With the recent Rio Olympic games, it was not entirely unexpected when doping once more permeated the media. This time it wasn’t Lance Armstrong, Maria Sharapova, or roguish Russian athletes in the limelight, but an attack by a cyber espionage group exposing an array of medical information to the public.

 The “Fancy Bears” scandal exposed numerous confidential medical documents including the medications athletes had taken under an approved TUE (Therapeutic use exemptions – more on these later). But what is the big deal with doping? Do drugs even affect sport performance? And more importantly, as health care professionals, why is it important to be aware of doping?

It may not surprise you that doping isn’t only a modern phenomenon. According to ancient documents within Norse Mythology, warriors were reported to take a substance coined Bufotenin – believed to increase strength. It is commonly found in mushrooms and on the skins of some toad species (delicious…).  The doping epidemic appeared to explode in the 1960’s. In the 1960 Rome Olympic games, Danish cyclist K. Jensen actually died with amphetamines taken to boost performance.

So does it work? Although some evidence is mixed, you have to remember that even a minute advantage can be all it takes between first and second place – that’s a gold medal and gracing the history books or failure and definitive anonymity. The science makes sense. Take blood doping for example – Injecting EPO stimulates red blood cell production, resulting in more haemoglobin, aiding oxygen transportation and a higher rate of aerobic respiration. Anabolic steroids build muscle size and strength by activating cellular protein synthesis, complementing muscular power and recovery. You can see the appeal when your legs are burning on the final climb of the Tour de France, or when you need to exit the 100m blocks pretty damn quickly on the world’s biggest stage.

When we get to the technicalities, doping methods are categorised as:

Prohibited Substances
•S1 Anabolic agents
•S2 Hormones and related substances
•S3 Beta-2 agonists
•S4 Agents with anti-oestrogenic activity
•S5 Diuretics and masking agents

Prohibited Methods
•M1 Enhancement of oxygen transfer
•M2 Chemical and physical manipulation
• M3 Gene doping 

With its associated dangers, not to mention in the interest of sportsmanship, many substances are prohibited. Whether a substance is prohibited or not depends on multiple factors including the sport itself and the level of competition. The World Anti-Doping Agency (WADA) deems a substance or method must be prohibited if it meets at least two of the following conditions:

• The substance or method has the potential to enhance, or does enhance, performance in sport.
• The substance or method has the potential to risk the athlete’s health.
• WADA has determined that the substance or method violates the spirit of sport.

(If you’re interested http://globaldro.com provides a comprehensive list of medications for the use of athletes and health care professionals alike.)

Contrary to popular belief, sport stars aren’t superhuman and illness may require them to take certain medications. So what happens when these medications are on the prohibited list? This is where the TUE comes in.

TUEs or Therapeutic Use Exemptions are tools whereby a competitor who has a genuine medical need for a banned substance can apply for immunity to use it, providing it doesn’t bestow an unjust advantage.

An athlete and their doctor must submit a TUE at least 21 days prior to the time of competition and a panel of three doctors will assess the application. Very occasionally, such as in a medical emergency or when circumstances mean there isn’t opportunity for an athlete to submit, retroactive TUEs can be applied for.

Now have a think about the following scenarios…

1) So let’s say you’re a GP and an athlete comes to you the day before a big game with a common cold. What do you advise him or her to take? Is there a risk?

You may not think so but actually there is. Pseudoephedrine is a substance found in many over the counter cold and flu preparations. In sports such as football and rugby it is prohibited when urinary concentration exceeds 150 microgram/ml. This is because of its properties as a stimulant. Just before the Sochi Olympics Ice Hockey final, Sweden’s star player, Backstrom, tested positive for this substance, allegedly under the advice of his team doctor. This infamously led to him missing out on the gold-medal game. When in doubt, check!

2) A 28-year-old shooter who has Long QT syndrome comes to your cardiology clinic. Currently competing at national level, he is an aspiring international athlete but is deemed high risk with his condition. Your consultant wants to put him on atenolol. Are there issues here?

There are most definitely issues here. In shooting (along with other sports such as archery where being as steady as possible is vital for success) beta-blockers are completely exempt in competition time. Unfortunately, this shooter will have to consider choosing a different sport!

3) You’re a gastroenterology registrar and are discharging a professional rugby player who has been treated for a flare of IBD with some prednisolone (40mg OD). The course is due to finish 2 days prior to a big game on Saturday. Does he need a TUE?

Yes! Oral steroids tend to have a washout period 5-7 days. An application process needs to take place for a TUE so that the player can play in competition, whilst completing his steroid course. This may fall on you as the treating doctor, or the medical personnel of their team.

Evidently, drugs in professional sport can provide numerous challenges. In the world of medicine, it is our duty to provide the best care for our patients. When dealing with this population it is best to check prescriptions and be cautious. With such a long and notorious history, it will be interesting to witness first hand the future of doping in sport.

References

Hughes D. 2015. The World Anti-Doping Code in sport: Update for 2015. Australian Prescriber. 38(5):167-170.

The World Anti-doping Agency. 2016. https://www.wada-ama.org/en/what-we-do/science-medical/therapeutic-use-exemptions Accessed: 01/11/2016.

Miller, R. 2002. The Encyclopedia of Addictive drugs. Greenwood Publishing. Pages 60-62.

The Global Drug Reference Online. 2016. http://www.globaldro.com/Home Accessed: 01/11/2016.