1. Athletic aids: fact or fiction? E.C. PERCY, MD
A major problem facing physicians involved in the daily care of amateur athletes in international competition is that of so-called doping. While there are many substances used that might be considered ineffectual or physiologic, the two main categories of substances considered as doping agents are stimulants and anabolic steroids. No substance is as yet known that will improve an athlete's performance. Often such substances are taken in error rather than in a misguided attempt to improve one's ability. These substances can be dangerous and, because of this, doping rules were established basically to protect the athlete. Anabolic steroids are particularly dangerous; they usually are taken by those engaged in lifting or throwing sports in an attempt to improve performance by increasing muscle bulk. There is as yet no scientific proof that performance is improved. Dope testing for stimulants should be carried out In a quantitative rather than quaiitatlve manner so that the athlete who has taken a small amount of a so-called stimulant (such as an asthma or common cold preparation) would not be excluded from competition. Rigid testing for anabolic steroids should be continued. Le dopage repr6sente un probieme majeur qu'ont & aifronter les m6decins impliques dans lea soins quotidlens aux athletes amateurs engag6s en Reprint requests to: Dr. B.C. Percy, 3550 C8te des Neiges Rd., Ste. 410, Montreal, PQ H3H 1V4
comp6tition internationale. Alors qu'il existe plusleurs substances qui peuvent .tre consider6es comme Inefficaces ou physiologiques, les deux principales cat6gories de produits consid6r6s comme substances dopantes sont les stimulants et les steroides anabolisants. II n'existe encore aucune substance reconnue capable d'am6liorer Ia performance d'un athl&te. On crolt que ces substances sont souvent prises par erreur, pas dans un effort malencontreux pour am6liorer son habilet6. Ces substances peuvent Stre dangereuses et, de ce fait, des r&giements concernant le dopage ont 6te 6tablis dana le but de proteger l'athl&te. Lea anabolisants sont particullirement dangereux; us sont habituellement utllia6s par lea leveurs et lea lanceurs dana l'eapolr d'ameiiorer lea performances en augmentant Ia masse musculaire; ii nexiste encore toutefois pas de preuve scientifique que Ia performance s'en trouve am6lioree. Lea epreuves antidopage pour lea stimulants devraient rechercher des resultata quantitatifa plutOt que qualitatifa de fa9on & ce qu'un athlete qul a pris une petite quantit6 d'un produit dit stimulant (tel qu'une preparation contre l'aathme ou le rhume) ne solt pas exciu des competitions. Lea tests rigides pour le d6pistage des anaboilsants devraient Stre maintenus. *The 10 papers in this symposium and the related editorial (page 563) were written by members of the Canadian medical team (playskians, therapists and a nurse) of the hit Olympiad.
Sport is defined as a "pleasant pastime; amusement; diversion . [or]*. participation in games or exercises While this definition would apply to recreational or amateur athletics, when professional sports are included the phrase "and sometimes for economic gain" should be added. To carry the definition to the level of international sport, the phrase "or for political gain" could also be added. In modern competitive sport, particularly at the international level, the merciless rigour of training for competition places increasing demands on the athlete to try to improve his or her performance.2 This improvement should be achieved sensibly through proper training and conditioning, sophisticated coaching and a more common-sense approach to dietary intake - that is, a greater emphasis on the physiologic aspects of athletic training. When the athlete is performing at his peak and still cannot meet local or world competitive standards he often turns to artificial aids in an attempt to augment his physical capabiities. These may include socially and legally acceptable nutritional aids such as vitamins, ginseng (generally harmless and ineffective), minerals (e.g., calcium and iron) and dietary manipulation. Physical aids such as acupuncture, blood transfusions, oxygen and high-altitude training have also been used. Psychologic support varies from the usual coach's pep talk to hypnotic suggestion. At the other end of the spectrum are the so-called doping agents, which are both morally and legally unacceptable under international regulations for ama-
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 601
teur sport. This broad grouping in- courage the use of artificial aids. The cludes stimulants, narcotic analgesics, total cost of this testing exceeded $1.6 depressants and the so-called muscle- million (C. Laurin: personal communibuilding drugs or anabolic steroids. cation, 1977). In this paper I have attempted to Generally the IOC has applied puniclarify the overemphasized problem of tive measures (i.e., disqualification from drug-taking among amateur athletes. I competition and loss of medals) in an contend that the alleged improvement attempt to discourage the use of doping in performance attributable to the tak- materials because of the health hazard ing of these aids is fiction, not fact. inherent in drug abuse. The medical Education of the athlete in this regard, commission of the IOC has also mainrather than application of punitive tained that, apart from the medical asmeasures, is the proper approach to this pects of doping and its possible deleproblem. terious effects on health, the moral aspects are important - that is, the use of doping agents is contrary to Background the rules of fair play, and without a The word dope is generally agreed set of rules that equalize sport there is to stem from the Dutch word dop, really no competition. In fact the use which is the name of a type of brandy of drugs often results in the athlete made from grape skins in South Africa. feeling guilty because he or she is A local hard liquor was said to have breaking the rules.4 been used by the Kaffirs as a stimulant at worship. The use of the term was Testing methods then broadened to include other socalled stimulating beverages. In cohA very sophisticated, highly accurate. temporary use the word has been ap- extremely expensive and time-consumplied to any substance that allegedly ing set of tests has evolved to disalters the performance of a competitor courage the athlete from resorting to in a sporting event. The term applies e use of drugs in international amaequally to humans and animals (e.g., te.i r athletic events.5 A random number race horses and dogs).2 of finishing positions to be tested are Although the word dope has been selected by the sport-governing body used for less than 100 years, artificial in a p.rticular discipline (e.g., cycling) aids have been used in an attempt to prior to the event without the knowlimprove athletic performance for over edge of the participants. For example, 2000 years. Brief references to the use the finishing positions 1, 2, 3, 5 and of such substances appear in very early 7 might be selected. Test marshalls at Olympic records, but it was not until the finishing line give the athletes who the last 100 years that verified cases finish in these positions a card with of doping in sports were reported. instructions to report to the dope-testCanal swimmers in Amsterdam in 1865 ing station for that venue as soon as were reported to have used dope, as possible; failure to do so could result were participants in the 6-day bicycle in disqualification. On arrival at the races in Holland in 1869. The first testing area the contestant selects a reported death in a bicycle race, in set of two similarly numbered bottles 1886, was found to be due to an over- and voids a specimen of urine into one dose of "trimethyl".2 There are also re- of the bottles (under the constant surports of athletes doping their opponents veillance of a member of the medical to make them lose. This practice, called commission). Half of the specimen is paradoping, is not uncommonly used as decanted into the second bottle and an excuse by athletes who have been the two bottles are sealed in the presfound to have a positive test for drugs ence of the athlete. One is forwarded during competition. immediately for testing; the second is Doping was first proven in 1910, refrigerated and, in the event of a when a saliva test on a horse revealed positive result from the first specimen, the presence of alkaloids.2 Numerous is tested similarly in the presence of other reports of positive tests have been the athlete or a member of his team. noted over the years in both animal The method of testing is gas chromaand human sporting events. The in- tography-mass spectrography and comcreasing number of deaths in humans puter interfacing.5 The results of the directly attributable to the use of dop- test are generally made known the ing agents eventually led the Interna- morning after the competition. tional Olympic Committee (IOC) in Testing for anabolic steroids was first 1968 to carry out doping tests at the carried out in Montreal in 1976, when winter Olympics in Grenoble and the urine specimens were submitted to summer Olympics in Mexico City. radioimmunoassay. The results of these During the 21st Olympiad in Montreal, tests, however, were not known for involving 7000 competitors, 2080 tests several days and medals could have were carried out in an attempt to dis- been presented by the time the results 602 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
