Is drug testing the answer?

Interesting Article from AAOS

By Michael F. Schafer, MD, and Mary Ann Porucznik

With the Beijing Olympics soon to begin, the issue of performance-enhancing drugs (PEDs) is center stage. According to the International Olympic Committee, 4,500 drug tests will be conducted during the games—more than in any previous Olympics. That many tests may be necessary to ensure that the playing field isn’t artificially raised by athletes who use erythropoietin (EPO), human growth hormone (HGH), or other types of PEDs.

To see just how effective drug testing is in identifying users and in deterring PED use, AAOS Now contributing editor Michael F. Schafer, MD, and managing editor Mary Ann Porucznik talked with Gary Green, MD, a consultant to Major League Baseball (MLB) on anabolic steroids and performance-enhancing drugs, and to MLB’s Elliot Pellman, MD, medical advisor for both MLB and the National Football League.

AAOS Now: What do you think the extent of usage is among the nonathletic population?

Dr. Green: It’s disturbing. If you do an Internet search for “buy anabolic steroids,” you get about 5.1 million Web sites. Type in “buy HGH” and you get more than 400,000 sites. It doesn’t take a math genius to realize that a few thousand athletes aren’t going to keep that many businesses operating. This is a societal problem.

Education programs on PEDs have to address the pressures and what we love about sports, which is the celebration of natural abilities. It’s important to focus on the reasons people take PEDs. Drugs change the sport from who can lift the most weight to who can take the most anabolic steroids.

Dr. Pellman: What we’re confronting is “pharmaceutical America.” Established pharmaceuticals must pass a rigorous scientific process on safety and efficacy before being allowed to be distributed to the general public, but unfortunately that is not the case with dietary supplements. Advertisements for supplements say they’ll help you live longer, look better, lose weight. And Americans are spending billions of dollars on supplements and making greater demands on physicians for pharmaceutical prescriptions. One of the biggest frustrations our athletes have is trying to understand what they can or cannot safely ingest without triggering a positive drug test.

AAOS Now: Are there any red flags that an orthopaedic surgeon could watch for to identify whether a boomer with an injury is taking PEDs?

Dr. Green: Look for the uncommon injury or tear. Shoulder injuries in a middle-aged man who is trying to play sports are not uncommon. But a patient taking anabolic steroids may have an unusual muscle tear, such as a psoas or triceps muscle tear. Or, if a severe injury results from a relatively low-energy event, you may want to think about anabolic steroids.

The main thing is to be open and listen. What you’re likely to hear is a patient who wants to “buff up” and wonders if you can prescribe something, or a patient who specifically requests a prescription for HGH or another PED.

We’ve had a lot of reports of orthopaedic surgeons who use HGH for injuries. Growth hormone is the only drug that I’m aware of that cannot be prescribed for off-label indications. A valid prescription for growth hormone has to be for an approved condition under U.S. Food and Drug Administration (FDA) regulations. Aging is not an FDA-approved condition; injury repair is not an FDA-approved condition. Pediatric short stature, Prader-Willi syndrome, chronic renal insufficiency—those are among the FDA-approved conditions for the use of HGH.

In my experience reviewing case files, I’ve not ever seen HGH used by itself. It’s usually combined with anabolic steroids, insulin, or other growth factors.

AAOS Now: How effective is drug testing in identifying PED users?

Dr. Green: Drug testing is never going to be totally effective in identifying every single PED user; it’s naïve to think that it will. An effective program can be a deterrent to those athletes considering using PED and also help protect those athletes who choose not to use PEDs.

Dr. Pellman: Protecting the integrity of the game is paramount, as is protecting the players who have made the choice not to use. Use of PEDs in the environment of professional sports can be seen as a “contagious disease.” If players think that they have to use PEDs to compete, you end up creating an artificial “level” playing field.

Dr. Green: Due to the limitations of testing, a negative test doesn’t necessarily mean that the person isn’t using drugs; it just means that, at that particular time, and for that particular drug, the test didn’t detect anything in the urine sample.

AAOS Now: What would be needed for an effective testing program?

Dr. Pellman: You have to begin with information and education. We need to start instructing players about dietary supplements. Players may make bad decisions, but you have to give them the information and warn them of the consequences. If used judiciously, drug testing can have a positive effect.

Dr. Green: An effective testing program has several components. It needs a first-rate collection system—a witnessed collection system that’s done state-of-the-art. Samples must be sent to a reputable lab that is competent for testing for these types of drugs, and the tests must be for the drugs that people are going to be using, such as anabolic steroids in a strength sport. There must be solid consequences if an individual tests positive, a fair appeals process, and some degree of transparency to assure the public that it is being conducted properly. Most importantly, the program must be able to respond to change; it can’t be a static process. A drug-testing program that’s effective in 2008 is not going to be effective next year or the year after. But if you can incorporate all these factors, then I think you can have an effective testing program.

In addition, education is important so that athletes know what the drugs are and what they can and cannot do.

Dr. Pellman: The biggest frustration players often have is trying to understand what they can or cannot take.

