Doping and Drug Misuse in Sport

Doping and Drug Misuse in Sport

Introduction to Doping and Drugs

  • Significant Pressures: The pressures to perform at competitive levels result in the use of substances for enhancement, a phenomenon known as doping (Reardon & Creado, 2014).

  • Scope of Problem: Although cycling has been subject to many high-profile cases of doping, this issue affects virtually all sports and age groups.

  • Performance-Enhancing Substances include:

    • Illegal drugs

    • Prescription medications

    • Over-the-counter dietary supplements (available in online stores, health food stores, and grocery stores).

  • Drug Detection Improvements: As detection methods become more sophisticated, athletes continuously evolve methods to avoid detection (Teale et al., 2012).

  • Medical Risks: The medical risks associated with doping necessitate thoughtful prevention and management techniques.

Sport Organization Policies

  • Substance Policies: Various organizations including high schools, governing bodies, universities, professional leagues, national and international bodies, and the Olympics have established substance policies.

  • Awareness of Policies: Athletes must stay updated on rapidly changing policies, as ignorance is not an acceptable excuse for testing positive.

  • World Anti-Doping Agency (WADA): Publishes the annual Anti-Doping Code which outlines rules and principles that organizations must adopt, implement, and enforce.

    • Prohibited Substances: The code specifies substances that are prohibited at all times (in and out of competition) and those prohibited only during competitions (from 11:59 PM on the day before the competition until the event concludes).

    • Expansion of Prohibited List: The WADA list may expand based on the specific needs of certain sports.

    • Reasons for Prohibition: WADA does not provide explicit reasons for the prohibition of substances, but criteria may include:

    • Performance enhancement

    • Negative impact on health

    • Negative impact on the spirit of sport.

    • High schools and colleges may have separate lists that may or may not align with WADA's guidelines.

Athlete Biological Passport

  • Concept: With WADA's influence, the athlete biological passport was developed to monitor specific parameters over time that indicate doping effects.

    • Function: This monitoring establishes individual baseline hormone and blood levels, identifying changes that may indicate doping practices.

    • Protection Against False Positives: The system is designed to protect athletes from false positives due to naturally occurring substances.

  • Testing and Penalties: Athletes competing at national and international levels undergo standardized drug testing with penalties for adverse findings, which can include:

    • Temporary or permanent ineligibility

    • Disqualification of results

    • Revocation of awards

    • Public sanctions and fines.

  • Therapeutic Use Exceptions (TUEs): Athletes may apply for TUEs if they have medical justifications for needing prohibited medications, a process also available through NCAA.

  • Therapeutic vs. Non-Therapeutic Enhancement: Clarification of therapeutic performance enhancement (e.g., SSRIs for depression) versus non-therapeutic or ergogenic enhancement.

Prevalence and Risk Factors

  • Prevalence Rates: Lifetime or current prevalence rates of doping vary significantly based on sport, substance, detection methods, and definitions, ranging from 1-70%.

    • Self-reported data tends to underreport the true prevalence.

    • Only 1-2% of WADA's urine and blood tests result in adverse findings, with 48% of those for androgens (de Hons et al., 2015).

    • Standard testing methods are often inadequate for detecting advanced doping techniques; recent reports indicate 43.6% - 57.1% of elite athletes reported doping in the past year.

  • Risk Factors for Doping:

    • Pressure to perform at high levels.

    • Need to maintain scholarships, paychecks, or sponsorship deals.

    • Coping with pain from injuries.

    • Development of substance abuse disorders from regular use.

    • Psychological and physiological drives to avoid withdrawal symptoms.

    • A history of doping practices that predates significant financial incentives in professional sports.

Androgens

  • Types of Androgens include:

    • Exogenous testosterone

    • Synthetic androgens (e.g., nandrolone, danazol)

    • Androgen precursors (e.g., dehydroepiandrosterone (DHEA), androstenedione)

    • Selective androgen receptor modulators (SARMs).

  • Side Effects of Androgens: Affect numerous body systems, including:

    • Reproductive: Decreased sperm production, fertility issues, reduced testicular size, increased risk of prostate cancer.

    • Cardiovascular: Dyslipidemia, indicated by abnormal cholesterol levels.

    • Hepatic: Hepatotoxicity, leading to liver damage.

    • Psychiatric: Risks include depression, mania, psychosis, and increased aggression.

