Performance Enhancing Drugs: What Parents Need to Know

Special guest post by Dr. Daniel Warner of Robinwood Orthopaedic Specialty Center.

Dr. Daniel Warner

     In a frequently referenced 1997 Sports Illustrated article, aspiring Olympians were asked two questions; “If you were offered a banned performance-enhancing substance that guaranteed that you would win an Olympic medal and you could not be caught, would you take it?” Remarkably, 195 of 198 athletes said yes. The second question was: “Would you take banned performance-enhancing drugs with a guarantee that you will not be caught, you will win every competition for the next five years, but then will die from adverse effects of the substance?” More than 50 percent of the athletes said yes to this question as well.

     Driven by the popularity of sports and athletes’ drive to succeed, the use of ergogenic (performance enhancing) drugs, or PEDs, is at all-time high in the United States today. Fifty-seven percent of high school students play on formal sports teams, and 1-3 million U.S. athletes nationally are taking some form of performance-enhancing drugs. Many of these athletes are youth who use these substances without knowledge of their risks and potential benefits.

     Powerful dietary supplements and energy drinks have become part of the PED landscape for some athletes. These drinks and supplements can be found in vitamin and grocery stores and even gas stations. Young people are also using dietary supplements in combination with stimulant prescription medications, such as those used for attention-deficit hyperactivity disorder. Ritalin and other amphetamines are used at surprising rates by teenagers.

     In addition to energy and dietary supplements, a growing number of non-elite athletes are using anabolic-androgenic steroids, or AAS, human growth hormones, or HGH, erythropoietin, or EPO and insulin.

     A series in Sports Illustrated outlined the breadth of the problem, which encompasses not only players but also media personalities, police and paramilitary personnel and ordinary Americans who want to look, feel and live “at the top of their game.” Eighty percent of PED users are reported to be non-elite athletes.

    The most common PEDs are anabolic steroids (eg. testosterone, androstanediol), creatine, stimulants (eg. amphetamine, ephedrine), Erythropoitetin, or EPO, and human growth hormone, or HGH. Although ephedra-based dietary supplements—which have also been used by athletes to reduce fatigue, lose weight and improve mental alertness—were banned by the U.S. Food and Drug Administration in 2004, their place is being taken by an increase in the use of drugs to treat ADHD among athletes.

What’s the appeal?
     Athletes may have several reasons for using performance-enhancing drugs. An athlete may want to: build mass and strength of muscles and/or bones; decrease injury recovery time; increase delivery of oxygen to exercising tissues; mask pain; stimulate the body; relax; reduce weight or hide the use of other drugs.

      Why are these drugs so appealing to athletes? Besides making muscles bigger, anabolic steroids may help athletes recover from a hard workout more quickly by reducing the muscle damage that occurs during the session. This enables athletes to work out harder and more frequently without overtraining. In addition, some athletes may like the aggressive feelings they get when they take the drugs.

     Athletes face enormous pressure to excel in competition. They also know that winning can get them more than a gold medal. A star athlete can earn a lot of money and a lot of fame and athletes only have a short time to do their best work. Athletes know training is the best path to victory, but they also get the message that some drugs and other practices can boost their efforts and give them a shortcut, even as they risk their health and their athletic careers.

Are PEDs ever used for medical reasons? 
     Anabolic steroids are used therapeutically in medicine to induce bone growth, stimulate appetite, induce male puberty and treat chronic wasting conditions, such as cancer and HIV/AIDS.

     EPO is used in treating anemia resulting from chronic kidney disease and myelodysplasia from the treatment of cancer.

     In children, HGH injections are approved for treating short stature of unknown cause as well as poor growth due to a number of medical causes.

In adults, approved uses of HGH include:

• Short bowel syndrome, a condition in which nutrients are not properly absorbed due to severe intestinal disease or the surgical removal of a large portion of the small intestine 
• HGH deficiency due to rare pituitary tumors or their treatment 
• Muscle-wasting disease associated with HIV/AIDS 

What are the consequences of using PEDs improperly? 

Men may develop:

• Prominent breasts 
• Baldness 
• Shrunken testicles 
• Infertility 
• Impotence 

Women may develop:

• A deeper voice 
• An enlarged clitoris 
• Increased body hair 
• Baldness 
• Infrequent or absent periods 

Both men and women might experience:

• Severe acne 
• Increased risk of tendinitis and tendon rupture 
• Liver abnormalities and tumors 
• Increased low-density lipoprotein, LDL cholesterol (the "bad" cholesterol) 
• Decreased high-density lipoprotein, HDL cholesterol (the "good" cholesterol) 
• High blood pressure/hypertension 
• Heart and circulatory problems 
• Prostate gland enlargement 
• Aggressive behaviors, rage or violence 
• Psychiatric disorders such as depression 
• Drug dependence 
• Infections or diseases such as HIV or hepatitis if you're injecting the drugs 
• Inhibited growth and development and risk of future health problems in teenagers 

What symptoms could help identify someone who is abusing PEDs?

Possible red flags include:

• Behavioral, emotional or psychological changes — particularly increased aggressiveness ("roid rage") 
• Changes in body build, including muscle growth, rapid weight gain and development of the upper body 
• Increased acne and facial bloating 
• Needle marks in the buttocks or thighs 
• Enlarged breasts in boys or smaller breasts in girls 
• The bottom line… people who are abusing PEDs will not be themselves. 

Is damage done from improper use of PEDs reversible? 

     In males, changes that can be reversed include reduced sperm production and shrinking of the testicles (testicular atrophy). Irreversible changes include male-pattern baldness and breast development (gynecomastia).

     In the female body, anabolic steroids cause masculinization. Breast size and body fat decrease, the skin becomes coarse, the clitoris enlarges and the voice deepens. Women may experience excessive growth of body hair but lose scalp hair. With continued administration of steroids, some of these effects become irreversible.

     Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during puberty and adolescence and provide the signals to stop growth as well. When a child or adolescent takes anabolic steroids, the resulting, artificially high, sex hormone levels can prematurely signal the bones to stop growing.

     Steroid abuse has been associated with cardiovascular diseases, including heart attacks and strokes, even in athletes younger than 30.

     Many abusers who inject anabolic steroids may use nonsterile injection techniques or share contaminated needles with other abusers. In addition, some steroid preparations are manufactured illegally under nonsterile conditions. These factors put abusers at risk for acquiring life-threatening viral infections, such as HIV and hepatitis B and C.

      The most dangerous of the withdrawal symptoms from anabolic steroid use is depression because it sometimes leads to suicide attempts.

References:
http://www.resoundinghealth.com/casebook/show/206
http://www.dmos.com/articles/Honkamp_Youth_Athletes_Feb_08.pdf
http://www.mayoclinic.com/health/performance-enhancing-drugs/HQ01105
Hayashi, A, AAOS Now,” PED use: Legal, natural, and deadly”, Oct 2008
Schafer, M, Porucznik, M, AAOS Now, “If you’re not cheating, you’re not trying”, June 2008