Tramadol

Tuesday, 8 April 2014


One of the unwelcome side effects of following pro cycling is a passing acquaintance with medicine. In recent years it’s been haematology first with the haematocrit count then EPO and DIY blood doping. Now a quick look at analgesia thanks to Tramadol, a powerful painkiller that’s being used and abused in the peloton. It seems a ban is only a matter of time.

What is Tramadol
Tramadol hydrochloride is the full name. To borrow from Wikipedia it’s “a centrally acting opioid analgesic used to treat moderate to moderately severe pain”. It’s sold under a range of brand names, a veritable A-Z from Acugesic to Zytrim.

It works on the brain and nervous system to reduce pain and is a medium to strong pain killer, this is not what people take for a headache. Instead it’s used for chronic and acute pain relief. As an opiate it can be addictive. Indeed as well as correct use it is also abused. By some measures prescription drugs, including Tramadol, are abused in greater quantities in the US than illegal drugs from heroin to cocaine et cetera. Tramadol is abused around the world thanks to its addictive properties, for example it’s been widely used in Gaza where the opiate properties provide relief to bored kids and tired tunnellers alike while the British are considering banning its sale. Searching the web for information on the molecule for this piece revealed countless websites offering it for sale.

As a painkiller it’s probably got greater uses in other sports, for example where injury during play is more common, for example football. But rather than taking painkillers following injury they are being consumed before. One study by football governing body FIFA revealed about one third of the players in the 2010 World Cup were regularly taking painkillers prior to a game. This could be anything from paracetamol to Tramadol. The point is that this drug is being used and abused all round us.

Back to cycling and there are tales of it being used in recent years. It was all quiet until one Tweet launched a thousand words:

Phinney tweet expressed what other were thinking and he expanded on it in an interview with (the now dead) website Velonation. Since then the subject has gained more coverage and there seem to be two uses:

  • as pain relief for injuries allowing riders to train or even race through an injury
  • it’s being taken in conjunction with caffeine, mixed into a “finish bottle”, a bidon consumed late in the race to provide a small “high” and numb the rider to an effort

It’s back in the news after several people have linked it crashes in the peloton.

“Tramadol to blame for classics crashes says Lotto-Belisol doctor”

That’s a headline from Cycling Weekly but it’s not quite what Doctor Jan Mathieu said. In the original interview he lists a range of risk factors from weather – warm conditions mean more riders are present in the finish – to the street furniture polynesia. Only at the end did Tramadol appear. Tramadol isn’t turning the peloton into opium-den zombies, it’s a matter of nuance matters where the painkiller could be a possible contributory factor in some incidents. Many crashes in the peloton occur early in the race, long before anyone is consuming a drink of water, yet alone a “finish bottle”.

An early crash in the Tour of Flanders, long before anyone reached for a “finish bottle”

But it still matters. We can’t reduce the street furniture very easily but we can ask why anyone would consume a powerful opiate during the final hour of a race. It’s not banned in competition but it is on the World Anti-Doping Agency’s monitored list. Here’s WADA’s explainer on their monitoring programme:

Laboratories will report the instances of reported use or detected presence of these substances to WADA periodically on an aggregate basis by sport and whether the samples were collected in-competition or out–of-competition. Such reports shall not contain additional information regarding specific samples.

WADA shall make available to International Federations and National Anti-Doping Organizations, on at least an annual basis, aggregate statistical information by sport regarding the additional substances. WADA shall implement measures to ensure that strict anonymity of individual Athletes is maintained with respect to such reports. The reported use or detected presence of a monitored substance shall not constitute an anti-doping rule violation.

In short WADA is testing for Tramadol but as it’s not banned, no individual is ID’d and only aggregate stats are reported to UCI, for example the percentage of athletes found with the molecule. Worryingly WADA’s saying it’s being used in cycling. Speaking to cyclingnews.com, Garmin-Sharp medic Prentice Steffen said “The MPCC has gotten behind my request to ask WADA to fast track it from the Monitor List to the banned list. We got a letter back from WADA saying that they were going to continue to watch for it and that they were getting a lot of positive tests for it, particularly in cyclists“. We’ve only got a quote in relation to a letter from WADA so the context of “a lot of positives” is unknown, even one in a hundred tests would be a lot compared to the general population.

