Drugs in Sport

Drugs in Sport The International Olympic Committee (IOC) Medical Code states "doping contravenes the ethics of both sport and medical science ... doping consists of the administration of substances belonging to prohibited classes of pharmacological agents or the use of various prohibited methods, or both". Misuse of drugs in sport is not new. Athletes have always expressed a need for speed, but some interpret this pharmacologically. The first documented report was in 1865, in swimming, when an unnamed drug was used to enhance performance in a canal race in Amsterdam. In 1955, 20% of cyclists in a French cycle race tested positive for drugs. Stimulants and anabolic steroids are the most common drugs implicated. In 1967, a British cyclist died under the influence of amphetamine during the 1967 Tour de France. In a study in West Glamorgan, 38.8% of body builders admitted to taking anabolic steroids to enhance their physique and performance. Similarly, in an American study, 54% of male body builders were abusing anabolic steroids. Of the 671 cases of drug abuse logged by the UK Drug Testing Programme, 273 involved stimulants while anabolic agents were implicated in 169 cases. Ben Johnston, the Canadian track athlete and former Olympic gold medal winner, was banned for abusing stanozolol; interestingly he now plays American football, a sport not policed for doping. The expulsion of Chinese swimmers from the 1998 World Swimming Championships in Perth also received worldwide media coverage. Doping is back in the news again this month. A leading UK track athlete, of Lucozade fame, was allegedly reported to be getting more of a fizz from the anabolic steroid, nandrolone, and a top US sprinter, who attributed his astronomically high testosterone levels to "pleasing his wife" the night before the drug test, was banned. Review of the UK drug testing programme reveals that sports most commonly implicated are athletics, cycling, rugby, football, powerlifting and weightlifting. One Step Ahead Methods of doping are becoming more advanced. According to Domhnall MacAuley, editor of the British Journal of Sports Medicine and former international rower, "tesing is becoming even more sophisticated, yet athletes seem to be at least one step ahead". Currently, the greatest concern to sports authorities are the new "sports designer drugs", the peptide hormones, predicted to be the scourge of the 2000 Olympic games in Sydney. These pose a particular problem in that they cannot be detected by currently available testing methods. Similarly, the prohibited method of blood doping is almost impossible to detect. However, not only is doping in sport against all principles of fair competition, it can also be dangerous to an athlete's health. In July of this year, the Irish Sports Council (ISC) was established to promote sports development in Ireland. Part of the remit of the ISC will be to evolve effective antidoping procedures; education and research into doping in sport will also be part of their agenda. How do Athletes obtain Drugs? Athletes may obtain drugs through three main networks: their physician, the black market and the proximity network. Many GPs prescribe drugs unwittingly, for what they trust is a genuine complaint. Many drugs, in particular the hightech agents are purchased on the black market. The proximity

network is the term used to describe acquisition of drugs from people within a close network e.g. coaches, teammates, and commonly relatives. The Role of Prescriber and Pharmacist Control of intentional and non-intentional drug abuse in sport requires the co-operation of athletes and prescribers. Athletes suffer the same cross-section of ailments as other patients and many sportsmen avoid all medicines because of concern about failing doping tests. A balance is needed to have a range of drugs available to manage a variety of common disorders while maintaining a level playing field. Prescribers should be aware of prohibited medicines and routes of administration compatible with sports. The BNF includes a useful reference section on drugs in sport. Prescribers' knowledge of drugs that are prohibited is generally poor. In a survey of GPs in West Sussex, only one-third were aware of the Sports Council guidelines given in the BNF and general knowledge of banned substances was highly variable. In the same survey, 20% of respondents said that they had been asked by patients to prescribe anabolic steroids for non-medical reasons. There is a need for provision of up to date information and advice to prescribers on drugs in sport. Different sports may have different regulations and drugs banned by one sports organisation may be allowed by another. Where there is any doubt, as to the compatibility of a drug in sport, athletes should be recommended to check with their governing body . The community pharmacist also has an important role to play in advising on appropriate use of medicines in sport. In addition to prescribed medicines, many OTC preparations also contain prohibited substances. For example, many cold, cartarrh and hayfever remedies contain sympathomimetics and analgesics may contain opioids and caffeine. It is noteworthy, that because OTC preparations are widely used for minor ailments, their abuse is more difficult to control. Table 2 lists drugs and doping methods banned by the International Olympic Committee (IOC). TABLE 2 Prohibited Classes of Substances and Prohibited Methods banned by the IOC Prohibited classes of substances Prohibited methods Classes of drugs subject to certain restrictions Stimulants Blood doping Alcohol Narcotics Pharmacological, chemical and physical manipulation Marijuana Anabolic agents - e.g. steroids, beta-agonists Local anaesthetics Diuretics Corticosteroids Peptide and glycoprotein hormones and analogues Beta-blockers Drugs allowed by the IOC. Drugs permitted for use in sport by the IOC Anaesthetics (local, intra-articular*) Beta-agonists (inhaled salbutamol, terbutaline, salmeterol)* Analgesics e.g. paracetamol, aspirin, codeine Corticosteroids (inhalers, topical, intra-articular)*

Antacids (simple)H2 antagonists (cimetidine, ranitidine) Antibiotics Oxymetazoline (topical) Antidiarrhoeals (diphenoxylate, loperamide, electrolyte replacement agents) Proton pump inhibitors Anti-emetics (metoclopramide, domperidone) Sodium cromoglycate Antihistamines * prior written notification of use required Prohibited Substances STIMULANTS Stimulants are the most common group of drugs abused in sport. They stimulate the nervous system and increase cardiovascular activity, reducing tiredness and muscle fatigue, and enhancing aggression, stamina and competitiveness. Amphetamines are the most potent. They are highly addictive and adverse effects include anxiety, arrythmias, hypertension, stroke and death. Indeed abuse of amphetamines has been attributed to a number of sports fatalities. Following the ban of amphetamines by the IOC, many turned to OTC cold and decongestant preparations containing stimulants such as ephedrine, pseudoephedrine and phenylpropanolamine. Although less potent than amphetamines, they have a similar effect; the IOC has set cut-off values, above which they are considered to be prohibited. Urine samples are considered positive at levels of >5 micrograms/ml for ephedrine and 10 micrograms/ml for pseudoephedrine and phenylpropanolamine. Where more than one substance is present, the quantities are totalled and if they exceed 10 micograms/ml, the test is positive. Caffeine is also a sympathomimetic and its abuse is widespread, but needs to be taken in significant amounts - the threshold for caffeine is 12 micrograms/ml. NARCOTICS Narcotics do not have significant performance enhancing potential and may even impair performance. Nevertheless they have been used to reduce pain and enable athletes to continue despite injury e.g. leg cramps in long distance events. They are also highly addictive. Their prohibition is based mainly on their reputation as illegal drugs. Banned substances include morphine, methadone and pethidine. In 1992, codeine and dihydrocodeine were removed from the banned list and more recently dextropropoxyphene was also permitted by the IOC. ANABOLIC AGENTS Two groups of drugs fall into the category, the anabolic androgenic steroids and the beta-2agonists. Anabolic androgenic steroids Anabolic steroids include nandrolone, oxandrolone, stanozolol, testosterone, metenolone, dehydroepiandrosterone (DHEA) and related substances. Over 100 different anabolic steroids are available. Testosterone is responsible for stimulating development of male sexual characteristics (androgenic effect) and the build up of muscle tissue (anabolic effect). Manufacturers of anabolic steroids aim to minimise the androgenic and maximise the anabolic effects. They improve performance by increasing muscle size and strength, allow athletes to train harder and longer, with improved recovery from training sessions and promote increased aggression and competitiveness. Anabolic steroids are known as 'training drugs' as they are often taken during training prior to competition and then stopped for several weeks before a competition to reduce the likelihood of positive testing. The presence of testosterone (T) to epitestosterone (E) in the urine in a ratio of greater than 6:1 constitutes an offence unless there is evidence that the ratio is due to an underlying physiological or pathological disorder. Side-effects of anabolic steroid abuse include: hypogonadism, gynaecomastia, acne, alopecia, stunted growth in teenage athletes, male and female infertility, aggression, cholestasis, cardiovascular disease and death.

