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The use of drugs to enhance sports performance is a global phenomenon that continues to receive wide media attention. The number, variety and use of legal and illegal drugs has increased in recent years.1 Drug misuse in elite sport is monitored internationally by the World Anti-Doping Agency (WADA), while Drug-Free Sport New Zealand (DFSNZ) is responsible for national athlete testing and education.Recently, it has been proposed that young athletes transition incrementally from their use of permitted to illegal substances, with the suggestion of harm minimisation as an approach to counter this.1 Health professionals, particularly doctors, are traditionally recognised by athletes as a trusted resource for all matters of drug efficacy and safety, including the use of dietary supplements and performance-enhancing agents.2 However, many physicians lack fundamental knowledge to provide adequate advice to athletes.3 This article references the body of research on doping prevalence in sport, discussing its associated culture, common reasons, key personnel and prevention strategies to assist medical professionals in the New Zealand context.Review methodologyMEDLINE, PubMed, Scopus and SPORTDiscus online databases were searched for peer-reviewed research from 2009 to January, 2015, using combinations of the terms, doping , performance enhancing drug* , performance enhancing substance* , drugs , anti-doping , education , sport* , prevalence , prevention , athlete* , elite , sub-elite, recreational and adolescent. A second-stage snowball search scanned reference lists of published articles for relevant manuscripts and considered articles recommended by the online databases at the time the original manuscripts were downloaded. A total of 232 references were identified that related to the prevalence, prevention and culture of drug misuse in sport. Only six of these were specific to New Zealand.Results and discussionDefinitionsFor the purposes of this review, doping is defined as a breach of the WADA rules, including use or attempted use of a prohibited substance or method. These include anabolic agents, peptide hormones, stimulants, diuretics, beta-2 agonists and recognised performance-enhancing methods, such as blood and gene doping, urine tampering or intravenous infusions unless medically indicated. The use of illicit recreational drugs, including narcotics and cannabinoids, is also considered a breach of the WADC. Contemporary literature uses the interchangeable terms performance-enhancing drugs (PEDs), banned drugs and doping with resulting confusion.1,4 In this review, doping infers the collective of PEDs, performance-enhancing methods and illicit drugs.Breaches of the WADA rules are considered either intentional or inadvertent. The former implies cheating, whereas the latter may result from supplement contamination or ignorance.1 Acts of doping in sport focus primarily on an intent to enhance performance, while inadvertent doping, not generally considered as purposeful, is deemed a consequence of either unknown product contamination or recreational drug use. However, the WADC applies strict personal liability to drug misuse, making no such discrimination when considering violations. As a result, any athlete found positive may be sanctioned in accordance with options from a reprimand, to the rarely used lifetime ban from sport. For the purposes of this review, the authors use doping to refer to deliberate, banned drug-use and inadvertent doping for product contamination or ignorance of the rules.PrevalenceA true prevalence of doping in sport is difficult to determine given the limitations of data collection, the intrusiveness of the questions and the obvious sensitivity of the responses. International drug testing results, collated by WADA, demonstrate an approximate prevalence of 2% positive tests per year. However, the true prevalence is thought to be closer to 10%5 with a recent review of the literature yielding an estimation of 14-39%.4In 2013/14, DFSNZ carried out 925 drug tests on elite athletes, with 4 violations, a doping prevalence of 0.004%, which compares to 0.007% in 2012/13 and 0.005% in 2011/12.6 However, these tests do not include gym users or athletes not subjected to anti-doping regulations. Another paper reported 5 of 32 New Zealand body builders admitting the use of androgenic anabolic steroids (AAS) at some stage in their career.6 Australian-based studies of doping amongst elite athletes reported an 8% response, compared with 52% in male gym users,7,9 while 25% of a Canadian cohort of junior provincial athletes reported PED use in the previous year,9 and up to 12% of an American high school student cohort reported AAS use.10,11 From these estimates, 10% of athletes seen by a health professional are possibly using a PED, and 1 in 3 are at risk of inadvertent doping from supplement use.Drug-User ProfileCompetitive athletes who intentionally dope are categorised as \u2026villains, mavericks and professionals. 1 Villains cheat deliberately, while mavericks display an ignorant disregard for the rules. Professionals however purported to be the largest group progress from diet and lifestyle changes, to supplementation, and finally to banned substance use. It is argued that these athletes are not cheaters, but products of the intensely competitive, commercialised world of elite sport, whereby they are driven to train with greater intensity for longer periods.At a recreational level, so-called gym users plus power and strength sportspeople are more likely to use AAS or growth hormone derivatives.12,13 This systematic review of anabolic steroid use listed appearance, aggression or enhanced performance as the most relevant reasons for doping.13 These dopers were characterised as being male, under 30 years of age, mistrusting of medical professionals and with comorbidities including depression and a history of illicit drug use.12,13 Furthermore, female AAS-users have a much higher risk of dependency than male counterparts.14 Therefore, recreational sportspeople with the characteristics described should prompt medical professionals to be wary of their potential for drug misuse.Times when athletes are at an increased doping riskThe culture of doping is as varied as the sports, sub-cultures, ability, ages and personalities of the users.1,2,15-19 Notwithstanding, some individual characteristics and specific determinants have emerged that could assist doctors who regularly manage athletes. As a group, athletes have been identified as being more likely to use a PED if offered the chance.20,21 Qualitative research involving a cohort of 147 UK athletes identified reliability, rule abiding and role modelling as protective behaviours, while rule breaking, bad temperament and a win-at-all-costs attitude were risk factors for doping.22 An athletes doping risk was also reported to increase during critical events, such as selection/de-selection,23,24 during recovery from injury and when negotiating crucial sponsorship deals.17 These transitions were considered to be times of psychosocial challenge with an enhanced risk of doping. At such times, social support, individual coping mechanisms2,25 and the influence of medical advice was deemed critical.3Entourage influence and knowledgeA complex of individuals, identified as the athlete entourage, contributes to the environment of every elite athlete. Doctors, coaches, trainers, family, friends, teammates and physiotherapists are acknowledged sources of knowledge, leadership and support.2 Yet a study of the anti-doping knowledge of 292 Australian support personnel revealed that 40% had no specific training, despite providing advice to athletes.26 This study also revealed that 32% of these support personnel ignored the unethical behaviour of colleagues, despite a WADC obligation to report doping offences irrespective of confidentiality.3 The importance of the coach in the social network is also emphasised, and for 292 New Zealand athletes interviewed, coaching style was a determinant in an increased athlete doping risk.19 This influence was also reflected by studies of elite Scottish,27 German,16 and Greek28 athletes.Culture of sportWhile the culture of sport has been identified as shaping an athletes attitudes and intentions to dope, the public and the media consider doping as simply another form of cheating.13,29 Athletes caught cheating are commonly portrayed as bad, with the role of their entourage often ignored,28 despite compelling evidence that they are complicit.17 Athletes are frequently villainised when caught using drugs in a recreational setting. Multiple Olympic gold medallist Michael Phelps was publicly chastised for his one-time use of cannabis,30,33 yet Barack Obama as a Presidential candidate was praised for honesty in declaring his youthful, cannabis and cocaine use.31Elite athletes are more likely to dope if they believe that other athletes are doping.21,32,33 For example, eight elite and neo-elite cyclists, interviewed prior to turning professional, viewed doping as cheating, yet once they became professional they regarded doping as an inevitable progression in performance enhancement. They also claimed elite sport as being deleterious to health, rationalising that PEDs conferred a protective influence.32,34 Boundaries can be blurred between legitimate performance enhancement, including physiological testing, nutritional supplementation or biomechanical computer-modelling and frank doping to compensate for media pressures, sponsorship or public expectation.35,36 Times of increased vulnerability demand concerted education and awareness from all stakeholders, particularly doctors.Dietary supplementsDietary supplementation in sport is common, with the internet, team mates, coaches and athletic trainers providing the most common sources of information.37 An unpublished survey of elite New Zealand athletes reported a 93% usage of 3 supplements in the prior 6 months,38 findings comparable to data from a similar Canadian study.37 Inadvertent doping is a potential consequence of supplementation, with products frequently not subjected to strict manufacturing and quality control. Fifteen percent of internet-sourced supplements have been reported with steroid contamination39 as well as potent psychoactive substances, including DMBA (1,3-dimethylbutylamine) and its analogues.39 Dietary supplement users are also shown to be at greater risk of doping than non-users, reflected in studies of elite UK athletes,15 Australian and Greek high school students,19,25 amateur Australian cyclists,24,36 and Croatian rugby players.41 A more permissive attitude towards doping has mirrored increasing supplement use, with recovery from injury or training, improved performance, increased muscle size and body image as common reasons.15,35,37 Sources of supplements and reasons for their use are matters for doctors to explore with athletes in their care.Body image and moral disengagementTo look good, is an oft-cited reason for recreational athletes, especially serious gym users, to use AAS and supplements.42 Both AAS and supplement use are reportedly associated with an increased alcohol and illicit drug consumption,13,42 low self-esteem or a negative body image, and participation in sports where muscle bulk is important.10 Product source is important, with 50-75% of PEDs being reportedly purchased online.21 One study used laboratory testing of 57 AAS or growth hormone derivatives purchased online and reported 42% being either contaminated with bacteria, containing no active anabolic ingredient or raising other safety issues.21 The same study reported that testing 634 nutritional supplements found many to contain some trace of AAS. The potential co-morbidities and risks for PEDs or supplements purchased online is important information for all medical professionals, but particularly doctors, to be aware of.Athletes frequently rationalise doping on spurious grounds that ignore health and safety.23,32 A strategy known as moral disengagement negates the immoral actions of cheating through established mechanisms of \u2026displacement or diffusion of responsibility, advantageous comparison, distortion of consequences, moral justification and euphemistic labelling .13 These phenomena are documented in body builders,7,13,35 weightlifters,23 cyclists,34 and in 1,188 Australian adolescents were predictive of doping attitudes, regardless of social demographics or athletic status.33 In order to counter forms of moral disengagement, medical professionals must recognise the process and develop appropriate counter arguments.35ConclusionsDespite the importance of sport in our society, there is a dearth of New Zealand research relating to sports doping. International figures suggest that doping is more common than figures would suggestand that deterrence through punitive measures alone is ineffective.An understanding of drug misuse in sport deserves a wider, empathetic view that embodies the culture of sport and the influence of the athlete entourage of support personnel.The most common reasons given for PED use are to improve looks, increase performance, to cope with the demands of training, or to recover from injury. More recent research also suggests impressionable young athletes may see doping as a natural progression of performance enhancement and be willing to risk sanctions and personal health in the pursuit of success.Regardless, athletes taking supplements or PEDs bought online risk their health through possible contamination.Effective educational strategies encourage themes of health, morality and refusal skills, while acknowledging that there are periods of increased athlete vulnerability. Medical professionals in particular need to be increasingly wary of these times of increased risk.Doctors treating competitive or recreational athletes carry a burden of responsibility in their knowledge of dietary supplementation and prohibited substances that reflects patient health and the spirit of sport embodied in the World Anti-Doping Code.\r\n

