Most everyone has heard of “Mother’s Little Helper” – meprobamate (brand name Miltown) – a sedative popularized in the 1966 Rolling Stones song. Because of its abuse potential, including by housewives of folklore, it eventually became a controlled substance. In 2013, another accommodating drug was popularized in the outdoor literature in an Outside magazine story, “Climber’s Little Helper.” It was not about unhappy housewives, but an amateur climber who took wildly high doses of dexamethasone to enhance his chances of summiting Mt. Everest and his ensuing complicated medical issues. But is there really “rampant use of performance-enhancing drugs” (PEDs) in the mountains – rampant enough to have if not a song written about it, then a sensational story – and is dexamethasone really “dope”? 

If “dope” is defined as “a drug taken by an athlete to improve performance” (Oxford English Dictionary), then yes, dexamethasone, a glucocorticoid prescribed for a number of indications, falls into this category. “Dex” is prohibited by the World Anti-Doping Agency (WADA):

Worldwide Anti-Doping Agency Prohibited List 2017

The same goes for acetazolamide, a carbonic anhydrase inhibitor indicated for glaucoma but prohibited by WADA because it is a diuretic. 

However, dexamethasone and acetazolamide are among the drugs recommended for the prevention and treatment of altitude-related illnesses by the Wilderness Medical Society.  

So should these drugs really be considered PEDs when taken during marches up mountains? It really depends on the setting (e.g., competition, organized expedition, leisure trekking) and whom you ask. The use of drugs to aid summit attempts has been around since early expeditions to Mt. Everest in the 1920s, so the debate has been smoldering – and occasionally erupting – long before the expose in “Climber’s Little Helper.” The editorial “Medical and Sporting Ethics of High Altitude Mountaineering: the Use of Drugs and Supplemental Oxygen” was published in Wilderness & Environmental Medicine in 2012 with an accompanying series of commentaries and there were definitely two camps on the issue.

Source:
http://www.wemjournal.org/article/S1080-6032(12)00103-2/pdf 

http://www.wemjournal.org/article/S1080-6032(12)00194-9/pdf

Two documents from the UIAA (International Climbing and Mountaineering Federation-Union International des Associations d’Alpinisme), address the issue of “Drug Use and Misuse in the Mountains.” The medical professionals version was published in High Altitude Medicine & Biology in 2016.

A version for mountaineers and medical laypersons can be found here. This version can also be accessed from the UIAA site, which contains a number of valuable recommendations under their “Library of Recommendations” section.

The UIAA Medical Commission summed up their recommendations with the following statement: 

“It is not the UIAA Medcom’s intention to judge. We simply welcome openness and honesty but also want to protect mountaineers from possible harm. We do believe that, wherever possible, the use of drugs specifically taken with the intention to enhance performance should be avoided in the mountains.”
-UIAA Medical Commission, 2014

In both documents, the UIAA listed drugs that could potentially be used for performance enhancement in mountaineering. The table below lists a number of the drugs, what they are used for, and major risks in taking; the last column also includes whether they appear on WADA’s prohibited list. The documents detail whether randomized clinical studies proving the efficacy of these drugs for use in mountaineering have been conducted. The WMS guidelines reviewed clinical studies as well. 

Supplemental oxygen use as a climbing aid is an entire discussion in and of itself and will not be discussed in further detail in this article.

“PERFORMANCE-ENHANCING DRUGS” USED IN MOUNTAINEERING

Source:
http://theuiaa.org/documents/mountainmedicine/English_UIAA-MedCom-Rec-No-22a-Drug-misuse-2014-V1-1.pdf

Rx=available by prescription only (in US); AMS=Acute Mountain Sickness; HACE=High Altitude Cerebral Edema; HAPE=High Altitude Pulmonary Edema

*UIAA noted: “For recreational mountaineering the use of corticosteroids has to be a personal decision but the risk/benefit equation is very different from acetazolamide since the potential side effects, interactions and problems are much greater.”

So is PED use all that rampant in mountaineering? Grayson Schaffer broke the latest story in the lay press in November 2016 in Outside: "How Many People Use Drugs on Everest?"

The Outside article summarized the results of an important study conducted by four altitude experts – Andrew Luks, Colin Grissom, Luanne Freer, and Peter Hackett – that appeared in High Altitude Medicine & Biology (available by subscription only at the time of this writing) [Luks AM, Grissom C, Freer L, Hackett P. Medication Use Among Mount Everest Climbers: Practice and Attitudes. High Alt Med Biol. 2016 Dec;17(4):315-322. Epub 2016 Oct 20.] The investigators wanted to try to answer systematically, since previous reports have all been anecdotal, the question of how widespread is the use and abuse of performance-enhancing drugs in the mountains, as well as the attitudes of climbers to using drugs. An anonymous survey was given to climbers attempting Mt. Everest between November 2014-July 2015. The survey was completed by 187 participants, who described medication use for 262 expeditions. Acetazolamide was used by 43 percent of respondents, followed by dexamethasone (5 percent), nifedipine (4 percent), sildenafil, tadalafil (2 percent), salmeterol (3 percent), and dextroamphetamine (1 percent). As well, 85 percent of climbers used supplemental oxygen. Overall, 57 percent of climbers did not use medications on their climb. 

The authors cautioned that their study may underreport the actual use of drugs for the following reasons: a high number of climbers did not answer the drug use question, the survey did not ask about the use of sedative-hypnotics (improve sleep), and the respondents did not include climbers from China. Another finding of the study was that a minority of the respondents who used acetazolamide claimed to use it to increase the chance of reaching the summit versus for altitude illness prevention. 

The results of this study corroborated those from an intriguing investigation conducted on Mont Blanc [Robach P et al. Drug Use on Mont Blanc: A Study Using Automated Urine Collection. PLoS One 2016; Jun 2;11(6):e0156786] in which the urine of climbers was anonymously collected from mountain huts and screened for the presence of drugs; 35.8 percent of the samples contained at least one drug, with acetazolamide appearing the most frequently (20.6 percent). 

So are PEDs dope or hype? Though the results of these studies suggest that their use may not be as widespread as anecdotally reported, stay tuned for further important research in this area.