Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the history of doping in athletes, the effects of different classes of substances used for doping, side effects of doping, the role of anti-doping organizations, and treatment of affected athletes. Doping goes back to ancient times, prior to the development of organized sports. Performance-enhancing drugs have continued to evolve, with "advances" in doping strategies driven by improved drug testing detection methods and advances in scientific research that can lead to the discovery and use of substances that may later be banned. Many sports organizations have come to ban the use of performance-enhancing drugs and have very strict consequences for people caught using them. There is variable evidence for the performance-enhancing effects and side effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

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Drug abuse in athletes

Oxygen is essential for life, and the body has developed an exquisite method to collect oxygen in the lungs and transport it to the tissues. Hb contained within red blood cells (RBCs), is the key oxygen-carrying component in blood, and levels of RBCs are tightly controlled according to demand for oxygen. The availability of oxygen plays a critical role in athletic performance, and agents that enhance oxygen delivery to tissues increase aerobic power. Early methods to increase oxygen delivery included training at altitude, and later, transfusion of packed RBCs. A breakthrough in understanding how RBC formation is controlled included the discovery of erythropoietin (Epo) and cloning of the EPO gene. Cloning of the EPO gene was followed by commercial development of recombinant human Epo (rHuEpo). Legitimate use of this and other agents that affect oxygen delivery is important in the treatment of anaemia (low Hb levels) in patients with chronic kidney disease or in cancer patients with chemotherapy-induced anaemia. However, competitive sports was affected by illicit use of rHuEpo to enhance performance. Testing methods for these agents resulted in a cat-and-mouse game, with testing labs attempting to detect the use of a drug or blood product to improve athletic performance (doping) and certain athletes developing methods to use the agents without being detected. This article examines the current methods to enhance aerobic performance and the methods to detect illicit use.

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Erythropoiesis-stimulating agents and other methods to enhance oxygen transport

Background Increasing numbers of travelers are visiting high altitude locations in the Andes The epidemiology of acute mountain sickness (AMS) among tourists to high altitude in South America is not well understood

Methods A cross‐sectional study to evaluate the epidemiology, pre‐travel preparation, and impact of AMS among travelers to Cusco, Peru (3,400 m) was performed at Cusco's International Airport during June 2010 Foreign travelers, 18 years or older, staying 15 days or less, departing Cusco were invited to participate Demographic, itinerary, and behavioral data were collected The Lake Louise Clinical score (LLCS) was used to assess AMS symptoms

Results In total, 991 travelers participated, median age 32 years (interquartile range 25–49), 555% female, 867% tourists, mostly from the United States (482%) and England (81%) Most (767%) flew from sea level to Cusco and 305% visited high altitude in the previous 2 months Only 291% received AMS advice from a physician, 19% recalled advice on acetazolamide Coca leaf products (628%) were used more often than acetazolamide (166%) for prevention AMS was reported by 485% and 171% had severe AMS One in five travelers with AMS altered their travel plans Travelers older than 60 years, with recent high altitude exposure, who visited lower cities in their itinerary, or used acetazolamide were less likely to have AMS Using coca leaf products was associated with increased AMS frequency

Conclusions AMS was common and adversely impacted plans of one in five travelers Acetazolamide was associated with decreased AMS but was prescribed infrequently Other preventive measures were not associated with a decrease in AMS in this population Pre‐travel preparation was suboptimal

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Acute mountain sickness impact among travelers to Cusco, Peru.

Rhodiola crenulata (R. crenulata) is widely used to prevent acute mountain sickness in the Himalayan areas and in Tibet, but no scientific studies have previously examined its effectiveness. We conducted a randomized, double-blind, placebo-controlled crossover study to investigate its efficacy in acute mountain sickness prevention. Healthy adult volunteers were randomized to 2 treatment sequences, receiving either 800 mg R. crenulata extract or placebo daily for 7 days before ascent and 2 days during mountaineering, before crossing over to the alternate treatment after a 3-month wash-out period. Participants ascended rapidly from 250 m to 3421 m on two separate occasions: December 2010 and April 2011. The primary outcome measure was the incidence of acute mountain sickness, as defined by a Lake Louise score ≥ 3, with headache and at least one of the symptoms of nausea or vomiting, fatigue, dizziness, or difficulty sleeping. One hundred and two participants completed the trial. There were no demographic differences between individuals taking Rhodiola-placebo and those taking placebo-Rhodiola. No significant differences in the incidence of acute mountain sickness were found between R. crenulata extract and placebo groups (all 60.8%; adjusted odds ratio (AOR) = 1.02, 95% confidence interval (CI) = 0.69–1.52). The incidence of severe acute mountain sickness in Rhodiola extract vs. placebo groups was 35.3% vs. 29.4% (AOR = 1.42, 95% CI = 0.90–2.25). 
R. crenulata extract was not effective in reducing the incidence or severity of acute mountain sickness as compared to placebo. ClinicalTrials.gov
 NCT01536288
 .

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Rhodiola crenulata extract for prevention of acute mountain sickness: a randomized, double-blind, placebo-controlled, crossover trial

Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the effects of different classes of substances used for doping, side-effects of doping, and treatment of affected athletes. There is variable evidence for the performance-enhancing effects and side-effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

The sports psychiatrist and performance-enhancing drugs

Background Studies show that the well-prepared traveller is less likely to suffer travel related illness. This study is designed to examine trekkers’ knowledge of altitude sickness in an attempt to see whether knowledge can protect against acute mountain sickness (AMS) and high altitude pulmonary or cerebral oedema (HAPE/HACE). Methods A convenience sample of 130 trekkers were interviewed in the Solu Khumbu region of Nepal. They were asked what action they would take firstly if they developed symptoms of AMS, and secondly, symptoms of HAPE/HACE whilst ascending. Options were to continue up, stay at the same altitude, descend or ask their guide. Results With symptoms of moderate to severe AMS, 37 trekkers (28 per cent) indicated they would continue their ascent while 113 (72 per cent) would not. Those individuals who proposed continued ascent were significantly more likely to be suffering from symptoms of AMS (p = 0.025) and had ascended significantly more rapidly over the preceding 72 h (p = 0.004) then those who proposed to halt their ascent. With regard to symptoms of HAPE/HACE, 12 (9 per cent) indicated they would not descend, demonstrating no association with AMS (p = 0.07) or ascent in preceding 72 h (p = 0.7). Conclusion Trekkers who indicated that they would act safely in the event of developing moderate to severe AMS were significantly less likely to be suffering from AMS when interviewed and had ascended significantly less altitude in the preceding 72 h being more likely to adhere to recommended ascent guidelines.

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Jennifer Vardy

Papers

Can knowledge protect against acute mountain sickness