AP IMPACT: Big Pharma cashes in on HGH abuse

A federal crackdown on illicit foreign supplies of human growth hormone has failed to stop rampant misuse, and instead has driven record sales of the drug by some of the world's biggest pharmaceutical companies, an Associated Press investigation shows.

The crackdown, which began in 2006, reduced the illegal flow of unregulated supplies from China, India and Mexico.

But since then, Big Pharma has been satisfying the steady desires of U.S. users and abusers, including many who take the drug in the false hope of delaying the effects of aging.

From 2005 to 2011, inflation-adjusted sales of HGH were up 69 percent, according to an AP analysis of pharmaceutical company data collected by the research firm IMS Health. Sales of the average prescription drug rose just 12 percent in that same period.

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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

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Unlike other prescription drugs, HGH may be prescribed only for specific uses. U.S. sales are limited by law to treat a rare growth defect in children and a handful of uncommon conditions like short bowel syndrome or Prader-Willi syndrome, a congenital disease that causes reduced muscle tone and a lack of hormones in sex glands.

The AP analysis, supplemented by interviews with experts, shows too many sales and too many prescriptions for the number of people known to be suffering from those ailments. At least half of last year's sales likely went to patients not legally allowed to get the drug. And U.S. pharmacies processed nearly double the expected number of prescriptions.

Peddled as an elixir of life capable of turning middle-aged bodies into lean machines, HGH — a synthesized form of the growth hormone made naturally by the human pituitary gland — winds up in the eager hands of affluent, aging users who hope to slow or even reverse the aging process.

Experts say these folks don't need the drug, and may be harmed by it. The supposed fountain-of-youth medicine can cause enlargement of breast tissue, carpal tunnel syndrome and swelling of hands and feet. Ironically, it also can contribute to aging ailments like heart disease and Type 2 diabetes.

Others in the medical establishment also are taking a fat piece of the profits — doctors who fudge prescriptions, as well as pharmacists and distributors who are content to look the other way. HGH also is sold directly without prescriptions, as new-age snake oil, to patients at anti-aging clinics that operate more like automated drug mills.

Years of raids, sports scandals and media attention haven't stopped major drugmakers from selling a whopping $1.4 billion worth of HGH in the U.S. last year. That's more than industry-wide annual gross sales for penicillin or prescription allergy medicine. Anti-aging HGH regimens vary greatly, with a yearly cost typically ranging from $6,000 to $12,000 for three to six self-injections per week.

Across the U.S., the medication is often dispensed through prescriptions based on improper diagnoses, carefully crafted to exploit wiggle room in the law restricting use of HGH, the AP found.

HGH is often promoted on the Internet with the same kind of before-and-after photos found in miracle diet ads, along with wildly hyped claims of rapid muscle growth, loss of fat, greater vigor, and other exaggerated benefits to adults far beyond their physical prime. Sales also are driven by the personal endorsement of celebrities such as actress Suzanne Somers.

Pharmacies that once risked prosecution for using unauthorized, foreign HGH — improperly labeled as raw pharmaceutical ingredients and smuggled across the border — now simply dispense name brands, often for the same banned uses. And usually with impunity.

Eight companies have been granted permission to market HGH by the U.S. Food and Drug Administration, which reviews the benefits and risks of new drug products. By contrast, three companies are approved for the diabetes drug insulin.

The No. 1 maker, Roche subsidiary Genentech, had nearly $400 million in HGH sales in the U.S. last year, up an inflation-adjusted two-thirds from 2005. Pfizer and Eli Lilly were second and third with $300 million and $220 million in sales, respectively, according to IMS Health. Pfizer now gets more revenue from its HGH brand, Genotropin, than from Zoloft, its well-known depression medicine that lost patent protection.

On their face, the numbers make no sense to the recognized hormone doctors known as endocrinologists who provide legitimate HGH treatment to a small number of patients.

Endocrinologists estimate there are fewer than 45,000 U.S. patients who might legitimately take HGH. They would be expected to use roughly 180,000 prescriptions or refills each year, given that typical patients get three months' worth of HGH at a time, according to doctors and distributors.

Yet U.S. pharmacies last year supplied almost twice that much HGH — 340,000 orders — according to AP's analysis of IMS Health data.

While doctors say more than 90 percent of legitimate patients are children with stunted growth, 40 percent of 442 U.S. side-effect cases tied to HGH over the last year involved people age 18 or older, according to an AP analysis of FDA data. The average adult's age in those cases was 53, far beyond the prime age for sports. The oldest patients were in their 80s.

Some of these medical records even give explicit hints of use to combat aging, justifying treatment with reasons like fatigue, bone thinning and "off-label," which means treatment of an unapproved condition

Even Medicare, the government health program for older Americans, allowed 22,169 HGH prescriptions in 2010, a five-year increase of 78 percent, according to data released by the Centers for Medicare and Medicaid Services in response to an AP public records request.

"There's no question: a lot gets out," said hormone specialist Dr. Mark Molitch of Northwestern University, who helped write medical standards meant to limit HGH treatment to legitimate patients.

And those figures don't include HGH sold directly by doctors without prescriptions at scores of anti-aging medical practices and clinics around the country. Those numbers could only be tallied by drug makers, who have declined to say how many patients they supply and for what conditions.

First marketed in 1985 for children with stunted growth, HGH was soon misappropriated by adults intent on exploiting its modest muscle- and bone-building qualities. Congress limited HGH distribution to the handful of rare conditions in an extraordinary 1990 law, overriding the generally unrestricted right of doctors to prescribe medicines as they see fit.

