Doping in Sports Michael J. Ross, MD Sports Medicine Physician, Rothman Institute Medical Director,...

Doping in SportsDoping in SportsMichael J. Ross, MDMichael J. Ross, MD

Sports Medicine Physician, Rothman InstituteSports Medicine Physician, Rothman InstituteMedical Director, The Performance LabMedical Director, The Performance Lab

August 24, 2012

August 25,2012

• 9/20/069/20/06

• Floyd Landis Floyd Landis becomes the first becomes the first Tour de France Tour de France winner to have winner to have his title revoked his title revoked for dopingfor doping

• Discuss some of the common doping Discuss some of the common doping agents abused by athletesagents abused by athletes

• Anabolic steroidsAnabolic steroids

• Other anabolicsOther anabolics

• StimulantsStimulants

• Blood dopingBlood doping

• Discuss strategies for obtaining Discuss strategies for obtaining desired effects without dopingdesired effects without doping

Doping at a glanceDoping at a glance

• 2007 Christian Moreni arrested at 2007 Christian Moreni arrested at Tour de FranceTour de France

• 2007 Mattias Kessler2007 Mattias Kessler

• 2007 Brazilian defender Marcao, 2007 Brazilian defender Marcao, suspended four months after testing suspended four months after testing positive for finasteride. (Masking positive for finasteride. (Masking agent)agent)

TestosteroneTestosterone

• 1996 Dean Capobianco, Australian 1996 Dean Capobianco, Australian 100m champion, tests positive for 100m champion, tests positive for anabolic steroid stanozolanabolic steroid stanozol

• Blames red meatBlames red meat

• 1996 Dieter Baumann 1500m and 1996 Dieter Baumann 1500m and 5000m5000m

• Blames positive testosterone test Blames positive testosterone test on spiked toothpasteon spiked toothpaste

TestosteroneTestosterone

• April 2006 Justin April 2006 Justin Gatlin Olympic Gatlin Olympic gold sprinter-gold sprinter-facing 8 year ban facing 8 year ban

• August 2007 August 2007 Chicago Bears Chicago Bears fullback Obafemi fullback Obafemi Ayanbadejo-4 Ayanbadejo-4 game suspensiongame suspension

TestosteroneTestosterone

• 1998 Dennis Mitchell 400m relay 1998 Dennis Mitchell 400m relay gold medalist and 4 time US gold medalist and 4 time US championchampion

• Had sex four times the previous Had sex four times the previous night and a lot of beernight and a lot of beer

TestosteroneTestosterone

• Increases Lean muscle massIncreases Lean muscle mass

• Increases red blood cell volumeIncreases red blood cell volume

• Decreases Body FatDecreases Body Fat

Testosterone effectsTestosterone effects

• AcneAcne

• Testicular Testicular suppressionsuppression

• Coronary Artery Coronary Artery DiseaseDisease

Testosterone side Testosterone side effectseffects

• Victor Conte

• Bassist, Nutritional Consultant, Convict

• Produced designer androgens

• custom-developed for elite professional athletes to evade doping detection

Bay Area Lab Cooperative

• Testosterone and EpiTestosterone are produced in equal amounts from a precursor

• If the Ratio of Testosterone:EpiTestosterone is greater than 1:1, doping is suspected

• Cutoff is 4:1

• RadioImmunoAssay

Detecting Testosterone

• Testosterone increases in response to:Testosterone increases in response to:

• IntervalsIntervals

• Strength trainingStrength training

• Testosterone decreases in response toTestosterone decreases in response to

• Low Intensity Endurance training Low Intensity Endurance training (L.I.E.)(L.I.E.)

Increasing Increasing Testosterone Testosterone

• One of the major hormones for One of the major hormones for controlling blood sugarcontrolling blood sugar

• Non functional in diabeticsNon functional in diabetics

• Synthetic insulin used to have a “C-Synthetic insulin used to have a “C-peptide,” not in recombinant insulinpeptide,” not in recombinant insulin

InsulinInsulin

• Insulin as a drug of abuse in body Insulin as a drug of abuse in body buildingbuildingBr. J. Sports Med., Aug 2003; 37: 356 Br. J. Sports Med., Aug 2003; 37: 356 - 357. - 357.