Beta-2-agonists Beta-2 agonists are not anabolic steroids, however they do have potent anabolic effects, Drugs such as salbutamol and clenbuterol, when taken orally, increase muscle mass improving muscular strength. Clenbuterol ("angel dust"), only available as a veterinary medicine, is also widely abused in the cattle industry. Salbutamol, salmeterol and terbutaline are permitted by inhalation, with written notification in advance of competition; the same applies to inhaled steroids. Asthmatics may be treated with therapeutic doses of theophylline, sodium cromoglycate and anticholinergics without prior medical notice. DIURETICS Diuretics e.g. frusemide, bumetanide, chlorthalidone, triameterene, hydrochlorothiazide tend to be abused by those competing in weight classes e.g. weight lifiting, boxing, wrestling and horseracing, to achieve rapid weight loss. Diuretic use prior to weigh-ins has been associated with serious adverse effects, such as profound hypotension and in one case pulmonary embolism. They are also used to enhance exertion of prohibited drugs to mask their presence in the urine by producing a significant dilution. PEPTIDE HORMONES Peptide hormones are the so-called sports designer drugs and are increasingly abused by athletes. Their attraction is that although they are synthetically produced, they are indistinguishable from the body's natural hormones and cannot be detected by current IOC testing methods. Human chorinonic gonadotrophin (HCG) is used to stimulate the production of endogenous testosterone. Human growth hormone (HGH), a particularly expensive drug, is also thought to have an anabolic effect. Recent data from studies in weight lifters however suggest that although it increases lean body mass, it does not significantly increase muscular strength. Side-effects associated with its abuse include acromegaly, gigantism and metabolic disturbances. Creutzfield-Jacob disease has been associated with some eastern European supplies of HGH. A detection method for HGH is currently under development. Insulin is also being abused, with potentially fatal consequences. Some athletes are putting their lives at risk by taking erythropoietin (EPO). EPO stimulates red blood cell production from the bone marrow. Synthetically prepared EPO (Eprex) is used medically to increase the haematocrit of patients with severe anaemia associated with chronic renal failure. It increases haemoglobin levels thereby increasing packed cell volume (PCV) and improving oxygenation of the blood. Eprex is being used in sport to enhance oxygen delivery to working muscles and improve athletic endurance. Abuse of EPO can increase the haematocrit in endurance athletes to very high levels. The viscosity of the blood is greatly increased which can lead to poor circulation, thrombotic lesions and myocardial infarction. It is thought that the high incidence of sudden death in some endurance athletes is due to abuse of EPO now considered to be perhaps the most deadly of the ergogenic drugs available. Prohibited Methods BLOOD DOPING Blood doping is also used to improve the oxygen capacity of the ahtlete's blood. It constitutes the administration of blood and red blood cells, usually preceded by withdrawal of the blood from the athlete who continues to train in a blood depleted state. The athlete's blood is stored and later reinfused, thereby boosting the PCV. Again this method is difficult to detect. Due to the difficulties associated with appropriate storage and reinfusion of blood, this method is being superseded by administration of EPO, as described above. PHARMACOLOGICAL, CHEMICAL AND PHYSICAL MANIPULATION The drug testing procedure may be manipulated by pharmacological, chemical and physical means and such procedures are also banned. A number of methods are used for tampering with the integrity and validity of urine samples collected for testing. Physical procedures include catheterisation and instillation of clean urine into the bladder, followed by simulation of voiding. Pharmacological means include the use of probenecid to inhibit renal excretion of steroids.

Epitestosterone is also added to the urine to reduce the T/E ratio. Drugs Subject to Certain Restrictions A number of drugs are subject to certain restrictions and others are prohibited by some sports authorities only. For example, corticosteroids may be given topically (i.e. nasal, ophthalmic, aural, anal, dermatological) and via inhalation and intraarticular injection, but only with prior written notification to the appropriate authority. Local anaesthetics are also permitted under predefined conditions, except for dental use. Betablockers reduce anxiety and tremor and so are banned in control sports such as shooting, archery, bowls, skijumping and synchronised swimming Nutritional Supplements Many athletes use ergogenic nutritional aids to benefit performance without damaging their eligibility for competition or indeed their health. Substances promoted as beneficial include carnitine, chromium picolinate and creatine. Many products are promoted as natural anabolic steroids, and advertised in lifestyle magazines, health food stores and more recently on the Internet. However, despite their widespread promotion, many claims are unsubstantiated and there is little evidence of benefit. In addition, purified amino acids are also taken as a rich protein source. Some products may also be harmful. Excessive intake of protein may cause liver and kidney damage. Hypervitaminosis is not uncommon. Creatine is currently in vogue and actively promoted by coaches, but again there is limited evidence of improved performance. Chromium picolinate is a food supplement claimed to accelerate lean body mass and concurrent loss of body fat. It is particularly popular with weightlifters and bodybuilders. Recent studies have failed to confirm any significant effects on muscular development and strength. Analogues of picolinic acid are known to affect metabolism of serotonin, dopamine and noradrenaline metabolism. Chronic renal failure has also been associated with ingestion of this supplement. High doses of sodium bicarbonate are taken by some athletes to enhance performance. Often referred to as soda doping it involves ingestion of up to 3 mg/kg sodium bicarbonate, approximately 30 minutes before exercise. The excess alkaline load buffers the lactic acid in the blood produced from fatigued muscles. The leg muscles are most susceptible to lactic acid accumulation. Hence the popularity of soda doping with competitive cyclists and sprinters. Ingestion of such high doses of alkaline salts is not without side effects. Fluid retention and abdominal bloating are common, as is thirst. Severe GI discomfort may occur and the excess sodium load may place undue strain on the heart. Alkalination of the urine also prolongs the halflife of prohibited substances such as amphetamines and pseudoephedrine, thereby enhancing their toxicity. Summary The use of performance enhancing drugs in sport contravenes the spirit of fair competition and can also be detrimental to an athlete's health. Many feel that a drug must be taken to level the playing field and for some "it is just one step from the belief that drugs can aid performance to the expectation that athletes must take drugs if they want to win medals". However, where some athletes deliberately take drugs to seek an advantage, others may inadvertently take a prohibited substance due to a lack of awareness.

