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Performance-enhancing substances: Be aware of the social phenomenon
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Performance-enhancing substances are taken by athletes and non-athletes alike. Many people start each day with a beverage that contains caffeine and multivitamin supplements, and may even support recovery from exercise with protein shakes or drinks that contain creatine.
The nutraceutical market is expected to reach $250 billion in next few years. Nutraceuticals include food, beverages and dietary supplements that provide the potential for improved health for consumers, and potentially improved athletic performance.
A remarkable addition to this list was the development and commercialization of creatine in the 1990s, which has been shown to be beneficial for athletic performance, especially in high-intensity and strength sports. During a walk-through of a professional or collegiate sports locker room, one is likely to see these performance-enhancing substances readily available to the athletes. However, it is the performance-enhancing substances you do not see in the locker room that concern those who deal with patients’ health and manage musculoskeletal problems. Some athletes, driven by their desire to reach their maximum athletic potential, will try any substance that can improve their physical, cognitive or psychological abilities. Therefore, the World Anti-Doping Agency has clearly defined what performance-enhancing substances are prohibited by athletes who compete in sports that have drug testing programs.
Even more challenging to health care providers is the increasing number of people in the general population who use supplements for improved performance in other areas of their life, including physical appearance, strength, cosmetic and cognitive enhancement. Its unmonitored use may result in health care concerns not readily apparent in the management of musculoskeletal problems.
Anthony A. Romeo
Risks can include abnormalities in liver and kidney function, hematopoietic abnormalities and alterations in the healing of tendons and ligaments. Furthermore, the psychological use of performance-enhancing substances can lead patients to be noncompliant with conservative postoperative regimens.
History and stigma
Part of the issue of using performance-enhancing substances is its stigma, for which history sheds some light. The ingestion of animal testicles as a supplement goes back centuries, but the development of synthetic testosterone became public in the 1930s. The German Army and their athletes used the supplements to improve aggressiveness and athletic performance. After World War II, the Russians and Germanic countries dominated world competitions in strength and weightlifting for decades when athletes used performance-enhancing substances. In the 1960s, the sale of anabolic steroids became public.
In 1968, the International Olympic Committee initiated its drug-testing program, but only one athlete tested positive. However, many have speculated that athletes and their physician consultants were able to stay ahead of the testing programs for decades. In 1976, the German women’s Olympic swim team won 11 of 13 gold medals, many of whom had muscles and voices consistent with testosterone supplementation. Not one swimmer tested positive for performance-enhancing substances based on the testing techniques of the time. However, years later, some of the athletes sued their government for giving them high doses of poorly monitored anabolic steroids, beginning as early as their teenage years.
During the last 40 years, the use of performance-enhancing substances has spread throughout athletic competitions. At times, it seems athletes, using pharmacists and physicians, have been in a high-level game with the drug-testing organizations who monitor the various sports, none more rigorously than the Olympics. The “steroid era” of Major League Baseball of the 1990s was an American drama played out on national news for many years. More players than ever hit 40 or more home runs per season. Players, who started careers as talented hitters but without the suggestion they would create historic achievements, have surpassed unattainable records.
It is now clear the use of performance-enhancing substances was rampant in baseball. It is also now evident that athletes caught using performance-enhancing substances are chastised, ridiculed and condemned as cheaters by failing to meet the general standards of morality and legality set for their sport. This characterization has led to continued efforts by the athletes to avoid positive tests for performance-enhancing substances, either by understanding testing protocols or by using substances with a very short window of positive testing.
In response to these efforts, major sports leagues spend millions of dollars every year to randomly test players, hoping to level the playing field. Even today, the “cat-and-mouse” game remains as some sports identify the time of testing so athletes have the opportunity to clear their systems of any markers of performance-enhancing substances.
Public scrutiny
The public scrutiny has led to the stigma that the use of performance-enhancing substances, in general, is immoral and unethical. However, what is unique to sports such as baseball or the Olympics is that these sports focus on highly measureable human performance. It makes sense to avoid the use of performance-enhancing substances so athletic performances can be compared across generations. Other sports, such as American football, have different measurements of success. However, even without the use of illegal performance-enhancing substances, there is an overall increase in the size, speed and athleticism demonstrated by the athletes. The athletes benefit from early age nutrition programs and nutraceutical supplementation, such as multivitamins, creatine, pre-workout supplements and post-workout recovery supplements. There appears to be no evidence of stigma with this form of performance-enhancing substances, and the National Football League has never been “healthier” in terms of fan interest and revenue.
In the general public, it is impossible to know exactly how many people use testosterone supplements or human growth hormone, but by all measures, the number is steadily increasing. Furthermore, these performance-enhancing substances are supplemented by drugs less familiar to physicians, including growth hormone-releasing factor, anti-estrogens, such as tamoxifen, human chorionic gonadotropin and insulin, for its ability to promote glucose absorption and muscle recovery.
Be aware and educate
While the high level athletes get all the attention, we, as physicians who deal with conditions related to the musculoskeletal system, need to be aware of the social phenomenon regarding the use of performance-enhancing substances. This awareness is added to our concerns about illicit drug use, narcotic use, smoking and other patient-related factors that can affect the outcome of medical interventions. We need to be educated about the effects and consequences of excessive use so we can recognize and discuss the issue with patients. For younger athletes, orthopedic surgeons have an even greater role for educating them about the risks of using performance-enhancing substances and safe and valuable alternatives.
The acceptance of performance-enhancing substances in the general population, including adolescent patients, has led to an increasing number of issues related to the supplements that require the continued education of orthopedic surgeons. It is not always possible to recognize the use of performance-enhancing substances, but when it is obvious or when a patient asks questions about their use, it is important to provide accurate and reasonable information.
One area that needs a revamped approach is the historic “scare tactic” that taking any performance-enhancing substance results in permanent problems, such as cancer, impotence, tendon ruptures, enlargement of male breasts, female masculinity and other medical conditions. While there are certainly cases associated with these risks, many athletes and non-athletes take relatively low doses and achieve significant benefit without any long-term effects. If we start the conversation about the horrific risks as if they are common, we lose opportunity to persuade a healthier approach to nutrition and supplementation.
We also need to continue to support the role of monitoring of and testing for performance-enhancing substances in sport. Athletes want to be able to compete against each other knowing their competitors are reaching for their ultimate human performance through proper nutrition, sleep and training techniques without the effects of performance-enhancing substances. We need to be able to discuss the risks of performance-enhancing substances use with not only young athletes, but also the patient population who chooses to use the supplements for goals other than athletic performance.
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Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.