• Define what constitutes performance-enhancing drugs
and identify the expected benefits and risks of use.
• Identify the most commonly used performance-
enhancing substances, their mode of action, side
effects, and expected outcomes.
• Utilize a structured approach to identify at-risk
• Identify healthy alternatives for adolescents in lieu of
abusing performance-enhancing drugs.
• 776 BC: Greek Olympians
• Scandinavian Mythology: The Berserkers
• A Performance-Enhancing Substance is any substance • 1807: Abraham Wood
taken in nonpharmacologic doses specifically for the • 1930s: Testosterone Synthesized
purposes of improving sports performance. • 1936: Berlin Olympics & Benzedrine
• 1952: Russian Weight Lifters
AAP Policy Statement, 2005 • 1954: Dr. John Ziegler
• 1958: U.S. Pharmaceutical Company
• 1959: Anabolic Steroid Use Reported by High School Football Player
• 1976: 68% of Olympic Athletes Admitted to Using Anabolic Steroids
• 1993: 3.8% of Middle School Students Reported Using Anabolic Steroids
• 2002: 58% of High School Athletes Report Using Some Form of Nutritional
• 2005: 4.7% of Males and 1.6% of Females reported weekly use of some kind
of performance-enhancing product
REMEMBER ME?? REMEMBER ME??
REMEMBER ME?? REMEMBER ME??
CHRISTOPHE BARRY BONDS
REMEMBER ME?? REMEMBER ME??
WIN AT ALL COSTS… EVIDENCE OF A PROBLEM
1997 Questionnaire of Aspiring Olympians:
• 58% of high school athletes have used some form of nutritional supplementation (Kayton,
1. “If you were offered a banned performance-enhancing Cullen, et. al., 2002).
substance that guaranteed that you would win an Olympic • In a 2003 study of nutritional substances, NONE of the participants discussed any negative
or potentially dangerous effects of nutritional supplementation (O’Dea).
medal and you could not be caught, would you take it?”
• Yearly nutritional supplement sales in the U.S. is $12 to $15 billion; sport supplements are
responsible for $800 million (Consumer Reports, 1999).
• The likelihood of performance-enhancing substance use increases with increasing physical
195 of 198 (98%) athletes said YES! activity (Dorsch & Bell, 2005).
• 57% of all high school students play on formal sports teams (Calfee & Fadale, 2006).
• 5.1% of adolescents have taken steroid pills or shots without a prescription one or more
2. “Would you take a banned performance-enhancing drug with a times during their life (MMWR, Youth Risk Behavior Surveillance, 2007).
guarantee that you will not be caught, you will win every • 40% of high school seniors did not perceive a significant risk associated with the use of
occasional use of anabolic steroids (Johnston, O’Malley, Bachman, et al., 2006).
competition for the next 5 years, but will then die from adverse
effects of the substance?” • 74% of students indicated that the primary source of information about supplements came
from their friends (Lattavo et al, 2007).
• Adolescents who report the use of any legal ergogenic supplement are nearly 26 times
more likely to report the use of AS compared with adolescents who do not report the use of
>50% of the athletes said YES! legal supplements (Lattavo et al, 2007).
ADOLESCENT VULNERABILITY COMMONLY USED SUBSTANCES
• Risk-Taking Behaviors
• Energy Drinks/Caffeine
• Peer Pressure
• Ephedra (Ephedrine Alkaloids)
• Preoccupation With One’s Own
Body & Body Image • Protein Powder Supplements
• Invincibility • Creatine
• Society’s Regard for • Growth Hormone
Professional Athletes • Steroid Precursors: DHEA &
• Social Status & Money Androstenedione
Associated with Garnering • Anabolic-Androgenic Steroids
CAFFEINE CAFFEINE: Side Effects
• Potential Benefits: Enhances submaximal aerobic and • Insomnia
endurance activities. • Tremors
• Mode of Action: Caffeine is an adenosine receptor antagonist. It • Headache
stimulates the CNS, increases catecholamine release, and
stimulates lipolysis. Caffeine may increase contractility of • Anxiety
skeletal and cardiac muscle and may increase metabolic rate. • Flushing
• Dosing: 5 mg/kg for ergogenic effect. • Palpitations
• Incidence of Use: 27% of adolescent athletes in the U.S. report • Premature Ventricular Contractions
caffeine use for performance enhancement (Magkos & Kavouras,
• Supraventricular Arrhythmias
PROTEIN POWDER PROTEIN POWDER: Side Effects
• Potential Benefits: Increase body mass and strength; Enhance
recovery from exercise.