Despite the law, illicit HGH spread around the sports world in the 1990s, making deep inroads into bodybuilding, college athletics, and professional leagues from baseball to cycling. The even larger banned market among older adults has flourished more recently.

FDA regulations ban the sale of HGH as an anti-aging drug. In fact, since 1990, prescribing it for things like weight loss and strength conditioning has been punishable by 5 to 10 years in prison.

Steve Kleppe, of Scottsdale, Ariz., a restaurant entrepreneur who has taken HGH for almost 15 years to keep feeling young, said he noticed a price jump of about 25 percent after the block on imports. He now buys HGH directly from a doctor at an annual cost of about $8,000 for himself and the same amount for his wife.

Many older patients go for HGH treatment to scores of anti-aging practices and clinics heavily concentrated in retirement states like Florida, Nevada, Arizona and California.

These sites are affiliated with hundreds of doctors who are rarely endocrinologists. Instead, many tout certification by the American Board of Anti-Aging and Regenerative Medicine, though the medical establishment does not recognize the group's bona fides.

The clinics offer personalized programs of "age management" to business executives, affluent retirees, and other patients of means, sometimes coupled with the amenities of a vacation resort. The operations insist there are few, if any, side effects from HGH. Mainstream medical authorities say otherwise.

A 2007 review of 31 medical studies showed swelling in half of HGH patients, with joint pain or diabetes in more than a fifth. A French study of about 7,000 people who took HGH as children found a 30 percent higher risk of death from causes like bone tumors and stroke, stirring a health advisory from U.S. authorities.

For proof that the drug works, marketers turn to images like the memorable one of pot-bellied septuagenarian Dr. Jeffry Life, supposedly transformed into a ripped hulk of himself by his own program available at the upscale Las Vegas-based Cenegenics Elite Health. (He declined to be interviewed.)

These promoters of HGH say there is a connection between the drop-off in growth hormone levels through adulthood and the physical decline that begins in late middle age. Replace the hormone, they say, and the aging process slows.

"It's an easy ruse. People equate hormones with youth," said Dr. Tom Perls, a leading industry critic who does aging research at Boston University. "It's a marketing dream come true."

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Associated Press Writer David B. Caruso reported from New York and AP National Writer Jeff Donn reported from Plymouth, Mass. AP Writer Troy Thibodeaux provided data analysis assistance from New Orleans.

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AP's interactive on the HGH investigation: http://hosted.ap.org/interactives/2012/hgh

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The AP National Investigative Team can be reached at investigate(at)ap.org

EDITOR'S NOTE _ Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

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NRA: 'Good guy with a gun' could have saved lives at Sandy Hook

The NRA's Wayne LaPierre speaks at Friday's press conference (Chip Somodevilla/Getty Images)

The National Rifle Association on Friday, a full week after the shooting at Sandy Hook Elementary School, gave its first response to the massacre that killed 20 schoolchildren in Newtown, Conn. Wayne LaPierre, the NRA's executive vice president, argued at a press conference in Washington, D.C., that gun control legislation would not prevent similar shootings and offered the organization's own proposal: a nationwide program that would place armed security in every school desiring protection.

"I call on Congress today to appropriate whatever is necessary to put armed police officers in every single school in this nation," LaPierre said. The proposed program, called the National School Shield, would help train and install security at schools nationwide under the leadership of former Arkansas Republican Rep. Asa Hutchinson.

"Innocent lives might have been spared," LaPierre said, if armed security was present at Sandy Hook. "The only thing that stops a bad guy with a gun is a good guy with a gun."

LaPierre, Hutchinson and David Keene, president of the NRA, all declined to take questions from the press and said NRA press officers won't be responding to the media until Monday.

LaPierre in part blamed mass shootings on "vicious, violent video games" such as "Bulletstorm," "Grand Theft Auto," Mortal Kombat" and  "Splatterhouse." He also reached back in time to place blame on movies like "American Psycho" and "Natural Born Killers" for portraying "life as a joke and murder as a way of life."

He added, "In a race to the bottom, media conglomerates compete with one another to shock, violate and offend every standard of civilized society by bringing an ever-more-toxic mix of reckless behavior and criminal cruelty into our homes—every minute of every day of every month of every year.”

He also criticized the media for vilifying guns and gun owners, and for publicizing inaccuracies about guns.

"Why is the idea of a gun good when it’s used to protect the president of our country or our police, but bad when it’s used to protect children in our schools?" he asked.

"It’s our duty to protect them," LaPierre said of the nation's schoolchildren. "It’s our right to protect them."

Part of the problem in protecting schools, he also said, is the designation of gun-free school zones. The zones "tell every insane killer in America that schools are the safest place to inflict maximum mayhem with minimum risk," he said.

Gun control advocates immediately decried the NRA's views as extreme and dangerous.

"Their press conference was a shameful evasion of the crisis facing our country," New York City Mayor Michael Bloomberg, an independent, said in a statement. "Instead of offering solutions to a problem they have helped create, they offered a paranoid, dystopian vision of a more dangerous and violent America where everyone is armed and no place is safe."

Bloomberg said NRA members support background checks for gun ownership because of gun violence. "As a country, we must rise above special interest politics," he added.

On Capitol Hill, Democratic Sen. Richard Blumenthal of Connecticut, who conceded that armed security could be "helpful in some instances, noted in a statement that "the NRA’s statement is sadly and shamefully inadequate—calling for more guns and rejecting real action against gun violence. At a defining, historic moment demanding courageous leadership, the NRA has declined to step forward as a credible and constructive partner."

