Performance-Enhancing Drugs:

Where are we now?

Gary Green, MD

Clinical Professor, UCLA Division of Sports Medicine

Medical Director, Research Director, Major League Baseball

MLB Consultant on Performance Enhancing Drugs

Pacific Palisades Medical Group

May 15, 2019

Ogden Surgical-Medical Society

Bringing Health Care to the World

Pitch Smart Is An Educational Initiative to Promote Safe Pitching Practices

Among Young Players

2Visit PitchSmart.org for more information

Visit PitchSmart.org for more information

First you have to know where you came from. . . . . .

Every time you build a better mousetrap. . .

The Mice Get Smarter!

6

Questions:

Who are they?

What do they have in common?

What is different?

7

1 game Demetrius Harris Kansas City Chiefs

4 games Victor Bolden Jr. San Francisco 49ers

4 games Julian Edelman Patriots

4 games David Irving Dallas Cowboys

4 games Robert Turbin Indianapolis Colts

2 games Reuben Foster San Francisco 49ers

2 games Jamon Brown Los Angeles Rams

2 games Aaron Jones Green Bay Packers

4 games Rashard Robinson New York Jets

2 games ArDarius Stewart New York Jets

1 game Kevin Pierre-Louis New York Jets

1 game Carlos Henderson Denver Broncos

4 games Daryl Worley Oakland Raiders

3 games Terrance Williams Dallas Cowboys

10 games Kyle Nelson San Francisco 49ers

4 games Darron Lee New York Jets

Indefinite Martavis Bryant Oakland Raiders

Indefinite Josh Gordon Patriots

NFL Drug Suspensions 2018 Season

8

Jorge PolancoMinnesota Twins Stanozolol 80 games SS

Robinson CanoSeattle Mariners Furosemide 80 games 2B

Welington Castillo Chicago White Sox Erythropoietin 80 games C

MLB PED Suspensions 2018

Minimum 80 games

Substance announced

Not eligible post-season or All-Star

Performance Enhancing Drugs in Sport

9

State-Sponsored Doping in Russia

12

State Sponsored Doping in Russia

13

State Sponsored Doping in Russia

14

State Sponsored Doping in Russia

16

Drugs and Athletes: A new phenomena?

•Ancient Greeks, Egyptians, Romans, Incas

•1896 - Use of strychnine, stimulants, first athlete death

•1950s - Anabolic steroids in weight lifters

•1960 - Danish cyclist Knud Jensen dies of amphetamine

overdose at Olympics

•1988 - Ben Johnson tests positive at Olympics

Athlete: “I wish to win an Olympic Victory”

Trainer: “[If so] you must submit to discipline

Follow a strict diet, give up sweet cakes,

Train under compulsion at a fixed hour in heat

Or in cold, you must not drink cold water,

Nor wine just when you feel like it:

You must have turned yourself over to your trainer

PRECISELY AS YOU WOULD TO A PHYSICIAN

Then when the contest comes on, you have to dig in

Beside your opponent, sometimes dislocate your wrist,

Sprain your ankle, swallow quantities of sand,

Take a scourging; yes and then sometimes

Get beaten along with all that.”

-Epictetos AD 55-135

Drugs and Athletes: A new phenomenon?

Arthur Linton, Welsh Grand National Champion. 1896

“If it takes 10 [pills] to kill you, I’ll

take 9.”

- Tom

Simpson,

Tour de France

Rider

Died: 1967 of amphetamine

overdose

Drugs and Athletes: A new phenomenon?

Athlete Drug Use and

Positive Drug Test

Prescribing/Advising Physician

Scientists/Researchers

Dieticians

Personal Advisors

Social Network

Peer Group

Coaches

Athletic Trainers

Why Care about Athletes and Ergogenic Drug

Use?

•Health And Safety Issues•Integrity of the Sport•Ethical Fair Play•Inaction Alternative?

