10 Performance-enhancing Drugs That Aren't Steroids

By: William Harris & Jennifer Walker-Journey  | 

Lance Armstrong
Before his epic fall from grace, Lance Armstrong finishes the Power of Four Mountain Bike Race on Aspen Mountain in August 2012 in Colorado. Armstrong admitted to doping just two months later. Riccardo S. Savi/Getty Images

It was an epic fall from grace. In October 2012, after years of speculation and repeated denials on his part, renowned cyclist Lance Armstrong admitted to doping. Erythropoietin, testosterone, hGH, blood transfusions — anything to give him more strength, more endurance, a faster recovery so he could win. And win he did. Armstrong won seven consecutive Tour de France titles and an Olympic bronze in his decorated cycling career. He was stripped of them all.

It was hardly an isolated incident. Almost every professional sport — from weightlifting to baseball to archery — has been scandalized by claims of doping. And many sports heroes have been dethroned as a result.

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Anabolic steroids are among the most popular performance-enhancing drugs of choice. Chemicals in this special class of steroids, which include testosterone, androstenediol, androstenedione, nandrolone and stanozolol, are credited with increasing muscle mass and strength, but drug tests can detect them easily.

In the 1980s and '90s, however, other doping alternatives started appearing on the scene. Now there are numerous performance-enhancing drugs (PEDs) that aren't classified as steroids. Their effects are quite varied, and some only benefit certain athletes playing certain sports. All of which makes it extremely tricky for regulatory agencies like the International Cycling Union and the World Anti-Doping Agency (WADA) to keep up — and to keep drugs out of competing athletes.

Today, more than 192 PEDs and methods (think: blood doping) are prohibited to some degree by WADA. New ones are constantly being developed as are the methods used to detect them.

Here we'll talk about 10 of these non-steroid PEDs, looking at their modes of action and their side effects. Most are individual drugs, but a few are classes of compounds. We'll start off with erythropoietin, the drug that ushered in the modern era of doping.

10: Erythropoietin (EPO)

EPO model
This model shows the hormone EPO, which athletes use to amp up red blood cell production and deliver oxygen to their muscles. Martin McCarthy/Getty Images

Red blood cells carry oxygen throughout the body, so it makes sense that if an athlete can increase their red blood cell count, they'll deliver more oxygen to their muscles and perform at a higher level. Blood doping — removing and preserving a supply of blood so it can be returned, via transfusion, to the body right before competition — is one way to do this. But it's messy and time-consuming. Taking erythropoietin, or EPO, increases red blood cell production without the need for transfusions.

The kidneys make the hormone naturally, although people with severe kidney disease don't have enough. That's what the biotechnology firm Amgen was looking to address when it introduced synthetic EPO in 1985. By the 1990s though, cyclists and other endurance athletes discovered that they could train longer and harder if they took the drug regularly.

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Not surprisingly, taking EPO comes with significant risk. Yep, significant risk. Studies have shown that it increases the risk of events such as stroke, heart attack and pulmonary edema. One theory suggests that the drug thickens the blood to the point where it produces fatal clots. Such complications may have contributed to the deaths of at least 20 cyclists by 2000, increasing the urgency to develop a reliable test to detect EPO [source: Zorpette].

In 2007, anti-doping agencies introduced the concept of a "biological passport," a record of the substances found normally in an athlete's blood and urine, created by repeated sampling over time. By comparing the results of a blood test administered right before a competition to the passport, officials can determine if an athlete has been using EPO or other performance-enhancing drugs.

9: Human Growth Hormone (hGH)

Blessing Okagbare
Nigeria's Blessing Okagbare won her 100-meter heat race during the Tokyo 2020 Olympic Games July 30, 2021. But she was later disqualified for testing positive for hGH. JEWEL SAMAD/AFP via Getty Images

Like EPO, human growth hormone (hGH) occurs naturally in the body. In fact, the pituitary gland, the pea-sized organ located at the base of the brain, produces hGH to stimulate growth in children and adolescents and to increase muscle mass in adults.