Nevertheless, drug doping is here to stay and effective doping control methods must be in place, supported by education, of both athletes and health care professionals, quality research and international collaboration. ........................................................................................................................................................... ........................................................................................................................

Use of performance enhancing drugs in sport In sports, the use of performance-enhancing drugs is commonly referred to by the disparaging term "doping", particularly by those organizations that regulate competitions. The use of performance enhancing drugs is mostly done to improve athletic performance. This is why many sports ban the use of performance enhancing drugs. Another similar use of medical technology is called blood doping, either by blood transfusion or use of the hormone erythropoietin (EPO). The use of drugs to enhance performance is considered unethical by most international sports organizations and especially the International Olympic Committee, although ethicists have argued that it is little different from the use of new materials in the construction of suits and sporting equipment, which similarly aid performance and can give competitors advantage over others. The reasons for the ban are mainly the alleged health threat of performance-enhancing drugs, the equality of opportunity for athletes and the supposedly exemplary effect of "clean" ("doping-free") sports in the public. This entry concerns the use of performance-enhancing drugs by humans. The use of such drugs is also common in horse racing and other equestrian sports, and in greyhound racing. Origin of the term "doping" There are many suggestions as to the origin of the word ‘doping’. One is that it is derived from ‘dop’ an alcoholic drink used as a stimulant in ceremonial dances in 18th century Southern Africa . Another suggestion is that the word comes from the Dutch word ‘doop’ (a thick dipping sauce) that entered American slang to describe how robbers stupefied victims by mixing tobacco with the seeds of Datura stramonium , known as jimsonweed, which contains a number of tropane alkaloids, causing sedation, hallucinations and confusion . By 1889, ‘dope’ was used in connection with the preparation of a thick viscous preparation of opium for smoking, and during the 1890s this extended to any stupefying narcotic drug. In 1900, dope was also defined as ‘a preparation of drugs designed to influence a racehorse’s performance’ History Texts going back to antiquity suggest that men have always sought a way to work harder or at least to suffer less as they were doing so. When the fittest of a nation were selected as athletes or combatants, they were fed diets and given treatments considered beneficial Scandinavian mythology says Berserkers could drink a mixture called "butotens", perhaps prepared from the Amanita muscaria mushroom, and increase their physical power a dozen times at the risk of "going crazy". In more recent times, the German missionary and doctor Albert Schweitzer wrote of Gabon in the early 19th century: "The people of the country can, having eaten certain leaves or roots, toil [pagayer] vigorously all day without feeling hungry, thirsty or tired and all the time showing a happiness and gaiety." A participant in an endurance walking race in Britain, Abraham Wood, said in 1807 that he had used laudanum, or opium, to keep him awake for 24 hours while competing against Robert Barclay Allardyce. By April 1877, walking races had stretched to 500 miles and the following year, also at the Agricultural Hall in Islington, London, to 520 miles. The Illustrated London News

chided: It may be an advantage to know that a man can travel 520 miles in 138 hours, and manage to live through a week with an infinitesimal amount of rest, though we fail to perceive that anyone could possibly be placed in a position where his ability in this respect would be of any use to him [and] what is to be gained by a constant repetition of the fact. The crowd loved it, however, and 20,000 a day came to watch . That encouraged promoters to repeat the races, at the same venue but with cyclists. They were the fastest humans on earth... "...and much more likely to endure their miseries publicly; a tired walker, after all, merely sits down - a tired cyclist falls off and possibly brings others crashing down as well. That's much more fun". The fascination with six-day bicycle races spread across the Atlantic and the same appeal to base instincts brought in the crowds in America as well. And the more spectators paid at the gate, the higher the prizes could be and the greater was the incentive of riders to stay awake - or be kept awake - to ride the greatest distance. Their exhaustion was countered by soigneurs (the French word for "carers"), helpers akin to seconds in boxing. Among the treatments they supplied was nitroglycerine, a drug used to stimulate the heart after cardiac attacks and which was credited with improving riders' breathing. Riders suffered hallucinations from the exhaustion and perhaps the drugs. The American champion Major Taylor refused to continue the New York race, saying: "I cannot go on with safety, for there is a man chasing me around the ring with a knife in his hand." Public reaction turned against such trials, whether individual races or in teams of two. One report chided: An athletic contest in which the participants 'go queer' in their heads, and strain their powers until their faces become hideous with the tortures that rack them, is not sport, it is brutality. It appears from the reports of this singular performance that some of the bicycle riders have actually become temporarily insane during the contest... Days and weeks of recuperation will be needed to put the racers in condition, and it is likely that some of them will never recover from the strain. The American specialist in doping, Max M. Novich, wrote: "Trainers of the old school who supplied treatments which had cocaine as their base declared with assurance that a rider tired by a six-day race would get his second breath after absorbing these mixtures." John Hoberman, a professor at the University of Texas in Austin, Texas, said six-day races were "de facto experiments investigating the physiology of stress as well as the substances that might alleviate exhaustion." Strychnine at the Olympics These "de facto experiments investigating the physiology of stress as well as the substances that might alleviate exhaustion" weren't unknown outside cycling. Thomas J. Hicks, an American born in England on January 7, 1875 won the Olympic marathon in 1904. He crossed the line behind a fellow American, Fred Lorz, whose concept of marathonrunning extended to riding half the way in a car. But nor did Hicks compete without outside help. His trainer, Charles Lucas, pulled out a hypodermic and came to his aid as his runner began to struggle. I therefore decided to inject him with a milligram of sulphate of strychnine and to make him drink a large glass brimming with brandy. He set off again as best he could [but] he needed another injection four miles from the end to give him a semblance of speed and to get him to the finish.

