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Steroids Scorch the Field of Dreams: MLB's Disgrace

Steroids Scorch the Field of Dreams: MLB's Disgrace
Andrew Pipe, MD, is Associate Professor of Medicine at the University of Ottawa, Ontario, Canada, and is also the Director of the Prevention and Rehabilitation Centre at the University of Ottawa Heart Institute.

Dr. Pipe worked as a physician at 5 Olympic games and was the Chief Medical Officer for Canada's l992 Olympic Team in Barcelona. He worked as the team physician for Canada's National Men's Basketball Team for 25 years, and has been appointed Chief Medical Officer for the 2006 Commonwealth Games to be held in Melbourne, Australia.

Dr. Pipe is a former president of the Canadian Academy of Sport Medicine and is a Fellow of the American College of Sport Medicine. He is renowned for his involvement in the fight against doping in sports and was one of the founders of the Canadian Centre for Ethics in Sport (CCES).

Dr. Pipe sat down with Pippa Wysong of Medscape to offer his unique perspectives concerning the scourge of anabolic steroids in major league baseball, which covers both the medical problems associated with steroid abuse and the need for a more robust testing strategy and penalty structure for players who abuse the drugs.

He also addressed the destructive culture in sports that supports the abuse of dangerous performance-enhancing drugs, especially in young adults.

Medscape: Why would baseball players be drawn to using anabolic steroids?

Dr. Pipe: Anabolic steroids increase strength and power, and artificially enhanced strength and power can lead to changes in performance. Athletes use anabolic steroids to increase strength and power.

Medscape: Are hitters the ones mostly attracted to these drugs?

Dr. Pipe: Yes. Although everybody in baseball is a hitter. Certainly the high-profile hitters have been the focus of the Congressional hearings. But they would be used in any sport in which strength and power are important elements of performance -- particularly if that sport is totally unregulated as far as the use of performance-enhancing drug use is concerned. There is little doubt from me that you're going to have a major issue in an unregulated sport.

Medscape: What medical problems can one expect to see with anabolic steroid use?

Dr. Pipe: In general, anabolic steroids can produce a number of effects depending on the nature of the steroid, the method of ingestion, dose, et cetera. There can be hepatic problems. We know anabolic steroids tend to lower HDL (good) cholesterol levels; we know they can give rise to a whole array of problems associated with androgen excess such as acne. There are large numbers of case reports of premature cardiovascular disease and stroke in individuals who have used anabolic steroids. There are case reports of cardiomyopathy in people who have used anabolic steroids.

Medscape: What is the main attitude about use of anabolic steroids?

Dr. Pipe: I think it is very important for us not to adopt a Reefer Madness approach to anabolic steroid use. The tendency is for those who are using anabolic steroids to say, "I know lots of people who are using these products and I don't see any of these health consequences, and people aren't dropping like flies around me with any of them, so blow it out your ears, doc."

Medscape: How definitive are the data on problems with steroid abuse?

Dr. Pipe: The other caveat is we have no clinical experience with a clearly defined population of individuals taking clearly defined doses of anabolic steroids who have been followed for years to allow us to say with any degree of credibility exactly what the side effects might be. It may be 10 or 20 years before we see the consequence of the use of anabolic steroids in high dose levels in individuals who have been using them in sports.

Medscape: So, the underground nature of steroid abuse causes problems for the medical professional because we don't know the doses or frequency. You don't know what to expect to happen in individual players because they may all be using them differently?

Dr. Pipe: We do have these anecdotal case reports and we do know something about the effects of anabolic androgenic steroids in general. In terms of being able to describe what the effects of certain doses of certain products in certain people are, precisely because of the underground nature of this phenomenon, we don't have the body of clinical evidence that allows us to identify them in the way that we might with other drugs and other dose levels.

Medscape: What are possible red flags physicians should watch for that could alert them to the possibility that a patient may be abusing anabolic steroids?

Dr. Pipe: Sudden dramatic increase in weight gain and changes in body silhouette, the appearance of florid acne in people who have been clear of acne previously. Changes in mood and behaviour -- there are some psychological or central nervous system effects of anabolic steroids. It is alleged that people using anabolic steroids may become much more aggressive, much more abrasive, and prone to violence.

