Published 10/1/2008
Annie Hayashi

PED use: Legal, natural, and deadly

Doping, athletes, and how orthopaedic surgeons can help

The use of performance-enhancing drugs (PEDs) among young athletes as well as among aging “baby boomers” has become widespread, according to Michael J. Stuart, MD, a participant in the American Orthopaedic Society for Sports Medicine (AOSSM) symposium on “Anti-Doping: Where do we go from here?”

“This is not a new problem but it is certainly growing,” said Dr. Stuart. “One of the problems is product marketing, which really glorifies PEDs—making them look helpful in all aspects of life. Unfortunately, many substances found in nature are ‘natural’ but they can also be dangerous.”

Marketed as natural substances, powerful dietary supplements and energy drinks have become part of the PED landscape for some athletes. Dietary supplements are classified as “nutritional supplements” by the Food and Drug Administration—allowing them to be sold over-the-counter, without any trials to demonstrate efficacy or safety.

Supplements and energy drinks can be found in vitamin and grocery stores—even at local gas stations. They promise quick weight loss, increased energy, faster workout recovery times, and a “buff body.”

The FTC weighs in
According to a report prepared by the Federal Trade Commission (FTC) for the Committee on Government Reform, “the dietary supplement industry represents a substantial and growing segment of the consumer healthcare market with an estimated $20.3 billion in industry sales in 2005.”

The FTC also reported that dietary supplements have been marketed specifically to appeal to adolescents trying to increase their body mass. In fact, some manufacturers advertise on MTV and other television stations that cater almost exclusively to teen audiences.

As a result of its concerns, the FTC has issued specific cautions about using supplements for “muscle building”—warning that some of the products may contain steroid ingredients.

A recent article in the Baltimore Sun (Sept. 8, 2008) discussed the dangers of some popular energy drinks. In addition to causing potentially severe gastrointestinal problems, these drinks contain very high levels of caffeine and other substances that are touted to increase endurance and muscle performance (Table 1).

Risky and deadly combinations
“It is the seduction of the quick fix—an immediacy to attain success—that drives so many people,” according to Aynsley M. Smith, PhD, Dr. Stuart’s colleague at the Mayo Clinic in Rochester. “The patience that athletes once had to have—to spend years on their sport, to improve their skill level in small increments—has greatly diminished.”

She cited the example of a young soccer player with a slight build who used creatine to “bulk up” and to feel more powerful. Eventually he realized that taking the drug was actually slowing him down and making him less effective on the field, and he stopped using it.

Unfortunately, not all athletes come to that kind of realization, opting rather to take different pills or combinations of pills.

Panelist David E. Brown, MD, suggested that “polypharmacy” (“multidrug regimens”) is routinely used by bodybuilders and discussed in Internet chat rooms.

On Internet forums, athletes discuss how to combine several different dietary supplements to sustain long workouts. They learn how to administer the medications and use multidoses to avoid side effects. Normal dosing instructions are customarily ignored, and different supplements are combined or “stacked.”

Taken in combination or over the recommended dose, these supplements can have serious—even lethal—results.

Young people are also using dietary supplements in combination with stimulant prescription medications such as those used for attention-deficit hyperactivity disorder. Ritalin and other amphetamines are used at surprising rates by teenagers (Table 2). Even more disturbing, most young people report obtaining these prescription drugs from friends or relatives.

Taking it to the next level
In addition to energy drinks and dietary supplements, a growing number of non-elite athletes are using anabolic-androgenic steroids (AAS), human growth hormones (HGH), erythropoietin (EPO) and insulin. In fact, 80 percent of PED users are reported to be non-elite athletes.

According to Dr. Brown, anabolic steroids produce excellent results for those working to improve their strength. With those gains, however, come risks—including hyperlipidemia, cancer, and testicular atrophy.

“Creatine has been around for a long time—helping about 2 out of 3 athletes increase their amount of muscle,” Dr. Brown said. “But it also increases the water content of the muscle—leading to dehydration problems, especially during summer-type conditions.

“EPO is among the most effective performance enhancers—markedly improving aerobic capacity for endurance athletes,” he explained. He pointed out that European cyclists improved their times 10 percent to 15 percent in the 1990s by using EPO injections. But EPO increases hematocrit to above 50 percent, which may lead to stroke and myocardial infarction due to sludging.

“About 20 European cyclists died from heart attacks in the late 1990s,” said Dr. Brown. “Unfortunately, it has become very common for some athletes to use multidrug regimens of AAS, HGH, EPO, and insulin.

