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Cheating to Win: Cardiovascular & PhysiologicalEffects of Performance-Enhancing Agents

Item Type text; Electronic Thesis

Authors Sill, Andrew Phillip

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

Download date 21/05/2018 23:03:12

Link to Item http://hdl.handle.net/10150/297758

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Table of Contents

Table of Contents ……………………………………………….…………………………………………………. i Abstract ……………………………………………………………….……………………………………...……. ii

Introduction ………………………………………………………………….…………………………………….. 1 Overview of the Cardiovascular System ……………………………………….………………………………. 1

The Heart ………………………………………………………………………………………………… 1 Blood Vessels and Blood ………………………………………………………………………………. 4

Performance Enhancing Drugs and Practices ……………………………………….………………...…….. 5 Blood Transfusions (Blood Doping) & Erythropoietin (EPO) …………………………………….… 5

Anabolic Steroids ………………………………………………………………………………….…… 9 Stimulants …………………………………………………………………………………….………… 12

Ephedrine ……………………………………………………………………………..……… 12 Amphetamine ………………………………………………………………….……………... 13

Cocaine ………………………………………………………………………….…….……… 14 Caffeine …………………………………………………………………….………….……… 15

Conclusion …………………………………………………………………………………………………..…… 16 Appendix A ……………………………………………………………………………………………………..… 17

References ………………………………………………………………………………………………………. 18 x

Table of Contents - PSIO 498H Andrew Sill

Monday, April 29, 2013 i

Abstract

The current societal factors placed on athletes have been causing a dramatic rise in the use of

performance-enhancing drugs and practices in recent years. The intensity of competition and the pressures from increases in talent and skill in athletic competitions have led many athletes to look for

illegal and alternative ways of increasing their own performance. The use of these methods, such as blood transfusions, EPO injections, anabolic steroids, and stimulants, has been shown to be detrimental

to cardiovascular health and the overall health of users. Side effects may cause permanent damage to vital organs and can lead to death over prolonged use. This literature review explains the mechanisms in

which these practices promote performance enhancement in athletes. In addition, the effects of these methods on the cardiovascular system and other vital systems is explained. Finally, the ways in which

athletic governing boards test athletes for illegal use of performance-enhancing drugs and practices is described. Many athletic organizations, such as the World Anti-Doping Agency and the International

Olympic Committee, have placed bans on these methods of performance enhancement in order to promote fair and safe athletic competitions for all participants.

Abstract - PSIO 498H Andrew Sill

Monday, April 29, 2013 ii

I. INTRODUCTION The cardiovascular system is one of the most important components to human life. Alterations in

this system, as well as alterations in other parts of the body, can be detrimental, even lethal, to athletes. The use of performance enhancing drugs and practices has been increasingly prevalent among athletes

because of the advantage it lends to the athletes over other competitors. Some effects include increased alertness, endurance, strength, as well as reduced pain and fatigue. Various methods have been used by

athletes to achieve these effects, including blood transfusions, EPO injections, anabolic steroids, amphetamines, ephedrines, and caffeine. Athletic governing organizations, such as the World Anti-Doping

Agency, have put forth efforts to eliminate the use of performance enhancing practices in an attempt to make athletic competitions fair for all participants. These organizations also put forth these regulations in

order to make the competitions safe for all athletes and reduce the risk of injury or death from overexertion of the human body. The use of performance enhancing drugs and practices has important

and dangerous outcomes on the cardiovascular system, as well as other crucial parts of the body. In this thesis, the methods in which performance-modifying practices is discussed, particularly the ways in which

the cardiovascular system responds. Three major categories include blood and EPO doping; anabolic steroids; and stimulants.

II. OVERVIEW OF THE CARDIOVASCULAR SYSTEM

The cardiovascular system is complex and is required for pumping blood, carrying oxygen, and moving nutrients throughout the body. It is made up of the pulmonary circulation, the systemic circulation,

and the coronary circulation, These include the heart, the blood, and the blood vessels. Within

each of these components, there are many important processes, such as the exchange of

gasses in the pulmonary circulation, the exchange of nutrients in the systemic circulation, the control

of blood flow in the blood vessels, and the movement of blood through the heart. All of these

processes can be described using physical equations, such as how cardiac output relates to

stroke volume and heart rate.

II. A. THE HEART The heart is considered one of the most

important organs of the body because it pumps blood through the body, therefore supplying cells

with everything they need to survive. The heart is a hollow organ composed of cardiac muscle

(myocardium), a special type of muscle that is

Honors Thesis - PSIO 498H Andrew Sill

Monday, April 29, 2013 1

Figure 1 - 1 Anatomy of the Heart. Heart Information Center.