AAOS Now: What are the limits to drug testing?

Dr. Green: One of the most important aspects of a program is the collection process. Is it random or announced? Are drug tests conducted throughout the year or only during playoffs? I’m always shocked when athletes test positive during the Olympics. They know when the games are, when their event is, what the half-life of the drugs are, so when an athlete tests positive during the Olympics, it’s usually because he or she wasn’t aware, or made a mistake, or decided to try to push the limits.

Look at the data from the National Collegiate Athletic Association. During competition testing, there are relatively few positives; during out-of-competition testing, the positive rate is higher.

AAOS Now: What happens with masking agents?

Dr. Green: In the past, athletes would dilute their urine by drinking a lot of water. To combat that, minimum specific gravities were established for acceptable samples. At the Olympics, if the sample doesn’t have greater than 1.005 specific gravity, the athlete stays until he or she produces an effective sample.

Having chaperones accompany athletes from the time they are notified that they will be tested until the actual test can help ensure that athletes don’t self-catheterize or attempt to substitute a hidden sample for their urine.

AAOS Now: What’s the current status of blood testing vs. urine testing?

Dr. Green: Urine testing is considered state-of-the-art for most drug testing. It’s effective for many common PEDs and gas chromatography-mass spectrometry has been accepted by the courts as legally admissible. Blood testing has not undergone that kind of scrutiny yet.

There’s also a difference between Olympic testing and professional sports testing. The Olympics can conduct their testing without having to bargain with unions. But with professional sports, the courts have ruled that testing is a collectively bargained issue, so unions are involved. And at the high school and college level, the issue is that the player is a minor.

We do not have a urine test for HGH; the only test for HGH that we have right now is a blood test, and it’s going to be used at the Beijing Olympics. As that test becomes more successful and widely available, pressure to do blood testing will increase. But because blood testing is more invasive, I don’t know how the courts will rule. In my mind, a drug test doesn’t really mean much until it’s been to court and upheld by an arbitrator. If the test can withstand the scrutiny of a high-profile challenge—as in the Floyd Landis case—you have a good test.

AAOS Now: How important are the consequences of testing positive in deterring use?

Dr. Pellman: I think that the initial punishment has to be significant enough to be seen by the athlete as an absolute deterrent and that additional failed tests must be followed by even harsher penalties. I also believe, given the complexity of this problem, that before an athlete is banned for life from a professional sport, the athlete must have the opportunity to become educated and reform. In major and minor league baseball, the initial penalty is a 50-game suspension; that could mean the end of a player’s career. In the NFL, it’s a 4-week suspension. For some players, that first positive test may mean their careers are over.

But this is a societal issue. Punishments should be significant enough to be a deterrent but not be so punitive that athletes become sacrificial lambs for the sins of society. People expect better of athletes, and that’s okay, but they also need to look around and ask what we’re doing as a society that is catalyzing this problem. We place all kinds of external pressure on athletes to succeed, often at any cost—including their health.

Dr. Green: The number of positives in minor league baseball dropped dramatically when the penalty for a positive test went from a 15-game suspension to a 50-game suspension. But younger kids are under pressure to perform and may not have access to safer and healthier alternatives. Drugs are a quick fix, and adolescents are looking for quick fixes. We need to give them proper education and healthier alternatives.

AAOS Now: What are MLB and the NFL doing to deter use of PEDs at all levels of sports?

Dr. Pellman: Each, in its own way, is focused on education—to the players, coaches, parents, school administration, the general public, and healthcare professionals—by funding conferences, advertising in concert with the Partnership for a Drug-Free American, working with the World Anti-Doping Association, the U.S. Anti-Doping Association, and other organizations, sponsoring and supporting grassroots organizations like the Taylor Hooton Foundation, and supporting government legislation that tightens and limits the access to PEDs, regulates the dietary supplement industry, and funds for scientific research.

AAOS Now: What role can healthcare professionals, coaches, and trainers play in deterring PED use?

Dr. Green: One of the most neglected groups in this arena is the coaches. Coaches have a great deal of influence on the lives of young athletes. They’re valuable allies, and coaching education is really important. I’d like to see coaches come out at the very beginning and say, “I will not tolerate anabolic steroid use on this team.” That would have a great impact. Coaches have to look at their role in encouraging or deterring use; my feeling is that if a coach is “neutral,” he or she is encouraging it.

Take, for example, what happened to Taylor Hooton, a 17-year-old athlete who killed himself after going off steroids. What got him started was that a coach told him he needed to get bigger. You can’t just tell a kid to “get bigger.” You’ve got to provide the nutritional information, a weight program, and realistic expectations. Giving good directions and alternatives is important.

Dr. Pellman: Doctors need to be objective and make decisions based on clinical data. I prefer to look at the use of PEDs as a healthcare issue similar to alcoholism, smoking, and a myriad of other issues. We need to develop different avenues of creating peer pressure not to use drugs or supplements—not only among the athletes, but among parents and coaches. They want these young athletes to compete, condone taking unreasonable risks even it means sacrificing long-term health and acting as enablers.

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