The press conference, despite the tight security at the Willard InterContinental Hotel where it was held, was interrupted twice by gun control protesters later identified as members of anti-war group Code Pink. A man rose from the press area in front of LaPierre during his speech and held up a pink cloth displaying the words "NRA Killing Our Kids." Later, a woman identified as Code Pink founder Medea Benjamin, unfurled a sign reading "NRA blood on your hands,” and shouted, "Reckless behavior coming from the NRA" and other comments as she was dragged out of the room.

A large security staff dressed in suits and wearing earpieces lined the perimeter of the makeshift stage as well as the room. Security staffers moved to sit directly in front and behind of LaPierre following the Code Pink protests as other security members stepped forward into the seating area.

Prior to the conference, gun control protesters as well as PETA protesters and others lined the street in front of the hotel entrance waving signs and shouting.

Pressure on lawmakers from gun-control advocates has increased in the wake of the shooting. President Barack Obama on Friday released a web video in response to an outpouring of White House petitions calling on the president to respond to gun violence.

“We hear you," Obama said in the video. "I will do everything in my power as president to advance these efforts, because if there’s even one thing we can do as a country to protect our children, we have a responsibility to try. But as I said earlier this week, I can’t do it alone. I need your help.”

Obama tasked Vice President Joe Biden to review potential gun legislation and other measures on which to act next session. Biden spoke Thursday to law enforcement leaders about banning assault weapons, though no further details were released on the private discussion.

California Sen. Dianne Feinstein has pledged to introduce a new federal assault weapons ban in January and has received support from several gun-rights advocates and from the White House.

Olivier Knox contributed to this report.

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Pakistani polio workers get police protection

LAHORE, Pakistan (AP) — Under police guard, thousands of health workers pressed on with a polio immunization program Thursday after nine were killed elsewhere in Pakistan by suspected militants who oppose the vaccination campaign.

Immunizations were halted in some parts of Pakistan and the U.N. suspended its field participation everywhere until better security was arranged for its workers. The violence risks reversing recent progress fighting polio in Pakistan, one of three countries in the world where the disease is endemic.

The Taliban have denied responsibility for the shootings. Militants have accused health workers of acting as spies for the U.S., alleging the vaccine is intended to make Muslim children sterile.

Taliban commanders in Pakistan's troubled northwest tribal region also said earlier this year that vaccinations can't go forward until the U.S. stops drone strikes in the country.

Insurgent opposition to the campaign grew last year after it was revealed that a Pakistani doctor ran a fake vaccination program to help the CIA track down and kill al-Qaida founder Osama bin Laden, who was hiding in the town of Abbottabad in the country's northwest.

There were a few attacks on polio workers in July, but the current level of violence is unprecedented. A polio worker died Thursday after being shot in the head in the northwestern city of Peshawar a day earlier, said health official Janbaz Afridi.

His death raised to nine the number of Pakistanis working on the campaign who have been killed this week. Six of the workers gunned down were women, three of whom were teenagers. Two other workers were critically wounded. All the attacks occurred in northwest Khyber Pakhtunkhwa province and the southern city of Karachi.

Despite the threat, local officials in the eastern city of Lahore continued the vaccination drive Thursday under police escort, said one of the top government officials in the city, Noorul Amin Mengal. About 6,000 Pakistani health workers were escorted by 3,000 police as they fanned out across the city, he said.

"It would have been an easy thing for us to do to stop the campaign," he said. "That would have been devastating."

Saddaf Malik, one of the polio workers in Lahore, said the killings sent a shudder of fear through him and his colleagues.

"We will carry on with our job with determination, but we want the government to adopt measures to ensure the security of polio vaccinators," he said.

This week's killings occurred as the government and the U.N. began a vaccination drive Monday targeting high-risk areas in the country's four provinces and the semiautonomous tribal region, part of an effort to immunize 34 million children under age 5. The campaign was scheduled to end Wednesday in most parts of the country, except for Lahore, where it ran a day longer.

Government officials ended the drive early in parts of Khyber Pakhtunkhwa and in Sindh province, where Karachi is the capital, said Elias Durry, the U.N. World Health Organization's senior coordinator for polio in Pakistan. The campaign ran its full course in the provinces of Baluchistan and Punjab, where Lahore is the capital, as well as in the tribal region, he said.

The government has approximately 250,000 people working on the campaign, said Durry. Most of them have other jobs, such as teaching or working as government clerks, and sign on to the vaccination drive to earn a little more money, about $2.50 per day, officials said.

The WHO and UNICEF have about 2,000 people between them who provide technical assistance to the polio teams across the country and educate locals about the program, said Durry and Michael Coleman, a UNICEF spokesman in Pakistan. The U.N. staff were pulled out of the field and asked to work from home Wednesday.

Workers were only able to immunize about 9 million children this week out of a target of 18.3 million because of the violence, said Durry.

Polio usually infects children living in unsanitary conditions, attacks the nerves and can kill or paralyze. Pakistan, Afghanistan and Nigeria remain the last battlegrounds for the fight against the disease.

There is no history of attacks on polio workers in Afghanistan, even though the country also faces a domestic Taliban insurgency. Muslim leaders in Nigeria have spoken out against polio vaccination in the country in the past, also claiming it makes children sterile. Many now support the campaign, but some Nigerians remain suspicious.

Prevention efforts have managed to reduce the number of cases in Pakistan to 56 this year, compared with 190 in 2011, a drop of about 70 percent. Most of the news cases in Pakistan are in the northwest, where the presence of militants makes it difficult to reach children. Clerics and tribal elders have been recruited to support polio vaccinations to try to open up areas previously inaccessible to health workers.

