GAT Issue: The Olympics and Anaesthesia - aagbi

The winning distance in the women’s Olympic shot put - since the introduction of effective testing in the 1980’s the winning
distance has fallen such that the winner in Beijing (2008) would not have made the final in Moscow (1980). 3
Penalties for Doping
The WADA code discusses in detail the types of doping violations
and their associated penalties, but the responsible body for the
administration and enforcement of this is the individual National Anti-
Doping Organisation’s. Ineligibility sanctions range from 1 year to lifetime
bans and the penalties handed down by doping authorities depend on
many factors, for example, first versus second time offences and missed
tests versus trafficking activities. This remains an area of controversy
in the international anti-doping community as the lack of hard and fast
rules introduces a degree of inconsistency; the penalties handed down
in different countries and different sports for the same violation can vary
greatly. It is felt that this “loophole” allows some organisations to take a
“soft approach” to performance enhancement.
On home soil, Dwain Chambers, the British sprinter banned from
competition for 2 years in 2003 for using tetrahyrdrogestrinone, has
recently won his appeal against the British Olympic Association and will
now be eligible to compete in this month’s games here in London if he
qualifies for Team GB. The BOA bylaw in contention held that any athlete
receiving a sanction of 6 months or more on doping violations would
not be eligible to represent Great Britain at Olympic events at any time
in their future career. The Court of Arbitration in Sport has upheld the
appeal by ruling in support of WADA’s stance that this policy amounts
to an additional sanction on the athlete, which is in breach of its global
code of which the BOA is a signatory. The WADA code is under review
at present, amendments will come into effect in 2013, and the BOA is
now likely to concentrate its efforts on their proposal to WADA that first
offences should carry a mandatory 4-year ban as well as missing one
Olympic Games, in the wake of this decision.
Substances in use
Androgenic Anabolic steroids (AAS)
The impact of anabolic steroid use came to the public’s attention with the
disqualification of Ben Johnson, after winning gold in the men’s 100-metre
sprint in Seoul in 1988, when stanazolol was detected in his urine. Clinical
trials confirm that AAS increase muscle strength and mass through a
number of mechanisms that are dose dependant, and that these effects
are additive to resistance training alone. Athletes are known to have used
doses up to 30-times higher than the physiological replacement dose
of these hormones. AAS have a wide range of serious adverse effects
including virilisation and reduced fertility, hepatotoxicity and increased
risk of hepatocellular carcinoma, dyslipidaemia and increased risk of
myocardial infarction, depression, mania and aggression.
Erythropoietin (EPO) and Blood Transfusion
Thought to have started in the 1970’s, blood doping is a method still
utilised by elite athletes and has resulted in high profile bans recently.
Training at high altitude can induce endogenous EPO production in the
renal tubules, promoting an increase in the total red cell volume, which
increases oxygen delivery to the muscles, in turn improving performance
particularly in endurance sports. Only about 50% of competitive athletes
respond to altitude training and it is notable that non-responders do not
improve their aerobic capacity. Recombinant EPO and its analogues, or
homologous and autologous blood transfusion, are alternative methods
used by athletes to expand their erythrocyte volume. The chief risk
associated with this practice is thrombosis, but the risk of infections
associated with blood transfusion is of particular concern when this
occurs in an unregulated fashion.
Growth Hormone (GH)
GH is a naturally occurring peptide hormone produced by the anterior
pituitary gland. “The Underground Steroid Handbook” written by Dan
Duchaine in 1982 advocated its use for performance enhancement at least
a decade before endocrinologists began prescribing it for therapeutic
replacement. The startling results achieved with replacement of GH in
deficient individuals have not been reproduced to the same extent in
trials using healthy adults, but increased skeletal muscle mass leading
to increased strength and power output have been observed, as well
as increases in the bioavailability of glucose and fatty acids. The effects
are short-lived, disappearing within weeks of the cessation of GH use,
and are not necessarily matched by an increase in other performance
indices such as the maximal uptake of oxygen (VO 2
max). However, these
clinical studies may not be suited to assess the effects of GH in individual
athletes who often use higher doses than those used in the trials and who
often combine GH with other performance enhancing drugs. The specific
test utilised by WADA for GH has a limited detection window of 24 hours,
which ensures this remains a concern for doping organisations. Indeed,
a recent investigation into Major League Baseball by a US senator found
a high level of GH use among players for performance enhancement
and to speed recovery from injury. The side effects of GH use include
fluid retention leading to hypertension and headaches, diabetes and a
cardiomyopathy. Anecdotally, some athletes use doses much higher than
those required for therapeutic replacement, and it is reasonable to predict
that they may develop features of acromegaly over time. Pharmaceutically
available GH is all produced using recombinant technology, but some of
the GH available to athletes on the black market is still pituitary-derived
which introduces the risk of prion disease to illicit users.
Insulin Like Growth Factor-1 (IGF-1) and Insulin
As the tests for detecting GH abuse develop there are anecdotal reports
that athletes, for example weightlifters, are increasingly turning to insulin
and IGF-1 as alternative performance enhancing agents. The two
substances have broadly similar actions in their anabolic effects and their
action on glucose metabolism, both of which might have abuse potential.
Adverse effects are principally hypoglycaemia and weight gain, but this
may be less problematic in an individual whose diet and training regimen
are closely monitored. After concerns were raised by the Russian medical
officer at the Nagano Olympic Games, the IOC immediately banned the
use of insulin in individuals without diabetes. WADA has subsequently
endorsed this and people with diabetes requiring insulin treatment must
obtain a TUE, however this might prove a difficult area to police.
The true prevalence of doping today is unknown due to the secrecy around
it; but the advent of professional sport and the huge financial rewards that
go with being the best, coupled with an ever increasing pharmacopoeia
and the athlete’s innate drive to win may all act to encourage continued
use of these methods. This damages the reputation of sport and may
harm the health of the athletes. Stringent efforts are therefore needed to
allow athletes around the world to “play true”.
Kate O’Connor
ST6, Bristol School of Anaesthesia
Professor Richard I.G. Holt
Human Development and Health Academic Unit,
University of Southampton
References
1. The official website of the World Anti-Doping Agency: www.wada-ama.org
2. The official website of UK Anti-Doping: www.ukad.org.uk
3. Holt, R.I.G. Diabetes and Doping. Chapter 8, 167-192. In Gallen, I. Type 1
Diabetes. Clinical Management of the Athlete. (1st Ed, 2012) Springer.
4. www.wada-ama.org/en/Anti-Doping-Community/Athletes-/QA-on-
Whereabouts/
5. www.wada-ama.org/en/Science-Medicine/Prohibited-List/QA-on-2012-
Prohibited-List/
6. www.wada-ama.org/en/Anti-Doping-Community/Athletes-/QA-on-TUEs/
Anaesthesia News July 2012 • Issue 300 19