Where are the boundaries?
Robert Palinkas, M.D.
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I have NO actual or potential conflict of
interest in relation to this educational activity
or presentation
Most of the agents I discuss have very limited
FDA approved use, and all off label use of any
agent in this talk is strongly discouraged
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Land of the Fighting Illini
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Substances used by athletes to improve their
performance
◦ Sometimes also used by military personnel to
enhance combat performance
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A broad group of agents
◦ Steroids (“roids”) are just one type of PED
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Not all PED’s are illegal
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Lean Mass builders
Stimulants
Painkillers
Sedatives
Diuretics
Blood boosters
Masking drugs
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Amplify muscle growth and/or reduce reduce
fat deposition
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Anabolic steroids
Androgens and Xenoandrogens
Human growth hormone
HCG
Antiestrogens
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Caffiene
Amphetamine
Methamphetamine
Beta agonists
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Beta blockers
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Epogen (EPO)
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Probenecid
epitestosterone
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To improve competitive position
◦ For example, body building
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To look better
◦ For example, easier weight loss
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To “feel” better
◦ For example, recapture libido from an earlier age
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Because of a distorted self image
◦ As in the eating disorders
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Because of a mental condition
◦ As part of obsessive compulsive disorder
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Because of financially driven providers
◦ Big pharma and entrepreneurial doctors
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Testosterone synthesized and changed 1935
1952 First use of anabolic steroids at the
Olympics
1976 IOC bans anabolics
1986 IOC begins testing for substances
WADA established- the World Anti Doping
Agency
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Most use
◦ Exercise
◦ Diet manipulation
◦ Various supplements
 Many can be obtained at your local nutrition store
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Some use
◦ Testosterone or pre-testosterone
 Usually cycled
◦ Anabolic steroids
 Usually cycled
◦ Antiestrogens
 To prevent gynecomastia-SERMs and aromatase inhibitors
◦ HGH or HCG
 To decrease fat and preserve testicular size
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Exercise is essential
◦ There is no way to build muscle without physical
training
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Nutrition is essential
◦ Need the substrates for new mass and replacement
through catabolism
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When both are in the right place, hormonal
influences can make a big difference
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Many patients devise their own hormone
regimen or use a regimen someone
recommended for them
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The recommender may be unlicensed
Most will use some form of anabolic steroid
Many will manipulate their testosterone
Some will add HGH
Some will use an antiestrogen agent like aromatase
inhibitors
The process involves alternating or varying
doses in a cycle or “stack”
◦ Combined with variation in diet and exercise
A generic sterol
Cholesterol
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Important organic molecules
Present in both plants, animals and fungi
Very versatile
◦ Used in cell membranes and as secondary
messengers
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Androgens
◦ Androgenic effects
 secondary sex characteristics
◦ Anabolic effects
 Growth of muscle mass and strength
 Increased bone density
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Continuous or frequent use is likely to result
in testicular atrophy and may result in
infertility
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Have both an androgenic effect and an
anabolic effect
◦ Some are significantly stronger at stimulating
muscle growth, lipolysis
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US pharmaceutical manufacturers
◦ Rarely
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Manufacturers outside the US
◦ A significant portion
◦ Some are from decent manufacturers
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Unlicensed US and foreign chemists
◦ The majority
◦ Some are legal over the counter agents
 “supplements” exempt from FDA oversight
 New agents, prehormones
◦ Some are just plain smuggled into the country
◦ Some are purchased on the internet
◦ Some are distributed by word of mouth in the
sports community
◦ Some are derived from unlicensed “medical”
operations
◦ Some are prescribed by licensed providers incented
by profit and sympathy
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Mostly Anabolic Steroid
Raw ingredients easily obtained
Don’t meet FDA standards
High Profit
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I had no difficulty
buying 63 pounds
of raw material on
the internet
Sale was not
completed
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HCG
◦ Strong lipolysis
◦ Used for weight loss
◦ Some protection from
testicular arophy
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HGH
◦ Supports lipolysis
◦ Strong muscle
growth
◦ Protects against
testicular atrophy
◦ Too numerous to list
 Creatine
 Not so bad
 Not so effective
 NO
 BCAA
 Safety Is a huge concern
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FDA: 70% of industry violate rules
About half are way off on potency
20% contain contaminants
3000 products recalled 2012
6000 complaints filed in 4 years
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Focus on insecurities
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Aging
Waning sexual function
Waning strength
Weight gain
Can be lucrative
◦ At least a 28 Billion dollar industry on supplements
alone
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Those that are illegal
Those that are dangerous
Those that come from questionable sources
◦ Possible contamination
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Those that are injected
Those that are outside the medical orthodoxy
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Testosterone
HGH
Synthol
A host of anabolic steroids
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Also called synthrol
An injectable viscous liquid
◦ Used cosmetically to increase muscle size
◦ Contains an oil, lidocaine and sometimes alcohols
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An evolving process
◦ Reluctance to impact the financial consequences
◦ Reluctance to draw attention or tarnish the sport
◦ New chemicals need new tests
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Depends on the sport
◦ Available resources for testing
◦ Strength of the regulatory agency
◦ Prevalence of use in the sport
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Requests for frequent testosterone assays
Claims about low testosterone but discordant clinical features
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Youth
Normal appearing testes
Muscular habitus
Absence of neurologic-hypothalamic clues
Evidence of doctor shopping or different views
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Estradiol
Estriol
Progesterone
DHEA
hGH
Prolactin
Sex hormone binding globulin
Insistence
Long lists of associated tests
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Out of our scope of practice
We follow the orthodoxy
◦ Not alternative medicine
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Need for fiscal stewardship
Draws McKinley staff into medicolegal
involvement
◦ Our action:
 lab restriction on estradiol testing in men and frequent
testosterone assays
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Some of this is a difference of philosophy
◦ Maybe we should all help patients use medications
to resist aging or for cosmesis
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Or morals
◦ Who are we to judge the way people wish to look
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But for now
◦ There is no universally accepted treatment regimen
approved for this application