Israrullah Khan, a villager who attended the funeral of the polio worker who died Thursday, said most of the clerics and Islamic political parties in Khyber Pakhtunkhwa were in favor of the campaign.

"We don't understand why these attacks have suddenly started," Khan said. "It's very sad because they were trying to save our children's future for very low wages."

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Associated Press writers Jamal Khan in Peshawar, Pakistan, Zaheer Babar in Lahore, Pakistan, Adil Jawad in Karachi, Pakistan, and Munir Ahmed in Islamabad contributed to this report.

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New Miss Universe says win shows confidence is all

LAS VEGAS (AP) — The 20-year-old Rhode Islander who brought the Miss Universe crown back to the U.S. for the first time in 15 years is hoping that her quick rise through the beauty pageant ranks and onstage stumble will show women that anything is possible.

Self-described "cellist-nerd" Olivia Culpo is assuming her new role as Miss Universe 2012 following her victory over 88 beauty queens from around the world Wednesday night at the Planet Hollywood casino on the Las Vegas Strip.

She tells The Associated Press that her yearlong transformation from Boston University sophomore to pageant winner proves that women can accomplish anything to which they set their minds.

She says she is glad she tripped slightly during the evening gown competition because it proves that confidence and poise matter more than perfect performance.

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AP IMPACT: Steroids loom in major-college football

WASHINGTON (AP) — With steroids easy to buy, testing weak and punishments inconsistent, college football players are packing on significant weight — 30 pounds or more in a single year, sometimes — without drawing much attention from their schools or the NCAA in a sport that earns tens of billions of dollars for teams.

Rules vary so widely that, on any given game day, a team with a strict no-steroid policy can face a team whose players have repeatedly tested positive.

An investigation by The Associated Press — based on interviews with players, testers, dealers and experts and an analysis of weight records for more than 61,000 players — revealed that while those running the multibillion-dollar sport say they believe the problem is under control, that control is hardly evident.

The sport's near-zero rate of positive steroids tests isn't an accurate gauge among college athletes. Random tests provide weak deterrence and, by design, fail to catch every player using steroids. Colleges also are reluctant to spend money on expensive steroid testing when cheaper ones for drugs like marijuana allow them to say they're doing everything they can to keep drugs out of football.

"It's nothing like what's going on in reality," said Don Catlin, an anti-doping pioneer who spent years conducting the NCAA's laboratory tests at UCLA. He became so frustrated with the college system that it was part of the reason he left the testing industry to focus on anti-doping research.

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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the first of a two-part series.

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While other major sports have been beset by revelations of steroid use, college football has operated with barely a whiff of scandal. Between 1996 and 2010 — the era of Barry Bonds, Mark McGwire, Marion Jones and Lance Armstrong — the failure rate for NCAA steroid tests fell even closer to zero from an already low rate of less than 1 percent.

The AP's investigation, drawing upon more than a decade of official rosters from all 120 Football Bowl Subdivision teams, found thousands of players quickly putting on significant weight, even more than their fellow players. The information compiled by the AP included players who appeared for multiple years on the same teams.

For decades, scientific studies have shown that anabolic steroid use leads to an increase in body weight. Weight gain alone doesn't prove steroid use, but very rapid weight gain is one factor that would be deemed suspicious, said Kathy Turpin, senior director of sport drug testing for the National Center for Drug Free Sport, which conducts tests for the NCAA and more than 300 schools.

Yet the NCAA has never studied weight gain or considered it in regard to its steroid testing policies, said Mary Wilfert, the NCAA's associate director of health and safety.

The NCAA attributes the decline in positive tests to its year-round drug testing program, combined with anti-drug education and testing conducted by schools.

The AP's analysis found that, regardless of school, conference and won-loss record, many players gained weight at exceptional rates compared with their fellow athletes and while accounting for their heights.

Adding more than 20 or 25 pounds of lean muscle in a year is nearly impossible through diet and exercise alone, said Dan Benardot, director of the Laboratory for Elite Athlete Performance at Georgia State University.

In nearly all the rarest cases of weight gain in the AP study, players were offensive or defensive linemen, hulking giants who tower above 6-foot-3 and weigh 300 pounds or more. Four of those players interviewed by the AP said that they never used steroids and gained weight through dramatic increases in eating, up to six meals a day. Two said they were aware of other players using steroids.

"I ate 5-6 times a day," said Clint Oldenburg, who played for Colorado State starting in 2002 and for five years in the NFL. Oldenburg's weight increased over four years from 212 to 290.

Oldenburg told the AP he was surprised at the scope of steroid use in college football, even in Colorado State's locker room. "There were a lot of guys even on my team that were using." He declined to identify any of them.

The AP found more than 4,700 players — or about 7 percent of all players — who gained more than 20 pounds overall in a single year. It was common for the athletes to gain 10, 15 and up to 20 pounds in their first year under a rigorous regimen of weightlifting and diet. Others gained 25, 35 and 40 pounds in a season. In roughly 100 cases, players packed on as much 80 pounds in a single year.

In at least 11 instances, players that AP identified as packing on significant weight in college went on to fail NFL drug tests. But pro football's confidentiality rules make it impossible to know for certain which drugs were used and how many others failed tests that never became public.

Even though testers consider rapid weight gain suspicious, in practice it doesn't result in testing. Ben Lamaak, who arrived at Iowa State in 2006, said he weighed 225 pounds in high school. He graduated as a 320-pound offensive lineman and said he did it all naturally.

"I was just a young kid at that time, and I was still growing into my body," he said. "It really wasn't that hard for me to gain the weight. I love to eat."