• Types: Whey, Casein, Colostrum • Dehydration
• Mode of Action: Protein is required to promote muscle • Kidney Dysfunction
anabolism following exercise. In order for muscle to use protein,
sufficient insulin must be present.
• Dosing: Recreational Athlete: 0.5 – 0.75 g/lb/day
Competitive Athlete 0.6-0.9 g/lb/day
Adolescent Athlete: 0.9 – 1.0 g/lb/day
Maximal Useable Amount: 1.0 g/lb/day
• Incidence of Use: Unknown
CREATINE CREATINE: Side Effects
• Potential Benefits: Increased strength; Improved performance in • GI Discomfort (Nausea, dyspepsia, diarrhea, abdominal pain)
short, anaerobic events; Weight gain (from increased muscle • Dehydration
• Weight Gain (1.6 – 2.4 kg)
• Mode of Action: Creatine is transported to muscle, heart, and
brain; 95% of bodily stores of Creatine remain in the muscle. • Muscle Cramps
Phosphocreatine availability is considered is the rate-limiting • Rash
factor in short, high-intensity activities.
• Dosing: Loading – 5 grams QID for 4-6 days
Maintenance – 2 g/day for 3 months
• Incidence of Use: 8.2% of 14-18 year olds (Smith & Dahm, 2000).
• Interactions: Carbohydrates increase absorption; Caffeine
decreases absorption. • Renal Compromise (Rare)
• Note: 30% of Creatine users are considered non-responders –
presumably because of maximal phosphocreatine stores.
EPHEDRA (EPHEDRINE ALKALOIDS) EPHEDRA: Side Effects
• Potential Benefits: Increase weight loss, delay fatigue. However, • Increased HR
there is NO CONVINCING EVIDENCE that they have ANY TRUE • HTN
BENEFIT for athletic performance.
• Mode of Action: Ephedra is a stimulant that has alpha and beta • Anxiety
adrenergic effects, enhances the release of norepinephrine, and
stimulates the CNS.
• Dosing: <25 mg/day for < 1 week
• Incidence of Use: 26% of MALE high school athletes and 12% of
• Paranoid Psychoses
FEMALE high school athletes have tried ephedra products
(Kayton et. al., 2002). • CVA
THESE SIDE EFFECTS ARE WHY EPHEDRINE WAS THE FIRST SUPPLEMENT
REMOVED FROM THE MARKET BY THE FDA IN 2004!
STEROID PRECURSORS: DHEA & ANDROSTENEDIONE STEROID PRECURSORS: Side Effects
• Potential Benefit: Increase testosterone levels to gain muscle • Lipid Profile
mass and strength. However, there is NO CONVINCING • Increased Estrogen levels in boys
EVIDENCE that they have ANY TRUE BENEFIT for athletic
performance. • Male Gynecomastia
• Mode of Action: DHEA is a weak androgen that converts to • Female Virilization
Androstenedione in the body, which then can be transformed • Priaprism
into either testosterone or estrone. Long-term use may
• Hyperplastic Prostatic Changes
downregulate endogenous testosterone.
