Performance-Enhancing Drugs?

The question of the use of performance-enhancing drugs has been in the newspapers lately, especially as regards baseball players and anabolic steroids. We are here going to discuss the use of many "performance-enhancing" drugs, with regard to their utility (do they really improve performance?), their legality, and whether or not a particular sport bans them. This blog will not discuss the morality of such drug use. I would like to point out, however, that if a drug both improves performance AND has dangerous side-effects, then it may be unfair to force other athletes to risk their health to compete on the same level as a drug-user.

We are not here going to discuss in detail the problem of false-positive urine tests. For those interested in this topic, there was an article several years ago in JAMA, or you can go back in time and read Jerry Rubin's "Steal This Urine Test". We all recall the Seinfeld episode (based on true events) when Elaine tested positive for opium because she had eaten a poppy-seed bagel. There is also the problem of finding a possible drug-masking chemical in your urine (e.g. a diuretic can dilute your urine below the testing cutoff), so the presence of a diuretic can be considered evidence of an attempt to falsify the test. Some companies who refuse to hire cigarette smokers test their urine for co-nicotine, a metabolite of nicotine. Unfortunately, tomatoes and several other vegetables contain a high concentration of co-nicotine, so some vegetarians will test positive for this chemical. As I recall, Advil can give a false-positive urine test for marijuana, and Robitussin a false positive test for PCP.

The question of legality of the drug is an interesting one. Lasix, which reduces pulmonary hemorrhage in horses, is legal only in New York State horse races.
Some sports events permit the use of inhaled beta-agonists for preventing exercise-induced asthma, and others do not. Some drugs are available in certain countries only by prescription, while in other countries they can be purchased over-the-counter, and they may be illegal in a third country.

The first question is whether or not a drug actually enhances athletic performance. We immediately run into the placebo effect, which has been shown to be as high as 30% in some cases. That is, a drug may not actually improve performance, but if an athlete believes that it does, it may. This is not farfetched: if you tell a hypnotized person that you are going to burn them and touch their forearm with an ice cube, they will develop a blister and reddening, just as if they were burned. Or, you can tell a group of subjects that they are about to receive a sleeping pill (or a CNS stimulant), and many will fall asleep rapidly in one case, and stay awake in the other.

STEROIDS (Anabolic, i.e. chemically related to testosterone): I have seen no published research that anabolic steroids improve baseball performance, or any other peak athletic performance. Yes, they do increase muscle mass (so weight lifters and body builders will use them), but it has not been shown that it enables you to drive a baseball or golf ball further, or serve harder in tennis, or throw a football further. It can make football lineman heavier, but it has not been shown to make them any quicker.

GROWTH HORMONE: I have read three studies. One of the two done in older men showed an increase in lean muscle mass, and the other did not. The third was done in younger men, and again showed a slight increase in muscle mass, but increase in athletic performance was not tested for.

CAFFEINE: I suppose we all used No-Doz (= caffeine in two cups of coffee) in college to help us stay up all night to study and then be awake enough to take the test the next day. I know of one study that showed increased scores in the GRE's, and caffeine does increase overall mental alertness. It also may decrease reflex reaction time in some sports, so you can hit the tennis ball earlier, etc. Caffeine also potentiates the pain relieving effects of aspirin and acetimenophen.

BETA-BLOCKERS (INDERAL): These medicines block the effect of adrenalin in your body and, if the drug is lipophilic and crosses the blood-brain barrier (as does Inderal) can exert a CNS calming effect, and I find it especially useful to treat patients with Mitral Valve Prolapse with associated palpitations and/or anxiety attacks. Because it also reduces tremors, many solo concert violinists will take Inderal before a performance. However, in the Biathlon in the Olympics, beta-blockers are banned. In the Biathlon, you ski and then shoot at a target. Obviously, the sooner your heart rate decreases and your hand tremor decreases, the sooner you will have a more accurate shot.

RITALIN: This (and Strattera, Concerta, and several other methylphenidate congeners) are used for students with ADD or ADHD.It seems to enhance concentration and improve academic performance. Since there can be a genetic component, often when a male teenager is diagnosed with ADD, his father also tries Ritalin, and finds that he functions more efficiently at the office. From what I have seen, Ritalin and other CNS stimulants do improve concentration (think of it as a stronger and longer-lasting form of caffeine). It seems that Ritalin makes the brain function more rapidly and more efficiently, and one wonders if all students would be better students if they were on Ritalin. In addition, if one is diagnosed with ADD, then, in addition to Ritalin, the student is given more time to take the SAT's, LSAT's, etc., even though (and this is not a pejorative comment) in the real world a judge will not give a lawyer with ADD an extra week in which to write a brief.

BENZEDRINE: This and other CNS stimulants was issued by the U.S. Gov't. to pilots on long-range missions, and other military members for PRN use when falling asleep could be dangerous.

VIAGRA: (or CIALIS or LEVITRA): This definitely improves the rapidity of penile erection in response to direct physical stimulation, and makes the penis firmer for a longer period of time. The drug is also a direct dilator of the pulmonary artery and its branches in the lung, and has an accepted medical use to treat primary pulmonary hypertension (a disease that can be fatal) as well as prevent high-altitude pulmonary sickness.

HYPNOTICS: The use of sleeping pills is well-accepted, and the only arguments seem to be the length of time they should be used, and whether or not all early-morning awakening is a sign of depression.

ATIVAN/VALIUM/XANAX: I have several patients who will take one of these half an hour before giving a speech or attending a meeting when senior executives will be present. When taken for this reason, the anxiolytic prevents paralyzing anxiety attacks, and permits the patient to function more efficiently.

PROZAC/ZOLOFT/PAXIL: Social phobia and panic attacks are real phenomena. Patients who need this drug to function do function more efficiently. They are encouraged to also get psychiatric help, but often their HMO does not cover it. Whether their personality when they take the drug is the "real" them is, I think, a question for metaphysicians, not family doctors.

TESTOSTERONE: Both men and women manufacture testosterone. I baseline the free testosterone level of all my patients at 40 years of age. If their sex drive then decreases to the point that they are bothered, (whether or not they are depressed), I repeat the measurement, and I use testosterone gel if it has decreased. There have been several articles by a Canadian Ob-GYN showing that menopausal women will also have increased sexual satisfaction if their testosterone level is raised to their pre-menopausal level.

ESTROGEN: Pills or vaginal cream. Some women have a decrease in sex drive and/or severe vaginal dryness in menopause. Many of them benefit from topical or oral estrogen replacement (which may also lead to a decrease in urinary tract infections). I explain this to them and refer them to their gynecoligist.

DIET PILLS: Whether or not they work, they can act as a mild anti-depressant, much in the same way that psychiatrists will prescribe low-dose Dexedrine to nursing home patients to improve their appetites.

DIURETICS: Too dangerous for chronic use for weight loss, but this does not stop jockeys and wrestlers to "make the weight".

PROVIGIL: The latest CNS stimulant on the market. It is prescribed for sleep-shift disorders, or chronic daytime fatigue. It is very popular for medical interns and residents for this very reason. I am unaware of any studies vis-a-vis the improvement of one's abilities as a student.

One of my patients reminded me of Dupont's slogan: "Better living through chemistry". This is ultimately a moral question, of course, in addition to a medical one. Each and every patient is a different combination of biochemicals, brain-body interactions, thought processes and belief systems, so each prescription must be thoroughly discussed with the patient by his family physician, who should be aware of the patient's expectations and limitations, and re-evaluates the patient carefully at periodic intervals.