Sports Pharmacology

•Ergogenic

•Recreational

•Therapeutic

To improve performance

To treat an underlying condition

Example: Amphetamines

Ergogenic: Amphetamines used by athletes

for increased energy and concentration

Recreational: Methamphetamine for

euphoric effects

Therapeutic: amphetamine/dextroamphetamine

(Adderal) for treatment of ADHD

WADA Prohibited List: Criteria for Inclusion

1) Evidence that it has the potential for or

enhances performance

2) Evidence that use poses an actual or potential

health risk

3) Use violates the spirit of sport according to

WADA

Must fulfill two of three:

WADA 2019 Prohibited SubstancesS1. Anabolic Agents

S2. Peptide Hormones, Growth Factors, related

substances and mimetics

S3. Beta Agonists

All banned except inhaled salbutamol, formoterol below

therapeutic levels by inhalation on for asthma treatment

S4. Hormone and Metabolic Modulators

S5. Diuretics and Masking Agents: In competition only

S6. Stimulants

S7. Narcotics

S8. Cannabinoids- natural and synthetic

S9. Glucocorticoids-systemic

And other substances with similar chemical structure

or similar biological effects

WADA Substances Prohibited In

Particular Sports

P1. Beta Blockers

WADA 2019 Prohibited MethodsM1. Manipulation of blood and blood components

M2. Chemical and Physical Manipulation

M3. Gene and Cell Doping

Austrian Skier Max Hauke

Caught on video

during police raid.

March 2019

MLB Prohibited Substances

A. Drugs of Abuse

B. Performance Enhancing Substances

C. Stimulants

D. Dehydroepiandrosterone (DHEA)

E. Diuretics and Masking Agents

F. Adding additional substances

Any new Schedule I, II or III substances

automatically added

NCAA Prohibited Substances

1. Stimulants

2. Anabolic Agents

3. Diuretics and other masking agents

4. Street Drugs

5. Peptide hormones and analogues

6. Anti-estrogens

7. Beta-2 Agonists

Therapeutic Use Exemption (TUE)

*The prohibited substance is needed to treat an acute Or chronic medical condition.

*The Athlete would experience a significant impairment To health if it were to be withheld

*The use of the prohibited substance is highly unlikely to produce additional enhancement beyond normal health

*There is no reasonable therapeutic alternative*The use is not a consequence of the use of a banned

substance.

Ergogenic Drugs

Why Do Athletes Use Performance-Enhancing

Drugs?

Coxless fours at Athens 2004

Result:

GB 6 minutes 06.98 seconds

Canada 6 minutes 07.06 seconds

Italy 6 minutes 10.41 seconds

Winning Margin: 0.08 seconds or 0.02% of race time

Bernard Kohl

2008 Third Place Tour de France

Winner, King of the Mountain

Disqualified after positive drug test

Passed 99/100 tests

Examples of Athlete Drug Use

Bernard Kohl Drug Use during Tour de France

• rHuEPO

• CERA

• hGH

• Thyroid Hormone

• Blood Transfusions

• Albumin

• Insulin

• Testosterone

• Designer Anabolic

Steroids

• Injectable cortisone

What are anabolic steroids?

Properly called “anabolic-androgenic steroids”

Definition of anabolic

Definition of androgenic

Do they work?

What are the adverse effects?

Anabolic-Androgenic steroid examples

• Testosterone (Depo-testosterone)

• Nandrolone (Deca-durabolin)

• Methandrostenolone (Dianabol)

• Oxandrolone (Oxandrin/Anavar)

• Oxymetholone (Anadrol)

• Stanozolol (Winstrol)

• Trenbolone (Finaplix)

• Boldenone (Equipoise)

Anabolic-Androgenic Steroids

Do They Work?

Anabolic Steroid Studies 1960’s

No Increase in Strength

?

