This is a direct continuation to our article on ‘Doping in Athletes’. The reader is referred to that article for further readings. Furthermore, the reader is advised to thoroughly peruse both articles to get a complete picture of the extent of doping in sports. As with the previous article, we will be featuring cyclists who were involved in doping controversies with a short description of how they were involved. This is by no means a comprehensive listing but rather a side feature to the article.
Tom Boonen tested positive for cocaine in a test on 26 May 2008. Since this was outside competition he does not face sanctions by the UCI or WADA but was barred from the 2008 Tour de France. Tom Boonen again tested positive for cocaine in an out of competition test on 27 April 2009.
The Olympic Games from 1984 to 2004
The case of ephedrine (Japanese athlete) was caused by a tea of herbal products (ginseng). The case of nandrolone (Finnish athlete) was very much discussed at the time, because the athlete denied use, causing great concern. Later, it was proved that the athlete had an autologous blood transfusion before the Games and the substance, being used months before, was transmitted by his own blood.
False medical certificates of hypertension were used in Los Angeles to justify use of ß-blockers in shooting. Diuretics were used in combat sports like judo, boxing, and wrestling, where the category of the athlete is dictated by their weight. Blood transfusion was used in cycling, and physical manipulation of the urine was done in weightlifting. For this reason, the IOC Medical Commission modified once more the list of banned pharmacologic classes in 1987, including ß-blockers and diuretics. Restricted substances and forbidden methods were also included, to prevent the use of local anesthetics and corticosteroids, and blood transfusions and physical manipulation of the urine. According to the new list, if the pH of the urine collected was not between 5 and 7, and the density was lower than 1.010, the sample was considered invalid and a new one requested, although both samples were sent to an IOC-accredited laboratory for analysis.
Probenecid was also detected for the first time by Manfred Donike in the Pan-American Games of Caracas, Venezuela, 1 year before the Games of Los Angeles and was included in the list as a pharmacologic manipulation of the urine. A system of escorts was also created by the IOC Medical Commission to accompany the athlete after their notification, to avoid physical manipulation of the urine in the dressing rooms.
In the Olympic Games of 1988 in Seoul, it was believed that the athletes would learn their lesson, and only a few positive controls would be detected. The reality, however, was very different. Many cases were detected, among them that of Ben Johnson, one of the more important athletes of his time, bringing great impact in the media the world over.
After the Summer Olympic Games of Seoul and the Winter Olympic Games of Calgary, because there was strong evidence of the use of erythropoietin (EPO) and human growth hormone by the athletes, the IOC Medical Commission included in the list of banned pharmacologic classes the peptide hormones. Marijuana was asked to be included by the IOC Congress, after a proposal of Joaquim Puello, President of the NOC of Dominican Republic, and the IOC Medical Commission agreed, after much discussion, to include this agent in the list of restricted substances, depending on the agreement of the respective international federation.
The class of anabolic steroids was changed to androgenic anabolic steroids, including also the ß2-agonists. Because many athletes seemed to use anabolic steroids and stop use 15 days before the 1988 Olympic Games in Seoul, Korea to avoid detection, out-of-competition doping control started after these Olympic Games in many international sports federations and was also ruled by the IOC.
On 2 July 2009 Clément Lhotellerie was dismissed from Vacansoleil’s team roster after the French 23-year old had tested on methylhexanamine on 28 April of that year. The substance, an active ingredient in nasal congestion medication, is listed on the banned lists of both the UCI and WADA. It is the second time in as many years that Lhotellerie has been dismissed by a team. Despite promising results in Paris–Nice, the Fleche Wallonne and the 4 Jours de Dunkirk, Skil-Shimano dissolved its contract with the rider last year after he failed to attend two appointments with the team.
Doping in Barcelona (1992) was not a main issue and only five cases were detected, two of them after the use of clembuterol. The other cases were caused by strychnine, norephedrine, and mesocarb. After the Games, there was a new change in the list of banned pharmacologic classes and methods. The concept of “related substances” was changed to include not only chemical structure but also pharmacologic action. For this reason, a new class of anabolic agents was established, including the anabolic androgenic steroids and also the ß2-agonists.
The pharmacologic class of ß-blockers was removed from the banned area and changed to the restricted area, but was banned in some sports, such as shooting, archery, pentathlon, equestrian, diving, and sailing. The most important decision was to include the possibility of blood sampling of the athletes, to permit a better determination of blood transfusion and use of hormones, in conjunction with urine sampling.
The Olympic Games of Atlanta in 1996 detected only two cases, both anabolic steroids. Ten athletes from Russia and Bulgaria were considered positive because of bromantan, however, a new stimulant amphetamine-type drug produced by the Russian Army. These athletes, penalized by the IOC Medical Commission, were later reinstated by the Tribunal Arbitral of Sports. They were not considered positive doping cases and were reintegrated to the Games. After Atlanta, bromantan was clearly added to the list before the Winter Games of Nagano.
