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What are the 19 known methods of cheating to pass performance enhancing drug tests?

19 Methods of Cheating (in alphabetical order):
1. Biosimilars 11. Micro-dosing (a, b)
2. Blood transfusion (a, b) 12. Perma Cleanse
3. Catheterization 13. Probenecid
4. The Cream 14. Protease (a, b)
5. Diuretics 15. Tattoos
6. Epitestosterone 16. Testosterone patches
7. Erythropoietin (EPO) (a, b, c, d, e) 17. Therapeutic use exemptions
8. Gene doping 18. Titrate testosterone/epitestosterone
9. Human growth hormone (HGH) 19. Urine replacement (a, b)
10. Masking agents  

Nathan Jendrick, fitness writer, in his 2006 book titled Dunks, Doubles, Doping: How Steroids Are Killing American Athletics, wrote the following:
Male fake phallus urination device image. Source: The Original Whizzinator website (accessed online Dec. 3, 2008)
"The following are methods that are currently used, were used at some point in history, or can supposedly be used to beat steroid tests in athletics...

Urine replacement [19.a]. It sounds simple, and in principle is, but getting it done can be just a little awkward... it involves exchanging an athletes urine, which he knows is dirty, and replacing it with clean urine. The clean sample is often purchased from a teammate, a neighbor, even over the internet. The Original Whizzinator [see picture] is among several kits available... that includes two vials of a clean sample, a holding bag, temperature control measures, and... a five-inch, lifelike prosthetic penis... in three colors: Black, flesh, and latino...

Epitestosterone [6].Testosterone is tested at a ratio of 6:1 (International Olympic Committee standards) to prevent any false positives. The ratio compares levels of testosterone to epistosterone [T/E ratio]. The normal testosterone-epitestosterone ratio is 1:1, but because top athletes are often genetically advanced, their ratios may differ compared to those of the average man. The 6:1 ratio is for most a large variance in their natural levels. [Editor's Note: The International Olympic Committee Medical Commission set a T/E ratio of 6:1 in 1982, but in 2005 the World Anti-Doping Agency (WADA) lowered the legal ratio to 4:1.] This leaves open the possibility for a certain amount of exogenous testosterone if one is careful enough to make sure the hormone stays within accepted limits. For those individuals already producing more hormone [testosterone] than their competition, or for those who want to use more than they can sneak in under the radar, epitestosterone is employed. When used, it increases the variable testosterone is compared to, thus allowing for increased amounts. As long as these levels are monitored... detection would be a very low risk.

Diuretics [5] and Perma Cleanse [12]. Athletes often take diuretics in an effort to cleanse their system before having to provide a sample. These can work tremendously well... One mail-order system that is supposedly undetectable as a diuretic or in any lab test but uses the same means to evade a positive test - detoxification - is Perma Cleanse... A classic method of evading positive drug tests is to couple the use of natural herb diuretics such as dandelion root, uva ursi, and caffeine with fasting."

2006 - Nathan Jendrick

Alex Duff, Reporter for Bloomberg news, stated the following in an Oct. 29, 2007 article titled "Athletes Fool Test of Banned Drug by Using Soap, Scientist Says," posted on Bloomberg.com:
"A few grains of household soap can destroy the banned drug EPO [7.a] in an athlete's urine sample, wrecking a test that cost $2 million to develop... Scientists made the discovery after a former Tour de France cyclist said he was given an unidentified powder to sabotage surprise tests... [A]nti- doping authorities may need to start checking for protease [14.a], a class of enzymes that destroys EPO and is in soap powder, dishwashing solution and contact-lens cleaner...

There's no reference to protease on the World Anti-Doping Agency's list of banned substances... [U]sing soap powder would destroy all EPO in urine, both synthetic and what is produced naturally by kidney cells."

Oct. 29, 2007 - Alex Duff

Dan Silkstone, Senior Sport Reporter for The Age (Australia), in a June 21, 2008 The Age article titled "The Amazing Adventures of Gene Doping Man," wrote the following:
"Gene doping [8] is a sophisticated method of cheating and a phrase you'll be hearing a lot more of soon... Many experts believe gene doping is already happening and warn that tinkering with human DNA to boost performance could seriously injure or even kill those who try it. Oh, and a test to detect it is years away - perhaps as much as a decade...

First, the gene that governs a certain desirable function is isolated - the source is usually another person. Then, in a laboratory, it is amplified - made more powerful. The gene is then inserted into a viral vector, a virus that has had the harmful part of its structure deactivated but which retains the ability to penetrate and colonise human cells. It is a sort of biological Trojan Horse. Adenovirus - a common cause of respiratory problems - is most often used but other viruses such as herpes simplex or even HIV are being looked at. The vector is injected into the athlete and begins to take over cells.

Once inside, the altered gene becomes part of the cell's DNA and recodes it to behave differently - producing, for example, more and stronger muscle or creating EPO, which in turn creates more red blood cells. The virus colonises cells at the same rate it would if carrying disease. Once the gene is embedded, it will be expressed. There is no turning back."