Examples of “stacking”

Drug Dose Therapeutic Dose

Methandrostenolone

(Dianabol)

75 mg subcutaneously every

other day

5 mg per day

Methenolone

(Primabolan)

150 mg subcutaneously

every other day

2.5-10 mg per day

Oxandrolone

(Oxandrin/Anavar)

20 mg orally per day 5-10 mg per day

Oxymetholone

(Anadrol)

100 mg orally per day 1.5 mg/kg/day

1996 Bhasin Testosterone Study

Experienced weight lifters

3X physiologic dose Testosterone

Bhasin, et al. NEJM 335:1-7, 1996

Women's Shot Put Final. Olympic Games 1972

1. Nadezhda CHIZHOVA (SOV) 21.03m.

2. Margitta GUMMEL (GDR) 20.22m.

3. Ivanka HRISTOVA (BUL) 19.35m.

4. Esfir DOLZHENKO (SOV) 19.24m.

5. Marianne ADAM (GDR) 18.94m.

6. Marita LANGE (GDR) 18.85m.

7. Helena FIBINGEROVA (CZE) 18.81m.

8. Yelena STOYANOVA (BUL) 18.34m.

Women's Shot Put Final. Olympic Games 1976

1. Ivanka HRISTOVA (BUL) 21.16m.

2. Nadezhda CHIZHOVA (SOV) 20.96m.

3. Helena FIBINGEROVA (CZE) 20.67m.

4. Marianne ADAM (GDR) 20.55m.

5. Ilona SCHOKNECHT (GDR) 20.54m.

6. Margitta DROESE (GDR) 19.79m.

7. Eva WILMS (GER) 19.29m.

8. Yelena STOYANOVA (BUL) 18.89m.

Helena Fibingerova 1972

Helena Fibingerova 1976

STATISTICAL RESULTS

WOMEN’S SWIMMING - 1972 OLYMPICS

EAST GERMANY RESULTS

• 0 Gold

• 2 Individual Silver

• 1 Individual Bronze

• 2 Relay Silver

• No Olympic or World Records

STATISTICAL RESULTS

WOMEN’S SWIMMING - 1976 OLYMPICS

EAST GERMANY RESULTS

• 10 of 11 individual Golds

• 5 other Silver

• 0 Bronze

• 1 Team Gold; 1 Team Silver

• 10 Olympic or World Records

STATISTICAL RESULTS

WOMEN’S SWIMMING - 1992 OLYMPICS

UNITED GERMANY RESULTS

• 1 Gold

• 2 Silver

• 4 Bronze

• 1 Team Silver; 1 Team Bronze

• No Olympic or World Records

Adverse effects of Anabolic Steroids

• Results of East German Doping Program

Muscle Tightness: 65% Deaths 3

Muscle Cramps: 15% Gynecomastia: 12

Fertility, impotence: 10% Severe Liver

Damage

Anabolic-Androgenic Steroids:

Adverse Effects

Adverse effects of Anabolic-Androgenic Steroids

• Cardiovascular- lowered HDL, atherosclerosis, hypertension

• Gastrointestinal- peliosis hepatis, liver cancer, liver abnormalities

• Genito-Urinary- infertility, prostate CA, BPH, impotence

• Musculoskeletal- tendon ruptures

• Psychological- psychosis, addiction, depression

• Impurities, contaminations, infections

• Youth- Depression, Growth Plate disturbances, accelerated puberty

Adverse effects of Anabolic Steroids

• Cardiovascular-

lowered HDL,

atherosclerosis,

hypertension

Adverse effects of Anabolic Steroids

• Gastrointestinal-

peliosis hepatis,

liver cancer, liver

abnormalities

Adverse effects of Anabolic Steroids

• Musculoskeletal-

tendon ruptures,

e.g. pec major tear

Gynecomastia

Why ban anti-estrogens, e.g. tamoxifen, anastrazole?

