Filmmaker Christopher Bell (right) interviews Jay Cutler in “Bigger, Stronger, Faster,” his film about the use of performance enhancing drugs in America.
Courtesy of Magnolia Pictures

AAOS Now

Published 8/1/2008
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Michael F. Schafer, MD; Mary Ann Porucznik

The seductiveness of supplements

Orthopaedic surgeons are seeing increased use of PEDs

Sylvester Stallone says human growth hormone (HGH) “increases the quality of your life.” Arnold Schwarzenegger says he has “no regrets” about using steroids. With endorsements like that, it’s no wonder that Americans—particularly Americans of a certain age—are turning to performance-enhancing drugs (PEDs).

As part of our continuing series examining PED use, AAOS Now contributing editor Michael F. Schafer, MD, recently spoke with three AAOS fellows about the incidence of PED use among patients in their practices:

Edward R. McDevitt, MD, is in private practice in Annapolis, Md. For 12 years, he served as chief of orthopaedics and sports medicine at the U.S. Naval Academy, and continues to volunteer his services.

Christopher D. Harner, MD, is a professor of orthopaedic surgery and chief of the division of sports medicine and director of the ortho­paedic sports medicine fellowship program at the University of Pittsburgh Medical Center.

Charles A. Bush-Joseph, MD, is a professor at Rush University Medical Center and the associate director of the Rush Orthopaedic Sports Medicine Fellowship Program in Chicago.

Dr. Schafer: Are you seeing patients who use PEDs in your practice?

Dr. McDevitt: I think the use of PEDs is increasing. People my age are asking how to get HGH because it will keep you from aging. They bring up Sylvester Stallone and say they want the benefits of HGH that he touts.

A man the other day wanted to know if he could get HGH, anabolic steroid gel, and insulin because his friends told him that the combination works better for anti-aging. They have some knowledge; they know the benefits of PEDs, but minimize the dangers of these drugs. The availability through the Internet makes it easier for the young athlete or the aging baby boomer to get these drugs.

Dr. Bush-Joseoph: I am also seeing increasing numbers of older recreational athletes seeking these drugs, specifically growth hormone. The easy availability of and obvious marketing on the Internet have taken away the fear of using them and the potential negative consequences. And when adults believe that these drugs are safe, that attitude will spread to youngsters, including athletes.

Dr. Harner: In the office setting, it is difficult for me to identify patients who may be using PEDs, especially those on lower doses. Occasional groups such as body builders are obviously taking PEDs. In terms of counseling, I will occasionally have patients who ask my advice on PEDs. I have never been asked to prescribe or recommend specific PED’s by patients or high school aged students. This does not mean, however, that the problem does not exist.

Dr. Schafer: What kind of outreach are you doing?

Dr. Harner: In our center, the primary care sports medicine faculty do most of the outreach to the athletes and coaches. To be honest, I am not sure how effective talking to high school athletes or their coaches is. For high school students, we try to do this during preseason physical examinations and through lectures to student athletes. In college, it is much more effective because of the testing and the support of athletic trainers, coaches, and administration.

Dr. McDevitt: We know kids are interested in using them, but not in hearing about them, which is discouraging. I struggle on how to get the message out that even though these drugs are seductive, the dangers are too great to get involved with them.

Dr. Bush-Joseph: Part of our job is to break through the scaremongering and provide the straight, educational information. Anecdotes about a player who died or is waiting for a heart transplant are the extreme; we have to focus on the other, less serious, more subtle side effects.

Dr. Schafer: I’m concerned about young athletes, in high school and college. How can we reach them?

Dr. Harner: It’s very difficult for me to identify PED use in a high school athlete. We talk to the trainers, but I think the parents are behind a lot of it. To reach high schoolers, we’ve got to get the message to parents and coaches that there are significant consequences. Maybe team physicians could collaborate to get the message out through parent-teacher and other organizations instead of waiting until the preparticipation physicals, when it’s too late.

One of the concerns with targeting parents is that they may be abusers. Right now we do face a dilemma in that we do not know the side effects of lower dose PEDs. We do know that high doses of drugs such as HGH and testosterone can lead to significant morbidity and even mortality as we have witnessed in professional athletes. What we do not know are the consequences of lower dose side effects of PEDs.

I think this is where Stallone and Schwartzenegger are coming from with their statements.

Dr. Bush-Joseph: I’ve been part of those high school programs where you address 200 to 300 athletes in the middle of the school day and you get a glassy-eyed response. We need to reach beyond the high school student to the other influences and decision-makers because the athletes themselves are not very receptive.