Ondrej Sosenka of the Czech Republic, who broke the UCI hour record in 2005, he tested positive for the banned stimulant methamphetamine and its metabolites during his national time trial championships in June 2008, he now faces a suspension which will mostly likely end his career.
For the Sydney Olympic Games (2000), the IOC Medical Commission included three peptide hormones and one prohibited method, and changed the term “marijuana” to “cannabis.” In the Sydney Olympic Games blood was collected in the aerobic modalities and for the first time there were controls of blood and urine after the opening of the Olympic village and before the beginning of the Olympic Games (out-of-competition tests).
After Sydney, the IOC Medical Commission was replaced in many capacities by WADA, which took the responsibility to produce the list of forbidden substances and the accreditation of doping laboratories. Sydney also was the last time that the Medical Commission was directed by Prince Alexander de Merode, who died 3 years later in Belgium.
In the Winter Games of Salt Lake City and the Olympiad of Athens (2004) the list was created by WADA and the Chairman of the Medical Commission was Arne Ljungqvist, an IOC Member from Sweden and the Chairman of the Medical Commission of IAAF. WADA also produced an independent report on the doping control operation of the Olympic Games in Sydney. With the exception of minor problems, all 2052 samples were duly collected, analyzed, and reported, and nine positive cases were detected.
Leonardo Piepoli, winner of stage 10 of the 2008 Tour de France, was sacked by his team for “violation of the team’s ethics code” the following day, though no positive test had been reported by that date. He confessed to his team manager that he had used the same MIRCERA, a new ‘third generation’ type of EPO, as team-mate Riccardo Riccò. On 7 October it was reported that Piepoli had tested positive for Continuous Erythropoiesis Receptor Activator on 4 July and 15 July.
In Athens, the list was of banned substances and methods was created by WADA, and the IOC stipulated an Olympic period, from the opening to the closing of the Olympic village, and decided that it was possible to conduct in-competition doping control in all athletes participating in the Games in this time period, not only in Greece but also in other countries. The high number of positive controls in weightlifting is not the result of a random distribution, as in the other sports. Weightlifting does its own out-of-competition doping control in all athletes participating in the Games 1 week before the opening ceremony. A total of 2800 controls were conducted by the IOC Medical Commission. In the period before the Games 11 positives were found, mainly in weightlifting.
After the Games, the report shows 14 positives, of which three were refusals of the athletes to perform doping control after their competition, in some cases even after receiving a gold medal. The refusals, according to an anonymous letter to the IAAF, were motivated by the use of a urinary device by athletes. The balloon, with manipulated and clean urine, is inserted in the anus of the athlete before the competition, and the catheter remains undetectable under the perineum and the penis. During the recollection of urine in the doping control room, the athlete contracts the gluteus and the elevator of the anus, eliminating the fake urine.
In the Athens Olympic Games, for the first time human growth hormone was found in the blood in 380 athletes, even if the method had only a small window of detection and was not accepted by most scientists of the area. Independent observers recruited by WADA audited the quality of doping control of this Games and their report can be found at the previously mentioned Web site of the Agency.
Athens showed a new form of judging of adverse analytic findings, a new terminology from the WADA Code for laboratory-positive cases. All cases were judged, not by the IOC Medical Commission, but by a Disciplinary Commission formed by three IOC members, with final approval of the Executive Committee, who notified the press. The Medical Commission only supervised randomly the operation of doping control and the medical care of the athletes in the Games
The same system was maintained for the Turin Winter Games, in 2006. The IOC established an Olympic period, from the opening to the closing of all Olympic villages, and during this time 616 urine samples and approximately 300 blood samples were collected from athletes. Only one female athlete from Belarus, from the biathlon team, had an adverse analytical finding for stimulant, later converted in Anti-Doping Rule Violation. The doping laboratory in Turin worked with a temporary accreditation, done by WADA to the group of Francesco Botre, which was helped by 11 other directors of accredited laboratories in the Games.
Patrick Sinkewitz of Germany tested positive for testosterone at the Tour de France 2007. Sinkewitz failed to start Stage 9 after colliding with a spectator the previous day. On 18 July 2007, Sinkewitz “A” blood sample tested positive for using testosterone/doping and was on the same day suspended by his team T-Mobile. On 31 July 2007, Sinkewitz was fired by the T-Mobile team after he declined to have his “B” blood sample tested. He also admitted to having used Testogel, a topically applied testosterone ointment. On 3 November, he admitted using banned EPO and blood transfusions in the past.