In addition to random drug testing, Iowa State is one of many schools that have "reasonable suspicion" testing. That means players can be tested when their behavior or physical symptoms suggest drug use. Despite gaining 81 pounds in a year, Lamaak said he was never singled out for testing.

The associate athletics director for athletic training at Iowa State, Mark Coberley, said coaches and trainers use body composition, strength data and other factors to spot suspected cheaters. Lamaak, he said, was not suspicious because he gained a lot of "non-lean" weight.

But looking solely at the most significant weight gainers also ignores players like Bryan Maneafaiga.

In the summer of 2004, Bryan Maneafaiga was an undersized 180-pound running back trying to make the University of Hawaii football team. Twice — once in pre-season and once in the fall — he failed school drug tests, showing up positive for marijuana use but not steroids.

He'd started injecting stanozolol, a steroid, in the summer to help bulk up to a roster weight of 200 pounds. Once on the team, he'd occasionally inject the milky liquid into his buttocks the day before games.

"Food and good training will only get you so far," he told the AP recently.

Maneafaiga's former coach, June Jones, said it was news to him that one of his players had used steroids. Jones, who now coaches at Southern Methodist University, believes the NCAA does a good job rooting out steroid use.

On paper, college football has a strong drug policy. The NCAA conducts random, unannounced drug testing and the penalties for failure are severe. Players lose an entire year of eligibility after a first positive test. A second offense means permanent ineligibility for sports.

In practice, though, the NCAA's roughly 11,000 annual tests amount to a fraction of all athletes in Division I and II schools. Exactly how many tests are conducted each year on football players is unclear because the NCAA hasn't published its data for two years. And when it did, it periodically changed the formats, making it impossible to compare one year of football to the next.

Even when players are tested by the NCAA, experts like Catlin say it's easy enough to anticipate the test and develop a doping routine that results in a clean test by the time it occurs. NCAA rules say players can be notified up to two days in advance of a test, which Catlin says is plenty of time to beat a test if players have designed the right doping regimen. By comparison, Olympic athletes are given no notice.

Most schools that use Drug Free Sport do not test for anabolic steroids, Turpin said. Some are worried about the cost. Others don't think they have a problem. And others believe that since the NCAA tests for steroids their money is best spent testing for street drugs, she said.

Doping is a bigger deal at some schools than others.

At Notre Dame and Alabama, the teams that will soon compete for the national championship, players don't automatically miss games for testing positive for steroids. At Alabama, coaches have wide discretion. Notre Dame's student-athlete handbook says a player who fails a test can return to the field once the steroids are out of his system.

The University of North Carolina kicks players off the team after a single positive test for steroids. Auburn's student-athlete handbook calls for a half-season suspension for any athlete caught using performance-enhancing drugs.

At UCLA, home of the laboratory that for years set the standard for cutting-edge steroid testing, athletes can fail three drug tests before being suspended. At Bowling Green, testing is voluntary.

At the University of Maryland, students must get counseling after testing positive, but school officials are prohibited from disciplining first-time steroid users.

Only about half the student athletes in a 2009 NCAA survey said they believed school testing deterred drug use. As an association of colleges and universities, the NCAA could not unilaterally force schools to institute uniform testing policies and sanctions, Wilfert said.

"We can't tell them what to do, but if went through a membership process where they determined that this is what should be done, then it could happen," she said.

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Associated Press writers Ryan Foley in Cedar Rapids, Iowa; David Brandt in Jackson, Miss.; David Skretta in Lawrence, Kan.; Don Thompson in Sacramento, Calif., and Alexa Olesen in Shanghai, China, and researchers Susan James in New York and Monika Mathur in Washington contributed to this report.

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Contact the Washington investigative team at DCinvestigations (at) ap.org.

Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the first of a two-part series.

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Snowstorm triggers deadly Iowa pileup

DES MOINES, Iowa (AP) — The first widespread snowstorm of the season crawled across the Midwest on Thursday, with whiteout conditions stranding holiday travelers and sending drivers sliding over slick roads — including into a fatal 25-vehicle pileup in Iowa.

The storm, which dumped a foot of snow in parts of Iowa and Wisconsin, was part of a system that began in the Rockies earlier in the week before trekking into the Midwest. It was expected to move across the Great Lakes overnight before moving into Canada.

On the southern edge of the system, a tornado destroyed several homes in Arkansas, and strong winds peeled roofs off buildings and toppled trucks in Alabama and led to flight cancellations in Texas.

In Iowa, drivers were blinded by blowing snow and didn't see vehicles that had slowed or stopped on Interstate 35 about 60 miles north of Des Moines, state police said. A chain reaction of crashes involving semitrailers and passenger cars closed down a section of the highway. At least one person was killed.

"It's time to listen to warnings and get off the road," said Iowa State Patrol Col. David Garrison.

Thomas Shubert, a clerk at a store in Gretna near Omaha, Neb., said his brother drove him to work in his truck, but some of his neighbors weren't so fortunate.

"I saw some people in my neighborhood trying to get out. They made it a few feet, and that was about it," Shubert said.

Along with Thursday's fatal accident in Iowa, the storm was blamed for road deaths in Kansas and Wisconsin. In southeastern Utah, a woman who tried to walk for help after her car became stuck in snow died Tuesday night.

The heavy, wet snow made some unplowed streets in Des Moines nearly impossible to navigate in anything other than a four-wheel drive vehicle. Even streets that had been plowed were snow-packed and slippery. Eight jackknifed semitrailers were reported on a section of Interstate 80 east of the city.

