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Howard Markel Dr. Howard Markel. If headlines could scream, then scream they did in early August According to nearly every newspaper, television, and radio broadcast in the world, early on Aug. She was only Long before the opiate and opioid epidemics struck American life with such resounding force, there were plenty of other prescription drugs abused to excess with deadly results. The vial containing the latter, a barbiturate known as Nembutal, was empty. In her last weeks to months, Marilyn was also consuming, if not abusing, a great deal of other barbiturates amytal, sodium pentothal, seconal, phenobarbital , amphetamines methamphetamine, Dexedrine, Benzedrine and dexamyl—a combination of barbiturates and amphetamines used for depression , opiates morphine, codeine, Percodan , the sedative Librium, and alcohol Champagne was a particular favorite, but she also imbibed a great deal of Sherry, vermouth and vodka. During this period, Monroe suffered from several mental health problems, including substance abuse, depression, and, most likely, bipolar disorder, along with physical ailments such as endometriosis and gall bladder disease. Lonely and harassed, Marilyn found getting to sleep especially difficult. This is a particularly lethal cocktail, not only because each of these drugs increase, or potentiate, the power of the other, but also because people who take this combination often forget how much they previously consumed, or whether they took them at all, and soon reach for another dose. On her last day of life, Saturday, August 4, Marilyn lolled about her home in a drug and alcohol-fueled haze. Her publicist Patricia Newcomb, her housekeeper Eunice Murray, a photographer named Lawrence Schiller, and her psychiatrist Ralph Greenson were also present, off and on, for most of that day. In , a U. Before leaving for the night, Dr. Greenson asked Murray, who had lived with the movie star, to keep a close eye on Marilyn. Marilyn was last seen alive at 8 p. At around a. An arm was stretched across the bed and a hand hung limp on a telephone. Greenson, who, upon arrival, broke through the window door with a fireplace poker to get to Marilyn. Sadly, it was too late. As the entire world learned later that morning, Marilyn Monroe had died of an apparent, or accidental, suicide. Who was she trying to call just before she closed her eyes for the last time? Was she murdered? Who was involved? And what about those pesky and unsubstantiated rumors about the involvement of John and Bobby Kennedy, not to mention the Mafia, the CIA and even members of the Communist Party? On and on it goes, each theory seeming to be crazier or more far-fetched than the last. But because of the sequestered nature of her demise, we will likely never know the precise details. What remains most cautionary to 21st century readers is that the majority of the substances Marilyn was abusing were prescribed to her by physicians, all of whom should have known better than to leave a mentally ill patient with such a large stash of deadly medications. The barbiturates that killed her are rarely, if ever prescribed, today. Nevertheless, Monroe, like Judy Garland, Michael Jackson, Prince, and too many other famous Hollywood stars who overdosed, was adept at manipulating her doctors to prescribe the drugs she craved and felt she needed to get through her tortured days and nights. The full-length, flesh-colored dress Monroe wore during her famous birthday tribute to President John F. Kennedy in , in background, is among the items to be auctioned. In , enough prescription painkillers were prescribed to medicate every American adult every four hours for one month. The most abused prescription drugs are painkillers, e. Although doctors prescribed many of these pills, many others were either purchased illegally or stolen from friends or relatives. Opiate or opioid narcotic painkiller drugs are the most common cause of prescription overdose deaths today. According to the U. Center for Disease Control and Prevention, prescription opioid overdose deaths have quadrupled since ; so, too, have the sales of these prescription drugs. From to , more than , Americans died from overdoses related to prescription opioids. In , alone, more than 14, people died from overdoses involving prescription opioids. Five decades after she died, and with the development of so many new, addictive, and potentially lethal painkillers and sedatives, this epidemic has only grown worse. Today, physicians, nurses, family members, and patients are all still struggling to grapple with its effects and stem its deadly tide. Howard Markel writes a monthly column for the PBS NewsHour, highlighting momentous historical events that continue to shape modern medicine. Support Provided By: Learn more. Sunday, Oct The Latest. World Agents for Change. Health Long-Term Care. For Teachers Newshour Classroom. NewsHour Shop. About Feedback Funders Support Jobs. Close Menu. Yes Not now. By — Dr. Leave your feedback. Share on Facebook Share on Twitter. Enter your email address Subscribe.
