Evaluation of prevalence of "doping" among Italian athletes

1048

We thank Mr M. Daffeh, Mr P. Cham, and Ms M. Joof for help in the field, and Dr B. M. Greenwood for his advice and encouragement.

vaccine in Guinea-Bissau: protective efficacy. Lancet 1988; ii: 809-11. 3. Tidjani O, Grunitsky B, Guerin N, et al. Serological effects of Edmonston Zagreb, Schwarz, and AIK-C measles vaccine strains given at ages 4-5 or 8-10 months. Lancet 1989; ii: 1357-60. 4. Markowitz LE, Sepulveda J, Diaz-Ortega JL, et al. Immunization of six

REFERENCES

month old infants with different doses of Edmonston-Zagreb and Schwarz measles vaccines. N Engl J Med 1990; 322: 580-87. 5. World Health Organisation WHO Weekly Epidem Rec 1990; 2: 6. 6. Whittle HC, Mann G, Eccles M, et al. Effects of dose and strain of vaccine on success of measles vaccination of infants aged 4-5 months. Lancet 1988; i: 963-66.

H, Hanlon P, O’Neill K, et al. Trial of high-dose EdmonstonZagreb measles vaccine in the Gambia: antibody response and side-effects. Lancet 1988; ii: 811-14. 2. Aaby P, Jensen TG, Hansen HL, et al. Trial of high-dose Edmonston1. Whittle

Zagreb measles

EPIDEMIOLOGY Evaluation of

prevalence of "doping" among Italian athletes

To evaluate

knowledge of, attitudes to, and use of illegal drugs and other forms of "doping" in sport

1015 Italian athletes and 216 coaches, doctors, and managers (technicians) were interviewed after selection on a quota basis. Overall, 30% of athletes, managers, and coaches and 21% of doctors indicated that athletic performance can be enhanced by drugs or other doping practices. Over 10% of athletes indicated a frequent use of amphetamines or anabolic steroids at national or international level, fewer athletes mentioning blood doping (7%) and beta-blockers (2%) or other classes of drugs. These proportions were 2-3 times higher for occasional use than for frequent use. Estimates by managers and coaches were much the same as those of athletes when allowance was made for larger random variation. 62% of athletes who acknowledged doping reported pressure to do so from coaches and managers. According to over 70% of athletes access to illegal substances was not difficult. Both athletes and technicians awarded higher scores to risk than to efficacy for any substance, although 42-67% of athletes and technicians regarded amphetamines and anabolic steroids as efficacious. 82% wanted stricter controls not only during competitions but also

during training. Introduction The public’s attention has been directed lately to the use of illegal substances or drugs in sport. Most of this attention has arisen because of specific anecdotal episodes and vehement commentaries in the medical press, and in the absence of any data on the prevalence of drug-taking in

sport. 1-9 In 1988 the Italian National

Olympic Committee

(CONI) and National Research Council (CNR) appointed independent committee to specifically conduct a survey on the knowledge about and attitudes of Italian athletes to "doping" practices. We report the main results of this an

survey.

Subjects and methods The survey was undertaken during the summer of 1989 by the DOXA Institute, the Italian branch of the Gallup International Research Institutes. The population sample was selected on a quota basis-ie, by requiring interviewers to select, on the basis of sex, age, and type of sport, the athletes or technicians (doctors, coaches, managers) to be questioned. Thus, the sampling frame included definition of the number of individuals to be interviewed within each geographical area, sex and age group, and type and level of competition. Individual subjects were not identified. This sample definition was not modified subsequently. The starting point for recruitment of athletes was the training site (eg, gymnasiums,

stadiums, sportsgrounds). Trained interviewers identified and questioned the subjects selected with two similarly structured questionnaires--one for athletes and one for technicians. Subjects were asked about the role in athletic performances of diet, other energy providing substances, and six categories of drugs (amphetamines, anabolic steroids, beta-blockers, diuretics, vasodilators, narcotics); treatments such as blood doping; the prevalence of doping practices; and the availability, desired side-effects, and the reasons for use of drugs and other substances. For example, the interviewer asked "I am now going to show you a list of substances. For each one please tell me whether you know it (ie, whether you have heard mention of it), ADDRESSES Institute DOXA,

Gallup International Research Institutes, (V. Scarpino, PhD); Institute of Pharmacological Research "Mario Negri", (S. Garattini, MD; C. La Vecchia, MD; G. Silvestrini, MD); National Council for Research (L. Rossi Bernardi, MD); Italian Federation of Sports Medicine, Rome (G. Tuccimmei, MD); Institute of Clinical neurology, University of Pavia (A. Arrigo, MD); Institute of

Pharmacology, Faculty of

Science, University of Pavia, Italy (G. Benzi, MD) Correspondence to Dr V. Scarpino, Institute DOXA, Gallup International Research Institutes, via Panizza 7, 20144 Milan, Italy.