The use of strychnine, far from being banned, was thought necessary to survive demanding races, says the sports historian Alain Lunzenfichter. The historian of sports doping, Dr JeanPierre de Mondenard, said: It has to be appreciated that at the time the menace of doping for the health of athletes or of the purity of competition had yet to enter the morals because, after this marathon, the official race report said: The marathon has shown from a medical point of view how drugs can be very useful to athletes in long-distance races. Hicks was, in the phrase of the time, "between life and death" but recovered, collected his gold medal a few days later, and lived for almost 60 more years, although he never again took part in athletics. [17] The Convicts of the Road In 1924 the journalist Albert Londres followed the Tour de France for the French newspaper, Le Petit Parisien. At Coutances he heard that the previous year's winner, Henri Pélissier, his brother Francis and a third rider, Maurice Ville, had resigned from the competition after an argument with the organiser, Henri Desgrange. Henri explained the problem - whether or not he had the right to take off a jersey - and went on to talk of drugs, reported in Londres' race diary, in which he invented the phrase Les Forçats de la Route (The Convicts of the Road): "You have no idea what the Tour de France is," Henri said. "It's a Calvary. Worse than that, because the road to the Cross has only 14 stations and ours has 15. We suffer from the start to the end. You want to know how we keep going? Here..." He pulled a phial from his bag. "That's cocaine, for our eyes. This is chloroform, for our gums." "This," Ville said, emptying his shoulder bag "is liniment to put warmth back into our knees." "And pills. Do you want to see pills? Have a look, here are the pills." Each pulled out three boxes. "The truth is," Francis said, "that we keep going on dynamite." Henri spoke of being as white as shrouds once the dirt of the day had been washed off, then of their bodies being drained by diarrhoea, before continuing: "At night, in our rooms, we can't sleep. We twitch and dance and jig about as though we were doing St Vitus's Dance..." "There's less flesh on our bodies than on a skeleton," Francis said. Francis Pélissier said much later: "Londres was a famous reporter but he didn't know about cycling. We kidded him a bit with our cocaine and our pills. Even so, the Tour de France in 1924 was no picnic. The acceptance of drug-taking in the Tour de France was so complete by 1930, when the race changed to national teams that were to be paid for by the organisers, that the rule book distributed to riders by the organiser, Henri Desgrange, reminded them that drugs were not among items with which they would be provided.

Up to speed with Benzedrine Benzedrine is a trade name for amphetamine. The Council of Europe says it first appeared in sport at the Berlin Olympics in 1936. It was produced in 1887 and the derivative, Benzedrine, was isolated in the USA in 1934. Its perceived effects gave it the street name "speed". British troops

used 72 million amphetamine tablets in the Second World War and the RAF got through so many that "Methedrine won the Battle of Britain" according to one report. The problem was that amphetamine leads to a lack of judgement and a willingness to take risks, which in sport could lead to better performances but in fighters and bombers led to more crash landings than the RAF could tolerate. The drug was withdrawn but large stocks remained on the black market. Amphetamine was also used legally as an aid to slimming. Everton have long been one of the top clubs in the English association football league. The club were champions of the 1962-63 season. And it was done, according to a national newspaper investigation, with the help of Benzedrine. Word spread after Everton's win that the drug had been involved. The newspaper investigated, cited where the reporter believed it had come from, and quoted the goalkeeper, Albert Dunlop, as saying: I cannot remember how they first came to be offered to us. But they were distributed in the dressing rooms. We didn't have to take them but most of the players did. The tablets were mostly white but once or twice they were yellow. They were used through the 1961-62 season and the championship season which followed it. Drug-taking had previously been virtually unnamed in the club. But once it had started we could have as many tablets as we liked. On match days they were handed out to most players as a matter of course. Soon some of the players could not do without the drugs. Now in Professional sports only 34% of the Athletes use Performance enhancing drugs. The club agreed that drugs had been used but that they "could not possibly have had any harmful effect." Dunlop, however, said he had become an addict. Benzedrine and its sister drugs were irresistible in other sports. In November 1942, the Italian cyclist Fausto Coppi took "seven packets of amphetamine" to beat the world hour record on the track. In 1960, the Danish rider Knud Enemark Jensen collapsed during the 100 km team time trial at the Olympic Games in Rome and died later in hospital. The autopsy showed he had taken amphetamine and another drug, Ronicol, which dilates the blood vessels. The chairman of the Dutch cycling federation, Piet van Dijk, said of Rome that "dope - whole cartloads -[were] used in such royal quantities." The British professional Jock Andrews used to joke: "You need never go off-course chasing the peloton in a big race - just follow the trail of empty syringes and dope wrappers." The Dutch cycling team manager Kees Pellenaars told of a rider in his care: I took him along to a training camp in Spain. The boy changed then into a sort of lion. He raced around as though he was powered by rockets. I went to talk to him. He was really happy he was riding well and he told me to look out for him. I asked if he wasn't perhaps "using something" and he jumped straight up, climbed on a chair and from deep inside a cupboard he pulled out a plastic bag full of pills. I felt my heart skip a beat. I had never seen so many fireworks together. With a soigner we counted the pills: there were 5,000 of them, excluding hormone preparations and sleeping pills. I took them away, to his own relief. I let him keep the hormones and the sleeping pills. Later he seemed to have taken too many at once and he slept for a couple of days on end. We couldn't wake him up. We took him to hospital and they pumped out his stomach. They tied him to his bed to prevent anything going wrong again. But one way or another he had some stimulant and fancied taking a walk. A nurse came across him in the corridor, walking along with the bed strapped to his back. Anabolic steroids Anabolic steroids (AAS) were first isolated, identified and synthesized in the 1930s, and are now used therapeutically in medicine to stimulate bone growth and appetite, induce male puberty, and