The foundation of the World Anti-Doping Agency
The idea of an international agency to regulate doping controls started after the Tour de France in 1998. During this competition the Government of France, which has a very strict national law on doping, faced problems in relation to the International Cycling Union. They represented governments and the Olympic movement, and they had different list and rules of conduct. Because of that, and after repercussions in the world press, the president of the IOC called an International Congress on Doping in Lausanne, Switzerland. The result of this congress, with the active participation of ministers of sport from Europe, Canada, and Australia, was to create an international body that would substitute the IOC in the control of the fight against doping in a harmonized way, with half of the position of the Foundation being conformed by the governments of all continents and half of the Foundation being conformed by the Olympic movement. The agency started activities in Lausanne, but later moved to Montreal, Canada, to avoid misinterpretation by the proximity of the IOC. The agency understood that the risk of being considered a department of the IOC justified the change of address.
The World Anti-doping Code was established at an international doping congress held in Copenhagen in 2003, and was enforced inJanuary 2004, with a complete list of banned substances and methods. The agency today has commissions working in the areas of medical and science, education and ethics, and athletes. There are also two important programs: the independent observer programs, which audit doping control in world and regional competitions; and the outreach program, directed toward athletes at major competitions.
The first definition when control of antidoping began was only related to an artificial increase in the performance of an athlete, using drugs or forbidden methods. The actual definition of doping, in accordance with the World Anti-Doping Code enforced in Copenhagen, is two of three things: the use of substances or methods able artificially to increment the performance of the athlete, the fact that these substances are harmful to the health of the athlete, and the fact that using doping is against the spirit of the Games.
Doping is contrary to the principles of the Olympics, of sports, and of medical ethics, even sports medicine ethics. It is forbidden to use doping, as it is to recommend, propose, authorize, or facilitate the use of any substance or method included in this definition. The permanent progress of pharmacology, sports medicine, and science of performance led to the appearance of new forms of artificial increment, which made necessary a strong legislation, dynamic, actual, and flexible.
Doping control can be in urine, in blood, or both. According to the World Anti-Doping Code, there are two types of antidoping control: controls in-competition and controls out-of-competition. The in-competition doping controls are done immediately after a sports event. In this type of control, one considers the entire menu of substances and methods proposed by WADA in its Forbidden list of Substances and Methods when in a so-called “Olympic period.” Out-of-competition testing can be done at any moment: in training, in the house of the athlete, or even near a competition.
The substances controlled in both kinds of tests are not identical. According to the Code the in-competition test includes all the banned classes of drugs and methods, but the out-of-competition test is more selective, including only anabolic agents, β2-agonists, agents with antiestrogenic activity, diuretic and masking agents, and all the banned methods. Stimulants, narcotics, and cannabis are not analyzedin this type of control.
There are other kinds of control, such as the one done during the period of time in the Olympics that comprises the controls in-competition during the entire period, from the opening to the closing of the Athletic village, and the health controls done just before some competitions, such as cycling, skiing, and skating, to control the levels of red cells in the blood of competitors. If the hematocrit is elevated, there is a “no start” established by the judges and the athlete is withdrawn from the competition, although the results are not considered a doping situation.
The ruling of WADA in doping control is accepted by all national Olympic committees (NOC), the IOC, the international sportsfederations, and governments of the world. The same list is also valid for the International Paralympic Committee and its sports.
Jan Ullrich was expelled from the Tour de France in the week prior to its commencement due to his involvement in the Operación Puerto doping case.
List of substances and methods banned by the World Anti-Doping Agency
Every year, the prohibited list of WADA is revised by the List Committee and, after ratification by the Committee of Health, Medical, and Science, goes to the Executive Committee for approval. The list the is posted to the Internet on the 1st of October, but comes into effect only on January 1st of the next year.
The list is used by all stakeholders in a way that, for the first time, there is real harmonization all over the sports world and the political world. The list opens with a sentence that mentions that “the use of any drug should be limited to medical justified indications” and begins by mentioning substances prohibited at all times. To consult the complete list with examples and explanations refer to the Web site www.wada-ama.org and click on “Prohibited List.”
Substances prohibited at all times (in- and out-of-competition) include the following:
- Anabolic steroids
Hormones and related substances
Agents with antiestrogenic activity
Diuretic and other masking agent
Methods prohibited at all times (in- and out-of-competition) include the following:
- Enhancement of oxygen transfer
Chemical and physical manipulation
The following categories list further substances prohibited in-competition:
Substances prohibited in particular sports include alcohol and β-blockers. The Prohibited List may identify specified substances that are particularly susceptible to unintentional antidoping rule violations because of their general availability in medicinal products or that are less likely to be successfully abused as doping agents.