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TABLE I-DETAILS OF THE INTERVIEWED SAMPLE ACCORDING TO SELECTION CHARACTERISTICS

TABLE 11-USE OF SELECTED DOPING PRACTICES AMONG TOP LEVEL ATHLETES ACCORDING TO ATHLETES AND TECHNICIANS

TABLE III-KNOWLEDGE AND BENEFIT/RISK EVALUATION OF VARIOUS DOPING PRACTICES BY ATHLETES AND TECHNICIANS

whether, in your opinion, it is a substance that helps improve an athlete’s performance (or is of some real use to an athlete), and whether it has harmful effects on the athlete". Thus for each substance we identified how many interviewees knew it, thought it was effective, and believed it to be harmful. The substances considered most effective and most harmful were found by comparsion of the frequency distribution figures. The subject’s opinion was also sought on the frequency and efficacy of existing

drug testing practices. DOXA briefed the interviewers on how to choose sports facilities recruit sportsmen and where to interview them (on the spot or in their homes). The interviewers were also provided with an introductory letter from CONI in which the objectives of the survey were described in general terms. The sportsmen approached were free to refuse the interview. The interviewers explained their interest in including subjects for each sport and typical sportsmen and women of various performance abilities and ages in each survey area; the subject was also told that anonymity would be guaranteed. Names of possible interviewees were not provided by CONI. The DOXA interviewers were required to ensure that no one other than the interviewee was present at interviews, and to arrange an appointment at the subject’s home if this was difficult. Statistical analyses were done at the DOXA Institute with standard methods for such studies. 10 at which to

Results 1015 athletes and 216 technicians were interviewed (table i). Overall, 30% of athletes, coaches, and managers and 21 % of doctors indicated that athletic performance can be enhanced by the use of drugs or other doping practices. In respect of estimated use of certain practices (table 11), over 10% of athletes thought that amphetamines or anabolic steroids were frequently used at national or international level, and that beta-blockers or other classes of drugs were less often used (data not shown); blood doping was reportedly used by 7% of athletes. These proportions were 2-3 times higher for occasional use, and similar opinions were expressed by the technicians, when allowance was made for the smaller number interviewed and hence greater random variation. Although these assessments are probably an underestimate of the true frequency of drug use, doping does seem to be restricted to top-level competitions. Reasons given by athletes for the use of doping practices were winning in competition (63%), improvement of training performance (9%), pain reduction (6%), and request by coaches (6%); 16% gave other miscellaneous reasons for doing so. Most of the athletes who reported drug use or doping practice had

done so under external pressure, whereas only 28% had themselves decided to do so. To confuse the issue a substantial proportion of subjects (35 % of athletes and 40 % of coaches and managers) reported that doping practices admitted in the past are now illegal. According to most athletes access to illegal substances was not difficult (39% not very difficult, 35% very easy). Table ill shows the athlete’s and technican’s benefit/risk evaluation of various doping practices. Several substances (amphetamines and anabolic steroids in particular) were judged efficacious by about half the athletes and technicians, and were known to most athletes. However, the proportions of athletes and technicians who believed the substances or practices were harmful were much higher than those who thought the same substance or practice was efficacious. Over two-thirds of athletes and technicians requested more frequent and efficacious control of the sports environment; 82% of athletes would be in favour of sports societies doing systematic checks for doping during training.

Discussion It is important to emphasise that these findings should be interpreted with caution since the sample was identified on the basis of quotas and not individuals. Random errors and other sources of bias, including that of selection, could have arisen. In the design stage of the survey two methods of selection were considered: (a) random selection of names and addresses of sportsmen registered with the various federations, after classification of addresses by region and by type of sport; and (b) assignment of interviewers to certain locations with a quota of interviews on the basis of type of sport, level achieved in that sport, and sex and age of the sportsmen. After careful analysis we found that only for some sports did the federations belonging to CONI (Italian Olympic Committee) have fairly comprehensive and up-todate lists of sportsmen for all levels of competition. For most sports only partial lists were available, and then only for the highest level competitions or from local associations. These associations were not approached since club officials might

