Daily summaries from the symposium in Stockholm 21-22 September 2012
Friday September 21, Norra Latin
Summary 1: Session 1 and Session 2
Every seat taken at the location at Norra Latin.
Friday September 21, Norra Latin
Summary 2: Session 3 and 4
Panel discussion. From left: Pilar Alvarez-Laso, Assistant Director General, UNESCO, Paris, Tim Armstrong, Doctor. WHO, Geneva, David Howman, General Director, WADA, Montreal and Professor Arne Ljungqvist.
Saturday September 22, Karolinska Institutet
Summary 3: Session 5 and Session 6
Session 5: The threat from underground activities and actions being taken against them
Criminal doctors, scientists and politicians: The two German doping systems.
Werner Franke, who was one those who revealed the East-Germany doping disaster (a disaster for sports and for individuals) from German Cancer Research Center (Heidelberg) spoke on “Criminal doctors, scientists, and politicians: the two German doping systems.”
There are today compelling evidence for the efficacy of anabolic steroids, from the files of DDR, which included almost all German athletes and all of the top elite. In East-Germany it was never called doping substances or anabolic steroids, but Unterstützende Mittle, i.e. “supportive means” – which later on was found to be the semantic for anabolic steroid preparations.
The female athletes treated were sometimes not older than 14 years old. As a reason for the treatment the athletes were informed that Western athletes work in the same way and that the East-Germans would have a handicap if they did not use the same means. All athletes selected for international events were obliged to silence regarding the “supportive means” by their coaches in written form. Many of the coaches and presidents were later brought to court in Berlin and were sentenced to 7-22 months in jail “for accessory to bodily harm.”
Werner Franke pointed out that doping and criminal acts have – unfortunately – not been limited to East-Germany. Companies and doctors like Conte, Valente, and Balco have specified in circumventing the doping regulations also in modern times.
Doping substances in nutritional supplements and nutrition
Hans Geyer from the German Doping Control Laboratory (Colonge) gave information on “Doping substances in nutritional supplements and nutrition.” The prevalence of doping substances in nutritional supplements, traditional Asian medicine, and meat products has been documented. Slimming products – declared to containt only a mixture of herbs – have also been found to contain doping substances.
Traditional Asian medicine is also a possible source of doping substances. In the world chamionship in football 2011 in Germany five North Korean players were positive with endogenous anabolic steroids. It was found that they had taken musk pods (preputial gland) from the musk dear which is said to have strong ergogenic action in traditional Korean medicine. It was found that they contained 16 anabolic steroids, of which 9 were already prohibited.
In conclusion, Geyer pointed out that faked nutritional supplements and contaminated meat are common because of easy availability of doping substances and illegal trafficking of doping substances.
INTERPOL involvement against the trafficking of doping substances
Mathieu Holz, criminal intelligence officer at INTERPOL (Lyon) discussed “INTERPOL involvement against the trafficking of doping substances.” He started by describing the INTERPOL – the largest international police organization gathering 190 members countries. Interpol have four (4) strategic priorities:
- Secure global police communication network
- Assisting in the Identification of Crimes and Criminals
- 24/7 Operational Support to Policing and Law Enforcement
- Capacity Building
INTERPOL has a high-security worldwide network for sharing criminal information between member countries. Their interest in trafficking of doping is connected to the trafficking of other drugs and the fact that doping abuse is not limited to athletes. It also includes both military personnel and police officers who want to enhance their image and performance.
There is an agreement between INTERPOOL and WADA (since February 2009) regulating exchange of information (police network) and sharing of expertise (scientific knowledge). One objective being to enhance and facilitate the exchange of information related to trafficking of doping substances. The detection of TB-500 found at the Brussels airport shortly before the start of Tour de France and how WADA called the expert committee of the prohibited list to classify TB-500 under “S2 Peptide hormone” as a substance that is permanently forbidden, is a good example of how this agreement works. However, this cooperation still face serious difficulties, most of all a lack of legal framework. A common European legal framework is needed to effectively fight doping.
The abuse of anabolic androgenic steroids in forensic cases – data from living persons and autopsies
From the National Board of Forensic Medicine in Linköping, Sweden, Yvonne Lood spoke on “The abuse of anabolic androgenic steroids in forensic cases – data from living persons and autopsies.”
The Linköping Forensic Toxicology Laboratory stands not only for quality but also quantity. Yearly it has made 40,000 tests gathered by the police for drug-related crimes and 15,000 for suspected drunk driving. To that comes 5,000 from forensic medical departments (autopsies) and 30,000 from correctional treatments (suspected drug abuse), and 6,000 from other parts of the health care and local social services (suspected drug abuse). It is obvious for people working in forensic medicine that androgenic anabolic steroids (AAS) are an increasing problem also outside elite sport:
- AAS are involved in serious criminality and unprovoked violence
- AAS use may be a gateway to other drugs
- AAS use causes medical and psychiatric problems
The Swedish customs and the police report an increasing illegal import of AAS into Sweden, but also import of pure substances used for local production of ampoules and tablets.
