The UCI Tramadol ban, and one brief thought on painkillers in sport

18 Jan 2019 Posted by

From planes to trains – today’s Short Thought on Sport in on the UCI’s tramadol ban and painkillers in sport!

It comes to you a train somewhere between London St Pancras and St Albans City station, where I’m headed to spend the weekend with Arsenal Football club ahead of their Premiership match against Chelsea.  I am due to give a talk to the club’s HP team and coaches later today, so that should be fun, and maybe the topic of a short thought (or a long one) some time in the future.  I’ll share my slides or something.

Anyway, I don’t have a lot of time, so this one WILL be short(er) than usual!

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The Tramadol ban

So the UCI has decided to ban tramadol, starting March 31st.  It’s been a while coming, and a positive step, taken without waiting for WADA to lead the way.  Tramadol, for those not in the know, is a pretty powerful pain killer that has been reported to be widely used in pro cycling (1 in 23 samples, according to tests, in 2017), including as part of so-called “finish bottles” given to riders near the finish of stages.  Mix up some caffeine pills, add some tramadol, and the theory goes, you have a rocket for the finish line.

This, to me, is clearly a tactic at performance enhancement.  One can argue whether the drug actually works, but the intention is clear, and so is the potential harm (accidents from being “loopy” to borrow a word used by Taylor Phinney, plus the risk of addiction and other side effects like depression).  I think banning it is an obvious step, one on which WADA has dragged its heels a little, and so it’s good that the UCI have gone ahead with it.

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Sanctioning the rider and the team

The most interesting thing about the ban is that they are not going to treat tramadol the same way they do substances like EPO, GH, testosterone, stimulants etc where you get the usual 4 year WADA treatment ban.

Instead, it’s a ‘softer stick’, where the first offense by a rider gets a CHF5000 fine, the second gets 5 months ban, the third 9 months (I’d like to have seen the escalation a little steeper, if I’m honest – I mean, by the time you’ve been caught once, and then twice, surely you should be punished more severely than 9 months for the third time!).

But what’s really interesting is the UCI’s approach to the team, which is where I think a few other sports could borrow the principle.  A team’s first offense (that is, their rider) gets the team a CHF10,000 fine, and the second offense will result in a ban for the whole team of between 1 and 12 months.  And that is really significant.  It puts the onus on teams to ensure their riders are compliant, and I think sends a strong message to the team to educate, and possibly also to prevent, tramadol use.

Reading between the lines, it also suggests that the teams have been identified as responsible for the use of Tramadol in the past.  Thus, punishing the collective and not just the rider may be aimed at cutting the problem off at its source.  This is a good thing, and has interesting implications.

There’s a possible predicament here, because the problem is that pain-killers like tramadol are “societally available”, in the sense that a rider can obtain them without needing his/her team doctor, and now the team will liable for its use.  Imagine you have an uncle whose had some minor surgery, gets given some, and the rider gets it.  Or you know someone who knows a doctor whose ethics are “questionable”.

Nevertheless, I think it’s a good step, and it’s a way to push a message of compliance through the sport that I think is absent for every other drug.  WADA talks about the “entourage”, so this issue is not new to anyone, but the UCI tramadol policy achieves, at least in theory, the effect of connecting everyone who might be responsible.

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Painkiller use, and bans, in other sports

And that brings me to the broader picture.  Last year, in rugby, a well known retired Irish player, Brian o’Driscoll, spoke about how in the later parts of his career, he was basically using painkillers and anti-inflammatories to get through matches, to the point of abuse.  He suggested it was widespread.  He was not the first to do so – reports of players abusing painkillers and anti-inflammatories had existed for years.

This is one of sport’s big problems. Society has normalized the use of painkillers to the extent that people don’t think twice about it. But when it is revealed to be common in sport, the reaction is different. There is thus a tension between what is acceptable to most in sport compared to society. The consequence of this is that it creates exactly the wrong combination of behaviours – you get painkiller use, and secrecy.

Ideally, you’d want no painkiller use/abuse. But if you’re going to have it, you’d at least want open and honest discussions about it. The reaction to O’Driscoll’s admissions suggest we’re a long way from it. There was debate over whether pain killer use is performance enhancing, and whether it should be discouraged, made illegal, or left alone, and a few days of lively debate.  

