‘Bali over the Counter’ : Exploring the Overseas Use and Acquisition of Anabolic-androgenic Steroids / Matthew Dunn, Kyle J.D. Mulrooney, Dean Biddau, Fiona H. McKay, Richard Henshaw

• Deviant Behavior 43 (2022) 4, p. 447-460
• Volume 43, 2022 - Issue 4 447-460

ABSTRACT

In the bodybuilding and fitness communities, anecdotal evidence suggests that some take ‘steroid holidays’, traveling to and living in foreign countries so as to have greater access to performance and image enhancing drugs (PIEDs). This study aimed to explore this phenomenon. Discussions in bodybuilding, fitness, and PIED forums formed the basis of this study. Several websites were identified and keyword searches were used to identify potential ‘threads’, which were downloaded and thematically analyzed. Twenty-two threads consisting of 254 posts from 188 individual forum members were included. Two themes were identified: (1) Product purchasing and (2) Logistics. In the first theme, the purchase of the products for individual use was a key feature, with their motivations centered on perceptions of legality, purity, and risk. In the second theme, discussions focused those members who sought to use the PIEDs they sourced in a foreign country within that country versus using foreign-sourced PIEDs in Australia. The perception that steroids may be cheaper, more readily accessible, or of better quality in countries in close proximity to Australia may lead some to travel to low- or middle-income countries to use or access PIEDs which could lead to legal and health risks.

Δ-4-Androstene-3,17-Dione Binds Androgen Receptor, Promotes Myogenesis in Vitro, and Increases Serum Testosterone Levels, Fat-Free Mass, and Muscle Strength in Hypogonadal Men / Ravi Jasuja, Pandurangan Ramaraj, Ricky Phong Mac, Atam B. Singh, Thomas W. Storer, Jorge Artaza, Aria Miller, Rajan Singh, Wayne E. Taylor, Martin L. Lee, Tina Davidson, Indrani Sinha-Hikim, Nestor Gonzalez-Cadavid, Shalender Bhasin. - (Journal of Clinical Endocrinology & Metabolism 90 (2005) 2 (1 February); p. 855-863)

• PMID: 15522925
• DOI: 10.1210/jc.2004-1577

Abstract

Previous studies of Delta 4-androstene-3,17-dione (4-androstenedione) administration in men have not demonstrated sustained increments in testosterone levels, fat-free mass (FFM), and muscle strength, and failure to demonstrate androstenedione's androgenic/anabolic effects has stifled efforts to regulate its sales. To determine whether 4-androstenedione has androgenic/anabolic properties, we evaluated its association with androgen receptor (AR) and its effects on myogenesis in vitro. Additionally, we studied the effects of a high dose of 4-androstenedione on testosterone levels, FFM, and muscle strength in hypogonadal men. We determined the dissociation constant (K(d)) for 4-androstenedione using fluorescence anisotropy measurement of competitive displacement of fluorescent androgen from AR ligand-binding domain. AR nuclear translocation and myogenic activity of androstenedione were evaluated in mesenchymal, pluripotent C3H10T1/2 cells, in which androgens stimulate myogenesis through an AR pathway. We determined effects of a high dose of androstenedione (500 mg thrice daily) given for 12 wk on FFM, muscle strength, and hormone levels in nine healthy, hypogonadal men. 4-Androstenedione competitively displaced fluorescent androgen from AR ligand-binding domain with a lower affinity than dihydrotestosterone (K(d), 648 +/- 21 and 10 +/- 0.4 nm, respectively). In C3H10T1/2 cells, 4-androstenedione caused nuclear translocation of AR and stimulated myogenesis, as indicated by a dose-dependent increase in myosin heavy chain II+ myotube area and up-regulation of MyoD protein. Stimulatory effects of 4-androstenedione on myosin heavy chain II+ myotubes and myogenic determination factor expression were attenuated by bicalutamide, an AR antagonist. Administration of 1500 mg 4-androstenedione daily to hypogonadal men significantly increased serum androstenedione, total and free testosterone, estradiol, and estrone levels and suppressed SHBG and high-density lipoprotein cholesterol levels. 4-androstenedione administration was associated with significant gains in FFM (+1.7 +/- 0.5 kg; P = 0.012) and muscle strength in bench press (+4.3 +/- 3.1 kg; P = 0.006) and leg press exercises (+18.8 +/- 17.3 kg; P = 0.045). 4-androstenedione is an androgen that binds AR, induces AR nuclear translocation, and promotes myogenesis in vitro, with substantially lower potency than dihydrotestosterone. 4-androstenedione administration in high doses to hypogonadal men increases testosterone levels, FFM, and muscle strength, although at the dose tested, the anabolic effects in hypogonadal men are likely because of its conversion to testosterone.

