Wednesday, November 2, 2016

Let's Talk About Drugs

Whenever the discussion of doping comes up, it is overwrought with passion. Runners as a demographic, and particularly ultrarunners, are generally well-educated and socially liberal people in favor of such social adjustments as prison reform. In two conversations about a week apart, a friend of mine supported pardoning non-violent drug offenders and then argued in favor of lifetime bans from sport at a doper’s first offense. What?

Of course, doping is a more personal topic within this community, likely making it easier to discuss standard drug law and ethics in the hypothetical, keeping passion and any personal affectation out of the discussion. Perhaps the majority of the issues regarding any real conversation about doping come from ambiguities and arbitrarity found in all aspects of doping, from substance control and banning lists to enforcement and follow-up on the parts of both athlete and federation.

I went on a run this winter with two good friends, both scientifically minded and generally logical people, one of a front-of-mid-pack guy and the other a sponsored athlete. This was not long after a previously-busted athlete entered The North Face 50 Mile Championships in San Francisco in December 2015 and The North Face made a vague, placid statement opposing drugs in sport. As occasionally happens on long runs, the conversation turned to drugs in sport. My sponsored friend emphatically proclaimed (and, to be clear, rightfully so) that dopers are taking money from the pockets of clean athletes and should be banned—a fair, though simplistic point.

But then, who is a doper, and how should they be both caught and punished? Let’s  define a doper as someone who uses a substance banned by the governing body of their sport, just as a criminal is someone who commits a  crime--this removed ethics and hypotheticals from the equation to focus on reality. Generally this governing body is regarded as the World Anti-Doping Agency (WADA) as well as, through some overlap of governing abilities, the IAAF (International Association of  Athletics Federations).  But, to further bureaucratic confusion, all of the IAAF’s subsidiaries such as the USATF, which then has its own brother anti-doping agency, the USADA, which is best known for its aggressive handling of the Lance Armstrong scandal.

Okay then, fine, what is WADA in charge of? Basically, any IAAF-sanctioned event, and this works effectively (relatively) at the international high-stakes level of track and field, marathons, and the like: The Diamond League in Europe, the Olympics (which is technically run by the International Olympic Committee, an entity that can veto an IAAF ban if they choose), the World Marathon Majors, the various ultra-distance world championships (which are separately governed by the IAU [International Association of Ultrarunners]), Comrades Marathon, and so forth. These all are subjected to criteria to maintain IAAF-sanctioned status, and with that stamp comes the support of those entities with regards to drug testing.

Watch the winner come through the finish line of any major marathon in the world, and you will see them swiftly handed a bottle of water and then followed around the finish area by an entourage that contains as least one anti-doping official there to keep an eye on the athlete until the athlete pees in a cup for them, as they watch. Then the athlete has to—as was well documented by Ellie Greenwood on her blog following her 2014 IAU World 100k victory—provide their whereabouts every day for at least the following year so that their assigned anti-doping official can surprise them—within an athlete-chosen hour window each day—at work, home, on a date, or at their mother’s funeral with a follow-up test for which the official stays by the athlete’s side until the athlete provides another urine sample.

Well, that is a doozy. However, it does bring us to the inherent issues of anti-doping control trail and ultrarunning, two sports which are, even with all their recent growth, fringe. Even if many of us glue ourselves to Twitter the last weekend every June, to be blunt the IAAF simply does not care about the Western States Endurance Run. UTMB recently had its first experience with true, confirmed doping by one of the race’s competitors and, because of the apparent delay in issuing a statement, I have a feeling the UTMB race organization was somewhat taken aback by the  doping, unsure of what their next step should be. The athlete in question, Gonzalo Castilo, placed 5th at UTMB in 2015 and received a 2 year IAAF ban the following Spring due to a positive test result from his finish line blood test at the 2015 UTMB--a ban that will end on March 17, 2017 (which is not actually 2 years from his infraction). Following the incident, the UTMB race organization released a statement revoking Gonzalo’s race finish.

Aside from those few high profile events that take anti-doping measures seriously and have the resources to back it up, such as UTMB, doping is such a small blip on the radar for the entities that govern competitive running with enough power to actually make a difference that no difference is made. The majority of hundred mile races, regardless of public notoriety, simply do not have the resources to implement any form of doping control, let alone a process that would actually be effective.  When I, considering starting a race, looked at the financials of a grassroots but consistently sold-out ultramarathon in the same area as mine to assess viability for myself, I noticed the director netted (and subsequently donated) barely more than $2000 from 200 entry fees; this shows we are a sport of passion and one where the money to implement doping control is nonexistent. The only company, or at least the first company to come to mind, that could financially implement drug control in the United States is The North Face to their series of races, but then athletes with something to hide could simply pass over these races in favor of a payday elsewhere. We are a sport where notoriety does not go hand in hand with financial incentive; I am sure plenty of athletes would choose Hardrock’s vistas over possibly winning Run Rabbit Run’s $12,000 first place paycheck.

A secondary issue of doping control comes with definition and ambiguity; even if all ultra-distance athletes out there believes themselves to be clean, they could still end up with a ban. The WADA ban list has 147+ substances on it that are prohibited at all times, and another list of comparable substances banned in competition only. This is a list all athletes entering appropriately-sanctioned races are expected to know and adhere to. The big offenders are easy to pick out (erythropoietin, testosterone, human growth hormone, etc.). However, if you delve below the surface, there is a lot more confusion in substance profiling (DHEA and beta alanine for example). The simple question: why are certain substances banned and other ones not? From my simple second list above, DHEA will be discussed later. Beta Alanine is itself an amino acid that the human body can derive from animal proteins. When supplemented, it has been clearly shown to boost athletic performance—specifically VO2 Max [1]. If you’d like, you can order beta alanine in large quantities from your online retailer of choice.

