BackgroundGiven the implications associated with the use of performance-enhancing substances (PESs), a variety of stakeholders from clinicians to managers must remain informed about usage precipitants and be able to anticipate conditions signaling athlete vulnerability to increasingly hazardous exposures.
ObjectivesTo gain deeper qualitative insight into athlete PES usage and explore the variables leading high-level athletes to escalate their PES use regimens. To reveal PES experiences of athletes during their careers and, unlike other studies, not to focus exclusively on 'doping' as measured by the use of WADA-banned substances.
MethodsA macro life course-based framework from which the data could emerge through a thematic coding analysis was utilized. Sixteen narrative life course histories of retired highperformance athletes report on the factors impelling their escalation in PES use, including for some, the first use of banned PES.
ResultsInformant reports, thematically coded, reveal performance maximization urgency to be a central factor in escalating PES use, driven by four variables: Requirements, Opportunities, Influencers and Outcomes. These variables each comprise two key components that stimulate an urgency ecosystem affecting an athlete's proximity to an escalation threshold.
Conclusions/ImportanceSuch a comprehensive investigation of PES use precipitants has not previously been undertaken. Advances in PES use were instantiated by a substantive, sometimes radical and often sudden increase in urgency to improve performance related to output requirements, specific demands, knowledge and access, timing windows, the competitive landscape, loyalty to coaches, efficiency expectations and likelihood of detection. This study informs incremental models of doping, the use of which is encouraged in order to analyze life course narratives to better understand athlete behaviors.