Performance-Enhancing Drugs and Supplements

You are dispatched to an apartment for a patient with abdominal pain. Upon arrival, you find a muscular 24-year-old male with severe facial acne complaining of severe flank pain. When you inquire about some abrasions and contusions, he tells you they are from a fight several days ago. His girlfriend confides that he has had an uncharacteristically volatile temper lately. He denies taking any prescription medications, but his girlfriend says he takes some “exercise stuff.” You transport the patient to the hospital without incident and learn later from the hospital staff that your patient was diagnosed with kidney stones.

Based on the five clues in this scenario, did you suspect that the patient might be abusing some type of performance-enhancing drug? Many EMS providers would likely miss the clues of anabolic steroid abuse. The use of steroids and other performance-enhancing drugs or supplements is not restricted to professional athletes, but is now commonplace among amateur body-builders, student athletes and health club members. Most EMS providers have either used some type of supplement, or know someone who has. Do you know which supplements are dangerous? Would you recognize a friend, coworker or patient whose health was at risk because of these supplements? This article introduces readers to the most frequently used performance-enhancing drugs and supplements and what the research says about their safety and effectiveness.

Drugs vs. Dietary Supplements

There are many different types of dietary supplements that are claimed to provide improved athletic performance, increased muscle mass and faster recovery time between workouts. By definition, a supplement is taken orally and contains at least one dietary ingredient, such as vitamins, minerals, herbs, botanicals or amino acids.1 The FDA regulates dietary supplements as foods, not drugs. Unlike prescription and over-the-counter drugs, dietary supplements are not required to meet FDA standards for efficacy, potency or safety before going to market.2

Prevalence

Exercise supplement use by pro athletes may be as high as 74% in some sports.3 Approximately 390,000 10–14-year-olds say they have taken some type of performance-enhancing substance4 and more than 500,000 8–10th graders have used anabolic steroids.5 Almost half of those who belong to a gym have used creatine, and one in four male gym-users has used ephedrine.6

A communication gap exists between authority figures and those likely to use a performance-enhancing drug or supplement. Part of that gap is due to a lack of knowledge by authority figures, such as coaches, parents and healthcare providers. That gap is widened when those authority figures are unable, or unwilling, to provide honest answers about supplement use. One study revealed that 70% of young people and 50% of parents could not identify any negative side effects from using performance-enhancing substances.7 Alarmingly, almost 40% of 10th graders believe that there are no serious dangers associated with anabolic steroid use.8

Anabolic Steroids and Other

Hormones

Anabolic steroids, also known as “roids” or “juice,” are a synthetic version of testosterone that can be taken orally or injected to help increase muscle mass quickly. The fact that anabolic steroids will increase muscle mass is not in question; the problem is the considerable risks associated with their use.

“There is no question [one] can put on enormous amounts of muscle mass if he takes enough steroids,” says Harrison Pope, MD, of Harvard Medical School.9 Anabolic steroid use is associated with numerous and deadly complications, such as myocardial infarction, liver cancer and HIV.10 About 10% of steroid users will experience severe mood swings or violent tendencies, referred to as “roid rage.”11 Depression is also a common side effect of steroid use, especially when users stop taking them. Anabolic steroids are not to be confused with corticosteroids, another family of steroids that have no body-building effects.

Anabolic steroids were developed in the 1930s to combat the loss of muscle mass due to disease. The controversy surrounding anabolic steroids began in the 1950s, when athletes from Eastern Bloc countries, which dominated the Olympic Games, were caught using them.12 Many of the male steroid users who competed during those games developed such large prostate glands they could only urinate with a Foley catheter. Some female athletes developed so many male characteristics that chromosome tests were needed to confirm their gender.

Anabolic steroids are only legal in the U.S. with a prescription and are used to treat conditions such as delayed puberty and impotence. According to the National Institute on Drug Abuse, it is not uncommon for steroid abusers to take 100 times what would be prescribed by a physician.13 The illegal sale of anabolic steroids, largely over the Internet, is a multimillion-dollar-per-year black market industry. Not surprisingly, the potency, strength and purity of these steroids are extremely unreliable.

