Response - Letter to the Editors

Based on the three inclusion criteria, the rationale of the List of Prohibited Substances and Methods is not only to prevent “cheating” in sport, i.e. unfair performance enhancement by the use of drugs, but also to protect the health of athletes, as well as the spirit of sport, as broad as the latter can be. Therefore, the avoidance of “cheating” should be of equal importance as the protection of health of athletes and the protection of the spirit of sport. According to the World Anti-Doping Code [[11]] any substance or method compromising two out of the above three criteria should be included in the List of Prohibited Substances and Methods.

Narcotics are used in the management of moderate or severe pain and still can be prescribed or provided to athletes because of pressures to perform competitively despite musculoskeletal injuries. It is acknowledged that narcotics can only be obtained with a physician's prescription and used under medical control, making the risks of inadvertent doping very low; however, the same stands for anabolic steroids, erythropoietin and many other substances on the List, which are widely misused.

The moderate use of cannabinoids before a competition is, for some athletes, efficient in “permitting the athlete to escape from social pressures and the relief of anxiety and stress” [[3]] and promotes a happy and euphoric mood state [[8]]. In this respect, cannabinoids are performance enhancing substances despite their inability to improve performance when examined under laboratory conditions. It is important to note here, that the performance level achieved in the laboratory is always far away from what is found on the field and even the interpretation of the results is quite different (2 or 3 % difference is in most cases not statistically significant at the laboratory while 0.1 or 0.01 % can make a lot of difference in competition). On the other hand, further to their well documented adverse effects [[6]] cannabinoids can be very serious in dangerous sports that rely on clear minds, quick reactions and split-second timing [[3]]. The proposal to limit the prohibition of cannabinoids to some concerned sports is not relevant as this will lead quickly to a specific list by International Federations which contradicts the idea of harmonization between all countries and sports (and differs from the possibility of adding some substances at the request of an International Federation; this is strictly reserved to substances without any effects in all the other sports).

Glucocorticosteroids improve the symptoms of arthritis or asthma thus improving exercise tolerance. In addition, in a healthy athlete when painful conditions (such as musculoskeletal injuries which are commonly encountered while competing) are treated with corticosteroids, individual's performance can be improved as a direct result of the relief of symptoms [[1]]. Moreover, the euphoric effect of glucocorticosteroids is documented [[1], [2]] and known to physicians; this also might be beneficial to athletes. Chronic use of corticosteroids is associated with severe adverse effects, even when therapeutic doses are administered [[5], [7]]. Therefore, at least two of the three inclusion criteria should be considered as fulfilled. Finally, glucocorticosteroids according to the statistics provided by the WADA-accredited laboratories for the year 2004 account for 16.6 % of all adverse analytical findings and are the second most commonly detected substances after anabolic agents [[12]].

Insulin, insulin-like growth factor-1 (IGF-1) and human growth hormone (hGH) interact in the regulation of metabolism and body composition and might enhance performance in several ways [[4], [9], [10]]. Studies aiming to examine the effects of insulin, IGF-1, and hGH on athletes are nowadays considered unethical and would be unlikely to receive ethical approval and funding. In addition, such studies cannot examine the effects of real life practices where long-term use, high doses, and polydrug regimens are commonly seen. As raised above the risk of inadvertent doping with insulin is also quite inexistent and the rationale to remove it is so far not clear.

The presence of a substance on the List of Prohibited Substances and Methods should reinforce its hazardous properties (especially in the absence of medical indication) apart from its potential performance enhancement capabilities and this should be the matter of proper and intensive educational programmes. Nowadays, it seems that athletes who want to cheat do not need anymore to look at the List for choosing the substance to abuse; on the contrary, for the majority of athletes the presence of a substance on the List acts as a warning thus preventing its use, for both health reasons as well as positive doping test avoidance.

References

• 1 Almekinders L C. Nonsteroidal anti-inflammatory drugs and corticosteroids. Bahrke MS, Yesalis CE Performance Enhancing Substances in Sport and Exercise. Champaign, IL; Human Kinetics 2002: 125-135
• 2 British Medical Association and Royal Pharmaceutical Society of Great Britain .British National Formulary. 47 edn. Oxon; Pharmaceutical Press 2004: 344-350
• 3 Campos D R, Yonamine M, de Moraes Moreau R L. Marijuana as doping in sports.  Sports Med. 2003;  33 395-399
• 4 George A J. Peptide and glycoprotein hormones and sport. Mottram DR Drugs in Sport. 3rd ed. London; Routledge 2003: 189-204
• 5 Henzen C, Suter A, Lerch E, Urbinelli R, Schorno X H, Briner V A. Suppression and recovery of adrenal response after short-term, high-dose glucocorticoid treatment.  The Lancet. 2000;  355 542-545
• 6 Heishman S J. Cannabis: clinical pharmacology and performance effects in humans. Bahrke MS, Yesalis CE Performance Enhancing Substances in Sport and Exercise. Champaign, IL; Human Kinetics 2002: 247-256
• 7 Kannisto S, Korppi M, Remes K, Voutilainen R. Adrenal suppression, evaluated by a low dose adrenocorticotropin test, and growth in asthmatic children treated with inhaled steroids.  J Clinical Endocrinol Metabol. 2005;  85 652-657
• 8 Reilly T. Alcohol, anti-anxiety drugs and sport. Mottram DR Drugs in Sport. 3rd ed. London; Routledge 2003: 256-283
• 9 Sonksen P H. Insulin, growth hormone and sport.  J Endocrinol. 2001;  170 13-25
• 10 Wallace J D, Cuneo R C. Growth hormone and sport. Kraemer WJ, Rogol AD The Endocrine System in Sports and Exercise. Oxford; Blackwell Publishing 2005: 544-577
• 11 World Anti-Doping Agency .World Anti-Doping Code. Montreal; WADA 2003
• 12 World Anti-Doping Agency .2004 adverse analytical findings reported by accredited laboratories. Overview of results. Available from: http://www.eada-ama.org/rtecontent/document/LABSTATS_2004 . November.24.2005