Aitor González, the winner of the 2002 Vuelta a España, tested positive twice in 2005, first during an out of competition test in August, and again during the 2005 Vuelta a España for a methyltestosterone metabolite. González claimed that the positive test was the result of a contaminated dietary supplement called Animal Pack prescribed by a doctor. González was handed a two year ban and retired soon afterwards.
Therapeutic use exemption of a banned substance
This section summarizes the International Standard for Therapeutic Use Exemption, published as an element of the World Anti-Doping Code of WADA in January, 2005. The Code, in its Article 44, allows the athlete, through their physician, to apply for the TUE. The use of the TUE is to make possible, for therapeutic reasons, to prescribe to an athlete a restricted or forbidden substance. This information should be kept confidential by the Panel of Experts of the international sports federation responsible for granting permission. It is always important to mention that a TUE should be submitted and approved at least 21 days before a competition. A TUE should have a period of validity. After the expiration, it can be requested again by the athlete.
WADA may reverse the granting or denial of a TUE and, in the last case, the decision of WADA can be appealed to the Court for Arbitration of Sport in Lausanne, Switzerland. To clear the athlete with a TUE the responsible panel should verify if the athlete will have a significant impairment of health if the medication is suspended during the event. The medication used should not produce an additional enhancement of performance and no alternative medication should exist.
The athlete should provide written consent for the transmission of all information related to the case to the panel that will judge the case and, if necessary, a third opinion may be requested. In this case, the identity of the athlete should not be known. All members of the TUE panels should sign a confidentiality agreement and keep all information reserved. The panel that judges a TUE should have at least three physicians, all with large experience in the treatments of athletes.
In terms of language, a TUE may be translated to another idiom, but English and French should remain mandatory. The name of the athlete and the sport should be very clear, and the athlete must list any previous requests. The applicant must include a comprehensive medical history of the pathology, laboratorial investigations, or imaging studies that are relevant for the case. The medication used should be named, along with the dose, frequency, route, and duration of administration. The decision of the Committee should be given within 30 days after the reception. If WADA should revise or change a decision, another 30 days is needed.
Some substances included in the List of Prohibited Substances are frequently used to treat medical conditions found in the athletic population. In this case, a full application is not necessary, and an abbreviated process can be established. Medications that can justify the use of an abbreviate process are the permitted β2-agonists (formoterol, salbutamol, salmeterol, and terbutaline), used by inhalation only, and glucocorticosteroids, used by nonsystemic routes. The abbreviated process is only considered for retroactive approval inemergency treatment in an acute situation or because of exceptional circumstances, especially if time and opportunity did not permit submission of the application.
The TUE is granted by the international federation concerned and the national antidoping organization (NADO) of the athlete should be notified, with a copy to WADA. The clearinghouse for all types of TUEs is WADA. The proper forms for abbreviated and full TUE should be requested to the NADO and NOC of the athlete, or copied from the Web site of WADA.
Francisco Pérez Sanchez tested positive twice for EPO during the 2003 Tour de Romandie when he won two stages and took the overall lead in spectacular fashionrace. He was suspended for 18 months from 18 October 2003 to 17 April 2005.
The use of supplements and herbal products by athletes
Most products supplements in the pharmacologic market, which include vitamins, minerals, and amino acids, are not controlled interms of contents by many world governments. A study made by Schanzer, sponsored by the IOC, showed that some of these products not only do not contain what they claim, according to the labels, but contain prohormones (nandrolone and testosterone) that may cause a positive doping control.
Because of this problem, athletes should only use traditional products tested before, to avoid contamination that, even unintentional, avoids sanctions. Some products with basis in herbal products, such as ma huang or ginseng, that are sold as energy boosters may contain banned substances or be contaminated by them. In some countries of the world, particularly in the countries of the Andes, one should avoid drinking the tea of cocaine, which can be present in the urine as metabolic of this drug.
Because it is not possible to ensure the quality of these products, and considering the fact that the use of supplements is not scientifically related in the literature to an increase in performance, the athlete should exert common sense in their use to avoid doping problems.
Additional Sources (Refer to Part 1 for other sources):
 Dirix A.: Medical guide. 2nd edition International Olympic CommitteeLausanne1992.
 WADA : The World Anti-Doping Code (version 3.0). WADAMontreal2003.
 WADA : The prohibited list. Science and Medical Committee. WADAMontreal2005.
 Schanzer W.: Analysis of non-hormonal nutritional supplements for anabolic-androgenic steroids: an international study. DSHSCologne2002.
 Feder M.G., Cardoso J.N., De rose E.H.: Informações sobre o uso de medicamentos no esporte, 2a. edição COBRio de Janeiro2000. [in Portugese]