Wastewater-based tracing of doping use by the general population and amateur athletes

Prevalence of Drug Use in Ultraendurance Athletes

PURPOSE

In competitive sport, classic methods of measuring drug prevalence, such as doping controls or questionnaires, are challenging. Here we describe a novel urine sampling method to measure drug use in athletes. We hypothesize that the prevalence of drug use in ultramarathon runners is measured more accurately with our sampling method than randomized-response questionnaires.

METHODS

Urine samples and associated demographic data were collected from male participants using blind, automated urinals at the start of ultramarathon races. Various nonprohibited and prohibited substances were subsequently screened. Concomitantly, 2931 male and female runners participating in the same ultramarathons completed an anonymized, randomized-response questionnaire regarding drug use.

RESULTS

Among 412 individual urine samples, 205 (49.8%) contained at least one substance, and 16.3% of the samples contained one or more prohibited substances. Substances detected in urine included nonsteroid anti-inflammatory drugs (NSAID) (22.1%), acetaminophen (15.5%), opioids (6.6%), diuretics (4.9%), hypnotics (4.4%), glucocorticoids (2.7%), beta-2 agonists (2.2%), cannabinoids (1.9%), and stimulants (1.2%). None of the samples contained erythropoietin-receptor agonists or suspicious testosterone. Drug use was not associated with the participants' characteristics or ranking. Respondents to the questionnaire reported using acetaminophen (13.6%) and NSAID (12.9%); however, no prohibited substances were declared.

CONCLUSIONS

There was a high prevalence of drug use among male ultramarathon runners, in particular, NSAID and painkillers; however, performance-enhancing drugs were marginally used. Blind urine sampling highlighted prohibited drug use not declared in questionnaires, and it is useful to assess the prevalence of drug use and/or doping in competitive athletes.

A rapid synthesis of molecularly imprinted polymer nanoparticles for the extraction of performance enhancing drugs (PIEDs)

It is becoming increasingly more significant to detect and separate hormones from water sources, with the development of synthetic recognition materials becoming an emerging field. The delicate nature of biological recognition materials such as the antibodies means the generation of robust viable synthetic alternatives has become a necessity. Molecularly imprinted nanoparticles (NanoMIPs) are an exciting class that has shown promise due the generation of high-affinity and specific materials. While nanoMIPs offer high affinity, robustness and reusability, their production can be tricky and laborious. Here we have developed a simple and rapid microwaveable suspension polymerisation technique to produce nanoMIPs for two related classes of drug targets, Selective Androgen Receptor Modulators (SARMs) and steroids. These nanoMIPs were produced using one-pot microwave synthesis with methacrylic acid (MAA) as the functional monomer and ethylene glycol dimethacrylate (EGDMA) as a suitable cross-linker, producing particles of an approximate range of 120-140 nm. With the SARMs-based nanoMIPs being able to rebind 94.08 and 94.46% of their target molecules (andarine, and RAD-140, respectively), while the steroidal-based nanoMIPs were able to rebind 96.62 and 96.80% of their target molecules (estradiol and testosterone, respectively). The affinity of nanoMIPs were investigated using Scatchard analysis, with Ka values of 6.60 × 106, 1.51 × 107, 1.04 × 107 and 1.51 × 107 M-1, for the binding of andarine, RAD-140, estradiol and testosterone, respectively. While the non-imprinted control polymer (NIP) shows a decrease in affinity with Ka values of 3.40 × 104, 1.01 × 104, 1.83 × 104, and 4.00 × 104 M-1, respectively. The nanoMIPs also demonstrated good selectivity and specificity of binding the targets from a complex matrix of river water, showing these functional materials offer multiple uses for trace compound analysis and/or sample clean-up.

Detection of emerging patterns of drug misuse in sports via wastewater monitoring: A mini-review and potential strategies