In an hour of reading on the WADA website, I could not find a clear definition of why substances in general are placed on the prohibition list—and to be clear I mean specific statements, not a list of vision statements; the ‘Q&A’ page gives a thorough breakdown of certain substances, but honestly I have no idea why these substances were chosen over others. So, let’s make our own clear reason, one that hopefully we can all agree on: the basis for prohibition is (or should be) simple: a substance provides an unfair competitive advantage and/or unnecessary health risk to the athlete; I include the second portion due to the risks inherent in use of certain PEDs outside of their intended use. For example, outside of sport (in its intended medical uses) erythropoietin (EPO), a hormone produced by the kidneys to promote red blood cell production, supplementation is common for severe anemia and various diseases that cause issues with blood filtration such as Crohn’s disease. Supplementation, however, is meant to bring depleted levels back within normal limits, not to increase them above normal. Supplementing EPO within the realm of performance enhancement—to boost red blood cell levels above normal for enhanced performance has significant associated health risks such as myocardial infarction, stroke, and venous thromboembolism [2]. Basically, the human body does not like having too much EPO. Athletes, at least at the elite level, likely attempt to eschew these risks by using the boost of red blood cells to increase training load to a level that would otherwise lower their count to an unhealthy low, effectively forcing their own anemic and subsequent normalized state, similar to the dip and spike found in medical patients utilizing EPO.

Interestingly, in my reading across the WADA website, the second question on the ‘Q&A’ page caught my eye, which is regarding plasmapheriesis (plasma transference—both donation and reception—in which they state that “for the donor, plasmapheresis is prohibited under M1.1 because the donor’s own red blood cells (and other blood components) are being reintroduced into the circulatory system after the plasma has been separated.” A friend of mine, who is a reasonably competitive athlete, donates plasma as often as he is allowed--plasma is often in shortage and many people do not want to donate plasma, as the process is more involved than simple blood donation and takes quite a bit more time. I know he is not doing this for any competitive advantage, and I am confident he is not even aware that he is now banned from any WADA-supervised competition—oh no!

Though I do not believe my friend would qualify for the following, this is a good segue to the only way around the prohibition list: therapeutic use exemptions (TUEs). These were made famous in particular by Galen Rupp and other Nike athletes’ usage of prescribed thyroid medication over the last several years--thyroid medication is sometimes argued as preventing endocrine fatigue common in endurance running. However, let’s look at the other side of the coin. In 2014, the United States Anti-Doping Administration (USADA) disqualified Kristi Anderson, a 51-year-old woman who won her age group but then failed her post-race drug test. The disqualifying substance? DHEA, a natural over-the-counter supplement any of us could drive to a pharmacy and purchase in large quantities right now. Kristi was recommended DHEA by a medical doctor following a visit and bloodwork that showed “low DHEA, practically nonexistent testosterone and low estrogen,” all of which is in line with her complaints of adrenal fatigue and menopausal symptoms. Technically, Anderson should have been aware of this substance being banned and should have either not taken it or applied for a TUE with the USADA, which seems strange because by her own admittance, Kristi is not even a member of the USATF [3]. Why should she care about all of these acronyms anyway? Kristi, and anyone else with a USADA ban, can run most any race—trail or road, ultra-distance or shorter—they please (at that race’s discretion of course) as the USATF’s reach is short and most races do not fall under its banner.

Up until 2004, caffeine was considered a banned substance by the WADA. A common series of arguments I’ve heard for defining performance-enhancing drugs is they are designed and created in a lab, they are not commonly taken (meaning daily-type supplementation) substances, and they are not natural. The first and third go hand in hand, and without (I hope) opening Pandora’s box I reject both of them with the changes regarding marijuana: a substance once fully banned by the WADA, marijuana is now only banned in-competition. The second one--that substances are not commonly taken--I can empathize with but have to reject, and caffeine is a great scapegoat for this thought experiment. Caffeine is a previously banned substance. This is a stimulant that is such an afterthought to modern society that there is not even an age-restriction on its purchase or use. A five year old can walk down to the corner store and get hopped up on 40oz coffee before kindergarten, and yet at until 2004 international sport deemed caffeine to provide an unfair advantage or be unsafe for sport.

For a minute, I ask you to forget all your prejudices against EPO. Just bear with me, this will be over soon. Imagine that we lived in a society that highly valued running long distances. EPO usage was so common that the majority of Americans make sticking that needle in their ass a part of their morning routine—right before they pour themselves some coffee. Everyone runs a 2:10 marathon, but they have to check in with their doctor ensure they are not close to stroking out from their morning EPO shot. Once a year, some teenager makes national news for taking a little too much and ending up in the hospital, but other than that, there is little repercussion to this rampant, doctor-aware usage of EPO.

That doesn’t sound too terrible or scary, right?

The point all of this is supposed to make is: where is the line? What should and should not be banned from sport? And my answer is: regardless of everything I just laid out, I have no fucking idea. But I do know that the current list and the current system are in need of serious reform.