Adverse effects of Anabolic Steroids Women

• Hirsutism

• Menstrual irregularities

• Male pattern alopecia

• Deepening of the voice

• Clitoromegaly

2003 2008

Tammy Thomas, Convicted 4/08 perjury in BALCO Case

Adverse effects of Anabolic Steroids

• Psychological

1. Over-aggressiveness

2. Psychosis

3. Addiction-

Physiologic vs. Psychological

4. Depression- suicide during

withdrawal

Adverse Effects of Anabolic Steroids

• Youth

• Premature closure of Epiphyseal plate

• Accelerated puberty

• Significant depression and Suicidality

Rob Garibaldi

Taylor Hooton

Efrain Marrero

Taylorhooton.org

Brian Stubstad Suicide Note. Former Patient of Revolution Clinic

Former Anabolic Steroid User

June 2, 2008

Risks of Injectable Anabolic Steroids

HIV

Hepatitis B, C

Endocarditis

Systemic infections

Impurities

Where Do You Usually Get Your Anabolic

Steroids?

• Other Physician 8%

• Friend/Family 17%

• Retail Store 12%

• Coach 7%

• Magazine/catalogue 4%

• Other 23%

• Team Physician 5%

• Internet 14%

• Teammate/Other Athlete

11%

• Athletic Trainer 6%

• Pro Scout/Agent 3%

• Strength Coach 2%

• Dietician 2%

2005 NCAA Study of Substance Use Habits of College Student-athletes of 19,676 athletes.

Dr. Green Report on Internet AAS

Methods:

Turned on Computer

Went to Google

Typed in Buy anabolic steroids

Results:

12,900,000 web sites

Time: 0.41 seconds

Conclusion: AAS easily available

Cost: Priceless

Internet search 5/1/19

Next Steps in Androgen Doping: SARMS

• Selective Androgen Receptor Modulators

• Target androgen receptors in muscle, bone, prostate

• Can be agonists or antagonists

• Animal and clinical trials in treatment of wasting

syndromes

• None have been approved for human use

• Non-steroidal anabolic agent

• Potential to cause anabolic effects on androgen

receptor without androgenic effects

• Banned by WADA 2008

• Banned by Major/Minor Leagues 2009

Andarine• Arylproprionamide-derived SARM

• Freely available on Internet for $100

• Detectable by LC-MS/MS

Drug Test Anal. 2009 Aug;1(8):387-92.

68

Clemson’s Dexter Lawrence banned 12/18

NCAA Positive test for Ostarine:

17th Pick in 2019 NFL Draft 4/19

JAMA. 2017 Nov 28;318(20):2004-2010. doi: 10.1001/jama.2017.17069.

PMID: 29183075

Dietary supplements

MLB Memo on SARMS February 22, 2019

•SARMS have not been approved for human use•Sold Illegally in Dietary Supplements

•SARMS have been detected in “low risk supplements” such as:Multivitamins

Electrolyte hydration productsB-vitamins

Possibly functional or fortified foods•Only way to be certain is NSF certified for sport supplements

50 Products Certified in 2010

298 in December 2014

700+ in November 2018

www.NSFsport.com

If it is not NSF-certified for Sport

Player takes at own risk

MLB-Associated Supplement

Certification Program NSF

HUMAN GROWTH HORMONE hGH

= naturally occurring family of isoforms of

different sizes

5 kilo Daltons (= kDa, mass units)

17k

20k

22k

etc.

HUMAN GROWTH HORMONE: hGH

• Theoretically, yes

• Practically, no effect in healthy individuals (including athletes) in multiple studies

• One study small increase in spinning speed

• Possible studies lack of effect vs. perceived effect

1. Type II error

2. Low dose, short duration of hGH

3. Potentiating effects of other drugs, e.g. AAS, Insulin

4. Athletes are different

5. Placebo effect

6. Peer/coach pressure

7. Advertising

Is hGH Ergogenic?