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Harm Reduction Journal volume 12 , Article number: 53 Cite this article. Metrics details. Recent exposes of drug use in sports suggest that doping might be more problematic than doping-control test results reveal. In light of the limitations associated with ZT-based policy, we propose an alternative policy, one based on controlled use and harm reduction principles. We argue that substance control policies underpinned by harm reduction HR principles of social utility and public value will deliver superior social outcomes. Second, HR prioritises athlete welfare over sport and brand reputation. We begin our commentary of the drugs in sport problem by asserting that drug use is both endemic in modern society and a feature of contemporary sport. Rather, the contextual complexities associated with drug use in sport make its management problematic. As a result, the rationale for, and mechanisms of, drug control remains a subject of heated debate. The prevailing policy is orchestrated by powerful global-sport authorities like the International Olympic Committee IOC , the World Anti-Doping Agency WADA , and international sport federations, which claim that drug use is cheating and should be eliminated through the imposition of severe punishments. However, we argue that the current policy has neither been successful in eliminating doping in sport, nor effective in protecting the health of athletes. Numerous studies suggest that prevalence rates could be much higher than doping control tests reveal \[ 1 , 2 \]. Athlete and coach surveys suggest higher rates of usage as well, although respondents tend to identify doping in their peers than admit their own personal use \[ 4 , 5 \]. When asked about personal use—either through questionnaires or interviews—the respondent results are closer to control test levels, with higher levels of illicit drug use than of performance-enhancing substance use \[ 6 \]. Doping prevalence may be even higher in serious recreational and fitness sports \[ 7 \], while usage by adolescents appears to be growing \[ 8 \]. The use of medications by elite athletes has also been shown to reach higher levels than the non-sporting public \[ 9 \]. One proposed solution to the doping problem involves even more rigorous testing protocols. They include greater frequency of random doping analyses, enforced medical follow-ups, stronger legislation against the possession of doping substances, and harsher penalties for athletes who use the substances \[ 10 \]. This harm reduction model presents an essentially utilitarian position, where ethical judgement and moral certitude are replaced by the practicalities of managing the multiple potential harms associated with elite sport. Our position maintains that the current WADA policy of zero tolerance will neither extinguish doping in sport nor protect the health and well-being of athletes. The evidence provided by athletes themselves supports our claim. In our studies \[ 11 , 12 \] and others \[ 13 \], many elite athletes make it clear that they would try any performance-enhancing substance as long as it is not banned. Safeguarding health plays a negligible role in the decision-making process. Athletes do not rely on a set of immutable moral boundaries. Yes, it does matter, because punitively driven deterrence does not work, especially when the motivation for substance use comes from the pursuit of superior performance. Consider the teenage Olympic-level gymnast in one of our studies who consumed analgesics by the handful to control her chronically agonising joint pain \[ 11 \]. An ever-vigilant scanner of the banned-substance list, she reported her delight as a stronger painkiller became available when it was removed from prohibition. Then, there was the case of a wheelchair powerlifter sanctioned by his governing body under a therapeutic exemption to use nandrolone decanoate to rehabilitate a torn pectoralis major. To speculate in the absence of evidence, it is also possible that some athletes employ higher dosages of normally banned substances while permitted to do so under the umbrella a therapeutic exemption. For example, supplement users hold more permissive attitudes to banned doping in sports than those not using supplements, where supplement users are three and a half times more likely to practice banned doping than athletes not using supplements \[ 20 \]. Barkoukis et al. In fact, young elite athletes who declare that supplementation is essential for sporting success are more likely to condone doping \[ 22 \]. Another important study indicated that body dissatisfaction, weight change behaviours, and supplement use are related to more lenient attitudes towards sport doping in adolescents \[ 23 \]. A similar study reported a relationship between the use of protein, creatine, and anabolic steroids, where the use of each former substance provided a statistical predictor of the next step in the hierarchy of drug use \[ 24 \]. Even athletes from club-level sport who have rejected the use of banned substances seem to recognise that in order to effectively transition to the next level, some additional substance use may be required \[ 26 \]. Similarly, our own research shows that while mid-level performing athletes nearly always fall short of using banned substances, they understand that in order to achieve national or international success, additional substance use is essential \[ 11 \]. Favourable views about substance efficacy and appropriateness are likely to undermine effective regulation by normalising their use \[ 18 , 19 \]. The threat of sanction, however severe, pales against a cost-benefit algorithm where failure is just as unpalatable as victory is compelling \[ 27 \]. And