1. Doping in sport is not a new phenomenon; athletes have taken performance-enhancing agents since the beginning of time. The legendary Arthurian knights supposedly drank magical potions from the cup of Merlin. Our own Celtic tales describe the use of strengthening potions to aid valour in battle and the druids' use of narcotics is well documented by historians. The berserkers', a class of ancient Norse warriors who fought frenziedly, "berserk" behaviour was attributed to a deliberate diet of wild mushrooms. The Ancient Olympics in Greece were riddled with corruption and doping to the extent that the games had to be dissolved.
2. In Ancient Rome, gladiators drank herbal infusions to strengthen them before chariot races and going into battle. Almost two millenia later, the first documented report in the medical literature was published in 1865 in the British Medical Journal, citing expulsion of a swimmer from an Amsterdam canal race, for taking an unnamed performance-enhancing drug.2 The first doping death occurred in 1886 in cycling.
3. Doping not only contravenes the spirit of fair competition, it can be seriously detrimental to health. Elite athletes who turn to doping take the greatest risks which seem to pale in contrast to their burning desire for gold. Anabolic steroids affect cardiovascular and mental health and are associated with an increased risk of neoplasms.5,6 Dietary supplements containing ephedra alkaloids have been linked to serious health risks including hypertension, tachycardia, stroke, seizures and death.7 This finding has lead to the recall of ephedra containing supplements in the USA and Canada. Deaths under the influence of drugs and combinations thereof are not uncommon in sport. The peptide hormones or so-called "sports-designer drugs" are thought to be the most dangerous, although the combination of amphetamines, anabolic steroids or antihypertensives combined with intense exertion in athletes are just as hazardous. America's dream girl Florence Griffith Joyner, "Flo-Jo", and the Cuban runner Chelimo both died from cardiovascular events at 38 years of age. Natural causes or doping? We will never know. President Bill Clinton said of Flo-Jo " we were dazzled by her speed, humbled by her talent and captivated by her style".
4. Accurate data on the prevalence of doping is difficult to accrue as it is not financially feasible to screen all athletes. Selection for doping is usually random e.g. medal winners, team captains, goal scorers, the number on a shirt or bib, or athletes who show a sudden or unexpected improvement in personal bests and world placings. The true incidence of doping tends to be more widespread than anti-doping control data would suggest. Several surveys have revealed alarming statistics.8 In a British Olympic Survey in 1996, 48% of athletes agreed doping was a problem; of these 86% stated it was most prevalent in track and field events. In 1989, an Australian Senate Standing Committee Report concluded that 70% of athletes who had competed internationally had taken drugs. One study found that men and women participating in sport are more likely to abuse drugs towards the end of their career.
5. Doping is not just a symptom of elite competition, it is also prevalent in amateur sports and school sports. In France, the incidence of deliberate doping in amateur sport is 5-15%.10 In 1993, the Canadian Centre for Drug-Free Sport estimated that 83,000 children between the ages of 11 and 18 years had used anabolic steroids in the previous 12 months.4 In a more recent American study, prevalence of anabolic steroid use in teenagers was 4-12% for boys and 0.5-2% for girls; in addition to school sports performance, males used anabolics to enhance physical appearance.11 In France, the incidence of adolescent doping is estimated at 3-5%, males again more commonly implicated.
6. The scale of drug use in body builders is thought to significantly exceed that of the elite athlete.12 Body builders use combinations of domestic, foreign and veterinary medicines to create "successful training programmes".12 In an American study, 54% of male body builders were abusing anabolic steroids.2 Androgenic anabolic changes are particularly marked in the female body builder who would otherwise only be exposed to trace levels of testosterone. The most commonly abused group of drugs are stimulants, followed by anabolic steroids.2 Alcohol is one of the most widely used drugs in the athletic population as a whole; it is implicated in sports injury and poor physiological performance and should be avoided by the serious athlete.
7. The advent of gas chromatography and mass spectrometry in the early 1980s transformed the success of drug testing. The main problem now for anti-doping control tests, is that although analytical tests are becoming increasingly sophisticated, the athletes who cheat are "at least one step ahead".18 The interface between science and law is evident in recent sports arbitration decisions.20, 21 One such example is the Yegorova and erythropoetin case. It is clear that testing procedures and application of the rule of strict liability alone will not win the war against drugs. Operational inconsistencies exist between countries and sports federations and progress is hampered by lack of international collaboration.22 New strategies are needed based on educational and psychological approaches.23, 24 Moreover the new age of gene transfer technology (GTT) will gradually render dope testing control systems obsolete; GTT will increase muscle growth by as much as 28%.4 Doping is a major ethical, educational, financial, health and management problem and governments have a poor track record in controlling its spread.
8. Blood doping is now passé and has been superseded by erythropoetin (EPO) and its analogue darbopoetin which surfaced in cross-country ski-ing at the 2002 Winter Olympics. These hormones are abused in endurance sports such as cross-country events and cycling and although new tests have been developed, detection of EPO remains difficult. Indeed problems with recently developed laboratory tests for EPO have undermined confidence in IOC accredited laboratories. A unique identifier for HGH has also been elucidated but requires more work and financial support to standardise the test. 18 Given the lack of a specific test and claims of human growth hormone performance benefits, abuse has markedly increased. The side-effect profile of HGH is particularly grim, the first presentation being acromegalic features. One of the first elite athletes to admit to the abuse of HGH was Ben Johnston.18 A relatively new addition to the fraudulent armamentarium are the artificial oxygen carriers such as haemoglobin solutions and perfluorocarbon emulsions, both of which have potentially lethal side-effects.
9. Prescribed medicines
It can be difficult to interpret and apply the IOC list and guidelines to prescribed medicines. Each medicine needs to be evaluated in its own right and status in sport clarified. Permitted routes of administration can be particularly confusing e.g. nasal steroids are permitted whereas inhaled steroids require notification. A problem unique to Ireland is the brand name variance that exists north and south of the border e.g. Klacid and Klaricid are the same antibiotic. It is not always banned drugs that are abused. Permitted anti-inflammatory agents such as NSAIDs are sometimes taken to not only alleviate pain and swelling but to allow the athlete to continue despite injury. The masking of pain may exacerbate injury. A Swiss study into the use of medications before sporting events showed a prevalence of NSAID use of 5-10%.29 Also many drugs that are permitted in sport may impair performance such as sedatives and some antidepressants. Sample analysis may be hampered by legitimate medicines. The widely prescribed antibiotic trimethoprim is one of the most common drugs to interfere with the testing matrix.
10. Despite the development of advanced drug testing systems, doping in sport, both deliberate and inadvertent, is on the increase in both elite, amateur and school sports. Doping in sport not only contravenes the spirit of fair competition it can be seriously detrimental to athletes' health. Whereas some take drugs to seek deliberate advantage, others feel pressurised into considering doping as the only viable option to level the playing field. Others inadvertently take prohibited substances due to a lack of awareness. A particular problem is the risk of today's supplement culture to accidental exposure and a positive drug test. An effective anti-doping program must incorporate educational components in addition to testing. Education needs to be collaborative and pro-active and include athletes, coaches, managers, governing bodies, and health-care professionals. The increasing problem of drug abuse in junior sports warrants special attention. Simplification and standardisation of procedures, policies and educational strategies is needed at international level. Pharmaceutical legislation needs to change to accommodate safety of medicines in sport. To date, governments have poured too much money into technology and establishment of rigorous drug testing methods without addressing the educational needs of sportsmen and women and youth cultures. Technological advances cannot address what is essentially a behavioural problem.
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