Drugs in Sport, revisited

Ask Vest Christiansen
Department of Public Health, Aarhus University

How do you review a handbook? It is not an independent, coherent work analyzing one topic, where you can dive into the arguments and criticize or endorse the analysis. And it is not an encyclopedia either, with only short descriptions for each entry. Drugs in Sport (2022), has the character of a reference work. The quality of each chapter depends on the individual author(s), while the book’s overall quality is a matter of the editors’ choices regarding composition and structure. With the internet at our fingertips, we are all just a few clicks away from finding explanations for the effects of a certain drug, but oftentimes we have no clue about the sender. This is why a trustworthy handbook continues to be a valuable resource. The editorial team is experienced and so the handbook comes across as thorough and reliable. As expected, it delivers on most questions related to specific drugs or classes of drugs that we come across as researchers, educators, coaches, athletes, and laymen.

Already when I reviewed the fifth edition of this book for idrottsforum.org, some twelve years ago, editor David Mottram was Professor Emeritus of Pharmacy Practice at Liverpool John Moores University. He still is! Mottram may have retired but appears to be very active. He was on the medical service team for Team UK at the 2012 London Olympics, and again in Rio in 2016. He provides training and education on the subject for the International Olympic Committee (IOC), the World Anti-doping Agency (WADA) and the International Testing Agency (ITA). If anyone, Mottram has solid insights into the broad topic of drugs in sport. This time, he has teamed up with colleague Neil Chester along with a host of other well-reputed international scholars to publish the eighth edition of his signature publication Drugs in Sport. The book has three parts and 29 chapters, as opposed to 24 in the edition I previously reviewed. Mottram is not only overseeing and editing but still the author or co-author of 13 chapters.

If anyone, Mottram has solid insights into the broad topic of drugs in sport.

The book is easy to navigate and is well-structured. Part I, the first seven chapters, concerns issues around drug use and drug testing such as the evolution of drug use in sport, prevalence, regulation, doping control, athlete support personnel, and medical services for international games. Part II follows with chapters of no less than 16 classes of drugs, opening with anabolic steroids – which are still the most prevalent group of drugs to appear in WADA’s Adverse Analytical Findings (AAF) – and ending with alcohol and sports nutrition. Part III have 5 chapters with interesting new additions discussing drug use in society, inadvertent use of prohibited substances, hormonal treatment of transgender athletes, medical considerations for athletes with disabilities, and governance and corruption in sport. All chapters hold valuable information. Let me provide four examples I found particularly interesting.

Prevalence

The chapter on doping prevalence now sits in the beginning of the book as chapter 3 (by Petróczi et al.) rather than at the end, a priority I approve of. It has a thorough discussion on the problems of establishing true or at least trustworthy data on prevalence of doping in sport. The lack of precise knowledge is one of the big ironies of drugs in sport. We know they are there, we know they are used, we know the motives (well enough), but little about how much, by whom, when and where. WADA’s testing figures show less than one percent anti-doping rule violations (ADRVs) – mind that the use of banned substances is only part of ADRVs. However, studies using indirect questioning techniques have estimated doping prevalence in athletics to be over 50 percent for some events (Ulrich et al., 2018). Even if the reliability of these high figures have recently been challenged, such a gulf in estimates amounts to saying: “We have no f*****g clue!” Which is worse than it may sound, since the whole anti-doping movement rests on there being a problem, but we do not know its magnitude.

The lack of convincing evidence for what the true prevalence might be is not primarily linked to the number of studies. Rather, it is the result of studies applying poor methodology, blurred boundaries between sports and (world) regions, over-/under-sampling of certain sports, imprecise reporting of laboratory figures, and inconsistent definitions of what constitutes doping. To illustrate the latter: If researchers in a survey ask respondents to report whether they have ever (or last season) committed an ADRV, the results obtained would theoretically be directly comparable to WADA testing figures. However, trusting the obtained data requires that respondents know what constitutes an ADRV, and very few do. And explaining in a survey what in ADRV is, is cumbersome and would lead to survey-fatigue and high drop-out rates. An alternative approach is to ask respondents if they ever (or last season) intentionally used a prohibited substance to increase their sporting performance. Researchers then rely on respondents’ own understanding of what a banned substance is and their intention to use such substances. The two methods obviously produce different results. While the first investigates doping from its judicial definition, the latter studies intent to dope. Not the same. Not comparable.

