To Dope or Not to Dope: That is the Ethical Question -- Part 1: An Expert Interview With Dick Pound

Richard Pound

Disclosures

September 18, 2006

Following on the heels of Dr. Garnier's impassioned plea and open letter, Medscape continues its discussions regarding the ethics surrounding the use of performance-enhancing drugs. Pippa Wysong of Medscape begins the first of our 2-part interview series with the World Anti-Doping Agency (WADA) by sitting down with Richard Pound. Mr. Pound is the Chair of the WADA, chair of the Olympic Games Study Commission, and Chancellor of McGill University in Montreal, Canada.

Pound was a swimmer and won a gold, 2 silvers, and a bronze medal for Canada at the 1962 Commonwealth Games in Australia, and was a double finalist at the 1960 Olympics in Rome.

He is also a Montreal tax lawyer and chartered accountant, and author of the book Inside the Olympics: A Behind-the-Scene Look at the Politics, the Scandals, and the Glory of the Games.

Charles Kearns, PhD
Editorial Director
Medscape Orthopaedics & Sports Medicine
ckearns@medscape.net

Medscape: Dr. Garnier, the Medical Director of WADA, recently posted a letter addressed to doctors who support doping in sports. What happened to prompt this?

Mr. Pound: Many of the substances used for performance enhancement are prescription drugs — athletes are getting them from somewhere on the basis of prescriptions written by doctors. Dr. Garnier just felt it was a timely and useful thing to do to draw attention to the problem.

Medscape: Why would any doctors support doping in sports? What are some of the reasons you've heard?

Mr. Pound: There are a whole bunch of self-serving justifications. A lot of it is about money --- many of these treatments are very expensive. Some say it's safer to do it under medical supervision than not. It's all complete nonsense. They know their patients, they know what their patients do for a living or in nonprofessional sports. And they know whether they're providing something that is a prohibited substance or method. I think there's an ethical duty on the part of physicians to not do this sort of thing.

Medscape: It sounds like WADA's testing procedures are pretty sophisticated. Is it true that anybody who is tested is likely to get caught?

Mr. Pound: The tests are getting better. Most of these doping substances and methods have been around for quite a while, so we've become pretty good at testing for them. We're pretty much on top of some of the newer ones, and there are now tests for things like erythropoietin (EPO) and human growth hormone (HGH). The science inherent in the tests is pretty well accepted, although there are predictable challenges and defenses on the part of anybody who has been caught. They try everything, they say it's not their sample, it wasn't sealed properly, the chain of custody is wrong, the test is no good, the substance was naturally produced. It's almost like there's some kind of checklist that's very predictable; we've heard it all before.

The thing is, we know the science before we put any test out there. We do our best to make sure it's scientifically reliable. We don't want to sanction some athlete for doping unless we're really quite certain that's what happened.

Medscape: So, science is making it pretty tough to cheat.

Mr. Pound: It is certainly making it tougher. We've got better tests, plus we don't just put random names in a hat --- we target-test where we think there may be a problem. In addition, as in the case of Landis, where the lab folks got a hugely elevated TE (testosterone-epitestosterone) ratio, then did another cross-check on it to make sure the testosterone they were finding was artificial. It's getting to the point where you can run but you can't hide.

Medscape: The tests sound so sensitive. Are they at all likely to pick up traces of substances that aren't a problem? For instance, smaller, therapeutic amounts of medications athletes might need for an actual health problem?

Mr. Pound: Well, there's the Therapeutic Use Exemption and a process that goes along with that. Athletes shouldn't be denied necessary medical treatment.

Medscape: What do you do when there is a positive result in the works?

Mr. Pound: The technician would say to the lab director something like, "I'm getting a positive here, and it's all double-checked." We want to make sure we get this right because if we have a positive there will be an appeal. So, we have to make sure we've got it done properly. By the time a sample is declared positive, there's a very high degree of scientific certainty that it was indeed a positive test.

Medscape: Is it just urine that's tested in athletes?

Mr. Pound: It's mostly urine, but sometimes blood is tested. The tried and true method of urinalysis and mass spectrometry are the work horses of drug testing.

Medscape: The list of prohibited subs is huge. You're not looking for every drug on that list in every test, are you?

Mr. Pound: In principle, yes. If you're a lab, what you get is a sample with a code number on it. You have no idea what sport or what athlete may be involved, so you're looking for the whole menu of prohibited substances. There are basically 4 or 5 major classes --- the growth enhancers, oxygen enhancers, anabolics, blood doping, and so on. While there are a lot of particular names on the list, most are within a limited number of classes.

Medscape: Does it cost a lot to do these tests?

Mr. Pound: Some of them, yes. I think the average cost is probably $500-$600.

Medscape: With WADA labs doing upwards of 180,000 tests each year, worldwide, that's a lot of money. All this cheating is taking away time and money that could be used for training and sports programs. How are the tests funded?

Mr. Pound: Sports federations have their own budgets for doping control, national organizations do, WADA does, governments do, professional sports leagues do. In the case of WADA, tests are funded 50-50 by the sport movement and by governments, the same ratio as all of our activities.