“Steroid-stacking” refers to the practice of taking multiple steroids, usually in 6–12- week cycles, for their combined effects. Lower doses are taken early in the cycle and gradually increased. During the back half of the cycle, the dose is gradually reduced. Users argue that this is a safer approach with fewer side effects, since they are taking lower quantities of any one drug. A “pyramid regimen” occurs when users take an increased dose for part of the stacking period, then stop for a period. Since steroids allow for an unusually rapid increase in muscle mass, the risk of stress injuries to muscles and tendons is high. As a result, users will sometimes add pain killers to the regimen so they can continue to work out while injured.

No hormones, including anabolic steroids, should ever be taken unless directed by a physician. There are significant risks associated with inappropriate use of anabolic steroids and other hormones. Although hormones do have legitimate medical uses, a reputable physician would never prescribe them to a young, healthy person who wanted them simply to increase muscle mass.

Human Growth Hormone (HGH)

HGH is a pituitary hormone that tricks the body into an artificial or prolonged state of puberty, leading to increased testosterone production. HGH increases muscle mass, accelerates loss of body fat and stimulates bone growth. Using HGH without a prescription is illegal and dangerous. Adverse effects of HGH include liver and joint problems, heart failure, hypertension, pituitary disorders and abnormal growth of the hands and feet.14

Adreno-Corticotrophic Hormone (ACTH)

ACTH, a pituitary hormone, accelerates the body’s ability to repair tissue. Since recovery time is reduced, it is used to allow more training in less time. Altering the body’s ACTH levels can lead to complications including loss of bone mass, hypertension, GI problems and insomnia.15

Erythropoietin (EPO)

Erythropoietin is produced by the kidneys. Also known as EPO, it is taken to boost the production of red blood cells.16 EPO can increase the body’s oxygen-carrying potential, which may offer a competitive advantage, and increases the hematocrit, which increases the risk of seizures, stroke and death.17

Insulin

Amazingly, insulin is being abused by some who believe it will provide a competitive advantage by speeding glucose delivery throughout the body. This procedure is extremely dangerous and can lead to insulin shock, seizures, permanent brain injury, coma and death. There is absolutely no evidence that insulin will help increase muscle mass or provide a competitive advantage.

Dietary Supplements

Androstenedione (Andro)

Andro is the dietary supplement made famous by baseball player Mark McGwire, who took it before it was banned. It is a steroid precursor used to make testosterone18 and presents the same health risks as anabolic steroids. According to FDA Commissioner Mark McClellan, “Anyone who takes these products in sufficient quantities is putting (himself) at risk for serious long-term and potentially irreversible health consequences.” The FDA has recently ordered manufacturers to stop selling andro until they can prove it is safe. A University of California Los Angeles (UCLA) study found that most brands of andro failed to meet the claims on their own labels for dose and ingredients.19 Several brands contained ingredients not listed on the label, including testosterone.20

Dehydro-epiandrosterone (DHEA)

DHEA, sometimes referred to as a prohormone, is another steroid precursor. The body converts DHEA several times, eventually leading to usable hormones, including testosterone. DHEA is responsible for about 50% of testosterone production in men.21 Some claim that DHEA’s androgenic properties will increase muscle mass similar to anabolic steroids. The FDA banned the sale of DHEA as a drug in 1996; however, it is still available as a dietary supplement.22 There is little research on the anabolic effects or side effects of DHEA. Some publications state side effects of DHEA may include liver problems, increased cancer risk and steroid- related complications.23

Creatine

Phosphocreatine, better known as creatine, is a naturally occurring compound that functions as a building block of protein.24 It is used to build muscle faster and cut down on recovery time. Research indicates that creatine appears to be an effective and relatively safe supplement to help increase lean body mass.25 Although creatine does not pose serious health risks like hormones and steroid precursors, there is anecdotal information that it may cause kidney problems.26 Small doses are reported to cause dry mouth, thirst and cramps.