Nevertheless, progress in how to generate valid prevalence data has been made over the last decade – a development the authors meticulously describe. Yet, the current level of evidence for doping prevalence remains segmented and incomparable. The chapter provides a lengthy, detailed, and thorough insight into these challenges and what we currently know.

Blood

Chapter 13, ‘Manipulation of blood and blood components’ by Yorck Olaf Schumacher, gives a good introduction into blood doping, EPO and some of the newer products that can increase the blood’s oxygen carrying capacity. While the chapter has much valuable information it lacks sufficient referencing – especially on the more anecdotal parts. For instance, Schumacher states that “manipulations of blood have […] widely been abused in all endurance sports over recent decades” and mentions that “Lasse Virén from Finland, openly admitted using blood transfusions to prepare for his races” (pp. 226-227). No references are provided. I also missed clarification of one of the small mysteries of blood doping. What happened to blood doping in cycling between 1984 and 2001? The procedure was reported to be used by Francesco Moser in his preparations for the two World Hour Records he sat in 1984. Also, the USA cycling team infamously utilized it for their successful campaign for the 1984 Olympics, whereafter it was banned (Gleaves, 2015). However, hereafter this efficient technique, in terms of performance enhancement, apparently disappeared from cycling. Why? Clearly, the introduction of EPO, that also cause increase in red blood cells without the logistical challenges required by blood transfusions, explains part of this. But EPO only became prevalent in the peloton around 1990-1992. Why did nobody in the intermediate period take an interest in a method that had proven so successful? Apparently, it vanished for more than 15 years only to reappear in Armstrong’s Team US Postal in the early 2000s when a test for EPO became available. I had hoped Schumacher could have informed me what happened in the meantime.

Gene-doping

Already when I was a sport science student in the 1990s, gene doping was a subject of fascination and imagination. While it was mesmerizing to discuss the potential of sprinters getting cheetah muscles, weightlifters with bear-powers and swimmers with dolphin skills, it was also pure science fiction. It still mostly is. Obviously, if successful, the effects of gene manipulations would have the advantage of being long lasting rather than acute or short term, and the active cells would be produced inside the body and so likely indistinguishable from normal cell production. Consequently, gene and cell manipulation would be harder to detect than conventional drug doping. Chapter 15, by Dominic Wells, provides detailed insights on these matters. In animals (e.g., knockout mice), genes can be added or inactivated in for instance muscle cells to create a specific outcome. But as genetic modifications are passed on to subsequent generations, they are ethically not acceptable in humans. In recent years especially the so-called CRISPR-technique has shown potential. Unsurprisingly, athletes have taken an interest in this, as it could be targeted to inactivate the myostatin gene, resulting in increased muscle mass that would be beneficial in power sports. In line with this, the most important candidates for gene doping benefitting athletes would be those that can (1) increase muscle mass, (2) modify metabolic properties of muscles, and (3) increase the carriage of oxygen in the blood. Not quite human versions cheetah, bear, and dolphin but also not unthinkable possibilities. Yet, even if we are moving closer to the point where gene doping could become reality, WADA’s testing figures indicate that gene doping is still more fantasy than reality. To date, there are no reported cases of gene or cell doping in sport.

Transgender and DSD athletes

Chapter 27 (by Bermon & Kajėniene)concerns transgender athletes and athletes with difference of sexual development (DSD). This topic was not included in the previous editions I have read. However, it is important to include it in a handbook like this for at least two reasons: (i) Because some of the drugs used for gender affirming therapies for both trans- and DSD athletes are on WADA’s list of banned substances and so these athletes may need to apply for therapeutic use exemptions (TUE); (ii) Athletic participation by trans- and DSD athletes causes authorities, International Federations, peers, and fans to ask questions about eligibility. Are transwomen (people assigned male at birth) free to compete among biological women? Should the rules that apply to transwomen also apply to DSD athletes?