The storm made travel difficult from Kansas to Wisconsin, forcing road closures, including part of Interstate 29 in northern Missouri and part of Interstate 80 in Nebraska. Iowa and Wisconsin activated National Guard troops to help rescue stranded drivers.

Those who planned to fly before the Christmas holiday didn't fare much better.

Shanna Tinsley, 17, and Nicole Latimer, 20, were both headed to the Kansas City area to see their families for the holiday when their flight Thursday morning out of Milwaukee's General Mitchell International Airport was canceled. Neither cared about a white Christmas.

"It would be cool I guess, but I'd rather be there than stuck without family with a white Christmas," Latimer said.

Added Tinsley, "Wisconsin is full of snow, you see it all the time."

In Chicago, commuters began Thursday with heavy fog and cold, driving rain, and forecasters said snow would hit by mid-afternoon.

Airlines delayed and canceled hundreds of flights out of Chicago's O'Hare and Midway international airports. Southwest Airlines, which has a hub at Midway, canceled all of its flights after 4:30 p.m.

In Texas, American Airlines reported 120 cancellations in Dallas because of thunderstorms.

Before the storm, several cities in the Midwest had broken records for the number of consecutive days without measurable snow.

In the Des Moines suburb of Urbandale, Kristin Isenhart, 38, said her three kids, ages 9, 5 and 3, were asking about going outside to play after school was canceled for the day.

"They are thrilled that it snowed," she said. "They've asked several times to go outside, and I might bundle them up and let them go."

As far as the region's drought, meteorologists said the storm wouldn't make much of a dent. It takes a foot or more of snow to equal an inch of water, said Brian Fuchs, a climatologist at the National Drought Mitigation Center.

Meanwhile, tens of thousands of people lost power in Arkansas, Iowa and Nebraska as heavy snow and strong winds pulled down lines. Smaller outages were reported in Alabama, Kansas, Missouri, Illinois and Louisiana.

"The roads have been so bad our crews have not been able to respond to them," said Justin Foss, a spokesman for Alliant Energy, which had 13,000 customers without power in central Iowa. "We have giant four-wheel-drive trucks with chains on them, so when we can't get there it's pretty rough."

Tom Tretter and his wife, Pat, had been without power since Wednesday night, and temperatures Thursday were dropping. The retired seniors were shoveling their steep driveway Thursday afternoon and scraping ice off the walkway to their Des Moines home.

"It's getting cold in the house," Tom Tretter said, leaning on his shovel in the driveway. "And I'm getting too old for this."

Blake Landau, a cook serving eggs, roast beef sandwiches and chili to hungry snowplow drivers at Newton's Paradise Cafe in downtown Waterloo, Iowa, said he has always liked it when it snows on his birthday. He turned 27 on Thursday.

"It's kind of one of those things where it's leading up to Christmas time," Landau said. "We don't know when we get our first snowfall, and I hope we get it by my birthday. It's nice to have a nice snowy Christmas."

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Beck reported from Omaha, Neb. Associated Press writers Scott Mayerowitz in New York; Carrie Antlfinger in Milwaukee; Heather Hollingsworth in Kansas City, Mo.; Jason Keyser in Chicago; Barbara Rodriguez in Des Moines; and Ryan J. Foley in Iowa City, Iowa contributed to this report.

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UN suspends polio drive in Pakistan after killings

PESHAWAR, Pakistan (AP) — The United Nations suspended its polio vaccination drive in Pakistan on Wednesday after eight people involved in the effort were shot dead in the past two days, a U.N. official said.

The suspension was a grave blow to the drive to bring an end to the scourge of polio in Pakistan, one of only three countries where the crippling disease still survives.

On Wednesday, gunmen shot at a woman working on the campaign in northwest Pakistan, killing her and her driver, one of five attacks during the day on polio workers. A male polio immunization worker was critically wounded in one of the shootings.

This week six other people have been killed who were working on the immunization program, which has been jointly conducted with the Pakistani government. No one has claimed responsibility, but some Islamic extremists charge that the program is a cover for espionage.

At the U.N., Secretary-General Ban Ki-moon condemned the killing as "cruel, senseless and inexcusable." He said the eight workers were among thousands across Pakistan "working selflessly to achieve the historic goal of polio eradication."

Sarah Crowe, spokeswoman for UNICEF, said the vaccination program has been suspended everywhere in Pakistan until an investigation by the Pakistani government is completed.

"This is undoubtedly a tragic setback, but the campaign to eradicate polio will and must continue," she said.

Some provincial governments in Pakistan continued to immunize children, independent of the U.N. drive.

Prevention efforts have managed to reduce the number of cases in Pakistan by around 70 percent this year compared to 2011, but the recent violence threatens to reverse that progress.

Suspicion for the attacks has fallen on the Pakistani Taliban because of their virulent opposition to the polio campaign, but the group's spokesman, Ahsanullah Ahsan, denied responsibility in a telephone call to The Associated Press. Police say they have killed two militant suspects and arrested a dozen others in connection to the attacks but did not say whether they were Taliban.

Militants accuse health workers of acting as spies for the U.S. and claim the vaccine makes children sterile. Taliban commanders in the troubled northwest tribal region have also said vaccinations can't go forward until the U.S. stops drone strikes in the country.

Insurgent opposition to the campaign grew last year after it was revealed that a Pakistani doctor ran a fake vaccination program to help the CIA track down and kill al-Qaida founder Osama bin Laden, who was hiding in the town of Abbottabad in the country's northwest.

The number of attacks this week on polio workers is unprecedented. They came as the government started a three-day vaccination drive Monday targeting high risk areas of the country, part of an effort to immunize millions of children under the age of five.