As soon as synthetic hGH became available as a prescription medication in 1985, when the U.S. Food and Drug Administration approved its use for a number of diseases that retard growth or cause muscle deterioration, athletes began eyeing it as a doping agent. They figured it could mimic the muscle-building effects of anabolic steroids. At first, the high cost of the medication discouraged widespread use as a PED, but, as the saying goes, where there's a will to win, there's a way.

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The 1996 Summer Olympic Games have been called the "hGH Games" because of the rampant use of the drug among competitors. And it continues to be a problem among athletes. In summer 2021, Nigerian sprinter Blessing Okagbare was kicked out of the Tokyo Olympics after testing positive for hGH.

Today, athletes get hGH from a variety of sources: doctors willing to write prescriptions for off-label use, online pharmacies, illicit websites for performance-enhancing drugs and clinics that use the hormone to reverse the effects of aging. A few athletes even turn to black-market dealers that collect hGH from human cadavers.

It's a risky gamble, especially considering the lack of scientific evidence to suggest that hGH actually increases athletic performance. Oh, and don't forget the side effects. Using hGH has been linked to a variety of medical conditions, including joint pain, muscle weakness, fluid retention, carpal tunnel syndrome, cardiomyopathy and hyperlipidemia [source: Mayo Clinic].

8: Bromantane

Marina Trandenkova
Russian runner Marina Trandenkova (3717) qualified for the finals in the 100-meter race at the 1996 Atlanta Olympic Games, but was later disqualified when she tested positive for bromantane. Wally McNamee/Corbis via Getty Images

Another performance-enhancing drug that made the 1996 Summer Olympic Games memorable for the wrong reason was bromantane, a sort of stimulant and masking agent combined. Several Russians tested positive for the drug, which at the time, was not included on the International Olympic Committee's (IOC's) list of banned substances. That didn't stop the IOC from disqualifying several Russian athletes, stripping medals from two and, ultimately, blacklisting bromantane based on its performance-enhancing effects.

The effects of bromantane are quite unlike any other PED. Russian army doctors developed bromantane as a stimulant, something they could give to soldiers and cosmonauts to help them feel more alert and fight fatigue. Soon after, Russian athletes got hold of the drug, reporting that it helped them perform at peak levels without feeling exhausted. But the story appears more complicated.

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Some anti-doping officials believe bromantane can hide the abuse of more serious drugs, such as steroids. This is known as masking, and it's just one more way athletes can find a way to cheat. For example, the masking agent probenecid stops the excretion of steroids for a few hours, decreasing the concentration of steroids in the urine. The exact masking mechanism of bromantane, however, remains unclear. That doesn't diminish the drug's appeal among athletes, who believe its stimulant/masking effects give them a doping double whammy.

7: Ephedrine

ephedrine
Baltimore Orioles pitching prospect Steve Bechler, who died Feb. 17, 2003, of complications from heatstroke, took three tablets every morning of Xenadrine RFA-1, a weight-loss drug that contains ephedrine. Chris Hondros/Getty Images

Bromantane gained popularity because it appealed on multiple fronts. But stimulants by themselves function reasonably well as performance-enhancing drugs. Athletes take stimulants to improve endurance, reduce fatigue and increase aggressiveness. And someone trying to qualify for a lower weight class may rely on stimulants for their ability to suppress appetite.

You may think first of amphetamines — prescription-only "speed" pills — when you hear of this class of drugs, but not all stimulants require a physician's signature. Ephedrine, for example, is available behind the counter in drug products, mostly as decongestants. (Dietary supplements containing ephedrine are illegal in the U.S.) Athletes, of course, aren't interested in these. They want ephedrine for an extra boost of energy despite the warnings that the drug can cause high blood pressure, dizziness, shortness of breath and cardiac arrhythmia.

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6: Diuretics

chlorthalidone
The water pill chlorthalidone is a diuretic that, if taken, makes athletes go to the bathroom more, hence they can lose weight. Wikimedia/(CC BY-SA 2.0)

Along with bromantane, diuretics have long served to mask steroid use. Diuretics are any drugs that affect kidney function, resulting in increased urine output. The "water pill" chlorthalidone, for example, prevents fluids and salts from being reabsorbed into the kidney tubules and returned to the blood. As a result, more water leaves the body.