“These athletes are also using anti-estrogen agents to try and minimize some of the estrogen side effects. They frequently add insulin as an anabolic agent and because they develop insulin resistance from the growth hormone injections,” Dr. Brown noted.

Because of the obvious and necessary ethical boundaries of medical research, it will be nearly impossible to study the “dosing and duration of dosing of the athletes who use these drugs.”

What can the orthopaedic surgeons do?
The final focus of the panel was on steps orthopaedic surgeons can take to help the athletes they see. Dr. Stuart had two suggestions. “Don’t contribute to the problem,” he said, “and educate yourselves, your patients, and your colleagues about PEDs.

“Look for the signs and symptoms of PED use, make the diagnosis, and intervene,” he advised. (See below “Signs and symptoms of PED use.”)

Resist the temptation to prescribe inappropriately in response to pressure, particularly from a coach or parent. Step back and look at your own practice. Attempt to deter athletes from cheating through education about the physical, psychosocial, legal, and ethical consequences of PED use,” he said. (See “How you can help young athletes” below.)

“Athletes using PEDs are out there. They have come into your office and you’ve missed it—the clear cut signs of PED use. All of us can go out and look at our patients and start thinking a little bit more about PEDs,” said Edward R. McDevitt, MD.

“If an older patient in obviously good shape has a ruptured pectoralis or biceps, ask whether he is taking steroids. This isn’t an injury that happens to a middle-aged guy very often,” Dr. McDevitt said.

He also recommended alternative learning sources for information about PEDs. “Muscle and fitness magazines may have more information than medical journals,” he said.

“When you see young athletes, just talk to them. Do they know anyone on their team using steroids? Sometimes young athletes will tell you that other teams are using steroids. Ask them if they have ever thought about using steroids to win games,” he advised.

“Talk to them about the use of energy drinks and dietary supplements. Which ones are they taking and how often? Ask them if they know of others who are using energy drinks,” said Dr. McDevitt.

The patient-physician relationship must remain primary in these conversations. The purpose is to help young athletes, not to report them to the authorities. “It doesn’t take long to have that conversation. If you can help a young athlete, I think it’s worth it,” concluded Dr. McDevitt.

The speakers reported no disclosures.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org

How you can help young athletes

Don’t aid and abet

  • Resist the temptation to prescribe inappropriately in response to pressure from athletes, parents, coaches, or management.
  • Thoughtfully consider if your practice is a source for narcotics and stimulants currently abused by patients and athletes.

Recognize abuse

  • Educate yourself.
  • Look for the symptoms and signs.
  • Ask your patients questions. Consider a questionnaire/interview form on performance enhancing substances to use as a guide in your practice.

Educate athletes, coaches, and parents

  • Organize a workshop or give a lecture: team meeting, coaches’ association, parent meeting, booster club, etc.
  • Write an article for the local and/or school newspaper.
  • Display “Clean Sports” posters in your waiting room, office lobby, or exam rooms. (Download from www.usantidoping.org/athletes)
  • Encourage young athletes to commit themselves to clean sport and fair competition by completing the Athlete Pledge Card. (Download from www.usantidoping.org/pledge_card.pdf)

Take charge

  • Ask athletes under your care to seek your advice on the use of dietary supplements or medications.
  • If you are a team physician, ask coaches and athletic training staff not to provide nutritional supplements or stimulants without your consent.
  • Promote mandatory education of personal trainers, fitness facilities, and gym personnel.
  • Cooperate with local, state, and federal authorities if you suspect certain gyms, clinics, and anti-aging clinics are a source of drugs for your patients.
  • Lobby for FDA approval of supplements—require standards, no contaminants, and label of ingredients.

Courtesy of Michael J. Stuart, MD

Signs and Symptoms of PED use
Be alert for symptoms

  • Personality change/mood swings
  • Euphoria/failure to recognize injury
  • Aggression/hostility/temper/flares
  • Physical/verbal abuse
  • Anxiety/tremor/insomnia
  • Defiance of rules
  • Depression
  • Decreased or increased appetite
  • Reluctance to talk about PEDs
  • Severe headaches
  • Menstrual irregularities

Be alert for signs

  • Rapid gain in weight and muscle
  • Tendon strain/rupture
  • High blood pressure
  • Acne
  • Stretch marks
  • Premature balding
  • Women: deep voice, facial hair, shrinking breasts
  • Men: breast enlargement, testicular atrophy