This would minimize confusion and erroneous argumentation as seen in articles by otherwise well-informed scholars, such as a recent original research article that completely misunderstands which DSD athletes are regulated and what constitutes an unfair advantage in sport.

Likely because of issues related to publication deadlines, the book only includes the IOC 2015 Consensus in the chapter, and so the new problems caused by the 2021 Framework is not addressed (International Olympic Committee, 2015, 2021). Nevertheless, the chapter is important and should be compulsory reading for those engaging in the debate on trans and DSD athletes’ inclusion/exclusion from women’s elite sport. This would minimize confusion and erroneous argumentation as seen in articles by otherwise well-informed scholars, such as a recent original research article that completely misunderstands which DSD athletes are regulated and what constitutes an unfair advantage in sport (Holmen, Petersen, & Ryberg, 2022). Holmen and colleagues thus confuse all types of DSD athletes with the few that are regulated, especially athletes with 46 XY DSD 5-ARD (5-alpha-reductase deficiency). This is a group of athletes that (a) have no ovaries, (b) never experienced menarche, (c) have testicles or testicular tissue,( d) produces testosterone in the male range, (e) can utilize the testosterone, (f) dominates female athletics and (g) are heavily overrepresented on medal podiums. For these reasons it is legitimate to ask questions about their eligibility in female sports. This chapter provides helpful background information for that discussion.

Overall impression

I like the book. It is a handbook or reference work, and its utility lies in its structure and composition and the overview it provides. It offers accounts of the structure and composition of each drug, its mechanisms of action, how it is used, its prevalence and possible detection methods. However, it is not analytical, examining or critical like for instance the chapters found in the Routledge Handbook of Drugs and Sport (Møller, Waddington, & Hoberman, 2015). Here is information rather than analysis. Everything is kept in a sober, neutral tone without moralizing or raising cautionary flags. It offers insights on all relevant classes of drugs to satisfy most readers. For the humanistic or social science-oriented scholar it gives the background information needed, and for the physiologist or pharmacologist it provides sufficiently detailed information on pharmacokinetics.

If any, my primary complaint is that the font size in the printed version is too small. This is a problem for most books from Routledge. But other than that, I recommend it as reference work for anyone working with questions related to performance enhancing drugs in sport.

Copyright © Ask Vest Christiansen 2023

References

Gleaves, J. (2015). Manufactured dope: How the 1984 US Olympic cycling team rewrote the rules on drugs in sports. The International Journal of the History of Sport, 32(1), 89-107.

Holmen, S. J., Petersen, T. S., & Ryberg, J. (2022). Leveling (down) the playing field: performance diminishments and fairness in sport. Journal of Medical Ethics, jme-2022-108497. doi:10.1136/jme-2022-108497

International Olympic Committee (2015), IOC consensus meeting on sex reassignment and hyperandrogenism. Retrieved from https://stillmed.olympic.org/Documents/Commissions_PDFfiles/Medical_commission/2015-11_ioc_consensus_meeting_on_sex_reassignment_and_hyperandrogenism-en.pdf

International Olympic Committee (2021), IOC Framework on fairness, inclusion and non-discrimination on the basis of gender identity and sex variations. Retrieved from https://olympics.com/ioc/documents/athletes/ioc-framework-on-fairness-inclusion-and-non-discrimination-on-the-basis-of-gender-identity-and-sex-variations

Møller, V., Waddington, I., & Hoberman, J. M. (Eds.). (2015). Routledge Handbook of Drugs and Sport. London & New York: Routledge.

Petróczi, A., Cruyff, M., de Hon, O., Sagoe, D., & Saugy, M. (2022). Hidden figures: Revisiting doping prevalence estimates previously reported for two major international sport events in the context of further empirical evidence and the extant literature. Frontiers in Sports and Active Living, 4. doi:10.3389/fspor.2022.1017329

Ulrich, R., Pope, H. G., Jr., Cleret, L., Petroczi, A., Nepusz, T., Schaffer, J., . . . Simon, P. (2018). Doping in Two Elite Athletics Competitions Assessed by Randomized-Response Surveys. Sports Medicine 48(1), 211-219. doi:10.1007/s40279-017-0765-4