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Understanding Two Categories of Appearance and Performance Enhancing Drugs, Substances

By Bill Heinz, M.D. on October 09, 2017 hst Print

Earlier this year, a position statement concerning Appearance and Performance Enhancing Drugs and Substances (APEDS) was approved by the NFHS Sports Medicine Advisory Committee (SMAC). This position statement is slightly different from the traditional position statements approved by the SMAC, in that it applies to athletes and non-athletes, and it contains a very honest and frank discussion concerning the use of APEDS.

In the past, the medical community has not been entirely honest to the lay community about the potential benefits from the use of APEDS, instead focusing on the side effects and dangers of their use. Unfortunately, this eventually led to a level of mistrust in athletes when the use of APEDS was discussed with them by health-care providers. The hope with the current position statement concerning APEDS was to provide accurate information about the hazards and potential benefits associated with the use of APEDS, and avoid the “Reefer Madness” commonly described with APEDS use and their side effects.

To accomplish this task, it helps to think of APEDS as divided into two broad categories:

1.) Legal, not banned for competition, and may have positive effects upon athletic performance. 

2.) Legal only when prescribed by a physician, illegal to possess without a prescription, can have a positive effect on athletic performance, banned by the NCAA, the United States Anti-Doping Agency (USADA) and
the World Anti-Doping Agency (WADA).

The category of “legal, not banned for competition and may have positive effects on athletic performance” includes substances such as protein powders, amino acids, caffeine and creatine. Studies have shown these products to be relatively safe, as long as they are used properly. It is highly recommended that if a student decides to use these, they do so under the guidance and supervision of a knowledgeable health-care provider.

Studies have shown that almost 40 percent of high school students report a history of protein supplement use, and that 18 percent of APEDS users in high school do not participate in sports. It is considered that this group uses APEDS for appearance enhancement, such as weight loss or gain. This category of APEDS is legal and is not banned in competition. However, their use can come with unwanted side effects and dangers. None of these products are regulated or routinely tested for efficacy or purity by the U.S. Food and Drug Administration (FDA).

Independent studies have found eight to 25 percent of these substances to be contaminated by heavy metals (such as lead and mercury), anabolic-androgenic steroids and/or stimulants. Caffeine is in a unique category, in that the FDA regulates the amount of caffeine allowed in foods and soft drinks, but not the amount allowed in energy drinks or supplements. This would explain why there can be dangerous levels of caffeine intake with the ingestion of multiple energy drinks. In fact, in 2011, almost 1,500 middle school and high school-aged children were treated in emergency departments for caffeine toxicity.

The second category of APEDS (legal only when prescribed by a physician, illegal to possess without a prescription, can have a positive effect on athletic performance, banned by the NCAA, USADA and WADA) contains substances such as anabolic-androgenic steroids (AAS), AAS prohormones (a precursor to the active form of the hormone or steroid), human growth hormone and stimulants (such as Ritalin and Adderall).

In this category, AAS and AAS prohormones are the most widely known. They work by enhancing protein synthesis and decreasing the breakdown of muscle. The net effect is to allow an increase in muscle size and strength, along with a quicker recovery after workouts. Hence, these substances are effective, but their use can come at a very high cost. If used during adolescence, they can cause premature closure of the growth plates and a decrease in final adult height. Other common side effects include cardiovascular disease, blood clots, stroke and an increased risk of suicide.

Just as important, the use of AAS and AAS prohormones is illegal without a prescription and their use is considered to be unethical, unfair and a form of cheating in athletics. This can pose a significant threat to the overall health and well-being of students and undermines the values we are trying to teach them while in high school.

Education about APEDS continues to be the hallmark to preventing their use. Despite advances in the detection of APEDS, random testing has not been proven to be an effective deterrent to their use. This education requires a concerted effort by school administrators, coaches, parents and medical personnel to not only educate students, but also speak out strongly against the use of APEDS.

Many resources are available to help with this effort, and are listed in the references below. In addition, a free course on APEDS is available through the NFHS Learning Center at www.NFHSLearn.com.

The use of APEDS by high school students is real, and statistics indicate that they are being used by your students, at your school. Education about APEDS, including accurate information concerning the effects, the side effects and dangers, and speaking out against such use is key in helping to reduce APEDS abuse. Talk with your students about their sports performance or appearance, and help them to understand that using banned and/or illegal APEDS is unfair, unethical and very likely dangerous to their health and well-being.


NFHS SMAC Position Statement on Appearance and Performance Enhancing Drugs and Substances http://www.nfhs.org/media/1018447/nfhs_position_statement_apeds_april_2017.pdf.

LaBotz M, Griesemer BA, AAP Council on Sports Medicine and Fitness. Use of Performance-Enhancing Substances. Pediatrics. 2016;138(1): e20161300.

Maughan RJ. Quality assurance issues in the use of dietary supplements, with special reference to protein supplements. J Nutr. 2013;143(11): 1843S-1847S.

Eisengerg ME, Wall M, Neumark-Sztainer D. Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics. 2012;130(6):1019-1026.

Taylor Hooton Foundation http://www.taylorhooton.org.

ATLAS and ATHENA Health Promotion and Substance Abuse Prevention. http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinicaldepartments/medicine/divisions/hpsm/research/atlas.cfm.

The National Center for Drug Free Sport, Inc. http://www.drugfreesport.com.