    • Other impacts: Premature growth plate closure, skin issues (acne, facial hair, baldness), decreased menstrual function, tendon ruptures, and injection infections.

  • Performance Outcomes: Increased testosterone levels have been shown to enhance muscle strength and mass (Storer et al., 2003). However, androgens have not been found effective for increasing endurance (Basaria et al, 2010).

  • Precursors and SARMs: Minimal evidence supports performance enhancement from androgen precursors or SARMs, despite some anecdotal claims.

Growth Hormone and Growth Factors

  • Effects of Human Growth Hormone (hGH):

    • Increases muscle mass.

    • Decreases adipose (fat) tissue.

    • Improves sprint capacity.

  • Growth Factors: Includes insulin-like growth factor (IGF) and insulin, with anabolic effects on muscle similar to hGH.

  • Side Effects: Known effects from hGH and growth factors include:

    • Insulin resistance

    • Hyperglycemia, or elevated blood sugar

    • Diabetes mellitus

    • Cardiomegaly, or enlarged heart

    • Premature growth plate closure

    • Myopathy, which affects muscle fibers

    • Hypertension

    • Edema, or fluid retention in tissues.

Stimulants

  • Types of Stimulants include:

    • Amphetamines, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, dimethylamylamine, cocaine, fenfluramine, pemoline, selegiline, sibutramine, strychnine, modafinil.

  • Effects:

    • Improve endurance and anaerobic performance.

    • Decrease feelings of fatigue and improve reaction time.

    • Increase alertness.

    • Aid in weight loss by allowing higher core body temperatures with less perceived effort, although this is potentially dangerous.

  • WADA Prohibition: Stimulants are prohibited categorically, but caffeine consumption is currently allowed at regulated levels in competition.

    • Caffeine: Although beneficial to a point, large doses do not enhance performance and can lead to adverse side effects.

  • Side Effects include:

    • Hypertension, tachycardia (rapid heartbeat), myocardial infarction (heart attack), stroke, heat illness, headaches, nausea, tremors, insomnia, anxiety, and psychosis.

Beta Agonists

  • Examples: Albuterol, formoterol, salmeterol.

  • Anecdotal Evidence: Indications exist of improved performance among swimmers using these agents prior to competition.

  • Physiological Effects:

    • Increased skeletal muscle mass.

    • Inhibition of protein breakdown.

    • Fat loss.

  • Usage Context: Swimmers commonly experience airway hyperresponsiveness and may require these substances to restore normal lung function.

  • Side Effects: Include tachycardia, anxiety, tremors, arrhythmias, and hyperglycemia.

Beta Blockers

  • Types of Beta Blockers: Propranolol, metoprolol, atenolol.

  • Physiological Effects:

    • Decreases heart rate.

    • Reduces hand tremors and anxiety.

  • Performance Enhancements: Particularly beneficial in sports requiring steadiness (e.g., archery, shooting, billiards).

  • Regulations: Prohibition in competition for specific sports and in some cases out of competition

  • Contradictions: Resulting decrease in heart rate may be ergogenic for some sports but detrimental in others due to reduced cardiopulmonary capacity.

Methods to Increase Oxygen Transport

  • Methods include: Blood transfusions and erythropoiesis-stimulating substances to potentially increase aerobic capacity.

  • Side Effects involve significant risks:

    • Myocardial infarction

    • Stroke

    • Deep vein thrombosis/pulmonary embolism

    • Blood clots

    • Hypertension

    • Antibody-mediated anemia.

Nutritional Supplements

  • Types: Vitamins, minerals, herbs, extracts, and metabolites.

    • Although not explicitly prohibited, they can be contaminated with banned substances like steroids or stimulants.

  • Excuse for Positive Tests: Substances being laced does not excuse a positive test result.

  • Creatine: The most popular supplement with evidence of increased maximum power output in specific studies, yet not prohibited. Risks include kidney disease (Baron et al., 2013).

Other Prescription Drugs

  • Diuretics and Masking Agents: Used in doping to facilitate rapid weight loss, particularly in sports like wrestling.

    • Potential side effects: dizziness, muscle cramps, rash, gout, renal insufficiency.

  • Masking Agents: Such as epitestosterone, conceal banned substances in testing.

  • Glucocorticoids: Employed for anti-inflammatory and analgesic properties but with limited performance enhancing evidence.

    • Side effects include hyperglycemia, fluid retention, muscle mass loss, osteoporosis, diabetes, hypertension, weight gain, obesity, cataracts, depression, mania, psychosis.

