THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 10 - OCTOBER 98

What's the Prescription for Drug Testing Woes?

Antidoping efforts in sports could be headed for major changes in the wake of a tumultuous Tour de France and other high-profile events that occurred over the summer (see "A Summer of Doping Scandals," below). The episodes underscored the pervasiveness of performance-enhancing drug use in sports and raised fresh doubts about the effectiveness of testing programs.

Such programs, which have chiefly been the province of physicians who treat elite athletes, may soon be familiar to physicians who care for high school teams. Since the US Supreme Court in 1995 removed legal roadblocks to high school drug testing (1), more high schools are asking questions about formal testing programs as a way to stem the use of performance enhancers and street drugs. To help answer the questions, the National Federation of State High School Associations (NFSH), based in Kansas City, Missouri, planned to beam a satellite teleconference on drug testing to a national audience of high school administrators, coaches, and other staff in late September. (Extensive resources on the topic are available on the NFSH web site at www.nfshsa.org.)

The Scope of the Problem

So far, antidoping efforts seem to have had little success. "Drug use in elite sports is epidemic," says Charles E. Yesalis, MPH, PhD, professor of health policy and administration and exercise and sports science at The Pennsylvania State University in University Park. Yesalis, lead author of a new book on steroids (2), contends that the 1996 Atlanta games were the most drug-infested games in Olympic history. "Athletes called them 'the growth hormone games,'" he says.

Epidemiologic information on the use of performance-enhancing drugs is scarce. The most recent survey (3) of anabolic steroid use in US adolescents showed that in 1995, 375,000 boys and 175,000 girls had used steroids at least once. Longitudinal comparisons by the same authors suggest that since 1990 steroid use is stable among boys but has doubled in girls. The authors concluded that prevention, intervention, and regulatory efforts to reduce steroid use among youth—especially girls—should be reevaluated.

Is Testing Worthwhile?

In July, International Olympic Committee (IOC) chief Juan Antonio Samaranch was quoted twice as saying he thought the IOC should trim its list of banned substances to include only drugs that are harmful to athletes' health. A subsequent IOC press release stated that the IOC's determination to fight doping was greater than ever and that Samaranch had been misinterpreted.

Nonetheless, Samaranch's comments have been construed as a retreat from aggressive drug testing, says Gary I. Wadler, MD, associate professor of clinical medicine at New York University School of Medicine in Manhasset, New York. "In my view, such a position would be ethically and morally indefensible and would represent a significant step backward," says Wadler, who was the lead author of a book on doping and sport (4) and won the IOC President's Prize in 1993 for his work on doping and sports. Despite all the problems with drug testing, Wadler says it should never be abandoned.

But Yesalis says current drug testing programs don't work. "Drug testing at this stage is a facade and a farce," he says. He contends that drug testing programs have not reduced drug use in sport and that major sports organizations support testing only for public relations reasons. After all, he says, sports organizations have a stake in bigger, faster athletes: "The public wants to pay to see football players who are larger than life and baseballs hit into the next county."

Andrew Pipe, MD, chair of the Canadian Centre for Ethics in Sport, sees a very different message in the recent doping scandals. They are "evidence of the fact that drug detection systems or other approaches to these matters are working, even if in a limited and, at times, imperfect way," says Pipe, director of the surgical follow-up clinic at the University of Ottawa Heart Institute and an editorial board member of The Physician and Sportsmedicine.

Flaws in Antidoping Policies

Current doping policies have failed to address complex issues, such as separating cheaters from those who have a legitimate need for or have unknowingly ingested a banned drug, according to Wadler. "Drug testing is a surrogate for reading somebody's mind. You try to understand what the athletes intended when they took a substance," he says. "The trip from the mind to the urine beaker is treacherous." Wadler sees other problems with drug testing as well:

• No clear definition of doping—without which there can be no strong policy.

• Unreliable or nonconfirmatory tests for banned substances such as erythropoietin (EPO), testosterone, and human growth hormone.

• National laws that conflict with rules set by international sports governing bodies. In Germany, for example, the "right of employment" law could nullify a doping suspension.

• Failure to revise banned-substance lists often enough to keep pace with what athletes are using.

Help for an Ailing System

Wadler and Pipe say one major need in the area of drug policy is to have an independent international organization, such as the World Health Organization, coordinate drug testing programs. Yesalis suggests that all sports pool their money in a $50-million to $100-million effort to develop reliable drug tests that stand up in court and to create an independent testing entity.

This approach would address the conflict of interest that sports organizations have, Wadler says. Because sports organizations have a large financial stake in the success of their athletes, they should not approve their own drug testing labs or test their own athletes. "There are some impeccably good people involved in testing, but it's an issue of perception," Wadler says.

Pipe says organizations in Scandinavia, Europe, Australia, and Canada have national testing programs. "The US is still one of the few western nations that do not have a comprehensive, coordinated national antidoping program," he says.