became known. Indeed, the tested athlete could have left the competition site and returned to his own country. In addition, if an athlete stops taking the anabolic steroid a few months prior to competition the drug may not be evident in a urine specimen. It may be stored, however, in fatty tissues for a longer period and traces may be found even 7 weeks after the drug has been discontinued. Doping agents
The Council of Europe in 1963 defined doping as "the administration or use of substances in any form alien to the body or of physiological substances in abnormal amounts and with abnormal methods by healthy persons with the exclusive aim of attaining an artificial and unfair increase of performance in competition. Furthermore various psychological measures to increase performance in sports must be regarded as doping."2 IOC list
The IOC rules list substances that are usually tested for (Table I).. The drugs listed in sections A, B and C are defined under IOC rules as stimulants - that is, substances that theoretically improve the athlete's performance. A stimulating substance is one that quickens or enhances some physiologic process. There are two types of stimulation: direct, wherein the drug initiates the excitatory reaction; and indirect, wherein the drug allows the cell or tissue to function at a higher level of activity because of removal of inhibiting influences. The drugs in sections A, B and C - and E, which was added for
the 21st Olympiad - act directly, whereas drugs in section D and alcohol act indirectly. None of the materials listed has been proven scientifically to improve performance. The athletes and the lay press in particular are responsible for the false impression that certain substances will improve an athlete's performance. Indeed, the taking of drugs by athletes has been based on the false and entirely subjective impression that certain substances can lead to better performance. The abuse of drugs by athletes may well reflect drug abuse by the general population, which may have been influenced by false advertising claims. The Canadian federal government has introduced legislation to prohibit false advertising claims. In addition, pharmaceutical firms are now obliged to list on labels the ingredients in their proprietary products. If physicians would limit the use of drugs to the treatment of disease, injury or defi-
ciency the problem of drug abuse could well be minimized. Amphetamines Amphetamines have been the most commonly used stimulant. These substances fit into the broad group of anorectic agents; therefore the medical profession must share in the blame for their abuse. Fortunately in Canada they are listed under schedule G of the Food and Drugs Act and Regulations as controlled drugs and can only be prescribed for the treatment of narcolepsy, hyperkinetic disorders in children, mental retardation, epilepsy, parkinsonism and hypotensive states associated with anesthesia. They apparently can still be obtained in the United States merely by paying a visit to a physician's office. Amphetamines do give a sense of heightened alertness and relieve fatigue and lassitude, but they do not necessarily improve performance. Karpovitch's properly designed double-blind study6 showed clearly the effect of amphetamines on the performance of 54 young athletes who were asked to perform five strenuous physical activities. There was no essential difference in the overall performance of those who took amphetamines over those who took a placebo. Unfortunately, all too often more attention is paid to poorly controlled studies that report improved performance with the use of amphetamines. One example is the study of Smith and Beecher,7 who stated that "the majority of subjects performed better under influence of amphetamine (14
mg. per 70 kg.) than placebo. The improvement was statistically significant". In my opinion the only significant fact in this study was that the results were of no significance. Amphetamines and other central nervous system stimulants make the taker more aggressive and hostile. The resultant impression of improved performance is essentially subjective and due to the euphoria associated with the use of these drugs. Often these drugs remove the normal physiologic restraints intended to prevent overexertion; the homeostatic mechanisms become altered and the cardiovascular and musculoskeletal systems may be overextended, resulting in irreversible damage to their tissues. Dependence on these drugs is the direct result of their continued use; the user needs a gradually increasing dose to obtain greater excitatory or euphoric effects to combat fatigue more effectively. The use of amphetamines is not common in North America among amateur athletes, who probably most often take these agents in the form of proprietary drugs for treatment of the common cold or asthma. Occasionally amateur athletes resort to taking so-called stimulants when they have passed their prime and no longer reach international standards in their discipline. The taking of drugs is apparently fairly common in North America among baseball8 and football players but is rare among professional hockey players in my experience. According to newspaper reports doping is widespread among professional cyclists in Europe. At the 21st Olympiad 2080 tests for
stimulants were carried out, with only 11 positive results. One of the positive results was due to medication taken in error for asthma. Anabolic steroids The anabolic steroids are a relatively new group of aids. They are most commonly taken by athletes in the lifting or throwing sports, wrestling and football. When androgens first became available for experimental and therapeutic use there was some interest among scientists in determining whether they could help maintain or restore strength in ageing men with presumably low androgen concentrations. During World War II they were given to victims of starvation to help restore a positive nitrogen balance. Anabolic steroids were developed as less masculinizing substitutes for androgens and were first used in weight lifters on the incorrect assumption that they would somehow increase the formation of muscle tissue from protein in those with a positive nitrogen balance and unlimited access to protein. They have been eagerly accepted by some athletes on this basis, though they are no longer used by the medical profession. Although anabolic steroids have been shown to produce a positive nitrogen balance and weight gain in growing cattle, there are no scientific data to show that they have this effect in mature humans.9 A number of workers, such as Ryan,10 have claimed that these substances improve muscle bulk and strength but their conclusions do not appear to be based on well designed double-blind studies. Amateur athletes who admit to taking anabolic steroids have adamantly stated to me that these agents have enhanced their performance; they have also stated that, in general, most athletes in these sports now take these agents during training. This is probably exaggeration but the use of these materials appears to be widespread. Some athletes have stated that their coaches occasionally promote the use of these agents. Anabolic steroids are usually taken in high doses along with a high-protein diet during intensive training. The mere taking of any aid will give the athlete a psychologic boost, but the improved diet, dedication and intensive training are undoubtedly the most important factors. The double-blind study of Fowler, Gardner and Egstrom1' revealed that there was essentially no difference in effect between anabolic steroids and a placebo when taken by young men (athletes and nonathletes) who either exercised or did not; however, exercise consistently produced imCMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 603