Texas Heart Institute

connected by gap junctions. In order for a cardiac muscle fiber contracts, calcium is released into the interior of the cell. This calcium causes a depolarization of the cell, which travels across gap junctions to

other neighboring cells, causing them to depolarize and contract as well. Therefore, the heart is a giant, beating muscle that works harmoniously to form a syncytium that pumps blood out of the heart and to the

rest of the body. As blood travels through the heart, it follows a distinct path (Figure 1). From the inferior and

superior vena cavae, blood enters the right atrium, which then pumps the blood through the tricuspid valve and into the right ventricle. There, the right ventricle contracts and pushes the blood past the

pulmonary semilunar valve and into the pulmonary circulation, where gasses are exchanged, oxygen is

picked up by the blood, and carbon dioxide is released. The pulmonary circulation takes place in

the lungs. Then the blood enters the left atrium, and soon proceeds into the left ventricle after crossing

the mitral, or bicuspid, valve. The contraction in the left ventricle pushes the blood past the aortic

semilunar valve and into the systemic circulation, where the oxygen and other nutrients are

distributed to the rest of the body. The blood flows through the arteries and into the veins, eventually

returning to the right atrium of the heart. This cycle happens every time the heart beats and continues

for the span of an individual’s life. The pulmonary circulation, as mentioned

previously, is where blood exchanges gas with the gas in the lungs. Blood is pushed from the right

ventricle through the pulmonary arteries and into the lungs. The blood vessels become increasingly narrow as the blood continues, until the vessels are only one blood cell width in diameter. These small

vessels are known as capillaries. At this point, gasses such as carbon dioxide and oxygen, are able to diffuse through the capillaries, allowing oxygen to enter the blood and carbon dioxide to leave the blood. It

is because of differing partial pressures between the blood and the air in the lungs that this process is possible without needing active transport. After the gasses have been exchanged, the blood flows into

larger veins that eventually return the freshly oxygenated blood to the left atrium of the heart. The systemic circulation is much longer than the pulmonary circulation. Once the newly

oxygenated blood reaches the left ventricle, it is pumped through the aorta and then into increasingly smaller and smaller arteries throughout the body. The arteries continually branch and become smaller,

until they become arterioles and eventually capillaries. The capillaries are the region where nutrients and gasses are exchanged with the cells of the body. Waste products are collected at the end of the capillary



Figure 2 - 2 Herbrandson, Cynthia. Cardiac Systems. "Learning

the Cardiovascular System."

beds. The capillaries converge and form larger vessels, called venules, and then continue converging to form veins. These veins return to the heart through the superior and inferior vena cavae (Figure 2).

The coronary circulation is a special type of circulation that supplies blood to the heart. It is important because it provides the heart with the oxygen and nutrients it needs to keep pumping. The

coronary circulation begins just after the blood enters the aorta. Small vessels branch off the aorta and then branch around the heart and into the myocardium, delivering the freshly oxygenated blood and

nutrients to the cardiac muscle fibers. The coronary circulation ends at the coronary sinus, which deposits the deoxygenated blood into the right atrium.

The cardiovascular system involves a great deal of physics that can help clarify how

the heart and vessels operate. First, and possibly one of the most important relationships,

is the Frank-Starling mechanism. This states that as the heart fills with blood, the muscles stretch.

The more they stretch, the stronger the ensuing contraction of the heart muscle will be. So if the

blood is pumping throughout the body at a high rate, such as during exercise, then the heart will

begin to have stronger contractions because the blood volume before contraction, known as

preload, is higher. There is a certain amount of blood

pumping through the heart at a given time. This is known as the cardiac output, or CO. It is a

measure of the volume of blood per minute that is pumped into the systemic circulation from the

heart. This value can be related to the heart rate and stroke volume in a simple equation. Heart

rate is the frequency of beats per minute that the heart contracts and stroke volume is the amount of blood that is pumped out with each beat. By multiplying the heart rate and stroke volume, one can find the

cardiac output. This formula is important for a variety of applications. If the heart rate and/or the stroke volume change due to stimuli, then the cardiac output will change proportionally. The equation is as

follows:

Cardiac Output (CO) = Heart Rate (HR) x Stroke Volume (SV)

There are ways to measure both heart rate and stroke volume. Heart rate can be measured by feeling a pulse in arteries near the surface of the skin or by listening to the heart beating. Stroke volume

requires more work to figure out, although it is still fairly simple. The amount of blood that is contained in the left ventricle before contraction is known as the end diastolic volume (EDV). This volume is the



Figure 3 - 4 Klabunde, Richard E., PhD. Cardiac Cycle.

Cardiovascular Physiology Concepts.

volume of blood when the heart is at rest. After contraction, only a portion of the original blood still exists in the ventricle. This volume is known as the end systolic volume (ESV). Diastole means relaxation and

systole means contraction. The difference between these volumes is the stroke volume, or the amount of blood pumped per beat. The equation for determining the stroke volume is given below:

Stroke Volume (SV) = End Diastolic Volume (EDV) - End Systolic Volume (ESV)

One other important method of measuring

heart function is viewing the electrical potentials of the heart (electrocardiogram, or ECG) (Figure 4). This

method measures the electrical waves generated by the cardiac tissue during each beat. A normal ECG

shows an upward-deflecting wave at the beginning of a beat, which is known as the P wave and is

representative of the atrial depolarization. A depolarization is the loss of negative potential in a

cell, meaning the cells become more positively charged. The next wave is the QRS complex,

representative of ventricular depolarization. It is much larger than the P wave because it is a greater

depolarization due to the larger size of the ventricles. The atria repolarize during this wave and are masked

by the large QRS complex. The next visible wave is the T wave, showing the ventricular repolarization. Repolarization means that the cells are returning to their resting state, a more negatively charged

potential. An irregular ECG can indicate a variety of ailments, such as irregular rhythms, cardiomyopathies, and myocardial cell death.