The IOC met August 20 in Lausanne, Switzerland, to set the agenda for a world conference on doping and sport, which will be held February 2 and 3, 1999, in Lausanne. According to an IOC press release, the four themes conferees will address will be the protection of athletes, legal and political aspects, ethics and preventive education, and financial aspects.

Physicians' Role

Physicians who have been quoted in the media on doping topics are unequivocal in their support of tough drug testing programs. However, some physicians are aiding and abetting athletes' doping practices. For example, a German court recently convicted a former team doctor for his role in giving swimmers steroids in the 1970s (5). And according to an Agence France-Press report (6), Bruno Roussel, director of one of the Tour de France teams under investigation for doping offenses, said drugs had been administered to his team "under strict medical conditions."

Cheating has always been the focus of drug testing policies, with concerns about athletes' health, unfortunately, being secondary, says Wadler. Among the most serious concerns are the potentially lethal effects of EPO use, he says. Wadler says he also has concerns about how the newest generation of purported performance-enhancers, such as human growth hormone and multiple-supplement use and abuse, affect athletes' health.

Physicians should be frank about these concerns when talking with athletes, Wadler adds. "There's a delicate balance between pointing out the dangers and overstating the risk, but the risks are real. You have to be honest and say, 'I'm worried about this.'"

Both Wadler and Pipe say physicians have a responsibility to go beyond health issues and speak with patients about the ethics of drug use. "We should speak clearly and unambiguously: Doping is fraud; it represents an attempt to deliberately falsify an athletic performance," says Pipe. He adds that many Canadian athletes have publicly voiced their support for better drug testing programs.

Physicians can effectively lend their support to more widespread antidoping initiatives, Pipe says. He suggests that physicians can push sports organizations to arm themselves with enough administrative resources and technical expertise to address doping issues competently.

References

1. Veronia School District v. Acton, 115 S.Ct. 2386 (1995)
2. Yesalis CE, Cowart VS: The Steroids Game. Champaign, IL, Human Kinetics, 1998
3. Yesalis CE, Barsukiewicz CK, Kopstein AN, et al: Trends in anabolic-androgenic steroid use among adolescents. Arch Pediatr Adolesc Med 1997;151(12):1197-1206
4. Wadler GI, Hainline B: Drugs and the Athlete. Philadelphia, Davis Co, 1989
5. Doctor, coach fined in East German doping trial. Associated Press, Aug 31, 1998. Available at www.nando.net/newsroom/sports/#02. Accessed Sept 4, 1998
6. Virenque denies drug report. Agence France-Presse, Sept 1, 1998. Available at www.afp.com. Accessed Sept 4, 1998

Lisa Schnirring
Minneapolis

A Summer of Doping Scandals

• Drug busts involving erythropoietin (EPO) nearly derailed the Tour de France bicycle race.

• US track and field athletes Randy Barnes and Dennis Mitchell were suspended for drug use, and Irish swimmer Michelle Smith de Bruin was suspended for tampering with her urine specimen.

• The race for a new home run record in baseball brought the revelation that slugger Mark McGwire uses androstenedione, a nutrition supplement that is legal in baseball but banned in some other sports.

• International Olympic Committee president Juan Antonio Samaranch made comments that suggested he favors a retreat from aggressive drug testing.

Team Physicians Manage a Mean Heat Streak

This past summer the southwestern United States suffered several weeks of triple-digit temperatures, causing hardships for athletes and concern for team physicians, particularly those who were involved with football summer workouts. In August, three high school football players died in heat-related incidents—one in North Carolina and two near Wichita, Kansas, according to a report on Wichita Online (www.wichitaeagle.com).

Some team physicians who were in the sun-baked trenches commented on how they helped players cope:

Leland A. Winston, MD, orthopedic surgeon and team physician, Rice University, Houston.
"It's been about 100°F here for the past 2 months. We spray the Astroturf field before practice—it cools it down, and the players' feet don't stick to it. We weigh players before and after practice. We get concerned if they lose more than 3% to 5% of their body weight. We're very aggressive about rehydration; when they're exhibiting symptoms, they can't absorb fluids quickly enough, and we don't hesitate to start an IV line. I'll bet every practice we have someone on an IV. It can't hurt them, and it certainly makes them feel better."

Brent S.E. Rich, MD, ATC, family physician in Phoenix and team physician at Arizona State University, Tempe.
"We [head trainer Perry Edinger and I] encourage athletes to drink fluids until their urine is light yellow to clear. Water caddies are available next to each group during the entire practice. Athletes have unlimited access to cold water and can partake after each play, if they wish. We encourage athletes to prehydrate right before practice, while they are in their position meetings. We have ice tubs on the field if an athlete starts to get in trouble. Probably the best strategy is encouraging athletes to stay around Tempe during the summer. There are conditioning activities that take place in the heat of the day to acclimatize the players and prepare them for game conditions."

James R. Barrett, MD, family physician in Oklahoma City and team physician at Del City (Oklahoma) High School.
"We make sure players prehydrate right before activity, whether they're thirsty or not. Also, we practice early in the morning or late at night."

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