provement in performance. The conclusion: it is good training, not anabolic steroids, that improves performance. Anabolic steroids appear to be readily available in limited quantities, though they are a prescription item listed under schedule F of the Canadian Food and Drugs Act and Regulations. The side effects of these drugs are frightening and include decreased libido, testicular atrophy, jaundice, cirrhosis of the liver, gynecomastia, salt and water retention, and hypertension. They may also cause premature closure of the epiphyses. During the 21st Olympiad 283 urine tests were carried out in a search for anabolic steroid abuse. There were eight positive results, seven in weightlifters and one in an athletics competitor. Other "aids" Blood transfusions are another means by which athletes attempt to improve their performance. The athlete has about a litre of blood withdrawn (by his team physician) approximately 3 weeks prior to competition. The blood is stored and given back to him 1 or 2 days before his competition. In the interim the individual's blood supply should be largely replenished by normal hematopoiesis. Theoretically the blood given before the competition increases the circulating blood volume and presumably the oxygen-carrying capacity of the blood, and as a result improves performance. However, a large number of the erythrocytes will have died during the 3-week interval, so the transfusion effect must be largely psychologic. This practice is also dangerous because of the risks of serum hepatitis, mismatched transfusions and infection. This misguided approach to improved performance should not be condoned. Oxygen administration before a race has no beneficial effect unless it is also done during the race. Similarly, highaltitude training prior to competition has not been shown to be of any great value in improving overall performance. A review of world record performances reveals that usually the winning athlete was not training at high altitude before the record was set. If altitude were a factor we might expect the Denver Broncos of the National Football League, who live and train at 1500 m during the football season, to be perennial Super Bowl champions. Alcohol, barbiturates and benzodiazepines are taken occasionally by athletes. Members of international shooting teams will occasionally admit to taking these agents to reduce tremor and steady their aim as well as to ease tension and thereby improve their over-
all performance. However, since eye tracking of a moving target is impaired by these drugs, accuracy in shooting must also be impaired.12 One of the "aids" most widely abused by athletes is the vitamin pill. All athletes seem to think that vitamin supplements are essential to good performance because of increased requirements during exercise - an erroneous belief. In general, vitamin supplements are indicated only for the treatment of a deficiency condition, and I doubt that any athletes have this problem. Indeed, there are probably more dangers in taking excessive amounts of the fatsoluble vitamins A and D. Preparations containing these substances are prohibited from being advertised or sold to the public without a prescription when the vitamin A content is more than 10000 IU or the vitamin D content more than 1000 IU. Even excesses of vitamin C have recently been suggested to be potentially dangerous. The R.gie de la sante de Quebec will no longer supply vitamins at public cost under the medicare scheme, considering that vitamins are not a tonic and are not required unless indicated by a deficiency state. Vitamins do not enhance performance, vitamin E claims to the contrary. It is difficult to convince athletes of this fact, however, and there are many who have become almost dependent on vitamins. During the 21st Olympiad the Canadian medical team made vitamins available to the athletes because we knew the materials were harmless. Often vitamin preparations, particularly those from Europe, contain additives that are banned in Canada, such as strychnine. The press and athletes in North America seemed to think that the East Germans, who did so well in the 1976 Olympics, must have been taking a "secret formula". Dr. I. Dardik is reported to be undertaking a controlled scientific study in an effort to dispel the myth of a "miracle pill".13 Problems with the regulations
It is difficult to prevent the taking of all substances considered doping agents because a large number are in over-the-counter pharmaceuticals. The athlete who has a common cold and takes a remedy given to him by his coach or another athlete may be taking a banned substance. Indeed, most common-cold remedies contain some form of decongestant belonging to the banned group of sympathomimetic drugs. In general, nasal and conjunctival decongestants must contain the forbidden substance in substantial amounts to be effective. A Canadian 604 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
athlete lost a medal in Mexico at the Pan-American Games in October 1975 and another was disqualified in the 1976 Olympics. Both were taking well known cold remedies available without a prescription in Canada. (These were not given to the athletes by the Canadian medical team.) Unfortunately the testing for sympathomimetic drugs is qualitative, not quantitative. I hope the testing will be modified slightly to recognize the quantitative aspects of drug use, for it is difficult to comprehend why an athlete who has diabetes can take insulin and another with hypothyroidism can take thyroid medication but an asthmatic is unable to take his usual medication without a penalty. Surely there is room in such cases for an acceptable quantitative urine test so that a therapeutic concentration of the drug could be recognized. Tests should be designed so as not to penalize athletes with a physical disability who are attempting to compete in spite of their problem. Some progress was made for the 1976 Olympics with the extension of the list of substances that could be used that previously had been banned (for example, some antiasthmatic drugs and an antidiarrheal drug containing narcotic analgesics). Analgesics are generally classified as banned drugs because they contain narcotics. Therefore many athletes who have trained for 3 or 4 years have been unable to compete or have had to perform below their normal potential because of the unrelieved pain of an injury incurred in training or competition. The only analgesic that can be used under the existing IOC rules is acetylsalicylic acid. An exception was made in the 1976 Olympics when injection of a local anesthetic was allowed provided the agent did not contain adrenalin. The team physician was required to submit a letter to the JOC medical commission before the event stating the reason for the injection. For the Canadian team this necessitated a large number of injections of local anesthetics and corticosteroids (several times into joints), whereas ordinarily a preparation containing codeine or a substitute would have been taken orally. Actually the use of local anesthetics is a form of doping as defined by the Council of Europe in 1963. One of our Canadian track and field competitors fell in a dormitory and sustained a fractured rib 10 days prior to the 20-km walk. As this was to be his fifth and probably last Olympiad he was determined to compete. We were unable to give him analgesics so resorted to an intercostal block immediately before the competition. He