Medscape: When it comes to amateur and semi-pro sports, what sorts of ergogenic drugs are being used that aren't being talked about a lot? There's so much talk about steroids in the media, but there must be other important ones the public isn't as aware of.

Mr. Pound: The designer steroids are among the ones that are out there now, where they take the traditional anabolic steroids that people have been able to find for years and tweak the molecule so they give off a different signature under mass spectrometry. That was the whole THG (tetrahydrogestrinone) revelation coming out of the labs that were producing it. THG was made by altering the molecule of another prohibited substance.

We've spent a fair bit of time doing our own investigation and have identified several other designer steroids and are ready for them. Our labs are in a position to recognize them when tests are done. Work on human growth hormone has been ongoing for quite a while. We've now got a means of identifying both natural and artificial HGH. But this all requires some education of the labs so they know what to look for, and we hope to provide a sort of kit to allow them to do it fairly easily.

Doping via genetic manipulation is on the horizon, too, and we're working on tests to identify that. It's an ongoing game of cat and mouse.

Medscape: A lot of people probably don't realize the amount of research WADA does in terms of developing tests. It sounds like a lot of effort is put in this direction?

Mr. Pound: Yes, we spend about 25% of our entire budget on research and development (R&D).

Medscape: How has this happened in sport?

Mr. Pound: This whole culture of cheating is symptomatic of what's going on in society in general. Think of Enron and other business failures, professional and academic cheating, media failures of governance and so forth. Unfortunately, it has spread to sports at all levels, from high schools to elite sports and professional sports.

Medscape: Where are the designer steroids showing up? Are they more commonly used in pro-sports?

Mr. Pound: Well, the THG from Balco [Bay Area Laboratory Cooperative] was showing up in Olympic sport, as well as in baseball and football. It's everywhere where people are looking for an edge and are prepared to pay for it.

Medscape: How many designer steroids are out there?

Mr. Pound: I'm not entirely sure. Not just THG, since we've identified about 4 or 5. Probably about half a dozen or so at this point, but I don't want to suggest that's a cap.

Medscape: Is it difficult to make designer steroids? I mean, are they coming from basement labs, or from more elaborate facilities?

Mr. Pound: Anybody with a Masters degree in biochemistry and access to basic laboratory facilities, maybe. But remember, being able to alter a molecule doesn't mean it'll be safe --- and the original molecules aren't safer either in sports doping. Even minor tweaks could potentially lead to unexpected and serious side effects and medical problems. You can't just make a drug and let people use it untested. It's all being done just to give a different signature in a test. The real danger, of course, is you don't know what that altered molecule and a particular dosage might do to the bodies of the athletes taking it. There have been some horrendous stories.

Consider the case of sprinter Kelly White, who was given THG in 2003, caught, and banned by the US Anti-Doping Agency. She was having a period every 2 weeks, blood pressure that was going through the roof, muscle cramps, and other problems. The people who produced it and gave it to her had no idea what the effects would be. A biochemist or pharmacologist will tell you that once you alter a drug molecule, it can change the intended physiologic interactions with receptors and systems in your body. It may have effects that are different from the original drug. You don't know what's going to happen, and athletes taking these compounds are just being made of one big dangerous and uncontrolled experiment.

Some of these people say, when problems develop, reduce the quantity and see what happens, but that's all experimentation, even small doses can wreak havoc --- you don't know. Now, THG (assuming there are merely classical side effects) is known to cause liver toxicity, heart problems, extra hair growth in women, and baldness and infertility in men. It can cause changes in mood ranging from feeling really great to depression, paranoia, and aggression.

Medscape: Designer steroids and genetic manipulation, is this a sign of things to come?

Mr. Pound: These are the problems of the first part of the 21st century. When you think about it, they're in the same place some of the standard drugs were in the 20th century. But we're much more organized at identifying them and catching them. We've got some money and a system set up to do testing, along with R&D, which never existed in the sport system before. It's possible, although not easy, to turn sports back into a fair-play game.

Medscape: As an organization, WADA isn't really that old. It has come a long way in a short number of years, hasn't it?

Mr. Pound: Yes, it has come a long way. We started our first tentative operations in the spring of 2000. Now we have 33 labs around the world which perform around 180,000 tests a year. More labs are on the way, but it's a fairly rigorous process to get WADA accreditation. We can have only 2 or 3 new ones a year, and there are all kinds of labs in the queue waiting to get accreditation.

Medscape: Are there any messages you'd like to pass on to physicians?

Mr. Pound: Make sure you know your patient. Why does somebody want a nontherapeutic prescription? You are faced with the ethical decision of whether to prescribe it or not, once you know it's not for therapeutic purposes. Doctors should certainly be familiar with, and tell patients about, the health risks. If you stop using these substances soon enough, most of these effects are reversible. If you're on them too long, they're not. They have very serious long-term consequences. I think the medical profession's credo is 'First, do no harm.' Doctors know if they've stepped over the ethical line or not, and they know what's therapeutic and what's not.

Medscape: Do any specific sports stand out in your mind as having an especially serious problem with doping?

Mr. Pound: They all do, and at all levels. The bad news is that there is no sport and no country that's immune to the risk.

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