Medscape: There has been speculation that teens cycling on and off these drugs are at risk for suicidal behaviour and depression. Do you agree with that?

Dr. Pipe: I'd be very careful about that phenomenon. Suicide is the leading cause of death outside of accidents in young people in those age groups. There is an understandable tendency on the part of their families to look for causes of their suicide. If somebody has been on anabolic steroids, it's very easy to suggest that is the cause of their suicide. It may very well be that their desire to use anabolic steroids to somehow produce a certain body image body size is actually a reflection of a fairly profound sense of preexisting personal unease.

Medscape: So you suspect that the mere desire to use the steroids by teens reflects dissatisfaction with themselves already? That the steroids don't cause depression or suicide?

Dr. Pipe: I'm a little wary. We start to get into the Reefer Madness area when we start saying all kinds of things. I'm open to exploring the psychological aspect and trying to understand it a little better. I'd be hesitant to say that anabolic steroids, when withdrawn suddenly in teenagers, cause them to commit suicide.

Medscape: Something has to be going on in your head before you decide to use them, right?

Dr. Pipe: Exactly.

Medscape: How should doctors talk to suspected steroid users?

Dr. Pipe: They should talk to them sensitively, and openly and honestly about the potential hazards that can be part and parcel of this use. I think that for doctors who are involved in sport and who have these athletes in their care, the nature of that responsibility is significantly different. If you are a physician who is privileged enough to be involved in the care of athletes in a sport environment, we have particular responsibilities not only to those athletes who are our patients, but also to the processes of sport.

Medscape: You're saying that sports doctors have special responsibilities and duties to encourage fair sport and good choices?

Dr. Pipe: Particularly if those sports have policies and rules and regulations about drug use in sport. To participate in the practise of steroid use is to become complicit in violating the rules and regulations, if not the fundamental ethics of sport. In that respect, it's no different from falsifying insurance claims, as far as I'm concerned.

Medscape: Where do most players get steroids?

Dr. Pipe: They purchase them over the Internet. They buy them from people in commercial gymnasiums; there's a flourishing black-market for these products. Other people who distribute steroids may be motorcycle gangs or cocaine traffickers.

Medscape: Are there doctors out there prescribing them?

Dr. Pipe: I'm sure there are. Only to the extent there are accountants who embezzle, journalists who plagiarize, and fringe practitioners who involve themselves in some of these kinds of practice.

Medscape: Is it possible for players to accidentally take these steroids, say from suspect protein supplements?

Dr. Pipe: That's very unlikely. There is no North American professional sport organization, with the possible exception of the NFL, that has anything like a meaningful antidrug program. That's the reason why major league baseball is coming under such fire and scrutiny. The likelihood of these players testing positive through nutritional supplement use ain't gonna happen 'cause they ain't getting tested.

Medscape: How should testing be done?

Dr. Pipe: I think increasingly people are of the view that in North America, professional sports organizations need to adopt approaches to doping control in sport that are equal to those that are administered for Olympic athletes. There is, increasingly, the view that it would be very helpful if international sport organizations had an independent agency such as the US Anti-Doping Agency, or in Canada the Canadian Centre for Ethics and Sport, or a World Anti-Doping Agency (WADA), a sanctioned organization doing this testing and managing these issues for them so there is absolutely no question of complicity or cover-up.

Medscape: What are the benefits of an external organization doing testing?

Dr. Pipe: Professional sport organizations can be assured that they have the highest-quality programs, the highest-quality testing in accordance with what are now seen as world standards in this respect.

Medscape: How does the United States compare to other countries when it comes to the testing of their athletes?

Dr. Pipe: To a very great extent, North American sport is the most significant outlier in this respect. National legislation in most European countries means that professional soccer players, and others, are subject to the exact same kind of testing by the same authorities that Olympic athletes might be subjected to.

Medscape: Is Canada in the same predicament as the United States?