Biological testing is a key component of the current anti-doping programme implemented by the authorities to detect doping in sports. Strategies such as longitudinal individualised data analysis and sport-specific analysis have been developed to increase the comprehensiveness of the testing. However, the trends of drug misuse in sports might not be effectively captured through today's testing plan. Wastewater testing, assembling individual-level data of a designated group to produce population-level results in one single aggregated sample, can be employed to as a complementary strategy offering added value for doping control. This paper presents an updated summary of the status of anti-doping testing and analytical methodologies for wastewater. The available literature on wastewater-based analyses of drugs prohibited in sports is reviewed. Publications surrounding sporting activities or competitions and others relevant to sports doping are selected. We debate between potential strategies and major limitations of using wastewater monitoring in anti-doping. Knowledge gaps and research directions, specifically on metabolites, stability, sensitivity, and ethical and legal considerations, are discussed. Choosing different wastewater sampling sites allows target sub-population that involved competing athletes and potentially reveal sport-specific or athlete-level-specific behaviour. Sampling from on-board toilets or athlete villages could target international-level athletes, sampling from the dormitories of national training centres allows monitoring of national-level athletes on a daily basis, and sampling from sports stadiums provides a full picture of drug use in the general population during an event. Confounding occurs as (i) the presence of non-athlete composition and the difficulty of analyses to be completely selective to the athlete population; and (ii) the identification of compounds prescribed legitimately with Therapeutic Use Exemptions, only banned in-competition, and naturally occurring. The practicalities of the approach are contextualised in monitoring the non-threshold substances such as anabolic agents, selective androgen receptor modulators, metabolic modulators, and hypoxia-inducible factor activators.

Assessment of the excretion of oxidative stress biomarkers and anabolic steroids based on sewage: A case study of college students and the general population

The use of wastewater-based epidemiology to evaluate the health and lifestyle of the population is a novel research interest. However, studies concerning the excretion of endogenous metabolites due to oxidative stress and the consumption of anabolic steroids have rarely been involved. In this study, we compared the effects of events such as final examination and sports meeting on the levels of four oxidative stress biomarkers (8-isoPGF_2α, HNE-MA, 8-OHdG, and HCY) and four prohibited anabolic steroids (Testosterone, Androstenedione, Boldenone, and Metandienone) in sewage, using university students and urban populations as studying target. It was found that the per capita mass load of the four oxidative stress biomarkers 8-isoPGF_2α, HNE-MA, 8-OHdG, and HCY in the sewage of Guangzhou urban area and university town were 256.6 ± 76.1, 9.4 ± 3.8, 1.1 ± 0.5, and 0.9 ± 0.4 mg/d/1000, respectively. The mean mass load of 8-isoPGF_2α was significantly higher than that before the COVID-19 pandemic (74.9 ± 29.6 mg/d/1000 people, P < 0.05). The per capita load levels of oxidative stress biomarkers were significantly higher (P < 0.05) during the 2022 exam week relative to the pre-exam period, indicating that the exams caused transient stress to students. The per capita mass load of androgenic steroids was 77.7 mg/d/1000 people. There was an increase in the per capita load level of androgenic steroids during the provincial sports meeting. In this study, we quantified the concentration of oxidative stress biomarkers and androgenic steroids in the sewage and better realized the application of WBE on the health level and lifestyle of the population during special events.

Efficient Validation Strategies in Environmental Analytical Chemistry: A Focus on Organic Micropollutants in Water Samples

This article critically reviews analytical method validation and quality control applied to the environmental chemistry field. The review focuses on the determination of organic micropollutants (OMPs), specifically emerging contaminants and pesticides, in the aquatic environment. The analytical technique considered is (gas and liquid) chromatography coupled to mass spectrometry (MS), including high-resolution MS for wide-scope screening purposes. An analysis of current research practices outlined in the literature has been performed, and key issues and analytical challenges are identified and critically discussed. It is worth emphasizing the lack of specific guidelines applied to environmental analytical chemistry and the minimal regulation of OMPs in waters, which greatly affect method development and performance, requirements for method validation, and the subsequent application to samples. Finally, a proposal is made for method validation and data reporting, which can be understood as starting points for further discussion with specialists in environmental analytical chemistry.

Wastewater-based epidemiology for comprehensive community health diagnostics in a national surveillance study: Mining biochemical markers in wastewater

