How Olympic athletes (legally) use banned drugs
Therapeutic Use Exemptions: Levelling the playing field, or unfair advantage?
When a Russian hacking group began releasing dozens of private medical files tied to Olympic athletes, it raised an interesting issue.
Namely, that many top competitors in a wide range of sports are privately — and legally — using banned substances by taking advantage of so-called Therapeutic Use Exemptions.
An athlete who obtains a TUE is allowed to use a drug that is otherwise prohibited, provided the athlete can prove that a significant health problem is being addressed by taking it, and that the banned substance won't act as a performance enhancer.
The TUE program had been operating quietly for the most part until a group of Russian hackers calling itself Fancy Bears last month began releasing reams of medical files stolen from a World Anti-Doping Agency database. The leaks they published online revealed that many high-profile athletes and Olympic medal winners have TUEs.
For example, American gymnastics star Simone Biles, who won four gold medals and a bronze at the Rio Olympics, was permitted to take drugs to treat attention deficit hyperactivity disorder (ADHD). U.S. basketball standout Elena Della Donne obtained a four-year exemption for both Adderall, used to treat ADHD, and hydrocortisone, an immunosuppressive drug often used to combat allergic reactions.
Another leak documented tennis star Serena Williams's TUEs for various drugs, while Britain's five-time Olympic champion cyclist Bradley Wiggins and Mo Farah, the two-time double Olympic 5,000m and 10,000m champion, also had medical documents exposed that showed their own TUEs.
Canadian soccer players Christine Sinclair, Sophie Schmidt, Rhian Wilkinson and Melissa Tancredi also had their medical data leaked, revealing long-expired TUEs for salbutamol. The drug, commonly sold under the brand name Ventolin, is used to improve breathing by opening airways in the lungs.
Level playing field?
Those condemning the leaks focused mostly on the breach of privacy.
"This is just another desperate attempt to distract from the real issue of state-sponsored doping and to smear the reputations of athletes and organizations from around the world who choose to operate with integrity and abide by the rules" said Travis Tygert, the CEO of the United States Anti-Doping Agency. "We are confident that people will see this for what it is: a malicious and illegal invasion of athlete privacy followed by a baseless smear campaign."
The argument in favour of TUEs, which were first introduced in the early 1990s, is that they level the playing field for athletes deemed to be suffering from legitimate medical concerns that can be treated with otherwise-banned drugs.
"The TUE process exists to get an athlete back to a state of normal," says Paul Melia, the CEO of the Canadian Centre for Ethics in Sport, which oversees anti-doping efforts in the country. "They probably continue to be disadvantaged because, even though they take the medication, they still suffer from the condition."
"I don't think we have to worry too much about it being an advantage."
The leaked medical records, though, did raise questions about the prevalence of TUEs for ailments like asthma and ADHD, and whether some athletes are using them to gain an edge.
"I like to believe in my heart that [TUEs] are used to level the playing field," says Canadian speed skater Denny Morrison, a four-time Olympic medallist. "But you see a heck of a lot of athletes with puffers, which seems statistically unlikely because for somebody to become a world-class athlete they probably wouldn't start out with a puffer."
Exemptions on the rise
Renowned exercise physiologist Ross Tucker regrets how information about TUEs came to light but is troubled by some of the drugs athletes were granted exemptions for.
"These are powerful drugs, not innocuous stuff like when you have hay fever or allergies. When you start talking about injections and oral use. it's a level above asthma, a level above taking an inhaler [for which you don`t need a TUE]. So you're talking about athletes that are medically quite sick.
"I wonder whether there is not something dubious there. You've got this athlete that either has severe allergies, severe arthritis, severe bronchitis, a severe chest infection. They are taking medication and then going out and winning elite sports events. That doesn't stack up in my opinion."
One fact can't be debated: the number of TUEs continues to rise. Between 2014 and 2016, the World Anti-Doping Agency says there has been a 48 per cent increase in the number of exemptions granted.
In 2015, there were 1,330 TUEs entered into WADA's data management system. According to an analysis by the U.K.'s Sports Integrity Initiative, 63 per cent of these exemptions were granted in three countries — the United States, Australia and France.
"The U.S. in 2015 received 653 TUE applications and it granted 402 of those. So 61 per cent were granted, and that was a 46 per cent increase over the previous year, so a massive increase," says the Sports Integrity Initiative's Andy Brown. "Australia received 369 TUE applications and it granted 234 of those, about 60 per cent."
In 2015, 78 Canadian athletes received TUEs. The CCES says 14 athletes competed in Rio under an exemption.
"No rules have been broken. These people have gone through the correct channels to get these TUEs," Brown says. "But it does appear that a lot of high-performance athletes have serious medical conditions."
Different countries, different rules
Much of the issue appears to stem from the wide array of ways in which TUEs are requested and granted.
It's done in a different way in every country. There is no set way of doing it," Brown says. "In some countries it's the national anti-doping agency, in other countries you have to apply to your international [sport] federation to get a TUE, and in other countries you have to through a government medical agency.
"When you have such a wide spectrum of interests, knowing as we do that sport can be manipulated by people who want their athletes to win, there could be people granting TUEs where they may not be necessary."
Canadian officials vigorously defend the system for granting TUEs in this country. The CCES's Paul Melia says a panel of at least three doctors reviews the diagnosis by the athlete's doctor.
"We have set up a very rigorous process that involves checks and balances, involves expert medical doctors reviewing medical information from the athlete's doctor, often accompanied by lab reports, physical tests. It's not treated lightly."
Melia says the idea of shopping for a doctor who will grant a diagnosis that will lead to a TUE is not viable in Canada.
"That might be true in some countries, but certainly not here in Canada," he says. "If an athlete has ADHD or diabetes, they are going to be diagnosed based on a series of tests for that particular illness. All of that has to be brought before three independent doctors who are experts in that area, have nothing to do with that athlete, no connection. They are just looking objectively and often asking for more documentation.
"It's not easy to get a TUE."
Melia says there needs to be more education around TUEs and how they work.
"One of the things we should learn from this is to be as transparent as possible about the process. But I would certainly stop well short of providing personal medical information in the name of transparency. It's not needed if people understand the process."
That being said, Melia expects increased scrutiny around TUEs and some of the ailments for which they are being granted.
"We do want to monitor the statistics and we do want to see if there are significant changes. We do want to look at the athlete population versus the general population to see if there is anything going on that might suggest there is an over-prescribing of these banned substances for medical conditions.
"I don`t know that to be true but it definitely bears close scrutiny on an ongoing basis."