Department of life sciences
Doping and sports
Collective expert assessment

Paris, december 1998

Contents

Introduction
A. The present state of affairs
B. Numerous determining factors
Conclusion
Recommendations

Introduction

Pierre de Coubertin, founder of the modern Olympic games, was one of the first to point out the necessity of protecting sport from the dangers threatening it as an institution. In 1923, in a speech delivered in Rome, he denounced "the intrusion of politics into sports, the increasingly venal attitude towards championship, the excessive worshipping of sport, which leads to a belief in the wrong values, chauvinism, brutality, overworking, overtraining, and doping".

The recent doping scandal of the last Tour de France cycling competition drew the attention of the media to practices which, until then, had remained covert. This media coverage has increased public awareness of this phenomenon. Indeed, due to their scope and sophistication, doping practices are a threat to more than just the world of sport. Though first considered to be no more than a cheating problem, the doping issue has reached such proportions that it now concerns society as a whole. As the stakes involved in sport grow higher and the phenomenon more widespread, the moral values attached to sport are increasingly called into question and the health of athletes increasingly at risk.

Furthermore, the close link observed between doping and addiction underscores the former's social and sanitary impact. This report shows that far from being limited to the world of high-ranking athletes, doping is an important public health issue.

A. The present state of affairs

1. The scope of the problem
A few examples are enough to give an idea of the scope of the problem: in 1986, a physician and two pharmacists were indicted for having sold over 2,000 phials of Tonedron, at 150 times their normal price. On December 2, 1995, near Lille, customs officers seized nearly 200,000 tablets and phials of anabolic drugs meant for the muscle-building club market. An article by P. Laure published in the magazine "Sport et Vie" n°44 (September 1997), analyzes in de tail the new opportunities offered by Internet: twenty-odd servers presenting all sorts of drugs, including anabolic steroids, corticoids and beta-blockers. A synthetic graph provides the market prices for these drugs — from 50 to 3,800 francs for the minimal dose — and shows that it is possible to obtain drugs listed among French prescription only drugs (lists I and II) as well as illegal drugs.
However, the empirical data presently available does not allow us to accurately assess the phenomenon. In 1966, 37 champions from 2 sports federations were tested and 12 were tested positive. In this small sample, the percentage of doped athletes was 37%. In 1992, 8,000 tests were carried out in 56 federations and only 69 tested positive: in this case, the rate fell to 1%. Indirect data, such as the seizure of banned drugs, the dismantling of distribution networks, as well as the tragic fate of some champions — between 1987 and 1990, "18 Belgian and Dutch cyclist champions died, apparently due to the use of erythropoietin" (Laure, 1995, p.136) — lead us to believe that the low percentage of positive tests does not mean that doping has disappeared, but that it is now possible to hide it. The percentages of doped athletes given in the press vary from 10 to 90%. But the level of the athletes or even the precise source of these figures are never mentioned, which only shows that the extent of the doping phenomenon is impossible to assess. It is thus all the more difficult, except in very rare cases, to cross the dependent variable "doping" with the independent variables which are necessarily taken into account in a sociological approach to the issue. The variations of doping behaviour according to gender, age, sociocultural background, education and other characteristics are unknown.
In short, the lack of objective data makes it difficult to carry out a sociological analysis of the issue; there is more information concerning opinions on the subject and efforts to control the phenomenon than on the phenomenon itself. There are several reasons for this: when carrying out a survey among people who are well-known, it is very difficult to maintain anonymity, since the questions asked concern the type of sport practised, the level attained, previous accidents, etc. Furthermore, there is the risk that revealing the phenomenon could possibly encourage its spread.

II. The aims
In order to enhance their performance, sportsmen use specific "methods" which optimize the qualities needed for their sport, on the basis of various physiological, biological, and psychological factors.
According to a widespread opinion, "upstream" doping, used for the above-mentioned aim, is "bad" and should be distinguished from "downstream", or "good" doping, meant to help athletes recover their physiological and biological balance. In fact, both types of doping are complementary, since they artificially boost the body's abilities, the second type of doping aiming to make up for the negative effects of the former.
Aerobic potential can be increased by increasing the blood's oxygen transfer capacity. This is very important in sports requiring staying power, rely on the body's energy metabolism, or require intense effort and varying sources of energy. After long-lasting or intense effort, glycogen reserves must be restored. A specially adapted nutritional strategy and drugs are then needed to modify the metabolic process. Methods include altitude training, self-transfusion, more recently, recombinant EPO, and of course glucocorticoids, etc.
When the aim is to increase strength and muscular power and improve technique, protein, natural or synthetic anabolic agents are frequently used, in combination with hyperprotein diets and muscle-building exercises. The balance between the increase in muscle mass and the loss of fat mass can be maintained thanks to growth hormones associated with aminoacids or other drugs with anabolic properties (but whose initial medical purpose is other), or with nutritional supplements.
To postpone fatigue and enable the body to reach its utmost limits, one can use antalgics, cardio-respiratory analeptics, central nervous system stimulants, several of which are strong anti-depressants and stimulants.
IIn sports where body features or size, tall or short, are important, such as body-building, the shape of the body can be modified through hormonal manipulations.
Various drugs are used to fight stress, facilitate sleep, remain in good physical shape, such as benzodiazepine derivatives and amphetamines, cannabinoids, alcohol, beta-blockers. For disciplines where it is important to stay alert, the sleeping-waking rhythm can be controlled thanks to amphetamines or more recent drugs.
Last, cultural and invidual factors also play a role in drug-taking behaviour. On the one hand, as concerns men, value is placed on the mesomorphic body type and muscular strength; physical stereotypes are spread by the media and the athletic subculture. On the other hand, one must take into account factors such as low self-esteem, or other psychological problems linked to for example to one’s body image and which existed prior to drug-taking.
Illicit drugs are of course taken on the sly. Several ways of hiding the fact exist: diluting urine, hemodilution, reducing kidney tubular secretions or the testosterone/epitestosterone ratio.