treat chronic wasting conditions, such as cancer and AIDS. Anabolic steroids also produce increases in muscle mass and physical strength, and are consequently used in sport and bodybuilding to enhance strength or physique. Known side effects include harmful changes in cholesterol levels (increased Low density lipoprotein and decreased High density lipoprotein), acne, high blood pressure, liver damage. Some of these effects can be mitigated by taking supplemental drugs. AAS user in sports began in October 1954, John Ziegler, a doctor who treated American athletes, went to Vienna with the American weightlifting team. There he met a Russian physicist who, over "a few drinks", repeatedly asked "What are you giving your boys?" When Ziegler returned the question, the Russian said that his own athletes were being given testosterone. Returning to America, Ziegler tried weak doses of testosterone on himself, on the American trainer Bob Hoffman and on two lifters, Jim Park and Yaz Kuzahara. All gained more weight and strength than any training programme would produce but there were side-effects. Ziegler sought a drug without after-effects and hit on an anabolic steroid, methandrostenolone, (Dianabol, DBOL), made in the US in 1958 by Ciba. The results were impressive - so impressive that lifters began taking ever more. Steroids spread to other sports where bulk mattered. Paul Lowe, a former running back with the San Diego Chargers American football team, told a California legislative committee on drug abuse in 1970: "We had to take them [steroids] at lunchtime. He [an official] would put them on a little saucer and prescribed them for us to take them and if not he would suggest there might be a fine." Olympic statistics show the weight of shot putters grew 14 per cent between 1956 and 1972, whereas steeplechasers grew 7.6 per cent. The gold medallist pentathlete Mary Peters said: "A medical research team in the United States attempted to set up extensive research into the effects of steroids on weightlifters and throwers, only to discover that there were so few who weren't taking them that they couldn't establish any worthwhile comparisons. Several successful athletes and professional bodybuilders have admitted long-term methandrostenolone use before the drug was banned, including Arnold Schwarzenegger and Sergio Oliva. Dianabol is no longer produced but similar drugs are made elsewhere. The use of anabolic steroids is now banned by all major sporting bodies, including the WTA, ITF, International Olympic Committee, FIFA, UEFA, all major professional golf tours, the National Hockey League, Major League Baseball, the National Basketball Association, the European Athletic Association, the WWE and the National Football League. However drug testing can be wildly inconsistent and, in some instances, has gone unenforced. A famous case of illicit AAS use in a competition was Canadian Ben Johnson's victory in the 100 m at the 1988 Summer Olympics. He subsequently failed the drug test when stanozolol was found in his urine. He later admitted to using the steroid as well as Dianabol, Testosterone Cypionate, Furazabol, and human growth hormone amongst other things. Johnson was stripped of his gold medal as well as recognition of what had been a world-record performance. Carl Lewis was then promoted one place to take the Olympic gold title. Lewis had also run under the current world record time and was therefore recognized as the new record holder, even though Lewis had technically been disqualified under IOC rules for testing positive for a banned substance. [citation needed] The case of East Germany In 1977, one of East Germany's best sprinters, Renate Neufeld, fled to the West with the Bulgarian she later married. A year later she said that she had been told to take drugs supplied by coaches while training to represent East Germany in the 1980 Olympic Games. At 17, I joined the East Berlin Sports Institute. My speciality was the 80m hurdles. We swore

that we would never speak to anyone about our training methods, including our parents. The training was very hard. We were all watched. We signed a register each time we left for dormitory and we had to say where we were going and what time we would return. One day, my trainer, Günter Clam, advised me to take pills to improve my performance: I was running 200m in 24 seconds. My trainer told me the pills were vitamins, but I soon had cramp in my legs, my voice became gruff and sometimes I couldn't talk any more. Then I started to grow a moustache and my periods stopped. I then refused to take these pills. One morning in October 1977, the secret police took me at 7am and questioned me about my refusal to take pills prescribed by the trainer. I then decided to flee, with my fiancé. She brought with her to the West grey tablets and green powder she said had been given to her, to members of her club, and to other athletes. The West German doping analyst Manfred Donike reportedly identified them as anabolic steroids. She said she stayed quiet for a year for the sake of her family. But when her father then lost his job and her sister was expelled from her handball club, she decided to tell her story. East Germany closed itself to the sporting world in May 1965 In 1977 the shot-putter Ilona Slupianek, who weighed 93 kg - tested positive for anabolic steroids at the European Cup meeting in Helsinki and thereafter athletes were tested before they left the country. At the same time, the Kreischa testing laboratory near Dresden passed into government control, which was reputed to make around 12,000 tests a year on East German athletes but without any being penalised. The International Amateur Athletics Federation suspended Slupianek for 12 months, a penalty that ended two days before the European championships in Prague. In the reverse of what the IAAF hoped, sending her home to East Germany meant she was free to train unchecked with anabolic steroids, if she wanted to, and then compete for another gold medal. Which indeed she won. After that, almost nothing emerged from the East German sports schools and laboratories. A rare exception was the visit by the sports writer and former athlete, Doug Gilbert of the Edmonton Sun, who said: Dr (Heinz) Wuschech knows more about anabolic steroids than any doctor I have ever met, and yet he cannot discuss them openly any more than Geoff Capes or Mac Wilkins can openly discuss them in the current climate of amateur sports regulation. What I did learn in East Germany was that they feel there is little danger from anabolica, as they call it, when the athletes are kept on strictly monitored programmes. Although the extremely dangerous sideeffects are admitted, they are statistically no more likely to occur than side-effects from the birth control pill. If, that is, programmes are constantly medically monotired as to dosage. Other reports came from the occasional athlete who fled to the West. There were 15 between 1976 and 1979. One, the ski-jumper Hans Georg Aschenbach, said: "Long-distance skiers start having injections to their knees from the age 14 because of their intensive training. He said: "For every Olympic champion, there at least 350 invalids. There are gymnasts among the girls who have to wear corsets from the age of 18 because their spine and their ligaments have become so worn... There are young people so worn out by the intensive training that they come out of it mentally blank [lessivés - washed out], which is even more painful than a deformed spine. Then on 26 August 1993 the records opened with the merger of the two Germanies and the evidence was there that the Stasi, the state secret police, supervised systematic doping of East German athletes from 1971 until reunification in 1990. Doping existed in other countries, says the expert Jean-Pierre de Mondenard, both communist and capitalist, but the difference with East Germany was that it was a state policy. The Sportvereinigung Dynamo (English:Sport Club Dynamo) was especially singled out as a center for doping in the former East Germany. Many former club officials and some athletes found

themselves charged after the dissolution of the country. A special page on the internet was created by doping victims trying to gain justice and compensation, listing people involved in doping in the GDR.. State-endorsed doping began with the Cold War when every eastern bloc gold was an ideological victory. From 1974, Manfred Ewald, the head of the GDR's sports federation, imposed blanket doping. At the 1968 Mexico City Olympics, the country of 17 million collected nine gold medals. Four years later the total was 20 and in 1976 it doubled again to. Ewald was quoted as having told coaches, "They're still so young and don't have to know everything." He was given a 22month suspended sentence, to the outrage of his victims. Often, doping was carried out without the knowledge of the athletes, some of them as young as ten years of age. It is estimated that around 10,000 former athletes bear the physical and mental scars of years of drug abuse, one of them is Rica Reinisch, a triple Olympic champion and world record-setter at the Moscow Games in 1980, has since suffered numerous miscarriages and recurring ovarian cysts. Two former Dynamo Berlin club doctors, Dieter Binus, chief of the national women's team from 1976 to 80, and Bernd Pansold, in charge of the sports medicine center in East-Berlin, were committed for trial for allegedly supplying 19 teenagers with illegal substances . Binus was sentenced in August, Pansold in December 1998 after both being found guilty of administering hormones to underage female athletes from 1975 to 1984. Virtually no East German athlete ever failed an official drugs test, though Stasi files show that many did, indeed, produce positive tests at Kreischa, the Saxon laboratory (German:Zentrales Dopingkontroll-Labor des Sportmedizinischen Dienstes) that was at the time approved by the International Olympic Committee, now called the Institute of Doping Analysis and Sports Biochemistry (IDAS). In 2005, fifteen years after the end or the GDR, the manufacturer of the drugs in former East Germany, Jenapharm, still finds itself involved in numerous lawsuits from doping victims, being sued by almost 200 former athletes. Former Sport Club Dynamo athletes who publicly admitted to doping, accusing their coaches:

