Special Report: Prohibited Classes of Substances and Prohibited Methods for Performance Enhancement
By Arthur Weltman, PhD
Synopsis: This overview discusses the various classes of banned substances, the reasons they are banned, and the desired effects for which athletes take them.
Source: Mottram DR. Banned drugs in sport. Does the International Olympic Committee (IOC) list need updating? Sports Medicine 1999;27(1):1-10.
During the recent Olympic Games in Sydney, Australia, there was considerable attention paid to the practice of "doping" to enhance athletic performance. The pressure to win and the riches and fame associated with success have contributed to a culture where many athletes will do almost anything to win. For example, in a 1995 poll of 198 elite U.S. athletes, the following question was asked: You are offered a banned substance with two guarantees: 1) you will not get caught; 2) you will win. Would you take the substance? Only three answered no. More frightening was the result of the question that followed. You are offered a performance enhancing substance with two guarantees: 1) you will not get caught; 2) you will win every competition you enter for the next five years and then you will die from the side effects of the substance. Would you take it? More than 50% said yes.
The International Olympic Committee (IOC) initiated drug testing in 1968 after a Tour de France cyclist from England died from an amphetamine overdose. Testing has consistently expanded and more sophisticated detection techniques have evolved. However, athletes still cheat. During the 1998 Tour de France, the coach and all nine riders of the top-ranked Festiva team of France were suspended after a team car was found to contain large quantities of amphetamines, steroids, "masking agents" (substances used to elude drug testing), and erythropoietin. A week later, four Chinese swimmers were banned for two years for using a banned diuretic at the world championships. During the recent Olympics in Sydney, seven competitors tested positive for various banned substances and a number of competitors (including 27 Chinese athletes) chose not to compete in the games presumably because of new anti-doping policies.
Doping is prohibited because it is fundamentally against the ethos of sport. In addition, many of the substances and methods used are harmful to the athletes’ health and can cause serious short and long-term damage. Nevertheless, the practice has become so commonplace in elite class athletics that it has necessitated the creation of the Olympic Movement Anti-Doping Code that addresses the use of banned substances and doping techniques. One of the problems with any anti-doping code is that many common medications, such as painkillers, cold medicines, and asthma medications, can contain prohibited substances. Athletes must be very cautious with any medication that they are taking because it is the athletes’ responsibility to know whether there are banned substances in medications that they are taking. If a competitor wants to use a prohibited substance for therapeutic use, he/she must have written approval of the Medical Advisory Committee of the IOC Medical Commission prior to the Olympic Games.
At each Olympic games, all medal winners and a random competitor are drug tested. In Atlanta, Ga, 2000 tests were conducted for 11,000 athletes. The minimum required sanction for a first offense with a major doping substance is a suspension from all competition for two years. Any records or medals achieved at the time of, or after, the sample was taken are stripped. In addition, other organizations (e.g., the International Federation) may choose to impose additional sanctions on the competitor.
What substances are banned? The Olympic Movement Anti-Doping Code Appendix A (www.nodoping.org) provides a list of prohibited classes of substances and prohibited methods (April 1, 2000). The list below identifies these prohibited substances and gives examples of the ergogenic benefits and risks associated with representative substances from each class.
Prohibited Classes of Substances
Stimulants
Stimulants include amineptine, amiphenazole, amphetamines, bromantan, caffeine, carphedon, cocaine, ephedrines, fencamfamin, mesocarb, pentetrazol, pipradrol, salbutamol, salmeterol, terbutaline (asthma treating drugs are allowed by inhaler only, provided written documentation of asthma and/or exercise-induced asthma is provided by the team physician to the relevant medical authority), and related substances.