II. B. BLOOD VESSELS AND BLOOD The blood vessels are crucial to the cardiovascular system because they provide a way for the

blood to be pumped to the body efficiently. The vessels are composed of arteries, arterioles, capillaries, venules, and veins. Arteries and arterioles carry blood away from the heart, whereas venules and veins

carry blood to the heart. Arteries do not always carry oxygenated blood and veins to not always carry deoxygenated blood, as seen in the pulmonary circulation. All the vessels contain walls made of cells that

allow the vessel to perform its necessary function. For example, arteries are elastic and allow for large changes in pressure, as seen in the aorta. Arterioles contain smooth muscle necessary for constriction

and relaxation of the vessels, which allows for the regulation of blood flow to different areas of the body. Veins and venules are able to stretch, allowing them to function as blood volume reservoirs. The larger

vessels, such as arteries and veins, usually have multiple cell layers. Capillaries, on the other hand, have only one layer of cells, making movement of oxygen, carbon dioxide, and nutrients across the capillary

walls easier.



Figure 4 - 3 ECG Tracing. National Instruments.

There is always pressure in the blood vessels, which allows blood to continuously flow in a unidirectional fashion. The pressure at a given point in a vessel is known as the blood pressure. At the

aorta, the first vessel of the systemic circulation, the pressure is the greatest. At the vena cava, the pressure is the lowest. This gradient of pressure causes blood to flow from the aorta throughout the body

and eventually back to the vena cava and the right atrium of the heart. The pressure is measured in millimeters of mercury (mmHg) and is a measurement of the systolic and diastolic pressures. The systolic

pressure is always greater because the heart is contracting and ejecting the blood at this point, whereas the diastolic pressure is lower because the heart is resting. A normal reading for blood pressure is given

as 120 mmHg / 80 mmHg, meaning 120 millimeters of mercury during systole and 80 millimeters of mercury during diastole (Figure 3).

The blood is the fluid that is responsible for the transport of nutrients and oxygen to cells. It is mostly made up of plasma, a clear liquid that contains ions, nutrients, and proteins. The blood also

contains red blood cells, which have hemoglobin within them, allowing them to bind oxygen and transport it to oxygen-deprived areas of the body. In addition, there are white blood cells in the blood, which aid in

fighting infections by searching out viruses, bacteria, and other pathogens. Finally, the blood contains platelets, which are cells that help with clotting after injury to a blood vessel. A normal blood sample has a

specific amount of red blood cells, white blood cells, and plasma. After centrifugation, the red blood cells make up 42% to 54% of the blood sample in an adult male, while the rest of the sample contains plasma

and a small layer of white blood cells.11

III. PERFORMANCE ENHANCING DRUGS AND PRACTICES Performance enhancing drugs and practices have been discussed in news articles and reports

since the early 20th century. There are many types of performance enhancers that have been used, such as blood transfusions, EPO, synthetic oxygen carriers, stimulants, anabolic steroids, narcotics, beta-2

agonists, and peptide hormones.5 Overall, 192 performance enhancing practices and substances have been banned by the WADA (World Anti-Doping Agency). Six hundred and twenty-five athletic-related

organizations have agreed to enforce the standards made by the WADA.6 From these data, we can conclude that these methods and substances might actually provide a significant advantage to an athlete,

considering the widespread use of them and the serious concern over controlling the use of these drugs and practices. This advantage makes athletic competition unfair for participants who have not engaged in

these practices and can also lead to harmful long-term effects on the athletes that engage in illegal substance use.

III. A. BLOOD TRANSFUSIONS (BLOOD DOPING) AND ERYTHROPOIETIN (EPO)

A major blood doping case involved the 1984 United States Olympic cycling team. The team was highly successful in that year’s Olympic games, bringing home a record of nine medals. However, many

of the cyclists contracted hepatitis soon after the games because they received infected blood transfusions from relatives. It was after this transfusion doping case that this version of blood doping was

discouraged and soon banned from hundreds of sports.7 Another major blood doping case, known as



Operación Puerto, occurred in May 2006 when a doctor was accused of helping over 200 athletes increase their performance in a variety of sports through the use of blood transfusions. In 2010, a similar

blood doping method known as EPO blood doping was detected in cyclist Floyd Landis, who was then stripped of his 2006 Tour de France victory. Most recently, in 2012, Lance Armstrong was officially

stripped of all the titles he earned since 1998 due to his inability to fight the USADA and WADA’s investigations of Armstrong’s alleged doping use.

Known as “blood doping” or “induced erythrocythemia”,7 blood transfusions and EPO injections can improve athletic performance of athletes by increasing their endurance as well as allowing athletes to

perform better at higher altitudes. Although this may seem only slightly helpful, blood doping can be significantly helpful in aerobic exercise, such as long distance running, cycling, and swimming. Blood

doping works by enhancing the oxygen uptake, transfer, and delivery in the body by increasing the red blood cell count in an athlete.

Blood transfusion doping can be practiced using two methods. The first method involves the athlete removing and storing blood from his or her body while their blood is at its freshest state, such as

after an hour or more of resting. After the blood is removed, the plasma is transferred back to the donor, leaving behind mostly red blood cells. Blood is “fresh” after rest because it is highly saturated with

oxygen, unlike during or following exercise where the blood might be lower in oxygen content. That is because during exercise, the body is quickly using the oxygen contained in the blood so that the muscles

keep working at their highest potential. So for blood doping to be effective, it is best to remove the athlete’s blood after they have been at rest for at least an hour because the red blood cells have the

highest carrying capacity for oxygen at that time. The second method of blood transfusion doping is using another person’s blood, as long as they

have the same blood type. The plasma is transfused back to the donor, leaving behind the oxygen rich red blood cells. This method is also most effective if the blood is taken after a period of rest.5

