From Whence To Where? Drugs. Prohibitions. Exemptions. and the Role of the Team Physician

Transcription

1 From Whence To Where? Drugs. Prohibitions. Exemptions. and the Role of the Team Physician Andrew Pipe, CM, MD, Dip Sport Med, FACSM University of Ottawa Heart Institute Ottawa, Ontario, Canada

2 A Personal Perspective Physician International Sport Sport Medicine Organizations Anti-Doping Organizations Teacher Researcher Olympic Medical Officer

3 May 6, :59.4

4 From Whence?

5 In the 19 th century, the continuous Six Day bicycle races began, requiring great physical strength and stamina.

6 A variety of performance enhancing mixtures were tried, including caffeine, ether, nitro-glycerine, strychnine and cocaine. Growth Hormone & IGF Research 2009;19:

7 The first doping fatality occurred in 1886 when Arthur Linton overdosed on tri-methyl (thought to be a compound containing either caffeine or ether) during a 600 km race. Growth Hormone & IGF Research 2009;19:

8 1967: Tommy Simpson dies during the Tour de France - amphetamines

9 Mexico Amphetamines

10

11 Why Use Steroids? Size Strength Power Endurance Mood Looks

12 Montreal 1976 Anabolic Steroids

13 The DDR Experience 1976 Dr. Manfred Hoeppner Montreal Olympic Games DDR win 11 of 13 Olympic events. In 1991 known that they had been injected with anabolic steroids by their coaches. We have come here to swim not to sing.

14 The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. 43 men randomized to one of four groups: Placebo: no exercise Testosterone: no exercise Placebo: plus exercise Testosterone: plus exercise 600 mg testosterone enanthanate or placebo, for several weeks Supraphysiologic doses of testosterone, especially when combined with strength training, increase fat-free mass and muscle size and strength in normal men. Bhasin A, Storer TW, Berman N et al. NEJM 1996;335:1-7.

15 Blood Packing After reinfusion, HB concentration increased 13%. In parallel there was an overnight increase in physical performance capacity (23%) and V O2max (9%).

16 Montreal 1976 Blood Doping?

17 Pan-Am Games Caracas 1983 Testing a reality 15 positives, but... many, many athletes flee intense public scrutiny a portent of things to come? the largest drug scandal in the history of doping control

18 The Making of a Champion: Chemistry or Coaching? if neglected this issue will grow like an undetected tumour until one day it will burst forth with unprecedented malignancy. the problems will become more complex in an era of recombinant therapies recombinant erythropoietin will undoubtedly pose challenges for sport

19 Canadian Anti-Doping Programme Begins Joint Sport Canada Sport Medicine Council of Canada Advisory Committee on Drug Use in Amateur Sport Cursory Drug Testing Begins: tests per year

20 The US Experience 1984 Dr. Herman Falsetti Los Angeles Olympic Games

21 Seoul 1988

22

23

24

25 The Dubin Commission

26

27 The Canadian Experience 1988 Dr. Jamie Astaphan Seoul Olympic Games 100M Final Ben Johnson tests positive for an AAS -- Stanozol

28 Some Startling Results ANABOLIC STEROID USE AMONG CANADIAN YOUTH 83,000 Users 24,000 Injecting 7,125 Sharing Needles Melia P, Greenberg L, Pipe A Clin J Sport Med 1996 (1) 9-14

29 1996 The Irish Experience 1996: Ireland s Michelle Smith wins 4 Olympic golds, is banned in 1998 for manipulating samples

30 Inadvertent Doping

31 WADA - AMA The World Anti-doping Agency Agence Mondiale Antidopage

32 The Prohibited List: THE LIST

33 Consideration for List If substance meets 2 of 3 criteria: 1. Performance Enhancement 2. Health & Safety Concerns 3. Spirit of Sport

34

35 A new, national USADA Anti-doping Agency in the USA with overall responsibility for Doping Control in US Olympic Sport USADA

36

37 THG, Gestrinone, and Trenbolone HO HO O THG O Gestrinone OH Victor Conte O Trenbolone

38 Victor Conte BALCO Dwain Chambers Bill Romanowski Tim Montgomery Barry Bonds Marion Jones

39

40 Physicians say they believe athletes began using the drug almost with the beginning of clinical trials in Then the deaths began. In 1987 five Dutch racers died suddenly. In 1988 a Belgian and two more Dutch riders died. In 1989 five more Dutch riders died, and last year three Belgians and two Dutch riders died. New York Times. May 19, 1991

41 The Tour de France 2004 Dr. Eufemiano Fuentes Dr. Michele Ferrari

42

43

44

45 Prof. Ken Fitch (AUS)

46 Therapeutic Use Exemptions to allow those with legitimate illness, injury or underlying condition to use otherwise prohibited medications or procedures to compete following an appropriate review by clinicians with experience in the care of the athlete

47 Therapeutic Use Exemptions Committee Structure Responsibilities Guidelines for Review Jurisdictions Appeals emphasizing the central role of clinicians

48 To Where?

49 The Challenges Capacity Capability Culture

50 The Challenges The TUE Process Quality of Applications: Clinical History Documentation

51

52 CCES

53 CCES

54 The Challenges Clinical Considerations: The Athlete with Disabilities

55 The Athlete with Disabilities

56 The Challenges Prevailing Medical Culture Local patterns of practice Local standards of care

57 ADHD/ADD Hormonal Replacement the aging athlete The transgendered athlete Glucocorticoids

58 The Challenges The Masters Athlete Other Practitioners PA s (Physician Assistants) NP s (Nurse Practitioners) NP s (Naturopathic Physicians)

59 Range of co-morbidities & medications Unconventional treatments The Older Athlete

60

61

62 The Challenges THC Alternative Medicine

63 Medical Marijuana

64 The use of Medical THC in the treatment of athletes with disabilities will require very careful oversight.

65 Athletes are sitting ducks for quackery!

66 Evidence-Based Sport Medicine The development of Anti-doping Rules and Regulations has, in many ways, improved sport medicine practice!

67 IV Fluid Administration Needle Use Policies

68 Analgesia and the Athlete Evidence-based approaches More effective Better care Greater safety

69 The Electronic Medical Record Enhancing every aspect of the quality of care provided to athletes.

70 The Challenges Other Practitioners PA s (Physician Assistants) NP s (Nurse Practitioners) NP s (Naturopathic Physicians) The Role of the Sport Scientist

71 The Important Role of the Physician Leadership Oversight Supervision Responsibility

72 Physician Leadership Enhancing the care; and shaping the attitudes, behaviours and environments of tomorrow s athletes!

73

74

75

76