Summary

Abstract

Aim

Drug misuse in elite sport is a world-wide phenomenon. This article explores the culture of contemporary sport, provides estimates of doping prevalence, discusses dietary supplementation and highlights major factors influencing high-performance athletes and their support personnel. The aim is to stimulate discussion, informed by the World Anti-Doping Code (WADC), which is particularly relevant to doctors caring for athletes.

Method

Online databases were searched for relevant peer-reviewed research from 2009 to 2015. Comparative New Zealand data have been included.

Results

Estimates of the prevalence of sports doping range from less than 1% to as high as 52%, dependent upon the demographics of the identified cohort. The culture of elite sport, personal stressors, competitive demands, financial reward and the influence of an entourage of support personnel were identified as critical determinants of drug misuse.

Conclusion

The culture of elite contemporary sport is seductive to many aspiring young athletes. To combat drug misuse, effective education should embody moral, ethical and clinical dangers, recognising the importance of support at times of increased athlete vulnerability. Inadvertent doping from product contamination is a recognised risk of unsupervised dietary supplementation. Doctors responsible for the care of high-performance athletes must be cognisant of these issues and the provisions of the WADC.

Author Information

Andrew N Curtis, University of Otago, Christchurch; David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Peter Burt, Dunedin School of Medicine, University of Otago, Dunedin; Hamish Osborne, Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin

Correspondence Email

david.gerrard@otago.ac.nz

Competing Interests

Dr. Gerrard reports he is currently the Chair of the World Anti-Doping Agency (WADA) Therapeutic Use Exemption Committeeand a member of the WADA Health Medicine and Research Committee, both voluntary positions.

