Caffeine is a performance enhancing drug and it is legal.  Its benefits are in endurance events, and it is only banned by the IOC (International Olympic Committee) in very large doses.  Few of the performance enhancing drugs have a substantial effect on performance.  The best documentation of benefit is in the case of blood doping and its modern substitute, erythropoetin. In 1984 several members of the U.S.­ Olympic bicycling team admitted to receiving blood transfusions. Erythropoetin is the natural hormone from the kidney, which stimulates red blood cell production.  Many people with chronic anemia no longer need blood transfusions because of it.  When erythropoetin became widely available in 1998, several members of the Belgian bicycle team died in their sleep from strokes induced by excessive blood viscosity almost surely induced by excessive initial doses of erythropoetin.  It is scarcely detectable directly.  Excessive hematocrit (percent of blood that is red cells) is readily detectable.  Lesser degrees of increased hematocrit due to this hormone are in recent years present in the majority of world class bicyclists.   Funding for research to differentiate natural from introduced erythropoetin has not been adequate (perhaps because the money has been better spent elsewhere).


Supplemental creatine increases energy stored as phosphocreatine in muscle, marginally increasing the ten seconds or so of intensive effort that can be sustained without oxygen.  This is enough for a brief effort like a sprint or weight lifting.  No toxicity has been demonstrated from the doses that have caused this modest performance benefit.  Creatine in larger doses does not further enhance performance because no additional creatine can be induced to enter the muscle.   


Anabolic steroids, such as testosterone, increase muscle mass, especially when accompanied by resistance exercise.  Testosterone accounts for the greater muscle mass of most males compared to females.  Androstenedione from plant sources is sold in health food stores as a dietary supplement.  Some of ingested androstenedione is converted to testosterone.  Excess testosterone causes testicular atrophy by making the natural production redundant.  In addition to the increased muscle mass induced by anabolic steroids, all of them reduce HDL cholesterol (high density lipoprotein cholesterol), sometimes called "good cholesterol".  Several deaths of former Olympic athletes in their late thirties and early forties are almost certainly due to this cause.  For example, "FloJo" Florence Griffin Joyner died suddenly and unexpectedly at age 38.  She had set some "untouchable" track records.  ­The folklore among elite athletes is that to break even one of these "untouchable" records requires the use of performance enhancing drugs.    Some folklore is true. 


You may wonder why such a potentially dangerous substance is available over the counter at health food­ stores.  In 1994 a new Federal Law was passed, which prevents supervision of dietary supplements by the FDA (Federal Drug Administration) except in cases of serious toxicity or death.


Other performance enhancing drugs of intermediate toxicity, which I won't discuss in detail include: ß blockers, which reduce tremor, but also reduce aerobic endurance, growth hormone, amphetamines (speed), ephedrine (removed from the market in 2004), About 1 in 20 American males and 1 in 40 females have used one or more of these drugs.  Less than one half of these users are athletes.  The others, mostly males, take them for body image problems.  Compare with anorexia nervosa.  About 25% of these people who inject themselves share needles. This has resulted in a handful of AIDS and hepatitis cases, a very small incidence compared to intravenous drug users.  Finally, two surveys of athletes a few years ago showed that 80% of them would take these drugs if they could be assured of an Olympic medal, and 50% would take the drugs if assured of a gold medal, even if the result would be death 20 years prematurely.







Children especially should be protected from foreclosing their future decisions.  I mention another body image problem with unintended consequences: breast implants in adolescents may prevent breast feeding later.  Breast fed premature babies at age 10 have 8 IQ points greater intelligence than otherwise similar bottle-fed premature babies.  Next, drugs which enhance mental performance. 


In the early 1990's, Dr.­ Kramer, author of Listening to Prozac, propounded the question: "What if Prozac enhances the performance of an already world class salesman; should society condone the use of it for such a purpose?"  So far the answer seems to be that although this class of new drugs is a breakthrough in the treatment of depression and obsessive compulsive syndromes, society is not ready to use them in normal people.  There are several new drugs which retard the progression of Alzheimer’s disease.  Do these enhance cognition in normal people?  Should we even seek an answer?  Note the parallel to the question we have already discussed about the use of drugs that may enhance athletic performance.  These are important public policy questions for all of us.  Don't just take one columnist's word for it.   


As I was contemplating writing on this topic, at first it occurred to me that I should not publicize athletic performance enhancing drugs for fear of subtly promoting them beyond my intentions.  Consider the problem of documenting the efficacy of the DARE program.  Could it be that the expected effectiveness of DARE for some is balanced by the unintended suggestion to others who might not otherwise have considered using illegal drugs.  Is the DARE program weakened by its compulsion to demonize all illegal drugs more or less equally, contradicting common knowledge of streetwise potential users?  In the 1960s Luther Terry as Surgeon General stated that alcohol and tobacco were greater health hazards than marijuana.  We doctors knew this to be true, even though it was an unpopular statement.  My conclusion about seeking publication of this article is that speaking the truth constructively has great merit.  If it can be done diplomatically without detracting from the reputation of the speaker, so much the better.  Especially, I hope that I have not gone beyond the facts.


John A. Frantz, M.D.

Chairman, Monroe City Council Board of Health

December 23, 2001


 Unnecessary questions are like  the screen saver on your computer monitor in that if you need your    brain suddenly for some vital purpose. it will be more ready to function, thus enhancing your survival. Furthermore, some fixed idea is less likely to burn a hole in your screen of consciousness.