Once the blood has been removed from the body and concentrated by removing the plasma, the blood is stored until needed. This removal of blood usually occurs about one month prior to competition,

therefore giving the athlete enough time to regenerate their own red blood cells to the normal level. Just prior to an aerobic race, the red blood cells are transfused back into the athlete, giving the athlete extra

oxygen-rich red blood cells. One transfused liter of blood can provide an athlete with an additional half-liter of oxygen per minute, which boosts the performance of muscles in the body. This increases the

muscles’ ability to utilize the oxygen by up to five percent.5

The final method of blood doping is achieved through a different process. Instead of removing red

blood cells from the body for use at a later time, athletes increase their red blood cell count by using synthetic erythropoietin (EPO). EPO is a naturally produced hormone made by the kidneys that increases

red blood cell production in the body. By intravenously injecting synthetic EPO into an athlete’s blood, the athlete can increase their red blood cell count in as little as four days, therefore achieving the same

effects as transfusion blood doping.12

These methods of performance enhancement are highly beneficial to an athlete in extended

aerobic competitions, such as in cycling that requires multiple days of racing. If an athlete were to receive



a transfusion of red blood cells or an EPO injection prior to a race, they would have a significant advantage over other riders who may not have as many red blood cells, therefore not as much of an

oxygen-carrying capacity in their blood. Both blood transfusions and EPO injections have similar effects on the hematocrit. The larger the amount of blood removed and transfused back into an athlete, the

greater the effects will be on the hematocrit. In addition, the larger the dose of synthetic EPO, the greater the response in the body. However, EPO is limited to the speed at which a body can produce new red

blood cells. On average, the body is able to produce two million new red blood cells per second.21

Blood transfusions are not easily detectable, especially if the blood that was transfused to the

athlete consists of the athlete’s own red blood cells. Since the red blood cells are coming from the same person, it does not show any differences in structure, genetics, or content. However, if the blood is coming

from a different person, the blood may be detectable based upon the differing genes in the cells of the blood. The only way to detect the possibility of blood transfusions in athletes is if they have a higher than

usual hematocrit, meaning their blood contains more than the usual amount of red blood cells. The WADA and UCI (International Cycling Union) have an upper limit of 50% red blood cells in the hematocrit

before considering a test to be positive for blood doping. A normal elite athlete has a hematocrit of around 44%. Blood transfusion and EPO doping can cause elevations in the hematocrit values by as much as

10%. Normal blood hemoglobin concentrations are around 152 g/L. Following blood transfusion or EPO doping, the hemoglobin concentration can rise to around 169 g/L.13 In addition, EPO injections are easier

to detect because synthetic EPO is slightly different than naturally produced EPO. Laboratories only need to use separation methods to find that there are two different types of EPO in an athlete’s blood. However,

EPO only remains present in the circulation for a few days after administration (although it can still affect the kidneys and red blood cell production for up to several weeks), so it may be necessary to rely on the

hematocrit values for determination of positive blood or EPO doping. When athletes are requested to provide blood samples for testing, they are required to give the blood sample within ten minutes of being

notified. This is because athletes started to inject saline (0.9% NaCl solution) into their circulation to cause their hematocrit levels to drop below the upper limit, therefore falsifying their test results.22

Blood transfusion and EPO doping may have a variety of effects on the body and cardiovascular system. Although blood doping has been shown to be harmful in many ways, it also could have some

beneficial effects for certain groups of people, besides enhancing athletic performance. Anemic people may lack the normal amount of red blood cells in the blood, causing less oxygen and nutrients to be

delivered to the tissues. Mild symptoms include weakness and shortness of breath during exercise.8 Blood transfusions and EPO injections have been shown to be beneficial for anemic patients because it

boosts their hematocrit, or red blood cell count, to a level that is closer to normal, therefore helping anemic patients to increase their red cell count, meaning more hemoglobin; therefore, more oxygen-

carrying capacity and more energy. Blood transfusion or EPO injections can cause hemoglobin concentrations to rise 17 g/L.13 In addition, blood transfusions and EPO injections are helpful for patients

receiving chemotherapeutic treatment for cancer. When undergoing chemotherapy, many red blood cells are killed in the body, so blood transfusions and EPO injections can help replace the depleted red blood

cell count, leading to as much as a 10% increase in red blood cells in a hematocrit.9, 13



However, blood transfusion and EPO injection doping can lead to a wide array of harmful side effects if overused or if used by a person who does not need a boost in red blood cells, such as athletes.

First of all, poorly stored blood could cause blood clots and serious illnesses, such as bacterial infections or DIC (disseminated intravascular coagulation). DIC is an effect of hemolyzed red blood cells that occurs

during blood storage or transfusion.18 On average, red blood cells have a life span of 127 days.19 The longer the red blood cells are stored, the greater the chance of developing DIC, as well as increased time

for bacterial growth. Also, a higher than normal red blood cell count can lead to thickening and increased viscosity of

the blood. Moving the viscous blood through the body increases the strain on the heart. This could lead to a cardiac condition known as hypertrophic cardiomyopathy. The heart walls become stronger, and

therefore larger, since the heart is working harder to push the “thick” blood. Over time, the thickening of the heart walls can have negative effects on the heart because the heart is unable to fill with as much

blood as usual. Although the contractions may be stronger, the volume ejected is less, leading to a reduction in stroke volume and a reduction in the amount of blood reaching the tissues per unit time. Over