Ninety-five percent of the body’s creatine resides in the skeletal muscle and serves as an energy buffer.27 Creatine is necessary for the regeneration of adenosine triphosphate (ATP).28 Without creatine, the body could not produce enough energy at sufficient rates during short, intensive exercise. Creatine may also increase glycogen stores in muscle tissue, making energy more readily available.29 Since creatine stores are depleted rapidly, there does not appear to be any benefit from creatine supplementation for high-intensity activities lasting longer than about 90 seconds.30

Those with low inherent creatine levels are the most likely to see results from taking a creatine supplement.31 A typical creatine loading phase is 20 grams per day for 5–10 days, followed by a maintenance phase of 2–5 grams per day.32 For most people, this will increase muscle creatine levels by about 25%. Once the muscles are fully saturated, taking more creatine is of no additional benefit. Early research indicates creatine may have therapeutic applications in patients with Lou Gehrig’s disease (ALS), muscular dystrophy and Parkinson’s disease.33

Herbal Supplements

Herbal supplements have become a popular alternative to anabolic steroids, because many of them can be purchased legally without a prescription. Some herbal supplements have anabolic properties, but the human body cannot convert plant sources into anabolic steroids. Ron Maughan, PhD, professor of physiology at the University Medical School in Aberdeen, Scotland, summarized herbal supplements by saying, “Any product that had a significant anabolic effect would be subject to controls. The fact that anabolic herbal supplements are not controlled is a clear indication of their lack of effect.”

Ephedra

Ephedra is similar to amphetamine, causing the user to feel energized. Ephedra causes sympathetic nervous system stimulation, elevated blood pressure and increased heart rate. Until recently, ephedra was a very popular and legal supplement used as a stimulant and appetite suppressant. Also known as ma huang, ephedra has clearly been the most controversial of all herbal supplements. For years before ephedra was banned in the U.S., there were concerns about the dangers it posed. After eight years, the FDA banned all supplements containing ephedra in April 2004, marking the U.S. government’s first ban on any dietary supplement.34

With a drug, the manufacturer must prove it is safe. With a dietary supplement, the burden of proof rests more on the FDA. To ban a dietary supplement, the FDA must demonstrate a significant or unreasonable risk to the consumer. This constraint can make it challenging for the FDA to protect the public in a timely manner. Adding to the difficulty, if manufacturers of supplements become aware of side effects, they are not required to report them to the FDA.

While it was still legal in the U.S., ephedra products made up less than 1% of all herbal supplements sold in the U.S., but were responsible for over 60% of all adverse reactions.35 Studies have linked ephedra to more than 150 deaths due to heart attacks and hemorrhagic strokes,36 including the death of Baltimore Orioles pitcher Steve Bechler.37 The University of California, San Francisco, found that people who take ephedra are 200 times more likely to experience complications than users of other herbal supplements.38 In addition to heart attack and stroke, other side effects include insomnia, tremors, palpitations, seizures and heat stroke.39 The ban on ephedra does not apply to chemically synthesized ephedrine, which is still allowed as an ingredient in over-the-counter medications like pseudoephedrine.40

Bitter Orange

Bitter orange, or synephrine, is becoming a popular legal substitute for ephedra. Bitter orange comes from the fruit of the Citrus aurantium plant and is chemically similar to ephedrine. There is very little research on the effectiveness or safety of bitter orange, but its stimulant properties make it likely that its side effects will be similar to those of ephedra.

Wild Yams

Some claim that wild yams (Dioscorea villosa) can enhance performance due to its anabolic properties. Wild yams contain a substance called diosgenin, which can be converted to DHEA in a laboratory setting. The human body is not capable of converting diosgenin to DHEA.41 Simply put, any product that claims it can increase testosterone levels or muscle mass because it contains diosgenin is a scam. Yams offer no performance-enhancing benefits, but there appears to be little risk of side effects.

Gamma-Oryzanol

Gamma-oryzanol, also known as rice bran oil, is derived from sterol and ferulic acid. It has been marketed as a way to raise serum levels of testosterone, but has no proven anabolic effect.42 Gamma-oryzanol is not well absorbed by the body, with less than 10% absorbed from the GI tract.43 Largely due to its poor absorption, there appears to be little risk of adverse reaction from gamma-oryzanol.

