An open dialogue about the problem of doping has been, up to this point, the third rail of cycling. Touch it and you die. The culture insists that anyone wishing to continue working in the sport remain silent on the issue, which perpetuates the problem.

But the tide appears to be turning. Team managers and riders are not being immediately fired for admitting a prior history of doping in the era before EPO testing. Breaking the silence is a huge step towards solving the problem. As the biggest names in the sport are falling, the anti-doping movement seems to be throwing a haymaker at the doping culture.

Sadly, doping continues, but its hold on cycling and other sports is weakening. UCI, WADA and USADA are catching dopers, and these successes are beginning to dictate team management. The culture is shifting away from the two most common doping models: the “if you ain’t cheatin’, you ain’t tryin’” doping infrastructure within a team or a “don’t ask, don’t tell” obliviousness. The most innovative management approach is medical testing within the team structure itself to discourage doping, as takes place at T-Mobile, or Slipstream’s third-party testing through the Agency for Cycling Ethics.

For team physicians who wish to work ethically, doping is our worst nightmare. Team doctors aren’t cops or lawyers, nor should we be. Our job is to keep the athletes healthy so they can perform to the best of their natural ability. As ethical anti-doping physicians our influence and expertise should be used to prevent doping through education and intervene when we encounter it. Some of us are organizing our efforts in these areas and others as the American Association of Cycling Team Doctors.

But in order to help solve the problem of doping, I figured I first had to understand it. So I went straight to the source — to reformed dopers themselves, some caught and some not, some active and some retired.

I’d like to make it clear that I don’t sympathize with dopers, nor do I think the punishment for a doping offense should be significantly altered. I do, however, think that the current WADA punishment-only system may throw the baby out with the bathwater. I believe that dopers can and should be rehabilitated. I would far rather have a reformed doper on my team, sharing his horrific experiences as a cautionary tale to his teammates, than to have an active doper glamorizing and promoting drug abuse.

My background is unusual and offers me the perspective to draw the conclusions that I am about to share. I have an undergraduate degree in psychology and intended to pursue psychiatry when I enrolled in medical school, but found emergency medicine more interesting when choosing a specialty. For 10 years I have served on the Rhode Island Medical Advisory Board of the Registry of Motor Vehicles. We oversee reinstatement of licenses to convicted drunken drivers. We compel repeated drunken drivers into treatment for alcoholism and require a year of sobriety before they can get their licenses back. This supports the state’s judical process, and it seems to be helping reduce recidivism. I serve on the Medical Advisory Board for the Rhode Island Workers Compensation Court, another collaboration between the legal system and the medical community. And I work in the emergency department of Roger Williams Medical Center, known for a strong addiction medicine and dual-diagnosis rehabilitation program.

For four years I’ve been privately interviewing professional cyclists who are in recovery from doping so that I might better understand what draws them to dope and what happens to them once they’ve gone to the dark side. I’m able to ask the questions nobody else can and hope to get honest answers because as a doctor I cannot and would not violate medical confidentiality. I’ve been privileged to learn from several athletes about their motivations and pressures as well as the medical problems they suffered as a result of their abuse of performance-enhancing drugs. These athletes aren’t permitted under current WADA/USADA code to speak publicly about their personal experiences of doping without fear of suspension. I can, however, share what I’ve learned without naming names.

The athletes described the doping culture in frightening detail. They outlined how doping can exist within a team infrastructure. Another athlete described a Mafia-like secret society that perpetuates doping and infects clean teams. I had never heard of Aranesp before a recovered rider explained its pharmacology to me.

While doping these riders lost a sense of the future and the consequences of their behavior. They described an exciting feeling of belonging to something, and an us-against-them camaraderie, not unlike the mentality of the so-called recreational drug culture.

I’ve been told that some foreign riders have come to the United States to escape a worse doping culture in their own countries, to be able to race in a team environment that supports clean riding. The same holds true for Americans returning to domestic teams after experiencing a worse doping culture on foreign-based squads. This is encouraging to hear.

Most surprising was the disclosure of common and long-lasting mental illness and frequent substance abuse among dopers. Some had alcohol- or substance-abuse histories before professional cycling. None was treated for mental illness until after doping. Those with substance-abuse histories escalated or started while doping. There was often a family history of addiction. They described an overwhelming and lingering psychological burden from their participation in doping that reminded me of Raskolnikov in “Crime and Punishment.” Some were relieved when they were caught, as it seemed the only way out of “the club.” I have heard more than once, “I’d be dead if I continued doping.”

And they’re not exaggerating. Marco Pantani and José Maria Jiminez were top athletes who died at what should have been the peaks of their careers as a result of doping, cocaine abuse and mental illness.

It made me wonder. From strictly a medical perspective, is doping simply a subvariant of substance abuse? Substance abuse and mental illness together are called “dual diagnosis” in psychiatric parlance because they go hand-in-hand.

One athlete said it better than I can:

“I would have to say the situation in pro cycling has always made me depressed and feeling bipolar, but I didn't try to commit suicide until after I did testosterone … I never smoked pot until after I did testosterone. It was instructed to me to use mary jane to relax my muscles after the ‘roids. Then came alcohol abuse, sex, drugs, and rock and roll.”

Another athlete described the use of opiates to mask pain and amphetamines to boost performance. The initial intent was performance enhancement, but these are addictive drugs whose users can find themselves forced to seek treatment in drug rehabilitation facilities.

Why is there so much mental illness and substance abuse related to doping? What can be done about it? If mental illness correlates with doping as I suspect, I worry even more about the long-term health of the athletes. I’m particularly alarmed by the studies that show life expectancy reduced by 25 years among those with mental illness. That is more than anyone bargains for when succumbing to the temptation to dope.

Can an athlete with a doping history quit using performance-enhancing substances and race clean with the support of a well-established dual-diagnosis treatment model in conjunction with the deterrent pressure of the WADA/USADA legal process? Can it be controlled with the 12-step model of addiction treatment used in Alcoholics Anonymous and Narcotics Anonymous?

Should team doctors recommend mental-health screening and counseling for their athletes with a history of doping? Might this be another technique to be added to an innovative new anti-doping team management style? Should WADA/USADA compel suspended athletes into mental-health counseling to rebuild their lives and reduce recidivism? Can athletes use a 12-step-based program to help each other?

Other sports are starting to study the lifelong health consequences for retired athletes. The NFL has established the Center for Retired Athletes. Their work discovered an increased risk of Alzheimer’s disease with repeated concussions.

My observations are not a scientific study. They might be considered more as a collection of case studies. Will sports-medicine research ultimately find a scientific link between cycling doping, substance abuse and mental illness? Will treatment strategies be developed and proven effective in the rehabilitation of athletes from doping? Serotonin reuptake inhibitors, such as Prozac, have shown some benefit to bodybuilders suffering from depression related to steroid withdrawal. I have heard of similar benefit in speaking with reformed dopers.

Some recovering dopers are still competing and functioning well, both on the bike and psychologically. They can speak privately to teammates to educate them about the personal cost of doping. All riders can exert peer pressure not to dope. Removing the veil of secrecy surrounding doping can only help solve the many problems it causes.

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Dawn Richardson is a former member of the Verizon Wireless-Cervelo Women's Cycling Team. She is a board-certified emergency medicine physician practicing at Roger Williams Medical Center in Providence, Rhode Island, and is a clinical instructor in emergency medicine at Brown Medical School. Send your questions to her at webletters@insideinc.com.Important note
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