Performance-enhancing drugs (PED) include prescription and over-the-counter (OTC) medications, illegal “street drugs,” and nutritional supplements that are believed to improve athletic performance. However, the term PED most often refers to anabolic-androgenic steroids (AAS), a large family of compounds also called anabolic steroids or simply steroids. Various other compounds, including certain other hormones, stimulants, diuretics, and creatine, are also considered PED. In recent years, there have been numerous revelations of the widespread use of illegal PED, or “doping,” by sports heroes and amateur athletes alike.
AAS are the most widely used—and abused— PED. AAS are growth inducers that were first developed in Europe in the 1930s to treat malnourishment and promote healing following surgery. Competitive weightlifters began using AAS in the 1950s, and the drugs gradually spread to other sports, until their use became pervasive. The most common legitimate use of AAS is for hormone-replacement therapy. At the high dosages used for performance enhancement, their anabolic effects rapidly build muscle size and strength. They may also increase energy and reduce muscle damage or hasten repair, allowing athletes to train harder and more frequently with faster recovery. The androgenic effects of AAS promote male sexual characteristics in both males and females. Some athletes report aggressive rushes from AAS that also may enhance performance.
Various other types of PED include:
Widespread use of the male sex hormone testosterone by athletes in the 1980s and 1990s led to the founding of the World Anti-Doping Agency (WADA) in 1999, with the goal of establishing and enforcing antidoping policies in competitive sports. It was the BALCO scandal of 2003, however, that revealed the pervasive use of anabolic steroids among elite professional athletes. Although accusations of banned PED use have long plagued the modern Olympic Games, revelations of a state-run doping program for Russian athletes at the 2014 Sochi Winter Olympics shocked the world.
AAS include testosterone and a large number of synthetic testosterone derivatives. AAS help metabolize proteins, increase the rate of skeletal-muscle synthesis, and provide a rush that masks fatigue. They are taken orally as tablets or capsules, through the skin as ointments or transdermal patches, or injected into muscles. AAS are sometimes combined with creatine, protein powders, and/or various antioxidants.
More than 1,000 different AAS have been synthesized since the 1950s under many thousands of international brand names. Although they are illegal in the United States and are prohibited by most athletic competitions, AAS are available OTC in some countries. They are also widely available through physician prescriptions and as veterinary and street drugs under a variety of names. The products of steroid metabolism can be detected in the urine for six months or longer after use, and athletes are routinely screened for AAS; however, the technology for detecting steroids in blood or urine—and distinguishing AAS use from the products of normal metabolism or legitimate medications—is often one step behind new “designer” steroids.
Common AAS include:
Steroid precursors, such as dehydroepiandrosterone (DHEA) and androstenedione (“andro”), are marketed as performance-enhancing nutritional supplements. DHEA is converted to androstenedione in the adrenal glands, testes, and ovaries. Androstenedione is converted to the sex hormones testosterone and estradiol in both men and women. Although their use as performance enhancers is illegal in the United States, evidence indicates that these precursors are unlikely to be effective AAS.
Abnormal concentrations of hormones, such as hGH, EPO, insulin, human chorionic gonadotropin (hCG), adrenocorticotropin (ACTH), or their metabolites or markers, in blood or urine samples, as well as platelet-rich plasma (PRP), indicating treatment with blood platelets, are considered evidence of prohibited PED use. Although exceptions are made for demonstrated physiologic or medical conditions, drug testing remains controversial because of large individual variations in normal levels of these substances.
Stimulants include caffeine, amphetamines, methamphetamine, and cocaine. Some prohibited stimulants, such as ephedrine and pseudoephedrine, are common in OTC nasal sprays, diet aids, and headache, cold, and flu remedies. Many medications that are commonly prescribed for asthma and other respiratory symptoms are strong stimulants, and some have anabolic properties.
Creatine supplements are commonly sold as powders, although other preparations are available. The liver produces about 0.07 oz. (2 g) of creatine daily, and it also is obtained from meat in the diet. Because muscles usually have adequate creatine stores and any excess is removed by the kidneys, the value of creatine supplements for performance enhancement had been questioned. Some studies have shown them to be beneficial and indicated that creatine also has the potential to lessen injury during training.
The loading dose of creatine monohydrate for adult athletic performance is generally 5 g four times daily for one week. The adult maintenance dose is generally 2–5 g daily.
The list of drugs prohibited by WADA is updated annually. All anabolic agents, peptide hormones, growth factors and related substances, hormone antagonists and modulators (which affect the activity of endogenous hormones in the body), beta-2 agonists (with certain exceptions), and diuretics and other masking agents are prohibited at all times. Stimulants, narcotics, cannabinoids, and glucocorticosteroids are prohibited in competitions. Certain sports also prohibit alcohol and beta-blockers. In general, a drug is prohibited if it meets two of the following three criteria:
Most PED have serious potential health risks. Furthermore, side effects and potential complications from the drugs may lead to a deterioration in athletic performance. Some PED, such as oxymetholone, a commonly abused AAS worldwide, are considered carcinogens. People with medical conditions should never use PED.
Steroids that are designed to be undetectable by standard drug tests and have no approved medical uses have never been tested for safety or effectiveness. Black-market PED smuggled in from abroad or manufactured clandestinely are particularly dangerous because they may be impure or mislabeled.
Performance-enhancing nutritional supplements are considered food by the US Food and Drug Administration (FDA) and are not regulated to the same extent as drugs. They are sometimes contaminated with synthetic hormones or other harmful substances. Products that are advertised as alternatives to FDA-approved drugs or illegal AAS, or that warn that they may cause positive drug tests, should be viewed with suspicion.
Although creatine is sometimes used by athletes to increase their weight, its prolonged use is more likely to increase muscle water retention than muscle mass. There have been reports of contaminated creatine supplements.
Although interactions involving PED and dietary supplements have not been well-studied, AAS may interact with:
Creatine may have negative interactions with:
Although at usual medical dosages, AAS are considered relatively safe with few side effects, at performance-enhancing dosages, they can cause a range of side effects, some of which may be irreversible. Side effects of AAS and steroid precursors in men can include breast enlargement, shrunken testicles, impotence, enlarged prostate, and infertility. Women may develop a deeper voice, enlarged clitoris, and increased body hair. Side effects in both men and women can include:
It may be possible to become physically or psychologically addicted to AAS. Hormone supplementation may be required to restore normal hormonal function after AAS are withdrawn. Depression is the most serious symptom of AAS withdrawal. If untreated, depression can last for more than a year and lead to suicidal behaviors.
Other complications from performance-enhancing AAS can include:
Side effects of hGH may include:
EPO can increase the risk of heart attack, stroke, pulmonary edema, kidney disease, and cancer progression or recurrence. Its use by competitive cyclists during the 1990s is believed to have contributed to at least 18 deaths.
Possible side effects of beta-2 agonists include:
Side effects of stimulants can include:
Diuretics at any dose affect the balance of fluids and salts in the body and can cause dehydration. Use of diuretics by athletes increases the risk for:
Although creatine is generally considered safe for adults at recommended dosages, high doses have the potential to cause kidney or liver damage. Side effects may include weight gain, dehydration, muscle cramps and strains, stomach pain, dizziness, nausea, diarrhea, and high blood pressure. Furthermore, supplements may prevent the body from producing its own natural stores of creatine.
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Margaret Alic, PhD