β₂-Agonists and physical performance : a systematic review and meta-analysis of randomized controlled trials / Babette M. Pluim, Olivier de Hon, J. Bart Staal, Jacqueline Limpens, Harm Kuipers, Shelley E. Overbeek, Aeilko H. Zwinderman, Rob J.P.M. Scholte. - (Sports Medicine 41 (2001) 1 (January) p. 39-57)

• PMID: 21142283
• DOI: 10.2165/11537540-000000000-00000

Abstract:

Inhaled β₂-agonists are commonly used as bronchodilators in the treatment of asthma. Their use in athletes, however, is restricted by anti-doping regulations. Controversies remain as to whether healthy elite athletes who use bronchodilators may gain a competitive advantage.

The aim of this systematic review and meta-analysis is to assess the effects of inhaled and systemic β₂-agonists on physical performance in healthy, non-asthmatic subjects. To this end, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to August 2009. Reference lists were searched for additional relevant studies. The search criteria were for randomized controlled trials examining the effect of inhaled or systemic β₂-agonists on physical performance in healthy, non-asthmatic subjects. Two authors independently performed the selection of studies, data extraction and risk of bias assessment. Parallel-group and crossover trials were analysed separately. Mean difference (MD) and 95% confidence intervals were calculated for continuous data and, where possible, data were pooled using a fixed effects model.

Twenty-six studies involving 403 participants (age range 7-30 years) compared inhaled β₂-agonists with placebo. No significant effect could be detected for inhaled β₂-agonists on maximal oxygen consumption (VO₂(max)) [MD -0.14 mL · kg⁻¹ · min⁻¹; 95% CI -1.07, 0.78; 16 studies], endurance time to exhaustion at 105-110% VO₂(max) (MD -1.5 s; 95% CI -15.6, 12.6; four studies), 20-km time trial duration (MD -4.4 s; 95% CI -23.5, 14.7; two studies), peak power (MD -0.14 W · kg⁻¹; 95% CI -0.54, 0.27; four studies) and total work during a 30-second Wingate test (MD 0.80 J · kg⁻¹; 95% CI -2.44, 4.05; five studies). Thirteen studies involving 172 participants (age range 7-22 years) compared systemic β₂-agonists with placebo, with 12 studies involving oral and one study involving intravenous salbutamol. A significant effect was detected for systemic β₂-agonists on endurance time to exhaustion at 80-85% VO₂(max) (MD 402 s; 95% CI 34, 770; two studies), but not for VO₂(max) (placebo 42.5 ± 1.7 mL · kg⁻¹ · min⁻¹, salbutamol 42.1 ± 2.9 mL · kg⁻¹ · min⁻¹, one study), endurance time to exhaustion at 70% VO₂(max) (MD 400 s; 95% CI -408, 1208; one study) or power output at 90% VO₂(max) (placebo 234.9 ± 16 W, salbutamol 235.5 ± 18.1 W, one study). A significant effect was shown for systemic β₂-agonists on peak power (MD 0.91 W · kg⁻¹; 95% CI 0.25, 1.57; four studies), but not on total work (MD 7.8 J · kg⁻¹; 95% CI -3.3, 18.9; four studies) during a 30-second Wingate test. There were no randomized controlled trials assessing the effects of systemic formoterol, salmeterol or terbutaline on physical performance.

In conclusion, no significant effects were detected for inhaled β₂-agonists on endurance, strength or sprint performance in healthy athletes. There is some evidence indicating that systemic β₂-agonists may have a positive effect on physical performance in healthy subjects, but the evidence base is weak.

β2-Agonists at the Olympic Games / Kenneth D. Fitch. - Clinical Reviews in Allergy & Immunology
1-Oct-2006, Volume 31, Issue 2-3, pp 259-268

The different approaches that the International Olympic Committee (IOC) had adopted to β2-agonists and the implications for athletes are reviewed by a former Olympic team physician who later became a member of the Medical Commission of the IOC (IOC-MC). Steadily increasing knowledge of the effects of inhaled β2-agonists on health, is concerned with the fact that oral β2-agonists may be anabolic, and rapid increased use of inhaled β2-agonists by elite athletes has contributed to the changes to the IOC rules. Since 2001, the necessity for athletes to meet IOC criteria (i.e., that they have asthma and/or exercise-induced asthma [EIA]) has resulted in imporved management of athletes. The prevalence of β2-agonist use by athletes mirrors the known prevalence of asthma symptoms in each country, although athletes in endurance events have the highest prevalence. The age-of-onset of asthma/EIA in elite winter athletes may be atypical. Of the 193 athletes at the 2006 Winter Olympics who met the IOC's criteria, only 32.1% had childhood asthma and 48.7% of athletes reported onset at age 20 yr or older. These findings lead to speculation that years of intense endurance training may be a causative factor in bronchial hyper reactivity. The distinction between oral (prohibited in sports) and inhaled salbutamol is possible, but athletes must be warned that excessive use of inhaled salbutamol can lead to urinary concentrations similar to those observed after oral administration. This article provides justification that athletes should provide evidence of asthma or EIA before being permitted to use inhaled β2-agonists.

