Elite athletes are a unique bunch, deserving no less attention than we provide to any patient, despite our occasional
difficulties in reconciling their seemingly trivial clinical demands. Obsessive-compulsiveness is a common pre-requisite
for contemporary high performance sport, and an athlete’s innate desire for an accelerated return to physical activity
can make them a clinically challenging prospect.
This editorial comment is not written with the intention of advising doctors how best to treat their patients – this
responsibility appropriately resides with the clinician. The aim of this article is to raise awareness of the international
“Code” for duty of care, which is unique to sport.1 It is important that clinicians who provide care for high
performance athletes familiarise themselves with these obligations, and consider them as no different as the protocols
followed, for example, for an occupational health check or an insurance medical examination.
Doping and drug testing in sport
One particularly perplexing area in sports medicine relates to the use of a group of restricted medicines, defined in
sport as “prohibited substances”. This is especially challenging when these medicines are also the usual recommended treatment
for particular medical conditions. Some physicians vigorously object to the intervention of an external authority that
restricts valid therapeutic options when patient wellbeing is the doctor’s primary responsibility. In principle there
is no argument with this opinion. However, in sport at the highest levels, certain decisions about the use of prohibited
medicines are non-negotiable.
Prohibited substances in sport
The internationally agreed List of Prohibited Substances in Sport was established to address the misuse of drugs for
purposes of performance enhancement.1 The list, containing common therapeutic medicines, is formulated and
reviewed annually by an international committee of experts appointed by the World Anti-Doping Agency (WADA).1
To qualify for consideration of list inclusion, a particular drug must meet two of the following three criteria defined
by WADA:
- The potential for performance-enhancement in sport
- The potential for harm when used for “non-clinical” purposes
- Being in violation of “the spirit of sport” as defined in the Code
Elite athletes are under the scrutiny of anti-doping authorities and are closely monitored and subjected to testing
both in- and out-of-competitive sport. To the public this may appear draconian and a major intrusion of privacy. But to
those familiar with contemporary sport, these practices have become “stock-in-trade” to a generation of competitors. These
athletes also have an obligation to disclose their status as a tested athlete to their doctor. In New Zealand, athletes
in the drug-testing pool will carry a small “wallet-card” provided by Drug-Free Sport New Zealand (DFSNZ), with relevant
identification and information for the doctor. However, despite the vigilance of anti-doping agencies and the acceptance
by the majority of athletes of strategies to minimise drug misuse, high profile cases provide a stark reminder that the
temptation to cheat by using banned, performance-enhancing substances is ever present.2
Therapeutic use of prohibited drugs in sport
When, on justified occasions, there is no alternative but to use a listed, prohibited substance to treat an athlete-patient
this can be done under the Therapeutic Use Exemption (TUE) process.12 This is a means by which athletes with
genuine medical conditions have the justification for receiving valid, essential treatment. The TUE process protects the
athlete from any punitive sanction arising from the presence of a banned substance detected by the analysis of their urine
or blood. However, in the interests of consistent application and international integrity, the TUE process is subject
to certain pre-requisites, including the provision of adequate diagnostic evidence and specialist endorsement to meet
the criteria for a successful TUE application.
The international committee of WADA responsible for establishing TUE Standards, has provided guidelines for several
conditions that commonly require the use of prohibited substances.1 Examples include chronic inflammatory
bowel disease (systemic glucocorticosteroids), attention-deficit hyperactivity disorder (methylphenidate or amphetamine),
hypogonadal hypogonadism (testosterone) and type 1 diabetes (insulin). The WADA website has instructions for physicians
managing these conditions in elite athletes subjected to doping control.
“Retroactive” therapeutic exemption would always be endorsed where the management of any life-threatening episode necessitates
the use of a prohibited substance, such as in an emergency department or acute surgical setting. Cases of athletes requiring
urgent surgical intervention or treatment for acute asthma or anaphylactic shock are examples frequently encountered in
this category. However, the attending physician still remains responsible for ensuring that a complete record is kept
of any prohibited substances used and a clear note of their clinical indication is provided to the athlete to substantiate
the TUE application.