- - Petr\u00f3czi A. The doping mindset Part I: Implications of the Functional Use Theory on mental representations of doping. Performance Enhancement & Health. 2013;2(4):153-63. Chan D, Hardcastle S, Lentillon-Kaestner V, Donovan R, Dimmock J, Hagger M. Athletes Beliefs About and Attitudes Towards Taking Banned Performance-Enhancing Substances: A Qualitative Study. 2014. Backhouse S, McKenna J. Doping in sport: A review of medical practitioners knowledge, attitudes and beliefs. Int J Drug Policy. 2011;22(3):198-202. de Hon O, Kuipers H, van Bottenburg M. Prevalence of doping use in elite sports: a review of numbers and methods. Sports Medicine. 2014:1-13. Batt A. The role of UK Anti-Doping in the fight against doping in sport. International Journal of Sport Policy and Politics. 2011;3(2):261-70. DFSNZ. Annual Report 2013/2014. Auckland, New Zealand: Drug Free Sport New Zealand, 2014. Probert A, Leberman S. The Value of the Dark Side: An Insight into the Risks and Benefits of Engaging in Health-compromising Practices from the Perspective of Competitive Bodybuilders. European Sport Management Quarterly. 2009;9(4):353-73. Dunn M, Thomas JO, Swift W, Burns L. Elite athletes estimates of the prevalence of illicit drug use: Evidence for the false consensus effect. Drug and Alcohol Review. 2012;31(1):27-32. Goulet C, Valois P, Buist A, Cote M. Predictors of the Use of Performance-Enhancing Substances by Young Athletes. Clinical Journal of Sport Medicine. 2010;20(4):243-8. Dandoy C, Gereige RS. Performance-enhancing drugs. Pediatrics in Review. 2012;33(6):265-72. Thorlindsson T, Halldorsson V. Sport, and use of anabolic androgenic steroids among Icelandic high school students: a critical test of three perspectives. Subst Abuse Treat Prev Policy. 2010;5:32. Sagoe D, Andreassen CS, Pallesen S. The aetiology and trajectory of anabolic-androgenic steroid use initiation: A systematic review and synthesis of qualitative research. Substance Abuse: Treatment, Prevention, and Policy. 2014;9(1). Boardley ID, Grix J, Dewar AJ. Moral disengagement and associated processes in performance-enhancing drug use: a national qualitative investigation. Journal of Sports Sciences. 2014;32(9):836-44. Ip EJ, Barnett MJ, Tenerowicz MJ, Kim JA, Wei H, Perry PJ. Women and anabolic steroids: An analysis of a Dozen users. Clinical Journal of Sport Medicine. 2010;20(6):475-81. Backhouse S, Whitaker L, Petroczi A. Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms. Scand J Med Sci Sports. 2013;23(2):244-52. Sas-Nowosielski K, Swiatkowska L. Goal orientations and attitudes toward doping. Int J Sports Med. 2008;29(7):607-12. Smith ACT, Stewart B, Oliver-Bennetts S, McDonald S, Ingerson L, Anderson A, et al. Contextual influences and athlete attitudes to drugs in sport. Sport management review. 2010;13(3):181-97. Yager Z, ODea JA. Relationships between body image, nutritional supplement use, and attitudes towards doping in sport among adolescent boys: implications for prevention programs. J Int Soc Sports Nutr. 2014;11(13):1-8. Hodge K, Hargreaves EA, Gerrard D, Lonsdale C. Psychological Mechanisms Underlying Doping Attitudes in Sport: Motivation and Moral Disengagement. Journal of Sport & Exercise Psychology. 2013;35(4):419-32. Dodge T, Stock M, Litt D. Judgments About Illegal Performance Enhancing Substances: Reasoned, Reactive or Both? Journal of Health Psychology. 2012;18(7):962-71. Graham MR, Ryan P, Baker JS, Davies B, Thomas N-E, Cooper S-M, et al. Counterfeiting in performance- and image-enhancing drugs. Drug Testing and Analysis. 2009;1(3):135-42. Whitaker L, Long J, Petr\u00f3czi A, Backhouse SH. Athletes perceptions of performance enhancing substance user and non-user prototypes. Performance Enhancement & Health. 2012;1(1):28-34. Kirby K, Moran A, Guerin S. A qualitative analysis of the experiences of elite athletes who have admitted to doping for performance enhancement. International Journal of Sport Policy and Politics. 2011;3(2):205-24. Stewart B, Outram S, Smith ACT. Doing supplements to improve performance in club cycling: a life-course analysis. Scandinavian Journal of Medicine & Science in Sports. 2013;23(6):e361-e72. Barkoukis V, Lazuras L, Lucidi F, Tsorbatzoudis H. Nutritional supplement and doping use in sport: Possible underlying social cognitive processes. Scandinavian journal of medicine & science in sports. 2015. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scandinavian Journal of Medicine & Science in Sports. 2014;24(5):846-56. Allen J, Taylor J, Dimeo P, Dixon S, Robinson L. Predicting elite Scottish athletes attitudes towards doping: examining the contribution of achievement goals and motivational climate. Journal of Sports Sciences. 2014:1-8. Barkoukis V, Lazuras L, Tsorbatzoudis H, Rodafinos A. Motivational and sportspersonship profiles of elite athletes in relation to doping behavior. Psychology of Sport and Exercise. 2011;12(3):205-12. Mazanov J, Huybers T, Connor J. Prioritising health in anti-doping: What Australians think. Journal of Science and Medicine in Sport. 2012;15(5):381-5. Macur J. Phelps Disciplined Over Marijuana Pipe Incident. New York Times. 2009 Feb 6, 2009. Seelye KQ. Barack Obama, asked about drug history, admits he inhaled. New York Times. 2006 Oct 24, 2006. Lentillon-Kaestner V, Hagger MS, Hardcastle S. Health and doping in elite-level cycling. Scandinavian Journal of Medicine & Science in Sports. 2012;22(5):596-606. Skinner J, Moston S, Engelberg T. The relationship between moral code, participation in sport, and attitudes towards performance enhancing drugs in young people. Montreal: World Anti-Doping Agency (WADA), 2012. Lentillon-Kaestner V. The development of doping use in high-level cycling: From team-organized doping to advances in the fight against doping. Scandinavian Journal of Medicine & Science in Sports. 2011;23(2):189-97. Engelberg T, Moston S, Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations. Sport Management Review. 2014. Outram SM, Stewart B. Condemning and condoning: Elite amateur cyclists perspectives on drug use and professional cycling. Int J Drug Policy. 2015. Lun V, Erdman KA, Fung TS, Reimer RA. Dietary supplementation practices in Canadian high-performance athletes. Int J Sport Nutr Exerc Metab. 2012;22(1):31-7. Hellemans I, MacDonald S, Skidmore P. Use of Dietary Supplements in Elite New Zealand Athletes. 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The use of drugs to enhance sports performance is a global phenomenon that continues to receive wide media attention. The number, variety and use of legal and illegal drugs has increased in recent years.1 Drug misuse in elite sport is monitored internationally by the World Anti-Doping Agency (WADA), while Drug-Free Sport New Zealand (DFSNZ) is responsible for national athlete testing and education.Recently, it has been proposed that young athletes transition incrementally from their use of permitted to illegal substances, with the suggestion of harm minimisation as an approach to counter this.1 Health professionals, particularly doctors, are traditionally recognised by athletes as a trusted resource for all matters of drug efficacy and safety, including the use of dietary supplements and performance-enhancing agents.2 However, many physicians lack fundamental knowledge to provide adequate advice to athletes.3 This article references the body of research on doping prevalence in sport, discussing its associated culture, common reasons, key personnel and prevention strategies to assist medical professionals in the New Zealand context.Review methodologyMEDLINE, PubMed, Scopus and SPORTDiscus online databases were searched for peer-reviewed research from 2009 to January, 2015, using combinations of the terms, doping , performance enhancing drug* , performance enhancing substance* , drugs , anti-doping , education , sport* , prevalence , prevention , athlete* , elite , sub-elite, recreational and adolescent. A second-stage snowball search scanned reference lists of published articles for relevant manuscripts and considered articles recommended by the online databases at the time the original manuscripts were downloaded. A total of 232 references were identified that related to the prevalence, prevention and culture of drug misuse in sport. Only six of these were specific to New Zealand.Results and discussionDefinitionsFor the purposes of this review, doping is defined as a breach of the WADA rules, including use or attempted use of a prohibited substance or method. These include anabolic agents, peptide hormones, stimulants, diuretics, beta-2 agonists and recognised performance-enhancing methods, such as blood and gene doping, urine tampering or intravenous infusions unless medically indicated. The use of illicit recreational drugs, including narcotics and cannabinoids, is also considered a breach of the WADC. Contemporary literature uses the interchangeable terms performance-enhancing drugs (PEDs), banned drugs and doping with resulting confusion.1,4 In this review, doping infers the collective of PEDs, performance-enhancing methods and illicit drugs.Breaches of the WADA rules are considered either intentional or inadvertent. The former implies cheating, whereas the latter may result from supplement contamination or ignorance.1 Acts of doping in sport focus primarily on an intent to enhance performance, while inadvertent doping, not generally considered as purposeful, is deemed a consequence of either unknown product contamination or recreational drug use. However, the WADC applies strict personal liability to drug misuse, making no such discrimination when considering violations. As a result, any athlete found positive may be sanctioned in accordance with options from a reprimand, to the rarely used lifetime ban from sport. For the purposes of this review, the authors use doping to refer to deliberate, banned drug-use and inadvertent doping for product contamination or ignorance of the rules.PrevalenceA true prevalence of doping in sport is difficult to determine given the limitations of data collection, the intrusiveness of the questions and the obvious sensitivity of the responses. International drug testing results, collated by WADA, demonstrate an approximate prevalence of 2% positive tests per year. However, the true prevalence is thought to be closer to 10%5 with a recent review of the literature yielding an estimation of 14-39%.4In 2013/14, DFSNZ carried out 925 drug tests on elite athletes, with 4 violations, a doping prevalence of 0.004%, which compares to 0.007% in 2012/13 and 0.005% in 2011/12.6 However, these tests do not include gym users or athletes not subjected to anti-doping regulations. Another paper reported 5 of 32 New Zealand body builders admitting the use of androgenic anabolic steroids (AAS) at some stage in their career.6 Australian-based studies of doping amongst elite athletes reported an 8% response, compared with 52% in male gym users,7,9 while 25% of a Canadian cohort of junior provincial athletes reported PED use in the previous year,9 and up to 12% of an American high school student cohort reported AAS use.10,11 From these estimates, 10% of athletes seen by a health professional are possibly using a PED, and 1 in 3 are at risk of inadvertent doping from supplement use.Drug-User ProfileCompetitive athletes who intentionally dope are categorised as \u2026villains, mavericks and professionals. 