• (Similar effects to steroids)
• Dosing: DHEA – 50 – 100 mg/day for up to 1 year
Androstenedione – 100 – 300 mg/day
• Incidence of Use: 4% of high school students have used steroid
precursors (Reeder et. al., 2002).
GROWTH HORMONE GROWTH HORMONE: Side Effects
• Potential Benefits: Decreases subcutaneous fat, increase
muscle mass, strength, and definition. However, there is NO
CONVINCING EVIDENCE that they have ANY TRUE BENEFIT for • Infection (R/T injection)
athletic performance. • Premature physeal closure
• Mode of Action: Growth hormone is converted into Insulin-Like • Jaw enlargement
Growth Factor I, which serves to increase protein synthesis, lipid
catabolism, and bone growth.
• Cardiovascular disease
• Dosing: Several times per month
• Impaired glucose tolerance
• Incidence of Use: 5% of high school students reported GH use
(Rickert et al, 1992). • SCFE
• Increased ICP (Rare)
• Papilledema (Rare)
ANABOLIC STEROIDS ANABOLIC STEROIDS: Side Effects
• Potential Benefits: Increased strength; Increased lean body IN MALES: IN BOTH:
mass; Less muscle breakdown. • Acne
• Testicular Atrophy
• Mode of Action: Increases protein syntheses within cells, which • Oligospermia • Tremors
results in the buildup of cellular tissue (anabolism), particularly • Gynecomastia (Irreversible) • Decreased HDL Cholesterol
in the muscles. They also have a anticatabolic effect by • Prostatic Hypertrophy • HTN
improving utilization of protein and inhibiting the catabolic effect • LVH
• Premature Balding/Male Pattern Baldness • Cholestasis
of glucocorticoids. Anabolic steroids are a synthetic derivative • Non-Specific in Liver Enzymes
of the hormone Testosterone. • Liver Tumors (Irreversible)
IN FEMALES: • Hepatitis (Rare & Irreversible)
• Types: Oral – Anadrol, Anavar, Diannabol, Winstrol • Muscle Strains and Ligament Strains
• Infertility • Growth Retardation/Premature Physeal
Injectible – Deca-Durabolin, Durabolin, Depo- • Deepened Voice (Irreversible) Closure (Irreversible)
• Hep B, Hep C, and HIV
Testosterone, Equipoise • Clitoromegaly (Irreversible) •Severe Mood Swings (“Roid Rage”)
Transdermal - • Hirsuitism (Irreversible)
• Incidence of Use: 5.1% of students have reported using anabolic • Breast Tissue Atrophy (Irreversible)
steroids (MMWR, 2008). • Amennorrhea
CASE STUDY: “Anthony”
Anthony is a 15 year old Caucasian
male who presents to your office on a
Thursday evening with a chief
complaint of being “tired”, “not feeling
well”, and intermittent dizziness.
Upon further clarification, Anthony
describes his symptoms as “feeling
slow” and “unable to focus”. He says
that he has been more thirsty and
more hungry than usual. He states
that 4 days prior to his visit, he had
bouts of nausea with a single episode
of vomiting. His dizziness is worsened
by movement, but denies any history
of syncope or chest pain.
PROFILE OF A USER DOPING JARGON
• Male • Doping – using PES
• Sports that demand high degrees of • Cycling – using a substance for a specific period of time and
strength, power, size or speed
then discontinuing use for a time
• Specialized, year-round athletes
• Athletes that have reached a plateau in
• Pyramiding – using a regimen for increasing and decreasing
their training dosing
• Those hoping for a college athletic • Stacking – using multiple performance-enhancing substances
scholarship/career in professional sports simultaneously
• Knowing teammates that use
• Use of other illicit substances
• Uses jargon associated with performance-
• Recent documented changes in weight or
ADDRESSING THE PROBLEM ADDRESSING THE PROBLEM
EDUCATION- • ASK, EDUCATE & OFFER HEALTHY ALTERNATIVES…
• Adolescents Training & Learning to Avoid Steroids Program • Persons with the most influence on practices included coaches
(ATLAS) (65%), sports dieticians (30%), and doctors (25%).
