A MEDICAL UNKNOWN: STEROIDS

Possible Health Costs Haven't Deterred Use

When big-name baseball players such as Ken Caminiti turn to
performance-enhancing drugs to try to hit farther and move to the top of
their game, they are also unwittingly signing up for a massive -- and
potentially dangerous -- experiment.

Steroids and other drugs that might boost athletic ability may be prevalent
in sports, but they are also, in many ways, a medical unknown, doctors and
researchers say. There have been few studies that determine what extra
strength the drugs may confer, or what long-term damage may arise.

Doctors say, "Don't." Athletes ask, "Why not?" The doctors can't provide a
definitive answer.

"Thousands of studies have been done on tobacco, alcohol, cocaine,
marijuana," said Charles Yesalis, professor of health and human development
at Pennsylvania State University, and one of the nation's leading
authorities on the types of performance-enhancing sports drugs. "But when
it comes to the effects of performance-enhancing drugs, five to 10 years
down the road -- who the heck knows?"

It's a critical problem for doctors and athletes alike as new questions
emerge about the use of potentially dangerous steroids and other drugs in
sports. Most data on the health and performance effects of steroids come
from animal research, studies of sick people or individual case reports,
rather than formal epidemiological studies in large, healthy populations,
said Jack Stein, deputy director with the Office of Science Policy at the
National Institute on Drug Abuse.

As a result, athletes such as Caminiti are emerging as human guinea pigs in
a vast uncontrolled experiment, self-medicating with anabolic steroids,
growth hormone, erythropoietin, stimulants, supplements and anything else
that might give them a competitive edge. As long as the possibility of
short-term gain outweighs any theoretical long-term disadvantages, drug use
will continue, say physicians and sports authorities.

Drug use has grown to alarming proportions in professional baseball,
according to an incendiary article in a recent issue of Sports Illustrated.
In the article, Caminiti admits that he won the 1996 National League Most
Valuable Player award while on steroids -- and adds that these drugs are a
widely accepted choice for ballplayers looking to improve performance.

Baseball is the only major professional sport that does not explicitly
outlaw steroid use. The major leagues do not test players for steroids,
unlike the NBA, NFL and the International Olympic Committee.

Even more troubling are reports of growing use of performance enhancers
among the nation's high school and college athletes, who, because of their
youth, could be vulnerable to side effects such as sterility; liver, kidney
and heart disease; skeletal disintegration; and death at an early age.

National surveys estimate that approximately 1 million young people between
ages 12 and 17 have taken performance-enhancing supplements or drugs. "They
see their best friend getting gains. They also see their friend is not
getting sick," said Michael Perko, associate professor of health education,
University of North Carolina at Wilmington, and a former soccer, ice hockey
and lacrosse coach.

'Cowboy Chemistry'

Drug regimens used by athletes -- such as mix-and-match "stacking,"
periodic "cycling" and dose-building "pyramiding" -- are based on rumor,
hearsay, superstition and scattered tactics. Dosage levels are guesswork, too.

'It's "cowboy chemistry," Yesalis said.

That do-it-yourself dosing has never been extensively studied, although
it's been observed since the 1930s, said NIDA's Stein.

"In terms of real careful epidemiological studies, those are limited,"
Stein said. "It's only in the past decade that we've begun tracking trends
in usage and the health consequences."

So it remains anybody's guess whether steroids were the cause of the brain
cancer that killed former Oakland Raiders member Lyle Alzado at age 43, as
he claimed. Or whether steroids are to blame for the heightened
irritability and anxiety of former Mr. Universe Bertil Fox, who murdered
his girlfriend and her mother.

Nor is it known what steroidal mechanism is behind the eased shoulder pain,
boosted alertness and shrunken testicles of Caminiti -- all side effects he
describes in the Sports Illustrated article.

Is human growth hormone linked to observations of swollen heads, impaired
speech and protruding brows in some professional ball players? No one is sure.

Even less is known about steroidal supplements such as
dehydroepiandrosterone (DHEA) and androstenedione (andro), which can be
purchased legally without a prescription at health food stores. According
to advertising hype, DHEA slows aging, burns fat, builds muscle and
strengthens the immune system.

Creatine is said to boost energy. Ephedra, a plant extract, is said to
improve the body's ability to burn calories. But not one of these claims
has been proved -- or disproved.

And there appears to be little appetite for rigorous scientific study of
these drugs in healthy people.