Athletes use stimulants (e.g., amphetamines) to try to gain an ergogenic edge. Although early research suggested that amphetamine use did not result in improved athletic performance, more recent research suggests that they may enhance skills that are important to performance. People who take amphetamines experience a decreased sense of fatigue, increased systolic and diastolic blood pressure, increased heart rate, redistribution of blood flow to skeletal muscles, elevation of blood glucose and free fatty acids, and increased muscle tension. Recent studies suggest that amphetamines can enhance speed, power, endurance, concentration, and fine motor coordination. However, the use of amphetamines is inherently dangerous. Dangers of amphetamine use include physiological or emotional drug dependency resulting in a cyclical compensatory dependency on amphetamines and barbiturates. General side effects include headache, agitation, insomnia, nausea, dizziness, and confusion which may all negatively effect performance. Prolonged intake of high doses of amphetamines can produce weight loss, paranoia, psychosis, repetitive compulsive behavior, and nerve damage.
Caffeine may be a possible exception to the general rule against taking stimulants. Some studies suggest that ingesting the amount of caffeine commonly found in 2.5 cups of coffee (330 mg, legal under current IOC guidelines of a urine concentration of < 12 mg/mL) one hour before exercising may extend endurance in the face of moderately strenuous exercise. This is thought to be due to increased mobilization of fat and, hence, glycogen sparing. However, most endurance athletes now take carbohydrate feedings during exercise as this is a more effective ergogenic aid that inhibits the mobilization of fat.
Narcotics
Narcotics include buprenorphine, dextromoramide, diamorphine (heroin), methadone, morphine, pentazocine, pethidine, and related substances. (Note: codeine, dextromethorphan, dextropropoxyphene, dihydrocodeine, diphenoxylate, ethylmorphine, pholcodine, and tramadol are permitted.)
Anabolic Agents
Anabolic androgenic steroids
a. clostebol, fluoxymesterone, metandienone, metenolone, nandrolone, 19-norandrostenediol, 19-norandrostenedione, oxandrolone, stanozolol, and related substances
b. androstenediol, androstenedione, dehydroepiandrosterone (DHEA), dihydrotestosterone, testosterone, and related substances
Beta-2 agonists
Beta-2 agonists include bambuterol, clenbuterol, fenoterol, formoterol, reproterol; also includes salbutamol, salmeterol, and terbutaline which can be authorized for therapeutic inhalation for asthma, and related substances.
It is clear that certain anabolic agents in combination with an adequate diet and training program can enhance the development of muscular strength. The American College of Sports Medicine (ACSM) recently published a Position Statement on Anabolic Steroids. The ACSM concluded that: 1) anabolic-androgenic steroids in the presence of an adequate diet and training program can contribute to increases in body weight, often in the lean compartment; 2) gains in muscle strength achieved through high intensity exercise and proper diet can be increased by the use of anabolic-androgenic steroids; 3) anabolic-androgenic steroids do not increase aerobic power or muscular endurance, although some endurance athletes do use them for their anti-catabolic properties which presumably speeds up the recovery process. Anabolic-androgenic steroids have been associated with adverse effects on the liver, cardiovascular system, reproductive system, and psychological status; the use of anabolic-androgenic steroids is contrary to the rules and ethical principles of athletic competition.
Although the ACSM position stand reviewed the literature regarding controlled substances, several so-called food substances (androstenedione, DHEA) are also considered as anabolic agents and are on the list of banned substances.
Clenbuterol, one of the beta-adrenergic agonists, has become popular among athletes because of its purported tissue-building, fat-reducing benefits. Although few human studies are available, animal studies suggest that clenbuterol increases skeletal and cardiac muscle protein deposition and slows fat gain by enhancing lipolysis. Because of these supposed properties, some athletes switch to clenbuterol after discontinuing steroids (during the "washout" period prior to competition). There have been short-term side effects reported in humans accidentally "overdosing" from eating animals that were treated with clenbuterol. These include muscle tremor, agitation, palpitations, muscle cramps, rapid heart rate, and headache. Although this drug may have some clinically legitimate promise in treating muscle wasting disease and the muscle loss associated with forced immobilization or aging, its use as an ergogenic aid cannot be justified or recommended.
Diuretics
Diuretics include acetazolamide, bumetanide, chlortalidone, etacrynic acid, furosemide, hydrochlorothiazide, mannitol (by intravenous injection), mersalyl, spironolactone, triamterene, and related substances.