III. The growing competition between technical and biological research and detection methods

1. The rules enforced by the medical commission of the IOC
The definition of doping established by the medical commission of the "International Olympic Committee" is based on the prohibition of certain types of pharmaceuticals. This definition also bans new substances which may have been developed by laboratories specifically for doping purposes.
In France, the list of banned substances and methods is given in an amendment to the appendix of the Convention contre le dopage of November 16, 1989, approved in Strasbourg on February 28, 1998, which entered in force on March 15, 1998.
Table I shows the new list (decree n°98-464, Journal Officiel de la République Française, 17 juin 1998).

New list of banned substances and methods

1. List of banned substances

A. Stimulants B. Narcotics, both natural and synthetic C. Anabolic agents D. Diuretics E. Peptide and glycoprotein hormones and analogs

II. Banned methods

A. Blood doping B. Pharmacological, chemical or physical manipulation

III. List of substances under restriction

A. Alcohol B. Marijuana C. Local anesthetics D. Corticosteroids E. Beta-blockers

All physicians have access to the detailed list, since it is quoted on p. 6 of the 1998 edition of the VIDAL medical dictionary ("Banned substances and methods").

2. Drugs which are detectable thanks to present testing methods
All natural or synthetic doping drugs (a to e) have a common physical and chemical characteristic, which is low molecular weight (under 500) (see table II). They can thus be detected by the usual analytical methods, such as gas chromatography, together with mass spectrometry.
The only problem with the detection of xenobiotics is the fact that analysts have to work with small samples, which are not always best suited to this type of testing. However, as concerns endogenous substances, their detection does not constitute sufficient proof of doping for the institutions in charge of enforcing the law.

Table II: example of the molecular weight of several molecules

Type of active substance	Example of substance	Molecular Mass (Mw)
a. Stimulants	Amphetamine Cocaine	135 303
b. Natural or synthetic anabolic agents	Nandrolone Testosterone	274 288
c. Narcotics and analgesics	Dextromoramide Propoxyphene Morphine	392 339 285
d. Beta-blockers	Pindolol Acebutol Propanolol	248 336 259
e. Diuretics and masking drugs	Ethacrinic acid Furosemide Canrerone	303 330 340
f. Peptide hormones	HGH LH EPO	22,400 30,000 30,400

More recently, recent research in organic synthesis and genetic engineering has produced new substances which are similar to natural peptide hormones (f) — a combination of aminoacids which can stimulate the endogenous secretion of substances such as androgenous steroids (hCG, LH, etc.) or corticoids (ACTH). These molecules have a much heavier molecular weight than the others (see table II). They are present in the body at very low levels of concentration, with considerable variations from one person to the next, and are influenced by environmental parameters such as effort, stress and/or fatigue. It is thus very difficult to distinguish between natural and artificial variations.