1 Villains cheat deliberately, while mavericks display an ignorant disregard for the rules. Professionals however purported to be the largest group progress from diet and lifestyle changes, to supplementation, and finally to banned substance use. It is argued that these athletes are not cheaters, but products of the intensely competitive, commercialised world of elite sport, whereby they are driven to train with greater intensity for longer periods.At a recreational level, so-called gym users plus power and strength sportspeople are more likely to use AAS or growth hormone derivatives.12,13 This systematic review of anabolic steroid use listed appearance, aggression or enhanced performance as the most relevant reasons for doping.13 These dopers were characterised as being male, under 30 years of age, mistrusting of medical professionals and with comorbidities including depression and a history of illicit drug use.12,13 Furthermore, female AAS-users have a much higher risk of dependency than male counterparts.14 Therefore, recreational sportspeople with the characteristics described should prompt medical professionals to be wary of their potential for drug misuse.Times when athletes are at an increased doping riskThe culture of doping is as varied as the sports, sub-cultures, ability, ages and personalities of the users.1,2,15-19 Notwithstanding, some individual characteristics and specific determinants have emerged that could assist doctors who regularly manage athletes. As a group, athletes have been identified as being more likely to use a PED if offered the chance.20,21 Qualitative research involving a cohort of 147 UK athletes identified reliability, rule abiding and role modelling as protective behaviours, while rule breaking, bad temperament and a win-at-all-costs attitude were risk factors for doping.22 An athletes doping risk was also reported to increase during critical events, such as selection/de-selection,23,24 during recovery from injury and when negotiating crucial sponsorship deals.17 These transitions were considered to be times of psychosocial challenge with an enhanced risk of doping. At such times, social support, individual coping mechanisms2,25 and the influence of medical advice was deemed critical.3Entourage influence and knowledgeA complex of individuals, identified as the athlete entourage, contributes to the environment of every elite athlete. Doctors, coaches, trainers, family, friends, teammates and physiotherapists are acknowledged sources of knowledge, leadership and support.2 Yet a study of the anti-doping knowledge of 292 Australian support personnel revealed that 40% had no specific training, despite providing advice to athletes.26 This study also revealed that 32% of these support personnel ignored the unethical behaviour of colleagues, despite a WADC obligation to report doping offences irrespective of confidentiality.3 The importance of the coach in the social network is also emphasised, and for 292 New Zealand athletes interviewed, coaching style was a determinant in an increased athlete doping risk.19 This influence was also reflected by studies of elite Scottish,27 German,16 and Greek28 athletes.Culture of sportWhile the culture of sport has been identified as shaping an athletes attitudes and intentions to dope, the public and the media consider doping as simply another form of cheating.13,29 Athletes caught cheating are commonly portrayed as bad, with the role of their entourage often ignored,28 despite compelling evidence that they are complicit.17 Athletes are frequently villainised when caught using drugs in a recreational setting. Multiple Olympic gold medallist Michael Phelps was publicly chastised for his one-time use of cannabis,30,33 yet Barack Obama as a Presidential candidate was praised for honesty in declaring his youthful, cannabis and cocaine use.31Elite athletes are more likely to dope if they believe that other athletes are doping.21,32,33 For example, eight elite and neo-elite cyclists, interviewed prior to turning professional, viewed doping as cheating, yet once they became professional they regarded doping as an inevitable progression in performance enhancement. They also claimed elite sport as being deleterious to health, rationalising that PEDs conferred a protective influence.32,34 Boundaries can be blurred between legitimate performance enhancement, including physiological testing, nutritional supplementation or biomechanical computer-modelling and frank doping to compensate for media pressures, sponsorship or public expectation.35,36 Times of increased vulnerability demand concerted education and awareness from all stakeholders, particularly doctors.Dietary supplementsDietary supplementation in sport is common, with the internet, team mates, coaches and athletic trainers providing the most common sources of information.37 An unpublished survey of elite New Zealand athletes reported a 93% usage of 3 supplements in the prior 6 months,38 findings comparable to data from a similar Canadian study.37 Inadvertent doping is a potential consequence of supplementation, with products frequently not subjected to strict manufacturing and quality control. Fifteen percent of internet-sourced supplements have been reported with steroid contamination39 as well as potent psychoactive substances, including DMBA (1,3-dimethylbutylamine) and its analogues.39 Dietary supplement users are also shown to be at greater risk of doping than non-users, reflected in studies of elite UK athletes,15 Australian and Greek high school students,19,25 amateur Australian cyclists,24,36 and Croatian rugby players.41 A more permissive attitude towards doping has mirrored increasing supplement use, with recovery from injury or training, improved performance, increased muscle size and body image as common reasons.15,35,37 Sources of supplements and reasons for their use are matters for doctors to explore with athletes in their care.Body image and moral disengagementTo look good, is an oft-cited reason for recreational athletes, especially serious gym users, to use AAS and supplements.42 Both AAS and supplement use are reportedly associated with an increased alcohol and illicit drug consumption,13,42 low self-esteem or a negative body image, and participation in sports where muscle bulk is important.10 Product source is important, with 50-75% of PEDs being reportedly purchased online.21 One study used laboratory testing of 57 AAS or growth hormone derivatives purchased online and reported 42% being either contaminated with bacteria, containing no active anabolic ingredient or raising other safety issues.21 The same study reported that testing 634 nutritional supplements found many to contain some trace of AAS. The potential co-morbidities and risks for PEDs or supplements purchased online is important information for all medical professionals, but particularly doctors, to be aware of.Athletes frequently rationalise doping on spurious grounds that ignore health and safety.23,32 A strategy known as moral disengagement negates the immoral actions of cheating through established mechanisms of \u2026displacement or diffusion of responsibility, advantageous comparison, distortion of consequences, moral justification and euphemistic labelling .13 These phenomena are documented in body builders,7,13,35 weightlifters,23 cyclists,34 and in 1,188 Australian adolescents were predictive of doping attitudes, regardless of social demographics or athletic status.33 In order to counter forms of moral disengagement, medical professionals must recognise the process and develop appropriate counter arguments.35ConclusionsDespite the importance of sport in our society, there is a dearth of New Zealand research relating to sports doping. International figures suggest that doping is more common than figures would suggestand that deterrence through punitive measures alone is ineffective.An understanding of drug misuse in sport deserves a wider, empathetic view that embodies the culture of sport and the influence of the athlete entourage of support personnel.The most common reasons given for PED use are to improve looks, increase performance, to cope with the demands of training, or to recover from injury. More recent research also suggests impressionable young athletes may see doping as a natural progression of performance enhancement and be willing to risk sanctions and personal health in the pursuit of success.Regardless, athletes taking supplements or PEDs bought online risk their health through possible contamination.Effective educational strategies encourage themes of health, morality and refusal skills, while acknowledging that there are periods of increased athlete vulnerability. Medical professionals in particular need to be increasingly wary of these times of increased risk.Doctors treating competitive or recreational athletes carry a burden of responsibility in their knowledge of dietary supplementation and prohibited substances that reflects patient health and the spirit of sport embodied in the World Anti-Doping Code.\r\n

