This is Part One of a three-part article. This first part will focus on the formal process of drug testing in sports, primarily at the international level. Part two continues with the formal process and part three discusses the tactics used by athletes to avoid drug detection. The article reflects the personal and cumulative experiences of the author who was intimately involved in drug testing for a variety of sports. In order to make sense of it all, a bit of history and background will be presented, as well. This is not intended to be a history of drug use or a complete review of all the tactics used, as it is unlikely that one person could know of every tactic. In cases where published reports (i.e. newspapers, TV, etc) have publicly stated information, the real names of the key players will be given. In other cases, where information has not been publicly stated or presented, names and identities will be changed or omitted. While the arsenal of drugs available to the athletes includes far more agents, the coverage here will focus on anabolic-androgenic steroid (AAS) use.
Drug Testing Nonsense
If I told you I was committed to an effort and was going to spend one million dollars of my money on a project, wouldn’t that seem like a sincere effort? Now let’s say you find out from a reliable source that the one million dollars represents mere pennies to me because I have tons of money. Then you find out that the project I was supposedly committed to is last on my funding list as far as financial commitment. Does it still seem like a high priority? This is the case with drug testing. In general, the International Olympic Committee (IOC) and other organizations talk a good game, but in reality, they are not sincere in their drug testing efforts. The historical evidence shows a repeating sequence of events since the implementation of drug testing: athletes take drugs, organizations develop tests, athletes beat tests, organizations come out with new tests, athletes beats tests, and so on. You get the point. Each time a new test is developed, drug testing officials release statements to the media indicating how sensitive the new techniques are. The tests get implemented and a very small percentage of athletes test positive for some type of banned substance. The drug testing officials then claim that based on their latest information, drug use is declining. This is comical, given all the data that indicates junior high school, high school, recreational, amateur and professional athletes are using steroids and other drugs. Yet somehow the IOC and other organizations want us to believe that they are cleaning things up based on the low number of positive drug test results. Given all the data that indicates drug use is prevalent, I feel that what the low numbers of positive drug tests actually indicate is how inadequate drug testing methods are.
Prohibited and Restricted Drug Categories
Prohibited and restricted drugs fall into three main categories: (1) short- or immediate-acting stimulants and beta-blockers, (2) anabolic agents, and (3) masking agents. Stimulants and beta-blockers tend to affect performance only if taken just before the event. Drug testing for this category of drugs is believed to be very effective. Based on drug testing data, stimulant use has been essentially abolished from high-level sports because they are detected so easily. Anabolic agents usually require weeks to obtain the desired effect and are sometimes referred to as training drugs. The training drugs are inherently more difficult to detect and can be discontinued in time to pass an announced or anticipated test. Masking agents are drugs that affect the detectability of other drugs. Examples of masking agents are diuretics, probenecid, and epitestosterone. These drugs are only useful at the time of the test and, except for epitestosterone, are relatively easy to detect.
Anabolic-Androgenic Steroids (AAS)
Of all the known drugs abused by athletes, anabolic-androgenic steroids (AAS) are probably the most widely publicized. Use of these agents is associated with side effects that have been reported in the literature. Reports from case studies by clinicians stir up the media, which always seem to somehow exaggerate the side effects. The clinical literature reports that AAS possible side effects include psychological and psychiatric disturbances, rupture of the myotendinous junctions, increased blood coagulation, an impaired blood lipid profile, gynecomastia, hypogonadism, cholestasis, skin disease, hypertension, stroke, and myocardial infarction. The negative consequences to the athlete’s health have not deterred the use of these substances, despite the drive to win.
Presently more than 100 different AAS are available. They can be taken either by mouth and swallowed, sublingually, injected, or from transdermal application. The basic chemical structures have been modified to increase the anabolic effects and reduce the androgenic effects. The anabolic effects of steroids lead to muscle-building and increased aggression, which enable people to train harder.
Originally, only power athletes, bodybuilders, and recreational weight trainers were believed to take AAS. Evidence accumulated that endurance athletes used them as a training aid by to improve recovery from high volume training loads. This was later confirmed by the positive tests of Chinese female distance runners for DHT, a topically applied androgen with a fairly short half-life in the blood. This has prompted some researchers to pose the following question: Since medical doctors and other health care professionals have consistently stated that steroids don’t enhance performance, why are we testing athletes for them? If they do work, then why are we telling athletes they don’t? The simple truth of the matter is that early studies on steroids used low dosages. To say that steroids didn’t work in general is based on the data from early research and leads one to draw an invalid conclusion. The more appropriate conclusion is that the particular substance administered did not prove to be anabolic at the dosage tested. However, the latest evidence published in the New England Journal of Medicine does indicate that AAS do work, and unlike what most people will tell you, they can also stimulate muscle growth without having to lift weights. Obviously though, lifting weights increases the potential for gains in muscle size and strength.