3. The problem of natural or semi-synthetic or synthetic substances
A certain number of substances normally used in specific medical circumstances are now being used in top level sports because of their positive effect on several physiological functions which play a role in sports.
Erythropoietin (EPO) was thus developed to treat anemia by stimulating the synthesis of red blood cells. Since it increases corpuscular mass and oxygen transfer capacity, this drug has been used for the past ten years in aerobic sports and as a rule all intense aero-anaerobic disciplines, whether practised continuously or alternately. In healthy subjects, it raises hemoglobin and hematocrite levels and improves staying and maximum aerobic power. Its use — through injections, as in standard medical practice — is simpler than transfusions which can cause problems and accidents. For the time being, anti-doping tests cannot detect EPO. It is commercialized under various denominations and sold in France at the Pharmacie Centrale des Hôpitaux.
Other drugs, either hardly commercialized or still awaiting market authorization, are known for their ability to increase oxygen transfer capacity, such as reticular haemoglobin, developed from a human molecule mainly used in hemorrhagic emergencies, in order to avoid having to determine the blood type for selective corpuscle transfusions. This is also the case of fluoro-carbons which are even more convenient since they keep well. They can also be used as a recovery activator after intensive effort. So far, no control procedure, in terms both of prevention and testing, exists for this type of drug. A solution to this problem should be found before it is commercialized, if possible.
The possibility of increasing muscular mass and acting on the anabolic or catabolic properties of the metabolism is extremely interesting for top-level sports. The use of androgens and anabolic agents has become increasingly widespread over the past 20 years, especially with the development of synthetic anabolic agents whose anabolic power is 30 to 50 times higher than that of natural androgens. The growth hormone (hGH) developed by genetic engineering has made it possible to avoid testing positive on synthetic anabolic agents. The recombinant growth hormone is available on the market*. It is used in all sports where performance is linked to muscular mass, as well as in aero-anaerobic sports, including team sports.
The production of IGF1 (Insulin-like growth factor), which completes the physiological action of the growth hormone, by genetic engineering complicates the issue. IGF1 used together with the growth hormone provides optimal results with smaller doses of both drugs and fewer side-effects. This may explain the standardization of a certain body shape and the disappearance of indirect signs of use of the single growth hormone. The availability of a second IGF2 opens new prospects in the field of energy metabolism.
To a lesser degree, interleukin 3 can be used singly or with another drug to enhance growth and stimulate corpuscle production. G-CSF is a growth enhancer which acts mainly on white corpuscles. Although it does not have any known effect on performance, it may help resist infections.
Analyzing peptide hormone levels in blood, especially the chorionic gonadotropin hormone (hCG), the growth hormone and EPO is thus of utmost importance. Synthetic peptide hormones presently in use have a chemical structure which is identical, or at least very similar to that of natural hormones, and it is impossible to distinguish their physical or chemical characteristics. Their dosage is at present determined by immunology techniques, but quantitative standards would be necessary to determine the exogenous presence of such substances.

4. Organizing the tests
Sports officials organize sports events, but the task of detecting illegal drugs is devolved to others. If an athlete tests positive, s/he is punished by sanctions. Three possible cases can occur:
- In the first case, tests show the presence of a banned substance which enhances performance more than would simple training. In this case, there is no question that this person must be sanctioned.
- In the second case, the tests show the presence of an illegal drug which does not necessarily enhance performance. Sanctioning the athlete for this would be unfair, since it would create an unequal situation between athletes and non-athletes, the latter not being tested.
- In the last case, the test does not reveal any illegal doping substance because it is "masked", new, or (temporarily) undetectable as an exogenous substance. In this case, testing is impossible, though justified.
The world of sport is understandably quite ill-at-ease regarding this complex issue. Indeed, sportsmen are used to dealing with extremely strict rules, in the sense that all that is not explicitly forbidden is allowable. This principle is actually what motivates technical progress, which in turn leads to a modification of the rules.
Another important problem concerns the tests' underlying principle: indeed, sports, as an institution, focuses on performance, not on the actors, whereas anti-doping tests focus on the actors, in other words on the athletes as individuals.
Considered necessary, though imperfect, these tests are at the same time perceived as imposed by external authorities; they are usually criticized and condemned on principle, and when it comes to the actual testing procedure, attitudes are often unclear: upon arrival of the physician in charge of carrying out the tests, athletes and organizers often join forces. If an athlete is tested positive, the entire "family" falls necessarily under suspicion, which leads to a tightening of group bonds. When a case of doping is announced, the athlete and his entourage usually protest loudly. Sports officials thus finds themselves in a contradictory situation: they ban doping and base their authority on this prohibition, but at the same time, when doping cases occur and persons are sanctioned, they express surprise, doubt, and minimize the issue. The attitude of sporting authorities is thus far from clear, especially if we consider that a century ago, doping was a poor man's resource to earn some profit from sports, and that today, doping has become extremely expensive. "Scientific" doping, with the accompanying "masking" procedures, is affordable only to the rich.
Improving the efficiency of antidoping tests does not mean increasing the frequency of testing but carrying them out more efficiently, for example by monitoring the athlete during the training period, and especially by improving detection methods and reducing the margin of error on the tested samples.
The task of laboratories specializing in drug detection is quite complex. To search for the possible presence of one of 300 illegal drugs and/or their metabolites, at any possible level of concentration in a selective and small urine sample, without any chemical diagnosis to help direct the search in any specific direction, requires extremely precise procedures in terms of sample preparation, methodology and interpretation of results. Every year, the list of banned substances gets longer and longer, which means that laboratory researchers must constantly revise and improve their detection methods.
Such a task is almost impossible when results must be ready within 24 hours.