bravely competed with pain but his performance was well below his personal best time. Surely it would have been better to allow him to take some form of acceptable analgesic in a therapeutic dose. What is really required for the busy physician working with Olympic athletes is not a list of banned drugs but a list of allowable ones. This list should include sympathomimetic drugs as well as analgesics, and the maximum acceptable therapeutic dose should be stated. At the 1976 Olympics le comit. organisateur des Jeux olympiques provided a list of the drugs available without cost in the excellent polyclinic in the Olympic Village. Unfortunately the list also included many that were designated in bold face as banned. The Canadian team did have its own small, but more than adequate, pharmacy in the village; none of the drugs made available at this clinic (through the generosity of Canadian pharmaceutical supply houses) was on the banned list. In this way the possibility of a banned drug being administered was minimized. All team members were warned about drug taking to such an extent that they almost became paranoic about taking medication (perhaps not a bad state). In spite of this, one athlete did take a forbidden drug for asthma and was caught and punished. Conclusion After 25 years of intense exposure to all levels of amateur and professional athletics as a physician, I believe that doping is not by any means as serious a problem on this continent as it is made to appear by the press. As with any individual, the athlete strives to win in his or her chosen field, but in their particularly intense desire to achieve victory, athletes tend to be superstitious, gullible, impressionable and hypochondriacal. They are apt to try almost anything to improve their performance, be it dietary, physical, psychologic or pharmacologic. So-called doping agents, however, appear to be used rarely by amateurs but more often by professionals, particularly football players. (The individual taking amphetamines is usually easy to spot during a game because he is generally aggressive and very often makes a tackle late, resorts to extremely rough play or misses an assignment.) One exception to minimal drug taking by amateurs is the use of anabolic steroids by athletes in lifting or throwing sports. This use is not to be condoned. There is no evidence that any of these materials improve performance and their inherent dangers are appreciable. Doping at the amateur level does not appear to be a problem and there does
not appear to be any justification for the media's feeling that the medals should be given to the pharmaceutical houses. A more positive approach should be taken in dope testing and therapeutically acceptable concentrations of certain banned drugs should be allowed prior to competition. The team physicians could submit a letter to the members of the lOG medical commission informing them of the diagnosis, the medication and the amount prescribed to a competing athlete prior to competition. Punitive measures are still necessary, however, to control the abuse of drugs, particularly anabolic steroids because of their inherent dangers to the user. I hope that in the future at international events a list of drugs that can be used rather than a list of banned drugs will be made available to team physicians. Sport plays an important role in our society and the abuse of medication SEPTRA . Summary by athletes merely reflects the habits [. (Trimethoprim +Sultamethoxazole) of our "pill-popping" populace. Perhaps INDICATIONS AND CLINICAL USES: Indicated for the following infections when caused by susceptible organisms: it is time that the medical profession URINARY TRACT INFECTIONS - acute, recurrent and chronic. reassessed its customary habits in pre- GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. scribing medication and slowed down UPPER AND LOWER RESPIRATORY TRACT INFECTIONS this alarming trend. Physicians may particularly chronic bronchitis and acute and chronic otitis media. GASTROINTESTINAL TRACT INFECTIONS. help propagate the myth that pills in- SKIN AND SOFT TISSUE INFECTIONS. crease performance by the way they SEPTRA is not indicated in intections caused by Pseudomonas, Mycoplasma or viruses. This drug has not yet been fully evaluated freely prescribe some medications. Even in streptococcal infections. Patients with evidence of marked liver if the taking of vitamins is harmless, CONTRAINDICATIONS: parenchymal damage, blood dyscrasias, known hypersensitivity to the prevailing misconception that they trimethoprim or sulfonamides, marked renal impairment where serum .says cannot be carried out; premature or newborn improve performance is perpetrated by repeatedduring the first few weeks of life. For the time being SEPTRA their continued misuse. Therefore phy- babies is contraindicated during pregnancy. If pregnancy cannot be eucluded, the possible risks should be balanced against the sicians should not prescribe them for expected therapeutic effect. indeterminate purposes. PRECAUTIONS: As with other sulfonamide preparations, critical of benefit versus risk should be made in patients with liver Improved athletic performance from appraisal damage, renal damage, urinary obstruction, blood dyscrasias, the taking of drugs is fiction, not fact. allergies or bronchial asthma. The possibility of a superinfection a non-sensitive organism should be borne in mind. Performance can only be improved by with DOSAGE AND ADMINISTRATION: Adults and children over 12 determined effort, proper conditioning years. Standard dosage: Two Septra tablets or one Septra OS tablet twice and dedicated training. daily (morning and evening). Minimum dosage and dosage for long-term treatment: One Septra References tablet or one-halt Septra DS tablet twice daily.
SEPTRA
* sequentially blocks two different bacterial enzymes (both vital for bacterial survival) * double blockade activity discourages development of resistance * achieves rapid, high blood levels; significant levels in lung tissue and sputum * well tolerated by most patients * convenient b.i.d. tablet dosage * licorice-flavored suspension well accepted by children
1. The Shorter Oxford English Dictionary, 3rd ed, Oxford, Clarendon Pr, 1944, p 1980 2. PROKOP L: The Problem of Doping, International Olympic Committee medical commission publ, Lausanne, 1972 3. Fn-c. KD: The ethics of artificial aids and the sportsman. NZ .1 Sports Med 312: 7, 1975 4. MILLER DM. RUSSELL KRE: Sport: A Contemporary View. Philadelphia, Lea & Febiger, 1971, p 27 5. DUGAL R, BERTRAND M: International Olympic Committee Medical Controls, Games of the XXJst Olympiad, Montreal, 1976, comit6 organisateur des Jeux olympiques 6. KARPOVITCH PV: Effect of amphetamine sulfate on athletic performance. JAMA 170: 118, 1959 7. SMITH GM, BEECHER 1-1K: Amphetamine sulfate and athletic performance. I. Objective effects. Ibid, p 542 8. Baseball vs. Drugs, Office of the Commissioner of Baseball, New York, Brothers Educ PubIs, 1970
9. RANGNO RE: Drugs in Sports: the Myth and Facts, annual symposium on sports medicine, U of Montreal, October 1973
10. RYAN AJ: The Use and Abuse of Drugs in Sports, PE 508 workshop, dept of physical education, U of Wisconsin, Madison
11. FOWLER WM JR, GARDNER GW, EG5TROM GH: The effect of an anabolic steroid on physical performance of young men. I Appl
Physiol 20: Proc R Soc 13. DOLINAR L: performance. 1976
1038, 1965 Med 69: 479, 1976 MD to study data on drugs, Physician Sports Med 4: 16,
12. WILKINSON IMS: Disorders of eye movement.
Maximum dosage: Overwhelming infections: Three Septra tablets or one and one-halt Septra OS tablets twice daily. Uncomplicated gonorrhea: Two Septra tablets or one Septra OS tablet tour times daily for 2 days. Children 12 years and under.t Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pedialric suspension twice daily. Children 210 5 years: One to two pediatric tablets or 2.5 to 5 ml pediatric suspension twice daily. Children 6 to 12 years: Two to tour pediatric tablets or 510 10 ml pediatric suspension or one adult tablet twice daily (Septra OS tablets should not be used for children under 12 years.) tin children this corresponds to an approximate dose 01 6 mg trimethoprim/kg body weight/day, plus 30 mg sultamethooazole/kg body weight/day, divided into two equal doses. DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazole, and coded WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100 SEPTRA OS TABLETS, each containing 160 mg trimethoprim and BOO mg sulfamethoxazole, and coded WELLCOME 02C. Bottles ot 50 and 250. SEPTRA PEDIATRIC SUSPENSION, each teaspoonful (5 ml) containing 40 mg trimethoprim and 200 mg sulfamethoxazole Bottles of 100 and 400 ml SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg sulfamethoxazole, and coded WELLCOME H4B Bottles of 100 Product monograph available on request
. Burroughs Welicome Salle, Qu6. Trade Mark
Ltd.