  • Psychiatric Medications: Usually not on the prohibited list, but some evidence indicates Bupropion may affect temperature perception under physically demanding conditions (Watson et al., 2005).

Recreational Drugs

  • Substances: Alcohol, cannabinoids, nicotine.

  • Current Regulations: WADA does not prohibit alcohol in competitions anymore. It has been used for pre-competition anxiety management and team cohesion post-competition but carries adverse effects like sedation and reduced recovery rates.

  • Cannabinoids: Recent WADA policies prohibit their use in addition to opioids, although cannabinoids may aid sleep and anxiety management.

    • Side effects include memory impairment and psychomotor slowness.

  • Opioids: Effective for pain but carry risks of dependence, nausea, and cognitive impairment.

  • Nicotine: Under WADA monitoring for its stimulatory effects, though accompanied by adverse outcomes like increased blood pressure and anxiety.

Gene Doping and Other Non-Drug Performance Enhancements

  • Gene Doping: Involves injecting DNA to enhance athletic performance, prohibited by WADA.

    • Potential benefits target genes associated with endurance, strength, and psychological effects but come with risks including cardiac hypertrophy and cancer.

  • Non-Drug Methods: Methods such as hypoxia induction (e.g., altitude training) are not prohibited and are gaining traction in enhancing performance through natural means.

Doping and Mental Health

  • Mental Health Connection: The interplay between mental health symptoms and substance use in athletes.

    • Athletes lacking coping strategies for stress may resort to doping.

    • Substances may temporarily alleviate symptoms of depression and anxiety, but lead to negative long-term mental health effects (e.g., rebound anxiety from marijuana).

  • Addiction Cycle: The need for increasing substance use to alleviate withdrawal symptoms may lead to further depression and anxiety.

Prevention

  • Role of Mental Health Clinicians: Essential for helping athletes develop coping strategies in the competitive sport environment.

  • Educational Outreach: Didactic education aims at informing athletes about the risks involved with doping and the medical consequences.

  • Drug Testing: An essential method for discouraging doping by detecting and penalizing violations. Effective drug testing is frequent, accurate, closely observed, and random.

Management

  • Motivational Interviewing: A therapeutic approach for managing doping and drug use, featuring the Transtheoretical Model (Prochaska et al., 1983) which comprises six stages:

    • Precontemplation: No intention of changing behavior.

    • Contemplation: Consideration of future behavior change.

    • Preparation: Readiness to act in the coming month.

    • Action: Recent behavioral change with intention to maintain it.

    • Maintenance: Sustained behavioral change lasting months, with ongoing intent.

    • Termination: No desire to return to unhealthy behaviors, with confidence to avoid relapse.

    • Athletes with positive test results generally remain in the precontemplation stage; motivational interviewing can assist in advancing them to contemplation.


Management Techniques

  • Essential Elements of Motivational Interviewing:

    • Clinician empathy to build rapport.

    • Discrepancy development between athlete's current state and future aspirations.

    • Rolling with resistance to avoid confrontation and encourage alternative perspectives.

    • Boosting self-efficacy for coping without ergogenic aids.

  • Other therapeutic options include:

    • 12-step programs (e.g., Alcoholics Anonymous, Narcotics Anonymous)

    • Cognitive Behavioral Therapy

    • Network therapy.

  • For those dealing with addiction, pharmacological interventions may be necessary, especially with comorbid conditions such as anxiety or depression.

Practical Applications

  • Regular Updates: Inform athletes continually about prohibited substances from WADA and relevant sports organizations.

  • Clinical Screening: Healthcare providers should assess all athletes for potential performance-enhancing strategies.

  • Education and Encouragement: When encountering athletes involved in doping, educate them about risks and promote discontinuation.

  • Integration of Motivational Interviewing: Should be part of clinical encounters with athletes known to be doping.

  • Supportive Network Education: All personnel in the athlete's support network should learn about doping risks and the importance of prevention.

  • Mental Health Inclusion: Mental health professionals should be a consistent presence in athlete support

  • Strong Prevention Policies: Enforce rigorous urine testing and prioritize educational programs that offer evidence-based alternatives to doping, focusing on nutrition, training, psychological techniques, and recovery.

Resources for Further Learning

  • Documentary: Watch "Untold: Hall of Shame" (2023) on Netflix to explore doping and drug misuse in sports.