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have sought to influence their members before the interview. In the most serious cases of doping, subjects were probably reluctant to take part in the survey and therefore more prone to refuse. On the other hand, there would have been even geater unwillingness had the interviewers been provided with names supplied by CONI since this organisation is thought by sportsmen to be the authority most directly concerned with drug checks and with the examination of the behaviour of individual sportsmen. DOXA, however, is familiar to the Italian public and is viewed as an independent organisation with a long tradition of respect for anonymity and privacy of interviewees. Its reputation undoubtedly encouraged interviewees to collaborate. Subjects rarely refused interviews and, after some initial suspicion and hesitation, the discussions were generally free and open. Since subjects were recruited in sports facilities and associations sportsmen who attended less often might have been under-represented. However, sportsmen who enrolled with a club but rarely attended were unlikely to know much about or to practice doping and would probably therefore have contributed little additional information to the survey. How reliable are the data obtained by this method in an area that is largely illegal and for which there are few comparative data? We are not aware of other surveys, at least in Europe, on attitudes and prevalence of doping among athletes, doctors, coaches, and managers. The survey’s major value is that it has produced preliminary qualitative estimates on a topic largely debated on the basis of emotional attitudes. 1-9 The main and probably the most worrying finding is that various doping techniques are largely known to most Italian

athletes and technicians, and are possibly used by a not inconsiderable number of top level athletes. The information we obtained might provide only conservative estimates of the true extent of doping. Even more worrying was the observation that, in most cases, athletes did not choose to use doping practices but that this was largely determined by their environment. The survey did reveal, however, that the subjects felt that seriousness of the side-effects of doping should be emphasised, and there was a general request for stricter controls, not only during competitions, but also during training. This is certainly a clear indication that most athletes are not in favour of doping, which was further reflected by a plea for more scientific and quantitative information. REFERENCES 1. Cowart VS. Issues of drugs and sports gain attention as olympic games open in South Korea. JAMA 1988; 260: 1513-16. 2. Dixon B. The modern Olympic ideal. Br Med J 1988; 297: 926. 3. Ferner RE, Rawlins MD. Anabolic steroids: the power and the glory? Br Med J 1988; 877: 877-78. 4. Collier J. Drugs in sport: a counsel of perfection thwarted by reality. Br Med J 1988; 296: 520. 5. Marshall E. The drug of champions. Science 1988; 242: 183-84. 6. Cowart VS. Accord on drug testing, sanctions sought before 1992 olympics in Europe. JAMA 1988; 260: 3397-98. 7. Buckley WE, Yesalis III CE, Friedl KE, Anderson WA, Streit AL, Wright JE. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988; 260: 3441-45. 8. Cowart VS. Random testing during training, competition may be only way to combat drugs in sports. JAMA 1988; 260: 3556-57. 9. Hallagan JB, Hallagan LF, Snyder MB. Anabolic-androgenic steroid use by athletes. N Engl J Med 1989; 321: 1042-45. 10. Armitage P, Berry G. Statistical methods in medical research, 2nd ed. Oxford: Blackwell, 1987.

VIEWPOINT Tissue pressure, posture, and

venous

ulceration

ANTHONY CHANT

1970s I carried out a series of experiments the clearance of subcutaneously injected sodium-24 relating and the venous system. 1-3 Most dramatic of all my observations was an almost perfect inverse relation between that clearance and changes in venous pressure with posture (figure). I interpreted my findings in controls and patients with treated and untreated venous disease in terms of transmural pressure changes, emphasising the importance of tissue pressure itself as an important capillary-bed regulatory mechanism. Those who objected to my hypothesis correctly pointed out that I had not actually measured tissue pressure and that the changes I described could be explained by vascular reflexes. In my experience, however, few reflexes are as precise as the relation shown in the figure. In each of ten patients, with only three or four points on the graph, regression coefficients of about 0.9 were

It is generally believed that postural changes in the circulation are due to either local or centrally mediated reflexes4-<> and that the net increase in transcapillary filtration in the vertical position is limited by precapillary sphincters.’ However, Levick and Miche1l8 have challenged this view; they said that the mechanism by which the capillary filtration coefficient in the foot is reduced on standing is unclear, but they quoted the work of Mellander et al,9 who proposed a myogenic response to increased vascular pressures. There is, however, evidence that other factors, such as tissue pressure, might indeed be relevant. In-vitro experiments with patch voltage clamp recordings showed that pressure changes can affect the permeability of vascular endothelium to calcium irons;l° the presence of mechano-transducing ion

obtained.

FRCS).

In the

early

ADDRESS. Department of Vascular Surgery, Royal South Hants Hospital, Graham Road, Southampton SO9 4PE, UK (A. Chant,