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Performance-Enhancing Drugs: Implications for Insurance

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Performance-Enhancing Drugs: Implications for Insurance Performance-enhancing drugs: implications for insurance Marianne E. Cumming The use of performance enhancers by otherwise healthy individuals may influence their overall well-being for better; or possibly, as a result of unintended side effects, for worse. It could also influence an individual’s insurance status; but it is very challenging for insurers to make an accurate risk assessment. Medical enhancement, the use of pharmaceutical agents to enhance performance, may be physical or cognitive enhancement or both. Performance-enhancing drugs or enhancers are commonly drugs approved to treat medical conditions; or alternatively they are used ‘off-label’ to improve performance or appearance. Modern pharmacy has made significant contributions to society through medical innovations and drug development. Early discoveries, such as insulin and penicillin, that some athletes consider enhancers Neuroenhancement drugs contributed to the emergence of a huge necessary to perform at an elite level. Cognitive enhancing drugs, also called pharmaceutical industry. Drug research ‘smart drugs’ or ‘nootropics’, include and development has focused primarily Use of enhancers may be even more amphetamine, methyphenidate, on treatments for diseases, with common in sports without doping modafanil and caffeine. Use in normal exceptions, notably oral contraceptives controls and in recreational sports. healthy individuals is reportedly in 1960. More recently we have seen the Additionally, pharmaceutical increasing with a prevalence reported in increasing medicalisation of conditions, enhancement for non-athletic purposes the range of 5% to 35% (Smith and such as anxiety or minor skin complaints, is increasingly found in the wider Farah, 2011). Although improved which would previously be seen as population. The pursuit of improved cognitive abilities with the use of within the normal remit of human performance in academia, business and stimulants have been reported, available circumstance. This trend has evolved into social environments has led to this data is limited. Benefits are most the use of pharmaceuticals for increase. This may have been driven by consistently reported in clinical enhancement, in the absence of disease competitive pressures; the relative populations; while evidence for benefit in and without a medical condition. performance of peers; and the perceived healthy individuals is mixed. Some efficacy and safety of marketed drugs. studies report enhancement with Performance-enhancing drugs are improved memory and possibly commonly associated in competitive Population surveys suggest use of drug executive functions; but others report sports. Doping, the use of performance- enhancement, particularly for cognitive impairment or detrimental effects. (Smith enhancing drugs in sports, is banned by performance, is gaining acceptance. and Farah, 2011) the majority of sports governing bodies. Reasons for the use of enhancers are Anti-doping campaigns have intensified various: they include increased Amphetamines have been used for over the recent years with coordinated concentration; reduced fatigue; improved medical and non-medical reasons for eradication campaigns; the founding of physical performance; competitive almost 100 years, including enhancing the World Anti-Doping Agency (WADA) advantage; and improved appearance by alertness in military settings, treating in 1999; and more reliable testing increased muscle mass and decreased depression and for athletic competition. methods. As testing has improved, body fat. Use of performance enhancing More recently, amphetamines and however, many believe that the ability to drugs among insurance applicants and methylphenidate, both common cheat the tests has also improved. It is policy holders may influence their health treatments for attention-deficit tacitly acknowledged that doping may and well-being. hyperactivity disorder (ADHD), have been continue to thrive in certain sports; and extensively used off-label to increase Published in Risk Dialogue Magazine No 16, September 2013: Human enhancement alertness, energy or concentration in is a major focus of anti-doping Despite being marketed as anabolic healthy individuals. This has especially campaigns. While use in elite athletes is steroids, androstenedione and been the case with university students, in often highly publicised, most use occurs dehydroepiandrosterone (DHEA), a trend dubbed ‘academic doping’. The in recreational athletes, body builders androgen precursors, have not been adverse effects of amphetamine and and non-athletes, with estimated use in shown to increase testosterone levels, methylphenidate are similar and include one percent of