Tribulus Terrestris

Some claim that tribulus terrestris (puncture vine) can increase testosterone levels by stimulating the pituitary gland.44 Research shows that tribulus has no effect on muscle mass or strength, but it has not been shown to have any significant side effects.45

Smilax

Smilax comes from desert plants containing sarsaparilla and contains the building blocks for artificial production of anabolic steroids.46 Some claim smilax increases serum testosterone levels because it contains saponins. Saponins are building blocks for the laboratory production of steroids; however, the body is unable to convert smilax into testosterone or any other steroid.47 There is no proof that smilax has any anabolic effect.48 Smilax does have diuretic properties that can increase the risk of dehydration and syncope.

Yohimbine

Yohimbine is extracted from either yohimbe bark or the South American herb quebracho. Some claim it increases blood flow through the testes, leading to higher testosterone levels. There is no proof that yohimbine has any anabolic effects, but it can be extremely dangerous. Combining yohimbine and tyramine (found in many foods and wines) can cause an acute spike in blood pressure.49 The body is normally able to deactivate tyramine, but yohimbine interferes with the process. In addition to hypertension, side effects of yohimbine include seizures, paralysis and death.50

Miscellaneous Substances

Gamma-Hydroxybutyrate (GHB)

The club drug GHB is a CNS depressant made by combining degreaser or floor solvent with drain cleaner. For some reason, a number of uninformed bodybuilders became convinced that they could build muscle mass while they slept by taking GHB. Some extremely uninformed bodybuilders took GHB around the clock, risking an overdose. A GHB overdose, as well as unsupervised withdrawal, can be fatal. Not surprisingly, there is absolutely no research to support the idea that GHB enhances muscle mass in anyone, awake or not.51

Diuretics

Diuretics are sometimes used to hide traces of illegal or banned substances. Competitive bodybuilders sometimes take diuretics before competition to shed excess weight and increase muscle definition. Taking diuretics, especially during increased physical activity, can lead to dehydration, syncope and heat-related emergencies.

Picking a Supplement

The use of most performance-enhancing drugs and supplements appears to be at best a waste of money, and at worst fatal. For those considering a supplement, here are some tips for selecting wisely:52

• Make sure the product carries a USP (U.S. Pharmacopeia) label. This means it has passed tests for purity and potency.
• Select a reputable manufacturer that provides easy access for consumers who have questions or complaints. Reputable manufacturers will be able to provide research that supports claims about their products.
• Avoid products that make vague, unclear or ridiculous claims.
• Always check with your doctor before taking a supplement.
• If it sounds too good to be true, it probably is.

The research, quality control and regulatory oversight of supplements are not able to keep up with consumer demand for “miracle products.” The facts suggest that most of the currently available performance-enhancing drugs and supplements do not deliver on the majority of their promises, or are not worth the risks. Some are ineffective and dangerous only to your pocketbook. Some, such as anabolic steroids, will work, but pose outrageous risks. Creatine is one of the few supplements that appears to have considerable research to support the claims made of it. Thorough research, consultation with a physician and a healthy skepticism continue to be the best approach toward any drug or supplement. EMS professionals familiar with the facts are better equipped to discourage use of dangerous supplements and recognize patients who are potentially at risk. For additional information on exercise supplements, visit the following websites:

• www.steroidabuse.org
• www.health.org
• www.gssiweb.com
• www.nida.nih.gov/
• www.fda.gov/cder/index.html
• www.supplementwatch.com.