The deadliest of Wednesday's attacks occurred in the northwestern town of Charsadda, where the female polio worker and her driver were gunned down, said senior government official Syed Zafar Ali Shah. Gunmen attacked two other polio immunization teams in Charsadda and one in the town of Nowshera, but no one was hurt in those attacks, he said.

Earlier in the day, gunmen shot a polio worker in the head in the city of Peshawar, wounding him critically, said Janbaz Afridi, a senior health official in surrounding Khyber Pakhtunkhwa province.

On Tuesday, gunmen killed five female polio workers — three of them teenagers — in a series of attacks in Karachi, the capital of southern Sindh province, and a village outside Peshawar. Two men who were working alongside the women were critically wounded in those attacks. A male polio worker was also shot to death in Karachi on Monday.

Police conducted two operations in Karachi in the wake of the shootings in which they arrested a dozen suspects and killed two suspected militants, said senior police official Shahid Hayat.

Several dozen polio immunization workers and human rights activists protested against the killings in Pakistan's capital, Islamabad, on Wednesday and demanded security for the field staff.

The Pakistani government also condemned the attacks, saying they deprive Pakistan's most vulnerable populations — specifically children — of basic life-saving health interventions. The U.N. said it was increasing security for its polio workers, but did not provide any details.

Polio usually infects children living in unsanitary conditions, attacks the nerves and can kill or paralyze. A total of 56 polio cases have been reported in Pakistan during 2012, down from 190 the previous year, according to the U.N. Most of the new cases in Pakistan are in the northwest, where the presence of militants makes it difficult to reach children.

The new campaign aimed to give oral polio prevention drops to 34 million children under the age of five. Clerics and tribal elders were recruited to support polio vaccinations in an attempt to open up areas previously inaccessible to health workers.

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Associated Press writer Rasool Dawar in Peshawar, Pakistan, and Adil Jawad in Karachi, Pakistan, contributed to this report.

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Google launches ‘scan and match’ music service

LOS ANGELES (AP) — Google is turning on a “scan and match” service for Google Music users to store copies of their songs online, offering for free what Apple charges $ 25 a year for.

The service, which launched Tuesday, cuts uploading time for those who want to save their music libraries online. It scans a user’s computer and gives them online access to the songs it finds, as long as they match the songs on its servers. Otherwise, it will upload songs to a user’s online locker.

The service is similar to Apple Inc.‘s iTunes Match, which includes online storage for 25,000 songs. Google Inc. allows storage for 20,000 songs and allows users to re-download the songs only at the same quality as they were at previously. Apple upgrades songs to iTunes quality.

Amazon runs a similar matching and uploading service called Cloud Player. It costs $ 25 a year for 250,000 songs. A free version is limited to 250 songs.

Google is still a fledgling entrant into music sales since debuting its store in November 2011, though it expects to benefit from the hundreds of millions of devices that use its Android operating system on mobile devices.

According to the NPD Group, Apple accounted for 64 percent of U.S. music sales online, followed by Amazon at 16 percent. Google has no more than 5 percent, according to NPD. Other services make up the rest.

Google had sold songs at a discount at the start, but that is less so the case now. For example, it was selling the top-ranked Bruno Mars song “Locked Out of Heaven” for $ 1.29 on Wednesday, the same as iTunes, and above the 99 cents on Amazon. But its album price was lower at $ 10.49 versus $ 10.99 at both iTunes and Amazon.

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Music, roses at singer Jenni Rivera's memorial

UNIVERSAL CITY, Calif. (AP) — Jenni Rivera's "celestial graduation" was marked by festive music, heartfelt speeches in Spanish and English and passionate chants of "Jen-ni! Jen-ni!"

Rivera's children and famed singers Olga Tanon and Joan Sebastian performed during the nearly 2 ½-hour memorial service Wednesday at the Gibson Amphitheatre, where thousands of fans gathered to salute the "Diva de la Banda" who died in a plane crash Dec. 9.

One fan, Veronika Flores, drove nearly eight hours from her home in Woodland, Calif., near Sacramento, to be united with other fans at the service.

"I just came to say goodbye to a Latina woman, La Gran Senora," she said, invoking the name of one of Rivera's most beloved songs.

Famed Mexican singers Marco Antonio Solis and Ana Gabriel and actors Lou Diamond Phillips and Kate del Castillo were also among the guests at Wednesday's service.

A red casket sat onstage amid a sea of white roses as images of Rivera played on three big screens. Family members embraced and kissed the casket at the conclusion of the service, laying more white roses atop it.

While most of the speeches and songs were delivered in Spanish, Rivera's children spoke in English, often directly to their late mother.

"We're not here to mourn the death," said son Michael, 21. "We're here to celebrate the life and graduation of a singer, an entertainer, a diva, a fighter, an entrepreneur, a philanthropist, and more than anything, a mother — the best mother."

He then called for 27 seconds of silence for the victims of the massacre in Newtown, Conn.

Rivera's youngest child, 11-year-old Johnny, was heartbreakingly poised as he said, "The person that everyone's talking about is my mom."

"Mama, I've been crying so much these last few days. I miss you so much," said the little boy, wearing a red bow tie like many of his family members. "I hope you're taking care of my dad and I hope he's taking care of you, too."

Rivera's second husband, Juan Lopez, died in 2009. The couple divorced in 2003.

Rivera's brothers and sisters spoke lovingly of the singer, calling her "the queen of queens," ''perfectly imperfect" and an "eternal diva." Her father said Rivera's "happiness, smile and care for the public will never be forgotten." He then performed a song he wrote about his daughter, a woman who rose from humble roots to become "la Diva de la Banda."