Three times, scientist Yesalis applied to the federal government for
funding to study the long-term consequences of steroid abuse by competitive
athletes.

"I gave up," Yesalis said. "I think the proposal is still sitting in a box
in my basement."

Perhaps the most authoritative study on the short-term benefits of
androgenic steroids was done six years ago on 40 men. In this study,
published in the New England Journal of Medicine, a team of California
researchers confirmed what steroid-shooting athletes have been insisting on
for years: the male hormone testosterone, combined with exercise, builds
muscles. Men who exercised and took steroids for 10 weeks put on an average
of 13 pounds of virtually pure muscle and could bench-press an extra 48 pounds.

"The benefits are real. That's why they're so popular. The drugs do work,"
said Dr. Robert Voy, director of drug testing for the U.S. Olympic
Committee at the 1984 and 1988 Games and a sports medicine physician in the
Las Vegas area.

A study published in the Journal of the American Medical Association in
2000 was the first to conclude that high doses of hormone-influencing andro
can elevate testosterone levels. However, the trial lasted merely one week
and failed to measure whether the dietary supplement can do what its
producers say it can: increase muscle size and mass. Nor did the study
conclude that the supplement has long-term side effects.

Avoiding Testing

Interviews reveal that there are many reasons why scientists, federal
authorities and athletes don't step forward for further testing. For instance:

* Pharmaceutical companies, which produce many of the drugs for legitimate
medical reasons, don't want to taint their product by studying its illicit
abuse.

* Hospital review boards, which are responsible for overseeing the ethics
and safety of clinical trials, balk at conducting any trial that
administers very high doses of drugs, such as the levels that athletes use.

Athletes "are using super-therapeutic doses, much higher than the ones we
give for therapeutic problems -- 10 times or more what you'd give in a
medical situation," Voy said. "You couldn't get permission to do it."

* The National Institute on Drug Abuse, which would fund such trials,
concurs. "To do a clinical trial -- that creates an ethical problem. We
protect human subjects" in research, Stein said. "Rarely do we do any type
of research study that actually involves giving high doses of an illicit
drug to human patients."

As an alternative, NIDA is now conducting in-depth interviews and physicals
of people who say they used the drugs.

* The U.S. Food and Drug Administration only reviews the safety and
effectiveness of drugs designed to cure ailments. Typically, well-hidden
side effects emerge during the FDA's massive "Phase 4" of drug studies,
done after approved agents have been widely dispensed to a diverse U.S.
population.

"These aren't illnesses," said Laura Bradbard of the FDA. "Say somebody
invents a drug that creates a faster runner -- well, slow running is not a
disease."

* Athletes are unlikely to step forward to volunteer in a formal trial,
which would no doubt reveal their drug usage.

"Due to the very nature of recruitment, it wouldn't work. The people who
are taking them are not about to sign up for an academic study," said Dr.
Don Catlin, director of the University of California-Los Angeles Olympic
Analytical Laboratory.

* Ingredients vary from product to product. Surveys have found that many
supplements do not contain what they claim, and many contain adulterated
ingredients. While some steroids are illegally diverted from U.S.
pharmacies, many more are smuggled in from foreign pharmacies or
synthesized in clandestine laboratories.

"Not a great deal of sophisticated science has been applied to the field.
It's too bad," Catlin said. "There is lots of speculation. There are lots
of case reports. There are lots of people saying it should be done. But
it's not ever been done. I'd love to do it. But it'll never happen."

Authorities agree on this: Even without further research, it is possible to
move forward on better education, more rigorous testing, perhaps a ban on
all performance enhancers. It is dangerous to delay while waiting for more
research to be done, they said. Prevention efforts need to start in schools
before youths feel the pressure to boost performance.

UNC-Wilmington's Perko said: "Warnings about negative side effects may work
with a 50-year-old but not a 15-year-old." He believes intervention should
begin even earlier.

"We know enough," said Dr. Gary I. Wadler, a fellow of the American College
of Sports Medicine, the largest sports medicine and exercise science
organization in the world.

"It is time to stand up and deal with this," Wadler said. "We owe it to the
public to make sure that our players are not tainted, to make sure that
they represent our best values, not our worst values."

IF YOU'RE INTERESTED

Two books offer good insight into performance-enhancing drugs:
"Performance-Enhancing Substances in Sport and Exercise," by Michael S.
Bahrke and Charles E. Yesalis, and "Drugs and the Athlete," by Gary I.
Wadler and Brian Hainline.