Related case:

CAS 2020_A_6892 Andrew Starykowicz vs USADA
August 5, 2020

In October 2019 the American triathlon Athlete Andrew Starkowics suffered from an acute respiratory infection with bronchoconstriction. He underwent medical treatment and used several prescribed medication including the prohibited substances Methylprednisolone (Medrol), Glucocorticoids including Fluticasone Furoate and Vilanterol inhalation powder (Breo).

The Athlete applied for a TUE for the use of Medrol and Breo and on 8 November 2019 the USADA TUE Committee granted the use of Medrol.

Before the approval of the TUE the Athlete had participated in an IRONMAN triathlon on 2 November 2019 and was subjected to sample collection. Consequently in December 2019 the World Triathlon Corporation (WTC) reported an anti-doping rule violation against the Athlete after his A and B samples tested positive for the substance Vilanterol without a valid TUE. After notification in December 2019 a provisional suspension was ordered.

At the time of the notification the Athlete had no TUE for Vilanterol due to his applications for Breo had been repeatedly denied by the USADA TUE Committee and finally by the WADA Therapeutic Use Exemption Committee. Both Committees deemed that suitable permitted alternatives were available but were not prescribed by his pulmonologist.

In March 2020 the Athlete appealed with the Court of Arbitration for Sport (CAS) challenging the denial of his TUE applications for Breo. However on 5 August 2020 CAS dismissed the Athlete's appeal and deemed that the Athlete failed to demonstrate that the existing alternative therapies suggested by USADA were not reasonable.

Hereafter WTC resumed the proceedings against the Athlete and contended that the Athlete had committed an anti-doping rule violation on two occasions without a valid TUE. In view of the amendment in the WADA Prohibited List regarding Vilanterol, WTC requested for a reduced sanction of 2 years.

The Athlete admitted the violation and the use of Vilanterol in and out of competition between October and November 2019. He requested for a reduced sanction based on No Significant Fault or Negligence. He acknowledged that pending his TUE application he was warned by USADA when participating in a competition without a TUE he would commit an anti-doping rule violation.

The Sole Arbitration regards that the Athlete is highly experienced and fully aware of his anti-doping obligations. Further he establishes that at the relevant time USADA timely had processed and granted the Athlete's TUE application and that significant delays in the application were attributed to the Athlete.

Considering the Athlete's conduct in this case the Sole Arbitrator concludes that the he had acted negligently while he was duly informed by USADA about permitted alternative medication. As a result the Athlete failed to establish that he bears No Significant Fault of Negligence.

Due to the Vilanterol amendment of the WADA 2021 Prohibited List the Sole Arbitrator decides on 25 November to impose a reduced period of ineligibility on the Athlete. The period of ineligibility will start on the date of the provisional suspension, 5 December 2019, and end on 1 Januari 2021.

On 23 February 2017 the World Triathlon Corporation decided to impose a 4 year period of ineligibility on the Athlete Murizio Carta for his refusal to provide a blood sample. Here the Athlete explained that he had a phobia of needles and he offered the USADA Doping Control Officer to provide a urine sample instead which was not acceptable to the WTC.

Hereafter in March 2017 the Athlete appealed the WTC decision and the Sole Arbitrator settled the case based on the written submissions of the parties.

The Athlete admitted that he refused to provide a blood sample and denied that this refusal was without compelling justification. He stated that he immediately said that he had a phobia of needles as confirmed by the medical certificate from October 2016. He says that he cooperated proactively by not only explaining his refusal to provide a blood sample, but offering repeatedly to provide a urine sample.
He argued that in the circumstances of his refusal to provide a blood sample no suspension was warranted or alternatively a 2 year period of ineligibility should be imposed.

The Arbitrator holds that the Athlete’s previous anti-doping rule violation is significant since it demonstrates his familiarity with anti-doping testing. In light of this previous violation in 2005 and the decision of the CAS arbitrator, and his acknowledgement that he previously had undergone numerous anti-doping controls, he must have known that anti-doping testing at the 2016 World Championships was a possibility.

The Sole Arbitrator concludes that the Athlete failed to provide compelling justification for his refusal to provide a blood sample, as requested. The Arbitrator deems that it is clear that the Athlete was negligent in not taking steps to address his alleged phobia of needles in advance of the 2016 World Triathlon Championships so as to be able to provide a blood sample if required. He then knowingly or intentionally refused to provide a sample when requested to do so.