Courtesy G. Baumann

hGH Isomer Test: Blood Test

prohibited

from the bottle

pharmaceutical

exogenous

RECOMBINANT

22k “rec”

natural

from the body

endogenous

from PITUITARY gland

= 5k,17k, 20k, 22k, etc.

identical

GROWTH HORMONE TEST

= 2 immunoassays

other immunoassay

measures

all other isoforms

= non-22k

“pit”

one immunoassay

measures

RECOMBINANT hGH

= 22k only

“rec”

rec/pit > threshold

hGH Isomer Test: Blood Test

USER

+ RECOMBINANT hGH

serum rec serum pit

rec/pit threshold: > 1.45 male, >1.8 female

First Positive hGH Test

•English Rugger Terry Newton tests

Positive for hGH February 2010

•Admitted using hGH

•Apparently targeted testing

•Testing at English Olympic Lab

•Validated use of isomer test

•Committed Suicide

September 2010

Minor League Baseball hGH positive test

• July 2011

• Colorado Rockie Minor

League Player Mike Jacobs

tests positive

• First North American

Professional hGH positive

• First truly “random” positive

test

• Admitted to using hGH

The Next Phase of hGH Testing: Pharmacodynamics

•Markers of GH use by immunoassay:

IGF-1: from Liver,

Procollagen type III (P-III-NP) from Bone

•Markers as indirect measure of GH use

•Measures actual effect

•Can potentially detect up to 2 weeks

•First used at London Olympics 2012

•Approved for widespread use in 2016

Detection of hGH using BioMarker Method

hGH Testing: Biomarker method• Has been validated for following conditions

1. Ethnicity

2. Injury

3. After Exercise

4. During Competition and Random time

5. Type of Sport

6. Androgen co-administration

7. Age

8. Storage conditions

• Positive Test after GH administration

After 2 days: 69-79% positive

After 5 days: 53-64% positive

After 14 days: 20% positive

hGH Biomarker Testing 2012

• 2 Russian Paralympian Weight Lifters test

positive at London Paralympics

• Both samples positive

• Second samples taken 2 days later also positive

• Both Athletes admit to use

• No challenge of new test

Vadim RakitinNikolay Marfin

hGH FDA Regulations

• 21 USC 333 (e)

• Cannot legally distribute for an unapproved purpose

• Only drug that a physician cannot legally write an “off-label” prescription

"We're doing a lot of stuff. Why not just add that last little bit [hGH] — a small dose, or whatever is prescribed by a doctor? What's wrong with that?” -Ryan Madson October 2015

FDA approved hGH Uses

Pediatric and Adult Growth Hormone Deficiency

Pediatric Short Stature

Small for gestational age

Prader Willi Syndrome

Chronic Renal Insufficiency

HIV Wasting

Turner Syndrome

Short Bowel Syndrome

Conditions for legal hGH prescribing

1. Must have a valid prescription from a PHYSICIAN

2. Must be a recognized medical condition according to FDA

3. Must be for a use the FDA has approved

What about anti-aging clinics?

Growth Hormone Releasing Peptide GHRP

•Potent stimuli for GH secretion

•Causes GH peak in 15-30 minutes, return to baseline in 2-3

hours

•Ghrelin analogs

•Many different types, GHRP-1, 2, 6, Ipamorelin

•Oral, IV, nasal routes

•Metabolites detectable by LC/MS at least 20 hours

•Has been detected in nutritional supplements

•Google Search: 137,000 sites “Buy GHRP”

•Sold for “research only” [sic]

Growth Hormone Releasing Peptides: Dying to Win?

• Australian Rugby Jon Mannah dies of

recurrent Hodgkins Lymphoma age 23

• Used CJC-1295 and GHRP-6

• Neither approved for human usehttp://wwos.ninemsn.com.au/article.aspx?id=8648732 April 26, 2013

Is Drug Testing the Answer?

There is always a well-known solution to every

human problem--neat, plausible, and wrong.

H.L. Mencken

Every time you build a better mousetrap. . .

The Mice Get Smarter!

What a urine drug test result can tell you

• what substance is present in the urine sample

• NOT the brand

• NOT the formulation (pill or syrup)

• NOT the route (by mouth or injection)

• NOT how much was taken

• NOT how long before urine collection it was taken

A urine test is negative if…

• the drug was never used

• or it was used used long ago (body has eliminated it)

• or it is present below the cut-off

• or it is present below the limit of detection of the test

• or it is a designer drug that the lab doesn’t look for

• or it is not tested for in this program.