— >3,000 HS Students • Most adolescent athletes do not make the most of their diet for
— Intervention Group – interactive classroom sessions and exercise performance before considering supplements (Gregory & Fitch,
training sessions focusing on nutrition, drug effects, and drug refusal 2007).
• Greater knowledge about supplements is associated with less
— Control Group – received brochures with similar information use (Feldman, 1995).
RESULTS: • Work with the FDA to clarify dietary supplements from drugs so
Intervention group was more knowledgeable about steroid and drug that we can protect consumers against potential adverse effects.
effects; less likely to believe supplement ads; more likely to reject drug
offers from peers. Even 1 year later, supplement use was lower in the • Avoid a “just say no” approach – offer alternatives to using and
intervention group; fewer new steroid users; students remained more give sound advice based on scientific data.
knowledgeable about ergogenic drugs.
INTERVIEWING ADOLESCENTS PHYSICAL EXAM
• INITIAL INTERVIEW:
• Most physical exams are
—Direct vs. Indirect Questioning
• Compare Height, Weight &
—Ask About Goals BMI to Previous
—Ask About Barriers & Limitations Measurements
• IN-DEPTH INTERVIEW: • Elevated BP
—Clarify the Extent of Use • Males: Acne, Male Pattern
— Assess the Degree of Risk Associated Testicular Atrophy, Severe
—Ask About Side Effects Striae
—Ask About Needle Sharing • Females: Hirsuitism, Clitoral
Megaly, Voice Deepening
—Ask About Other Substances
Bahrke, M. S., Yesalis, C. E., Kopstein, A. N., & Stephens, J. A. (2000). Sports Medicine, 6, 397-405. Field, A. E., Austin, S. B., Camargo, C. A., Taylor, C. B., Striegel-Moore, R. H., Loud, K. J., & Colditz, G. A. (2005).
Brown, J. T. (2005). Anabolic steroids: What should the emergency physician know? Emergency Medicine Exposure to the mass media, body shape concerns, and use of supplements to improve weight and shape among
Clinics of North America, 23, 815-826. male and female adolescents. Pediatrics, 116, e214 – e220.
Buzzini, S. R. R. (2007). Abuse of growth hormone among young athletes. Pediatric Clinics of North America, 54, Ford, J. A. (2007). Substance use among college athletes: A comparison based on sport/team affiliation. Journal
823-843. of American College Health, 55, (6), 367-373.
Calfee, R., & Fadale, P. (2006). Popular ergogenic drugs and supplements in young athletes. Pediatrics 117, e577 Gaffney, G. R., & Parisotto, R. (2007). Gene doping: A review of performance-enhancing genetics. Pediatric
– e589. Clinics of North America, 54, 807-822.
Carpenter, P. (2007). Performance-enhancing drugs in sport. Endocrinology and Metabolism Clinics of North Goldberg, L., Bents, R., Bosworth, E., Trevisan, L., & Elliot, D. L. (1991). Anabolic steroid education and
America, 36, 481-495. adolescents: Do scare tactics work? Pediatrics, 87, (3), 283-286.
Casavant, M. J., Blake, K., Griffith, J., Yates, A., & Copley, L. M. (2007). Consequences of use of anabolic Greene, J. P., Ahrendt, D., & Stafford, E. M. (2006). Adolescent abuse of other drugs. Adolescent Medicine Clinics,
androgenic steroids. Pediatric Clinics of North America, 54, 677-699. 17 (2), 283-318.
Centers for Disease Control & Prevention. Youth risk behavior surveillance – United States, 2007. Surveillance Gregory, A. J. M., & Fitch, R. W. (2007). Sports medicine: Performance-enhancing drugs. Pediatric Clinics of
Summaries, November 21, 2008. Morbidity and Mortality Weekly Report 2008, 57. North America 54, 797 – 806.