In patients with certain conditions, such as heart disease, diuretics can also help control high blood pressure. But athletes who take anabolic steroids pop diuretics to dilute their urine, which decreases steroid concentration and makes it much more difficult to detect in drug tests. (Of course, athletes can be tested for diuretics though, too.) Weightlifters and boxers may also down water pills to expel large amounts of fluid, which qualifies them to compete in a lower weight category. Then, right before the match, they stop taking the pills to return to their heavier fighting weight, giving them an advantage against their opponent. Of course, an athlete taking diuretics may also get dizzy, become dehydrated or experience a severe drop in blood pressure — symptoms that make it hard to fight with the eye of the tiger.

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5: Albuterol

Paula Radcliffe
Famed British marathon runner Paula Radcliffe (pictured here during the 2008 Olympics) has exercise-induced asthma. Many athletes rely on inhaled albuterol to deal with their asthma. Alexander Hassenstein/Bongarts/Getty Images

Sometimes, a drug's effect on athletic performance depends on how it's administered. Take the beta2-agonist albuterol. This well known asthma drug works by relaxing the muscles lining the bronchial tubes, allowing more air to flow into the lungs. Athletes with asthma (believe it or not, elite athletes tend to have higher rates of asthma than people in the general population) commonly use inhaled albuterol to treat their symptoms, allowing them to compete without shortness of breath [source: Kindermann].

But what about athletes who don't have asthma? Could they suck in a few shots of albuterol and increase their lung capacity? According to research published in the journal Sports Medicine, this performance-enhancing effect simply doesn't exist. The authors found that, in 17 of 19 clinical trials involving non-asthmatic competitive athletes, the performance-enhancing effects of inhaled beta2-agonists could not be proved.

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All bets are off, however, when an athlete takes albuterol orally or by injection. When administered in this fashion, albuterol has been found to have anabolic properties, which means it can help build muscle like steroids and, according to a 2020 study published in the British Journal of Sports Medicine, it can also boost sprint and strength performance.

Another orally ingested beta2-agonist known as clenbuterol — or clen— packs an even bigger punch than albuterol. Athletes in several sports — cycling, swimming, baseball and soccer — have tested positive for clenbuterol use, although many have claimed that the drug could be traced to contaminated food. While clenbuterol has historically been given to animals to produce leaner meat, it has been banned for use in meat since 1991 in the U.S. and since 1996 in the European Union.

4: Gamma Hydroxybutyrate (GHB)

GHB
You might know of GHB as the date-rape drug, but it's been a drug of choice among body builders since the '80s. chayanuphol/Shutterstock

If the acronym sounds familiar, it probably is. GHB is known as a "date rape" drug because it can quickly render a user so relaxed and euphoric — especially when combined with alcohol — that they are easily taken advantage of. Even scarier, it can cause amnesia, improving the chances that predators who slip the tasteless chemical into an unsuspecting imbiber's cocktail will get away with their misdeeds.

Because of the risks it posed, GHB was banned by the Drug Enforcement Administration (DEA) in 2000 but then brought back to the market two years later after it was found to be useful in treating narcolepsy. It's use has since been expanded to include another rare sleeping disorder, but GHB is only prescribed under strict safety controls.

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Even before it gained fame as a date rape drug, GHB was thought to improve exercise performance and muscle mass. There's even some scientific evidence that GHB increases growth hormone concentration. The drug apparently became popular among bodybuilders looking for alternatives to steroids in the 1980s when the hormones were first being controlled. Mike Fox, who was a personal trainer and good friend to retired New York Mets' player Mike Piazza, shot himself while trying to give up GHB in 2000. Bodybuilder Mike Scarcella, who was Mr. America and Mr. USA, died in August 2003 during a GHB withdrawal while hospitalized after a bar fight in Texas.