Dr. McDevitt: In Annapolis, we have a mandatory educational program for youth coaches. They have to attend every two years, and we introduce the topic of PEDs and try to get the word out about the dangers of these drugs.

Dr. Schafer: What bothers me is the idea that it may not be easy to get parents to help deter PED use by young athletes if the parents themselves are users.

Dr. McDevitt: You have to be open, take the time, and ask your patients about what drugs they’re taking and about what supplements they’re taking. I know we’re busy, but we need to have this discussion with them. Many of my patients are taking 15 to 20 dietary supplements and vitamins. We need to tell them that there are no controls over these supplements; they’re not tested. An athlete may take a supplement, not realize that it includes testosterone products or other things, and subsequently fail a drug test.

Dr. Bush-Joseph: In my experience performing preparticipation physicals, I can see that players’ bodies are changing. I think what Major League Baseball (MLB) has done, by instituting such dramatic consequences, has led to significant behavioral changes. The numbers have come down dramatically since forced drug testing was introduced.

Dr. McDevitt: Four states—New Jersey, Texas, Florida, and Illinois—are testing at the high school level. The only way PED use is going to stop is with more testing and severe consequences for testing positive. No one wants a team to lose, but the consequences must have an impact not only on the player but also on the team.

Dr. Schafer: What resources are you aware of from the AAOS or the American Orthopaedic Society for Sports Medicine (AOSSM)?

Dr. McDevitt: I did a slide show for Orthopaedic Knowledge Online on ergogenic drugs in sports, which is available on the Web site, along with some corresponding patient education materials on creatine supplements and steroids. The AOSSM summer meeting is featur­ing a symposium on drugs in sports.

Dr. Bush-Joseph: We really do need a consensus statement or a position statement on PEDs. I also believe we need data on noncatastrophic use of these drugs so we have hard and fast numbers beyond the potential consequences of dying of heart failure, liver failure, or diabetes. That’s the kind of information that will enable our members to speak intelligently on the issue, instead of simply saying “don’t, don’t, don’t.”

Dr. Harner: This should be a topic in some form at every annual meeting in both organizations. In addition to symposiums and instructional course lectures, we need to encourage basic science research in this area, especially in looking at the side effects of lower-dose PEDs.

Dr. Schafer: Any final thoughts?
Dr. McDevitt:
We cannot ignore the dangers of PEDs because we want our team to win. We have to be the ones to focus on the safety of our players, just as we make the hard decision to hold out an athlete who has a concussion. We won’t get any thanks, but we have to do it.

Dr. Bush-Joseph: I think it would be a good idea to work with the Orthopaedic Research and Education Foundation and other organizations to look at the basic science and clinical research projects that could give us some real data.

Dr. Harner: The MLB experience has led to a significant decrease in the use of PEDs. I believe it is time for the National Collegiate Athletic Association (NCAA) to consider testing all high school athletes entering college. If they test positive, then they would be suspended or eliminated from participating in NCAA sports. This could go a long way in changing attitudes at the high school level. Physicians could lobby decision makers to enforce this rule.

Dr. McDevitt: It’s a total mindset and it will be tough to change society’s attitude that there’s no such thing as a good loser—you’re just a loser. We put so much pressure on players to win, we have a lot to do!

Dr. Schafer: Thank you all for your participation. We hope that this series of articles will stimulate our readers to think about performance-enhancing drugs and supplements, their influence on patients, and the need for effective testing and real consequences to deter use. We also hope that readers will get involved in their communities to educate their patients and the parents of the student athletes about stimulants, supplements, and performance-enhancing drugs. We encourage our readers to share their thoughts and successful strategies with us so that we can all learn from them.

Michael F. Schafer, MD, is chair of the department of orthopaedic surgery at the Northwestern University Feinberg School of Medicine; he can be reached at MSchafer@nmff.org

Mary Ann Porucznik is the man­aging editor of AAOS Now. She can be reached at porucznik@aaos.org

A urine test for HGH?
As this issue of AAOS Now went to press, the Washington Business Journal was reporting the development of a urine test for human growth hormone (HGH). According to its developers, the test, which uses nano­technology to amass the HGH particles into a detectible size, could be available within the year and would be able to detect the synthetic hor­mone as much as 2 weeks after its use. Until now, only blood tests have been available to detect HGH, and only within 48 hours after use.