that is before any economic incentives add impetus. To compound matters, elite athletes use prohibited performance-enhancing substances to bolster training and recovery as much as to supplement in- competition performance, leaving only out-of-season testing to sidestep. Studies have also revealed that it is possible for athletes to successfully use micro-dosing strategies in order to pass tests \[ 28 \]. Vigilant testing and heavy sanctions stimulate athletes to use more dangerous substances and combinations for both masking and performance purposes. Our most recent research, as well as other meta-studies, shows that elite sport presents a special problem because its performance demands encourage, and perhaps even impel, the experimental use of substances \[ 13 , 14 , 29 \]. Perhaps more worrisome is Fincoeur et al. In , WADA introduced its global anti-doping code. The code contains a list of banned substances including performance-enhancing drugs like EPO, human growth hormone, anabolic androgenic steroids, the more powerful anti-inflammatory drugs and stimulants, and a range of non-performance enhancing, illicit drugs like cannabis, ecstasy, and cocaine. Exemptions exist in the code for athletes who can demonstrate a legitimate therapeutic purpose for a banned substance. In these instances, athletes with documented medical conditions like asthma can request a therapeutic use exemption from their national anti-doping agency and national sport governing body. According to WADA, sport organisations hold a duty of care to the athletes who participate in their competitions and, as a result, must be protected through prohibitions on substances incurring health risks. According to the code, the spirit-of-sport encapsulates the ideals of Olympism, the celebration of the human spirit, fun, and joy, courage, teamwork, excellence in performance, respect for the rules and other participants, dedication and commitment, character and education, community and solidarity, ethics, fair play, and honesty. If a drug meets two of the above three criteria, it will be listed as a banned substance. Under the WADA code, drugs like EPO, human growth hormone, steroids, and stimulants both enhance performance and constitute a health risk, and therefore remain banned. WADA policy also places illicit drugs under the banned-substance umbrella. However, unlike the all-year-round ban on performance-enhancing drugs, the illicit drug ban only applies to in-competition or in-season use. While cannabis, ecstasy, and cocaine do not enhance performance, they do introduce health risks. Crucially, because their illegal use undermines the spirit-of-sport, they too are banned. In fact, any illicit drug is, according to WADA, contrary to the spirit-of-sport since it diminishes the good name and public image sport commands. Caffeine, however, no longer appears on the banned list. Although caffeine improves performance, it is not illegal, does not incur health concerns, and fits the play-true requirement. Yet, studies reveal that athletes binge-drink and use recreational drugs to alleviate the pressure accumulated from demanding seasons of abstinence and stress \[ 33 \]. The use of analgesics and painkillers also remains unclear especially when under legitimate prescription by medical practitioners. Athletes occupy a world where drug use is embedded in community culture and practice. While large numbers of drugs are misused and produce significant social costs, they also provide the community with a better quality of life. A cursory look at mainstream drug use statistics shows that drug use is not an aberrant behaviour confined to a problematic subculture of deviants and misfits \[ 34 \]. While the social burden of illicit drug use is undeniably severe, conflating the so-called war on drugs with a war on doping may risk ignoring the unique elite sporting context. Importing illicit drug policy into the sporting arena assumes that performance doping mirrors recreational and addictive drug behaviours, which doping undermines sport and morality in a similar way as criminal drug trafficking, and that doping decisions can be influenced by rational evaluations of the risk of severe penalties \[ 35 , 36 \]. It might also be ambitious to expect elite athletes to eliminate their use of drugs when society as a whole relies on drugs to help its members cope with the pressures and tensions of daily living and to help them feel psychologically and physically better. Such mixed messages become compounded when we assume that using an over-the-counter drug with significant side effects is acceptable, but the use of an illicit drug with no greater side effect is not only taboo but also indicative of a moral failing. The message can be further confused when officials, journalists, and fans not only demand that athletes always perform at their best but also remind them that failure will be publically scrutinised. In analysing a series of case studies, Carstairs exposed the complex and often contradictory responses to doping expressed through the popular media, message boards, and polls \[ 37 \]. Athletes who have failed drug tests can receive sympathy and condemnation simultaneously. We contend that the primary principle of sound drug management in sport should be HR. In the context of sport, the HR approach illuminates three principles. First, drug use is not just a sporting matter nor is it a criminal or legal