longer periods of time, this could lead to heart failure and eventually death. In addition, since the blood is becoming more viscous and “thicker,” there is a chance for clots to form in the blood. When clots form,

they can block important vessels to the brain, heart, lungs, or other areas of the body, leading to stroke, heart attack, pulmonary emboli, or tissue death, respectively. Extra red blood cells can also effect the

vasculature of the cardiovascular system, as well as the kidneys and lungs. The kidneys are highly sensitive to blood pressure. When extra blood is added to the body, the blood pressure rises and could

cause the kidneys’ filtration system to fail, leading to a “leaky” and damaged kidney. When blood pressure rises in the lungs, the small capillaries can become leaky and allow red blood cells and plasma to cross

into the alveoli, leading to fluid in the lungs. The fluid can block important surfaces for gas exchange, leading to a decrease in respiration. At rest, the blood pressure will not increase with transfusion or EPO

doping. However, it is during submaximal exercise that the blood pressure can increase by as much as 14 mmHg above normal blood pressure, leading to possible damage to the kidneys, lungs, and capillaries.

The transfusion of extra blood usually contains many platelets as well. An excessive amount of platelets in the veins and arteries could cause thrombosis, which is the formation of a blood clot inside a vessel,

thereby disrupting the flow of blood.6,10

As with any blood transfusion, there is a risk of contracting blood-borne illnesses such as

hepatitis, malaria, cytomegalovirus, or HIV. It is also possible to contract an ordinary infection, since the skin is being punctured, leaving a route for bacteria to enter the body.7 It has been shown that blood

transfusions can cause elevated levels of suppressor T cells, as well as decreased function of natural killer cells, macrophages, and monocytes. The cause and meaning of these effects is not currently

known.20 However, it leaves the recipient of the blood transfusion to be somewhat immunosuppressed and vulnerable to infections and other diseases. The reason that the body may become somewhat

immunosuppressed after receiving a blood transfusion might be a result of hemolyzed red blood cells in the transfusion. When the lysed red blood cells enter the circulation, the body’s immune defenses may



become preoccupied with cleaning up the dead cell components, leaving the rest of the body to be unprotected from various pathogens.

Blood transfusion and EPO doping have not been found to have any significant effects on the

ECG, meaning that it does not have a direct impact on the conduction system of the heart.14

III. B. ANABOLIC STEROIDS Steroids include a class of molecules consisting of multiple rings in the molecular structure

(Figure 6). Steroids are important for many bodily functions and include common molecules such as vitamin D, cholesterol, estrogen, and testosterone. Within the overall category of steroids are

corticosteroids and anabolic steroids. Anabolic steroids are defined as substances that are related to the male sex hormones and can promote

skeletal muscle growth and the development of male characteristics.

They can be naturally produced within t he body o r a l so syn the t i ca l l y

manufactured (Figure 5). Anabolic steroids are only legally available with a

prescription when patients are in need of them for normal growth. In the case of

a patient having abnormally low levels of testosterone during development,

anabo l i c s te ro ids tha t p romote testosterone production may be legally

used and helpful for contributing to normal growth.17 As with blood doping, anabolic steroids are sometimes used by athletes to synthetically increase muscle size, strength, and endurance. Athletes such

as Roger Clemens, Alex Rodriguez, Floyd Landis, and Jose Canseco have all been found guilty of illegal anabolic steroid use in their careers.15 Steroid use is found in a variety of professional sports such as

baseball, football, hockey, cycling, and many more. Anabolic steroids promote their desired anabolic, muscle-building, effects through direct

stimulation of cells in the body. They also promote androgenic, or sex characteristic, effects such as hair growth on the face and body, increased aggressiveness, and hair

loss on the scalp. The anabolic steroids act by binding to receptors within the cells in the cytoplasm. These receptors then travel into the

nucleus and bind to specific genes within the DNA, activating the genes. This effect is known as “genomic” or “direct” because the

steroids promote a direct stimulation of genes within the cells by causing transcription of the DNA. Once the desired DNA segment is

transcribed, the new mRNA is moved out of the nucleus, modified, and translated into a protein that causes the desired effect on the



Figure 5 - 30 "All About Anabolic Steroids and Benefits." IBuySteroids.com

Figure 6 - 31 Andrews, Ryan. Testosterone Molecule. Digital image. Precision Nutrition.

Precision Nutrition, Inc.

body (Figure 7).16 Steroids can be administered orally or via a subcutaneous injection.16 The steroids

have the effect of stimulating cell growth and increasing muscle mass, as well as aiding in muscle

recovery. Therefore, steroids are usually injected prior to a workout session or a competition so that

the muscles can repair quickly and reduce fatigue.5

Steroid use is detectable using

laboratory tests. Urine samples are tested for synthetic steroids and also for elevated levels of

hormones in the body, such as testosterone. Steroids remain in the body and can be found in the

urine for up to a year after injection or ingestion, but most only remain in the body for about six months.

