Seven uncertainties in sports doping

By Kate Harvey, Senior Research Officer, and Ranveig Svenning Berg, Communications Officer

Today, the 2016 Olympic and Paralympic Games will spring to life with an opening ceremony that promises samba, supermodels, and even the odd sportsperson.

But in the build-up to the Games, the topic which has dominated the sporting press has focused not on the records that might be broken, or the personal bests that might be achieved, but rather on the use of performance-enhancing drugs.

One high-profile recent debate has been prompted by a World Anti-Doping Agency’s (WADA) report which concluded that Russia’s Ministry of Sport “directed, controlled, oversaw the manipulation of athlete’s [sic] analytical results or sample swapping”; and the subsequent decision of the Court of Arbitration for Sport to uphold a decision to ban all Russian track and field athletes from the Rio Olympics.

Just before this decision was delivered, the British Library (BL) and the British Physiological Society (BPS) played host to two separate, but well-timed, events around doping in sports. At the BL, the question was whether doping in sport was “fair game”; whereas the BPS event considered the emergence of a “new generation for anti-doping tests”. But what both of these events provided was an unshakeable awareness of the many ‘unknowns’ which surround doping in sport.

So, in what may be the first Buzzfeed-type blog for Nuff’ said, we give you a list of seven uncertainties that jumped out to us at these two events.

1. The extent of doping in sport

Perhaps unsurprisingly, there is no reliable data on the extent of doping in sport, a problem acknowledged by Nicole Sapstead of UK Anti-Doping (UKAD) at the BL event. Although WADA identifies around 1-2% of samples each year which have either adverse analytical findings (AAFs) or atypical findings (ATF) of prohibited substances or its metabolites or markers, some studies suggest that the rate could be much higher (see, for example, a 2014 Dutch study which suggests between 14% and 39% of elite athletes intentionally dope).

The potential discrepancies between those who dope, and those who actually get caught doping, has been summarised by WADA’s Director General David Howman:

“There continues to be the “dopey” doper who is regularly caught through standard testing protocols, with a large number still risking in-competition testing. This doper effectively catches himself. On the other hand, there is the “sophisticated” doper who continues to get away with cheating.”

Some also argue that for all the insecurities in knowledge of the extent of doping in professional athletics, doping might be an even bigger issue in recreational sports – and one that we know little about. At the RPS, for example, a story was told about a Korean student admitting he had doped in the hope that it would help him to get a scholarship to study in the US.

But why does it matter that there is uncertainty around the extent of doping? One view is offered by Roger Pielke Jr. in a column published in Nature last year.

“Drug testing in sport, as currently implemented, might catch the occasional cheat and could deter others, but these results do little to help design an anti-doping strategy, and to independently assess whether it works. For that, we need to know whether the number of athletes doping is going up or down. And to do that, we need a reliable measure of what proportion of athletes dope. The problem – and the best way to manage it – is very different if 1% of athletes dope than if 50% of them do.”

If the general view is that anti-doping strategies should be enforced – a view questioned by Professor Andy Miah at the BL event – it might be argued that more effective and wider data collection is a necessary first step (especially considering the estimated US$350 million spent each year by sporting bodies on drug testing around the world). This might be a question of testing more systematically, more randomly (see Pielke article), or of undertaking further research into detection strategies.

2. What doping ‘does’ for performance: the research gap

The WADA list of prohibited substances is long, and subject to continuous updates as new performance-enhancing substances emerge. There’s even an app, developed by WADA, to keep users up to date on its list of prohibited substances. But why are some substances banned, and others not?

Uncertainty about the real effect of many drugs was a key theme at both events with speakers pointing to the history of drugs and technologies such as EPO being banned, then removed from the list, then banned again, perhaps suggesting that decisions about what to ban may depend more on trends in use than about evidence on harms or efficacy.