• Insulin is anabolic at large doses.Insulin is anabolic at large doses.

• Imports amino acids into cells to Imports amino acids into cells to speed recovery and muscle buildingspeed recovery and muscle building

• Imports glucose into muscle cells to Imports glucose into muscle cells to be stored as glycogenbe stored as glycogen

What it doesWhat it does

• Too much can cause low blood Too much can cause low blood sugar, change in mental status and sugar, change in mental status and comacoma

• Fat deposition at injection siteFat deposition at injection site

• Can only be used in cases of Can only be used in cases of glycogen depletionglycogen depletion

• AdiposityAdiposity

Side EffectsSide Effects

• Bodybuilders find it easy to obtain Bodybuilders find it easy to obtain insulin to help them in traininginsulin to help them in training

• BMJBMJ 1997;314:1280 (26 April) 1997;314:1280 (26 April)

• Glycogen depletionGlycogen depletion

• Replace calories as high glycemic Replace calories as high glycemic carbohydratecarbohydrate

• Incorporate protein into recovery Incorporate protein into recovery mixmix

• 1g/kg carbohydrate + 0.3g/kg 1g/kg carbohydrate + 0.3g/kg proteinprotein

What else to doWhat else to do

• Anabolic hormoneAnabolic hormone

• Secreted in pulses, the largest pulse Secreted in pulses, the largest pulse happens in the first 1 hour of sleephappens in the first 1 hour of sleep

Growth HormoneGrowth Hormone

• Increases recovery (acute)

• Increased amino acid uptake into muscle

• Increased glycogen through glucose uptake

• Increases Energy (chronic)

• Stimulates fatty acid release from adipose tissue

• Increases sensitivity to fatty acid release

GH Effects

• 6/06: Diamondback pitcher Jason 6/06: Diamondback pitcher Jason Grimsley possessed a season's Grimsley possessed a season's worth of hGH, federal indictmentworth of hGH, federal indictment

• 9/07: Washington Redskins tackle 9/07: Washington Redskins tackle Jon Jensen:"very naive and foolish" Jon Jensen:"very naive and foolish" to think that NFL players aren't to think that NFL players aren't using human growth hormone.using human growth hormone.

• "maybe 15, 20%" of the league's "maybe 15, 20%" of the league's players use illegal performance-players use illegal performance-enhancing substances. enhancing substances.

• Wade Wilson, Dallas Cowboys QBWade Wilson, Dallas Cowboys QB

Braces and a six pack

• GH deficiencyGH deficiency

• Pituitary disorder Pituitary disorder

• GH a potential treatment for: GH a potential treatment for:

• frailtyfrailty

• osteoporosisosteoporosis

• morbid obesity morbid obesity

• cardiac failurecardiac failure

Growth hormone (GH) Growth hormone (GH) replacementreplacement

• Increases recovery (acute)Increases recovery (acute)

• Increased amino acid uptake into muscleIncreased amino acid uptake into muscle

• Increased glycogen through glucose Increased glycogen through glucose uptakeuptake

• Increases Energy (chronic)Increases Energy (chronic)

• Stimulates fatty acid release from Stimulates fatty acid release from adipose tissueadipose tissue

• Increases sensitivity to fatty acid releaseIncreases sensitivity to fatty acid release

• Increases lean muscle massIncreases lean muscle mass

What it doesWhat it does

• CancerCancer

• Bony ChangesBony Changes

• Jaw and ForeheadJaw and Forehead

• Long bones if still growingLong bones if still growing

• Coronary artery diseaseCoronary artery disease

• CardiomyopathyCardiomyopathy

Side EffectsSide Effects

19922005

• Restful sleepRestful sleep

• Avoid pre-bedtime snacks containing Avoid pre-bedtime snacks containing fat or carbohydratefat or carbohydrate