They are easily detectable, so many athletes will go through great measures to falsify or modify their urine samples. The most obvious way of hiding steroid

use is through using another person’s urine. The easiest way to use this method would be to have a person urinate in a tube or jar and then empty the contents into a urine sample. Laboratories are now

checking the temperature of the urine in an attempt to catch those that use urine from another source. Since the urine would be outside the body while waiting to give the urine sample, it causes the urine to

not be at the appropriate temperature when delivered into the sample. If the urine is colder than it should be, laboratories can assume that the given urine sample is from another source. With these new

regulations, people and athletes are going to extreme measures to pass urine tests. A device called the “Whizzinator” is available for purchase online (Figure 8). This device is a kit of toxin-free urine in a holding

bag, a rubber tube, organic heating pads, and a syringe. These items allow the user to easily falsify warm urine, therefore passing a urine test for drugs or steroids.24 In addition, there are many substances that

can mask the steroids (Uricovac, Uninorm, Desuric, Benzobromide, Anturan, Bumetanide, and

Carinamide). These substances work by delaying the release of trace amount of steroids from the

body, therefore lowering the amount of steroids in the urine. Some of these drugs also act as a diuretic

(normally used for weight loss by causing fluid loss), causing the urine to be highly diluted, which lowers

the concentration of steroids and hormones in the urine.5, 25,26

As mentioned, steroids may actually be beneficial to some people who have certain

illnesses. Corticosteroids, although they are very



Figure 8 - 24 "Whizz Kit." Whizzinator.

Figure 7 - 23 Pitoccelli, Jay. "Endocrine Systems." Lecture

Notes for Endocrine Systems.

different from anabolic steroids, are extremely important in the medical field. They are highly anti-inflammatory, making it useful in the treatment of arthritis, asthma, rashes, and skin disorders. Anabolic

steroids are also useful in the medical field, despite their bad reputation received from the press after discovering the abuse of anabolic steroids by many athletes. In patients with long-term wasting disorders,

such as cancer and HIV, anabolic steroids can help these patients retain muscle mass and bone density.27 This can slow the degenerative process and allow the patients to maintain relatively healthy lives.

Some other conditions that respond favorably to anabolic steroid treatment include anemia, malnutrition, short stature, osteoporosis, and hypogonadism.28

Anabolic steroids can produce a large range of adverse side effects. These side effects vary in degree based upon the dosage received by a patient. Anabolic steroids most commonly affect

cardiovascular parameters of the body, including heart rate, blood pressure, and blood lipid content. Studies have shown that anabolic steroids increase nonmyofibrillar filaments in muscle cells, leading to a

thickening of the heart wall. The increase in size provides passive support during contraction, but does not directly increase the strength of contraction.32 The increase in heart rate is thought to be a result of the

inhibition of monoamine oxidase (MAO), an enzyme that assists in the breakdown of neurotransmitters. Norepinephrine directly increases heart rate in the body, so when the breakdown of norepinephrine is

inhibited, the stimulation of the heart is increased and, as a result, heart rate increases.29 Blood pressure also increases as a result of the increased heart rate. Also, steroids lead to higher reuptake of ions in the

kidneys, such as sodium, which then lead to higher reuptake of fluids and water. With the combined effects of fluid and ion retention as well as increased heart rate, steroids can dramatically increase blood

pressure. The final cardiovascular effect of steroids is the decrease in “good” high-density lipoproteins (HDL) as well as the increase in “bad” low-density lipoproteins (LDL). All of the cardiovascular effects from

steroids can lead to atherogenic conditions, causing symptoms such as a lowered left ventricle ejection fraction, ventricular arrhythmias, and plaque buildup in vessels.28

Anabolic steroids also exert androgenic effects upon many parts of the body. The prostate is sensitive to androgens and will grow in size, potentially blocking urine from flowing and leading to

problems with the bladder and kidneys. In addition, the skin (especially on the scalp and face) is extremely sensitive to androgens, leading to acne formation and loss of hair. Since anabolic steroids are

hormones, they also cause changes in the endocrine system. Anabolic steroids are able to bind and activate receptors for glucocorticoid, progesterone, and estrogen production. These hormones can lead to

many changes in the body, such as altering blood glucose levels, changing hormone feedback systems, and decreasing the level of sperm production.28

Anabolic steroid usage has been prevalent in sports for decades. It was first banned in Congress in 1988 by the Anti-Drug Abuse Act, along with many other illegal drugs and substances. 33 At that time,

anabolic steroid usage had begun to surface in Major League Baseball, but had still not been specifically banned by the MLB. Beginning in the early 1990s, players such as Mark McGwire, Ken Griffey Jr.,

Sammy Sosa, and many others began to shatter previous home run records. This brought up a concern about the usage of illegal substances that could improve player performance and strength. Soon after, the

MLB set up the Mitchell Commission to investigate and prosecute MLB players who had illegally used



steroids to improve performance. Many players were investigated and found to be guilty of steroid use. At the same time, the National Football League and NCAA placed bans on steroid usage and then began

investigations of suspected athletes. 34 Steroids remain banned by many athletic organizations and many organizations have now begun rigorous and random drug testing of all athletes in an attempt to deter

steroid and other performance enhancing drug usage.35

III. C. STIMULANTS

Stimulants, also known as amphetamines, are yet another example of performance enhancing drugs used by athletes. Starting in the early 2000s, stimulants were banned by many athletic

organizations, around the same time that blood doping, EPO injections, and anabolic steroids were banned as well. Stimulants, which closely resemble naturally produced adrenaline and noradrenaline

molecular structures, provide athletes with increased alertness, confidence, concentration, and a feeling of extra energy. These effects lead to improved reaction time, decreased fatigue, distorted pain

perception, and an increased tendency for risky decisions. Overall, this often leads to improved athletic performance. They exert their effects through direct or indirect stimulation of the central nervous system,

which then leads to changes in the rest of the body as well. They also act on the sympathetic nervous system, leading to changes in the central nervous system as well.42 Stimulants have become popular in

sports due to these beneficial effects, but remain banned by many athletic organizations. There

are many different types of stimulants, all of which can lead to negative effects from use.36, 37

The various forms of stimulants, which use different pathways to create similar results in the

body, include methylenedioxymethamphetamine ( M D M A ) , c o c a i n e , a d r e n a l i n e ,

methamphetamine, and ephedrine.5 Although legal, caffeine is also a stimulant and is

c o m m o n l y u s e d t o e n h a n c e a t h l e t i c performance. Until 2004, high doses of caffeine

were banned in Olympic sports. However, because of caffeine’s widespread use, the ban

was lifted.