The ethics of the misuse of drugs in sport
Disgraced cyclist Lance Armstrong was legendary for his survival from testicular cancer and his unprecedented success
in seven consecutive Tour de France races. However late in 2012, the widely publicised Report of the United States Anti-Doping
Agency (USADA) was the final straw for Armstrong.3 This document provided unequivocal evidence that his Tour
de France successes were enhanced through the use of autologous blood transfusions and an expensive intravenous cocktail
that included recombinant erythropoietin, testosterone and corticosteroids. These drugs were administered and closely
monitored by medical associates who cunningly circumvented routine drug-testing procedures. Armstrong’s undoing was arguably
sports greatest “drug-bust” but it provided clear confirmation of medical complicity and the “athlete entourage”, and
raised concerns for the disregard of ethical clinical practice.4 Dr Michele Ferrari, the Italian physician
implicated with Armstrong, was linked to trafficking, possession and assisting doping. He has received a lifetime sports
ban from WADA and the final opinions of the medical jurisdiction are awaited.
Pehaps the most distasteful experiment in the use of performance-enhancing drugs in sport was demonstrated by the government
of the former German Democratic Republic (GDR) during the period of the 1960s to 1980s. East German physicians, scientists
and coaches collaborated in systematic drug administration to athletes, under the sanction of the GDR Ministry for State
Security (Stasi). This clandestine programme of experimentation involved athletes, predominantly females, who received
high dose potent drugs without concern for moral or ethical principles.5 – 9 Under the pretence of research,
thousands of “subjects” were implicated in “…one of the largest pharmacological experiments in history… running for more
than three decades…”. 5
The consequences of this era in East German sport and politics were profound and far-reaching. Young, female athletes,
to whom excessive doses of anabolic androgenic steroids had been administered, suffered long-term consequences. The true
facts of this horrendous “experiment” were not made public until the unification of Germany in 1989 when official Stasi
documents became available for scientific scrutiny.5, 8, 9 The world of clinical medicine and sport science
still reels from the revelations. In this contemporary human experiment, “…government policy, measured in gold medals,
gave scant regard to human suffering and permanent disability.”10
An increasingly vocal body of contemporary medical opinion has declared the misuse of drugs in sport as an unethical
and illegal practice and the Medical Council of New Zealand (MCNZ) has added its support.11 In 2010 an updated
statement entitled “Prescribing performance-enhancing medicines in sport” was posted on the MCNZ website. It states: 11
“Any doctor who knowingly prescribes, administers, traffics, supplies or otherwise assists in the use of prohibited
substances, for the deliberate purpose of enhancing sports performance and helping a sports person to cheat, may be
subject to disciplinary proceedings and may be liable to a charge of professional misconduct.”
Providing health care for an athlete: frequently asked questions
Q: What obligations do athletes have in terms of drug testing?
A: Elite-level, New Zealand athletes are constantly under scrutiny by our National Sports Anti-Doping Agency, Drug-Free
Sport New Zealand (DFSNZ). These profiled athletes must adhere to doping control procedures in accordance with their obligations
to the World Anti-Doping Code established by WADA. This may require the witnessed collection of a urine sample for analysis
following an event (“in-competition testing”) or without prior notice, involving a sample being collected at a training
venue, a residence or elsewhere (“out-of-competition testing”). Athletes may also be required to undergo blood sampling
as part of the “athlete biological passport”.
Q: How do I know if a patient is a tested athlete?
A: It is the responsibility of individual athletes to inform their doctor of their status as a listed athlete who may
be tested for prohibited substance use. In New Zealand, athletes in the testing pool will usually carry a small “wallet
card” provided by DFSNZ, with relevant identification and information for the doctor. It is also important to be aware
of an athlete who is not currently subject to drug testing in sport, but who may be called in to compete at very short
notice.
The testing that the athlete undergoes may be both at the time of competition and at random. It is important then, that
clinicians do not assume that a medicine will only be in the body for a short time and can be used in between competitions.
Most prohibited substances are prohibited at all times.
Q: What obligations does a doctor have when treating an elite athlete?
A: When providing care to a patient who is an elite athlete, it is necessary to become familiar with the requirements
for sports anti-doping. Before administering or prescribing medicines to an athlete who might be subjected to doping control,
it is important to first clarify whether the intended medicine is included on the WADA Prohibited List.
