when legal is not allowed

Monday, June 10, 2013

The story says that Major League Baseball has reached an agreement with the owners of Biogenesis, a now defunct clinic in Florida, who allegedly supplied performance enhancing drugs to numerous players, including stars like Alex Rodriguez and Ryan Braun. Guilt by association has now been established, regardless how the story ends. However, while baseball may not like human growth hormone (marketed by Pfizer as Genotropin), HGH is a legal medication, available to appropriate patients by prescription. The issue for sport and society is how to explain to young athletes and their families, the risk and rewards of using a medication that has very real adverse side effects.

The story needs to start with a doctor having the power to write a prescription for a medication. While the pharmaceutical company lists the indications for which that drug is approved, once it is on the market, a doctor can prescribe it for any patient they see fit, but it is patient (and physician) beware, since studies may not have been done to establish “off label” benefit or risk. There are success stories and off-label can enter the norm. For example, erythromycin, an antibiotic, may work to help diabetic patients whose stomachs don’t empty well and metoclopramide (Reglan) used for nausea and vomiting, when injected intravenously, is now used routinely to treat migraine headaches. There is power in the doctor’s pen or computer keyboard to sign prescriptions, matching diagnosis and treatment, regardless of the science that may or may not exist.

Back to HGH. Human growth hormone is normally produced in the pituitary gland located in the brain. It circulates in the blood stream and stimulates liver cells to produce Insulin Growth Factor 1 (IGF-1), the active ingredient that stimulates growth. Almost all cells have IGF-1 receptors, being especially active on bone, cartilage and muscle, as well as nerve, bone marrow and lung cells, regulating cell growth and development.

In children, without adequate HGH being produced in the brain, IGF-1 levels are not adequate to promote growth and short stature may occur. The cause may be genetic, acquired (for example a head injury or tumor) or idiopathic, where the cause is unknown. In adults, the only indications are decreased HGH levels because of pituitary disease, hypothalamus disease (the gland that stimulates the pituitary), surgery, radiation therapy or trauma. That has not stopped the new anti-aging industry from promoting HGH as the new fountain of youth. In non-mammals, IGF-1 can slow aging but that research has yet to be proven in mammals, let alone humans.

The ability to compete at a high level in sports requires genetic predisposition, talent and a lifetime of work. Fans reward that dedication and athletes reap the rewards of adulation and money. The use of performance enhancing drugs may unlevel the playing field and the trickle-down effect may cause unintended, significant side effects to the users. When college players feel the need to use HGH to compete with the pros, it causes high school players to consider its use to compete for scholarships. The statistics say that up to 10% of high school athletes have tried anabolic steroids.

The problem is in the side effects. In teens that are still growing, complications of HGH use include scoliosis, if there is already a potential, and slipped femoral capital epiphysis, a fracture through the growth plate of the hip. Other issues include unmasking diabetes, hypothyroidism, pancreatitis, raised pressure within the brain and increasing the cancer risk in some patients. In addition, there can be significant skin swelling, muscle and joint pains, including carpal tunnel syndrome. And then there is the increased mortality rate in acutely ill patients who are using HGH.

The use of HGH and other performance enhancing drugs is banned in baseball. Their use is considered cheating presumably because of the risk to the player. Other performance enhancements, like eye surgery to improve vision, are allowed. On the field, some rules are allowed to be broken. It is “allowable” to throw a spitball or otherwise doctor the ball, as long as you are not caught (Gaylord Perry, Hall of Famer) or the fans can be forgiving for using a corked bat (Graig Nettles, Albert Belle).

For many athletes, the lure large sums of money and the fame of pro sports career, outweighs the real risk that comes with the use of performance enhancing drugs. The sad news is that there are very few who will make the big leagues and the many who have not climbed the ladder, will feel the physical consequences of their drug use without tasting success. A sport may deem drug use unacceptable, but pressure to win may override that decision, especially when the use of that drug is legal.

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the ethics of doping

Monday, February 4, 2013

The latest edition of the Super Bowl had more than its share of compelling story lines, brother versus brother, an aging veteran playing his final game and a new quarterback whose star was rising. But underneath all of that positive good feeling was the menace of a couple drug abuse scandals raising their dark heads.  A shady Florida anti-aging clinic run by a doctor and his son was implicated in providing anabolic steroids to some of the best baseball players in the world. And in a perhaps stranger case, Ray Lewis presumably used deer antler spray, holographic stickers and special water to recuperate from a significant arm injury.

Ray Lewis first.  Deer antler velvet is a long sought after oriental remedy that presumably increases performance. One chemical that it does contain in very minute quantities is IGF-1, insulin- like growth factor, a banned substance in athletic competitions, including the NFL.

This is how it works. The hypothalamus, a gland in the brain, produces Growth Hormone Releasing Factor that signals the pituitary, another gland in the brain to release Growth Hormone. This signals the liver to release IGF-1 into the blood stream to stimulate the growth and proliferation of many cells in the body including muscle, bone cartilage and nerves. While IGF-1 has a major benefit in increasing performance, its downside is that the hormone inhibits or decreases programmed cell death. Many of the body’s cells have a defined life span and billions of cells die each day. Interfering with the life cycle of a cell can potentially lead to significant diseases like cancer. Old cells may contained old, damaged DNA that gets passed to new generation cells.

The general public tends to consider the use of performance enhancing drugs cheating however using IGF-1 spray raises an interesting ethical issue. Deer antler spray has insignificant amounts of this chemical, but, more importantly, the spray is deactivated by digestive enzymes in the mouth and stomach, does not enter the bloodstream and causes no biologic effect within the body. IGF-1 is chemically related to insulin and for this same reason, insulin cannot be taken by mouth nad must be injected into the body. Any positive benefit received from the use of oral IGF-1would be due to a placebo effect, and likely also the benefit found in the use of stickers and special water. Thus the ethical dilemma. Mr. Lewis’ intent was to use a performance enhancing drug but the one chosen was improbable and ineffective. The intent to commit a crime did not result in one being committed but there was benefit in the actions.

As for the athletes who received performance enhancing drugs including testosterone and growth hormone from the Biogenesis clinic run by Dr. Pedro Bosch and his son Anthony, no ethical question exists. The investigation by the Miami New Times is a worthwhile read. While it is not illegal for the doctor to prescribe and inject hormones into his patients, their use in the athletic arena is not allowed. Each sport has its own list of banned substances, but performance enhancing drugs like anabolic steroids are never allowed.

There are four tiers of athletes. The first includes those who are genetically gifted and work hard to excel and maximize those gifts. The second are those not so endowed but whose dedication to their sport allows them to perform at an elite level. Tier three is reserved for those who are gifted but who do not invest the time and effort to succeed and finally the lower tier is reserved for those with little talent and less effort. The use of performance enhancing drugs is a shortcut used to elevate their game to the next level. If it means becoming a superstar or just making the team, the use of PEDs unlevels the playing field and makes the competition unfair.

The public expects that athletes succeed because of hard work, motivation and dedication. We cheer the success of those on the podium but sadly, a tinge of cynicism can limit our ability to celebrate. If one athlete dopes, we presume that others are implicated by association. If Ray Lewis used deer antler extract, (a 21st century snake oil), then he did not cheat in the technical sense of the word. He did not benefit from IGF-1, but only because he failed the science.

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