III. C. 1. EPHEDRINE Ephedrine is a very common stimulant used in sports because of its highly effective stimulant

properties. Ephedrines include many substances, such as pseudoephedrine, norephedrine, methylephedrine, norpseudoephedrine, and methylpseudoephedrine. Ephedrines elicit their effects

through a release of noradrenaline in the central nervous system, activating α and β receptors. As a result, heart rate increases, leading to an increase in cardiac output. However, this causes increased



Figure 9 - 51 "Light Me Up." I Got Fired So I Became an Actress. WordPress.com

pressure in the vasculature, resulting in sustained high blood pressure. Ephedrine also contains some smooth muscle relaxation properties, which can help open up airways and allow for more ventilation to

occur in the lungs. Overall, ephedrines can lead to increased energy, less exhaustion, improved muscle strength, and increased metabolism.40

Ephedrines are easily detected through urine samples of athletes. According to the WADA, concentrations of 10 µg/ml or more are considered to be positive results of ephedrine use. However, the

WADA does allow therapeutic uses of ephedrine for athletes who suffer from ailments that require the use of a stimulant for relief, such as asthma. Such therapeutic uses will not reach positive levels of ephedrine

in urine samples. Ephedrine has an elimination half-life of around 3 to 6 hours.40

As mentioned, ephedrines can be medically useful for the treatment of asthma and allergies

because they help relax smooth muscle in airways. It also acts as a nasal decongestant. It can be found in many nutritional and dietary supplements, as well as energy drinks.40

The illicit use of ephedrines at high levels can lead to many side effects, including arrhythmia, hypertension, myocardial infarction, seizure, and cerebrovascular injury. Because ephedrines cause

increased heart rate and blood pressure, they are often speculated to be a factor in the death of certain athletes. On a smaller scale, ephedrines may cause dizziness, restlessness, hallucinations, confusion,

and respiratory difficulties. These effects have led the FDA to provide recommendations on consumption limits of products containing ephedrines.40 Carl Lewis, an American sprinter, was caught for using

ephedrine in 1988. Diego Maradona, an Argentinian soccer player, was also caught for ephedrine use in 1994, just before his competition in the World Cup.52

III. C. 2. AMPHETAMINE

Amphetamines were first produced in the 1920s and were used to help reduce fatigue and increase the alertness of soldiers and army personnel in World War II. Since their inception,

amphetamines have become prevalent in a variety of forms, including methamphetamine, dimethamphetamine, methylendioxyamphetamine (MDA), and methylendioxymethamphetamine (MDMA

or ecstasy). All of these forms work on the central nervous system to increase the release of noradrenaline and dopamine, leading to increased alertness, concentration, and a sense of euphoria. In

addition, amphetamines reduce anxiety and boost self-confidence. In regards to performance enhancements, MDMA has been shown to increase heart rate (tachycardia), systolic, and diastolic blood

pressure through a carrier-mediated serotonin release acting on the 5-HT receptors, causing an athlete to feel increased energy.39 The psychological effects of MDMA are elicited from a release of dopamine,

norepinephrine, and serotonin in the brain, causing 5-HT1A receptor activation, which has been linked to emotional excitation and euphoria. All methamphetamines were banned in 1985 by the U.S. Government

and classified as DEA Schedule I narcotics.38 Prior to classification as a narcotic, MDMA had been shown to be beneficial for treatment of PTSD and other psychological disorders. However, due to its

classification as a narcotic by many governments worldwide, it is not prescribed anymore. The urinary detection of amphetamines and derivatives of amphetamines is done with an

immunoassay. Any positive results are screened again using gas chromatography/mass spectrometry for



confirmation. Amphetamines have an elimination half life of 7 to 32 hours. Positive levels of amphetamines are detectable for around 24 to 48 hours after peak dosage.41

As mentioned, amphetamines were first used in WWII to increase alertness and reduce fatigue in soldiers. Since then, amphetamines have also been used for the treatment of post-traumatic stress

disorder. They have also been shown to be useful for the treatment of asthma and other breathing disorders.42

Prolonged and elevated use of amphetamines has been shown to lead to many side effects as a result of the physiological effects from the drugs. Amphetamines reduce appetite and fatigue, so over

prolonged use, amphetamines can lead to detrimental nutritional habits and malnutrition, as well as lack of sleep and psychosis. Over time, this can lead to anorexia, physical weakness, heart irregularities, and

insomnia. In addition, amphetamines cause a feeling of euphoria, which can be psychologically addictive. When prolonged use of the drugs is stopped, there may be withdrawal effects such as depression,

hallucinations, and anger.42 Barry Bonds and Jason Giambi, both Major League Baseball players, were convicted of amphetamine use.53

III. C. 3. COCAINE

Cocaine is one of the most commonly used stimulants worldwide, originating mostly from Peru,