5. Present detection techniques
Detection techniques are practically the same in all laboratories with international accreditation.
The first analytical stage, called the "fast" stage, is based on immunological or radioimmunological methods, separative methods such as gas chromatography and liquid chromatography (GC and HPLC) and methods associating two techniques, such as chromatography/mass spectrometry (GS-MS, HPLC-MS), chromatography/atomic emission detection (GC-AED).
Obviously, it is important to attain a maximum degree of sensitivity at this level, in order to avoid falsely negative tests.
At this initial level of analysis, the samples can be sorted out so as to determine those containing illegal substances, or, more generally speaking, those which do not look quite normal.
The second stage of analysis consists in formally identifying the substances (illegal or not) detected during the first stage and searching for various possible metabolites, determining their level of concentration and identifying the drug as precisely as possible by looking for other characteristic active ingredients or vehicles.

* The recombinant growth hormone is made by several pharmaceutical companies. It is very easy to use. Its use is restricted by French law but it is much freer in other countries of the European community.

IV. The impact of doping on health

1. Potentially fatal risks
In 1886, Arthur Linton died during the Bordeaux-Paris race. In 1904, the marathon runner Thomas Hicks collapsed after winning the Saint-Louis Olympics: he had taken strychnine. Dorando Pietri died in London in 1908 for the same reason. In 1960, the cyclist K. Jensen died during the 100 km road run in the Rome Olympics. The drug Ronicol was blamed. In 1967, Tom Simpson, a professional world cycling champion, collapsed and died while climbing the Mont Ventoux after having taken amphetamines. In 1975, anabolics killed Kangasniesmi, a weight lifter. His muscles gave in under the weight and the iron bar fell down, breaking his spine.
These grave accidents, and there are many more, are well-known. It would be difficult to ignore them, since they happened during competitions, in view of the public and TV cameras. This, however, is only the visible part of the damage done by doping: indeed, little is known about its effects once the athlete has left the sports arena or given up his/her career. We do know for a fact that several great champions suffered from serious health problems after leaving sport. And we also know that there is a direct relationship between certain drugs and certain health problems, such as heart disease or cancer: the existence of a causal relationship between doping and disease thus appears increasingly probable.
However, an additional difficulty resides in the fact that some substances are very often used together with another, main, drug, that some substances of the same nature (but bearing different names) are used together, and that these cocktails undeniably have a positive effect on performance.

1.1. Potentially dangerous drug cocktails
No single drug can satisfy the numerous demands made on athletes to improve performance, stimulate staying power, sustain effort during training, eliminate stress. For this reason, s/he can be tempted to use drug cocktails, either as "scientific doping" and/or as "easy" doping, the latter being used by athletes with limited financial means.
These "cocktails" can be made up of different drugs whose combined effect increases their power, or of similar drugs with different names, which, when taken together, bring the dosage to toxic levels.
Among these combinations: amphetamines combined with corticoids, cardio-respiratory analeptics or cocaine, caffeine or ephedrin; EPO with aspirin and/or an anticoagulant, or natural or synthetic glucocorticoids; to recover strength, a combination of glucose-enriched serum added to insulin, IGF1, and as a supplement, androgens, GH, beta 2-agonists. The list of possible combinations is much longer, since cocktails are elaborated and adapted according to need.

1.2. Pharmacodependency
Several doping substances used by athletes are considered by psychiatrists as addictive, leading to drug abuse and dependence, and their psychological effects and impact on behaviour have been described in the context of the study of dysfunctions linked to drug use (cf. DSM-IV, American Psychiatric Association, 1994). Caffeine intoxication can lead to nervousness, overexcitement, insomnia, or attacks of anxiety in certain persons. Cocaine or amphetamine intoxication can cause hyperactivity, anxiety, stereotyped and repetitive behaviour, anger and violent behaviour, altered judgement. Their chronic use can cause dulled emotions, fatigue, sadness, social withdrawal, or, as concerns cocaine, persecution mania and aggressiveness. According to De Mondenard (1991), marijuana, which is used by some athletes either for its disputed stimulating effect or for the feeling of calm it provides before an event, can sometimes cause anxiety, dysphoria and social withdrawal.

2. Clinical and biological signs indicating an iatrogenic disease
Drug abuse can lead to the development of iatrogenic diseases which must be diagnosed early and with precision. The drugs used — generally in combination and at high dosages — provoke changes in the person taking them, modifies in his/her homeostasis, behaviour, and morphology. As a result, a clinical and biological semiology of doping with a diagnostic tree should urgently be drawn up as a diagnostic tool for physicians. Such a medicalized approach to doping could lead to further investigation of the problem by specialists and to the establishment of certificates of inaptitude to sport.
This approach is only possible in the framework of a system centered on the long-term monitoring of athletes, conducted in specialized centers, by teams of clinical specialists in sports medecine and thanks to sophisticated equipment for the evaluation of the athletes' functional ability to sustain effort. This medical/athletic monitoring would be computerized and carried out in close collaboration with the athlete's personal physician.