Diuretics are generally used for weight control. They are typically used by jockeys, wrestlers, and gymnasts to keep their weight down. Other athletes who are taking banned drugs will use diuretics to increase fluid loss. These athletes hope that the extra fluid in the urine will result in a decreased concentration of banned substances in the urine, a practice known as "masking."
There are no known direct ergogenic effects of diuretic use. As a matter of fact, much of the fluid loss results from the loss of extracellular fluid, including plasma. This reduction in plasma volume can result in a reduction in maximal cardiac output, which in turn results in decreased maximal oxygen consumption and impaired endurance performance. In addition, the diuretic-induced reduction in plasma volume can impair temperature regulation during exercise as well as result in electrolyte imbalance with resultant muscle fatigue and muscle cramping.
Peptide Hormones, Mimetics, and Analogues, Including:
- Chorionic Gonadotrophin (hCG) prohibited in males only;
- Pituitary and synthetic gonadotrophins (LH) prohibited in males only;
- Corticotrophins (ACTH, tetracosacride);
- Recombinant Growth Hormone (rhGH);
- Insulin-like Growth Factor (IGF-I) and all of the respective releasing factors and their analogues;
- Erythropoietin (EPO);
- Insulin (permitted only to treat athletes with documented insulin-requiring diabetes mellitus).
The use of human growth hormone (GH) in competitive athletes has been on the rise since it was "discovered" by the powerlifting community in the early 1980s. GH is thought to provide similar benefits as anabolic steroids. The effects of GH that interest athletes include: stimulation of protein and nucleic acid synthesis in skeletal muscle; stimulation of bone growth (in bones where the growth plates have not fused); increased lipolysis and an overall decrease in body fat; increased blood glucose levels; and enhanced healing after musculoskeletal injuries. The risks of using GH include carpal tunnel syndrome, acromegaly, cardiomyopathy, insulin resistance leading to type 2 diabetes, and edema leading to hypertension.
Erythropoietin is a hormone that stimulates the production of red blood cells from the bone marrow. Recombinant erythropoietin (EPO) is used by endurance athletes to increase red blood cell concentration which results in an increase in oxygen carrying capacity of the blood. This leads to an increase in VO2 max and enhanced endurance performance. Uncontrolled and unmonitored use of erythropoietin can lead to dangerous increases in blood viscosity, augmented exercise induced systolic blood pressure, increased risk of stroke, blood clotting, heart attack, heart failure and death.
Prohibited Methods
- Blood Doping;
- Administering artificial oxygen carriers or plasma expanders;
- Pharmacological, chemical, and physical manipulation.
Classes of Prohibited Substances in Certain Circumstances
- Alcohol
- Cannabinoids
- Local anesthetics
- Glucocorticosteroids
- Beta-Blockers
Out-of-Competition Testing
Unless specifically requested by the responsible authority, out-of-competition testing is directed solely at prohibited substances in anabolic agents, diuretics, (peptide hormones, mimetics, and analogues, and prohibited methods.
Summary
As can be seen from the extensive list of agents that are banned, the fight against doping is a continuous battle. The real problem is not related to major competitions. Athletes can use a number of classes of drugs out of competition, discontinue those drugs prior to competition, and technically be "drug free" during competition. Until random out-of-competition drug testing is initiated, it is doubtful that a major reduction in doping will occur. The recently formed World Anti-Doping Agency may have the capabilities to initiate these tests, but it will require the cooperation of the International Sports Federations as well as governments who must agree to be zealous about drug testing.
Suggested Reading
1. The World Anti-Doping Agency. www.wada-ama.org.
2. The Olympic Movement Anti-Doping Code. www.nodoping.org.
3. McArdle WD, Katch FI, Katch VL. Essentials of Exercise Physiology. Baltimore, Md: Lippincott Williams & Wilkins; 2000.
4. Wilmore JH, Costill DL. Physiology of Sport and Exercise. Human Kinetics. Champaign Ill; 1999.
5. American College of Sports Medicine. The use of anabolic-androgenic steroids in sports. Sports Medicine Bulletin 1984;19:13.
6. Sonksen P. Editorial. Growth Hormone & IGF Research 2000;10:107.
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