by athletes in an attempt to expand on what cannot be provided by diet alone. Unfortunately, because of DSHEA, there is no independent testing of ingredients in supplements, and there is no government research or oversight with regard to supplement effectiveness, adverse effects, or interaction of ingredients. Studies have demonstrated that up to 20 percent of supplements – particularly supplements that claim anabolic or body-building effects – are tainted with prohibited anabolic agents. Thus, an athlete may innocently take a supplement to improve his or her performance, and may then test positive for a banned substance.
Some athletes have a sense of invincibility, and this includes taking anabolic agents without fear of side effects. However, there are numerous known side effects of anabolic agents, such as:
o Psychiatric and emotional disturbances, including rage and psychotic break from reality.
o Musculoskeletal injury, including tendon weakness and rupture.
o Cardiovascular injury, including premature myocardial infarction (heart attack) from fatty blockage of coronary arteries.
o Cancer risk, especially prostate cancer in males.
· Masking Agents: Masking agents are taken with the intent of hiding other performance-enhancing drugs. Since most drug tests are through analysis of urine, a masking agent can theoretically affect the chemical analysis of urine, thereby interfering with analysis. Diuretics are the simplest and most classic form of masking agents. Diuretics increase urine production and excretion, and therefore dilute the urine. In a very dilute urine sample, it will be more difficult to detect other drugs. Diuretics and other masking agents do not enhance performance, but can cause serious side effects such as dehydration and abnormally low potassium in the body.
· Stimulants: Stimulants are drugs that increase alertness, attention, and energy, while also elevating blood pressure, heart rate and respiration. Historically, stimulants have been used to treat asthma, obesity, and certain neurological disorders; however, as their potential for abuse and addiction became apparent, the medical use of stimulants has become more constricted. Today, stimulants are used to treat narcolepsy, attention deficit hyperactivity disorder (ADHD), and occasionally depression. Stimulants mimic the effects of the brain chemicals norepinephrine (adrenaline-like chemical) and dopamine (pleasure chemical).
Stimulants are the most unique of the performance-enhancing drugs because they are also commonly used to treat ADHD, and they are used in a widespread manner as recreational drugs of abuse. ADHD is a disorder that comprises inattention, hyperactivity and impulsiveness. A common medical treatment for ADHD is prescription stimulants. In 2013, it was estimated that ADHD affects between 8 to 20 percent of the adolescent and young adult population. However, ADHD often co-exists with other psychiatric conditions, as noted in Figure 1.
Figure 1. ADHD and Other Psychiatric Conditions
In addition, stimulants are increasingly used as cognitive enhancement medications in individuals who do not suffer with ADHD or other psychiatric conditions, as noted in Figure 2.
Figure 2. The Spectrum of Stimulant Use
Thus, there are often imprecise boundaries between the use of stimulants as therapy and wellness enhancement.
Commonly used stimulants include:
o Dextroamphetamine stimulants include Dexedrine and Adderall.
o Methylphenidate stimulants include Ritalin and Concerta.
Both classes of drugs act in the brain in a similar fashion by enhancing the effects of norepinephrine and dopamine.
Stimulants may be used as PEDs because they increase alertness, attention and energy, and may also increase aggressiveness. Performance-enhancing stimulant use has been documented in a wide variety of sports, including baseball, cycling, football and track and field. Stimulants may be used as recreational drugs to help increase wakefulness and energy in the setting of a long party, and often as a counter-medication to alcohol or narcotic use. Stimulants may be used “off-label,” meaning that they have not been prescribed to the individual for ADHD or another legitimate medical condition, for cognitive enhancement. In this setting, stimulants are most often utilized in colleges with competitive academic standards. Indeed, surveys indicate that 16 to 60 percent of college students use stimulants for non-medical/cognitive enhancement use.
Despite the widespread use of stimulants as “neuroenhancing” drugs (e.g., drugs taken to improve cognition), scientific evidence does not support the conclusion that stimulants are cognitive enhancers. However, the effects of stimulants on the user’s emotions and feelings are an important contributor to the user’s perceptions of improved academic performance. For example, if you take a stimulant for the purposes of studying, and you feel more awake and ‘stimulated’ during the study process, you are likely to believe that your cognitive performance will be improved.