Elite athletes’ negative tests

• Ben Johnson passed 19 drug tests while on steroid stanozolol (1980s).

• Kelli White passed 17 drug tests while on steroids (THG, testosterone), stimulants, and EPO (2000s).

• Dwain Chambers passed multiple drug tests while on THG in 2000s.

• Marion Jones reportedly passed 116 drug tests

I did it

2010

“I didn’t do it

2006-2010

Floyd Landis

Marion Jones

Alex Rodriguez

Anabolic Steroids and Testing by different organizations:

• Major League Baseball: All Schedule III AAS banned: 80 game ban first positive, 162 game, Life*

• Minors Baseball, VSL, Rookie league: All schedule III plus DHEA, etc: 80-full season-life

• NFL- 4-game suspension first positive

• NCAA: 1-year suspension

• WADA/USADA: 2-year suspension

* May reapply in 2 years

Drug Testing Alone Won’t Deter everyone

Three types of people:

1.Those who will obey the rules no matter what

2.Those who will obey the rules to avoid getting caught

3.Those who will disregard the rules no matter what

Which category are you in?

When do you slow down?

Elements of a Successful Deterrence Program

• Organizational and Stakeholder commitment

o Financial

o Administration and athletes

• Transparency

• Highest Quality Testing

o Collection

o Laboratory Analysis

o Results Reporting

• Fair and Equitable

o Appeal Process

o Therapeutic Use Exemption Policy

• DETERRENCE

WHAT IS PED DETERRENCE?

1. If an athlete uses a banned substance, are they are likely to be tested?

2. If the using athlete is tested, is the drug likely to be detected?

3. If the using athlete tests positive, are they likely to be sanctioned?

4. If the using athlete is sanctioned, does the penalty offset the rewards?

5. Deterrence is dependent on:• Frequency of testing• Effectiveness of testing (e.g., timing, testing for

correct drugs, accuracy, limits of detection)• Unpredictability of testing• Swiftness of discipline

Continued Advancements in Drug Testing

Research

About The PCC

• Founded in 2008 by the U.S. Olympic Committee, the

National Football League, Major League Baseball and

the U.S. Anti-Doping Agency.

• Acts to protect the integrity of sport and public health by

engaging and supporting the world’s top scientists and

innovators in high-quality anti-doping research and

development.

• Facilitates adoption of methods into WADA-accredited

laboratories.

• Aspires to help generate the world’s most influential,

effective and coveted methods and resources for

detecting and deterring the use of performance

enhancing substances by all athletes in all sports at all

levels.

Investigating Oral Fluid

and Exhaled Breath as

Alternative Matrices for

Anti-Doping TestingCollaborative Research Between USADA, MLB,

PCC, CDT, SMRTL

Oral Fluid

• Passive diffusion

• Dependent on

physicochemical properties

of drug

• Salivary flow / pH

• Matrix interference

possibility

Transport mechanism of plasma

components into the salivary gland

J Bras Patol Med Lab, v. 49, n. 4, p. 247-255, Aug 2013

Exhaled Breath

• Exhaled breath contains both volatile and

non-volatile compounds.

• Aerosol particles contain the non-volatile

components. Particles of sizes about 1 µm

in diameter are always present in human

breath, most particles are <1 µm in

diameter.

• The particles are composed of surfactant, a

liquid that is secreted in the distal airways

and is crucial for lung function.

• Surfactant composition is functionally

important and complex, and consists of

lipids, mainly phospholipids, and proteins.

QUANTISAL™ ORAL FLUID COLLECTION DEVICE

Sensabues EXHALED BREATH DEVICE

Can Change Happen in Sports?

Joint Drug Program

December 13, 2007

“I think [MLB’s drug policy] is an insult to the fight against

doping in sport, an insult to the intelligence of the American

public and an insult to the game itself. I think it's a complete

and utter joke.”

