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                                                           • 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.

DEFINITION                                                 HISTORY
                                                           • 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??

                            ARNOLD                                                                           BEN
                        SCHWARZENEGGER                                                                     JOHNSON


REMEMBER ME??                                                         REMEMBER ME??

                                   CHRISTOPHE                                                                          BARRY BONDS
                                   TEAM FESTIVA

REMEMBER ME??                                                         REMEMBER ME??

                                       ALEXANDER                                                                                      YOUR
                                        RODRIGUEZ                                                                                    PATIENT!

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
  Professional Contracts

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.
                                                                        • Headache
  • Dosing: Loading – 5 grams QID for 4-6 days
                                                                        • Fatigue
      Maintenance – 2 g/day for 3 months
                                                                        • Dyspnea
  • Incidence of Use: 8.2% of 14-18 year olds (Smith & Dahm, 2000).
                                                                        • Anxiety
  • 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.
                                                                        • Arrhythmias
  • Mode of Action: Ephedra is a stimulant that has alpha and beta      • Anxiety
    adrenergic effects, enhances the release of norepinephrine, and
                                                                        • Tremors
    stimulates the CNS.
                                                                        • Insomnia
  • Dosing: <25 mg/day for < 1 week
                                                                        • Seizures
  • 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
                                                                        • MI
                                                                        • Death
                                                                        THESE SIDE EFFECTS ARE WHY EPHEDRINE WAS THE FIRST SUPPLEMENT
                                                                                   REMOVED FROM THE MARKET BY THE FDA IN 2004!


  • 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
                                                                         • HTN
  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
                                                                                                                     • Jaundice
• Mode of Action: Increases protein syntheses within cells, which        • Oligospermia                              • Tremors
                                                                                                                     • Edema
  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
                                                                         • Infertility

                                                                         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

                                  • Athletes
                                  • 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-
                                    enhancing drugs
                                  • Recent documented changes in weight or
                                    body composition
                                  • ANYONE!

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).
     role playing.
                                                                                • 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

                                                                                                                    • Most physical exams are
 —Review      Confidentiality
 —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
                                                                                                                      Baldness, Gynecomastia,
 —   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



REFERENCES                                                                                                                 REFERENCES
 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
 (2), 204-216.
                                                                                                                            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,
 54, 691-699.
 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.