Summary

Abstract

Aim

Drug misuse in elite sport is a world-wide phenomenon. This article explores the culture of contemporary sport, provides estimates of doping prevalence, discusses dietary supplementation and highlights major factors influencing high-performance athletes and their support personnel. The aim is to stimulate discussion, informed by the World Anti-Doping Code (WADC), which is particularly relevant to doctors caring for athletes.

Method

Online databases were searched for relevant peer-reviewed research from 2009 to 2015. Comparative New Zealand data have been included.

Results

Estimates of the prevalence of sports doping range from less than 1% to as high as 52%, dependent upon the demographics of the identified cohort. The culture of elite sport, personal stressors, competitive demands, financial reward and the influence of an entourage of support personnel were identified as critical determinants of drug misuse.

Conclusion

The culture of elite contemporary sport is seductive to many aspiring young athletes. To combat drug misuse, effective education should embody moral, ethical and clinical dangers, recognising the importance of support at times of increased athlete vulnerability. Inadvertent doping from product contamination is a recognised risk of unsupervised dietary supplementation. Doctors responsible for the care of high-performance athletes must be cognisant of these issues and the provisions of the WADC.

Author Information

Andrew N Curtis, University of Otago, Christchurch; David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Peter Burt, Dunedin School of Medicine, University of Otago, Dunedin; Hamish Osborne, Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin

Correspondence Email

david.gerrard@otago.ac.nz

Competing Interests

Dr. Gerrard reports he is currently the Chair of the World Anti-Doping Agency (WADA) Therapeutic Use Exemption Committeeand a member of the WADA Health Medicine and Research Committee, both voluntary positions.

- - Petr\u00f3czi A. The doping mindset Part I: Implications of the Functional Use Theory on mental representations of doping. Performance Enhancement & Health. 2013;2(4):153-63. Chan D, Hardcastle S, Lentillon-Kaestner V, Donovan R, Dimmock J, Hagger M. Athletes Beliefs About and Attitudes Towards Taking Banned Performance-Enhancing Substances: A Qualitative Study. 2014. Backhouse S, McKenna J. Doping in sport: A review of medical practitioners knowledge, attitudes and beliefs. Int J Drug Policy. 2011;22(3):198-202. de Hon O, Kuipers H, van Bottenburg M. Prevalence of doping use in elite sports: a review of numbers and methods. Sports Medicine. 2014:1-13. Batt A. The role of UK Anti-Doping in the fight against doping in sport. International Journal of Sport Policy and Politics. 2011;3(2):261-70. DFSNZ. Annual Report 2013/2014. Auckland, New Zealand: Drug Free Sport New Zealand, 2014. Probert A, Leberman S. The Value of the Dark Side: An Insight into the Risks and Benefits of Engaging in Health-compromising Practices from the Perspective of Competitive Bodybuilders. European Sport Management Quarterly. 2009;9(4):353-73. Dunn M, Thomas JO, Swift W, Burns L. Elite athletes estimates of the prevalence of illicit drug use: Evidence for the false consensus effect. Drug and Alcohol Review. 2012;31(1):27-32. Goulet C, Valois P, Buist A, Cote M. Predictors of the Use of Performance-Enhancing Substances by Young Athletes. Clinical Journal of Sport Medicine. 2010;20(4):243-8. Dandoy C, Gereige RS. Performance-enhancing drugs. Pediatrics in Review. 2012;33(6):265-72. Thorlindsson T, Halldorsson V. Sport, and use of anabolic androgenic steroids among Icelandic high school students: a critical test of three perspectives. Subst Abuse Treat Prev Policy. 2010;5:32. Sagoe D, Andreassen CS, Pallesen S. The aetiology and trajectory of anabolic-androgenic steroid use initiation: A systematic review and synthesis of qualitative research. Substance Abuse: Treatment, Prevention, and Policy. 2014;9(1). Boardley ID, Grix J, Dewar AJ. Moral disengagement and associated processes in performance-enhancing drug use: a national qualitative investigation. Journal of Sports Sciences. 2014;32(9):836-44. Ip EJ, Barnett MJ, Tenerowicz MJ, Kim JA, Wei H, Perry PJ. Women and anabolic steroids: An analysis of a Dozen users. Clinical Journal of Sport Medicine. 2010;20(6):475-81. Backhouse S, Whitaker L, Petroczi A. Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms. Scand J Med Sci Sports. 2013;23(2):244-52. Sas-Nowosielski K, Swiatkowska L. Goal orientations and attitudes toward doping. Int J Sports Med. 2008;29(7):607-12. Smith ACT, Stewart B, Oliver-Bennetts S, McDonald S, Ingerson L, Anderson A, et al. Contextual influences and athlete attitudes to drugs in sport. Sport management review. 2010;13(3):181-97. Yager Z, ODea JA. Relationships between body image, nutritional supplement use, and attitudes towards doping in sport among adolescent boys: implications for prevention programs. J Int Soc Sports Nutr. 2014;11(13):1-8. Hodge K, Hargreaves EA, Gerrard D, Lonsdale C. Psychological Mechanisms Underlying Doping Attitudes in Sport: Motivation and Moral Disengagement. Journal of Sport & Exercise Psychology. 2013;35(4):419-32. Dodge T, Stock M, Litt D. Judgments About Illegal Performance Enhancing Substances: Reasoned, Reactive or Both? Journal of Health Psychology. 2012;18(7):962-71. Graham MR, Ryan P, Baker JS, Davies B, Thomas N-E, Cooper S-M, et al. Counterfeiting in performance- and image-enhancing drugs. Drug Testing and Analysis. 2009;1(3):135-42. Whitaker L, Long J, Petr\u00f3czi A, Backhouse SH. Athletes perceptions of performance enhancing substance user and non-user prototypes. Performance Enhancement & Health. 2012;1(1):28-34. Kirby K, Moran A, Guerin S. A qualitative analysis of the experiences of elite athletes who have admitted to doping for performance enhancement. International Journal of Sport Policy and Politics. 2011;3(2):205-24. Stewart B, Outram S, Smith ACT. Doing supplements to improve performance in club cycling: a life-course analysis. Scandinavian Journal of Medicine & Science in Sports. 2013;23(6):e361-e72. Barkoukis V, Lazuras L, Lucidi F, Tsorbatzoudis H. Nutritional supplement and doping use in sport: Possible underlying social cognitive processes. Scandinavian journal of medicine & science in sports. 2015. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scandinavian Journal of Medicine & Science in Sports. 2014;24(5):846-56. Allen J, Taylor J, Dimeo P, Dixon S, Robinson L. Predicting elite Scottish athletes attitudes towards doping: examining the contribution of achievement goals and motivational climate. Journal of Sports Sciences. 2014:1-8. Barkoukis V, Lazuras L, Tsorbatzoudis H, Rodafinos A. Motivational and sportspersonship profiles of elite athletes in relation to doping behavior. Psychology of Sport and Exercise. 2011;12(3):205-12. Mazanov J, Huybers T, Connor J. Prioritising health in anti-doping: What Australians think. Journal of Science and Medicine in Sport. 2012;15(5):381-5. Macur J. Phelps Disciplined Over Marijuana Pipe Incident. New York Times. 2009 Feb 6, 2009. Seelye KQ. Barack Obama, asked about drug history, admits he inhaled. New York Times. 2006 Oct 24, 2006. Lentillon-Kaestner V, Hagger MS, Hardcastle S. Health and doping in elite-level cycling. Scandinavian Journal of Medicine & Science in Sports. 2012;22(5):596-606. Skinner J, Moston S, Engelberg T. The relationship between moral code, participation in sport, and attitudes towards performance enhancing drugs in young people. Montreal: World Anti-Doping Agency (WADA), 2012. Lentillon-Kaestner V. The development of doping use in high-level cycling: From team-organized doping to advances in the fight against doping. Scandinavian Journal of Medicine & Science in Sports. 2011;23(2):189-97. Engelberg T, Moston S, Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations. Sport Management Review. 2014. Outram SM, Stewart B. Condemning and condoning: Elite amateur cyclists perspectives on drug use and professional cycling. Int J Drug Policy. 2015. Lun V, Erdman KA, Fung TS, Reimer RA. Dietary supplementation practices in Canadian high-performance athletes. Int J Sport Nutr Exerc Metab. 2012;22(1):31-7. Hellemans I, MacDonald S, Skidmore P. Use of Dietary Supplements in Elite New Zealand Athletes. Dunedin: Department of Human Nutrition, University of Otago, 2009 2009. Report No. Geyer H, Parr MK, Koehler K, Mareck U, Schanzer W, Thevis M. Nutritional supplements cross-contaminated and faked with doping substances. J Mass Spectrom. 2008;43(7):892-902. Cohen PA, Travis JC, Venhuis BJ. A synthetic stimulant never tested in humans, 1,3-dimethylbutylamine (DMBA), is identified in multiple dietary supplements. Drug Testing and Analysis. 2015;7(1):83-7. Sekulic D, Bjelanovic L, Pehar M, Pelivan K, Zenic N. Substance use and misuse and potential doping behaviour in rugby union players. Research in Sports Medicine. 2014;22(3):226-39. Dodge T, Hoagland MF. The use of anabolic androgenic steroids and polypharmacy: A review of the literature. Drug and Alcohol Dependence. 2011;114(2-3):100-9.- -