matter. Instead, drug use in sport constitutes a serious social issue \[ 38 \]. Second, HR obviates the need for any form of moral certitude \[ 39 \]. Instead, it accepts that drug use exists in sport and will never be completely eliminated. Third, although HR does not condone the use of drugs in sport, it acknowledges that when it does occur, policy makers have an obligation to develop public health measures that reduce drug-related harm to all athletes, irrespective of their status or ambition \[ 40 \]. For example, policies that exclusively pursue the elimination of doping do not account for high or low risk use. Conversely, some evidence indicates that harm reduction polices providing education, private support, and rehabilitation, lower the social costs and cultural damage associated with substance use \[ 41 \]. The key issue for HR therefore has less to do with the short-term brand equity and credibility that might be tarnished by a drug use or drug trafficking incident, and more to do with the long-term best interests of sport participants. Unlike current drug control policies, HR is not about obstructive policing, incessant testing, onerous investigation, and severe sanctioning. Instead, it focuses on building structures and systems that deliver a number of harm reduction outcomes including for example: 1 the creation of a playing environment where safety and effective harm management are strategic priorities; 2 a drug supply and distribution system that is regulated through the direct involvement of physicians and pharmacists; 3 the design of promotional campaigns that educate athletes about the risks associated with various substances; 4 the early intervention of medical support where damage to oneself or to others has occurred through some form of drug use; 5 the availability of broad-based drug rehabilitation and counselling services that allow athletes to remediate their high risk behaviours; and 6 a transparent listing or register of the drugs used by all sporting bodies and athletes. In this context, regulation becomes useful only in so far as it lessens the potential harm of participants. Despite the pressures on serious athletes to use substances as they move along the performance pathway, our data show that mid-tier athletes practice considerable self-determination in selecting which substances to utilise \[ 14 \]. The same thinking that leads individuals to improve their equipment technologies, strengthen their training programmes, and take nutritional supplements, also leads them to evaluate the benefits and costs of not only pushing the boundaries by using complex, high-dose multi-mix supplements but also by crossing the boundary into the realm of banned drug use. Yet we know little about these cogitations, when athletes are most vulnerable during their life cycles and the decision-making that emerges as a consequence. These findings suggest that sports officials have a window of opportunity for guiding serious athletes into safe and legal substance use through well-timed educational campaigns that deliver non-judgmental analyses of the strengths and weaknesses of substance use in all of its intricacies. We should also not forget that the majority of published studies have focused on clinical populations and case studies which tend not to address the supra-therapeutic regimens and complex pharmacology employed by athletes. Moreover, the most dangerous and prolific usage of substances can be found in groups primarily interested in recreational performance and image-enhancement, be it to build muscle, strip fat, or iron-out cellulite \[ 42 , 43 \]. Equally, it also allows for a stronger platform of education and social marketing and the provision of personnel and facilities that ensure a safe and protective sport environment where athlete welfare holds sovereign. A zero-tolerance approach to drug use in sport leverages a strong sense of moral certitude, but it has not worked \[ 45 , 46 \]. Harm reduction approaches will never eliminate use, but they deliver a humane service to a cohort of talented performers who deserve a safe and supportive workplace in which to ply their highly skilled and heavily sought-after trade. We have one policy model driven by a fundamentalist concern for punishment, zero tolerance and abstinence, and another underpinned by an idealistic concern for athlete autonomy, agency, and safety. However, these policy options are difficult to precisely evaluate, since subjectivity and bias inevitably get in the way of an impartial analysis, even where a lot of objective evidence has been compiled. A harm reduction approach will deliver greater autonomy to athletes, while pro-actively seeking to contain the damage to users and the people around them. Pitsch W, Emrich E. The frequency of doping in elite sport: results of a replication study. Int Rev Sociol Sport. Article Google Scholar. Dimeo P, Taylor J. Monitoring drug use in sport: the contrast between official statistics and other evidence. Drugs: Educ Prev Polic. Google Scholar. Prevalence of doping use in elite sports: a review of numbers and methods. Sports Med. Perceived incidence of drug use in Australian sport: a survey of athletes and coaches. Sport Soc. Scand J Med Sci Sports. Randomized response estimates for doping and illicit drug use in elite athletes. Drug Alcohol Depend. Doping in fitness sports: estimated number of unreported cases and individual probability of