Health care delivery is changing rapidly and that brings new opportunities for error, according to a speaker at the 34th midyear clinical meeting of the American Society of Health-System Pharmacists (ASHP), held in Orlando, Florida, from December 5 to 9, 1999. Almost 16,500 people gathered at the Orange County convention centre for the meeting, including participants from 35 countries. This three-page report, contributed by Laurence Goldberg (consultant pharmacist) and Christine Clark (medical writer) looks at some of the topics covered
If athletes were offered a drug that would guarantee an Olympic gold medal, but carried a 50 per cent risk of death within five years, 80 per cent would take the drug, Dr Michael Linder (director, sports medicine programme, University of Alabama, school of medicine) told the ASHP meeting. He added that dietary supplements were used extensively by young athletes and accounted for $6bn sales annually. Many of the products were heavily advertised. As they were not licensed medicines, it was not necessary to demonstrate product safety before they were offered for sale.
Drugs had long been used to enhance performance, explained Dr Linder. For example, anabolic steroids had been used to increase aggressiveness during the 1939-45 world war and hashish was used to reduce fear in Muslim soldiers fighting the crusaders. More recently, performance-enhancing drugs had made their entry into professional sport. At the 1956 Olympic games, Russian sportsmen had been found to be using anabolic steroids and at the 1960 Olympic games a cyclist's death had been linked to the use of amphetamines.
It was important to understand that a successful athletic performance might depend on a change as small as a fraction of 1 per cent, said Dr Linder. Anabolic steroids did improve performance in the short term and it was counter-productive to deny this. Athletes simply distrusted pharmacists and doctors who said that anabolic steroids were unhelpful and only increased the risk of early death. There was a tendency now to use naturally occurring testosterone supplements. The clearest evidence of abuse was given by the testosterone:dehydroepitestosterone ratio. This was normally 1:1 and a ratio of 1:6 or above indicated abuse.
Stimulants were used to induce euphoria, increase alertness and to decrease perceptions of fatigue. They included amphetamines, pseudoephedrine, ephedrine and phenylpropanolamine. Dr Linder said that pseudoephedrine was a favourite of his local hockey team, although there were no studies or dose recommendations to support the use of either pseudoephedrine or ephedrine. Ephedrine was readily available in weight-loss products, some of which contained up to three times the FDA-approved dose.
Caffeine was a proven performance-enhancer, although it required plasma levels of more than 12mg per ml, the equivalent of a 1000mg dose in three hours.
The performance benefits of cocaine were questionable and heavily outweighed by the side effects, said Dr Linder.
Nicotine was historically believed to improve performance and he was expecting to find an athlete wearing multiple nicotine patches one day.
Depressants had also found a place in sport. Alcohol and marijuana caused relaxation and increased confidence but generally impaired performance.
Beta-blockers were banned for competitive shooting. This was because professional marksmen trained to pull the trigger between heartbeats and so a drug that slowed the heart rate made the task easier and could enhance performance. Another approach to performance enhancement was the use of recombinant erythropoietin or the related practice of "blood doping". Blood doping, explained Dr Linder, involved removal of two pints of blood two months in advance, and then reinfusion immediately before the competition. This had the effect of increasing the athlete's oxygen carrying capacity (VO2 max) by 8-9 per cent and their time to exhaustion by 17-23 per cent. At elite level, particularly among cyclists, the use of recombinant erythropoietin was common, and more than 17 deaths among cyclists had been attributed to its use. The drug increased the viscosity of the blood and raised blood pressure.
Human growth hormone increased fat utilisation and protein synthesis and could cost more than $700 per week. It also caused bony overgrowth, hypothyroidism and heart disease. In spite of these problems, in Dr Linder's experience, some athletes would use all their income to obtain supplies.
Anabolic steroids increased muscle protein and allowed more intense training. In men they caused testicular atrophy, gynaecomastia and prostate hypertrophy, while in women they led to irreversible hirsutism, deepening voice and clitoral enlargement. If taken by children, anabolic steroids would cause premature closure of the epiphyses and consequent short stature. Some users practised "stacking", that was, concurrent use of oral and injectable products. This had the effect of increasing calorie requirements to 4-6,000 kCal/day. There was a danger that food bills could even exceed the steroid bills. Anabolic steroids were widely available, mainly through gyms. A large number of high school pupils claimed to have used anabolic steroids, said Dr Linder, although most were not athletes.
There was an underground publication which listed all the anabolic steroids products available in the world and gave detailed information on how to obtain and use them, he added.
Finasteride was not a banned product and it was widely advertised in the underground literature as a performance-enhancer, on the basis of its ability to increase testosterone levels. There were, however, no studies to support its use.
Turning to dietary supplements, Dr Linder explained that athletes used a wide range of dietary supplements to enhance their performance. They obtained information from health food store staff, coaches, gym owners, fellow athletes and the internet, but conspicuously not from health care professionals.
Dr Linder himself had been shocked when an athlete's parents had asked him which were the safest supplements to use. It would have been more appropriate to ask if supplements were safe at all, he said.
Among high school athletes, 70 per cent used the amino acid derivative creatine and among "responders", it appeared to improve performance for short bursts of maximal activity. Unfortunately it might also cause cardiac muscle hypertrophy, muscle cramps and kidney damage. Nevertheless, in 1999 sales were likely to exceed $500m.
Soda-loading was a practice that was believed to delay the onset of muscle fatigue and was popular with runners, said Dr Linder. It involved taking sodium bicarbonate in a dose of 300mg/kg 30 minutes before exertion. This often caused diarrhoea and bloating as a side effect.
Ginseng was also recommended but there were no published studies to support its use as an energy enhancing agent and it was frequently adulterated with ephedrine.
Other products, including bee pollen, inosine and yohimbine, were advertised but all lacked supporting literature.
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