Basic Overview of Drug Testing
On an annual basis, over 100,000 drug tests are conducted worldwide at a cost of $30 million. The drug tests are designed to detect and deter abuse of performance-enhancing drugs by competitors. The testing procedures for drug abuse in sport are strict and at times deemed unfair. They are deemed unfair because athletes are responsible for knowing what is banned despite the fact that additions are made almost daily to the list of banned substances. This has prompted researchers to recommend to athletes that the best possible solution is to avoid all drugs unless listed on the allowed substance list. The IOC has decided that drug tests will require confirmation, whenever possible, by gas chromatography and mass spectrometry, which define several chemical features of an abused drug, in effect producing a drug fingerprint. In addition, prior to the 1996 Olympic Games in Atlanta, the IOC required competitors to agree to a contract that prohibited them from taking any action beyond arbitration if they failed a drug test.
Drug Test Timing
When athletes know when a drug test will occur, they can prepare for it and thereby neutralize the effects of drug testing on the use of performance enhancing drugs and/or masking agents. Year-round short-notice and no-notice testing are the most effective means to curtail the use of training drugs because they make athletes always at risk to be tested. Sports have recently begun to invest in this type of testing despite the high cost and difficulty in administration. Some countries claim to have achieved no-notice testing. The IAAF and international federations for swimming and weightlifting conduct year-round, short-notice testing. In the United States, the NCAA and the National Football League (NFL) have short-notice (1-2 days) programs, and the United States Olympic Committee (USOC) has approved the implementation of a no-notice program.
Obtaining a Urine Sample
The drug testing procedure begins with taking a urine sample. While this sounds simple, it initiates a formal and highly regulated procedure to ensure that the urine sample that arrives at the laboratory actually comes from the athlete in question, with no opportunity to tamper with the sample. Why is urine used and not blood or other tissues? There are several reasons. Blood draws would require medical or paramedical staff and hence incur additional costs. Other tissues may not be valid for analysis under all conditions. Once selected for drug testing, the athlete is notified by an official and asked to sign a form acknowledging this notification. The athlete may or may not be accompanied by an official and must attend the testing station within the designated period. The testing station is supposed to be a private, comfortable place where plenty of drinks are available. Many times it is set up inside a specially designed mobile testing unit. Independent sampling officers, whom are trained and appointed by the respective governing body, carry out the collection of urine samples. Each officer carries a time-limited identity card and a letter of authority for the event to which they are allocated.
Before giving a urine sample, the athlete is told to select two numbered bottles. After providing the sample (about 100 ml), the athlete must voluntarily complete a form. The athlete declares any drug treatment taken in the previous seven days and must check and sign that the sample has been taken and placed in the bottles correctly. The urine sample is then sent for analysis to a laboratory currently accredited by the IOC. In the event of a positive test result, the laboratory will notify the governing body of the sport, who will then notify the athlete. The rules of the governing body of the particular sport determine what happens next. The rules vary across governing bodies, sports, and countries. An athlete is usually suspended while a positive result is investigated, but has the right to have a second analysis of the urine sample. This analysis may be observed directly by the athlete or by the athlete’s representative. There follows a hearing, at which time the athlete’s case is presented. An appeal can be made, and there have been successful appeals both in the United States and other countries.
The testing procedure must be strictly adhered to so that all athletes receive the same treatment. Collection of the urine sample has to be observed because drug abusers may attempt to falsify the results by tampering with the samples. Volume, pH, and in some cases specific gravity and temperature of the sample are tested immediately. These simple tests check for some of the known methods of cheating the drug tests at this early stage. The urine pH is tested to detect attempts at changing the nature of the sample, which can affect the analysis of certain drugs, as well as their metabolism and clearance. Sodium bicarbonate, for example, can be taken by mouth in order to change urine pH. The pH is also tested to verify that the level of degradation, which a sample may have experienced by the time it is tested, is within acceptable limits. The specific gravity is checked for attempts to dilute the concentration of drugs, as is the case by deliberate diuretic use.
To ensure that the sample actually comes from the athlete, the testing officer must be able to see the urine flow from the athlete into the bottle. Male athletes are asked to strip to their waist and lower their shorts to their knees. Female athletes must also be observed very closely while they void a sample. This procedure can be very awkward, embarrassing, and humiliating. For a young athlete, giving a urine sample under these circumstances can be very traumatizing. Many people, regardless of age, are uncomfortable with the idea of being observed while giving a urine sample. The situation is further complicated if an athlete has been competing in an endurance sport and is dehydrated or competing at a weight category where they are reluctant to drink excess fluid.
