Banned substances in Sport Dr Lervasen Pillay MBChB(Tuks), MSc(Med)Sports Medicine(Wits)
What is a banned substance? Defined by World Anti-Doping Association (WADA) as a substance and/or method which enhances sport performance in an athlete There are 4 distinct defined groups within which doping infringements can be classified : 1. Prohibited substances at all times 2. Prohibited methods at all times 3. Prohibited substances and/or methods in competition 4. Prohibited substances and/or methods in certain sports
What is doping? Doping derived from dutch word doop viscous opium juice. Defined by WADA as the presence of a prohibited substance, it's metabolites or markers in an athletes body The following instances also constitute a violation of doping regulations : 1.Use, attempted use, trafficking or possession of a banned substance or prohibited method. 2. Refusing or evading sample collection 3. Failure to provide whereabouts or valid reason for not complying with ant-doping process 4. Tampering with the doping control process 5. Administration/attempted administration, aiding or covering up any anti-doping process or regulation
Why is doping control important? 1. Keep the sport fair 2. Avoid acute, acute on chronic and chronic medical problems in the elite sporting population 3. Uphold the ethics of medicine and participating in sports 4. Each country has a NADO (National Anti-Doping Organisation, e.g. SAIDS) WADA releases their new list every year on the 1 st January with additions and exclusions
Timeline of Performance enhancing use in Sports 776 BC 393 BC first Olympics indulged in meat, ate animal hearts and testicles, drank wine potions and hallucinogenics. 100 AD Gladiators used stimulants and hallucinogenics fed horses hydromel (alcoholic beverage from alcohol) and fighters used strychinine for endurance and intensity Late 19 th century French cyclists and Lacrosse teams Preparations from cocoa leaves (cocaine/alkaloid pre-cursors) helped with endurance and delayed fatigue 1904 1920 Olympics Thomas Hicks marathon runner concoction of brandy and strychinine and almost died. A common practice amongst teams and coaches secret formula cocaine became scheduled in 1920 1928 IAAF the first established anti-doping measures in track and field 1940 1945 soldiers in WWII used amphetamines for fatigue, endurance and mood 1950 s Italian and Dutch cyclists used amphetamines as the soldiers did 1958 development of the first anabolic steroid Dr John Bosley Ziegler Dianabol
Timeline of PED s continued He developed it after noticing Russian athletes using testosterone and experimented on a synthetic version on US athletes 1960 First athlete died in Olympics associated with doping Danish Knut Jensen -100km time trial cyclist 100km event fell fractured skull further tests revealed presence of a stimulant called Ronicol in his sytem 1967 Tour de France Tommy Simpson UK died amphetamines and brandy his motto if it takes 10 to kill you, then take 9 1967 IOC develops a medical commission protect athlete health, respect for medical and sport ethics and equality for all competitors 1968 first doping control at Olympics narcotic analgesics, alcohol and stimulants no testing available for steroids. Hans-Gunnar Liljenwenwall pentathlete - stripped of bronze- positive for alcohol calmed in nerves in shooting 1975 anabolic steroids added to banned substance list better testing methods tested in 1976 Olympics in Montreal 1983 random testing - Pan Am Games US and other athletes pulled out of games
Timeline PED s 1988 Ben Johnson stripped of Gold in 100m stanozolol banned 2 years blame a herbal drink was spiked banned for life in 1993 after second positive 1991 East German Swimming coach admits 2 decades of use of PED s critical part of training regime 1994 Diane Modahl swimmer Commonwealth Games banned for 4 years after testing for PED s wins the appeal as she argues that her sample was not stored properly returns in 1996 1998 Atlanta Olympics - Irish swimmer Michelle Smith 4 year ban fails for testing positive for alcohol sample showed lethal levels of alcohol poured whiskey into urine sample container instead 1998 Mark McGwire admits using steroid precursor not on banned list then hits 70 homeruns and breaks 37 year old record 1999 WADA is established in Lausanne 2004 WADA takes over control of the Banned substances list caffeine removed