June 21, 2008 - Dan Silkstone

Shannon Sovndal, MD, Emergency Medicine Physician at Boulder Community Hospital and former doctor of the Slipstream cycling team, in a Sep. 28, 2004 VeloNews article titled "The Hamilton Case: A Doctor Explains Blood Doping," explained:
Blood transfusion bag. Source: istockphoto.com (accessed online Dec. 3, 2008)
"Blood transfusions [2.a] have long been used to enhance athletic performance. Transfusions are an extremely straightforward, simple, and effective method of increasing the blood's oxygen carrying capacity. The term 'blood doping' refers to various techniques used to increase the oxygen carrying capacity of blood.

Recently, recombinant human erythropoietin, more commonly known as 'EPO,' [7.b] has been the drug of choice. However, with the advent of more effective and inclusive testing, the use of EPO has become more difficult and complex... Because of the increased risk of detection... athletes may turn to an older form of blood doping that, until recently, has been virtually undetectable.

There are two methods of doping through blood transfusions: autologous and homologous. With an autologous transfusion, an athlete receives his or her own blood. An athlete donates blood, stores it, and then receives the blood at a later point in time... In a homologous transfusion, the blood comes from another person. The benefit of homologous transfusion is no decrease in performance during the donation period."

Sep. 28, 2004 - Shannon Sovndal, MD

Paul Kelso, Chief Sports Reporter for the Daily Telegraph, wrote the following in a July 31, 2008 article titled "Blood Doping Goes Viral as Cheats Slip through the Net," published in the Guardian:
"EPO [7.c], typically produced from cultured animal cells, is detectable in urine for less than a week, but cheats have become more sophisticated in the way they use it. A decade ago they would take large quantities of EPO in the off-season to build up red blood cells, and redose prior to competition. Now there is a growing trend towards micro-dosing [11.a], where athletes take small, barely detectable amounts of EPO to maintain levels.

Another barrier to detection is the growing variety of EPO products available through the legitimate pharmaceutical market and in cheaper generic forms... Most recently testers successfully caught three cyclists on the Tour de France... That test was only possible because of the cooperation of the manufacturer, a relationship that does not exist with those producing generics.

Cheats have also become adept at manipulating tests... Typically an athlete will put a protease [14.b] powder in his pocket before a test, transfer it to his fingers and then urinate over his hand into the sample bottle to ensure that the test is meaningless. Alternatively, if the doping control officer insists that they wash their hands first, male athletes can secrete the powder under their foreskin and transfer it that way."

July 31, 2008 - Paul Kelso

Michael S. Schmidt, Sports Reporter for the New York Times, wrote the following in a Jan. 9, 2009 article titled "More Exemptions in Baseball for Amphetamine Use Among Players," published in the New York Times:
"[I]t was revealed that the number of major leaguers claiming [therapeutic use] exemptions [17] for attention deficit disorder had risen to 103 in 2007 from 28 in 2006. The implication was that players, faced with the 2006 ban on amphetamine use, were making claims of attention deficit disorder so that they would be allowed to use stimulants like Ritalin and Adderall...

106 players were granted therapeutic use exemptions for attention deficit disorder in 2008... about 8 percent of the major league players... The percentage of American adults who have been given a diagnosis of attention deficit disorder is somewhere between 1 and 3.5 percent, according to the National Institute of Mental Health, although some experts believe the actual number is much higher, citing a large number of undiagnosed cases."

Jan. 9, 2009 - Michael S. Schmidt

Jacquelin Magnay, Senior Sports Writer for the Sydney Morning Herald, stated the following in a May 1, 2008 article titled "Drug-Test Blitz on Olympians," published on the Sydney Morning Herald web site:
"Micro-doses [11.b] of drugs and hormones, chemically altered molecules of steroids, testosterone patches [16] and the old doping chestnut, human growth hormone [9], were the trends in drug taking by cheating athletes...

HGH, despite being used for decades, was still being abused by athletes, especially in combination with steroids... Despite recent research showing that HGH is ineffective on its own... athletes were using it to boost the effect of other performance-enhancing drugs.

Michael Ashenden, an Australian scientist specialising in blood doping, has shown athletes can take regular low doses of the blood-boosting hormone erythropoietin (EPO [7.d]) in combination with insulin growth factor or HGH. The combination accelerates the impact of EPO but enables the user to escape detection for the smaller dose of EPO."

Jan. 9, 2009 - Jacquelin Magnay

Sky News, the UK's first 24-hour news channel, stated the following in an Aug. 7, 2008 article titled "Olympic Cheats Use 'Drug Tattoos," posted on its website:
"Olympic cheats are taking performance-enhancing drugs via tattoos [15] in an effort to win gold... Inserting drugs through tattoo needles increases the effect of drugs, meaning athletes can take smaller doses and 'fly under the radar' in dope tests.

Research in Germany has shown that delivering DNA vaccines via tattoo was 16 times more effective than injecting through the muscles or veins as the vibrating tattoo needle prepares the body's immune system and increases the body's response to the drug...

Former Australian Institute of Sport researcher Robin Parisotto said... 'With some of these things the technology is so new, the concept so bizarre, that there would only be a handful of well tapped-in athletes using it - but they will be experimenting at the Beijing Olympics because it is the ultimate. The problem is that some of the drugs would now fly under the radar with the tattoo technique because athletes would be taking a much smaller dose.'

