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Abstract
This article reviews identified individual “risk factors” and exogenous cultural factors and processes associated with performance-enhancing substance use and misuse and successful and unsuccessful intervention efforts.
Addendum
“Winning isn't everything; it's the only thing.”
Vince Lombardi, the Hall of Fame American football coach
On August 24, 2012, the United States Anti-Doping Agency (. USADA) stripped Lance Armstrong, a former American professional road racing cyclist and seven-time winner of the Tour de France, of all competitive results dating back to August 1, 1998 for using and distributing performance-enhancing drugs. USADA also banned Armstrong from any future activity or competition for which it has jurisdiction, in other words, a lifetime ban. Armstrong, while publicly maintaining his innocence, decided not to challenge the USADA sanctions. In a statement, Armstrong said that the USADA had engaged in “an unconstitutional witch hunt” based on “outlandish and heinous claims.” Two months later, on October 22, 2012, the Union Cycliste Internationale, cycling's governing body, accepted USADA's decision, confirming the lifetime ban and the stripping of titles. More recently, on November 2, 2012, the World Anti-Doping Agency announced their agreement with the USADA decision. Reaction from Armstrong's corporate sponsors and charities was swift and extensive as Nike, Anheuser-Busch, and even Armstrong's own cancer charity, Livestrong, quickly severed ties.
While doping is banned in sport, some athletes, coaches, physicians, and others defend their use of various substances more as “performance-enablers,” “engenderers,” or “restoratives” (pseudoephedrine for colds, beta-blockers to reduce anxiety, and anti-inflammatories) that permit athletes to compete rather than as “performance-enhancers” or “assistive additives” employed to improve their performance (e.g., anabolic steroids). As former French cycling star Richard Virenque has stated, “We don't say doping. We say we're preparing for the race. To take drugs is to cheat. As long as the person doesn't test positive, they're not taking drugs.” Virenque says he took certain products that “for me were vitamins, fortifiers” without being drugs. “My hope was not to fall ill, not to test positive” (Lille, France, Associated Press, October 24, 2000). Later, Virenque tried to explain how he was led to indulge in doping. “Bike riding requires permanent sacrifice. It means training 11 months out of 12 and 110 days of racing in whatever the weather conditions. Early in life I realized I did not have the intellectual potential so I decided to dedicate myself to cycling. As a teenager I did not smoke. I did not go to discos like 95 per cent of youngsters do. After awhile, suffering becomes harder. Your heartbeats swing from 140–180 a minute for long hours. It's not just like walking up stairs, you can only overcome pain with treatment (doping in cycling's slang) and fan's support” (Lille, France, electronic Telegraph, October 28, 2000).
Similar to Virenque's explanation for doping, nearly 50 years ago, Jacques Anquetil, a five-time winner of the Tour de France stated, “For fifty years racers have been taking stimulants. Obviously we can do without them in a race, but then we will pedal 15 miles an hour (instead of 25). Since we are constantly asked to go faster and to make even greater efforts, we are obliged to take stimulants (Gilbert, B. Drugs in Sport: Parts 1, 2, and 3. Sports Illustrated, June 23, June 30, and July 7, 1969).
Athletes such as Richard Virenque, Jacques Anquetil, and Lance Armstrong use performance-enhancing drugs for a variety of reasons: to win, to set new records, to gain prestige and notoriety from their fans, and for financial gain –with the money often coming from lucrative endorsement contracts. There are many visible and silent stakeholders in an athlete's success and failure. Consequently, the widespread use of performance-enhancing drugs by athletes is not always a question of personal choice as it is often presented, but a direct result of the over-commercialization of sports and the pressure exerted on athletes by stakeholders to win and break records. A few hundredths of a second or a few millimeters can determine whether years of training and sacrifice will amount to a lifetime of success and large financial rewards or completely forgotten.
Notes
3 The reader is reminded that “risk factors” suggest some type of causal outcome. The reader is referred to Hills's criteria for which were developed in order to help assist researchers and clinicians determine if posited risk factors were causes of a particular disease or outcomes or merely associated. (Hill1965) Editor's note.
4 The often used nosology “drugs of abuse” is both unscientific and misleading in that (1) it mystifies and empowers selected active chemicals into a category whose underpinnings are neither theoretically anchored nor evidence-informed and which is based upon “principles of faith” held and transmitted by a range of stakeholders representing a myriad of agendas and goals, and (2) active chemical substances of any types-``drugs”- are used or misused; living organisms can be and are all-too-often abused. Editor's note.
5 The reader is reminded that the diagnosis of a “substance use disorder” is a relatively new diagnosis which is based upon a consensus-based taxonomy which is not empirically informed (American Psychiatric Association, 1994). In order that any diagnosis be useful for treatment planning, it should “offer,” minimally, three critical, necessary types of information: etiology, process, and prognosis …which are not always known. Secondly, a diagnosis, when demystified, is simply the outcome of an information gathering process to be used for decision making. Thirdly, the underpinnings for diagnostic criteria can be theory-driven, empirically based, individual, and/or systemic stake holder-bound, based upon “principles of faith,” etc. All-too-often the needs or agendas of the classifier (individuals as well as systems) are not adequately considered or noted. Lastly, whereas all diagnoses are taxonomy categories or labels, all labels are not diagnoses. Editor's note.
6 Treatment can be usefully defined as a unique, planned, goal directed, temporally structured, multidimensional change process, of necessary quality, appropriateness and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.), implemented under conditions of uncertainty, can be failable and associated with iatrogenic effects, and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—including AAS users, which are not also used with nonsubstance users. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically based, “principle of faith-based”, tradition-based, etc.) continue to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life and well-being treatment-driven models, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success as well as failure. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can include controlled environments. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the ‘‘informed model’’ in which the patient makes the decision(s). Editor's note.