One of Rivera's brothers said his sister "made it OK for women to be who they are. Jenni also made it OK to be from nothing with the hopes of being something."

The family asked that Latin radio stations play Rivera's song "La Gran Senora" at noon Thursday in her honor.

The service was closed to most media, although a broadcast of the proceedings was made available.

The burial will be private.

Rivera's last album before her death, "La Misma Gran Senora," topped the Latin albums chart this week, selling 27,000 copies — the best sales week for any Latin album this year. Rivera also holds three spots on the Billboard 200 albums chart.

Rivera and six other people died Dec. 9 in a northern Mexico plane crash that remains under investigation. Rivera, a mother of five children and grandmother of two, was 43.

Rivera sold more than 15 million copies of her 12 major-label albums. Her soulful singing style and honesty about her tumultuous personal life won her fans on both sides of the U.S.-Mexico border. She was also an actress and reality TV star.

Born in Los Angeles, Rivera launched her career by selling cassette tapes at flea markets. By the end of the 90s, she won a major-label contract and built a loyal following.

Many of her songs deal with themes of dignity in the face of heartbreak, which Rivera spoke of openly with her fans.

She had recently filed for divorce from her third husband, was once detained at a Mexico City airport with tens of thousands of dollars in cash, and publicly apologized after her brother assaulted a drunken fan who verbally attacked her in 2011.

"She was a fighter, a woman who can push boundaries," said Flores. "That's why I liked her, because I'm just like her."

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Experts: Kids are resilient in coping with trauma

WASHINGTON (AP) — They might not want to talk about the gunshots or the screams. But their toys might start getting into imaginary shootouts.

Last week's school shooting in Connecticut raises the question: What will be the psychological fallout for the children who survived?

For people of any age, regaining a sense of security after surviving violence can take a long time. They're at risk for lingering anxiety, depression, post-traumatic stress disorder.

But after the grief and fear fades, psychiatrists say most of Newtown's young survivors probably will cope without long-term emotional problems.

"Kids do tend to be highly resilient," said Dr. Matthew Biel, chief of child and adolescent psychiatry at MedStar Georgetown University Hospital.

And one way that younger children try to make sense of trauma is through play. Youngsters may pull out action figures or stuffed animals and re-enact what they witnessed, perhaps multiple times.

"That's the way they gain mastery over a situation that's overwhelming," Biel explained, saying it becomes a concern only if the child is clearly distressed while playing.

Nor is it unusual for children to chase each other playing cops-and-robbers, but now parents might see some also pretending they're dead, added Dr. Melissa Brymer of the UCLA-Duke National Center for Child Traumatic Stress.

Among the challenges will be spotting which children are struggling enough that they may need professional help.

Newtown's tragedy is particularly heart-wrenching because of what such young children grappled with — like the six first-graders who apparently had to run past their teacher's body to escape to safety.

There's little scientific research specifically on PTSD, post-traumatic stress disorder, in children exposed to a burst of violence, and even less to tell if a younger child will have a harder time healing than an older one.

Overall, scientists say studies of natural disasters and wars suggest most children eventually recover from traumatic experiences while a smaller proportion develop long-term disorders such as PTSD. Brymer says in her studies of school shootings, that fraction can range from 10 percent to a quarter of survivors, depending on what they actually experienced. A broader 2007 study found 13 percent of U.S. children exposed to different types of trauma reported some symptoms of PTSD, although less than 1 percent had enough for an official diagnosis.

Violence isn't all that rare in childhood. In many parts of the world — and in inner-city neighborhoods in the U.S., too — children witness it repeatedly. They don't become inured to it, Biel said, and more exposure means a greater chance of lasting psychological harm.

In Newtown, most at risk for longer-term problems are those who saw someone killed, said Dr. Carol North of the University of Texas Southwestern Medical Center, who has researched survivors of mass shootings.

Friday's shootings were mostly in two classrooms of Sandy Hook Elementary School, which has about 450 students through fourth-grade.

But those who weren't as close to the danger may be at extra risk, too, if this wasn't their first trauma or they already had problems such as anxiety disorders that increase their vulnerability, she said.

Right after a traumatic event, it's normal to have nightmares or trouble sleeping, to stick close to loved ones, and to be nervous or moody, Biel said.

To help, parents will have to follow their child's lead. Grilling a child about a traumatic experience isn't good, he stressed. Some children will ask a lot of questions, seeking reassurance, he said. Others will be quiet, thinking about the experience and maybe drawing or writing about it, or acting it out at playtime. Younger children may regress, becoming clingy or having tantrums.

Before second grade, their brains also are at a developmental stage some refer to as magical thinking, when it's difficult to distinguish reality and fantasy. Parents may have to help them understand that a friend who died isn't in pain or lonely but also isn't coming back, Brymer said.

When problem behaviors or signs of distress continue for several weeks, Brymer says it's time for an evaluation by a counselor or pediatrician.

Besides a supportive family, what helps? North advises getting children back into routines, together with their friends, and easing them back into a school setting. Studies of survivors of the Sept. 11 terrorist attacks found "the power of the support of the people who went through it with you is huge," she said.

Children as young as first-graders can benefit from cognitive-behavioral therapy, Georgetown's Biel said. They can calm themselves with breathing techniques. They also can learn to identify and label their feelings — anger, frustration, worry — and how to balance, say, a worried thought with a brave one.

Finally, avoid watching TV coverage of the shooting, as children may think it's happening all over again, Biel added. He found that children who watched the 9/11 clips of planes hitting the World Trade Center thought they were seeing dozens of separate attacks.

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EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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