Dr. Pipe: Yes, to the extent that professional sport in Canada is the NHL, professional baseball, the NBA, and the CFL. None of those organizations have any meaningful anti-doping programs. Though, in Canada, the CFL is moving toward consideration of how they can get involved in these kinds of testing programs.

Medscape: In pro as well as amateur baseball, is there any sense of the scope of the problem?

Dr. Pipe: It's very difficult to know. I would hazard a guess that the problem is more prevalent than people think. But it's because there is no program in place that no one has any really reliable data on which to base any estimate of the extent of these kinds of practices.

Medscape: How would one go about figuring out the scope of the problem?

Dr. Pipe: There is considerable experience internationally now in terms of how you run an anti-doping program. That anti-doping program includes year-round, out-of-competition testing conducted by an independent organization with management of those results invested in that same organization. Once you've run a number of tests, you have a pretty good sense of the prevalence of the problem just by the proportion of tests that are positive

Medscape: Baseball did undertake some testing of players.

Dr. Pipe: Professional baseball got an awful awakening when they rather begrudgingly introduced testing of some kind, with the understanding that testing would not be continued unless a certain proportion of the players tested positive. And that proportion of players was considerably in excess of anything anybody had estimated.

Medscape: Hadn't people thought of baseball as a drug-heavy sport? Is this a rude awakening?

Dr. Pipe: I don't think it's a rude awakening. You may recall 2 or 3 years ago the whole androstenedione-Mark McGwire issue, which should have been, and was for many of us, the clue that there was something seriously amiss here. It drew attention to the fact that baseball had no meaningful kind of program in place.

It has taken the Balco case and Barry Bonds and all this kind of stuff to further embed that concept. If people are only waking up to it now, they've been sleeping pretty soundly.

Medscape: What other drugs are baseball players taking?

Dr. Pipe: The sky's the limit. One would expect that the standard drugs of abuse in many sports would find their way to baseball. I would think anabolic steroids would be prominent on that list.

Medscape: If someone is using anabolic steroids, is it safe to stop cold turkey? Is there no withdrawal or rebound?

Dr. Pipe: I think it is safe to say you can stop cold turkey.

Medscape: Is there such a thing as "safe doping"?

Dr. Pipe: Do you want sport to be competition between humans, or do you want sport to be competition between pharmacologists? That's the question you've got to answer. If your answer to that is you don't really care, then you've created a kind of sport or quasi-sport experience in which you're prepared to let anything go.

Medscape: Are there different attitudes about doping in different sports?

Dr. Pipe: It's interesting to consider the public perception of what is allowable, permissible in the world wrestling entertainment world as opposed to public disdain and scorn for athletes in other sporting endeavours who get involved in these kinds of practises. It's quite clear that the public, in the broadest sense, looks at things like the world of professional wrestling as farcical entertainment. They don't really care what the heck happens to the athletes or what they do.

On the other hand, people who are strong supporters of sport look at sport, and see great value as a humanistic pastime that can add richness and texture and advantage to a culture and a community. If you mess with that culture and turn it into a pharmacologic free-for-all, you've destroyed something very special.

Medscape: There are differences in the culture and attitudes of wrestling vs baseball. Is that a reason baseball is such as big deal now, something about its own culture?

Dr. Pipe: Baseball is symbolic; it holds a special place in America's culture. The values of a community are reflected in the values of its most prized cultural pastimes. If you're going to say it's okay to have a drug-addled sport, basically what you're saying is that this cultural or sporting icon is just reflective of a drug-addled culture. Some would argue that baseball is a reflection of a culture mired in drugs.

I think that's the reason people who are truly serious about sport and value its role as a cultural force are particularly concerned that we exercise appropriate stewardship over it.

Medscape: Can physicians help with the attitudes and culture of sport?

Dr. Pipe: I think physicians can be very powerful proponents of that view. Most of us as physicians who are involved in sport are involved in sport because we see sport as being a wonderful opportunity to optimize health and all those other good things. It saddens us to think that, geez, medicine's contribution to sport in a perverse sense is to contribute to this doping kind of culture.

Medscape: At all levels of play, and among different leagues, is doping in Canadian baseball as bad as in the United States?