Timeline PED s 2006 Zach Lund banned for Finasteride hair growth was no on list Jan 1 2005 and removed 2009 Court of Arbitration reduced from 2 years to 1 year no significant fault or negligence 2008 Mario Jones stripped of Gold medal imprisoned for 6 months lying to federal investigators about steroid use. Russian rowing officials banned for 1 year and athletes 2 years systematic doping with offences. MLS first doping ban - Jon Conway and Jeff park androstatiendione and boldenone metabolites after using supplements 2009 Michael Phelps received 3 months fro Marijuana. French tennis player Richard Gasquet positive cocaine after kissing a girl in a club. Manny Rodriguez banned for steroids blames his doctor. 2010 Floyd Mayweather and Manny Pacquiao cancel biggest fight ever as they didn t want to give pre competition anti-doping samples 2011-5 North Korean female soccer players banned for steroids argue it was deermusk in their Chinese supplements 2015 whistleblowers several track and field positive tests no sanctions
In and out of competition?? Prohibited Substances S0 to S5 and Prohibited Methods M1 to M3 are prohibited IN AND OUT of competition (ALL times)-presented in the next few slides Prohibited Substances S6 to S9 and Prohibited substances in particular sport (P1 and P2) are prohibited in competition unless specified - presented in the slides afterward
[S(0) to S(5) and M(1) to M(3)] Prohibited substances and methods at ALL times (in and out of competition)
Prohibited substances 1. Non-approved substances (S0) 2. Anabolic agents (S1) 3. Peptide hormones, growth factor, related substances and mimetics (S2) 4. Beta 2 agonists (S3) 5. Anti-oestrogenics (Hormone and metabolic modulators) (S4) 6. Diuretics and masking (S5) 7. Stimulants (S6) 8. Narcotics (S7) 9. Cannaboids (S8) 10. Glucocorticosteroids (S9)
Non approved substances (S0) A pharmacological substance which does not appear on the list and/or does not have any government health regulatory approval for use in humans (e.g. drugs in pre-clinical, clinical development, discontinued, designer drugs or substances approved for veterinary use only)
Anabolic agents (S1) Diffrentiate into 2 types : 1. Androgenic Anabolic Steroids * Exogenous origin - a substance not ordinarily produced by the body including substances with similar chemical structure and effect #includes substances like nandrolone * Endogenous origin (when the AAS is administered exogenously ) -a substance ordinarily produced by the body naturally. Includes their metabolites and isomers #testerone and metabolites 2. Other anabolic agents #Clenbutirol These substance are linked to hepatic damage, acute tendon rupture, increase cardiac risk (by decreasing HDL cholesterol)
Peptide hormones, Growth factors and related substances (S2) Prohibited similar chemical structure and similar biological effect Erythropoetin Stimulating Agents (EPO) Human growth hormone (HGH) Insulin like growth factors (IGF) and corticotrophins Fibroblast growth factors, Platelet derived growth factors, hepatocyte growth factors, mechano growth factors, vascular endothelial growth factors or any growth factors affecting muscle and tendon degradation, vascularisation, energy utilisation or fibre type switching
Beta 2 Agonists (S3) All beta 2 agonists as well as there isomers EXCEPT!!! NOT PROHIBITED: Inhaled salbutamol (max 1600 mics/24 hrs) Formeterol and (max 54 ics/24hrs) /or Salmeterol (max 200 mics/24 hrs) as long as taken as per manufacturerers indications and dosage Salbutamol > 1000ng/dl or Formeterol >40ng/dl in urine will be considered as an Adverse Analytical Finding (AAF) unless the athlete can prove it was according to the prescribed therapeutic dosage Reason it's banned - can have ergogenic effects orally
Hormone and Metabolic modulators(s4) Prohibited and includes: Aromotase inhibitors Selective Estrogen Receptor Modulators (SERMS-Tamoxifene) and SARMS A = Androgenic) Anti-oestrogenic substances (clomiphene) Agents modifying myostatin function (causes unopposed muscle growth), metabolic modulators (insulin, MELDONIUM)
Diuretics and masking agents (S5) Agents including those with similar biological function Common use - anti-hypertensive Includes probenecide, acetazolamide, spironolactone, thiazides (NEW-2016) EXCEPT Drosperinone, pamabron, opthalmic use of carbonic anyhydrase inhibitors Increases renal clearance thereby masking actual levels of other possible substances If used with a substance that has threshold limits (Salmeterol, salbutamol, formeterol, ephidrine, methylephidrine, pseudoephidrine), a TUE is applicable masking agent and the drug above
