Athletes need performance-enhancing drugs to treat illness

Are these medications being used to treat genuine illnesses? It’s difficult to tell. Image from

Ever wondered how many athletes are legally allowed to take “performance-enhancing drugs”? You read correctly - many elite athletes are given official permission to use drugs that are otherwise banned in sport.

This is because a number of elite athletes have common disorders such as diabetes, asthma, and attention-deficit hyperactivity disorder (ADHD) that are often treated with prescription drugs that are considered performance-enhancing if used by athletes without these disorders.

The stimulant methylphenidate (Ritalin), for example, is often prescribed to treat ADHD in children and young adults but its use is prohibited in sport by the World Anti-Doping Agency (WADA) because it may enhance explosiveness, power, strength or stamina.

Athletes who want to treat their medical condition with a drug that would otherwise be banned must apply for a Therapeutic Use Exemption (TUE). To qualify, they must be diagnosed by a medical practitioner and have their request approved by the Australian Sports Drug Medical Advisory Committee (ASDMAC).

But the number of TUE applications submitted to ASDMAC has reportedly increased in the wake of the Australian Crime Commission’s recent report into doping in sport.

So, are these medications being used to treat genuine illnesses?

Each year in their annual report, the Australian Sports Anti-Doping Authority (ASADA) lists all the substances for which ASDMAC approved at least one TUE. In 2011-12 TUEs were granted for 37 different substances. The list included stimulants commonly used to treat ADHD, as well as other drugs such as modafinil (for sleep disorders), hydrocortisone, insulin, oxycodone, human growth hormone and testosterone.

The annual report also lists the total number of TUEs granted for each sport. Last year there were 202 TUEs approved across across 58 different sports, from cricket and rugby, to badminton and water polo. Those with the highest number of TUEs were swimming, cycling, AFL, and athletics (they were also the top four in the previous year).

This information gives us a small insight into patterns of prescription drug use among athletes, but some things remain hidden. We know, for example, that last year ASDMAC approved at least one TUE for methylphenidate (Ritalin), but it’s impossible to tell from the annual report alone how many TUEs were granted for this drug. Was it only one? Ten? One hundred?

We also cannot tell how many TUEs for methylphenidate were approved in high-profile sports such as swimming, cycling, Australian Rules football, and rugby league.

The prescription of stimulants to treat ADHD increased by more than 80% in Australia last decade and ADHD is a condition that affects many young people from all walks of life. It is becoming increasingly common to continue stimulant treatment into a person’s twenties. Given this, we might expect to see an increase in the number of TUEs for such medications.

It is a source of frustration for public health researchers that ASDMAC (a government-funded body) has refused requests to reveal the number of TUEs that have been granted for each substance, making it difficult to assess the appropriateness of the use of these drugs.

My requests for this information for research purposes were denied by ASDMAC on two different occasions last year. First, ASDMAC claimed this information was confidential and revealing it could breach the privacy of athletes. But it was not explained how simply confirming the number of TUEs approved in Australia for methylphenidate would reveal information that is any more confidential than that which is already published in ASADA’s annual report.

When asked to re-consider, ASDMAC then argued the data would have no value to a researcher unless they also knew the total number of athletes required to obtain a TUE (ASDMAC claimed that this number was “huge but unknown”). Is it really up to ASDMAC to decide what information is relevant to researchers?

In the United States last year, 116 Major League baseball players were granted a TUE for treatment of ADHD. This represents around 9% of the league, prompting some to wonder about the number of sluggers who have ADHD.

Some suggest a high number of TUEs indicates a problem with the approval process or that some players may be trying to bypass anti-doping laws.

But there is another possibility that could indicate a need for public health attention. We should be concerned, for example, if there was a lower-than-expected number of TUEs for a drug that is used to treat a common disorder like ADHD. Could this mean that some athletes with ADHD are going untreated? What other treatments are they using, and are they in fact receiving the appropriate treatment? And do some athletes view the TUE process as too complicated to bother applying?

Therapeutic exemptions are an important part of ensuring athlete well-being, but the failure to publicly disclose information about TUEs unnecessarily raises suspicions about the process. It’s time for ASDMAC to enhance our understanding of these issues and avoid creating the impression that there is something to hide.

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