But the alleged performance-enhancing benefits of GHB live on. In 2015, "Full House" actor John Stamos was arrested for driving erratically through Beverly Hills under the influence of GHB. Stamos claimed he was taking the drug to "lean out" body mass before his new TV show, "Grandfathered."

3: Beta Blockers

Kim Jong-Su
North Korea's Kim Jong-Su (right) won silver in the 2008 Olympics 50m and bronze in the 10m pistol shooting, but was later disqualified when he tested positive for banned beta blocker drugs. ISSOUF SANOGO/AFP via Getty Images

It's easy to see why baseball players, cyclists, boxers, swimmers and runners sometimes turn to pharmaceuticals for a competitive advantage. These sports require deep reservoirs of muscle strength and endurance — the very targets of the most popular performance-enhancing drugs.

But what about sports like pistol shooting or archery? They certainly demand a keen eye, a steady hand and rock-solid concentration but not Herculean strength. Even so, athletes in these sports may also take PEDs. In fact, two North Korean pistol shooters competing in the 1998 Olympic Games in Seoul, South Korea, tested positive for propranolol.

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As it turns out, propranolol belongs to a class of drugs known as beta blockers, which nonathletes use to control high blood pressure. Beta blockers work by blocking the effects of epinephrine, a hormone secreted by the adrenal glands that increases blood circulation. People who take beta blockers have a slower heart rate and more relaxed blood vessels, conditions that help reduce blood pressure.

But the drugs have an interesting secondary effect: They also mask anxiety by diminishing nervous sweat and trembling and are sometimes prescribed off-label to treat performance anxiety. And that's exactly why marksmen are drawn to the drugs. If they have a steadier hand, they can perform better in competition. In addition to propranolol, beta blockers include atenolol, acebutolol, alprenolol, bisoprolol and metoprolol, all of which are banned in pistol shooting and archery.

2: Tamoxifen

Marlon Byrd
Boston Red Sox player Marlon Byrd received a 50-game suspension from Major League Baseball in 2012 for taking the banned substance tamoxifen. J Rogash/Getty Images

In June 2012, outfielder Marlon Byrd faced a 50-game suspension after testing positive for tamoxifen, a substance banned from Major League Baseball and many other sports. Why would an athlete want to take a drug normally used by breast cancer patients? The answer lies in some interesting biochemistry.

Many breast cancers have receptors for estrogen, a hormone that promotes the development and maintenance of female characteristics of the body. When estrogen molecules fit into these receptors like a key fitting into a lock, the malignant cells become activated. Tamoxifen blocks these estrogen receptors, interfering with the cancer's ability to grow and develop. This is why scientists refer to tamoxifen as an anti-estrogenic agent.

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Now let's turn our attention to a homerun slugger taking steroid injections — usually synthetic testosterone — to grow his muscles. Large doses of the male hormone cause the body to produce additional estrogen. This in turn can result in enlarged breasts, a feature that most power hitters find unappealing. To counteract the effects of estrogen and mask their steroid use, these players may opt to take tamoxifen. That means anti-estrogens don't really enhance performance, but, because they alleviate symptoms of PEDs, they appear on the World Anti-Doping Agency's list of more than 200 banned substances and methods.

1: Creatine

Emily Campbell
Weightlifters, like Great Britain's Emily Campbell, may opt to pop the over-the-counter supplement creatine. It's not a banned substance. Martin Rickett - PA Images/PA Images via Getty Images

There's one popular performance-enhancing drug that won't land an athlete in hot water with anti-doping agencies. It's creatine, and it's not a drug at all, at least according to the U.S. Food and Drug Administration (FDA). Because it's an over-the-counter supplement, creatine is regulated like a food by the FDA, which means creatine manufacturers don't conform to the same standards as pharmaceutical companies.

That doesn't diminish its appeal. Creatine remains one of the most widely used substances among athletes, especially football players, sprinters and weightlifters. Why? Because a growing body of evidence suggests that the chemical does indeed deliver athletic benefit by boosting levels of adenosine triphosphate (ATP) in muscle tissue. ATP powers muscle contractions, so increasing ATP levels is clearly a desirable thing. But the benefit seems to be limited to short, high-energy bursts of muscle activity, not long, slow burns common in endurance athletes.