doping. J Adolesc Health. Article PubMed Google Scholar. The use of drugs and nutritional supplements in top-level track and field athletes. Am J Sports Med. Use of doping agents, particularly anabolic steroids, in sports and society. Contextual influences and athlete attitudes to drugs in sport. Sport Manag Rev. Stewart B, Smith A. Player and athlete attitudes to drugs in Australian sport: implications for policy development. Int J Sport Pol. Social psychological determinants of the use of performance-enhancing drugs by gym users. Health Educ Res. Doing supplements to improve performance in club cycling: a life-course analysis. The role of ideology in shaping drug-use policies in Australian sport. Bell K, Keane H. Soc Sci Med. Kleinig J. Ready for retirement: the gateway drug hypothesis. Subst Use Misuse. Petroczi A, Aidman E. Psychological drivers in doping: the life-cycle model of performance enhancement. Subst Abuse Treat Prev Policy. Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms. Nutritional supplement and doping use in sport: possible underlying social cognitive processes. Scand J Med Sci Sports ; Doping and supplementation: the attitudes of talented young athletes. Relationships between body image, nutritional supplement use, and attitudes towards doping in sport among adolescent boys: implications for prevention programs. Sports Nutr Rev J. Psychology of Men and Masculinity. Cooper C. Run, swim, throw, cheat: the science behind drugs in sport. Oxford: Oxford University Press; Doping use among young elite cyclists: a qualitative psychosociological approach. Doping in competition or doping in sport? Brit Med Bull. Eur J Appl Physiol. Rethinking drugs in sport: why the war on drugs in sport will never be won. Oxford, UK: Routledge; Why did they do it? Frank discussions with former Tunisian athletes who have engaged in doping. Kirkwood K. J Sport Soc Issues. Drugs, recreational drug use and attitudes towards doping of high school athletes. Int J Sports Med. Caulkins JP, Reuter P. Re-defining the goals of national drug policy: recommendation from a working group. Am J Public Health. Gao J. Reflection on the present strategies of war on doping. Coomber R. How social fear of drugs in the non-sporting world creates a framework for doping policy in the sporting world. International Journal of Sport Policy and Politics. Carstairs C. The wide world of doping: drug scandals, natural bodies, and the business of sports entertainment. Addiction Res Theor. Marlatt G. Basic principles and strategies of harm reduction. In: Marlatt GA, editor. Harm reduction: pragmatic strategies for managing high risk behaviors. New York, NY: Guilford; Wodak A. Harm reduction is now the mainstream global policy. Bennett D. Harm reduction and NFL drug policy. Drugs and society. Boston: Jones and Bertlett Publishers; Human enhancement drugs: the emerging challenges to public health. Smith A, Stewart B. Body perceptions and health behaviors in an online bodybuilding community. Qual Health Res. Kayser B, Broers B. The olympics and harm reduction? Harm Reduction Journal. Why we should allow performance enhancing drugs in sport. Br J Sports Med. Kaiser B, Smith A. Globalization of anti-doping: the reverse side of the medal. Br Med J. Download references. The authors wish to thank Dr. Simon Outram for his critical insights into the ethics of substance use in sports and his advice on the different ways in which zero tolerance and harm reduction approaches impact on player health and welfare. You can also search for this author in PubMed Google Scholar. Correspondence to Bob Stewart. AS developed the arguments in favour of a harm reduction approach to the control of substance use in sports and prepared the first version of this paper. BS addressed the substance use policy implications of adopting a harm reduction approach and prepared the final version of the paper. Reprints and permissions. Smith, A. Why the war on drugs in sport will never be won. Harm Reduct J 12 , 53 Download citation. Received : 12 August Accepted : 02 November Published : 10 November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Download ePub. Abstract Recent exposes of drug use in sports suggest that doping might be more problematic than doping-control test results reveal. Background We begin our commentary of the drugs in sport problem by asserting that drug use is both endemic in modern society and a feature of contemporary sport. An alternative policy We contend that the primary principle of sound drug management in sport should be HR. Conclusions Despite the pressures on serious athletes to use substances as they move along the performance pathway, our data show that mid-tier athletes practice considerable self-determination in selecting which substances to utilise \[ 14 \]. References Pitsch W, Emrich E. Article Google Scholar Cooper C. Google Scholar Kirkwood K. Google Scholar Gao J. Article Google Scholar Carstairs C. Article Google Scholar Marlatt G. Google Scholar Wodak A. Google Scholar Download references. Acknowledgements The authors wish to thank Dr. Smith View author publications. View author publications. Additional information Competing interests The authors declare that they have no competing interests. About this article. Cite this article Smith, A. Copy to clipboard. Contact us Submission enquiries: journalsubmissions springernature.
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