Remember Dario Frigo, caught at the 2002 Giro d’Italia with bags full of saline which had been sold to him as the blood doping agent HemAssist (see Lindsay, 2011; Tucker and Dugas, 2011 for an interesting take on this drug in cycling)? Frigo claimed never to have used the drug, but if he had used the saline he believed to be HemAssist it is quite possible it would have had a significant effect on his performance…

This week it was reported that about half of German doctors have sent patients away with placebo treatments, with Bavaria leading the way at 88% of doctors engaged in what might (or should) be seen as distinctly unethical. The ethics of placebo treatments are complex, and even those that advocate a cautious engagement with the placebo effect in treatment and research (such as Ben Goldacre) draw the line at some aspects of lying to patients or the general public, or misrepresenting placebo effects as something other than they are (see e.g., Goldacre, 2008; 2009; or 2011).

Placebos are mainly used in science to help distinguish between the real effects of treatments and the often physiological effects of believing one is being treated. However, it has long been known that the fake treatments used in medical trials have sometimes powerful effects, which themselves have to be factored out. In sports science, studies have found that the belief in the performance enhancing effects of certain drugs (e.g., Ariel & Saville, 1972; Beadie, Stuart, Coleman & Foad, 2006) or indeed legal carbohydrate drinks, as in Clarke, Hopkins, Hawley & Burke, 2000) seems to enhance performance in similar ways to actually taking them. One study even found that many sportspeople are consciously aware of the placebo effect, and are happy to attempt to exploit it to maximise their performance. Tucker and Dugas (2011) however, note that there is line to be drawn (cf. Goldacre) between engaging with the placebo effect and simply accepting any quackery one likes…

This raises the possibility that one of the main reasons that sportspeople choose to dope is not that it actually raises their performance directly, but that it corresponds to their beliefs that a product will help them. Even if the drug does not have a direct physiological benefit, this belief will validate the efficacy of the drug by improving performance. The mechanisms by which this actually occurs are still being debated, but one accepted manner in which this might work is that a placebo could cause individuals to unconsciously train harder or longer. Many of the drugs associated with professional sports have dubious efficacy. Unlike rEPO, human growth hormone, for example, has not been found to improve sports performance spectacularly, yet is misused widely as a performance enhancing drug (see Tokish, Kocher & Hawkins, 2004 for a review).

To conclude, any effort to engage with the misuse of drugs in sport must grapple with the psychological aspects of doping, including the beliefs of athletes and where these come from, not just invest in detection and sanctions. This is not the same as naively campaigning to convince people that drug use is bad or wrong (see e.g., Donovan, Egger, Kapernick & Mendoza, 2002 who articulate some powerful evidence for a more complex approach). In a future post I will attempt to show where we might look for some clues to help us along this path.

UPDATE

@festinagirl reminded me of Willy Voet’s account of how he substituted glucose for a ‘time trial special’ preparation provided by a Spanish soigneur leading to Richard Virenque’s outstanding final time trial performance in the 1997 Tour de France. This reminded me of the stories told to David Walsh by riders regarding the infamous Bernard Sainz: no-one he was treating really knew for sure what was in many of the preparations he supplied to riders, and although some had in inkling that some of the preparations were illegal (like Rene Wenzel), others (like Philippe Gaumont) were fairly convinced that the medications were homeopathic (i.e., effectively placebo). What is interesting about this is that it is only recently, with better testing and more draconian sanctions for doping infractions, that many riders have needed to make a scientific distinction between ‘real’ and ‘fake’ medications. In Fausto Coppi’s day (or indeed Anquetil’s) the boundary between quackery and sports medicine was much more fluid. There is an interesting account of some of the vintage quackery in professional cycling era read Jean Bobet’s Tomorrow, we Ride (2008).