•

Daniela Hunger

•

Αν δ ρ ε α

Πο λ λ α χ κ

Former Sport Club Dynamo athletes disqualified for doping:

•

Ilona SlupianekHYPERLINK \l "cite_note-53"] (Ilona Slupianek was tested positive along with three Finnish athletes at the 1977 European Cup, becoming the only East German athlete ever to be convicted of doping)

Based on the admission by Pollack, the United States Olympic Committee asked for the redistribution of gold medals won in the 1976 Summer OlympicsHYPERLINK \l "cite_note-54"[. Despite court rulings in Germany that substantiate claims of systematic doping by some East German swimmers, the IOC executive board announced that it has no intention of revising the Olympic record books. In rejecting the American petition on behalf of its women's medley relay team in Montreal and a similar petition from the British Olympic Association on behalf of Sharron Davies, the IOC made it clear that it wanted to discourage any such appeals in the future. Modern times Currently, tetrahydrogestrinone (THG) and modafinil are causing controversy throughout the sporting world, with many high profile cases attracting major press coverage as prominent United

States athletes have tested positive for these doping substances. Some athletes who were found to have used modafinil protested as the drug was not on the prohibited list at the time of their offence; however, the World Anti-Doping Agency (WADA) maintains it is a substance related to those already banned, so the decisions stand. Modafinil was added to the list of prohibited substances on 3 August 2004, ten days before the start of the 2004 Summer Olympics. Doping in association football Unlike individual sports such as bicycling, weight-lifting, and track and field, football (soccer) is not widely associated with performance enhancing drugs. Like most high-profile team sports, football suffers more from an association with recreational drugs, the case of Diego Maradona and cocaine in 1991 being the best known of those. Football has however been criticised for not sanctioning players implicated in performance enhancing drug scandals. Most recently, Operation Puerto implicated approximately 50 cyclists and 150 sportspersons of other sporting codes, including several "high profile soccer players". While the cyclists were named and pursued by the governing bodies of cycling, none of the soccer players were named or punished for their involvement in the doping ring. Endurance sports In 1998 the entire Festina team were excluded from the Tour de France following the discovery of a team car containing large amounts of various performance-enhancing drugs. The team director later admitted that some of the cyclists were routinely given banned substances. Six other teams pulled out in protest including Dutch team TVM who left the tour still being questioned by the police. The Festina scandal overshadowed cyclist Marco Pantani's tour win, but he himself later failed a test. More recently David Millar, the 2003 World-Time Trial Champion, admitted using EPO, and was stripped of his title and suspended for two years. Still later, Roberto Heras was stripped of his victory in the 2005 Vuelta a España and suspended for two years after testing positive for EPO. Sports lawyer Michelle Gallen has said that the pursuit of doping athletes has turned into a modern day witch-hunt. Reaction from sports organizations Many sports organizations have banned the use of performance enhancing drugs and have very strict rules and consequences for people who are caught using them. The International Amateur Athletic Federation, now the International Association of Athletics Federations, were the first international governing body of sport to take the situation seriously. In 1928 they banned participants from doping, but with little in the way of testing available they had to rely on the word of the athlete that they were clean. It was not until 1966 that FIFA (soccer) and Union Cycliste Internationale (cycling) joined the IAAF in the fight against drugs, closely followed by the International Olympic Committee the following year. Progression in pharmacology has always outstripped the ability of sports federations to implement rigorous testing procedures but since the creation of the World Anti-Doping Agency in 1999 more and more athletes are being caught. The first tests for athletes were at the 1966 European Championships and two years later the IOC implemented their first drug tests at both the Summer and Winter Olympics. Anabolic steroids became prevalent during the 1970s and after a method of detection was found they were added to the IOC's prohibited substances list in 1976. Over the years, different sporting bodies have evolved differently to the war against doping.

Some, such as athletics and cycling, are becoming increasingly vigilant against doping in their sports. However, there has been criticism that sports such as soccer and baseball are doing nothing about the issue, and letting athletes implicated in doping away unpunished. An example of this was Operation Puerto - approximately 200 sportspersons were implicated in blood doping. Of these, approximately 50 were cyclists and 150 were other sportspersons, including several "high profile soccer and tennis players" . The cyclists were pursued over their involvement, with many of them getting bans, such as Ivan Basso and Tyler Hamilton. By contrast, not a single soccer player involved in the doping ring was named, and to this day, all remain unpunished. A handful of commentators maintain that, as outright prevention of doping is an impossibility, all doping should be legalised. However, most disagree with this assertion, pointing out the claimed harmful long-term effects of many doping agents. However, with no medical data to support these claimed health problems, it is questionable at best. Opponents claim that with doping legal, all competitive athletes would be compelled to use drugs, the net effect would be a level playing field but with widespread health consequences. However, considering that anti-doping is largely ineffective due to both testing limitations and lack of enforcement, this is not markedly different than the situation already in existence. Another point of view is that doping could be legalized to some extent using a drug whitelist and medical counseling, such that medical safety is ensured, with all usage published. However, under such a system, it is likely that athletes would attempt cheat by exceeding official limits to try to gain an advantage; however, this is pure conjecture as drug amounts do not always correlate linearly with performance gains. Thus, to police such a system could be as difficult as policing a total ban on performance enhancing drugs. Anti-Doping organizations and legislation WADA Anti-Doping Convention of the Council of Europe The Anti-Doping Convention of the Council of Europe in Strasbourg was opened for signature on 16 December 1989 as the first multilateral legal standard in this field. It has been signed by 48 states including the Council of Europe non-member states Australia, Belarus, Canada and Tunisia. The Convention is open for signature by other non-European states. It does not claim to create a universal model of anti-doping, but sets a certain number of common standards and regulations requiring Parties to adopt legislative, financial, technical, educational and other measures. The main objective of the Convention is to promote the national and international harmonisation of the measures to be taken against doping. In their constitutional provisions, each contracting party undertakes to: •

create a national co-ordinating body;

•

reduce the trafficking of doping substances and the use of banned doping agents;

•

reinforce doping controls and improve detection techniques;

•

support education and awareness-raising programmes;

•

guarantee the efficiency of sanctions taken against offenders;

•

collaborate with sports organisations at all levels, including at international level;

•

and to use accredited anti-doping laboratories.