the population (Sjöqvist et strength or performance. Adverse effects insomnia, nervousness, rare cases of al. 2008) include increases in serum levels of psychosis, anorexia, elevations in blood oestrogen and lutenising hormone (LH) pressure, sudden cardiac death, and The frequency of adverse effects of AAS which are of unknown significance, and addiction potential. use in healthy individuals is not clearly negative effects on serum lipids have identified. Risks may be underestimated been reported. Modafinil, a novel stimulant approved for in the medical literature due to under- use in the treatment of excessive daytime reporting of illicit use. Equally, use could Human growth hormone (HGH), sleepiness associated with narcolepsy, be overestimated given an anti-doping relatively common as enhancer for sleep apnea and shift work sleep environment or due to other factors such athletes, increases lean body mass but disorder, has been used non-medically as combination drugs or adverse training has no demonstrated beneficial effect on by military personnel to manage fatigue effects without established causality. strength or exercise capacity in trained and increasingly is used in academic and athletes (Liu 2008). HGH was evaluated business settings. Modafinil has been Cardiovascular adverse effects, including in a randomised controlled trial with shown to have modest enhancing effects hypertension, left ventricular recreational athletes. HGH significantly on several aspects of cognitive hypertrophy, myocardial ischemia, increased lean body mass and decreased performance (Repantis et al., 2010, arrhythmias, thromboembolism and fat mass in both men and women; and Müller et al., 2013) Modafinil may be blood lipid abnormalities, have been increased sprint capacity in men also better tolerated than amphetamines but reported (Angell et al. 2012, Urhausen et administered testosterone (Meinhardt et may still cause anorexia, elevations in al.2004 D’Andrea et al., 2007). AAS al., 2010). Adverse effects are significant, blood pressure and tachycardia. have been associated with psychiatric including insulin resistance, diabetes, abnormalities including disorders of soft tissue edema, hypertension, Caffeine, the most widely used stimulant, mood and aggressive behaviour. cardiomegaly, myopathy, and carpal is known to increase mental alertness, Associations between AAS use and risky tunnel syndrome. Cases of Creutzfeldt- energy, and the ability to concentrate. Its behaviours including illicit drug use, Jakob disease, a fatal neurodegenerative use as a cognitive enhancer is alcohol or opioid misuse, drinking and disease, have been associated with the widespread, including use of caffeine- driving, or violent or criminal activities use of cadaveric human HGH. containing energy drinks. Caffeine’s have been reported (McCabe et al. 2007, cognitive enhancing effects are likely Buckman et al 2009). Oral synthetic Other performance enhancing drugs indirect through its action on arousal 17-alpha-alkylated androgens have been The list of drugs considered enhancers mood and concentration (Nehlig, 2010). associated with liver toxicity including continues to expand as available drugs, It also has analgesic properties and has elevated liver enzymes, cholestatic developed and approved for disease been associated with possible decreased jaundice, and peliosis hepatitis. Cases of entities, are being used as enhancers. risk of type 2 diabetes, Parkinson’s hepatocellular adenomas or carcinomas Antidepressants, anxiolytics, disease, Alzheimer’s disease, certain have been reported with long-term use antipsychotics, and certain cancers and even all-cause mortality in (Gorayski et al. 2008). Increased risk of anticonvulsants may improve mood and some studies (Lopez-Garcia et al., 2008). benign prostatic hypertrophy and anxiety when used by individuals without Risks include headache, anxiety, tremors, prostate cancer with AAS use has been any diagnosed condition. Similarly, oral insomnia, depression, possible suggested but not conclusively proven hypoglycemics, antihypertensives and substance misuse, elevated blood and tendon rupture has also been particularly cholesterol lowering HMG- pressure and potentially coronary or reported. Additionally, AAS users may CoA reductase inhibitors (statins) may be arrhythmic events. use other substances to gain muscle used in cardiovascular risk factor mass, lose fat mass or to otherwise prevention outside of thresholds for Androgens and other hormones enhance physical appearance with recommended treatment guidelines. Anabolic androgenic steroids (AAS) are added adverse effects. synthetic analogs of the naturally Beta blockers, a class of medications occurring hormone testosterone known Human chorionic gonadotropin (hCG) approved for treatment of several for their anabolic (muscle-building) and stimulates
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