3. Psychopathological problems
Knowledge about the possible psychological and behavioral effects of drugs on athletes stems exclusively from publications describing isolated cases of pathological reactions to the use of anabolic steroids, and from experimental research carried out on animals, voluntary human subjects, either healthy or taking these drugs for therapeutic reasons, or still, from more or less systematic comparisons conducted within small groups of athletes, both taking and not taking drugs.
For example, problems linked to body image occur more frequently than average in body-builders taking anabolic steroids. These subjects often suffer from "reverse anorexia", feelings of dissatisfaction regarding their body, and bulimia.
Amateur weight-lifters of the male sex taking high doses of anablic steroids are more aggressive towards objects and verbally aggressive during training. Their periods of waking are longer and they are more irritable, anxious, suspicious and negative. Mood changes are more frequent and personal relationships more difficult when they are "on" drugs than when they are "off", or than in non-users.

B. Numerous determining factors

Due to rising financial stakes and the toughening of the competition for recognition and fame, athletes and their entourage tend to search for additional ways of improving performances, even if it means disobeying the rules established by the sports federations. Today, science has developed very effective drugs to enhance performance and hasten the recovery of athletes facing increasing constraints (schedule, competitions, events, etc.). Many athletes use drugs. The wealthier athletes use them under the supervision of competent professionals, while the others, in order to "stay in the race", resort to self-medication on the basis of advice or information gathered in stadiums ("poor man" doping), unaware of the risk they run.
The analysis of determining factors shows that both sociological and personal factors must be taken into account.

I. Calling into question sports institutions: the sociological point of view
A sociological study of the doping issue must be based on the analysis of relationships between sports actors holding various positions and whose interests differ. With the development of sports as a business, the interaction between two different rationales, that of athletic performance and that of profit, has become increasingly complex, leading us to raise the question of the power of sports.
Competition sports are dominated by a complex system of interdependent actors:
- the federations, whose aim, among others, is to ensure that rules and traditions are respected,
- the athletes, who compete mainly for glory; however, through their unions and associations, they demand recognition as professional players, as well as better working conditions,
- the educators and coaches who wish to protect their interests, as opposed to those of their employers (the clubs),
- the referees, employed by federations or professional leagues, who wish to improve their working environment (professionalization, protection against violence and pressure, etc.)
- the professional clubs (Unions of professional football clubs, basketball clubs, etc.) who aim to some profit from their investment in sports, either in financial terms or in terms of public image, etc.)
- the consultants, sometimes grouped together in multinational firms (International Management Group, Proserv, News Corporation, etc.), who manage the athletes' business. Some of them own TV channels, shares in broadcasting rights for the more popular sporting events,
- showbusiness companies, which try to reconcile the interests of the public with those of their clients (sponsors, sports announcers) and those of the actors (the athletes).
- companies selling sports and leisure equipment (equipment makers, distributors, service companies, etc.) and sponsors,
- the specialized medical (sports physicians), paramedical, pharmaceutical professions;
- journalists hunting for pictures, declarations, revelations which could be of interest to news editors wishing to satisfy their readers'/viewers' demands,
- academics and researchers who publish articles and speak out on the subject and thus wield some influence on public opinion and on the various actors involved,
- persons practising sports or sports fans, who, as consumers (of lessons, images, clothing, equipment, etc.), support the entire system. Due to their numbers (evaluated in terms of audience, number of copies sold, etc.), they play a very important role (events postponed to ensure better attendance, scandals stifled so as not to shock, etc.). Thanks to them, sponsors, businessmen and professional athletes are able to earn a living.
When high level sports are governed by federations or olympic bodies, thanks to state support or because of these institutions' monopoly over the award system (their titles being the only "noble" titles), the rules of the game remain stable and more or less protected against attacks of businessmen wishing to adapt the rules of sport to public demand. However, when federations have little authority, sport can turn into show business, opening the way for corruption, cheating and rule changes.

