A Doctor’s Perspective - CASM Annual Conference Part 1
Doping, Injuries, and other Issues from the Canadian Academy of Sports Medicine Annual Conference

By Dr. Jennifer Walker, MD CCFP.

While attending the recent annual conference of the Canadian Academy of Sports Medicine, I realized there were a number of topics that would be of interest to cycling fans.  A number of the injuries and conditions discussed are either common in cycling or have occurred recently in prominent riders.   Plus there was discussion of ongoing issues such as doping that affect cycling. 

Performance Enhancing Drugs
Unfortunately, use of performance-enhancing drugs in sport is an issue that has been in the forefront, particularly in cycling again recently.  I found it interesting to attend a session presented by a staff member of the Canadian Centre for Ethics in Sport (CCES) – their purpose is “to promote ethical conduct in all aspects of sport in Canada”.  They administer the Canadian Anti-Doping Program, which is compliant with the World Anti-Doping Program as determined by WADA.  At the session, there was a significant amount of frustration expressed by some of the doctors who have been to major games or who work for pro teams.  This frustration was regarding areas of potential confusion in the WADA Prohibited List, as well as lack of standardization between countries and sports federations regarding Therapeutic Use Exemptions (TUEs).    

A substance (or method) can be included on the WADA Prohibited List if it is deemed to meet two of the following three criteria:  it has performance-enhancing effects, it has potential or actual health risks, and/or WADA determines that it “violates the spirit of sport”.  The last criteria is thought by some to be quite nebulous, and would include some “social drugs” as well as the recent suggestion to ban the use of altitude tents.  WADA’s draft Prohibited List for 2007 is currently being reviewed by stakeholders before being finalized in the fall and coming into effect in January 2007.  A new website, the Global Drug Information Database (http://www.didglobal.com), allows athletes to look up medications by their Canadian and UK brand-names to check whether something is permissible or not.   

Areas of debate and confusion currently include beta-2-agonists (used for asthma treatment), glucocorticosteroids (GCS – have anti-inflammatory effects and different from anabolic steroids), and stimulants.  CCES has apparently been pushing for the exclusion of common beta-2-agonists plus GCS from the List, or at least to raise the threshold for these.  There is not much evidence that they have any significant performance-enhancing effect, and they are commonly used for genuine medical reasons.  

Therefore, there is a high risk of inadvertent positive tests and a lot of TUEs must be completed by physicians and processed by the national anti-doping organizations.   In 2005, a number of Australian sports federations (including the AFL) also petitioned that GCS be removed from the List.  Many sports injuries are treated with GCS in the form of cortisone injections, and these require an abbreviated TUE form to be completed. Topical GCS including skin, ear, eye, and nasal preparations already are permitted without a TUE (e.g., the type of skin cream Lance Armstrong was apparently prescribed that caused a positive test in 1999). 

As for stimulants, while quite a number are specifically listed as prohibited for in-competition usage, there is also the statement, “and other substances with a similar chemical structure or similar biological effect(s)”, suggesting that all potential stimulants are banned.  Yet stimulants such as caffeine and pseudoephedrine are no longer prohibited but only monitored.  Stefan Schumacher had the situation where he tested positive in 2005 for cathine, listed as prohibited, but also known as norpseudoepinephrine. The alternate name is not specifically listed, and was the name apparently checked by his team doctor and the Dutch cycling federation and thought to be allowable.  One would hope that WADA could clear up some of the confusion and concentrate more on substances/methods known to be significantly performance-enhancing.  

Standardization of TUE's
The lack of standardization regarding TUEs is also a problem. These may be granted if an athlete would experience significant health problems without taking the prohibited substance/method, therapeutic usage would not cause performance-enhancing effects, and there is no reasonable alternative for treatment. There is not always mutual recognition among various sports federations or national anti-doping organizations, so work is being done to develop international medical guidelines for the TUE process. An example given was beta-2-agonists (bronchodilators) for asthma – in Canada, only an abbreviated TUE form need be completed, but if an athlete is competing internationally, pulmonary function test results may be required as well. 
Among the most common full TUE applications in Canada are the following:
1) methylphenidate (Ritalin) and Dexedrine for ADD/ADHD.
2) prednisone for Crohn’s disease.
3) insulin for diabetes mellitus.
4) finasteride (Propecia) for alopecia/hair loss.
5) short-term narcotics for post-operative pain control. 

Of interest to me was that although we commonly think of certain drugs or methods such as blood transfusions as being “performance-enhancing”, other techniques exist as well.  In another session I learned that “boosting” among spinal-cord injury athletes involves inducing a pain stimulus below their injury level (e.g., by blocking their urinary catheter) in order to induce a condition called autonomic dysreflexia. This causes a potentially dangerous increase in blood pressure and heart rate, and up to a 10% improvement in performance. So far, the only way to try to detect this is by doing random blood pressure checks before races.  This then is analogous to the hematocrit testing done in cycling, and is another example of inferring cheating through “health checks”, even if it can’t be conclusively proven that an athlete really used a prohibited substance or method. 

Dr. Walker's report will be continued in Part 2

References (part 1):
Canadian Centre for Ethics in Sport - http://www.cces.ca
World Anti-Doping Agency - http://www.wada-ama.org/
Masters, Roy.  “Ban on cortisone a giant headache for AOC”, Sydney Morning Herald. May 20, 2005 (http://www.smh.com.au/news/Sport/Ban-on-cortisone-a-giant-headache-for-AOC/2005/05/19/1116361677991.html)
 “Schumacher Waiting for Verdict”, Cycling News. August 11, 2005 (http://www.cyclingnews.com/news.php?id=news/2005/aug05/aug11news2)