Dear Dr. Dawn;I am a Type 1 diabetic cyclist and I use an insulin pump to control my blood sugars.

I keep reading about Marco Pantani being suspended for having insulin in his possession. How is insulin used as a performance enhancer? When I’m riding my pump is delivering little to no insulin to keep my sugars from going too low (bonk). I thought I knew how it worked – what’s up? -- Chris Erickson

Dear Chris;
Before I get into specifics of the role of insulin in doping, let me first take a position on doping in general as a physician. When I graduated from medical school I took the Hippocratic oath, which requires me to keep people from harm and injustice. It includes phrases like, ”I will neither give a deadly drug to anybody who asked for it nor will I make a suggestion to this effect,” and “I will prevent diseases where I can.” That being said, it seems that every town has its “Dr. Feelgood.” I know mine does. Every drug addict in town lists him as their primary-care physician. They are all on prescription Oxycontin, Klonopin, Dilaudid, etc. And even with a pharmacopia of “legal” prescriptions, their urine tests for illicit drugs usually light up like a Christmas tree.

I probably spend an hour per shift tending to their medical problems, such as overdoses, withdrawal, hepatitis C, complications from HIV, life-threatening infections from needle use, etc. Sometimes Dr. Feelgood is so busy handing out pills that he misses serious medical conditions in his patients. I’ve even seen some delayed diagnosis of cancers.

These doctors eventually get shut down by their state licensing boards, but not before they have spread misery, addiction and illness for years, all in the name of making a buck. They are one-man shows and have admitting privileges at no hospitals because they don’t know how to take care of sick people. When our previous Dr. Feelgood was run out of town about four years ago, our ER became a combat zone of angry and desperate drug withdrawal.

While addicts have their lines on doctors, so do unethical athletes. In many cases, these are the same doctors. If you obtain insulin or another performance-enhancing pharmaceutical from one of these quacks, does it make you feel safer that you obtained it ”legally?” Is your team doctor interested in your long-term health or simply results in the next race while putting you in harm's way?

Sad to say, in some circles, pro cycling and other endurance sports take a lot of doping cues from the world of professional bodybuilding, and insulin is the new flavor-of-the-month in endurance sports doping.

The dope on insulin
Before I try to explain the premise behind insulin and doping, let me first state a disclaimer: I suffered terribly through my endocrinology, pharmacology and biochemistry classes as a medical student and passed them largely by cramming. I am by no means an academic expert. I can follow the academic conversations pretty well without visibly moving my lips. My experience is clinical. I treat complications of insulin use among diabetics on a daily basis. I’m going to explain it as best I can and then focus on all the things that can go terribly wrong with insulin use and abuse.

In the illicit parts of the bodybuilding world, insulin is most often abused during a steroid "crash cycle" in a dangerous attempt to maintain muscle mass, and has a reputation as the “ultimate anabolic,” according to my sources at U.S. Antidoping.

Insulin is sometimes abused concomitantly with various anabolic steroids and growth hormone during ‘roid cycles. Sometimes really scary hazardous industrial chemicals like dinitrophenol are added to the mix to burn fat while maintaining muscle mass between cycles. These toads are the same geniuses that brought us Gamma-hydroxy-butyrate (GHB) - the notorious date-rape drug - as a sleep-inducing agent that purportedly spikes growth hormone. I have put several GHB overdose bodybuilders on life support.

Here’s their twist on better living through chemistry: Insulin supports glucose uptake out of the bloodstream and into the cells, especially to muscle and liver, where it is stored as glycogen. It also drags protein into the muscle cells along with the glucose.

We all know glycogen is our friend, and more muscle mass to a degree is helpful in our sport. Hypoglycemia leads to an elevation in growth hormone, and insulin causes hypoglycemia. Growth hormone equals muscle mass. Sounds good so far. Your pancreas produces insulin naturally unless you are a diabetic. Your pancreas takes perfectly adequate care of this insulin, glucose and protein job all by itself when you eat or drink a recovery protein shake after a workout.