Although many stimulant users do not believe they are involved in criminal activity through non-prescription use, it is important to note that stimulants are Schedule II medications, which is the same schedule as narcotics. Stimulants are Schedule II drugs because there is a considerable potential for abuse and addiction. Distributing stimulants illegally is a felony. Because of the potential for stimulant abuse, many institutions are tightening rules on the diagnosis of ADHD and subsequent stimulant prescriptions.
In addition to addiction, there are several potential side effects of stimulants, including:
· Psychiatric disorder, including rage, paranoia and psychosis.
· Dangerous elevation of blood pressure, with subsequent heart attack or stroke.
· Irregular heartbeat and seizures.
· Elevated body temperature, which, if combined with any combination of dehydration and sickle cell trait, can cause rhabdomyolysis and death.
· Cocaine is a recreational drug with a very narrow window for medicinal use. Cocaine is obtained from the coca plant, and it works in a way very similar to prescription stimulants by increasing brain norepinephrine and dopamine. Cocaine can be snorted, smoked, or injected, and all of these routes of administration lead to a very rapid onset of action of the drug, which is its recreational appeal. Potential side effects of cocaine are similar to prescription stimulants, but are amplified when large doses are taken in a short period of time.
· Caffeine originates naturally in 63 species of plants and is the most widely consumed drug in America. Caffeine is most commonly ingested in coffee and tea, but is also present in chocolate, beverages, over-the-counter pills, and energy drinks. Caffeine exerts its brain effect by blocking adenosine receptors. Adenosine normally inhibits activity, so blocking its effect leads to increased energy and wakefulness.
Caffeine doses vary, depending on the drink or food (See Caffeine/Energy Drink Posterfor more details). When used in a ‘societal’ dose (e.g., a cup of coffee or tea) caffeine has a mild stimulant effect and is usually well tolerated. Caffeine is regulated in sport when taken in large doses, and in such a setting is considered a doping agent. However, large doses of caffeine, especially over 500mg, can cause heart palpitations, restlessness, insomnia, irritability, anxiety and reduced cognitive and physical performance.
· Energy drinks, like supplements, are not regulated by the FDA. In addition to containing potentially large doses of caffeine (often not stated on the label), energy drinks may be adulterated with amphetamine-like compounds, specifically dimethylamylamine (DMAA). Energy drinks also commonly contain amino acids and other additives. More than a third of teenagers consume energy drinks. Energy drinks and other over-the-counter supplement products have become a possible source of positive drug tests at both the Olympic and NCAA level. Because energy drinks may be consumed rapidly, the user may inadvertently ingest a large dose of caffeine, possibly with other stimulants, and can develop similar side effects to other stimulants.
· Beta-2 agonists are medications that are commonly used to treat asthma. When inhaled, they lead to immediate bronchodilation. Asthma is a condition in which the airways become constricted, and beta-2 agonist use leads to immediate symptomatic relief. Weak evidence exists that beta-2 agonists may improve performance as a stimulant, and for this reason athletes must obtain approval for their use.
· Blood Doping and Erythropoietin: Blood doping refers to the practice of intravenously infusing blood into an individual in order to induce erythrocythemia (increase the amount of red blood cells). The procedure may be autologous (one’s own blood) or homologous (donated blood). Erythropoietin is a naturally occurring hormone that originates in the kidney, and that regulates the amount of red blood cells in the body. Erythropoietin can now be produced synthetically and administered by way of injection. When used for non-therapeutic purposes, erythropoietin produces changes in the body similar to blood doping, which means that there are more red blood cells available for transferring oxygen.
Blood doping and erythropoietin are used as PEDs by athletes who wish to improve their endurance. By increasing the amount of red blood cells available to transport oxygen to the contracting muscle, such doping improves aerobic power. This means that in long distance events such as cycling, running and cross-country skiing, the athlete has more capacity to utilize oxygen.
Side effects of homologous blood transfusions include serious immune reactions and the transfer of viral diseases such as hepatitis and HIV. Autologous blood doping and erythropoietin use carries with it the potential for too many red blood cells in the body, which can cause hypertension, congestive heart failure and stroke.