Interestingly, the liver produces creatine every day, so taking supplemental creatine is a little bit like adding extra frosting to an already-frosted cake. Not only that, but excess amounts of the chemical also exit the body through the kidneys, making it unnecessary to power-gulp creatine tablets with the idea that doing so will deliver extra benefit.

And one final cautionary note: In some cases, supplements have been known to pick up contaminants from other substances, including performance-enhancing drugs. Try explaining that one to the team doctor.

Originally Published: Nov 6, 2012

Performance Enhancing Drugs FAQ

What are performance-enhancing drugs in sports?
Performance enhancing drugs are used by some athletes as a stimulant to build muscle mass, increase endurance and enable them to train harder. It can also give athletes an edge over other contestants during competition.
Why do athletes choose to take performance enhancing drugs?
Many athletes take some form of performance enhancing drugs, such as steroids known as anabolic-androgenic steroids to increase muscle mass and strength. While the use of performance enhancing drugs has been banned by many sports’ governing bodies, some athletes still use them despite the risk of being caught.
What are the most popular performance-enhancing drugs?
While there are many different types, some of the most common ones include human growth hormones, beta-blockers, anabolic steroids and erythropoietin.
What PEDs do sprinters use?
The most-used performance enhancing drug used by sprinters is called “Devil's Playground.” It is an anabolic steroid that enhances the synthesis of muscle protein, resulting in a significant increase in a runner’s speed.
What PEDs do NFL players use?
According to reports, nearly 40 percent of current NFL players use some form of performance enhancing drug. Creatine is a popular substance that isn’t banned by many sports regulatory bodies, including the NFL.

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  • Buchen, Lizzie. "Are COX-Blockers the New Steroids?" Discover Magazine. April 8, 2008. (Oct. 17, 2012) http://blogs.discovermagazine.com/discoblog/2008/04/08/are-cox-blockers-the-new-steroids/
  • Butcher, Pat. "Bromantan is Russians' 'rocket fuel'." The Independent. Aug. 3, 1996. (Oct. 17, 2012) http://www.independent.co.uk/sport/bromantan-is-russians-rocket-fuel-1307987.html
  • Calamia, Joseph. "EPO: A Doping Drug Makes an Unwanted Cycling Comeback." Discover Magazine. May 26, 2010. (Oct. 17, 2012) http://blogs.discovermagazine.com/80beats/2010/05/26/epo-a-performance-enhancing-drug-makes-an-unwanted-cycling-comeback/
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  • Kindermann, W. "Do inhaled beta(2)-agonists have an ergogenic potential in non-asthmatic competitive athletes?" Sports Medicine. 2007. (Oct. 17, 2012) http://www.ncbi.nlm.nih.gov/pubmed/17241101
  • Mayo Clinic Staff. "Performance-enhancing drugs: Know the risks." Mayo Clinic. Dec. 23, 2010. (Oct. 17, 2012) http://www.mayoclinic.com/health/performance-enhancing-drugs/HQ01105
  • Ogbru, Omudhome. "Cox-2 Inhibitors." MedicineNet. (Oct. 17, 2012) http://www.medicinenet.com/cox-2_inhibitors/article.htm
  • Prewitt, Alex. "Marlon Byrd suspended 50 games for PED use." Boston.com. June 25, 2012. (Oct. 17, 2012) http://www.boston.com/sports/baseball/redsox/extras/extra_bases/2012/06/marlon_byrd_sus.html
  • Shermer, Michael. "The Doping Dilemma." Scientific American. April 2008. https://www.scientificamerican.com/article/the-doping-dilemma/
  • Wright, Karen. "Works in Progress." Discover Magazine. Feb. 1, 2002. (Oct. 17, 2012) http://discovermagazine.com/2002/feb/featworks/?searchterm=performance%20enhancing%20drugs
  • Zorpette, Glenn. "The Chemical Games." Scientific American Presents: The Athlete's Body. 2000. https://www.docme.su/doc/1764238/-scientific-american-presents-building-the-elite-athlete-...

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