This manuscript showcases results from a large scale and comprehensive wastewater-based epidemiology (WBE) study focussed on multi-biomarker suite analysis of both chemical and biological determinants in 10 cities and towns across England equating to a population of ∼7 million people. Multi-biomarker suite analysis, describing city metabolism, can provide a holistic understanding to encompass all of human, and human-derived, activities of a city in a single model: from lifestyle choices (e.g. caffeine intake, nicotine) through to health status (e.g. prevalence of pathogenic organisms, usage of pharmaceuticals as proxy for non-communicable disease, NCD, conditions or infectious disease status), and exposure to harmful chemicals due to environmental and industrial sources (e.g. pesticide intake via contaminated food and industrial exposure). Population normalised daily loads (PNDLs) of many chemical markers were found, to a large extent, driven by the size of population contributing to wastewater (especially NCDs). However, there are several exceptions providing insights into chemical intake that can inform either disease status in various communities or unintentional exposure to hazardous chemicals: e.g. very high PNDLs of ibuprofen in Hull resulting from its direct disposal (confirmed by ibuprofen/2-hydroxyibuprofen ratios) and bisphenol A (BPA) in Hull, Lancaster and Portsmouth likely related to industrial discharge. An importance for tracking endogenous health markers such as 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA, an oxidative stress marker) as a generic marker of health status in communities was observed due to increased levels of HNE-MA seen at Barnoldswick wastewater treatment plant that coincided with higher-than-average paracetamol usage and SARS-CoV-2 prevalence in this community. PNDLs of virus markers were found to be highly variable. Being very prevalent in communities nationwide during sampling, SARS-CoV-2 presence in wastewater was to a large extent community driven. The same applies to the fecal marker virus, crAssphage, which is very prevalent in urban communities. In contrast, norovirus and enterovirus showed much higher variability in prevalence across all sites investigated, with clear cases of localized outbreaks in some cities while maintaining low prevalence in other locations. In conclusion, this study clearly demonstrates the potential for WBE to provide an integrated assessment of community health which can help target and validate policy interventions aimed at improving public health and wellbeing.

The burden of city's pain treatment - A longitudinal one year study of two cities via wastewater-based epidemiology

This paper explores Wastewater-Based Epidemiology (WBE) as a tool enabling understanding of city's pain treatment in an intercity longitudinal study. An intensive 13-month monitoring programme was undertaken in two adjacent urban areas in South-West England: a small commuter town Keynsham and the city of Bath (>180 samples collected). The study has shown a great potential of using triangulated WBE and National health Service (NHS) prescription data in understanding pain treatment in two contrasting communities with strong apparent seasonal patterns of short pain medications vs chronic pain treatment as well as the type of treatment used (e.g. oral vs topical). Community-wide usage of Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and paracetamol in the intercity study is population size and season driven with the highest usage recorded in winter months. This contrasts with other pain pharmaceuticals, especially those used for chronic pain, where no/limited seasonal usage was recorded. Unmetabolized NSAIDs are, to a large extent, directly disposed of into the sewerage system bypassing metabolism due to their topical application. This is particularly apparent in winter months with naproxen showing the highest seasonal variability. Pharma/met (ratio of pharmaceutical and its metabolite concentration) analysis allows for tracking topical (non-metabolic) application/down-the-drain disposal of pharmaceuticals with frequent instances of direct disposal of NSAIDs into the sewerage system observed. Normalisation of pharma markers to population size shows comparable estimates of pharma usage in the two cities confirming population as the main driver of pharma loads in wastewater. Variable application patterns of pain pharmaceuticals make back-calculation of intake more convoluted. Intake calculated using percentage excretion of parent NSAIDs will likely lead to overestimation, as it is assumed that NSAIDs are subject to extensive metabolism (this is not the case for topical applications). Intake calculated using percentage excretion of metabolites (or parent compound) as consumption markers leads to underestimation of NSAIDs usage due to contributions from topical application not being accounted for. Prescription data indicates cumulative internal and topical usage, but the data ignores large proportion of over-the-counter usage. Therefore, we have proposed a combined approach allowing for estimation of total usage including, and differentiating between, topical application and oral administration.

Recreational Athletes' Use of Performance-Enhancing Substances: Results from the First European Randomized Response Technique Survey

BACKGROUND AND AIM

Measuring the prevalence of doping in recreational sport is difficult. However, to fit their initiatives, National Anti-Doping Organizations are interested in knowing the numbers, so their scarce resources are not wasted. The present study aimed to estimate the prevalence of doping and over-the-counter medicine use for performance enhancement among recreational athletes in eight European countries.

DESIGN

A survey covering + 200 sports aimed at recreational athletes 15 years and older was distributed via social media to sports clubs and individuals in eight European countries. To overcome social desirability bias, we applied indirect questioning by using the Randomized Response Technique and asked for the use of over-the-counter medicine and doping for the year 2019.

RESULTS

The prevalence of the use of over-the-counter medications for performance enhancement was estimated at 10.4%. We differentiated between the concept of "doping" as the behavior to enhance performance in a certain sport and the concept of "a doper" as a property of a person. The prevalence of dopers in recreational sport was found to be 0.4%, with 3.1% male and 0% female dopers. Responses were separated into four categories: "Artistic sports," "Combat sports," "Games," and "CGS sports" (i.e., sports measured in centimeters, grams, and seconds). The overall prevalence of doping in recreational sports was found to be 1.6%, and the results from Artistic and CGS sports did not differ significantly from this. However, in Games we found an estimated doping prevalence of 6.9%.

