Doping in Endurance Sports

Alistair Simpson / Consultant Anaesthetist / NHS Lothian

Following the Tour de France and the recent revelations from the world of athletics, doping is once again in the news. We know that many of our readers are athletes themselves or spend time covering endurance events so we asked Dr Alistair Simpson, anaesthetist and international triathlete, to talk us through its history, testing and some interesting and infamous drugs of abuse.

Fausto Coppi with Riccardo Filippia winning the Trofeo Baracchi in 1953 (Wikimedia Commons)

Interviewer: “Do cyclists take la bomba (amphetamine)?”

Coppi: “Yes, and those who claim otherwise, it’s not worth talking to them about cycling.”

“And you, did you take la bomba?”

“Yes. Whenever it was necessary.”

“And when was it necessary?”

“Almost all the time!^”

So ran the famous dialogue between an interviewer and Fausto Coppi, an Italian cyclist of the 1940s and 50s regarded by many as one of the finest – if not the finest cyclist – the world has ever seen. We may be amused or surprised by their conversation, but our surprise is perhaps more at the candour of Coppi rather than the reality which he unveils. After all, who believes cyclists – particularly from that era – to be ‘clean’, i.e. competing without the benefit of banned ergonomic aids? Indeed, cycling has been so mired in seemingly endemic doping that even now many of the public believe professional cyclists to be routinely using banned substances. And whilst it is certainly true that the sport has changed and that doping is not nearly as prevalent as it once was, the infrequent but recurring reports of riders yielding positive results does little to dissuade this belief.

However, it would be naïve to think that it is only cycling that suffers from doping. Indeed there are many instances of athletes from a wide variety of sports being found using banned substances. Marion Jones (anabolic steroids), Dwain Chambers (anabolic steroids), Justin Gatlin (amphetamines and testosterone/related drug), Pakistani fast bowlers Shoaib Akhtar and Mohammad Asif (anabolic steroids) and American tennis player Wayne Odesnik (steroids) are just some of those who have sought an advantage beyond that allowed by the sporting body of conduct.

A paradigm shift

Attitudes have not always been thus. In the early twentieth century, some teams would actively advertise their adoption of the latest techniques with which they sought to gain an advantage over their competitors. This acceptance of performance enhancing drugs mirrored the public’s attitude to recreational drug use, which at that time was seen as far more acceptable than it is now. However, by the 1960s, the public attitude towards recreational drug use had shifted and with it, views about the use of performance enhancing drugs. The death of one of Britain’s finest cyclists, Tom Simpson, during the 1967 Tour de France and the subsequent discussion of his amphetamine use, also contributed towards changing perceptions and moves towards controlling and banning substances.

While the public’s attitude may have changed, the actual use of doping in sport did not. Just as cycling moved from amphetamines to other ergogenic aids such as erythropoietin, athletes in other sports also secretly embraced drugs which were perceived to give them an edge. Doping was also not limited to individual athletes: some countries, in an attempt to demonstrate the superiority of their political idiom on the world stage, embarked on state-sponsored doping. Indeed, following the fall of the Iron Curtain, documents became available that detailed the use of performance enhancing drugs in a wide range of athletes on an industrial scale.

Legalisation and the WADA Criteria

So where does this leave us today? There are those who would call for all drugs to be legalised, thus creating a level playing field and avoiding the need for testing. Certainly this would resolve anomalies in the system, where a drug such as caffeine – one of the more effective drugs at improving sporting performance – is legal, whereas others are not. It would also solve the problem of trying to keep track of illegal drug manufacturers, who create new and innovative ways of delivering a sporting edge while avoiding being caught by drug testers. And herein lies the ethical heart of the debate: should the use of performance enhancing drugs be legalised? If not, why not? And what actually constitutes doping as opposed to nutritional supplementation or training techniques?

The international governing body for the control of doping in sport is the World Anti-Doping Agency (WADA). WADA sets out three criteria for banning substances which go some way towards defining doping and providing the arguments in favour of controlling it. The three criteria are: (1) posing a health risk to the athlete; (2) enhancing performance; and (3) being against the spirit of the sport. It should be noted that for a drug to be banned, only two of these three criteria must be fulfilled. Let’s consider each criterion in turn:

1) Health risk to the athlete

This ultimately is a paternalistic view, but would be well supported by cases of morbidity and mortality as a result of doping. Whilst some may argue that legalising doping may be safer for the health of athletes, this seems unlikely since a certain cohort of athletes will still try to seek an additional advantage, often secretively, involving inherently greater risks. Legalised doping may also pressure athletes into taking substances they would otherwise have avoided through a financial imperative and to meet the expectations of sponsors.

2) Performance enhancement

This argument is the most straightforward: an athlete gains an advantage over a competitor through means which are not deemed to be fair, i.e. cheating. However, things become more complicated when one tries to define why drugs are seen as cheating compared to, for example, new training methods. Again, we come back to society’s ideas regarding drug use. Public attitudes to recreational and performance enhancing drug use are inherently linked. Therefore, it follows that if our society generally perceives recreational drug use negatively, so too will performance enhancing drugs be considered to be negative in the context of sport. In this sense the method of drug ingestion is also important: food, such as coffee (containing caffeine) and beetroot juice (which increases nitric oxide levels) and work such as altitude training camps (increasing erythropoietin levels, amongst other beneficial physiological adaptations) are seen as acceptable. However, undisguised drugs in the form of pills or injections are viewed negatively and banned.