Therefore the Sole Arbitrator decides on 26 June 2017:

1.) Mr. Carta's appeal from the WTC's Charge of Anti-Doping Rule Violation and Notice of Sanction under the IRONMAN Anti-Doping Rules, dated 23 February 2017 is dismissed;
2.) the Suspension and Sanction set out in the Charge of Anti-Doping Rule Violation and Notice of Sanction remain in place;
3.) each Party shall bear its own costs; and,
4.) all other or further claims are dismissed.

Would you dope? A general population test of the Goldman dilemma / James Connor and Jason Mazanov. - (British Journal of Sports Medicine 11 (2009) 43 (October), p. 871-872)

• Doi: 10.1136/bjsm.2009.057596

Abstract

OBJECTIVE:
To test Goldman's dilemma on a general population sample by asking whether they would take the Faustian bargain of a drug that guaranteed sporting success but would result in their death in 5 years' time. Between 1982 and 1995 a bi-annual survey using this dilemma suggested half of all elite athletes would take the drug.

DESIGN:
A random telephone survey of 250 members of the Australian general public, with counterbalanced presentation of success and death.

MAIN OUTCOME MEASURES:
Respondents gave age, gender, sports engagement and response to the dilemma (yes/no).

RESULTS:
Only two of a sample of 250 reported they would take the bargain offered by the dilemma.

CONCLUSIONS:
Athletes differ markedly from the general population in response to the dilemma. This raises significant practical and ethical dilemmas for athlete support personnel. The psychometry of the dilemma needs to be established more comprehensively for general and athlete populations.

Would they dope? Revisiting the Goldman dilemma / James Connor, Jules Woolf, Jason Mazanov. - (British Journal of Sports Medicine 47 (2013) 11 (July); p. 697-700)

• DOI: 10.1136/bjsports-2012-091826

Abstract

BACKGROUND/AIM:
Discussions of doping often report Goldman's sensational results that half of the elite athletes asked would take a drug that guaranteed sporting success which would also result in their death in 5 years' time. There has never been any effort to assess the properties of the 'Goldman dilemma' or replicate the results in the post World Anti-Doping Agency context. This research evaluated the dilemma with contemporary elite athletes.

METHODS:
Participants at an elite-level track and field meet in North America were segregated into an interview or online response. After basic demographics, participants were presented with three variant 'Goldman' dilemmas counter-balanced for presentation order.

RESULTS:
Only 2 out of 212 samples (119 men, 93 women, mean age 20.89) reported that they would take the Faustian bargain offered by the original Goldman dilemma. However, if there were no consequences to the (illegal) drug use, then 25/212 indicated that they would take the substance (no death condition). Legality also changes the acceptance rate to 13/212 even with death as a consequence. Regression modelling showed that no other variable was significant (gender, competitive level, type of sport) and there was no statistical difference between the interview and online collection method.

CONCLUSIONS:
Goldman's results do not match our sample. A subset of athletes is willing to dope and another subset is willing to sacrifice their life to achieve success, although to a much lesser degree than that observed by Goldman. A larger scale online survey is now viable to answer important questions such as variation across sports.

Would Relaxation of the Anti-doping Rule Lead to Red Queen Effects? / Bengt Kayser, Adreas De Block. - (Sport, Ethics and Philosophy (2020) 7 June); p. 1-15)

• DOI: 10.1080/17511321.2020.1770846

ABSTRACT

One of the claims sometimes advanced in favour of anti-doping is that allowing doping would lead to a uniform increase in performance in comparison to no doping. The idea is that if all athletes would use doping, this would just shift the playing field to a higher level without a change in ranking, but at a higher health cost. In this paper, we critique this contention. We first develop our theoretical framework, with reference to the so-called Red Queen effect. We then argue that, if doping were allowed, Red Queen effects would not be the rule. We also show that to some extent Red Queen effects would occur, but these would not necessarily be morally problematic. We end by developing an argument in favour of a more liberal approach of doping, since such would allow escaping from today’s runaway effects of anti-doping efforts.

World-class cyclists on erythropoietin (EPO) / J.A. Heuberger, A.F. Cohen. - (British journal of clinical pharmacology (2014) 3 (March) : p. 582) doi: 10.1111/bcp.12186.

Comment on:
Little soldiers in their cardboard cells / E. van Breda, J. Benders, H. Kuipers. - (British journal of clinical pharmacology (2014) 3 (March) : p. 580-581) doi: 10.1111/bcp.12187.

Comment on:
Erythropoietin doping in cycling: lack of evidence for efficacy and a negative risk-benefit / J.A. Heuberger, J.M. Cohen Tervaert, F.M. Schepers, A.D. Vliegenthart, J.I. Rotmans, J.M. Daniels, J. Burggraaf, A.F. Cohen. – (British journal of clinical pharmacology (2013) 6 (June) : p. 1406-1421) doi: 10.1111/bcp.12034.