At least 75 mL must be given under close scrutiny and the urine is split into 2 portions as “A” and “B” bottles. The athlete chooses the two coded bottles and the samples are sealed by the athlete. In most cases, only the athlete handles the urine and collection containers until sealed. The containers are sealed with tamper-proof strips, placed inside other sealed containers, wrapped in tamper-evident seals, and coded. The independent official observing the sample procedure records all of the information on a document. This initiates a chain-of-custody record to be continued by anyone who handles the specimen until the urine is used up or discarded in the laboratory. The laboratory staff never knows the athlete’s name, only the bottle identification number. Everyone who handles the sample must understand the importance of the chain of custody and the essential role of maintaining it. The chain of custody guarantees that the sample content is protected and that the sample tested is from the correct athlete.
The possibility of sabotage of a urine sample has been raised many times by athletes. It is for this reason that that athletes should ensure that the testing procedure is observed rigorously for their own protection. Samples should be dispatched in the appropriate containers and all paperwork completed without any errors. After this the athlete is no longer part of the process and must rely on the integrity and accuracy of the system. The sample is then taken and sent by courier, along with a chain-of-custody document, to an accredited laboratory.
While the test protocol may seem excessive and violate certain rights of privacy and decency, there are important reasons for this protocol. There are many reports of athletes using elaborate arrangements of catheters to provide an alternative sample, bringing condoms filled with drug free urine to the testing station, and even catheterizing themselves and instilling drug free urine. If athletes go to these lengths to avoid detection, the testing protocol must be strict.
At the elite level, athletes are subject to year-round random testing. At any time, an independent sampling officer may call unannounced and request a urine sample. While this comes across straightforward on paper, in practice there are many difficulties. Frequently, athletes travel the world and finding the athlete can be difficult. After the independent sampling officer asks around to find the athlete in question, it is unlikely that the testing remains a surprise.
Storing the Sample
The proper storage of samples is important to the reliability of the tests. Once collected, the sample must be protected so that the fluid, when tested in the laboratory, reflects the composition of the sample as it left the body of the person being tested. As part of sports doping policy, urine is not refrigerated or frozen until it reaches the laboratory. In a clinical setting, great care is taken to ensure that the sample tested is as near as possible to the condition in which it left the body. This is accomplished by adding a preservative or more often by refrigerating or freezing the sample. With worldwide testing in sports, samples are sent all over the world and there can be delays in delivering them to labs.
While refrigeration or freezing of the sample is the usual practice in the clinical setting, note that this is definitely not the case in sports. The addition of chemicals to prevent bacterial growth in the urine could preserve the specimen and may be a more practical alternative. Athletes, however, regard this method with some suspicion and think that this may introduce the possibility of tampering with the sample. Current scientific evidence indicates that their fears are misplaced. Urine contains thousands of bacteria from many different species. This is even more the case for a sexually active female. Urine collected from a female athlete will contain skin cells and microorganisms from the intestine flushed to the vaginal area by sweat. Many bacteria are ubiquitous and survive even in tap-water plumbing; if the water were used to wash any of the sample containers, other microorganisms could be added to the sample. Bacteria, in a container to which urine is added, will flourish in such a medium that is infinitely richer in nutrients than the water in which they have survived. Many constituents of urine support the growth of such bacteria, and metabolism presents a serious problem in drug testing because of the risk of falsifying doping test results. In this regard, urine contains several steroids that are utilized by bacterial enzymes that can interconvert endogenous steroids to the extent of producing testosterone in the urine. Because of the steroid concentrations in the urine, even a low conversion rate of steroids to T will produce a level of T sufficient to distort the test result. So athletes should be more concerned if officials don’t add something to the urine sample and not the other way around.
Laboratory Protocols
Laboratories need to maintain high standards of practice in order to retain the respect of the sports community. In the event of an appeal for a positive test result, the data and procedures may have to withstand scientific and legal scrutiny. This makes accurate and complete presentation of the results essential. Accredited laboratories involved in drug testing may also exchange samples in a quality control program to confirm that they agree on the findings. If a lab comes up with results that are not consistent with other labs, they fail the quality control tests and accreditation can be withdrawn. While these quality control tests are not usually made public, some experts feel that they should be made available to all parties, especially in the case of legal disputes. Examples of quality controls include urine or water samples to which banned drugs have been added. In addition, urine samples from someone who has taken the banned drugs must also be taken. The reason for both procedures is that compounds can behave differently in urine samples derived from the body after drug administration. This procedure and the appropriate use of reference compounds is important for the interpretation of results from the drug tests.
Part Two – Formal process of drug testing in sports continued.
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