RECENT PUBLICATION OF CONFIDENTIAL MEDICAL DOCUMENTS leading American athletes, including Venus Williams and Simone Biles, not only gave rise to a new round of discussion of modern anti-doping rules, but also once again questioned the objectivity of the staff of the main anti-doping organization WADA. An inherently ordinary situation always leads to a difficult discussion about the status of a professional athlete and the future of big-time sports in general, and only an expert can separate facts from speculation. Why the scandal that has arisen has no grounds and how things are in big sports with various medications, endocrinologist Nikita Taller explains in detail.
The excitement in the domestic media regarding the published documents is quite understandable: not even a month has passed since the end of the Olympic Games, in which almost a third of the representatives of Russia did not participate - for various reasons, but somehow connected with suspicions of using prohibited substances. And then documents pop up with "steroids", "opiates" and "amphetamines" legalized for Russia's main competitors, and a series of comments about the "Williams brothers", "anabolic athletes", old memes about Americans and lengthy statements about diagnoses from officials of the Ministry of Foreign Affairs.
Formally, the situation is extremely simple: when an athlete has a chronic disease requiring appropriate course or lifelong treatment, or is injured, or prepares for surgery, or simply “catches a cold” during the next flight between competitions, he is examined by a certified specialist and issues a conclusion on the need for treatment … The data is sent via a special system to WADA for the execution of the so-called TUE - therapeutic exception. Thus, a prohibited drug becomes temporarily permitted for medical reasons - its further detection in a doping test is compared with data on the course of treatment and its duration, which excludes the possibility of uncontrolled admission outside the previously agreed course.
The easiest way to explain this is with the Williams sisters. For more than twenty years they have been playing in one of the most traumatic sports, while now Serena is 34 years old, and Venus is 36, which is considered a "critical" age for modern tennis (in the 90s tennis athletes barely reached 30). Without the periodic use of painkillers (in this case, quite strong semi-synthetic opioids) and anti-inflammatory drugs (glucocorticosteroids), they cannot continue their performance. In addition, Venus has Sjogren's syndrome - an autoimmune disease with a predominant lesion of the glands of external secretion, often combined with even more serious disorders of the immune system. Due to this disease, Williams did not perform for a while.
Sjogren's syndrome requires the use of glucocorticosteroids. Although these are steroids, unlike the notorious "anabolic steroids", they have the opposite catabolic effect, that is, with prolonged use, they contribute to a decrease in muscle mass, the development of muscle weakness and an increase in the risk of fractures. None of this definitely improves athletic performance. Among the visitors of specialized training sections there are underground schemes with a combination of "anabolic steroids" and "catabolics", but it is impossible to carry out such a scheme through doping tests and remain "clean" after that.
Interestingly, glucocorticoids, in particular prednisone, were used during tournaments - for example, at the French Open in 2015, which ended with the victory of Serena Williams, despite a previous injury.Can this be considered a scam? Perhaps not: the drugs used do not improve physical performance, but neutralize the consequences of the injury. The tournament organizers are extremely interested in the participation of the most popular athletes in the later stages and, of course, in the finals.
The premature end of the match due to injury or refusal to participate is reputational and financial problems, and for Serena herself it is a distancing of the opportunity to set another record (in this case, by the number of victories at Grand Slam tournaments). So TUE is a legalized method of extending the sports life of top players. We want to see Lionel Messi, LeBron James or Serena Williams at the sites as often as possible, and medical services are meeting the consumer. This probably justifies the choice of more serious painkillers, which are not available in our country even for palliative therapy of cancer patients, but available in other regions.
Therapeutic exclusion is a common situation. The director of the FMBA sports medicine center, Andrey Sereda, confirmed that at the Olympic Games in Rio de Janeiro, "for one or another urgent indication, four athletes were issued permits for therapeutic use" and "no obstacles, nagging from the services that are considering these documents" did not see. “Yesterday one of the athletes of our national team in one of the hospitals required the appointment of illegal drugs - similar, by the way, to those used by the Williams sisters. We drew up the documents at night, sent them for consideration today, and with a probability of 120% I am sure that we will receive permission for this from TUE, because we justified it with a discharge from the hospital, with the conclusion of a doctor who, for urgent indications, introduced this drug,”he quotes words of the R-Sport specialist. Moreover, according to statistics, it is glucocorticosteroids, diuretics (diuretics) and selective β2-adrenomimetics (inhaled drugs for the treatment of bronchial asthma) that are the most commonly prescribed TUE drugs.