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The use of drugs to enhance sports performance is a global phenomenon that continues to receive wide media attention. The number, variety and use of legal and illegal drugs has increased in recent years.1 Drug misuse in elite sport is monitored internationally by the World Anti-Doping Agency (WADA), while Drug-Free Sport New Zealand (DFSNZ) is responsible for national athlete testing and education.Recently, it has been proposed that young athletes transition incrementally from their use of permitted to illegal substances, with the suggestion of harm minimisation as an approach to counter this.1 Health professionals, particularly doctors, are traditionally recognised by athletes as a trusted resource for all matters of drug efficacy and safety, including the use of dietary supplements and performance-enhancing agents.2 However, many physicians lack fundamental knowledge to provide adequate advice to athletes.3 This article references the body of research on doping prevalence in sport, discussing its associated culture, common reasons, key personnel and prevention strategies to assist medical professionals in the New Zealand context.Review methodologyMEDLINE, PubMed, Scopus and SPORTDiscus online databases were searched for peer-reviewed research from 2009 to January, 2015, using combinations of the terms, doping , performance enhancing drug* , performance enhancing substance* , drugs , anti-doping , education , sport* , prevalence , prevention , athlete* , elite , sub-elite, recreational and adolescent. A second-stage snowball search scanned reference lists of published articles for relevant manuscripts and considered articles recommended by the online databases at the time the original manuscripts were downloaded. A total of 232 references were identified that related to the prevalence, prevention and culture of drug misuse in sport. Only six of these were specific to New Zealand.Results and discussionDefinitionsFor the purposes of this review, doping is defined as a breach of the WADA rules, including use or attempted use of a prohibited substance or method. These include anabolic agents, peptide hormones, stimulants, diuretics, beta-2 agonists and recognised performance-enhancing methods, such as blood and gene doping, urine tampering or intravenous infusions unless medically indicated. The use of illicit recreational drugs, including narcotics and cannabinoids, is also considered a breach of the WADC. Contemporary literature uses the interchangeable terms performance-enhancing drugs (PEDs), banned drugs and doping with resulting confusion.1,4 In this review, doping infers the collective of PEDs, performance-enhancing methods and illicit drugs.Breaches of the WADA rules are considered either intentional or inadvertent. The former implies cheating, whereas the latter may result from supplement contamination or ignorance.1 Acts of doping in sport focus primarily on an intent to enhance performance, while inadvertent doping, not generally considered as purposeful, is deemed a consequence of either unknown product contamination or recreational drug use. However, the WADC applies strict personal liability to drug misuse, making no such discrimination when considering violations. As a result, any athlete found positive may be sanctioned in accordance with options from a reprimand, to the rarely used lifetime ban from sport. For the purposes of this review, the authors use doping to refer to deliberate, banned drug-use and inadvertent doping for product contamination or ignorance of the rules.PrevalenceA true prevalence of doping in sport is difficult to determine given the limitations of data collection, the intrusiveness of the questions and the obvious sensitivity of the responses. International drug testing results, collated by WADA, demonstrate an approximate prevalence of 2% positive tests per year. However, the true prevalence is thought to be closer to 10%5 with a recent review of the literature yielding an estimation of 14-39%.4In 2013/14, DFSNZ carried out 925 drug tests on elite athletes, with 4 violations, a doping prevalence of 0.004%, which compares to 0.007% in 2012/13 and 0.005% in 2011/12.6 However, these tests do not include gym users or athletes not subjected to anti-doping regulations. Another paper reported 5 of 32 New Zealand body builders admitting the use of androgenic anabolic steroids (AAS) at some stage in their career.6 Australian-based studies of doping amongst elite athletes reported an 8% response, compared with 52% in male gym users,7,9 while 25% of a Canadian cohort of junior provincial athletes reported PED use in the previous year,9 and up to 12% of an American high school student cohort reported AAS use.10,11 From these estimates, 10% of athletes seen by a health professional are possibly using a PED, and 1 in 3 are at risk of inadvertent doping from supplement use.Drug-User ProfileCompetitive athletes who intentionally dope are categorised as \u2026villains, mavericks and professionals. 1 Villains cheat deliberately, while mavericks display an ignorant disregard for the rules. Professionals however purported to be the largest group progress from diet and lifestyle changes, to supplementation, and finally to banned substance use. It is argued that these athletes are not cheaters, but products of the intensely competitive, commercialised world of elite sport, whereby they are driven to train with greater intensity for longer periods.At a recreational level, so-called gym users plus power and strength sportspeople are more likely to use AAS or growth hormone derivatives.12,13 This systematic review of anabolic steroid use listed appearance, aggression or enhanced performance as the most relevant reasons for doping.13 These dopers were characterised as being male, under 30 years of age, mistrusting of medical professionals and with comorbidities including depression and a history of illicit drug use.12,13 Furthermore, female AAS-users have a much higher risk of dependency than male counterparts.14 Therefore, recreational sportspeople with the characteristics described should prompt medical professionals to be wary of their potential for drug misuse.Times when athletes are at an increased doping riskThe culture of doping is as varied as the sports, sub-cultures, ability, ages and personalities of the users.1,2,15-19 Notwithstanding, some individual characteristics and specific determinants have emerged that could assist doctors who regularly manage athletes. As a group, athletes have been identified as being more likely to use a PED if offered the chance.20,21 Qualitative research involving a cohort of 147 UK athletes identified reliability, rule abiding and role modelling as protective behaviours, while rule breaking, bad temperament and a win-at-all-costs attitude were risk factors for doping.22 An athletes doping risk was also reported to increase during critical events, such as selection/de-selection,23,24 during recovery from injury and when negotiating crucial sponsorship deals.17 These transitions were considered to be times of psychosocial challenge with an enhanced risk of doping. At such times, social support, individual coping mechanisms2,25 and the influence of medical advice was deemed critical.3Entourage influence and knowledgeA complex of individuals, identified as the athlete entourage, contributes to the environment of every elite athlete. Doctors, coaches, trainers, family, friends, teammates and physiotherapists are acknowledged sources of knowledge, leadership and support.2 Yet a study of the anti-doping knowledge of 292 Australian support personnel revealed that 40% had no specific training, despite providing advice to athletes.26 This study also revealed that 32% of these support personnel ignored the unethical behaviour of colleagues, despite a WADC obligation to report doping offences irrespective of confidentiality.3 The importance of the coach in the social network is also emphasised, and for 292 New Zealand athletes interviewed, coaching style was a determinant in an increased athlete doping risk.19 This influence was also reflected by studies of elite Scottish,27 German,16 and Greek28 athletes.Culture of sportWhile the culture of sport has been identified as shaping an athletes attitudes and intentions to dope, the public and the media consider doping as simply another form of cheating.13,29 Athletes caught cheating are commonly portrayed as bad, with the role of their entourage often ignored,28 despite compelling evidence that they are complicit.17 Athletes are frequently villainised when caught using drugs in a recreational setting. Multiple Olympic gold medallist Michael Phelps was publicly chastised for his one-time use of cannabis,30,33 yet Barack Obama as a Presidential candidate was praised for honesty in declaring his youthful, cannabis and cocaine use.31Elite athletes are more likely to dope if they believe that other athletes are doping.21,32,33 For example, eight elite and neo-elite cyclists, interviewed prior to turning professional, viewed doping as cheating, yet once they became professional they regarded doping as an inevitable progression in performance enhancement. They also claimed elite sport as being deleterious to health, rationalising that PEDs conferred a protective influence.32,34 Boundaries can be blurred between legitimate performance enhancement, including physiological testing, nutritional supplementation or biomechanical computer-modelling and frank doping to compensate for media pressures, sponsorship or public expectation.35,36 Times of increased vulnerability demand concerted education and awareness from all stakeholders, particularly doctors.Dietary supplementsDietary supplementation in sport is common, with the internet, team mates, coaches and athletic trainers providing the most common sources of information.37 An unpublished survey of elite New Zealand athletes reported a 93% usage of 3 supplements in the prior 6 months,38 findings comparable to data from a similar Canadian study.37 Inadvertent doping is a potential consequence of supplementation, with products frequently not subjected to strict manufacturing and quality control. Fifteen percent of internet-sourced supplements have been reported with steroid contamination39 as well as potent psychoactive substances, including DMBA (1,3-dimethylbutylamine) and its analogues.39 Dietary supplement users are also shown to be at greater risk of doping than non-users, reflected in studies of elite UK athletes,15 Australian and Greek high school students,19,25 amateur Australian cyclists,24,36 and Croatian rugby players.41 A more permissive attitude towards doping has mirrored increasing supplement use, with recovery from injury or training, improved performance, increased muscle size and body image as common reasons.15,35,37 Sources of supplements and reasons for their use are matters for doctors to explore with athletes in their care.Body image and moral disengagementTo look good, is an oft-cited reason for recreational athletes, especially serious gym users, to use AAS and supplements.42 Both AAS and supplement use are reportedly associated with an increased alcohol and illicit drug consumption,13,42 low self-esteem or a negative body image, and participation in sports where muscle bulk is important.10 Product source is important, with 50-75% of PEDs being reportedly purchased online.21 One study used laboratory testing of 57 AAS or growth hormone derivatives purchased online and reported 42% being either contaminated with bacteria, containing no active anabolic ingredient or raising other safety issues.21 The same study reported that testing 634 nutritional supplements found many to contain some trace of AAS. The potential co-morbidities and risks for PEDs or supplements purchased online is important information for all medical professionals, but particularly doctors, to be aware of.Athletes frequently rationalise doping on spurious grounds that ignore health and safety.23,32 A strategy known as moral disengagement negates the immoral actions of cheating through established mechanisms of \u2026displacement or diffusion of responsibility, advantageous comparison, distortion of consequences, moral justification and euphemistic labelling .13 These phenomena are documented in body builders,7,13,35 weightlifters,23 cyclists,34 and in 1,188 Australian adolescents were predictive of doping attitudes, regardless of social demographics or athletic status.33 In order to counter forms of moral disengagement, medical professionals must recognise the process and develop appropriate counter arguments.35ConclusionsDespite the importance of sport in our society, there is a dearth of New Zealand research relating to sports doping. International figures suggest that doping is more common than figures would suggestand that deterrence through punitive measures alone is ineffective.An understanding of drug misuse in sport deserves a wider, empathetic view that embodies the culture of sport and the influence of the athlete entourage of support personnel.The most common reasons given for PED use are to improve looks, increase performance, to cope with the demands of training, or to recover from injury. More recent research also suggests impressionable young athletes may see doping as a natural progression of performance enhancement and be willing to risk sanctions and personal health in the pursuit of success.Regardless, athletes taking supplements or PEDs bought online risk their health through possible contamination.Effective educational strategies encourage themes of health, morality and refusal skills, while acknowledging that there are periods of increased athlete vulnerability. Medical professionals in particular need to be increasingly wary of these times of increased risk.Doctors treating competitive or recreational athletes carry a burden of responsibility in their knowledge of dietary supplementation and prohibited substances that reflects patient health and the spirit of sport embodied in the World Anti-Doping Code.\r\n