W-7002
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 605
A major problem facing physicians involved in the daily care of amateur athletes in international competition is that of so-called doping. While there are many substances used that might be considered ineffectual or physiologic, the two main categories of substances considered as doping agents are stimulants and anabolic steroids. No substance is as yet known that will improve an athlete's performance. Often such substances are taken in error rather than in a misguided attempt to improve one's ability. These substances can be dangerous and, because of this, doping rules were established basically to protect the athlete. Anabolic steroids are particularly dangerous; they usually are taken by those engaged in lifting or throwing sports in an attempt to improve performance by increasing muscle bulk. There is as yet no scientific proof that performance is improved. Dope testing for stimulants should be carried out In a quantitative rather than quaiitatlve manner so that the athlete who has taken a small amount of a so-called stimulant (such as an asthma or common cold preparation) would not be excluded from competition. Rigid testing for anabolic steroids should be continued. Le dopage repr6sente un probieme majeur qu'ont & aifronter les m6decins impliques dans lea soins quotidlens aux athletes amateurs engag6s en Reprint requests to: Dr. B.C. Percy, 3550 C8te des Neiges Rd., Ste. 410, Montreal, PQ H3H 1V4
comp6tition internationale. Alors qu'il existe plusleurs substances qui peuvent .tre consider6es comme Inefficaces ou physiologiques, les deux principales cat6gories de produits consid6r6s comme substances dopantes sont les stimulants et les steroides anabolisants. II n'existe encore aucune substance reconnue capable d'am6liorer Ia performance d'un athl&te. On crolt que ces substances sont souvent prises par erreur, pas dans un effort malencontreux pour am6liorer son habilet6. Ces substances peuvent Stre dangereuses et, de ce fait, des r&giements concernant le dopage ont 6te 6tablis dana le but de proteger l'athl&te. Lea anabolisants sont particullirement dangereux; us sont habituellement utllia6s par lea leveurs et lea lanceurs dana l'eapolr d'ameiiorer lea performances en augmentant Ia masse musculaire; ii nexiste encore toutefois pas de preuve scientifique que Ia performance s'en trouve am6lioree. Lea epreuves antidopage pour lea stimulants devraient rechercher des resultata quantitatifa plutOt que qualitatifa de fa9on & ce qu'un athlete qul a pris une petite quantit6 d'un produit dit stimulant (tel qu'une preparation contre l'aathme ou le rhume) ne solt pas exciu des competitions. Lea tests rigides pour le d6pistage des anaboilsants devraient Stre maintenus. *The 10 papers in this symposium and the related editorial (page 563) were written by members of the Canadian medical team (playskians, therapists and a nurse) of the hit Olympiad.
Sport is defined as a "pleasant pastime; amusement; diversion . [or]*. participation in games or exercises While this definition would apply to recreational or amateur athletics, when professional sports are included the phrase "and sometimes for economic gain" should be added. To carry the definition to the level of international sport, the phrase "or for political gain" could also be added. In modern competitive sport, particularly at the international level, the merciless rigour of training for competition places increasing demands on the athlete to try to improve his or her performance.2 This improvement should be achieved sensibly through proper training and conditioning, sophisticated coaching and a more common-sense approach to dietary intake - that is, a greater emphasis on the physiologic aspects of athletic training. When the athlete is performing at his peak and still cannot meet local or world competitive standards he often turns to artificial aids in an attempt to augment his physical capabiities. These may include socially and legally acceptable nutritional aids such as vitamins, ginseng (generally harmless and ineffective), minerals (e.g., calcium and iron) and dietary manipulation. Physical aids such as acupuncture, blood transfusions, oxygen and high-altitude training have also been used. Psychologic support varies from the usual coach's pep talk to hypnotic suggestion. At the other end of the spectrum are the so-called doping agents, which are both morally and legally unacceptable under international regulations for ama-
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 601
teur sport. This broad grouping in- courage the use of artificial aids. The cludes stimulants, narcotic analgesics, total cost of this testing exceeded $1.6 depressants and the so-called muscle- million (C. Laurin: personal communibuilding drugs or anabolic steroids. cation, 1977). In this paper I have attempted to Generally the IOC has applied puniclarify the overemphasized problem of tive measures (i.e., disqualification from drug-taking among amateur athletes. I competition and loss of medals) in an contend that the alleged improvement attempt to discourage the use of doping in performance attributable to the tak- materials because of the health hazard ing of these aids is fiction, not fact. inherent in drug abuse. The medical Education of the athlete in this regard, commission of the IOC has also mainrather than application of punitive tained that, apart from the medical asmeasures, is the proper approach to this pects of doping and its possible deleproblem. terious effects on health, the moral aspects are important - that is, the use of doping agents is contrary to Background the rules of fair play, and without a The word dope is generally agreed set of rules that equalize sport there is to stem from the Dutch word dop, really no competition. In fact the use which is the name of a type of brandy of drugs often results in the athlete made from grape skins in South Africa. feeling guilty because he or she is A local hard liquor was said to have breaking the rules.4 been used by the Kaffirs as a stimulant at worship. The use of the term was Testing methods then broadened to include other socalled stimulating beverages. In cohA very sophisticated, highly accurate. temporary use the word has been ap- extremely expensive and time-consumplied to any substance that allegedly ing set of tests has evolved to disalters the performance of a competitor courage the athlete from resorting to in a sporting event. The term applies e use of drugs in international amaequally to humans and animals (e.g., te.i r athletic events.5 A random number race horses and dogs).2 of finishing positions to be tested are Although the word dope has been selected by the sport-governing body used for less than 100 years, artificial in a p.rticular discipline (e.g., cycling) aids have been used in an attempt to prior to the event without the knowlimprove athletic performance for over edge of the participants. For example, 2000 years. Brief references to the use the finishing positions 1, 2, 3, 5 and of such substances appear in very early 7 might be selected. Test marshalls at Olympic records, but it was not until the finishing line give the athletes who the last 100 years that verified cases finish in these positions a card with of doping in sports were reported. instructions to report to the dope-testCanal swimmers in Amsterdam in 1865 ing station for that venue as soon as were reported to have used dope, as possible; failure to do so could result were participants in the 6-day bicycle in disqualification. On arrival at the races in Holland in 1869. The first testing area the contestant selects a reported death in a bicycle race, in set of two similarly numbered bottles 1886, was found to be due to an over- and voids a specimen of urine into one dose of "trimethyl".2 There are also re- of the bottles (under the constant surports of athletes doping their opponents veillance of a member of the medical to make them lose. This practice, called commission). Half of the specimen is paradoping, is not uncommonly used as decanted into the second bottle and an excuse by athletes who have been the two bottles are sealed in the presfound to have a positive test for drugs ence of the athlete. One is forwarded during competition. immediately for testing; the second is Doping was first proven in 1910, refrigerated and, in the event of a when a saliva test on a horse revealed positive result from the first specimen, the presence of alkaloids.2 Numerous is tested similarly in the presence of other reports of positive tests have been the athlete or a member of his team. noted over the years in both animal The method of testing is gas chromaand human sporting events. The in- tography-mass spectrography and comcreasing number of deaths in humans puter interfacing.5 The results of the directly attributable to the use of dop- test are generally made known the ing agents eventually led the Interna- morning after the competition. tional Olympic Committee (IOC) in Testing for anabolic steroids was first 1968 to carry out doping tests at the carried out in Montreal in 1976, when winter Olympics in Grenoble and the urine specimens were submitted to summer Olympics in Mexico City. radioimmunoassay. The results of these During the 21st Olympiad in Montreal, tests, however, were not known for involving 7000 competitors, 2080 tests several days and medals could have were carried out in an attempt to dis- been presented by the time the results 602 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