Furthermore the Convention describes the mission of the Monitoring Group set up in order to monitor its implementation and periodically re-examine the List of prohibited substances and methods which can be found in annex to the main text. An Additional Protocol to the Convention entered into force on 1 April 2004 with the aim of ensuring the mutual recognition of anti-doping controls and of reinforcing the implementation of the Convention using a binding control system. Drug testing Statistical Validity Professor Donald A. Berry has argued that the closed systems used by anti-doping agencies do not allow scientific (statistical) validation of the tests.. This argument was seconded by an accompanying editorial in the magazine Nature (7 August 2008) . Don Catlin In 1982, Don Catlin founded the UCLA Olympic Analytical Laboratory, the first anti-doping lab in the United States, which he directed for the next 25 years. The lab was responsible for testing at the Olympic, professional and collegiate levels and grew to become the world’s largest testing facility. In the 1990s, Catlin's lab was first to offer the carbon isotope ratio test, a urine test that determines whether anabolic steroids are made naturally by the body or come from a prohibited performance-enhancing drug. In 2002 at the Winter Olympics in Salt Lake City, he reported darbepoetin alfa, a form of the blood booster EPO (erythropoietin), for the first time in sports. In 2002, he identified norbolethone, the first reported designer anabolic steroid used by an athlete. In 2003, as a key part of the investigation of BALCO, he identified and developed a test for tetrahydrogestrinone (THG) or “The Clear,” the second reported designer anabolic steroid. Later that year, the Chicago Tribune named Catlin Sportsman of the Year. In 2004, he identified madol, the third reported designer anabolic steroid, also known as “DMT,” and since 2004 he and his team have identified several more designer steroids. Blood doping Blood doping is the practice of boosting the number of red blood cells (RBCs) in the circulation in order to enhance athletic performance. Because they carry oxygen from the lungs to the muscles, more RBCs in the blood can improve an athlete’s aerobic capacity (VO2 max) and endurance. Methods The term blood doping originally meant doping with blood, i.e. the transfusion of RBCs. RBCs are uniquely suited to this process because they can be concentrated, frozen and later thawed with little loss of viability or activity. There are two possible types of transfusion: homologous and autologous. In a homologous transfusion, RBCs from a compatible donor are harvested, concentrated and then transfused into the athlete’s circulation prior to endurance competitions. In an autologous transfusion, the athlete's own RBCs are harvested well in advance of competition and then re-introduced before a critical event. For some time after the harvesting the athlete may be anemic. Both types of transfusion can be dangerous because of the risk of infection and the potential toxicity of improperly stored blood. Homologous transfusions present the additional risks of communication of infectious diseases and the possibility of a transfusion reaction. From a logistical standpoint, either type of transfusion requires the athlete to surreptitiously transport frozen RBCs, thaw and re-infuse them in a non-clinical setting and then dispose of the medical paraphernalia.

In the late 1980s, an advance in medicine led to an entirely new form of blood doping involving the hormone erythropoietin (EPO). EPO is a naturally-occurring hormone growth factor that stimulates the formation of RBCs. Recombinant DNA technology made it possible to produce EPO economically on a large scale and it was approved in US and Europe as a pharmaceutical product for the treatment of anemia resulting from renal failure or cancer chemotherapy. Easily injected under the skin, pharmaceutical EPO can boost hematocrit for six to twenty four weeks, or longer. The use of EPO is now believed by many to be widespread in endurance sports.[citation needed] EPO is not free of health hazards: Excessive use of the hormone can raise hematocrit above 70% which can cause polycythemia, a condition wherein the level of RBCs in the blood is abnormally high. This causes the blood to be more viscous than normal, a condition that strains the heart. Some elite athletes who died of heart failure — usually during sleep, when heart rate is naturally low—were found to have unnaturally high RBC concentrations in their blood. Red blood cell count (hematocrit) goes down with age and EPO also has health benefits, especially after age 50 to prevent senility and in general a loss of neurons.

Detection of blood doping A time-honored approach to the detection of doping is the random and often-repeated search of athletes’ homes and team facilities for evidence of a banned substance or practice. Professional cyclists customarily submit to random drug testing and searches of their homes as an obligation of team membership and participation in the UCI ProTour. In 2004, British cyclist David Millar was stripped of his world time-trial championship after pharmaceutical EPO was found in his possession. Because athletes sometimes inject or infuse non-banned substances such as vitamin B or electrolytes, the possession of syringes or other medical equipment is not necessarily evidence of doping. It has also been possible to link athletes to blood doping entirely through documentary evidence, even if no banned substance has been found and no athlete has failed a doping test. The Operación Puerto case is a recent example. A more modern approach, which has been applied to blood doping with mixed success, is to test the blood or urine of an athlete for evidence of a banned substance or practice, usually EPO. This approach requires a well-documented chain of custody of the sample and a test method that can be relied upon to be accurate and reproducible. Athletes have, in many cases, claimed that the sample taken from them was misidentified, improperly stored or inadequately tested. Yet another detection strategy has been to regard any apparently unnatural population of RBCs as evidence of blood doping. RBC population in the blood is usually reported as hematocrit (HCT) or as the concentration of hemoglobin (Hb). HCT is the fraction of blood cells by volume that are RBCs. A normal HCT is 41-50% in adult men and 36-44% in adult women. Hemoglobin (Hb) is the iron-containing protein that binds oxygen in RBCs. Normal Hb levels are 14-17 g/dL of blood in men and 12-15 g/dL in women. For most healthy persons the two measurements are in close agreement. There are two ways in which HCT and Hb measurements can suggest that the blood sample has been taken from a doping athlete. The first is simply an unusually high value for both. The Union Cycliste Internationale (UCI), for example, imposes a 15-day suspension from racing on any male athlete found to have an HCT above 50% and hemoglobin concentration above 17 grams per deciliter (g/dL). A few athletes naturally have high RBC concentrations (polycythemia), which they must demonstrate through a series of consistently high hematocrit and hemoglobin results over an extended period of time.