Yvonne Lood concluded that there is an increasing use of AAS in Sweden. Users of AAS in Sweden are primarily young men (99.2 %, median age 25 years old) using supraphysio-logical doses of AAS are used (>10,000 ng AAS and/or metabolites per mL urine). The use of AAS is often combined with other illicit drugs.
The role of intelligence in anti-doping and at major events
Nicole Sapstead, UK Anti-Doping Director of Operations (London) spoke on “The role of intelligence in anti-doping and at major events.”
Sapstead provided several examples of sources of intelligence: tip offs, atheltes’ performance, law enforcement, testing, whereabouts, ADOs and sport, Athlete Biological Passports (ABPs) etc. She concluded that there must be better coordination between ADOs and that the intelligence work will not lead to an increase in the number of tests – but in the quality of the tests carried out.
Session 6: Adverse medical and social effects of doping
Overview of neurobiological aspects of doping substances
From the Department of Pharmaceutical Bioscience (Uppsala) Fred Nyberg spoke on “Overview of neurobiological aspects of doping substances”
Nyberg stated that it is well accepted from a scientific standpoint that doping agents affect the brain. This statement was supported by a number of examples taken from recent studies.
A survey directed to around 3,000 high school students showed a correlation between use of AAS and abuse of alcohol and narcotics as well as a correlation between use of AAS and violence.
Studies have shown that AAS affects the brain by causing an imbalance to its rewarding system. An increased sensitivity to other drugs of abuse has also been detected and recent experimental animal studies have demonstrated that AAS may also affect memory and cognitive functions.
Clinically it is common knowledge – also backed by scientific data – that androgenic, anabolic steroids increase aggressive behavior and induce a competitive and dominant behavior. AAS induce an alteration compatible with enhanced sensitivity towards defensive aggression, and therefore it can be demonstrated that nerve pathways and brain regions are involved in aggression. However, in society this may be difficult to investigate as the individuals engaged in violence – especially planned violence – also use Rohypnol®, alcohol, cannabis, spice, opiates, hormones, cathinones, ecstacy, cocaine, and amphetamine. However, it is well known that combining AAS with central stimulants enhances their action on excitatory circuits and increases aggressive behavior.
Diagnostics and clinical features of abusers of anabolic androgenic steroids
Anders Rane, Clinical Pharmacology, Karolinska University Hospital (Stockholm) reported on his research “Diagnostics and clinical features of abusers of anabolic androgenic steroids”
The large variation in disposition, effects and adverse reactions of drugs, is also true for anabolic androgenic steroids. Genetic factors are probably the single most important cause of this variation.
Metabolic steps up-stream and down-stream of testosterone are genetically variable and contribute substantially to the variation in disposition of testosterone, the most common doping agent in sports and in society. Large inter- and intra-ethnic variation in testosterone glucuronidation and excretion is described as well as the pit-falls in evaluation of testosterone doping test results. There are also interethnic differences with 7 percent of Caucasians having a minimal excretion of testosterone and 74 percent of Asians having a minimal excretion.
When it is established that the T/E ratio has a much higher inter- than intra-individual variability, future test programs ought to switch from population-based to individual-based T/E cut-off ratios. Otherwise there is a high risk of missing doped individuals with the UGT2B17 del/del genotype. Bayesian analysis and genotype information together increase the sensitivity of the T/E test and reduce the number of false negatives.
Adverse somatic effects of anabolic-androgenic steroids
Ingemar Thibblin from Forensic Medicine (Uppsala) spoke on “Adverse effects of anabolic- androgenic steroids” based on his forensic studies.
The use of anabolic androgenic steroids (AAS) has been associated with hypertrophy of the left cardiac ventricle (LVH) as diagnosed by echocardiography. Case reports suggest that AAS-related LVH may lead to sudden death.
Heart weight controlled for age and body mass was significantly higher for the AAS positive, and they had more cardiac fibrosis. The myofibers exceeds the critical limit for oxygenation in a significant number of cases.
The analysis of the logarithm of heart mass by multivariate statistics implied that strong correlations existed between body mass and heart mass, height and heart mass, age and heart mass, and trauma (bleeding) and heart mass. After controlling for these factors, a significantly higher heart mass was found among the AAS-positive males.
Ingemar Thibblin concluded that there is:
- nearly evidence for causality between AAS use and
- death and hospitalization for circulatory disease
- cardiac hypertrophy
- possible causality between AAS use and
- cardiac fibrosis
- clear causality between long term AAS use and severe testicular changes
Saturday September 22, Karolinska Institutet
Summary 4: Session 7 and Session 8
Session 7: The care of drug addicts
Anabolic-androgenic misuse - medical treatment against poor health and early death
Thord Rosén (Gothenburg, Sweden) spoke on “Anabolic-androgenic misuse: medical treatment against poor health and early death.”
Rosén’s main message was that AAS-abuse is dangerous and life-threatening both in the short term and long-term perspectives. Therefore the society must be better at identifying the patients with AAS-abuse, not seldom combined with an abuse with other drugs.