• Encourage training intensity, while Encourage training intensity, while discouraging training volume discouraging training volume without intensitywithout intensity

• Arginine as “secretogogue”Arginine as “secretogogue”

What else to doWhat else to do

• Catabolic hormoneCatabolic hormone

• Release glucose and fatRelease glucose and fat

• Stress steroidsStress steroids

GlucocorticoidsGlucocorticoids

• Increased energy from release of Increased energy from release of sugar and fatsugar and fat

What it doesWhat it does

• Muscle breakdownMuscle breakdown

• Central obesityCentral obesity

• Moon faciesMoon facies

• OsteopeniaOsteopenia

• Adrenal suppressionAdrenal suppression

Side EffectsSide Effects

• Caffeine for fatty acid releaseCaffeine for fatty acid release

• Maximize glycogen Maximize glycogen “supercompensation”“supercompensation”

What else to doWhat else to do

• Increase alertness and (perceived) Increase alertness and (perceived) energyenergy

• Mimics effects of adrenalineMimics effects of adrenaline

• CocaineCocaine

• AmphetamineAmphetamine

• PhenylpropanolaminePhenylpropanolamine

• EphedrineEphedrine

StimulantsStimulants

• VO2max= HR x SV x (A-V)02

• 2005 Mariano Puerta, French Open 2005 Mariano Puerta, French Open finalistfinalist

• Traces of cardiac stimulant in Traces of cardiac stimulant in bloodblood

• Claimed it was from his wife’s Claimed it was from his wife’s menstrual pain medication when menstrual pain medication when he drank her waterhe drank her water

• 1999 Javier Sotomayor, Olympic 1999 Javier Sotomayor, Olympic high jump gold medalist and world high jump gold medalist and world record holder, tests positive for record holder, tests positive for cocaine at Pan Am Gamescocaine at Pan Am Games

• Fidel Castro blames it on a CIA Fidel Castro blames it on a CIA conspiracyconspiracy

• NCAA reports an increase in positive NCAA reports an increase in positive stimulant (and cocaine) tests since stimulant (and cocaine) tests since 2001-20022001-2002

• 58.3% of collegiate hockey players 58.3% of collegiate hockey players admit to stimulant (ephedrine, admit to stimulant (ephedrine, pseudoephedrine, amphetamin) usepseudoephedrine, amphetamin) use

• Current Sports Medicine Reports, September,2004Current Sports Medicine Reports, September,2004

• April 2004: Track sprinter Torri April 2004: Track sprinter Torri Edwards tests positive for Edwards tests positive for Nikethamide-2 year ban. Nikethamide-2 year ban. “Accidentally” taken in an over the “Accidentally” taken in an over the counter medicationcounter medication

• 2003 100m and 200m sprinter Kelli 2003 100m and 200m sprinter Kelli White tests positive for ModafinilWhite tests positive for Modafinil

• 1998 Dennis Mitchell 400m relay 1998 Dennis Mitchell 400m relay gold medlaist tests positive for gold medlaist tests positive for testosteronetestosterone

• Cory Stringer All-pro offensive Cory Stringer All-pro offensive linemandied from combination of linemandied from combination of ephedra and heat illnessephedra and heat illness

• 2003 Steve Belcher dies of heat 2003 Steve Belcher dies of heat stroke while using ephedrinestroke while using ephedrine

• 2007 800m freestyle world 2007 800m freestyle world champion Oussama Mellouli banned champion Oussama Mellouli banned for 18 monthsfor 18 months

• Increases time to exhaustionIncreases time to exhaustion

• Increases cardiac outputIncreases cardiac output

• Increases liver and muscle glycogen Increases liver and muscle glycogen releaserelease

• Bronchial dilatationBronchial dilatation

• Appetite suppressantAppetite suppressant

Ephedra: What it Ephedra: What it doesdoes

• Pre-disposition for heat illnessPre-disposition for heat illness

• Appetite suppressantAppetite suppressant

• Insomnia (affects GH)Insomnia (affects GH)