(3) Against the spirit of the sport

The final argument regards notions such as fairness and fair play, which create a positive image of sport and in turn resonate with most observers of sport. Although this is clearly very idealistic, there are practical implications too: sport is a business, and it must have a positive image if it is to attract viewers and sponsors alike. For a demonstration of the power of negative publicity, witness the wholesale withdrawal of sponsors from athletes (such as Lance Armstrong) and teams (such as the Rabobank cycling teams) following doping allegations.

The trouble with testing

While WADA continues to prohibit the use of certain drugs, athletes must be tested for the presence of these substances for the ban to be enforced. This is not an easy task. Some drugs have a short half-life but have performance enhancing effects which last much longer. Drug testing may be undertaken in or out of competition, and sometimes with no prior warning, but even then the statistical chances of yielding a positive result may still be low. Drug developers may also attempt to avoid a positive test by developing new drugs which are not tested for but which provide proven benefits. Therapeutic Use Exemption (TUE) certificates may also be abused, allowing banned substances to be used under the pretence of a legitimate medical need. This is one of the accusations which has been made against Nike Oregon Project coach Alberto Salazar.

The biological passport was introduced to address some of these issues: an athlete’s baseline biological markers are measured and recorded, and then these values are rechecked at intervals to detect anomalies which may suggest doping. It is an effective method, at least in theory, and is currently used in athletics, football and professional cycling.

Doping is not new and nor is it going to be eliminated soon. Nevertheless, it is important to attempt to detect doping and deter would-be dopers. Easy access to banned substances via the internet and the development of new drugs makes this all the more challenging. We have rules which govern which drugs can and cannot be used, just like rules in every other aspect of sport. As athletes, spectators and observers, we must ensure these rules are adhered to and we must continue to strive to ensure that everyone plays fairly.

The WADA Prohibited List

WADA effectively regulates doping at an international level through the publication of its World Anti-Doping Code and its associated Prohibited List. It is funded and operated by an equal mix of sporting representatives and governmental figures from various different countries. The Prohibited List is revised annually and states what substances and methods are legal or illegal, both in and out of competition. As might be expected, it is an extensive document. Below is a selection of some of the infamous and unusual substances featuring on the list.

Erythropoietin (EPO)

As abused by / Lance Armstrong and many, many other endurance athletes

Why abuse it? / Stimulates RBC production, increasing haematocrit and thus oxygen-carrying capacity, increasing oxygen delivery to muscles

Of note / In an attempt to circumvent EPO testing, athletes have turned to alternatives such as continuous erythropoietin receptor activator (CERA). Although CERA is also banned (and tested for), other red cell stimulators are likely to be abused in the future.

Blood transfusions

As abused by / Athletes implicated in Operación Puerto

Why abuse it? / Raises haematocrit thereby increasing oxygen delivery to tissues

Of note / Blood transfusions can be either autologous (from the individual) or allogenic (from another donor). Many athletes were implicated in the practice through the Spanish police operation Operación Puerto in 2006. Although much of the attention has been on professional cyclists, athletes from other sports were also implicated including football and tennis.

Testosterone

As abused by / Ben Johnson (track sprinter), Dennis Mitchell (track sprinter), and a lot of East Germany’s female athletes

Why abuse it? / Testosterone increases muscle protein synthesis via activation of IGF-1 (which explains why IGF-1 is also banned) and uses amino acids more efficiently inside muscle cells. Muscle size, strength and fat-free mass is increased.

Of note / Interestingly, it is not clear if testosterone increases maximum achievable performance or if the same effect could be reached by training alone. There is no ambiguity for female athletes, where there is a clear improvement in performance. Side effects include male characteristics, which may actually curb its use in women.

Amphetamines

As abused by / Cyclists before they discovered EPO, e.g. Tom Simpson

Why abuse it? / Removes limiters to exercise intensity, allowing repeated very high intensity exertions

Of note / When establishing whether or not amphetamines work, there is an intrinsic problem of separating the physiological benefit from the psychological effect. The psychological effect may even cause a physiological improvement by removing limiters to exercise. Ultimately the evidence is somewhat equivocal.

Caffeine

As abused by / Anyone who wants a legal improvement in athletic performance

Why (ab)use it? / Caffeine is a competitive antagonist at adenosine receptors and stops dopamine-mediated inhibitory pathways, allowing exercise to continue for longer. It can improve time to exhaustion in running and cycling by a remarkable 20-50%.

Of note / Caffeine was previously banned by WADA, but now features on their watch list. The means caffeine is tested for so that WADA can monitor its usage, but it remains legal.

Xenon

As abused by / The Russians

Why abuse it? / Works by stimulating hypoxia-inducible factor (HIF)-1a and thus stimulating EPO.

Of note / Xenon is cleared from the body after a few hours but its effects last for days, making detection difficult. Although it was used by Russian athletes with governmental approval, it was added to the Prohibited List in September 2014.