The big TUE debate

Doping : With many athletes opting for Therapeutic Use Exemption, there's a need to strike the right balance

After Major League Baseball added amphetamines to its list of banned substances in 2007, many players appeared to exploit a loophole. They applied for what is known as a Therapeutic Use Exemption (TUE), a waiver to use a prohibited drug for a legitimate medical reason.

Before amphetamines were barred, 28 players had received exemptions to treat attention deficit disorder. After the ban took effect, 103 players secured permission. Seemingly overnight, the number of professional baseball players with attention-deficit diagnoses soared.

That episode nearly 10 years ago remains a vivid case study in a vexing wrinkle of anti-doping efforts in sports — one that received renewed attention this week, when hackers published private medical information about Serena Williams, Venus Williams and Simone Biles. How do sports officials determine what is a medical necessity and what is an effort to enhance athletic performance?

“Getting the right balance is always challenging,” said Olivier Niggli, director general of the World Anti-Doping Agency, the global regulator of drugs in sports. “We try to put safeguards in place to ensure this isn’t a one-organisation decision.”

The private choices to grant special permissions to the world’s athletes are made by sports organisations, and shared with anti-doping authorities and the International Olympic Committee.

The documents released this week, by Russian hackers who breached the World Anti-Doping Agency’s databases, revealed that Biles and the Williams sisters had received clearance to use banned drugs, prompting some critics in Russia to proclaim that US athletes had an unfair edge in the Rio Olympics. The athletes in question had secured proper medical approvals, sports authorities said.

“The athletes mentioned did not violate any anti-doping rules during the Olympic Games Rio 2016,” the Olympic Committee said in a statement.

On Wednesday, the hackers published new documents, showing exemptions granted to 10 other Americans, besides athletes from Germany, Denmark, Poland — and one from Russia, boxer Mikhail Aloyan, who won a silver medal in Rio. Among the US athletes was Bethanie Mattek-Sands, who won the women’s doubles title at the US Open on Sunday, and a gold medal at the Rio Games.

WADA prohibits athletes from taking, as of 2016, some 300 substances. They are as varied as alcohol and anabolic steroids, and they include medications typically used to treat conditions like asthma, pain and attention disorders.

Many of the prohibitions are absolute — at no point should athletes use the drug — while some are limited to the time of competition, the concentration of a substance, or the method of administration — oral versus injectable, for instance. That list of banned substances, updated each year, is finalised by a panel of medical experts selected by WADA.

Some substances are prohibited only during competition, because they are commonly used in daily life, Niggli said. “There are over-the-counter substances you need — cold medicine,” he said. “If they were banned out of competition, we’d see an explosion of exemption requests which would be unmanageable.”

International athletes seeking to take a banned substance typically apply through their sport’s governing body — in the case of the Williams sisters, the International Tennis Federation, and in the case of Biles, the gymnastics federation. A basic criterion for the requests: There must be no alternate, non-prohibited medication that could address the athlete’s condition.

The sports organisations review the justifications for each athlete’s request — the diagnosis, medical history and symptoms, and the duration of drug use — and make a decision, sometimes in concert with an athlete’s national anti-doping organisation. WADA’s guidelines on banned substances extend to exemptions, allowing, for instance, that one-time waivers to treat chronic conditions like attention deficit disorder can last for up to four years. The files published this week indicated 13 therapeutic use exemptions for Venus Williams and 10 for Serena. Some of those exemptions lasted for four days, some for a year.

Stuart Miller, director of the International Tennis Federation’s anti-doping programme, approved the applications, and he said the Williams’ medical records showed that the system had worked properly. “Anybody who is an athlete and is subject to an anti-doping programme, like the Williams sisters, is subject also to getting ill and having medical conditions,” Miller said. “They’re not immune from that.”

Miller said the tennis federation received an average 100 requests annually, a sizable number of which were withdrawn before they were ruled on. A panel of medical professionals considered each case file in a blind review, excluding the identity of the requesting athlete, he said, and ultimately approved roughly 50 to 60 percent of the requests.

In his 10-year tenure over the programme, Miller said that a case involving Mattek-Sands — the US tennis player whose files were published Wednesday — was the only one WADA had overturned. Her application for drugs to treat “adrenal insufficiency” — hydrocortisone and DHEA — was approved in 2013 by the tennis federation but revoked in 2014 by WADA, which believed DHEA would enhance her performance.

Dr Alan Rogol, an endocrinologist who works with the US Anti-Doping Agency on its review of exemption requests, called some of the decisions “no brainers,” like approving insulin for an athlete with Type 1 diabetes. But he said the use of DHEA, such as Mattek-Sands had requested, should “never” be approved.

Crucial to deciding what exceptions may be granted to athletes, Niggli said, in consideration of whether an athlete’s performance will unfairly benefit. In the sport of shooting, for instance, some athletes with heart conditions have appealed to use beta-blockers, which can reduce tremors when aiming a gun. In 2010, a paraplegic Paralympic athlete, Robert Berger of New Zealand, applied to take metoprolol, a beta-blocker, to address heart disease. Sports authorities ruled against Berger, prompting him to appeal to the sports court, which upheld the prohibition, considering the competitive advantage he stood to gain from the drug to be too great.

Though that court ruling was made public, typically decisions about exceptional drug use are confidential. “It’s often very private information,” Niggli said. “Do athletes who take substances for something very intimate — birth control — should they be public about that?”

Meanwhile, anti-doping authorities, who have faced scrutiny this year related to the doping scandal emanating from Russia, said that increased funding for WADA would also translate into more careful policing of therapeutic exemptions.