A recent, more sophisticated method of analysis, which has not yet reached the level of an official standard, is to compare the numbers of mature and immature RBCs in an athlete's circulation. If a high number of mature RBCs is not accompanied by a high number of immature RBCs--called reticulocytes--it suggests that the mature RBCs were artificially introduced by transfusion. EPO use can also lead to a similar RBC profile because a preponderance of mature RBCs tends to suppress the formation of reticulocytes. A measure known as the "stimulation index" or "off-score" has been proposed based on an equation involving hemoglobin and reticulocyte concentrations. A normal score is 85-95 and scores over 133 are considered evidence of doping. (The stimulation index is defined as Hb (g/L) minus sixty times the square root of the percentage of RBCs identified as reticulocytes.) These threshold levels, and their specific numeric values are sources of controversy. Establishment of incorrect threshold values is one way that false positive test results can be produced by a doping control program.

Detection of EPO use Some success has also been realized in applying a specific test to detect EPO use. An inherent problem, however, is that, whereas pharmaceutical EPO may be undetectable in the circulation a few days after administration, its effects may persist for several weeks. In 2000 a test developed by scientists at the French national anti-doping laboratory (LNDD) and endorsed by the World Anti-Doping Agency (WADA) was introduced to detect pharmaceutical EPO by distinguishing it from the nearly-identical natural hormone normally present in an athlete’s urine. The test method relies on scientific techniques known as gel electrophoresis and isoelectric focusing. Although the test has been widely applied, especially among cyclists and triathletes, it is controversial, and its accuracy has been called into question. The principal criticism has been toward the ability of the test to distinguish pharmaceutical EPO from other proteins that may normally be present in the urine of an athlete after strenuous exercise. The validity of a doping conviction based on the EPO test method was first challenged successfully by Belgian triathlete Rutger Beke. Beke was suspended from competition for 18 months in March 2005 by the Flemish Disciplinary Commission after a positive urine test for EPO in September 2004. In August 2005, the Commission reversed its decision and exonerated him based on scientific and medical information presented by Beke. He asserted that his sample had become degraded as a result of bacterial contamination and that the substance identified by the laboratory as pharmaceutical EPO was, in fact, an unrelated protein indistinguishable from pharmaceutical EPO in the test method. He claimed, therefore, that the test had produced a false positive result in his case. In May 2007, Bjarne Riis, Rolf Aldag, Erik Zabel, and Brian Holm, all former members of the Telekom cycling team, admitted to using EPO during their cycling careers in the mid-1990s. Riis also relinquished his title as champion of the 1996 Tour de France. EPO was again a factor in the various doping scandals at the 2007 Tour de France, including the suspension of Spanish cyclist, Iban Mayo.

Detection of blood transfusions In the case of detecting blood transfusions, a test for detecting homologous blood transfusions (from a donor to a doping athlete) has been in use since 2000. The test method is based on a technique known as fluorescent-activated cell sorting. By examining markers on the surface of blood cells, the method can determine whether blood from more than one person is present in an athlete’s circulation.

The American cyclist Tyler Hamilton failed this test during the 2004 Olympics but was allowed to keep his gold medal because the processing of his sample precluded conducting a second, confirmatory test. He appealed a second positive test for homologous transfusion from the 2004 Vuelta a España to the International Court of Arbitration for Sport but his appeal was denied. Hamilton's lawyers proposed Hamilton may be a genetic chimera or have had a 'vanishing twin' to explain the presence of RBCs from more than one person. While theoretically possible, these explanations were ruled to be of 'negligible probability'. At present there is no accepted method for detecting autologous transfusions (that is, using the athlete’s own RBCs), but research is in progress and the World Anti-Doping Agency (WADA) has promised that a test will eventually be introduced. The test method and its introduction date are to be kept secret in order to avoid tipping off doping athletes. The assay under development may be a measure of 2,3-bisphosphoglycerate (2,3-BPG) levels in an athlete's red blood cells. Because 2,3-BPG is degraded over time, the stored blood used in autologous transfusions will have less 2,3-BPG than fresh blood. A 2,3-BPG concentration lower than normal may therefore be an indication of autologous transfusion.

Military use In 1993, U.S. Special Forces commanders at Fort Bragg started experimenting with blood doping, also known as blood loading. Special forces operators would provide two units of whole blood, from which red blood cells would be extracted, concentrated, and stored under cold temperatures. Twenty-four hours before a mission or battle, a small amount of red blood cells would be infused back into the soldier. Military scientists believe that the procedure increases the soldiers' endurance and alertness because of the increase in the blood's capability to carry oxygen. In 1998, the Australian Defence Forces approved this technique for the Special Air Service Regiment. Senior nutritionist at the Australian Defence Science and Technology Organization Chris Forbes-Ewan is quoted as saying that, unlike in sport, "all's fair in love and war." "What we are trying to gain is an advantage over any potential adversary," Forbes-Ewan said. "What we will have is a head-start." In this study, over 50 performance-enhancing drugs and techniques were rejected. The six that were approved are caffeine, ephedrine, energy drinks, modafinil, creatine, and blood-loading.

Notable blood doping cases Tour de France rider Alexander Vinokourov, of the Astana Team, tested positive for two different blood cell populations and thus for homologous transfusion, according to various news reports on July 24, 2007. Vinokourov was tested after his victory in the 13th stage time trial of the Tour on July 21, 2007. A doping test is not considered to be positive until a second sample is tested to confirm the first. Vinokourov's B sample has now tested positive, and he faces a possible suspension of 2 years and a fine equal to one year's salary. He also tested positive after stage 15. Vinokourov's teammate Andrej Kashechkin also tested positive for homologous blood doping on August 1st, 2007, just a few days after the conclusion of the 2007 Tour de France (a race that had been dominated by doping scandals). His team withdrew after the revelation that Vinokourov had doped. According to Russian investigators, 19-year-old New York Rangers prospect and Russian hockey player Alexei Cherepanov was engaged in blood doping for several months before he died on

October 13th, 2008, after collapsing on the bench during a game in Russia. He also had myocarditis

Preventative measures It was revealed in autumn 2007, following another troubled year for professional cycling, that the sport's governing body (UCI) would introduce mandatory "blood passports" for all professional riders. The scheme, thought to be the first of its type in any sport, involves using blood and urine samples to create a medical profile that could be compared to results of subsequent doping tests. Blood doping can be very effective but also very dangerous. Negative effects There are many side-effects to blood doping. The simple act of increasing the number of RBCs in the blood stream makes blood thicker. This can also make it clot more readily. This has shown an increase in the chances of heart attack, stroke, and pulmonary embolism. This has been seen in cases where there is too much blood reintroduced into the blood stream. Blood contamination during preparation or storage is another issue. This was seen in 1 in every 500,000 transfusions of RBC in 2002. This contamination can lead to sepsis or an infection that affects the whole body. This may seem like a small number, but, as blood doping becomes more popular among athletes, infections due to the procedure may increase. Also certain medications used to increase RBCs can reduce liver function and lead to liver failure, pituitary problems, and increases in cholesterol levels.