In 1980, Muhammed Ali, a model sportsman in so many ways, was soundly beaten in a fight with Larry Holmes. Following the fight Ali appeared sluggish and had difficulty speaking and walking. He later admitted that, “I took too many thyroid pills. Always used to double up on my vitamins. Bad idea with thyroid pills. Started training at 253 [pounds], went down to 217 [pounds] for the fight. Too much. People saying, ‘Oooh, isn’t he pretty?’ But I was too weak, didn’t feel like dancing. I was dazed. I was in a dream.”1
Any rheumatologist can figure out that Ali had developed a myopathy from the excess thyroid medication he took to trim down for the fight. Ali’s difficulty speaking persisted even after he stopped the thyroid medication, probably a precursor to the Parkinson’s disease that has plagued his later life.
A Boost by Any Other Name
Ali’s use of what he saw as a performance-enhancing drug received no opprobrium (maybe because he lost and the drug likely contributed to his loss). More recent attempts at enhancing athletic performances pharmacologically have been more successful but have led to disqualification. The disruption of the 2006 Tour de France, stripping of Floyd Landis’ victory in the Tour, the controversy over Barry Bonds’ home-run record, and Marion Jones’ admissions on the use of steroids have all made us more aware of the role of drugs in sports.
Performance-enhancing drugs are seen as cheating, a disgraceful shortcut to strength or endurance. A list of banned substances compiled by the bodies that regulate sports includes a variety of stimulants, anabolic steroids, b-adrenergic agents, diuretics, and hormones. But it must be obvious that many of the agents that athletes take offer no less of a boost. The best example of a permissible performance-enhancing substance is Gatorade, a sports drink concocted by researchers at the University of Florida to more rapidly replace the energy, fluid, and electrolytes lost by the Florida Gators football team (hence the name Gatorade) while playing in a swamp in full gear.
The fact that Gatorade enhances athletic performances is a point of pride to the makers of the drink. According to their Web site, “Soon after the researchers introduced their Gatorade formula to the team, the Gators began winning … outlasting a number of heavily favored opponents in the withering heat and finishing the season at 7–4. It was their first winning season in more than a decade.”
Gatorade is not banned and huge coolers of the stuff are centerpieces on the sidelines of many teams. The highly regulated diets, vitamin supplements, and elemental nutrient supplements that are so prominent on the training tables of elite athletes are also permissible performance-enhancing substances.
The Logic of Performance Enhancement
Why is one substance banned, but another dispensed freely to athletes? Clearly, the listing of banned agents is arbitrary and includes agents that offer a clear advantage in terms of endurance, strength, or other characteristics but—as with Gatorade—even combinations of simple sugars, minerals, and water may yield significant performance advantages. So, does the fact that something is naturally available make it a permissible performance-enhancing substance? There is nothing in nature that is the color of some of the Gatorade flavors, and erythropoietin is a natural substance. Nevertheless, the former is permissible and use of the latter can get you banned from competitive sports. Neither safety nor efficacy is the criterion for putting an agent on the banned substance list. Although caffeine has a wide safety window, it may also be toxic in high enough concentrations, but caffeine is not on the list of banned substances (nor is thyroid hormone). I would probably suffer a cardiac arrest if a large cooler of ice-cold Gatorade was dumped on me, so it, too, has its toxicity.
“Organic” compounds are not prominent on the list of banned substances but it is clear that just being natural makes a substance no less likely to be abused—cocaine, cannabis, and opiates are the best examples of banned natural substances. And, being artificial doesn’t always make a substance toxic (vanillin and most vitamins are no less tasty or effective than their natural forerunners) any more than being natural makes it safe.
As an intern in Cincinnati, I saw many teenagers in the emergency room who had smoked jimson weed (Datura stramonium; also known as loco weed) for the hallucinations it induces, but who suffered from an overdose of atropine and scopolamine naturally present in this plant. (The mnemonic for the overdose is, “Dry as a bone, red as a beet, and crazy as a loon.”)
Perhaps we should extend our concern about performance-enhancing drugs to other fields. I, for one, propose that we outlaw the pizza and coffee for housestaff that lets them work longer when they are on call. Wouldn’t video games be fairer if ingestion of Mountain Dew and Jolt Cola was forbidden? Banning cheesecake from the diet of NFL linemen and Sumo wrestlers would probably eliminate unfair size advantages. And the dating game would certainly be more equitable—if not more challenging—if wine and oysters are taken off the menu at romantic restaurants.
Unlike Muhammed Ali, Floyd Landis overcame a significant rheumatologic problem—avascular necrosis of the hip (secondary to a fracture)—to win the Tour de France, a grueling three-week bicycle race. That all of the opiates that must have been required to keep him on his bicycle did not mask the presence of androgenic steroids in his urine is a tribute to modern technology, which has been both a boon and a bane to athletics.
Dr. Cronstein is Paul R. Esserman professor of medicine at NYU School of Medicine in New York.
Reference
- Vecsey G. At 39, Ali Has More Points to Prove. New York Times. Nov. 29, 1981.