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Are pain killers performance enhancing? Depends…

On the first issue (performance enhancement), there’s a philosophical bias each person brings to answer that question. I think it depends a little bit on context.  When a cyclist takes tramadol in the final 40km of a stage, that is clearly performance-enhancing, in my opinion.  

Think about it from first principles – what limits performance for a cyclist (or for a runner)?  In some contexts, the limiting factor is oxygen supply to muscles, so you use EPO or blood doping to overcome it.  In other circumstances, performance is limited by muscle strength or power (for a sprinter), so you use testosterone to overcome it.  Performance is sometimes limited by recovery, and once again, Testosterone and growth hormone can bypass normal limitations, and thus enhance performance.

Now think about a cyclist or runner near the end of a race, approaching max efforts. They have pain, the body’s natural protective mechanism, and one of the key things that contributes to fatigue – it forces an athlete to slow down because it makes further exertion too unpleasant.  This is part of the conscious regulation of pacing strategy.  So what do you do?  You shut the signal off with a powerful drug.

If that’s not performance enhancing, nothing is.  It’s pretty clear cut that a person who is not injured, and who bypasses normal physiological regulation using a drug that is usually reserved for controlled hospital use, is doping.

There are other instances where I think it’s less clear cut that it’s performance enhancing, and it’s here that the point I want to emphasize is that we can’t separate or divorce sport from normal life or society.  

For instance, if I’m traveling for work, and I have a major business meeting in the morning, but I sleep very badly on an unfamiliar hotel bed, wake up with a neck in agony, nobody would think anything of it if I took a painkiller or an anti-inflammatory to reduce my pain just to get through the day.  OK, I’m not going to be taking tramadol (if I did, then I’m taking my chances in that meeting), but a milder form is not a problem, provided I don’t do it all the time.

So why then should a sports person who is suffering from a minor issue be denied what is available to society?  And so here, the point I’m getting to is that I don’t think we should unduly deny people access to an intervention that society accepts as normal simply because they’re good at pedaling a bike or throwing a rugby ball around.  In this regard, I’m sympathetic to the athlete.

However, I’m not sympathetic enough to approve of the use of the very powerful drugs.  Milder ones, yes.  Potent prescription drugs usually given for severe pain?  No. The issue is degree or scale.

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Take a lead from the medical community

And the solution may be to let sports be led by the medical community. There is already a system in place to regulate the use of drugs.  Drugs receive a scheduling status that either allows or prevents them from being obtained without a prescription.  So for instance, when I was in Dublin a few years back, I needed anti-inflammatories for my back, but couldn’t even get those, and the most powerful thing I could walk out of a Boots with was aspirin (in SA, you can get them, which is one geographical challenge for this concept).

In any event, in my opinion, any drug that the medical fraternity has deemed powerful enough to require a script from a doctor, or perhaps one that is above a certain classification (S3 or higher in SA) should be banned for use in competition, whereas drugs below that cut-off (S2 and below) should be allowed.  The onus would then be on the doctor and player to manage the use, and then the vehicle or policy illustrated by the UCI’s stance on tramadol can come into play.

The practical issue here is testing – there are potentially hundreds of drugs that are S3 or higher, and testing for all of them may be prohibitively expensive.  If that’s a barrier that the experts realize exists, then discuss it work around a solution.  Identify a shorter list of drugs that should be tested for, and perhaps others need not be.  

The point I’m making is that the regulation of drugs in the every day population is already done.  Sport doesn’t have to reinvent the wheel here, it just needs to work out how to apply the same principles to its context.
This way, I think some of the stigma can be taken out of the situation, and players won’t be unduly denied access to drugs for innocuous issues.

However, it also prevents them from having potentially unlimited access to very powerful pain medication, which I think is bad on many fronts.  I think it is performance-enhancing, no matter how someone wants to argue that it “simply returns the player to their healthy state”.  The model I’m arguing from is that pain is a natural protective mechanism, and it is a performance limiter.  And so eliminating it enhances performance, and should be stopped.  But only at a certain level, and applying common sense, using a ‘softer stick’, seems the most reasonable compromise to me.

Ross

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