Committee on Sports Medicine and Fitness (2005). Adolescents and anabolic steroids: A subject review. Hatton, C. K. (2007). Beyond sports-doping headlines: The science of laboratory tests for performance-enhancing
Pediatrics, 99, 904-908. drugs. Pediatric Clinics of North America, 54, 713-733.
Committee on Sports Medicine and Fitness (2005). Use of performance-enhancing substances. Pediatrics, 115, Herbal Rx: The promise and pitfalls. (1999). Consumer Reports, 44-48.
1103 – 1106. Holland-Hall, C. (2007). Performance-enhancing substances: Is your adolescent patient using? Pediatric Clinics
Cribb, P. J., Williams, A. D., Stathis, C. G., Carey, M. F., & Hayes, A. (2007). Effects of whey isolate, creatine, and of North America, 54, 651-662.
resistance training on muscle hypertrophy. Medicine & Science in Sports & Exercise, 298-307. Kayton, S., Cullen, R. W., Memken, J.A., & Rutter, R. (2002). Supplement and ergogenic aid use by competitive
Dawson, R. T. (2001). Drugs in sport – the role of the physician. Journal of Endocrinology, 170, 55-61. male and female high school athletes. Medicine and Science in Sports and Exercise, 35, S193.
Department of Health and Human Services (2007). Youth Risk Behavior Surveillance. Morbidity and Mortality Kerksick, C. M., Rasmussen, C., Lancaster, S., Starks, M., Smith, P., Melton, C., Greenwood, M., Almada, A., &
Weekly Report (57), 28-56. Kreider, R. (2007). Impact of differing protein sources and a creatine containing nutritional formula after 12 weeks
of resistance training. Nutrition, 23, 647-656.
Dorsch, K. D., & Bell, A. (2005). Dietary supplement use in adolescents. Current Opinion in Pediatrics, 17, (5),
653-657. Kerr, J. M., & Congeni, J. A. (2007). Anabolic-androgenic steroids: Use and abuse in pediatric patients. Pediatric
Clinics of North America, 54, 771-785.
Feldman, E. B. (1995). Nutrition concepts for the primary care/generalist physician. Southern Medical Journal, 88, Lattavo, A., Kopperud, A., & Rogers, P. D. (2007). Creatine and other supplements. Pediatric Clinics of North
America, 54, 735 – 760.
Magkos, F., & Kavouras, S. A. (2004). Caffeine and ephedrine: Physiological, metabolic and performance-
enhancing effects. Sports Medicine, 34, (13), 871-889.
O’Malley, P. M., Johnston, L. D., Bachman, J. G., Schulenberg, J. E., & Kumar, R. (2006). How substance use
differs among American secondary schools. Prevention Science, 7, (4), 409-420.
O’Dea, J. A. (2003). Consumption of nutritional supplements among adolescents: usage and perceived benefits.
Health Education Research, 18, 98-107.
Pommering, T. L. (2007). Erythropoietin and other blood-boosting methods. Pediatric Clinics of North America,
Reeder, B. M., Rai, A., Patel, D. R., Cucos, D., & Smith, F. (2002). The prevalence of nutritional supplement use
among high school students: A pilot study. Medicine and Science in Sports and Exercise, 34, S193.
Rickert, V. I., Pawlak-Morello, C., Sheppard, V., & Jay, M. S. (1992). Human growth hormone: a new substance of
abuse among adolescents? Clinical Pediatrics, 31, 723-736.
Smith, J., & Dahm, D. L. (2000). Creatine use among a select population of high school athletes. Mayo Clinic
Proceedings, 75, (12), 1257-1263.
vandenBerg, P., Neumark-Sztainer, D., Cafri, G., & Wall, M. (2007). Steroid use among adolescents: Longitudinal
findings from project EAT. Pediatrics, 119, 476-486.