The situation with Simone Biles is more complex and controversial. ADHD (attention deficit hyperactivity disorder, ADHD) began to be actively studied not so long ago, although, according to some experts, this is a fairly common phenomenon among children (observed in 3-7%). Relatively speaking, if you had a violent, impulsive and restless deskmate, a poor student and a bully, then perhaps this is not a defect in upbringing, but the very ADHD. In Russia, such a diagnosis is rarely made, but in the United States it is quite an ordinary practice.
Psychotropic drugs are prescribed, including methylphenidate and ameftamines - there are a lot of methods already tested or under investigation. The application is based on the fact that with attention deficit disorder, functional disorders of the work of neurotransmitters (for example, dopamine and norepinephrine) occur in certain parts of the brain, in particular in the prefrontal cortex. These are purely functional, not anatomical disorders: in other words, in the connections between brain cells, the wrong substances are produced, in the wrong quantities and in the wrong place. The use of psychostimulants promotes an increase in neurotransmitter activity in these cerebral systems.
It is important to understand that the effect of these drugs will differ in a conventionally healthy person and a patient with ADHD. Does this give the professional athlete an advantage? Probably yes, especially in those sports where the balance of normal arousal, which gives physical and psychological vigor, and inhibitory processes, which limit excessive activity and contribute to increased endurance, motivation and alertness, is important. In addition, they temporarily improve memory, including "muscle" memory.
All this helps in sports that require constant concentration and exact repetition of previously repeatedly worked out elements, and artistic gymnastics certainly belongs to these.Amphetamines also have a fat burning effect, which can also be important for gymnasts. As a result, we get a contradiction: patient Biles has every right to receive such therapy, but Simone probably would not have had such a stable performance without concomitant therapy, because ADHD itself would provoke haste and excess movement. Recall that the same diagnosis was made in childhood to the great swimmer Michael Phelps.
We come to the most difficult question in professional sports: does an athlete with certain defects and developmental features, fully or partially resolved with the help of treatment, have the right to compete according to the same rules as other people. High achievements in sports - the result of selection for genetic characteristics or a product of modern legalized pharmacology? Already, modern medicine has the ability to predict the potential advantages and disadvantages of a particular sport for a particular person: to determine the type of muscle tissue that predisposes to sprint or stayer loads, connective tissue defects that determine the risk of injury, and so on.
What if there is a place for “imperfect” athletes like Biles in a future like this? Where is the line between the medication support needed to equalize athletes and the potential benefit? In modern sports (in professional Olympic, not Paralympic) there is a place for people with growth disorders (Leo Messi underwent a long course of therapy due to growth hormone deficiency, and the drugs taken are on the prohibited list), athletes with diabetes mellitus (insulin is the same anabolic hormone), people with impaired immune systems and organ transplants (both take the notorious glucocorticosteroids). If for each of these categories will be organized their own world championships and the Olympic Games, it will be discrimination.
The closed nature of WADA, the inability to clearly formulate the rules of the game and their justification create the impression of chaos in the organization. In recent years, drugs not only with unproven safety, but also with absolutely unproven efficacy in professional sports have been added to the list of prohibited drugs. What and to whom is given meldonium or a slightly earlier banned analogue of trimetazidine, which is extremely popular in the countries of the former CIS, it was not possible to substantiate clearly. Some accepted him because they believed, others forbade him because they did not believe.
As a doctor, I am sad to read the news about doping scandals with our athletes, especially in team and "technical" sports, where the very expediency of doping and its essential effectiveness is extremely doubtful. Indeed, in many situations this happens due to carelessness and disorganization. This can be the intake of dietary supplements for weight loss with an unspecified composition or energy drinks containing the weak psychostimulant methylhexanamine. Another example is taking diuretics, which in some sports can be used to remove other drugs more quickly, but most are used only to cut excess weight before training, so as not to get penalized for being overweight.
The same glucocorticosteroids are taken as a remedy for the treatment of inflammatory processes, including injuries to tendons, joints, and so on. It is exclusively a matter of monitoring a sports doctor, documenting all means and discharging those very therapeutic exceptions, which has not happened even once in ten years in the case of Maria Sharapova. That is why Serena Williams is still on the court, and Maria is not. But Pandora's box has already been opened, and, apparently, we are waiting for streams of previously confidential information about leading athletes.
Photos: sharpshutter22 - stock.adobe.com, Sherry Young - stock.adobe.com (1, 2, 3)