When you sleep, growth hormone spikes, and insulin levels help muscles recover, repair and build. Now, here’s the downside. The IOC banned insulin use among non-diabetics in 1998. Humalog is the insulin-abuse drug of choice because it is derived from human DNA, has a short half-life and cannot yet be detected by a test. My diabetic Cat. 4 professor training buddy joked that Lilly, the manufacturer, really ought to add an extra protein that makes your urine turn blue. To get busted now the drug patrol has to pop you in possession of insulin, like they did Marco Pantani at the 2001 Giro.

Pantani had already been booted from the 1999 Giro with a high ‘crit, suggestive of EPO abuse, which was not then but is now easy to detect in a drug test. He’s tiny and could use some muscle mass for time trials. If the insulin-tainted syringe was his (he maintains it wasn’t), it could have been part of an attempt to give nature a helping hand and boost muscle mass. It’s doubtful that he would be using insulin without growth hormone and steroids. The prospect of emaciated, diminutive Pantani in a ‘roid rage would be terribly amusing were it not so damn sad. One of the biggest risks you face if you dabble in insulin abuse is that a hypoglycemic reaction (low blood sugar) can result in death, coma, brain damage or an epileptic fit. I read a case report of a 30-year-old bodybuilder who injected a high dose of insulin before a competition and went into a coma with seizures. He did not respond to intravenous push dextrose or a dextrose drip. He ended up on life support in an intensive-care unit. Darwin award.

Hypoglycemic reactions happen sometimes to seasoned intelligent diabetics, so what makes you, an amateur, so special? Diabetics like our curious diabetic friend Chris take insulin to stay alive, and have to live with the risks. Most of us don’t.

A milder hypoglycemic reaction will include confusion, sweating and unconsciousness. You might be too confused to call 911. If the EMTs find you they’ll have no idea you’ve taken insulin since you’re not a known diabetic, and may not be sharp enough to give you dextrose just in case. I’m one of the EMS medical directors for my city and I see this oversight all the time.

I’ve certainly been horrified on more than one occasion to get a call from the lab that the stroke victim or passed-out drunk I thought I had diagnosed correctly was really suffering from hypoglycemia. They all woke up two minutes after I administered dextrose. Oops.

Other than hypoglycemic reactions, you can expect complications from needle use. Cellulitis is a dangerous skin infection that can lead to a hospitalization on antibiotics or become a potentially fatal blood infection known in layman’s terms as "blood poisoning." The same germs that cause blood poisoning can take up residence on one of your heart valves. At best you’ll spend six weeks in the hospital on antibiotics. If that doesn’t work, you’ll get a plastic heart-valve replacement and be on blood thinners the rest of your life. Or you’ll die suddenly from the infected valve exploding.

Sharing is not always good
I have also encountered complications caused by the mentality of needle-doping bodybuilders that you could just as easily expect to happen to needle-doping cyclists. Sometimes insulin needles are hard to come by and you’ll end up taking a chance sharing a needle with a friend. Count on hepatitis C, HIV and other fun communicable diseases you thought only junkies could get. Doping bodybuilders overcome their natural fear, get a taste for needles and sometimes say, "What the hell, let’s try cocaine, meth or heroin." Party drug abuse is much higher among dopers.

Delayed complications of insulin abuse are yet to be determined. Keep an eye on aging bodybuilders because they’ll be the first to go since they are the ones that started this insanity.

For most of us our physiological ordinariness is what puts an end to our dreams of greatness. It’s best to accept it and leave it at that. It is not worth the risk to your health to try to make a silk purse out of a sow’s ear by doping. You’ll also privately hate yourself for cheating and winning, and you know it. Stay away from doping products, needles, sketchy supplements and quacks. Your goal here is to live a long and healthy life, and doping just is not safe or ethical.As for you, Chris, if you keep cycling, manage your weight, eat a healthy diet, and micromanage your blood sugars with your insulin pump, you can expect to live a long, healthy life.

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Dawn Richardson is a board certified emergency medicine physician in practice at Saint Anne’s Hospital in Fall River, Massachusetts. She is frequent contributor to SG: surf snow skate girl magazine, and is interested in health-related issues for cyclists, and women’s health. She welcomes medical questions pertaining to cycling, bearing in mind that if it ain’t emergency medicine she may have to do some work to figure out an answer. Please send your questions or issues to "Ask the Doctor" in care of WebLetters@7Dogs.com.Important Notice:
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