became known. Indeed, the tested athlete could have left the competition site and returned to his own country. In addition, if an athlete stops taking the anabolic steroid a few months prior to competition the drug may not be evident in a urine specimen. It may be stored, however, in fatty tissues for a longer period and traces may be found even 7 weeks after the drug has been discontinued. Doping agents
The Council of Europe in 1963 defined doping as "the administration or use of substances in any form alien to the body or of physiological substances in abnormal amounts and with abnormal methods by healthy persons with the exclusive aim of attaining an artificial and unfair increase of performance in competition. Furthermore various psychological measures to increase performance in sports must be regarded as doping."2 IOC list
The IOC rules list substances that are usually tested for (Table I).. The drugs listed in sections A, B and C are defined under IOC rules as stimulants - that is, substances that theoretically improve the athlete's performance. A stimulating substance is one that quickens or enhances some physiologic process. There are two types of stimulation: direct, wherein the drug initiates the excitatory reaction; and indirect, wherein the drug allows the cell or tissue to function at a higher level of activity because of removal of inhibiting influences. The drugs in sections A, B and C - and E, which was added for
the 21st Olympiad - act directly, whereas drugs in section D and alcohol act indirectly. None of the materials listed has been proven scientifically to improve performance. The athletes and the lay press in particular are responsible for the false impression that certain substances will improve an athlete's performance. Indeed, the taking of drugs by athletes has been based on the false and entirely subjective impression that certain substances can lead to better performance. The abuse of drugs by athletes may well reflect drug abuse by the general population, which may have been influenced by false advertising claims. The Canadian federal government has introduced legislation to prohibit false advertising claims. In addition, pharmaceutical firms are now obliged to list on labels the ingredients in their proprietary products. If physicians would limit the use of drugs to the treatment of disease, injury or defi-
ciency the problem of drug abuse could well be minimized. Amphetamines Amphetamines have been the most commonly used stimulant. These substances fit into the broad group of anorectic agents; therefore the medical profession must share in the blame for their abuse. Fortunately in Canada they are listed under schedule G of the Food and Drugs Act and Regulations as controlled drugs and can only be prescribed for the treatment of narcolepsy, hyperkinetic disorders in children, mental retardation, epilepsy, parkinsonism and hypotensive states associated with anesthesia. They apparently can still be obtained in the United States merely by paying a visit to a physician's office. Amphetamines do give a sense of heightened alertness and relieve fatigue and lassitude, but they do not necessarily improve performance. Karpovitch's properly designed double-blind study6 showed clearly the effect of amphetamines on the performance of 54 young athletes who were asked to perform five strenuous physical activities. There was no essential difference in the overall performance of those who took amphetamines over those who took a placebo. Unfortunately, all too often more attention is paid to poorly controlled studies that report improved performance with the use of amphetamines. One example is the study of Smith and Beecher,7 who stated that "the majority of subjects performed better under influence of amphetamine (14
mg. per 70 kg.) than placebo. The improvement was statistically significant". In my opinion the only significant fact in this study was that the results were of no significance. Amphetamines and other central nervous system stimulants make the taker more aggressive and hostile. The resultant impression of improved performance is essentially subjective and due to the euphoria associated with the use of these drugs. Often these drugs remove the normal physiologic restraints intended to prevent overexertion; the homeostatic mechanisms become altered and the cardiovascular and musculoskeletal systems may be overextended, resulting in irreversible damage to their tissues. Dependence on these drugs is the direct result of their continued use; the user needs a gradually increasing dose to obtain greater excitatory or euphoric effects to combat fatigue more effectively. The use of amphetamines is not common in North America among amateur athletes, who probably most often take these agents in the form of proprietary drugs for treatment of the common cold or asthma. Occasionally amateur athletes resort to taking so-called stimulants when they have passed their prime and no longer reach international standards in their discipline. The taking of drugs is apparently fairly common in North America among baseball8 and football players but is rare among professional hockey players in my experience. According to newspaper reports doping is widespread among professional cyclists in Europe. At the 21st Olympiad 2080 tests for
stimulants were carried out, with only 11 positive results. One of the positive results was due to medication taken in error for asthma. Anabolic steroids The anabolic steroids are a relatively new group of aids. They are most commonly taken by athletes in the lifting or throwing sports, wrestling and football. When androgens first became available for experimental and therapeutic use there was some interest among scientists in determining whether they could help maintain or restore strength in ageing men with presumably low androgen concentrations. During World War II they were given to victims of starvation to help restore a positive nitrogen balance. Anabolic steroids were developed as less masculinizing substitutes for androgens and were first used in weight lifters on the incorrect assumption that they would somehow increase the formation of muscle tissue from protein in those with a positive nitrogen balance and unlimited access to protein. They have been eagerly accepted by some athletes on this basis, though they are no longer used by the medical profession. Although anabolic steroids have been shown to produce a positive nitrogen balance and weight gain in growing cattle, there are no scientific data to show that they have this effect in mature humans.9 A number of workers, such as Ryan,10 have claimed that these substances improve muscle bulk and strength but their conclusions do not appear to be based on well designed double-blind studies. Amateur athletes who admit to taking anabolic steroids have adamantly stated to me that these agents have enhanced their performance; they have also stated that, in general, most athletes in these sports now take these agents during training. This is probably exaggeration but the use of these materials appears to be widespread. Some athletes have stated that their coaches occasionally promote the use of these agents. Anabolic steroids are usually taken in high doses along with a high-protein diet during intensive training. The mere taking of any aid will give the athlete a psychologic boost, but the improved diet, dedication and intensive training are undoubtedly the most important factors. The double-blind study of Fowler, Gardner and Egstrom1' revealed that there was essentially no difference in effect between anabolic steroids and a placebo when taken by young men (athletes and nonathletes) who either exercised or did not; however, exercise consistently produced imCMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 603