- Dick Pound, WADA Chairman

November 2003

“[MLB] hasn’t acted to protect the integrity of baseball or sent

the right message to the millions of teenagers who idolize

ballplayers.”

- Rep. Henry Waxman

March 2005

“There was a collective failure to recognize the [performance

enhancing drug] problem as it emerged and deal with it early

on.”

- Sen. George Mitchell

December 2007

Can Change Happen in Sports??

Can Change Happen in Sports?

“Baseball now defines the state of the art for drug policy in pro

sports. Baseball has surpassed all other sports in cutting edge

drug testing.

- Tom Verducci, Sports Illustrated

November 2011

“Baseball can rightly boast that it has the best drug testing

program among our country’s professional sports leagues.”

- Rep. Henry Waxman

January 2013

“MLB has become a valuable partner to WADA and a leader in the

fight against doping in sport. It has developed a robust program

over recent seasons that many team sports might usefully

replicate.”

- David Howman, WADA Director General

June 2013

Post-Mitchell Progress

Senator George Mitchell

MITCHELL REPORT

RECOMMENDATIONS

• Department of Investigations

• Disclosure Policy

• Reporting Hotline

• Logging of Packages

• Background Checks

• Random Drug Testing of Club

Personnel

Significant Investigations (2007 – 2016)

119

Signature

Pharmacy

2007-2008

Anthony

Galea

2010-2011

Crema

Santiaguera

2012Biogenesis

(Anthony

Bosch)

2013

Stanozolol

Investigation

2015

Al Jazeera

Investigation

2015MLB has conducted multiple investigations into the use,

possession and distribution of PEDs since 2007; most of

which have centered around anti-aging clinics and pseudo-

medical personnel

Post-Biogenesis: Changes to MLB Program

120

1INCREASED TESTING

Annual testing increased from 5,391 in 2013 to 11,526

in 2018

2TOUGHER PENALTIES

Penalties increased from 50/100/Lifetime to

80/162/Lifetime

3MANDATORY IRMS

At least one sample from every player will be subject to

IRMS analysis each season

4SHIFT IN PLAYER PERSPECTIVE

MLB athletes are tired of cheating and want a clean

game

Structure of Professional

Baseball

•Major Leagues

•30 Clubs

•1,200 Players

•162 games in 186 Days

•Minor Leagues

•245 Clubs in U.S.,

Canada and D.R.

•7,500 Players

•Variable Season Lengths

(56-140 games)

Overview of MLB Drug Programs:

Players• Joint Drug Program (“Major League Drug Program”)

• Major League Players, represented by MLBPA

• Minor League Drug Program

• All domestic and international Minor League

players

• International and Domestic Prospect Programs

• Top U.S. and international prospects (pre-

employment)

• International Amateurs

• Trainer Partnership Program

• Clearinghouse Program

125,000 drug

tests for

PEDs in the

past 5

seasons

Overview of MLB Drug Programs:

Employees

• Commissioner’s Drug

Policy

•Random testing for all

League and Club non-

playing personnel

• Umpire Drug Program

•Pre-game drug & alcohol

testing program for all

MLB game officials

Current Joint Drug Program

• Independent administration and transparent public

reporting

• Year-round no-notice testing

• All testing performed by WADA-accredited laboratory

• Annual review and update of Program with MLBPA

• Strict liability program

• Neutral arbitration panel review on appeal

• Suspension publicly announced and without pay

• Analytical and non-analytical violations

• Secondary Sanctions: No post-season, All-Star Game, or

post-season financial shares for suspended players

2018 Joint Drug Program

•TESTING

o Total Drug Tests: 11,526+1,199 from 2017

+7,950 from 2008

o Urine samples: 9,282

+1,047 from 2017

+5,796 from 2008

o Blood samples: 2,244

•Total do not include 2017-8 off-season tests (+1,200)

2017 Joint Drug Program

2018 Annual Report

RESULTS

• 11 Total Positive Tests (0.09%)

• PEDs (8)

oBoldenone (2)

oClostebol (1)

oDHCMT(2)

oEPO (1)

o Ipamorelin (1)

oStanozolol (1)

• Stimulants (1)

oD-Amphetamine (1)

Diuretics (2)- Furosemide (2)

102 TUE Granted

101 ADHD

Can Change Happen in Sports?