1. Playing with the rules: a risky game
As the stakes involved in competition sports grow higher, the rule is to get around the rules. Not to take risks with the rules, or not being able to ensure one's protection if suspected of cheating can mean being left out of the race. Those who have nothing or not much to lose are the first to resort to cheating to attain their goal. Those on the higher rungs of the social ladder are in a much better position than others to play that dangerous game without getting caught. Persons who have access to information, to more or less legal ways of getting round the rules (waivers, corruption, or getting those in charge of enforcing the rules to close their eyes), and resort to all kinds of loopholes to get around the law, move ahead faster and remain in dominant positions longer than those who have no way of doing so. (A "wealthy" club or athlete, in terms of both money and information, has easier access to the services of physicians, or of laboratories specialized in doping and masking drugs than "poor" clubs or athletes).
To explain why certain athletes, federations, physicians, referees, resort to cheating, it is necessary to question the entire international sports system, nowadays entirely focused on the tough competition for medals and money. Not to take drugs when others are taking them would mean to lose. In this context, a special study on the side effects of the drugs most used by athletes ought to be be commissioned and results publicized among regularly competing athletes. Players' and athletes' unions or associations would be in the best position to carry out these information campaigns, since they can protect athletes who are already locked in the system — forced to take drugs, or addicted. Of course, athletes are under very high pressure, if only because only the "best" are selected for competition; the pressure is exerted by actors who have an interest in seeing "their" athletes win — federations, TV channels, consulting firms, directors of professional clubs, coaches, event organizers, sponsors, etc. There is a direct link between doping and the question of power relationships between these various actors. Internationally recognized associations and unions (such as in golf or tennis) would thus be the best source of information and protection for athletes.

2. The declining authority of the federations
Two processes are responsible for the decline of the power of federations.
In the first place, sports are now practised by all, whereas before World War II, the working classes, women, and adults over 50 did not practise sports. The growing TV audience for sports events has generated new sources of profit, leading to the professionalization of the most popular sports. The sponsors of "show-business sport" represent a counter-authority for federations, whose power stems from two main sources: the monopoly on "noble sports" titles, which are a hundred years old for the more traditional disciplines, and a network of clubs and volunteer educators who coach millions of athletes and organize their activities. These two elements are essential to the development of a sports elite, for the benefit of showbusiness managers, independent professional leagues, sponsors, etc. The recruitment by private companies of an elite trained in state subsidized clubs (professional clubs or teams) is reminiscent of the transfer to the private sector of graduates of the French state subsidized grandes écoles system.
The second reason for the decline of the power of federations is the development of other types of sports ("leisure" sports, "street" sports) which, according to national surveys, draws as large a public as there are licensed athletes, in other words about 12 million people. Along with the emergence of these "new" sports, there has been a change of attitude towards federations, which tend to be considered as service providers rather than authorities. Athletic excellence is viewed differently from one generation to the next; nowadays, the winner (according to the rules) is not necessarily the "best" player. "Excellence" is less a question of measurable, objective performance than one of self-expression and style, mirroring the aspirations of a generation. "Fun" sports remain competitive, of course, but creativity and artistic expression are nevertheless central. These "new" sports include skateboarding, rollerblading, acrobatic biking, break-dancing, border-crossing, jumping contests, etc.
Demographic and social transformations may explain why the principles which dominated 19th and 20th-century sports no longer correspond to the expectations of most members of today's new generations. Though institutional sports have managed so far to preserve the illusion that their principles were universal, it now appears that they are not eternal; they only hold true in a world where the values, beliefs and ideals they represent are shared by all.

II. Individual factors and the critical age question

1. Varying degrees of susceptibility
In addition to sociological factors, individual factors also play a significant role. Group pressure and financial interests can drive most, if not all, athletes to dope themselves. Nevertheless, doping behaviour — the age at which an athlete will begin to use drugs and the development of addiction — is also determined by individual factors. In this respect, it should be noted that there are many former top athletes among chronic drug users. Heroin or any other drug thus acts a replacement for sport, which for them was practically a drug in itself.
Several reasons have been suggested to explain this phenomenon. On the one hand, the daily and mechanical practise of sports blocks unpleasant thoughts and anesthetizes the mind, in the same way as heroin. Furthermore, when a person attempts to exceed his/her physical limits, the body secretes endorphin which acts as an endogenous drug. Although no specific study has been carried out on the relationship between sports, doping and drug addiction, enough scientific data exists to show that there is a great deal of inequality among athletes in this respect.

1.1. Temperamental factors
Personal temperament also determine the choice of behaviour in a given situation. It is a known fact that differences in behaviour are determined for a large part by biological factors, in particular as concerns reactivity towards the environment and need for stimulation. Thus, it has been shown that highly reactive persons tend to prefer situations which have low stimulating power, and conversely for persons with low reactivity. The need for strong sensations (according to the notion defined by Zuckerman) and new and intense experiences is governed by the need to reach a high level of sensorial activation. However, the forms of behaviour aimed at reaching this level of activation may vary a great deal: drugs and alcohol, danger, adventure (dangerous sports, mountain-climbing, hang gliding, etc...). In the understanding that each individual has his/her own personal optimal level of activation and his/her own way of reaching it, one can see how persons who enjoy taking risks may be liable to use psychostimulants or drugs.