provement in performance. The conclusion: it is good training, not anabolic steroids, that improves performance. Anabolic steroids appear to be readily available in limited quantities, though they are a prescription item listed under schedule F of the Canadian Food and Drugs Act and Regulations. The side effects of these drugs are frightening and include decreased libido, testicular atrophy, jaundice, cirrhosis of the liver, gynecomastia, salt and water retention, and hypertension. They may also cause premature closure of the epiphyses. During the 21st Olympiad 283 urine tests were carried out in a search for anabolic steroid abuse. There were eight positive results, seven in weightlifters and one in an athletics competitor. Other "aids" Blood transfusions are another means by which athletes attempt to improve their performance. The athlete has about a litre of blood withdrawn (by his team physician) approximately 3 weeks prior to competition. The blood is stored and given back to him 1 or 2 days before his competition. In the interim the individual's blood supply should be largely replenished by normal hematopoiesis. Theoretically the blood given before the competition increases the circulating blood volume and presumably the oxygen-carrying capacity of the blood, and as a result improves performance. However, a large number of the erythrocytes will have died during the 3-week interval, so the transfusion effect must be largely psychologic. This practice is also dangerous because of the risks of serum hepatitis, mismatched transfusions and infection. This misguided approach to improved performance should not be condoned. Oxygen administration before a race has no beneficial effect unless it is also done during the race. Similarly, highaltitude training prior to competition has not been shown to be of any great value in improving overall performance. A review of world record performances reveals that usually the winning athlete was not training at high altitude before the record was set. If altitude were a factor we might expect the Denver Broncos of the National Football League, who live and train at 1500 m during the football season, to be perennial Super Bowl champions. Alcohol, barbiturates and benzodiazepines are taken occasionally by athletes. Members of international shooting teams will occasionally admit to taking these agents to reduce tremor and steady their aim as well as to ease tension and thereby improve their over-
all performance. However, since eye tracking of a moving target is impaired by these drugs, accuracy in shooting must also be impaired.12 One of the "aids" most widely abused by athletes is the vitamin pill. All athletes seem to think that vitamin supplements are essential to good performance because of increased requirements during exercise - an erroneous belief. In general, vitamin supplements are indicated only for the treatment of a deficiency condition, and I doubt that any athletes have this problem. Indeed, there are probably more dangers in taking excessive amounts of the fatsoluble vitamins A and D. Preparations containing these substances are prohibited from being advertised or sold to the public without a prescription when the vitamin A content is more than 10000 IU or the vitamin D content more than 1000 IU. Even excesses of vitamin C have recently been suggested to be potentially dangerous. The R.gie de la sante de Quebec will no longer supply vitamins at public cost under the medicare scheme, considering that vitamins are not a tonic and are not required unless indicated by a deficiency state. Vitamins do not enhance performance, vitamin E claims to the contrary. It is difficult to convince athletes of this fact, however, and there are many who have become almost dependent on vitamins. During the 21st Olympiad the Canadian medical team made vitamins available to the athletes because we knew the materials were harmless. Often vitamin preparations, particularly those from Europe, contain additives that are banned in Canada, such as strychnine. The press and athletes in North America seemed to think that the East Germans, who did so well in the 1976 Olympics, must have been taking a "secret formula". Dr. I. Dardik is reported to be undertaking a controlled scientific study in an effort to dispel the myth of a "miracle pill".13 Problems with the regulations
It is difficult to prevent the taking of all substances considered doping agents because a large number are in over-the-counter pharmaceuticals. The athlete who has a common cold and takes a remedy given to him by his coach or another athlete may be taking a banned substance. Indeed, most common-cold remedies contain some form of decongestant belonging to the banned group of sympathomimetic drugs. In general, nasal and conjunctival decongestants must contain the forbidden substance in substantial amounts to be effective. A Canadian 604 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
athlete lost a medal in Mexico at the Pan-American Games in October 1975 and another was disqualified in the 1976 Olympics. Both were taking well known cold remedies available without a prescription in Canada. (These were not given to the athletes by the Canadian medical team.) Unfortunately the testing for sympathomimetic drugs is qualitative, not quantitative. I hope the testing will be modified slightly to recognize the quantitative aspects of drug use, for it is difficult to comprehend why an athlete who has diabetes can take insulin and another with hypothyroidism can take thyroid medication but an asthmatic is unable to take his usual medication without a penalty. Surely there is room in such cases for an acceptable quantitative urine test so that a therapeutic concentration of the drug could be recognized. Tests should be designed so as not to penalize athletes with a physical disability who are attempting to compete in spite of their problem. Some progress was made for the 1976 Olympics with the extension of the list of substances that could be used that previously had been banned (for example, some antiasthmatic drugs and an antidiarrheal drug containing narcotic analgesics). Analgesics are generally classified as banned drugs because they contain narcotics. Therefore many athletes who have trained for 3 or 4 years have been unable to compete or have had to perform below their normal potential because of the unrelieved pain of an injury incurred in training or competition. The only analgesic that can be used under the existing IOC rules is acetylsalicylic acid. An exception was made in the 1976 Olympics when injection of a local anesthetic was allowed provided the agent did not contain adrenalin. The team physician was required to submit a letter to the JOC medical commission before the event stating the reason for the injection. For the Canadian team this necessitated a large number of injections of local anesthetics and corticosteroids (several times into joints), whereas ordinarily a preparation containing codeine or a substitute would have been taken orally. Actually the use of local anesthetics is a form of doping as defined by the Council of Europe in 1963. One of our Canadian track and field competitors fell in a dormitory and sustained a fractured rib 10 days prior to the 20-km walk. As this was to be his fifth and probably last Olympiad he was determined to compete. We were unable to give him analgesics so resorted to an intercostal block immediately before the competition. He