Prohibited Methods 1. Manipulation of blood and blood components (Enhancing O2 delivery ) (M1) 2. Chemical and Physical Manipulation (M2) 3. Gene doping (M3)
Manipulation of blood and blood components (M1) The following is prohibited : 1. Administration of autologous, homologous or heterologous blood into the circulatory system 2. Artifically enhancing uptake, transport and delivery of oxygen EXCEPT by the use of supplemental oxygen 3. Any form of intravascular manipulation of blood or its components by a physical or chemical means
Chemical and physical manipulation (M2) Prohibited : 1. Tampering or attempting to tamper or interfere with the doping control process or samples Mclaren report 2. Intravenous infusion or injection of more than 50ml / 6hrs period unless legitemately required during hospital admission or a procedure
Gene Doping (M3) Prohibited : 1. Transfer of polymer of nucleic acids or nucleic acid analogues 2. The use of normal or genetically modified cells
Includes S(0) to S(5) and M(1)to M(3) Prohibited substances IN competition and PARTICULAR sports
Stimulants (S6) Prohibited Usually use it to keep alert, awake, competitive and aggressive a: Non specific stimulants include amphetamine and cocaine b: Specified stimulants include ephedrine, methylhexamine, pseudoephedrine Since 2014 Monitoring program and NOT banned - nicotine, caffeine, bupropion, phenylephrine, phenylpropolamine, pypradol and synephrine Cathine-prohibited if concerntration > 5mics/ml in urine Ephidrine and methylephidrine prohibited if concerntration >10mics/ml urine Local epinephrine and adrenalin in anaesthetic is NOT prohibited Pseudo ephidrine Prohibited when concentration >150mics/ml urine
Narcotics (S7) Prohibited examples are heroin, morphine and pethidine Not only from hallucinogenic, perceived increase in endurance but illegal!!
Cannabinoids (S8) Natural cannabis, (NEW 2016 hashish, marijuana) synthetic (THC) or mimetics are prohibited
Glucocorticoids (S9) Prohibited when given oral, intramuscular, intravenous or rectal. Intra-articular, inhalation, intra-nasal, peri-tendinous are not prohibited - but it's always a good idea to note it on a doping control form
Prohibited substances in certain sport P1 : Alcohol (ethanol) Using breathalyser or blood. Doping violation equivalent to blood alcohol concerntration of 0.1g/l Airsport Automobile Archery Powerboating P2 : Beta blockers (e.g propanalol, atenalol) Archery and Shooting (in AND out of competition) Automobile Billiards Darts Golf Skiing/Snowboarding
Therapeutic Use Exemptions Application no less than 21 days prior to event unless it's an emergency Completed form and supporting documentation (xrays, ultrasound, MRI, blood results) Application will be considered by the committee - there is no other alternative medication or alternatives have failed, withdrawal of the medication will cause serious health risks. Apply for retrograde TUE in the case of emergency medical medication and use of a band substances with necessary (e.g. asthmatic with status asthmaticus, life threatening allergic reaction)
Declaration of use When medication is used, one must declare that it was used on the doping control form this is the athletes responsibility but you may assist by giving the athlete details of the medication. SAIDS meds used in last 7 days separate paper and legible Chaperone/DCO transfer info to form always a good idea to confirm all has been captured correctly Advisable to add EVERYTHING that the athletes (including supplements etc)
Supplements : SAIDS position statement In 2011. Does not support any supplement Advises on proper diet Not only doping risk but health risks can be implicated with supplements Consumers must be aware Supplement market is not regulated As a practitioner, one should not endorse supplements HFL-a company that tests products. Indicated by image on label. 1.Informed nutrition-random batches are testing for substances on the WADA list. 2.Informed sport - every batch produced is tested Just one method to reduce risk but not 100% Identifying supplements chemical structure, huge promise from the product
Eating advice Be Aware of Banting!!