Recently, Maria Sharapova was suspended from tennis for two years on detection of the drug Meldonium. She had taken this drug legally, purportedly for health reasons, for ten years before it was banned in January this year – seemingly because of an increase in athletes using it with the intention of enhancing their performance. Owen Gibson, chair of the BL event, has written on this case, and at the event itself noted: “My job this year seems to be as much about corruption and cheating as it is about the actual sport on the pitch.” Similar cases appear on a weekly basis, as evidenced by UKAD’s news webpages, leaving one with the impression that being a ‘clean’ athlete may be less about staying clear of a particular substance than it is about keeping tabs on which are allowed at any given time.

But how much do we know about what various banned substances actually ‘do’ for athletes’ performance?

This is where a wall higher than the pole-vault world record seems to have been erected, with the words “research trials” emblazoned on it as, without research, the true effect of performance-enhancing substances remains uncertain. As one speaker pointed out at the BL, randomised controlled trials, often considered the gold standard for assessing the effectiveness of medical treatment, are simply not feasible within doping contexts.

At the BPS event, it was also suggested that there is reticence among ethics committees and research funders to support research involving human participants due to concerns about the ethical acceptability of such research. The corollary of this approach is that substance bans are implemented without certainty of the tangible effects of a substance on performance. There are, of course, anecdotal reports of substances’ effects on performance, but a question may arise as to whether this is ‘enough’ on which to base a ban.

However, research in ‘standard’ medical settings does not just focus on the effectiveness of a particular treatment, but also on its safety, which brings us to the question of harms.

3. The harms / risks of taking performance-enhancing drugs

Lack of evidence around the harms or risks of taking WADA banned substances may impact on the safety of a significant number of professional athletes, especially if higher estimates of the extent of doping (see point 1 above) are to be given credence.

A literature review around performance-enhancing substances in sports notes, for example, that the side effects of EPO “should not be underestimated” and that “adverse effects include hypertension, headaches, and an increased risk for thromboembolic event… Furthermore, with large doses, EPO may cause death”. It goes on to observe that “during the first year EPO was released, five Dutch cyclists died of unexplained causes.” Such observations highlight that, unlike packets of cold and flu remedies in bathroom cabinets which provide detailed breakdowns of various risks, no such information is available to dopers: instead, they rely on luck, and the anecdotal experiences of others.

With this in mind, it was suggested at the BL event that the possible long-term harms of using performance-enhancing drugs is a significant argument for banning them. However, at the same event this suggestion was countered by an argument which held that the safety of athletes can be improved significantly through the open monitoring of performance-enhancing drugs – i.e. envisaging a situation where performance-enhancing substances are no longer banned.

4. How doping substances are administered, and by whom

Recent high-profile cases such as the Russian doping programme and earlier revelations including “the most sophisticated, professionalized and successful doping program that sport has ever seen” by the US Postal Service Pro Cycling team have exposed tactics and approaches to doping on a large scale. But what do we know about how performance-enhancing drugs are administered more widely?

Clearly, those who are involved in administering banned substances to athletes will be far from open about their methods. Thus, as highlighted by UKAD at the BL event, there is a reliance on intelligence-led enforcement, and an active policy of ‘going after the coach’ where there is a suspicion that he / she is providing access to banned substances to a number of athletes. Indeed, given what kind of medical equipment and infrastructure is sometimes required to administer – and cover up the use of – substances, it is hard to imagine many athletes being able to manage doping on their own. However, aside from deduction and statements from athletes who have themselves been ‘caught’, the evidence is, again, seemingly limited.

5. What the general public think about the ethics of sports doping

Some evidence has been gathered on public views of the use of performance-enhancing drugs in professional sports contexts. For example, a US study involving 2,000 people found that just over half agreed with the statement that “knowing that athletes have been caught using performance-enhancing drugs in the past makes the Olympics less enjoyable”; 88% of participants in this study also felt that “more action needs to be taken to prevent the use of performance-enhancing drugs at the Olympics and in all professional sports.” Furthermore, in a recent BBC world service poll, 57% of the 19,000 people surveyed across 19 countries said doping has had “a lot” or “some” negative effect on the level of attention they will pay the Olympic Games, though opinions varied between countries.