1.2. Motor activity as a source of gratification
Physical exercise requires the participation of the body's physiological systems and modifies its homeostasis. In particular, it modifies the activity of several cerebral neurotransmitter systems. In animals, heavy exercise, prolonged exercise and overexercising have opposite effects. For most neurotransmitters, the release increases, then decreases (with slowing down of activity) if the exercising lasts a long time.
Furthermore, it is a known fact that exercising can lead to hormonal changes, by increasing the secretion of prolactin, of the growth hormone and corticosteroids. Some of these hormones have a powerful effect on most neurotransmitter systems.
These neurotransmitter systems are both the target of doping substances and the providers of gratification. As a result, it is easily conceivable that proneness to addiction should entail doping behaviour, with doping substances taken together with other drugs. This is all the more true for persons with a need for strong sensations.

2. Adolescence: a period of major risk

2.1. Taking doping substances together with drugs: the risk for teenagers and top athletes
The subject of doping is usually exclusively related to sports, since doping drugs are used to enhance performance, as opposed to other forms of addictive behaviour. In fact, in recent years, the parallel between doping and drug addiction has become increasingly obvious, and some authors, such as P. Laure (1995), have been considering whether one should not "regard doping not only as a way of enhancing performance but also, and most importantly, as a new form of drug addiction". Indeed, it has long been known that the use of "doping" substances such as amphetamines, and more recently, anabolic steroids, can lead to drug abuse and physical and psychological dependence.
Between 1980 and 1990, several epidemiological surveys were conducted in United States high schools. Their aim was to evaluate teenagers' consumption of anabolic steroids, possibly in combination with other drugs. This represents a new phenomenon among teenagers, whether or not they practise sports, and the reason they gave for taking drugs was the wish to improve physical appearance and muscular strength. According to the surveys, 2 to 4% of teenagers of both sexes, but mostly boys, had used anabolic steroids. The average age at which they begin is 14 (ranging from 8 to 17), and the proportion of users is slightly higher among those practising sports.
Recent surveys conducted in American and Canadian high schools show that teenagers practising sports admitted to having taken anabolic steroids in order to improve their performance, but that they also drank, smoked and used other drugs, in the same way as those who did not practise sports.
The first surveys conducted on the drug habits of young American athletes date back to the early 1980s. These surveys showed that athletes took psychoactive drugs just as did their non-athletic peers. Subsequent studies carried out in the early 90s do not confirm the generally accepted idea that sports students use more drugs and drink more alcohol than others. Neither do they confirm the existence of an anabolic doping "epidemic" in American colleges. Recent studies carried out in Canada among athletes of both sexes underscore the importance of alcohol and caffeine consumption.
In conclusion, the various epidemiological surveys conducted in the United States and Canada, in various environments, with students practising competition sports, or not practising sports, show that there are not many differences in the choice of drugs in general, whether these are legal, such as alcohol, illicit, or "doping" substances. The distinction between use and abuse is not clearly marked.

2.2. Psychopathological disorders underlying the abuse of psychoactive drugs
Certain psychiatric disorders are more frequently observed among young drug addicts, a fact which raises the question of whether these disorders play a role in determining a subject's proneness to drug-taking. Depending on the survey, emphasis is laid on some substances rather than others, but globally, all are involved (tobacco, alcohol, marijuana, hard drugs such as cocaine). The vast majority of users are male. However, "externalized" disorders are not the only explanations for drug addiction among these teenagers. "Internalized" or "emotional" disorders — mood changes, anxiety — are also frequently observed. It is important to determine whether these observations apply to doping substances as well.
Important semiological similarities have been observed between the behavioural and biological characteristics of athletes and those of persons suffering from eating disorders. Thus, amenorrhea, which often happens in cases of mental anorexia, is a frequent problem among long-distance runners. These connections show that the intensive practise of sports is often in itself a form of addiction. In the same line of thought, one may note that eating disorders are extremely frequent among young female gymnasts.
Another disorder, hyperactivity with attention deficiency** may be an underlying problem in cases of drug abuse. Given its frequency among children, as well as among teenagers and adults, it would be particularly interesting to study its incidence in a large sample of young athletes and correlate this disorder with drug and/or doping substance abuse. This disorder affects 2 to 3% of the adult population. Drug abuse usually begins during adolescence or in early adulthood, and affects 10 to 20% of adults.
In conclusion, there seems to be a close link between psychoactive substance abuse and motor hyperactivity. Hyperactivity is probably a risk factor for drug abuse (including doping), and at the same time it can determine a person’s choice to practise a sport. Epidemiological studies are of course necessary, but there is enough evidence indicating that certain athletes are more prone than others to doping and drug addiction.

** Hyperactivity begins early in childhood and affects 6 to 9% of school-age children. It is defined in the Dictionary of Medical science as a "persistent form of lack of attention and/or hyperactivity/impulsiveness, more frequent and severe than what is usually observed in other subjects at a similar stage of development".