Dr. Pipe: At all the different levels of the sport, I think it would be safe to say no. I think there are a couple of reasons. One is the greater availability of drugs in general in the United States. Second is that prominence of sport, particularly football, where size and strength and power are much more important elements for success than might be the case in sports such as soccer and hockey as it's typically practiced in Canada.

That is not to say that we should adopt a Polyanna approach. Canada has had its doping problems in the past. Geez, we embarrassed ourselves in front of the world in 1988: the Ben Johnson scandal.

Medscape: Teens in the United States are under special pressure because many are competing for scholarships, through baseball. Does that hold true in Canada, too?

Dr. Pipe: That's another factor of sport life in the United States that's not the same here.

Medscape: Does Canada test baseball players at any level?

Dr. Pipe: Canada's professional baseball players are members of the US professional baseball leagues, and they have no testing programs. The only baseball players who would be tested in Canada as well as in the United States would be those individuals who are selected to play on an Olympic baseball team.

Medscape: How does testing Olympic baseball affect things?

Dr. Pipe: This has been an issue with members of Olympic baseball teams. You had the situation in Athens where the Greek team, which was largely made up of Americans who had dual citizenship, had issues with American athletes testing positive for steroids.

Medscape: Do steroids affect kids/teens/adults very differently?

Dr. Pipe: One of the side effects of steroids is that they will cause premature arrest of the growing bones. Steroid use can actually prevent young athletes from reaching their ultimate adult height at a particularly vulnerable time.

Medscape: What about other physical problems?

Dr. Pipe: The effects of anabolic steroids are so diverse, and they affect a multiplicity of organ systems. For instance, while they will increase the strength of muscle, they will paradoxically decrease the strength of tendons. You have the phenomenon of patellar and bicipital tendon rupture being more common in those using anabolic steroids.

Medscape: Do many people have the attitude that doping is okay, but getting caught is dumb?

Dr. Pipe: I'm sure that that attitude exists in some circles, and I'm sure you've got a very permissive culture simply because there have been no programs in place in professional sport in North America.

Medscape: What is known about the psycho-neuro effects of steroids?

Dr. Pipe: There's a fair amount written in the medical literature. The leading expert in that area is Dr. Harrison Pope at the McLean Hospital in Boston, Massachusetts, who has written extensively about these matters.

Medscape: Are these effects dose dependent ?

Dr. Pipe: I'm sure the effects of any drug are dose dependent.

Medscape: Is doping a problem in hockey?

Dr. Pipe: Yes. With the exception of Olympic and intercollegiate hockey in Canada, and the Quebec junior hockey league, there are no testing programs in any professional sport in Canada. You've got professional hockey whether it's NHL or Major Junior A or American Hockey League or Western Hockey League level. So yes, I think there is undoubtedly a problem.

Medscape: Is no sport safe from steroid abuse?

Dr. Pipe: Not at the professional level. The irony is the people who have really demonstrated responsibility in terms of trying to address this problem have been Olympic or amateur sports, or collegiate sports. They're the ones who feel the face of public criticism every time athletes test positive, whereas the highest-profile athletes in our communities, professional athletes, have lived in a world in North America where anything goes.

Medscape: How well do mandatory testing programs work out?

Dr. Pipe: They work very well.

Medscape: What is your perspective on the US Congressional hearings?

Dr. Pipe: I've only read about them in the press, but I think they're drawing attention to a very significant issue in a very significant sector of US life. Americans love their sport, they see sport as part of the American way of life. I think that all of a sudden light is being shone on some of the seedier aspects of sport. In that respect alone, these hearings are useful.

Medscape: Maybe they'll lead to better mandatory testing?

Dr. Pipe: The whole question is complex. Not only does major league baseball have to make some decisions about the programs it wants to introduce, but you also need, in a professional sport environment, to secure the support of players' associations.

I've never been able to understand players' associations, which presumably exist for the benefit and welfare of their members. They do not seem to realize that the programs that would address drug use among their members would be in the best interest of their members' health and welfare.

Coming Soon in Medscape Orthopaedics & Sports Medicine:

The Day they Burned The McGwire Bats: Major League Baseball's Disgrace, Part II

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