Colombia, and Bolivia. Similar to other stimulants, it reduces fatigue, hunger, and induces a sense of

euphoria. It acts on the central nervous system to release dopamine and norepinephrine. It also

causes the inhibition of re-uptake of these neurotransmitters, eventually leading to craving and

addition.42

Cocaine can be detected through a variety

of tests and can result in positive results even months after drug use. In urine tests, cocaine use is

distinguished by a level of 300 ng/mL of benzoylecgonine or more and is usually reliable in showing cocaine use within the past five days. Hair tests can be successful in confirming drug use even after 90

days. Saliva and blood testing can also be done to check for cocaine usage in the past two days. This method is usually only used in cases to detect for very recent drug use.43

Cocaine has been commonly used as a local anesthetic in eye, nose, ear, mouth, and throat surgeries. It is able to prevent the transmission of action potentials along nerves in the area, causing the

patient to not feel pain. In addition, cocaine is a vasoconstrictor and can help slow bleeding of mucous vessels in the ears, nose, and throat.43

Prolonged use of cocaine can also lead to many side effects. It can lead to cravings and withdrawals, as mentioned previously, which ultimately result in depression and suicidal thoughts. It also

reduces blood flow to the heart and can cause large increases in heart rate and blood pressure. This can



Figure 8 - 50 S, Tim. "How to Quit Cocaine." Sober Nation. Sober Nation

potentially lead to cardiac arrest. Administrations of over 1200 mg of cocaine can produce lethal results, such as tremors, cardiac arrhythmia, fever, difficult respiration, and lack of oxygen.43

Cocaine use by athletes has been prevalent in recent years. Martina Hingis, a tennis player, tested positive for cocaine use in the 2007 Wimbledon competition. Shawn Kemp, a basketball player

who was on the Seattle Supersonics in the 1990s, tested positive for cocaine use as well. Mike Tyson, a superstar boxing champion, admitted to struggling with cocaine addiction and openly speaks about it in

an effort to curb its use in younger generations.

III. C. 4. CAFFEINE Caffeine, a legal stimulant found in coffee, teas, chocolate, and much more, is one of the most

commonly ingested stimulants in the world. It is usually consumed in a beverage, but can also be found in pill form. It works by blocking adenosine receptors in the brain and other organs of the body. When

stimulated by adenosine, these receptors slow activity of the central nervous system, resulting in tiredness. By blocking these receptors through competitive inhibition, caffeine can mask the feeling of

tiredness and cause an increase in alertness. Caffeine reaches a maximum concentration about 15 to 45 minutes after ingestion and has a half-life of about 5 hours.44 Caffeine can be detected through urinary

analysis and the level of caffeine in the body can be calculated using the known half-life of the compound.

Caffeine administration has been shown to not only increase alertness and reduce fatigue, but it has

also been shown to reduce blood flow to the brain, which is helpful in the treatment of migraine

headaches. Over-the-counter migraine medicines such as Excedrin contain pain killers, as well as caffeine to

combat the excess blood flow to the brain during a migraine. It also can increase heart rate, which is

desired in the treatment of heart failure. It is also able to relax smooth muscles of the bronchial tubes, which

can be useful in the treatment of asthma or other respiratory diseases.43

Extended use of caffeine is not particularly dangerous, but can still lead to unwanted side effects. It is a powerful diuretic, therefore leading to excessive urine output and dehydration. It also hinders fine

muscle control. Tasks involving fine-tuned movements may be harmed by excessive caffeine consumption. It can also lead to headaches, irregular heartbeats, anxiety, sleep disturbances, and fatigue.

Withdrawal symptoms are seen with frequent and large caffeine consumption. These symptoms include fatigue, mild levels of depression, and headache. No findings have shown caffeine effects to be

permanent. Most users will overcome withdrawal symptoms within a few days to weeks.43

Prior to 2004, the International Olympic Committee banned the use of caffeine because it was

found that at doses of 600 mg or more, athletes could gain substantial performance enhancing effects.



Figure 9 - 49 Burton, Kevin. "Fast Caffeine Metabolism for Better Sleep with Sulforaphane." Kevin Burtons NEW

FeedBlog. WordPress.com

Alex Watson and Steve Hegg are just some of the many athletes disqualified before 2004 for high levels of caffeine in their blood.46, 47 After 2004, the WADA and IOC removed caffeine from their list of banned

substances because it was determined that at high concentrations, caffeine could actually inhibit athletic performance. This is because of the lack of concentration and tremors experienced at high levels.45

IV. CONCLUSION

The current societal factors placed on athletes has been causing a dramatic rise in the use of performance enhancing drugs and practices in recent years.48 The intensity of competition and the

pressures from increases in talent and skill in athletic competitions has led many athletes to look for illegal and alternative ways of increasing their own performance. The use of these methods, including

blood doping, EPO injections, anabolic steroids, and stimulants, has been shown to be detrimental to cardiovascular health and the overall health of users. Many athletic organizations, such as the World Anti-

Doping Agency and the International Olympic Committee, have placed bans on these methods of performance enhancement. These organizations now test athletes for banned substances in an attempt

to reduce the use of these practices. By doing this, they are leveling the playing field and keeping athletic competitions fair and clean. Not only are they accomplishing this, though. By banning players who have

used these practices and by screening athletes for any signs of use, they are maintaining the health of these athletes and curbing any negative effects in the long run.



Appendix A

Poster Session



References

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