Conclusion : a growing public health issue

This report presents several points related to public health and social issues.
In general terms, it can be said that doping methods have become so complex, and available drugs so numerous, that doping has become more and more dangerous for top athletes. Furthermore, doping is also becoming more and more widespread and begins increasingly early among young, and unsupervised, athletes.
Doping is also linked to a lack of objective information concerning the risks involved in the use of the most recent substances. Since their positive effects are felt well before their negative side-effects, it is difficult to convince athletes and coaches not to use them.
The 1990s saw the development of many new forms of physical exercise. As opposed to "sliding sports", which emerged in the 1980s and are practised in natural and open spaces, the "alternative" sports of the 1990s are practised in confined, urban, spaces. Called "street sports", they represent more than just sport; they are identified with a specific culture and their aim is to provide strong sensations (sliding, falling, avoiding). They are played in the dangerous environment of the city, as opposed to traditional sports, practised within the safe framework of federations which try to eliminate risk by improving security conditions (protection masks, gloves, ski-stop, safety jackets, etc.) The link between these new types of sport and addiction is clear: "Getting high" is a combination of sporting risk and drugs. Street sports events and group drug use often go together.
At the same time, the spread, if not the systematic use, of supplements in all sports is frequent among athletes, regardless of level or age. These supplements are supposed to consist mainly of vitamins, as well as "energy-giving" elements — a first step towards doping.
The increasingly young age of the affected population is a great cause for concern. The potential risk is very high, both in terms of the distortion of the image of sports among young people and the spread of a type of behaviour which, as evidence shows, can lead to addiction.

Recommendations

On the basis of this analysis, several recommendations, classified according to 6 main themes, can be formulated.

I. Epidemiological surveys
IIn order to assess the extent of the doping phenomenon, it is necessary to conduct epidemiological surveys, even though the criteria on which to base these studies may be difficult to define. These surveys should analyze both the medical and social aspects of the problem:
- medical surveys should describe the phenomenon and determine its impact on the physical and psychological health of the subjects (link between doping and drug addiction, role of the Observatoire de la Santé);
- sociological surveys should aim to define the attitudes, beliefs, contexts and positions of the different actors participating in the sports system.

II. Organization of the medical follow-up
The medical monitoring of doping cases must be carried out over a long-term period. This can be done by:
- setting up multidisciplinary networks
- the formal introduction of doping semiology and its diagnostic tree in daily practise (diagnosis, clinical, biological, medical, paramedical, sociological follow-up);
- guaranteeing the independence, by contract, of physicians working with athletes;
- creating a separate medical specialty, "sports medecine", in the curricula of medical schools.

III. Pharmacovigilance
The incidence of doping on the short, medium or long term must be evaluated in the framework of drug monitoring surveys. Several proposals can be made:
- to introduce the notion of "athlete" or "former athlete" in the drug monitoring document which is presently being drawn up (upon initiative of the European Commission);
- to encourage the development of specific research on doping substances, especially the newer ones which are in the process of obtaining marketing authorizations.
- to create a permanent think-tank on the subject of future substances.

IV. Technology watch
Due to the development of new technologies in the field of medication, food, equipment, as well as scientific research in the fields of biology, physiology, psychology, related to sports and health, efforts and thought should be devoted to the following:
- the improvement of actual detection techniques (applied, for the time being, in a repressive framework);
- the formulation of recommendations on the basis of the technical and financial feasability of tests)
- the study of the evolution of sports techniques and equipment
- the promotion of research on future techniques (biotechnologies, genetic manipulations, etc.)

V. Education and Information
Objective education and information should be provided not only to athletes but to all of society (parents, educators, officials, the general public, etc.). To this end, it is necessary to:
- inform athletes, officials and the public about the nature of the problem, the rights and obligations of the actors concerned. This could be done through educational workshops.
- include doping and its semiology in the compulsory curriculum of medical schools;
- promote awareness among health professionals and educators, physical education teachers, sports educators and coaches;
- update information thanks to modern means of communication (FM radio, Internet).

VI. Doping and politics
The doping problem must be examined in the context of the political and economic issues surrounding it. Two possible approaches can be suggested here:
1) Carrying out an analysis of the sports system and of the power relationships between the actors involved.
2) Including athletes and/or their representatives (unions, associations) in systems set up to regulate decision-making processes in national and international sports institutions (federations, consulting firms), and defining strategies to fight doping in sports, based on three important criteria: time, place, player.
As concerns the first criterion, sports schedules must be adapted to avoid overworking the athletes.
The choice of a strategy must also include working conditions and facilities, the age at which an athlete can begin to compete, etc.
3) Contracts should be drawn up between employers and physicians (term contracts) and between employers and athletes (work contracts), as well as collective agreements.
In conclusion, we suggest that several of these proposals be included in the terms of reference of the future independent administration in charge of fighting doping. By implementing such measures, European institutions would be taking action to deal with the doping problem and trigger a movement whose consequences can only be positive for the international sports community.