References

1. National Institutes of Health. Dietary Supplements: Background Information. https://ods.od.nih.gov/factsheet/dietarysupplements.asp.
2. Coleman E, Nelson-Steen S, Maughan R, Skinner R. Gatorade Sports Science Institute Sports Science Exchange Roundtable 50. www.gssiweb.com/reflib/refs/601/SSERT_50.cfm.
3. Rawson E, Clarkson P. Scientifically debatable: Is creatine worth its weight? Sports Science Exchange 91(16): 4, 2003.
4. Shaffer I. The Science and Policy of Performance-Enhancing Products. Blue Cross and Blue Shield Association Conference, 2002. https://ods.od.nih.gov/news/conferences/ShaferScience_and_Policy.pdf.
5. Zickler P. NIDA initiatives targets increasing teen use of anabolic steroids. NIDA Notes 15:3, August 2000.
6. Brink W. The science and policy of performance enhancing supplements. LifeExtension, March 2002.
7. Op. cit., Shaffer.
8. National Institute on Drug Abuse. Research Report Series: Anabolic Steroid Abuse. www.drugabuse.gov/ResearchReports/Steroids/anabolicsteroids3.html.
9. Kowalski K. The truth behind the hype. Current Health 2(29): 6, Feb. 2003.
10. Op. cit., National Institute on Drug Abuse.
11. Kowalski K. Steer clear of steroid abuse. Current Health 2(25): 7, March 1999.
12. Mishra R. Steroids and sports are a losing proposition. FDA Consumer 25(7): 24, Sept. 1991.
13. National Institute on Drug Abuse. Quiz: Anabolic Steroids. https://teens.drugabuse.gov/parents/documents/steroids_quiz.pdf.
14. Op. cit., Kowalski, The truth behind the hype.
15. Ibid.
16. Ibid.
17. Ibid.
18. Wagner C, Morgan M. FDA warns against using andro. Chicago Tribune, March 12, 2004.
19. Op. cit., Brink.
20. Ibid.
21. Kohrt WM. Potential Beneficial Effects of DHEA in Humans. https://ods.od.nih.gov/news/conferences/KohrtPEP_conf_2002.pdf.
22. Supplement Watch. DHEA. www.supplementwatch.com/supatoz/supplement.asp?supplementId=102.
23. Ibid.
24. Volek J. Creatine Supplementation in the 21st Century. https://ods.od.nih.gov/news/conferences/Creatine_Volek.pdf.
25. Op. cit., Brink.
26. Op. cit., Volek.
27. Op. cit., Rawson.
28. Ibid.
29. Op. cit., Brink.
30. Op. cit., Rawson.
31. Ibid.
32. Archer MC. Use of oral creatine to enhance athletic performance and its potential side effects. Clin J Sports Med 9(2), April 1999.
33. Op. cit., Brink.
34. Rados C. Ephedra ban: No shortage of reasons. FDA Consumber Magazine, March–April 2004.
35. Associated Press. Company files suit challenging ephedra ban. https://msnbc.msn.com/id/4900028.
36. Ibid.
37. Ibid.
38. Ibid.
39. U.S. Food and Drug Administration. FDA Fact Sheet: HHS Acts to Reduce Safety Concerns Associated with Dietary Supplements Containing Ephedra. www.fda.gov/bbs/topics/NEWS/ephedra/factsheet.html.
40. Op. cit., Rados.
41. Op. cit., Coleman.
42. Fry AC, Bonner E, Lewis DL, et al. The effects of gamma-oryzanol supplementation during resistance exercise training. Int’l. J Sports Nutr. 7(4): 318, Dec. 1997.
43. Supplement Watch. Gamma-Oryzanol. www.supplementwatch.com/supatoz/supplement.asp?supplementId=133.
44. Op. cit., Coleman.
45. Brown GA, Vukovich MD, Reifenrath TA, et al. Effects of anabolic precursors on serum testosterone concentrations and adaptations to resistance training in young men. Int’l. J Sports Nutr. and Exercise Metabolism. 10(3):340, Sept. 2000.
46. Op. cit., Coleman.
47. Ibid.
48. Ibid.
49. Ibid.
50. Ibid.
51. Op. cit., Kowalski, The truth behind the hype.
52. U.S. Food and Drug Administration. Tips for the Savvy Supplement User: Making Informed Decisions and Evaluating Information. www.cfsan.fda.gov/~dms/ds-savvy.html.