República Dominicana

• Demographics and Economics

o Impoverished island country of 10 million people

o Annual gross domestic product per capita of $10K

o 35% of population lives below the poverty line

o Average annual salary: $5,150 U.S.

MLB in the Dominican Republic

• MLB D.R. Operations

o Fully staffed MLB Office in capital city of Santo Domingo

o Full-time personnel dedicated to anti-doping education and investigations

• MLB Academies

o All 30 MLB Clubs provide education, housing and training

o Formal leagues run among MLB academies in summer and winter

Baseball in the Dominican Republic

• Dominican Players in MLB

o ~12% of Major League Players (20% in Minor Leagues)

o Average annual salary: $4.25 million

o Players of D.R. descent are some of MLB’s highest earners

o Risk/Reward: Financial Gain vs. Moral Considerations and Rules Compliance

o “Baseball is Hope”

Challenges in the Dominican Republic

• Financial Incentives to Dope

o The Dominican Republic lacks the infrastructure to develop youth talent

o Buscónes provide instruction and food/lodging for % of signing bonus

o $50 - $60 million in signing bonuses to Dominican prospects annually

o Significant financial incentives for prospects to be bigger, faster, stronger

Challenges in the Dominican Republic

• Legality and Access

o Anabolic steroids are not illegal in the Dominican Republic

o Available over-the-counter without a prescription at Pharmacias

o “Injection culture” involving veterinary products, NSAIDS and vitamins

o Homemade mixtures of injectable substances are commonplace

o Unknowing administration to players by Buscónes

99% of positive test results in the D.R. since

2005 have been for Anabolic Androgenic

Steroids. The vast majority involve easily

detectable steroids like Boldenone,

Nandrolone and Stanozolol.

Unlike the U.S. Minor Leagues, Stimulants

and sophisticated PEDs do not appear to be

used.

Testing in the Dominican Republic

The number of positive tests for Performance Enhancing Substances have

declined in the Dominican Republic each season since 2005 in a similar rate to the

U.S. Minor Leagues.

Deterrence in the Dominican Republic

Education Only

Education +

Sanctions

Education + Sanctions +

Financial Disincentives +

Cultural Changes

•D.R. labor and health laws prevented MLB from imposing sanctions prior to 2008,

so the only response to a positive test before 2008 was follow-up counseling and

education.

•Changes in D.R. laws and MLB policies has allowed MLB to monitor and study the

effectiveness of different deterrence methods over a 10-year period

Major Doping Scandals in Sport

• Soviet Bloc and German Democratic Republic

1970-1980’s

• Ben Johnson 1988 Olympics

• Major League Baseball 1990-2003

• BALCO Consortium 2000’s

• hGH use in professional sports 2000’s

• Lance Armstrong and Cycling Doping

• Russia Doping 2010-16

What do they all have in Common?

All Involved Physicians!!!

1980 GDR 4 x 100m Women’s Medley Relay Team

The coaches and doctors were our guardians,

the people we trusted at sports school.

I’ll never know how good I could have been

[without drugs].

-Rica Reinisch

Athlete Drug Use and

Positive Drug Test

• Prescribing/Advising Physician

• Scientists/Researchers

• Dieticians

• Personal Advisors

• Social Network

• Peer Group

• Coaches

• Athletic Trainers

Rather fail with honor

than succeed by fraud.

-Sophocles, Greek Dramatist (496-406, BC)

•Clark Madsen, MD

•Teresa Puskedra

•Ogden Surgical-Medical

Society

•MLB Office of the

Commissioner

•Partnership for Clean

Competition

THANKS!!