• Tachycardia, arrhythmias and heart Tachycardia, arrhythmias and heart diseasedisease

• Mental status changesMental status changes

• Fatigue depression and lethargyFatigue depression and lethargy

Side EffectsSide Effects

• Caffeine 4-5mg/kg + Caffeine 4-5mg/kg + pseudoephedrine 1mg/kgpseudoephedrine 1mg/kg

• Minimizes side effects, maximizes Minimizes side effects, maximizes ergogenic effectergogenic effect

What else to doWhat else to do

• Muscles perform best when they can Muscles perform best when they can use oxygen and glucose to make use oxygen and glucose to make energy.energy.

• Red blood cells transport oxygen Red blood cells transport oxygen from the lungs to the musclesfrom the lungs to the muscles

BloodBlood

• VO2= HR x SV x (A-V)02

• Spanish police raid a lab/office of Spanish police raid a lab/office of Madrid based hematologist, Madrid based hematologist, Eufamanio FuentesEufamanio Fuentes

• Multiple high-end athletes implicated Multiple high-end athletes implicated in his blood doping ringin his blood doping ring

• Spanish soccer

• Tennis

• Cycling

Operation PuertoOperation Puerto

• Extra blood increases Extra blood increases aerobic/endurance potentialaerobic/endurance potential

• 1984 Ed Burke, PhD and US Cycling 1984 Ed Burke, PhD and US Cycling Federation coaches admit to Federation coaches admit to providing homologous and providing homologous and autologous blood transfusions to US autologous blood transfusions to US Olympic Cycling TeamOlympic Cycling Team

• US wins gold in the Road Race and US wins gold in the Road Race and medals for the first time since 1912medals for the first time since 1912

• Who wins, where were the 1984 Who wins, where were the 1984 Olympics held?Olympics held?

Alexi GrewalFirst gold medal in

road cycling since 1912

Alexi had just

finished a 2 week

suspension for

ephedrine

• ErythropoetinErythropoetin

• 12-15% increase in power12-15% increase in power

• Decreased lactate accumulationDecreased lactate accumulationEur J Appl

Physiol. 2002 Mar;86(5):442-9

• 7% increase in VO2max 7% increase in VO2max MSSE 2000 Jul;32(7)MSSE 2000 Jul;32(7)

• rEPO v AranesprEPO v Aranesp

• CERACERA

• Take it out, train, put it backTake it out, train, put it back

• EPO changed everything...All of a sudden whole teams were ragingly fast; all of a sudden i was struggling to make the time limits...I’d be on climbs, working as hard as I’d ever worked, and right alongside me would be these big-assed guys, and they’d be chatting like we were on the flats!

• Andy Hampsten, winner Tour of Italy

• Fleche Wallone, 1994: three riders from Gewiss team rode away from the pack

• After the race, team doctor Michele Ferrari was asked about EPO use

• “I don’t prescribe the stuff, but you can buy EPO in Switzerland without a prescription”

• “EPO is not dangerous; it’s the abuse that is. It’s also dangerous to drink 10 liters of orange juice”

• Late 1980’s and early 1990’s Dutch Late 1980’s and early 1990’s Dutch cyclists keep dying in their sleepcyclists keep dying in their sleep

• Blood is too thick and clots develop Blood is too thick and clots develop with the slow heart ratewith the slow heart rate

• Risk of blood borne diseasesRisk of blood borne diseases

• Ricco: septic after transfusionRicco: septic after transfusion

• WADA spent millions of dollars over years

• Ferrari took 5 minutes

• Microdosing not detected by Blood Passport Eur J Appl Physiol 2011 Sep;111(9)

EPO Dosing

• Altitude trainingAltitude training

• Altitude tentsAltitude tents

• Hypoxic trainingHypoxic training

What else to doWhat else to do

• Beware the athletesBeware the athletes

• Know what is being usedKnow what is being used

• Know what training/dietary Know what training/dietary alternatives to offeralternatives to offer