Summary

Abstract

Aim

Drug misuse in elite sport is a world-wide phenomenon. This article explores the culture of contemporary sport, provides estimates of doping prevalence, discusses dietary supplementation and highlights major factors influencing high-performance athletes and their support personnel. The aim is to stimulate discussion, informed by the World Anti-Doping Code (WADC), which is particularly relevant to doctors caring for athletes.

Method

Online databases were searched for relevant peer-reviewed research from 2009 to 2015. Comparative New Zealand data have been included.

Results

Estimates of the prevalence of sports doping range from less than 1% to as high as 52%, dependent upon the demographics of the identified cohort. The culture of elite sport, personal stressors, competitive demands, financial reward and the influence of an entourage of support personnel were identified as critical determinants of drug misuse.

Conclusion

The culture of elite contemporary sport is seductive to many aspiring young athletes. To combat drug misuse, effective education should embody moral, ethical and clinical dangers, recognising the importance of support at times of increased athlete vulnerability. Inadvertent doping from product contamination is a recognised risk of unsupervised dietary supplementation. Doctors responsible for the care of high-performance athletes must be cognisant of these issues and the provisions of the WADC.

Author Information

Andrew N Curtis, University of Otago, Christchurch; David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Peter Burt, Dunedin School of Medicine, University of Otago, Dunedin; Hamish Osborne, Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

David Gerrard, Medicine, Dunedin School of Medicine, University of Otago, Dunedin

Correspondence Email

david.gerrard@otago.ac.nz

Competing Interests

Dr. Gerrard reports he is currently the Chair of the World Anti-Doping Agency (WADA) Therapeutic Use Exemption Committeeand a member of the WADA Health Medicine and Research Committee, both voluntary positions.