Cheating athletes are also combining the erectile dysfunction drug Viagra with doses of nitrous oxide, or laughing gas. Both drugs increase the flow of oxygen in the blood stream and therefore boost sporting performance."

[Editor's Note: WADA released a statment on Sep. 25, 2008 noting that it did not include Viagra on the 2009 Prohibited List (147 KB) , but it is conducting studies to determine whether to ban the use of Viagra in the future. Nitrous oxide is legal in the US under the supervision of a dentist or doctor, but federal law prohibits the sale or distribution of it for recreational consumption.]

Aug. 7, 2008 - Sky News

Matt McGrath, Senior Broadcast Journalist at the British Broadcasting Corporation (BBC), in a July 21, 2008 BBC News article titled "Concerns Over Olympic Drug Test," stated the following:
"[A] growing problem is the rise of copycat versions of EPO [7.d]. Because the medicine has been so successful financially, companies in India, China and Cuba have developed drugs that do a similar job in the body, but have a slightly different molecular fingerprint. These cheap versions of EPO, often called biosimilars [1], can be easily bought over the internet... Some scientists who track and monitor the development of copycat EPO drugs say there could be up to 80 different versions now being manufactured in different parts of the world."

July 21, 2008 - Matt McGrath

Mark Fainaru-Wada, Investigative Reporter for ESPN, and Lance Williams, MA, Investigative Reporter for the Center for Investigative Reporting, wrote the following in their 2006 book Game of Shadows: Barry Bonds, BALCO and the Steroids Scandal That Rocked Professional Sports:
"The Cream [4] [a testosterone-based ointment distributed by BALCO] was designed to mask the use of other steroids. It was a mixture of synthetic testosterone and epitestosterone. Epi, as it was known in the drug-testing culture, was present in the body but had no known function. [The Cream] helped the athlete maintain a normal ratio and it concealed what otherwise would be a telltale sign of the use of an undetectable steroid: an abnormally low testosterone level. When a person takes steroids, the body stops producing testosterone to the point that it can bottom put at zero. A zero level would set off red flags for drug testers, but The Cream elevated testosterone enough to avoid suspicion."

July 21, 2008 - Mark Fainaru-Wada Lance Williams, MA

The Canadian Broadcasting Corporation (CBC), in its July 27, 2006 "Sports" website section titled "TOP 10 Notable Drug Scandals - Doping & Drug Infractions that Rocked the Sports World," offered the following:
"During the 1996 Atlanta Olympic Games. Michelle Smith was the pride of Ireland after winning three gold and one bronze medal in the pool... After her Olympic success, it was discovered that FINA, swimming's international federation, had repeatedly expressed concern that Smith was unavailable for out-of-competition drug tests from 1995 onward. Finally, in 1998, two drug testers showed up at Smith and de Bruin's home. Smith gave them a sample, but because she was wearing a bulky sweater, the tester couldn't see what she was doing. The sample was sealed and sent to a Barcelona lab for examination. The results were shocking. The sample contained a level of alcohol that would be fatal if consumed by a human. FINA concluded that the sample had been manipulated, that whiskey had been added as a masking agent [10]...

Attention cross-country skiers: If you want to cheat, you may not want to leave that blood-transfusion [2.b] equipment lying around your house. That's what some members of the Austrian cross-country ski team did at the Salt Lake City Olympic Games. The IOC began an investigation after a cleaner found blood-transfusion materials in a residence used by the Austrians during the Games. The team's results were reassessed, and after a three-month investigation, two athletes (non-medallists) were disqualified and two team officials were banned from the next two Winter Olympics. The Austrians claimed the equipment was used for ultraviolet radiation treatment of athletes' blood to treat and prevent colds and flu, not for performance-enhancing purposes."

July 27, 2006 - Canadian Broadcasting Corporation (CBC)

David R. Mottram, PhD, Professor of Pharmacy Practice at Liverpool John Moores University, in his 2003 book titled Drugs in Sport, wrote the following:
"Anecdotal evidence of urine substitution [19.b], catheterization [3] [insertion of a tube into the bladder via the urinary tract to drain or inject urine] and in some cases actually having the sample provided by impostors threatened the effectiveness of the testing system. Athletes also tried to use substances to inhibit renal excretion, such as Probenecid [13] and to titrate testosterone/epitestosterone [18] levels in the body... Significantly, very few cases of manipulation are ever confirmed as doping offences, indicating perhaps the difficulty of presenting evidence.

The most well-known case to have been heard was that involving Katrin Krabbe, Silke Muller and Grit Breuer, whose urine samples provided during a training session in South Africa bore such a similarity it led to the allegation that they had been provided by the same person. Evidence brought forward at the disciplinary hearing in London in June 1992 concluded that the same individual probably had provided the samples and that an opportunity had existed for the athletes to catheterize urine from another person prior to the sample collection."

2003 - David R. Mottram, PhD

[Editor's Note: ProCon.org thanks Dr. Tom Werner, Professor Emeritus of Chemistry at Union College, for providing us with research for use in this presentation.]