bravely competed with pain but his performance was well below his personal best time. Surely it would have been better to allow him to take some form of acceptable analgesic in a therapeutic dose. What is really required for the busy physician working with Olympic athletes is not a list of banned drugs but a list of allowable ones. This list should include sympathomimetic drugs as well as analgesics, and the maximum acceptable therapeutic dose should be stated. At the 1976 Olympics le comit. organisateur des Jeux olympiques provided a list of the drugs available without cost in the excellent polyclinic in the Olympic Village. Unfortunately the list also included many that were designated in bold face as banned. The Canadian team did have its own small, but more than adequate, pharmacy in the village; none of the drugs made available at this clinic (through the generosity of Canadian pharmaceutical supply houses) was on the banned list. In this way the possibility of a banned drug being administered was minimized. All team members were warned about drug taking to such an extent that they almost became paranoic about taking medication (perhaps not a bad state). In spite of this, one athlete did take a forbidden drug for asthma and was caught and punished. Conclusion After 25 years of intense exposure to all levels of amateur and professional athletics as a physician, I believe that doping is not by any means as serious a problem on this continent as it is made to appear by the press. As with any individual, the athlete strives to win in his or her chosen field, but in their particularly intense desire to achieve victory, athletes tend to be superstitious, gullible, impressionable and hypochondriacal. They are apt to try almost anything to improve their performance, be it dietary, physical, psychologic or pharmacologic. So-called doping agents, however, appear to be used rarely by amateurs but more often by professionals, particularly football players. (The individual taking amphetamines is usually easy to spot during a game because he is generally aggressive and very often makes a tackle late, resorts to extremely rough play or misses an assignment.) One exception to minimal drug taking by amateurs is the use of anabolic steroids by athletes in lifting or throwing sports. This use is not to be condoned. There is no evidence that any of these materials improve performance and their inherent dangers are appreciable. Doping at the amateur level does not appear to be a problem and there does
not appear to be any justification for the media's feeling that the medals should be given to the pharmaceutical houses. A more positive approach should be taken in dope testing and therapeutically acceptable concentrations of certain banned drugs should be allowed prior to competition. The team physicians could submit a letter to the members of the lOG medical commission informing them of the diagnosis, the medication and the amount prescribed to a competing athlete prior to competition. Punitive measures are still necessary, however, to control the abuse of drugs, particularly anabolic steroids because of their inherent dangers to the user. I hope that in the future at international events a list of drugs that can be used rather than a list of banned drugs will be made available to team physicians. Sport plays an important role in our society and the abuse of medication SEPTRA . Summary by athletes merely reflects the habits [. (Trimethoprim +Sultamethoxazole) of our "pill-popping" populace. Perhaps INDICATIONS AND CLINICAL USES: Indicated for the following infections when caused by susceptible organisms: it is time that the medical profession URINARY TRACT INFECTIONS - acute, recurrent and chronic. reassessed its customary habits in pre- GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. scribing medication and slowed down UPPER AND LOWER RESPIRATORY TRACT INFECTIONS this alarming trend. Physicians may particularly chronic bronchitis and acute and chronic otitis media. GASTROINTESTINAL TRACT INFECTIONS. help propagate the myth that pills in- SKIN AND SOFT TISSUE INFECTIONS. crease performance by the way they SEPTRA is not indicated in intections caused by Pseudomonas, Mycoplasma or viruses. This drug has not yet been fully evaluated freely prescribe some medications. Even in streptococcal infections. Patients with evidence of marked liver if the taking of vitamins is harmless, CONTRAINDICATIONS: parenchymal damage, blood dyscrasias, known hypersensitivity to the prevailing misconception that they trimethoprim or sulfonamides, marked renal impairment where serum .says cannot be carried out; premature or newborn improve performance is perpetrated by repeatedduring the first few weeks of life. For the time being SEPTRA their continued misuse. Therefore phy- babies is contraindicated during pregnancy. If pregnancy cannot be eucluded, the possible risks should be balanced against the sicians should not prescribe them for expected therapeutic effect. indeterminate purposes. PRECAUTIONS: As with other sulfonamide preparations, critical of benefit versus risk should be made in patients with liver Improved athletic performance from appraisal damage, renal damage, urinary obstruction, blood dyscrasias, the taking of drugs is fiction, not fact. allergies or bronchial asthma. The possibility of a superinfection a non-sensitive organism should be borne in mind. Performance can only be improved by with DOSAGE AND ADMINISTRATION: Adults and children over 12 determined effort, proper conditioning years. Standard dosage: Two Septra tablets or one Septra OS tablet twice and dedicated training. daily (morning and evening). Minimum dosage and dosage for long-term treatment: One Septra References tablet or one-halt Septra DS tablet twice daily.
SEPTRA
* sequentially blocks two different bacterial enzymes (both vital for bacterial survival) * double blockade activity discourages development of resistance * achieves rapid, high blood levels; significant levels in lung tissue and sputum * well tolerated by most patients * convenient b.i.d. tablet dosage * licorice-flavored suspension well accepted by children
1. The Shorter Oxford English Dictionary, 3rd ed, Oxford, Clarendon Pr, 1944, p 1980 2. PROKOP L: The Problem of Doping, International Olympic Committee medical commission publ, Lausanne, 1972 3. Fn-c. KD: The ethics of artificial aids and the sportsman. NZ .1 Sports Med 312: 7, 1975 4. MILLER DM. RUSSELL KRE: Sport: A Contemporary View. Philadelphia, Lea & Febiger, 1971, p 27 5. DUGAL R, BERTRAND M: International Olympic Committee Medical Controls, Games of the XXJst Olympiad, Montreal, 1976, comit6 organisateur des Jeux olympiques 6. KARPOVITCH PV: Effect of amphetamine sulfate on athletic performance. JAMA 170: 118, 1959 7. SMITH GM, BEECHER 1-1K: Amphetamine sulfate and athletic performance. I. Objective effects. Ibid, p 542 8. Baseball vs. Drugs, Office of the Commissioner of Baseball, New York, Brothers Educ PubIs, 1970
9. RANGNO RE: Drugs in Sports: the Myth and Facts, annual symposium on sports medicine, U of Montreal, October 1973
10. RYAN AJ: The Use and Abuse of Drugs in Sports, PE 508 workshop, dept of physical education, U of Wisconsin, Madison
11. FOWLER WM JR, GARDNER GW, EG5TROM GH: The effect of an anabolic steroid on physical performance of young men. I Appl
Physiol 20: Proc R Soc 13. DOLINAR L: performance. 1976
1038, 1965 Med 69: 479, 1976 MD to study data on drugs, Physician Sports Med 4: 16,
12. WILKINSON IMS: Disorders of eye movement.
Maximum dosage: Overwhelming infections: Three Septra tablets or one and one-halt Septra OS tablets twice daily. Uncomplicated gonorrhea: Two Septra tablets or one Septra OS tablet tour times daily for 2 days. Children 12 years and under.t Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pedialric suspension twice daily. Children 210 5 years: One to two pediatric tablets or 2.5 to 5 ml pediatric suspension twice daily. Children 6 to 12 years: Two to tour pediatric tablets or 510 10 ml pediatric suspension or one adult tablet twice daily (Septra OS tablets should not be used for children under 12 years.) tin children this corresponds to an approximate dose 01 6 mg trimethoprim/kg body weight/day, plus 30 mg sultamethooazole/kg body weight/day, divided into two equal doses. DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazole, and coded WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100 SEPTRA OS TABLETS, each containing 160 mg trimethoprim and BOO mg sulfamethoxazole, and coded WELLCOME 02C. Bottles ot 50 and 250. SEPTRA PEDIATRIC SUSPENSION, each teaspoonful (5 ml) containing 40 mg trimethoprim and 200 mg sulfamethoxazole Bottles of 100 and 400 ml SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg sulfamethoxazole, and coded WELLCOME H4B Bottles of 100 Product monograph available on request
. Burroughs Welicome Salle, Qu6. Trade Mark
Ltd.
W-7002
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 605