- - Petr\u00f3czi A. The doping mindset Part I: Implications of the Functional Use Theory on mental representations of doping. Performance Enhancement & Health. 2013;2(4):153-63. Chan D, Hardcastle S, Lentillon-Kaestner V, Donovan R, Dimmock J, Hagger M. Athletes Beliefs About and Attitudes Towards Taking Banned Performance-Enhancing Substances: A Qualitative Study. 2014. Backhouse S, McKenna J. Doping in sport: A review of medical practitioners knowledge, attitudes and beliefs. Int J Drug Policy. 2011;22(3):198-202. de Hon O, Kuipers H, van Bottenburg M. Prevalence of doping use in elite sports: a review of numbers and methods. Sports Medicine. 2014:1-13. Batt A. The role of UK Anti-Doping in the fight against doping in sport. International Journal of Sport Policy and Politics. 2011;3(2):261-70. DFSNZ. Annual Report 2013/2014. Auckland, New Zealand: Drug Free Sport New Zealand, 2014. Probert A, Leberman S. The Value of the Dark Side: An Insight into the Risks and Benefits of Engaging in Health-compromising Practices from the Perspective of Competitive Bodybuilders. European Sport Management Quarterly. 2009;9(4):353-73. Dunn M, Thomas JO, Swift W, Burns L. Elite athletes estimates of the prevalence of illicit drug use: Evidence for the false consensus effect. Drug and Alcohol Review. 2012;31(1):27-32. Goulet C, Valois P, Buist A, Cote M. Predictors of the Use of Performance-Enhancing Substances by Young Athletes. Clinical Journal of Sport Medicine. 2010;20(4):243-8. Dandoy C, Gereige RS. Performance-enhancing drugs. Pediatrics in Review. 2012;33(6):265-72. Thorlindsson T, Halldorsson V. Sport, and use of anabolic androgenic steroids among Icelandic high school students: a critical test of three perspectives. Subst Abuse Treat Prev Policy. 2010;5:32. Sagoe D, Andreassen CS, Pallesen S. The aetiology and trajectory of anabolic-androgenic steroid use initiation: A systematic review and synthesis of qualitative research. Substance Abuse: Treatment, Prevention, and Policy. 2014;9(1). Boardley ID, Grix J, Dewar AJ. Moral disengagement and associated processes in performance-enhancing drug use: a national qualitative investigation. Journal of Sports Sciences. 2014;32(9):836-44. Ip EJ, Barnett MJ, Tenerowicz MJ, Kim JA, Wei H, Perry PJ. Women and anabolic steroids: An analysis of a Dozen users. Clinical Journal of Sport Medicine. 2010;20(6):475-81. Backhouse S, Whitaker L, Petroczi A. Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms. Scand J Med Sci Sports. 2013;23(2):244-52. Sas-Nowosielski K, Swiatkowska L. Goal orientations and attitudes toward doping. Int J Sports Med. 2008;29(7):607-12. Smith ACT, Stewart B, Oliver-Bennetts S, McDonald S, Ingerson L, Anderson A, et al. Contextual influences and athlete attitudes to drugs in sport. Sport management review. 2010;13(3):181-97. Yager Z, ODea JA. Relationships between body image, nutritional supplement use, and attitudes towards doping in sport among adolescent boys: implications for prevention programs. J Int Soc Sports Nutr. 2014;11(13):1-8. Hodge K, Hargreaves EA, Gerrard D, Lonsdale C. Psychological Mechanisms Underlying Doping Attitudes in Sport: Motivation and Moral Disengagement. Journal of Sport & Exercise Psychology. 2013;35(4):419-32. Dodge T, Stock M, Litt D. Judgments About Illegal Performance Enhancing Substances: Reasoned, Reactive or Both? Journal of Health Psychology. 2012;18(7):962-71. Graham MR, Ryan P, Baker JS, Davies B, Thomas N-E, Cooper S-M, et al. Counterfeiting in performance- and image-enhancing drugs. Drug Testing and Analysis. 2009;1(3):135-42. Whitaker L, Long J, Petr\u00f3czi A, Backhouse SH. Athletes perceptions of performance enhancing substance user and non-user prototypes. Performance Enhancement & Health. 2012;1(1):28-34. Kirby K, Moran A, Guerin S. A qualitative analysis of the experiences of elite athletes who have admitted to doping for performance enhancement. International Journal of Sport Policy and Politics. 2011;3(2):205-24. Stewart B, Outram S, Smith ACT. Doing supplements to improve performance in club cycling: a life-course analysis. Scandinavian Journal of Medicine & Science in Sports. 2013;23(6):e361-e72. Barkoukis V, Lazuras L, Lucidi F, Tsorbatzoudis H. Nutritional supplement and doping use in sport: Possible underlying social cognitive processes. Scandinavian journal of medicine & science in sports. 2015. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scandinavian Journal of Medicine & Science in Sports. 2014;24(5):846-56. Allen J, Taylor J, Dimeo P, Dixon S, Robinson L. Predicting elite Scottish athletes attitudes towards doping: examining the contribution of achievement goals and motivational climate. Journal of Sports Sciences. 2014:1-8. Barkoukis V, Lazuras L, Tsorbatzoudis H, Rodafinos A. Motivational and sportspersonship profiles of elite athletes in relation to doping behavior. Psychology of Sport and Exercise. 2011;12(3):205-12. Mazanov J, Huybers T, Connor J. Prioritising health in anti-doping: What Australians think. Journal of Science and Medicine in Sport. 2012;15(5):381-5. Macur J. Phelps Disciplined Over Marijuana Pipe Incident. New York Times. 2009 Feb 6, 2009. Seelye KQ. Barack Obama, asked about drug history, admits he inhaled. New York Times. 2006 Oct 24, 2006. Lentillon-Kaestner V, Hagger MS, Hardcastle S. Health and doping in elite-level cycling. Scandinavian Journal of Medicine & Science in Sports. 2012;22(5):596-606. Skinner J, Moston S, Engelberg T. The relationship between moral code, participation in sport, and attitudes towards performance enhancing drugs in young people. Montreal: World Anti-Doping Agency (WADA), 2012. Lentillon-Kaestner V. The development of doping use in high-level cycling: From team-organized doping to advances in the fight against doping. Scandinavian Journal of Medicine & Science in Sports. 2011;23(2):189-97. Engelberg T, Moston S, Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations. Sport Management Review. 2014. Outram SM, Stewart B. Condemning and condoning: Elite amateur cyclists perspectives on drug use and professional cycling. Int J Drug Policy. 2015. Lun V, Erdman KA, Fung TS, Reimer RA. Dietary supplementation practices in Canadian high-performance athletes. Int J Sport Nutr Exerc Metab. 2012;22(1):31-7. Hellemans I, MacDonald S, Skidmore P. Use of Dietary Supplements in Elite New Zealand Athletes. Dunedin: Department of Human Nutrition, University of Otago, 2009 2009. Report No. Geyer H, Parr MK, Koehler K, Mareck U, Schanzer W, Thevis M. Nutritional supplements cross-contaminated and faked with doping substances. J Mass Spectrom. 2008;43(7):892-902. Cohen PA, Travis JC, Venhuis BJ. A synthetic stimulant never tested in humans, 1,3-dimethylbutylamine (DMBA), is identified in multiple dietary supplements. Drug Testing and Analysis. 2015;7(1):83-7. Sekulic D, Bjelanovic L, Pehar M, Pelivan K, Zenic N. Substance use and misuse and potential doping behaviour in rugby union players. Research in Sports Medicine. 2014;22(3):226-39. Dodge T, Hoagland MF. The use of anabolic androgenic steroids and polypharmacy: A review of the literature. Drug and Alcohol Dependence. 2011;114(2-3):100-9.- -

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