However, a brief literature search turned up very little research which explores why people may hold these views: that is, examining the public’s ethical ‘thinking’ around performance-enhancing drugs. An opportunity to address ethical questions may arise soon as UKAD hold talks with the Government to criminalise doping. Given the international nature of sport there might also be a case for a comparative review of public opinions on sports doping across the globe.

6. Why some countries, and some sports, appear to have higher rates of doping than others

WADA has produced some interesting data on sports which have higher rates of doping than others. Its 2014 statistics indicate, for example, that in summer Olympic sports, 1.9% of all samples from weightlifters had AAFs, compared with 0.2% for volleyball (summarised further by this BBC article). However, as this Nature article points out:

“Current doping tests are anything but random, at least in a statistical sense. Some athletes are tested several times, others not at all. In 2013, USADA says that it conducted 9,197 tests on 4,640 athletes. Decisions on which athletes were subjected to these tests were determined ‘strategically’… The same is true for existing global statistics. WADA says that it tested 176,502 samples (not individual athletes) in 2013, and that 1% gave ‘adverse analytical findings’.”

Similarly, at the BL event, Owen Gibson observed that there is less appetite for finding out about doping in some sports, notably professional football. Moreover, it was also noted that in some competitions, such as weightlifting, the use of substances would sometimes be explicitly acknowledged with no apparent impact on audience support.

But it is not just individual sports which dope more than others: different countries may appear to do so too. An article by the Independent which summarises WADA’s most recent data on the number of positive drug tests recorded in its accredited laboratories identified a list of countries who had the highest number of positive tests for banned substances across all sports. The dubious honour of the ‘top five’ spots in this list are, from highest to lowest, Russia, Turkey, France, India, and Belgium (the UK is in 24^th place) – though see point above about random vs targeted testing.

Again, the BL and BPS events highlighted that little is known about why some countries dope – or are caught doping – more than others. This is another key question that arguably needs to be addressed in order to satisfy the broad aim of making sport ‘clean’.

7. What lies ahead for doping?

Perhaps the biggest unknown of our list of seven is how dopers, doping ‘enablers’, researchers, enforcers, and audiences will operate in the future.

For the dopers, how will they ‘get ahead’ of the testing systems to avoid detection? Recent stories around retrospective sampling of athletes’ samples highlights that, even if an athlete is cleared once, further tests may be developed to ‘catch them’ at a later point. This was highlighted by Professor Yannis Pitsiladis at the BPS event, who observed: “if you are involved in doping, you can’t sleep at night. It’s just a matter of time.”

For the enablers and dopers, how will they identify which substances enhance performance, and are not yet banned? Part of the battle in the game of cat and mouse with the enforcers may be, as pointed out at the BPS event, that the next generation of performance enhancing drugs will be those which improve performance, but leave the athlete’s systems much more quickly than current formulations, thus making detection much harder: even at present, the detection window for EPO after it’s been administered is just 36-48 hours.

For the enforcers, the prospect of emerging ‘omics’ – genomics, transcriptomics, and metabolomics – may provide more tools for the detection of banned substances, as highlighted at the BPS event. However, while the science improves, more low-tech issues may remain tough nuts to crack, such as athletes not making themselves available for testing (as reported recently in the case of British cyclist Lizzie Armitstead).

And for audiences? Each day for the next few weeks, we will no doubt witness some astonishing and outstanding performances from Olympic and Paralympic competitors. Will we think some of these are just too good to be true? Let’s watch and see…

Ethics around sporting performance and doping has previously been addressed at the Council’s Forward Look event in 2014, and remains on the Council’s longlist of future work topics. Download a summary of the 2014 discussion / read the background paper Sports science and medicine: ethics.