Since 2002 there is a resource center for hormone abusers at Sahlgrenska Hospital in Gothenburg, where 170 patients have been treated so far. There are also centers in Sweden in Örebro and Stockholm. The Gothenburg center offers endocrinologist and social assistant, but there are connections to psychiatry, clinical physiology and cardiology, intern medicine, plastic surgery, orthopedic surgery, dermatology, and urology. For each patient the first visit takes 2-3 hours and includes medical history with AAS-drugs, a medical examination, lab-tests (routine and hormone analyses including AAS in the urine), ECG/UCG, and questionnaires.
The typical patient in the resource center is a male 17-30 years training at gyms 5-6 days/week. AAS-start 2-3 years after start of training and there is an unstable social situation. There is a mixed abuse, often 6-10 weeks cures with 2-3 agents at the same time about 250 mg/week (35 mg/week).
The Anti-Doping hotline – the Swedish experience
Ylva Böttiger (Stockholm) spoke on ”The Anti-Doping hotline – the Swedish experience.”
In the early 1990s, it was realised that doping was not only a question of cheating in sports – it had become a public health issue. Thus, in 1993, the Anti Doping Hotline (Dopingjouren) was started at the Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm.
Today, “Dopingjouren” is financed equally by the Ministry of Culture and the Ministry of Health and Social Affairs and has by now answered more than 40,000 calls and e-mails. It has four employees plus one doctor on 20 percent. The aims are to provide and increase the knowledge about the medical consequences of the abuse of anabolic androgenic steroids and similar substances in society and in health care, to provide guidance and support to abusers and their family members, including referrals to appropriate health care facilities, and to provide guidance and support to health care staff and other professionals that come into contact with the abuse of AAS.
Their website contains information and research as well as Questions and Answers. 60-70,000 visitors are registered on the website annually and 2,500 questions are registered annually via calls and mails. Typical questions are:
Abusers: what about these side-effects? should I seek treatment? Relatives: are these symptoms related to AAS? is there treatment available? Health care: how to diagnose and treat abuse? Police, customs: identification of substances? Sports, gym: how to prevent the abuse of AAS?
Session 8: Problems of today and tomorrow, and potential solutions
Designer performance enhancing drugs: what you do not know may hurt you
Christiane Ayotte, Director of Doping control laboratory (Montreal) spoke on “Designer performance enhancing drugs: what you do not know may hurt you.“
There are several different types of doping to enhance sport performance, but sometimes the athlete is unaware of the risks he or she is taking.
Nutritional supplements are part of the diet of many athletes, but the dietary supplement industry is mostly unregulated. As a consequence, an abundance of supplements of dubious value, content and quality are now available around the world.
Some products have been shown to contain prohibited substances such as ephedrine, caffeine, or steroids that were not listed on the label. Urine samples collected after the administration of these supplements can test positive.
The problems of doping in sport and the increasing use of nutritional supplements by athletes are issues that intersect to the degree that a large number of supplements may contain substances that are banned in sport. Many supplements also contain substances that are associated with significant health hazards. Athletes consuming such supplement products may jeopardize their sporting status, and their health.
Athletes need to be aware of the problems that can follow supplement use, and sport authorities need to ensure that nutritional education and guidance for athletes is of the highest standard. The need for the appropriate regulation of dietary supplements is emphasized.
Aspects related to the threat of misuse of gene technology – today and tomorrow
Theodore Friedmann from the Gene Therapy Center at University of California (San Diego) looked into the future as he talked about “Aspects related to the threat of misuse of gene technology – today and tomorrow”.
Humans have long sought to enhance themselves through cosmetic surgery and drugs. In the future, genetic manipulation may also be in our enhancement tool kit in the quest for healthier, happier and longer lives.
Some early experimental studies illustrate the potential of gene therapy for treating diseases. Although highly effective in some models, these gene therapy techniques are imperfect and still highly risky, as demonstrated by severe adverse events such as treatment-induced leukemia, or even deaths.
Genetic doping in sport is based on genetic modifications for therapy of disease, which may be a multi-edged sword. Gene doping is a new challenge to sports, but may open doors to human genetic enhancement and eugenics. The genetic manipulations may cure many diseases that today only can be palliated, and maybe prevent “normal” muscle degeneration of aging. We live today in an enhancing society (glasses, hearing aid, cosmetic surgery, pills against impotence, surgery for obesity etc). The society tolerates and rewards enhancement in sport – but only to a certain limit. If drug and surgical enhancement are OK, why should not genetic “improvement” of normal traits?
There are conceptual and ethical problems as well as purely technical ones. But the main reason to why we, according to Friedmann, should be careful when applauding the new technology is that gene modification is likely to badly wrong.
The symposium was honored by the presence of H.R.H. Prince Daniel of Sweden who has great interest in health and fitness issues as a former entrepreneur within the fitness industry in Stockhom. From left: Professor Arne Ljungqvist, H.R.H. Prince Daniel, Sir Craig Reedie from the Intenrnational Olympic Committee.