DISCUSSION

The estimates for the prevalence of dopers and doping in this study do not equal Anti-Doping Rule Violations as stipulated by the World Anti-Doping Agency. Still, while doping is not absent in recreational sport in Europe, it appears to be a low frequent phenomenon. Also, the differences in doping prevalence between the sports categories might reflect structural and competition-related differences, rather than differences in the logic of the sporting competition or discipline-related subcultures.

CONCLUSION

While few recreational athletes appear to use illegal drugs to enhance performance, those who do use them are more often men than women. Yet, 1 in 10 recreational athletes uses over-the-counter medication for performance enhancement and more than 4 out of 10 use medication for other reasons than performance enhancement when doing sports. The highest doping prevalence was found in the sub-category of Games, which can likely be attributed to competition-related differences between the categories. Therefore, research on doping in recreational sports needs tailored approaches to come to a better understanding of the phenomenon.

Wastewater research and surveillance: an ethical exploration

The current COVID-19 pandemic has given wastewater research a huge impetus. While wastewater research has some promising applications, there are as yet no well-developed ethical guidelines on how and under what conditions to use wastewater research. The current perspective paper aims to explore the different ethical questions pertaining to wastewater research and surveillance and to provide some tentative guidelines on the desirability of different types of applications. This paper shows that wastewater research offers interesting possibilities, but that legal regulation and ethical guidelines are still lacking, while there are ethical risks involved. The perspective indicates that it is important to look beyond the regulation of data collection and to shift the focus to the question how the analysis and use of wastewater data can be supervised.

Human population as a key driver of biochemical burden in an inter-city system: Implications for One Health concept

This paper tests the hypothesis that human population and city function are key drivers of biochemical burden in an inter-city system, which can be used to inform One Health actions as it enables a holistic understanding of city's metabolism encompassing all of the activities of a city in a single model: from lifestyle choices, through to health status and exposure to harmful chemicals as well as effectiveness of implemented management strategies. Chemical mining of wastewater for biophysico-chemical indicators (BCIs) was undertaken to understand speciation of BCIs in the context of geographical as well as community-wide socioeconomic factors. Spatiotemporal variabilities in chemical and biological target groups in the studied inter-city system were observed. A linear relationship (R² > 0.99) and a strong positive correlation between most BCIs and population size (r > 0.998, p < 0.001) were observed which provides a strong evidence for the population size as a driver of BCI burden. BCI groups that are strongly correlated with population size and are intrinsic to humans' function include mostly high usage pharmaceuticals that are linked with long term non-communicable conditions (NSAIDs, analgesics, cardiovascular, mental health and antiepileptics) and lifestyle chemicals. These BCIs can be used as population size markers. BCIs groups that are produced as a result of a specific city's function (e.g. industry presence and occupational exposure or agriculture) and as such are not correlated with population size include: pesticides, PCPs and industrial chemicals. These BCIs can be used to assess city's function, such as occupational exposure, environmental or food exposure, and as a proxy of community-wide health. This study confirmed a strong positive correlation between antibiotics (ABs), population size and antibiotic resistance genes (ARGs). This confirms the population size and AB usage as the main driver of AB and ARG levels and provides an opportunity for interventions aimed at the reduction of AB usage to reduce AMR. Holistic evaluation of biophysicochemical fingerprints (BCI burden) of the environment and data triangulation with socioeconomic fingerprints (indices) of tested communities are required to fully embrace One Health concept.

In-Sewer Stability Assessment of Anabolic Steroids and Selective Androgen Receptor Modulators

