Diana Heiman, MD Associate Professor, Family Medicine Residency Director East Tennessee State University

Diana Heiman, MD Associate Professor, Family Medicine Residency Director East Tennessee State University

Objectives Introduce governing bodies in sport Review banned and restricted substances Discuss therapeutic exemptions List Anti-doping resources

Doping Definition Use of any substance or method to increase performance, being harmful to the health of the athlete or being against the values of the game When at least two of the above conditions are present, a substance can be banned by WADA All athletes are responsible for knowing what is in the foods and supplements they ingest!

Governing Bodies in Sport World Anti-Doping Agency (WADA) Established in 1999 to harmonize antidoping policies in all sports and all countries United States Anti-Doping Agency (USADA) Created in 2000 The national anti-doping organization for the Olympic movement in the US

USADA Covered Organizations Covers all Olympic, Pan American and Paralympic sport in the US www.teamusa.org

Banned and Restricted Substances Prohibited at all times Anabolic Androgenic Steroids (AAS) Other anabolic agents Clebuterol Selective androgen receptor modulators Peptide hormones, growth factors and related substances EPO HGH Beta-2 agonists Hormone and metabolic modulators Aromatase inhibitors Selective Estrogen Receptor Modulators Diuretics and other masking agents

Banned and Restricted Substances Prohibited methods Manipulation of blood and blood components (?PRP OK) Chemical and physical manipulation Tampering with samples collected during Doping Control IV infusions of over 50 ml during a 6 hour period unless related to hospital admission or clinical investigation Gene doping

Banned and Restricted Substances Prohibited In-Competition All of the prior substances and methods Stimulants Bupropion, caffeine, nicotine, phenylephrine, PPA, pipradol and synephrine are not banned (Monitoring Program) Pseudoephedrine banned only when urine concentration > 150 micrograms/ml Narcotics Cannabinoids Glucocorticosteroids (oral, IV, IM, rectal)

Banned and Restricted Substances Prohibited in specific sports Alcohol (In-Competition only) Aeronautic, archery, automobile, karate, motorcycling, powerboating Beta blockers (In-Competition only unless listed) Archery also Out-of-Competition, automobile, billiards, darts, golf, shooting also Out-of-Competition, skiing/snowboarding in ski jumping, freestyle aerials/halfpipe and snowboarding halfpipe/big air

Banned and Restricted Substances Monitoring Program Substances that are not on the prohibited list, but are monitored for patterns of misuse in sport Stimulants as previously noted In-Competition only Narcotics hydrocodone, morphine/codeine ratio, tapentadol, tramadol In-Competition only Glucocorticosteroids Out-of-Competition only

Testing Performed In-Competition and Out-of- Competition Out-of-Competition testing performed based upon automated draw taking into consideration athlete ranking, risk of doping in the sport, test history File whereabouts forms quarterly so the athlete can be found for testing

Therapeutic Use Exemption (TUE) Permission to use, for therapeutic purposes, substances or methods contained in the List of Prohibited Substances or Methods where Use would otherwise be prohibited. Therapeutic - Of or relating to the treatment of a medical condition by remedial agents or methods; or providing or assisting in a cure. Cases reviewed by TUE Committee made up of at least 3 physicians

TUE Granted when: Athlete would experience a significant impairment to health if the substance or method was withheld in treatment of an acute of chronic medical condition. The Therapeutic use of the substance or method would not enhance performance other than returning the athlete to a normal state of health following treatment of a medical condition. Treatment to increase low-normal levels of an endogenous hormone are not acceptable. There is no reasonable Therapeutic alternative to the use of the substance or method. The necessity of the use of the substance or method cannot be a consequence of the prior use, without a TUE, of a substance or method which was prohibited at the time of use.

TUE Cannot be approved retrospectively except Emergency treatment or treatment of an acute medical condition was necessary Due to exceptional circumstances, there was insufficient time or opportunity for an applicant to submit, or a TUE committee to consider, an application prior to Doping Control.

NCAA Drug Testing Policy (WADA-certified labs) Started in 1986 Started in 1990 90% DI, 65% DII, 21% DIII

NCAA Banned drugs Stimulants Anabolic agents Alcohol and beta blockers (rifle only) Diuretics and other masking agents Street drugs Peptide hormones and analogues Anti-estrogens Beta-2 agonists Restricted drugs and procedures Blood doping Local anesthetics (under some conditions) Manipulation of urine samples Beta-2 agonists allowed with prescription and by inhalation only Caffeine if concentrations in urine exceed 15 micrograms/ml

NFL Policy and Program for Substances of Abuse (part of CBA) AAS Hormones (and all related substances to agents below) HGH and animal GH s HCG IGF EPO Bets-2 Agonists Anti-Estrogenic Agents Masking agents Diuretics Epitestosterone Probenecid Finasteride Certain stimulants (including pseudoephedrine unless prescribed by Club medical personnel)

NBA Anti-Drug Program (part of CBA) Drugs of Abuse Amphetamine and its analogs LSD Opiates Heroin PCP Marijuana and its by-products Steroids, Performance Enhancing Drugs, and Masking Agents (SPEDs) includes stimulants Diuretics

MLB Joint Drug Prevention and Treatment Program (part of CBA) Any and all drugs on Schedules I and II of the Code of Federal Regulations Schedule of Controlled Substances (= drugs of abuse), plus below Natural and synthetic cannibinoids Cocaine LSD Opiates MDMA (Ecstacy) GHB PCP Performance Enhancing Substances all AAS on Schedule III, hormones and all designer steroids Stimulants (not including PPA or pseudoephedrine)

NHL Performance Enhancing Substances Program (part of CBA, may be modified given current negotiations) Substances relevant to the sport of hockey modified from the WADA banned substance list No list published online

Antidoping Resources Partnership for Clean Competition (www.cleancompetition.org) FOUNDING PARTNERS: CONTRIBUTORS: CORPORATE DONORS:Amgen Inc. (2011) MISSION: To protect the integrity of sport and public health by engaging and supporting the world's top scientists and innovators in high quality anti-doping research and development.

Antidoping Resources Drug Free Sport (www.drugfreesport.com) The National Center for Drug Free Sport (Drug Free Sport ) is a company devoted to preventing drug abuse in athletics. As the premier provider of druguse prevention services for athletic organizations, Drug Free Sport provides strategic alternatives to traditional drug-use prevention programs. More importantly, Drug Free Sport is a SPORT drug-use prevention company. Unlike traditional third-party drug-testing administration companies that conduct primarily workplace and insurance testing, Drug Free Sport works exclusively with sports organizations and their athletes. Drug testing, drug policy development, education for athletes, resource for athletic trainers and physicians

Antidoping Resources World Anti-Doping Agency (www.wadaama.org) United States Anti-Doping Agency (www.usada.org)

Conclusions WADA and USADA govern all Olympic and USA sport athletes NCAA guidelines apply to most collegiate athletes All professional sports have their own testing programs and banned substances that are linked to the CBA for that sport