If the medicine is prohibited, and no permitted alternative is available, then it is necessary to apply for Therapeutic
Use Exemption (TUE) on the athlete’s behalf.
Q: How do I know which medicines are prohibited?
A: The list of substances prohibited by the World Anti Doping Agency (WADA) is large. Substances are classified under
four categories: substances prohibited at all times for all sports, substances prohibited during competition, substances
prohibited from specific sports and limited-use substances.
Many of the prohibited medicines are not routinely prescribed in general practice. However, some prohibited medicines
are very commonly used in the community, such as insulin, oral corticosteroids, beta-2 agonists (therapeutic use via inhaler
is permitted) and diuretics.
Q: How do you access the WADA List of Prohibited Substances?
A: Check the medicine in the New Zealand Formulary. If a medicine has restrictions on its use based on the current WADA
list, it is indicated as “restricted in sport” under Cautions.
For further information on the medicine, visit the DFSNZ website
(www.drugfreesport.org.nz); click on “check your medications
online” to search for individual medicines, or phone 0800 DRUGFREE, or text the name of the medicine or active ingredient
to 4365 (texts cost 20 cents) for full details of its status.
MIMS resources display ‘athlete’ or an athlete logo next to each medicinal substance, to indicate a permitted medicine
or medicine that is permitted with restrictions.
The full 2013 Prohibited List is also available from the World Anti Doping Agency (WADA), see:
www.wada-ama.org/en/Resources
Q: What is the process of Therapeutic Use Exemption?
A: The TUE process protects all athletes and their medical advisors in situations where, in the athlete’s best health
interests, the use of a prohibited drug is indicated.
Ideally the application should be made before treatment begins. However, the TUE process also allows retroactive approval
to be granted in some situations, e.g. treatment in emergency situations, and exceptional circumstances such as the accidental
prescription of prohibited substances. The requirements of TUE are included on the application form available on the DFSNZ
website. It is necessary to demonstrate a clear diagnostic process and specialist endorsement, especially where the drugs
used have a high potential for performance enhancement, e.g. the use of anabolic androgenic agents or potent stimulants.
Further information on TUE and a downloadable application form is available from:
Q: Can athlete patients be prescribed the usual medicines for asthma?
A: The inhaled beta-2-agonists currently permitted in sport (WADA, 2013) are salbutamol (maximum 1600 micrograms over
24 hours), formoterol (maximum delivered dose 54 micrograms over 24 hours) and salmeterol (recommended therapeutic regimen
as per medicine datasheet).
Beta-2-agonists by any other method than inhalation are prohibited.
Inhaled corticosteroids are permitted. Oral, IM or IV corticosteroids are prohibited.
A TUE must be applied for if an athlete requires a prohibited medicine (or dose) for control of their asthma.
Q: What can athlete patients be prescribed for pain and inflammation?
A: Pain and inflammation are common in people competing professionally in sport. Mild analgesics and anti-inflammatories,
for general treatment of pain, inflammation or headache are permitted options. For example, paracetamol, non-steroidal
anti-inflammatory agents, codeine and tramadol are all permitted medicines on the WADA list. Strong opioids, such as oxycodone
and morphine, are prohibited during competition.
Beware of combination products and supplements
There have been many cases of athletes who have unknowingly taken prohibited substances which have been “hidden” in
a product. Dietary, nutritional and sport supplements and herbal products are not manufactured to the same standard as
medicines, and may contain substances that are prohibited in sport.
Labelling standards for supplements manufactured in New Zealand and overseas do not always require a complete list of
components on the product label. Therefore, it is often not possible to guarantee the status of a supplement that is used
in sport. Elite athletes need to be aware of this risk, and be cautious about the use of supplements; reputable products
should be chosen, and the ultimate responsibility that they do not contain prohibited drugs remains with the athlete.
“Cough and cold” preparations have been implicated in cases of use of prohibited substances, but this is less common
now since pseudoephedrine (prohibited in sport) was removed from over-the-counter cough and cold products. Pseudoephedrine
is now only available on prescription (as a single product), and is a controlled medicine.