Wastewater-based epidemiology is a potential complementary technique for monitoring the use of performance- and image-enhancing drugs (PIEDs), such as anabolic steroids and selective androgen receptor modulators (SARMs), within the general population. Assessing in-sewer transformation and degradation is critical for understanding uncertainties associated with wastewater analysis. An electrospray ionization liquid chromatography mass spectrometry method for the quantification of 59 anabolic agents in wastewater influent was developed. Limits of detection and limits of quantification ranged from 0.004 to 1.56 μg/L and 0.01 to 4.75 μg/L, respectively. Method performance was acceptable for linearity (R² > 0.995, few exceptions), accuracy (68-119%), and precision (1-21%RSD), and applicability was successfully demonstrated. To assess the stability of the selected biomarkers in wastewater, we used laboratory-scale sewer reactors to subject the anabolic agents to simulated realistic sewer environments for 12 h. Anabolic agents, including parent compounds and metabolites, were spiked into freshly collected wastewater that was then fed into three sewer reactor types: control sewer (no biofilm), gravity sewer (aerobic conditions), and rising main sewer (anaerobic conditions). Our results revealed that while most glucuronide conjugates were completely transformed following 12 h in the sewer reactors, 50% of the investigated biomarkers had half-lives longer than 4 h (mean residence time) under gravity sewer conditions. Most anabolic agents were likely subject to biofilm sorption and desorption. These novel results lay the groundwork for any future wastewater-based epidemiology research involving anabolic steroids and SARMs.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology

Performance- and image-enhancing drug (PIED) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology, and associated public health implications. An overview of WBE is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives, and recommendations for monitoring PIEDs in wastewater.

Tracing consumption patterns of stimulants, opioids, and ketamine in China by wastewater-based epidemiology

Illicit drug use has long been a key issue of international concern, and the true situation is unknown to the relevant authorities. To develop a profile of comprehensive consumption patterns of illicit drugs in China, data from 34 wastewater treatment plants in 25 cities were collected to analyze four classes of drugs, including amphetamine-type stimulants, opioids, ketamine, and cocaine. They were identified and quantified in samples using methods based on gas chromatography coupled to mass spectrometry. According to the wastewater-based epidemiology (WBE) approach, an analysis of the consumption pattern was performed regarding per inhabitant consumption based on the revised metabolic rate. The consumption quantity of illicit drug and precursor was divided into four categories based on statistical difference analyses: methamphetamine and ephedrine (precursor) were the predominant drugs in the first category, followed by ketamine and heroin in the second category, methcathinone and 3,4-methylenedioxymethamphetamine (MDMA) in the third category, and cocaine and methadone in the fourth category. There were distinctive spatial patterns: heroin and cocaine consumption was higher in Southern China than in Northern China, heroin consumption was higher in Western China than in Eastern China, and the consumption of each drug differed across seven regions of China, especially with ephedrine and methcathinone consumption higher in North China; heroin consumption higher in Southwest, Central, and Northwest China; and ketamine and MDMA consumption higher in East, South, and Central China. Compared with findings in previous studies, there were temporal patterns, in which ketamine consumption presented a downward trend but heroin remained stable. Based on correlation analyses, there were the polydrug abuse patterns between heroin and cocaine, methcathinone and ketamine, and cocaine and MDMA. In general, this study based on WBE provides a comprehensive evaluation of drug consumption in China.

Longitudinal wastewater sampling in buildings reveals temporal dynamics of metabolites

Direct sampling of building wastewater has the potential to enable "precision public health" observations and interventions. Temporal sampling offers additional dynamic information that can be used to increase the informational content of individual metabolic "features", but few studies have focused on high-resolution sampling. Here, we sampled three spatially close buildings, revealing individual metabolomics features, retention time (rt) and mass-to-charge ratio (mz) pairs, that often possess similar stationary statistical properties, as expected from aggregate sampling. However, the temporal profiles of features-providing orthogonal information to physicochemical properties-illustrate that many possess different feature temporal dynamics (fTDs) across buildings, with large and unpredictable single day deviations from the mean. Internal to a building, numerous and seemingly unrelated features, with mz and rt differences up to hundreds of Daltons and seconds, display highly correlated fTDs, suggesting non-obvious feature relationships. Data-driven building classification achieves high sensitivity and specificity, and extracts building-identifying features found to possess unique dynamics. Analysis of fTDs from many short-duration samples allows for tailored community monitoring with applicability in public health studies.

Wastewater Analysis for Community-Wide Drugs Use Assessment

Wastewater-based epidemiology (WBE) complements existing epidemiology-based estimation techniques and provides objective, evidence-based estimates of illicit drug use. After consumption, biomarkers - drugs and their metabolites - excreted to toilets and flushed into urban sewer networks can be measured in raw wastewater samples. The quantified loads can serve as an estimate for the collective consumption of all people contributing to the wastewater sample. This transdisciplinary approach, further explained in this chapter, has developed, matured and is now established for monitoring substances such as cocaine and amphetamine-type stimulants. Research currently underway is refining WBE to new applications including new psychoactive substances (NPS).