Doping control process In and out of competition testing. First done in 1968 Olympic Games in Mexico-reasondue to amphetamine related deaths in the 1960 Olympics and 1967 Tour de France. It's done at accreditted laboratories-africa has none recently in June lost accreditation in the north as well as Bloemfontein due to outdated equipment and poorly serviced presently samples are flown to Qatar of Europe Athlete needs to give there whereabouts to federation out of competition In competition (defined as 12hrs prior to event to when event ends)- Athletics-Placed positions always tested, volunteers in first 10. Team sport minimum 4 - two from each team. Testing can be targeted - whistleblowers. Doping control Chaperone with athlete from end of event-athlete is advised that he will be tested. Chaperones document everything - any drinks that have been had, if the athlete was out of sight etc. Sample given with the doping control officer visualises sample collection. Sample split into A and B (sometimes there s a partial sample as well). Athlete has samples in his vision at all times until it is placed in the courier bag. Sometimes blood testing is done-more for specific agents, develop a biological passport etc. Urine - 90mls - split into sample A(60mls) and sample B(30mls)-SG 1.00-1.05 Professional behaviour during chaperoning, testing-entire process - can be used against the doping process should there be a positive test
...cont Doping control Results are reported - on sample A - if positive for an agent - Adverse Analytical Finding (AAF). Should sample B be tested or the athlete dose not want it to be tested then an Anti-Doping Rule Violation (ADRV) is registered and necessary steps to take action begin
Common M2 violations Paraplegic athletes use methods like catether clamping and filling the bladder with Saline in order to increase adrenalin response (boosting) Other common methods :
Advice to medical support staff 1. Do not indiscriminantly advise on supplements - educate yourself first - due diligence to investigate products, get a letter from the company originally signed, advise them to take legal responsibilty etc. 2. First do no harm - proper medication for proper indication 3. Use evidence based methods of management all the time not always easy in the sports medicine environment 4. Use every interaction as an opportunity to educate athletes, coaches and parents about doping, medication and supplement usage 5. Educate yourself in the doping regulations/process of each particular sport
Example : AAF notification
Important changes to be implemented in the WADA code from 2014 Last changes were in 2014 1. Assisting someone evading an ADRV (can involve management, coach, fitness coach, doctors, physio, kit manager -anyone!) and working with someone that is a banned person (prohibited association) 2. Ban for positive ADRV increased from 2 years to 4 years. Reduced to 2 years only if : a. athlete tests positive on a non specified substance but can prove the ADRV was unintentional b. athlete tests positive on a specified substance but the National Doping Office cannot prove it was intentional 3. Ban for positive ADRV increased from 2 years to 4 years. Reduced to 2 if: the athlete can prove failure to submit a sample was unintentional 4. Assisting someone to try and get away with an ADRV (2-4 years ban) 5. Associating with someone that is banned (1-2 years) 6. If banned, there is a limited right to train and can be tested during the ban period 7. Sentences can be reduced depending on specified circumstances but WADA must agree to the decision. Prompt voluntary admission can lead to a significant reduction in the ban. 8. More than 2 members of a team found ADRV-entire team banned, points docked, disqualification 9. Move toward plea bargains
Doping and kids Recent study showed that kids between 12 and 17 years are doping more often. Across all spectrums in sports-4% Usually under advisement by team mates and coaches Pressures by parents, schools, team mates and coaches
Olympics doping
...cont Olympic doping Adverse/atypical results ncreased by 20% Number of tests only increased by 0.8% 2012-4723 2013-5962 Adverse findings even in chess! Football - 28000-140 adverse findings (0.5%) Cyclists - 22000-1.2% adverse findings Rugby - 6000-1.3% adverse findings Veronica campbell Brown - banned 2013 - diuretic Asafa Powell - 2013 - oxalifrine "I want to be clear in saying to my family, friends and, most of all, my fans worldwide that I have never knowingly or wilfully taken any supplements or substances that break any rules," "I am not now - nor have I ever been - a cheat." "I don't have a sabotage story... I basically put my trust in someone and was let down,"