Why isn’t it banned?
Because not all drugs are banned. An athlete might need powerful painkillers following a serious injury, for example broken bones after a bike crash. This invites the question of Therapeutic Use Exemptions, if an athlete is in serious pain following an injury then by all means do the paperwork, get the TUE letter, and use the painkiller. But if an athlete needs such a powerful drug then surely they’re in no healthy state to race?

Indeed this seems to be the approach that’s being taken as the MPCC teams ask for it to be banned. The MPCC is a group of teams and others looking to go beyond the WADA Code. Sometimes mocked the group has actually achieved plenty, for example it’s behind the “no needles” policy in pro cycling and it tests cortisol levels as part of a “health check” which stops many resorting to cortisone abuse. This cortisol test is a good idea but also an mirror for Tramadol testing. Again if a rider needs to take cortisone then they probably need to stop racing and rest, an identical argument applies to anyone who needs to take Tramadol.

The MPCC teams have agreed not to use it but I don’t think they test for it so there’s no way to prevent its use. There are 11 World Tour teams but that means seven outside. It doesn’t mean the seven are using it either, for example Team Sky have backed a ban for Tramadol and a recent Humans Invent podcast reported that Geraint Thomas wasn’t using as he rode the Tour de France with a fractured hip.

Safe dose?
Even if it’s not banned it doesn’t mean it’s safe. Bear in mind that those willing to take pharmaceuticals will often exceed the dosage; to make the point look at widespread EPO use in the peloton which, when it was undetectable, saw wild consumption. If medical advice says take two pills then someone will take three and another will take four or even six.

Note: if so this could be pure placebo given ingested Tramadol typically needs one hour to start acting and even two or three before it reaches peak levels in the blood stream

Conclusion
It might be a contributory factor in some crashes but so are many things from fatigue to weather to street furniture. Maybe tram lines are more dangerous than Tramadol? Crash risks are hard to quantify so let’s put talk of accidents aside. What’s more certain is the first order side-effects of such a powerful drug, from nausea to addiction and that if you need a painkiller this strong then you probably shouldn’t be taking part in a bike race.

This is a drug to be avoided wherever possible and reserved only for real analgesic use but it’s showing up in anti-doping control samples. It seems like it’s only a matter time until it’s banned by WADA. What if the UCI ruled first?

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{ 47 comments }

weeclarky April 8, 2014 at 2:27 pm

Really interesting – and depressing – thanks. What about Xenon gas that seems to be have a miracle effect? Anyone know what the real story is?

The Inner Ring April 8, 2014 at 2:56 pm

Cyclingtips has a good read on it.

In French, an article in Le Monde looks at Xenon and yes, a miracle effect where the people promoting the research seem linked to sales of xenon gas. There’s little evidence outside of Russia that it works and besides, if it was effective the Russian XC ski team and others would have won more medals in Sotchi

Michal April 9, 2014 at 2:12 am

Russian men went 1-2-3 sprint finish in longest XC Olympic distance race (50km) @Sochi.

Simma April 9, 2014 at 2:38 pm

A look at who got medals doesn’t really show the true story of the XC skiing at the olympics, I follow the sport quite heavily and there was just a lot of medals up for grabs as Norway had 2-3 of it’s stars off form and the waxing team made some big mistakes which got a lot of press for men and women.

The russians were no better than they had been all season.

Bundle April 8, 2014 at 3:11 pm

Very interesting. As with all substances that could be banned, the usual questions. Does it effectively and inequivocally improve performance? If yes, does it, when used in its assumed optimal performance-enhancing dosage, cause significant health damage or present a significant health risk? Only with 2 “yes”, I’d think a ban would be appropriate.

AK April 8, 2014 at 11:34 pm

Interesting point of view. That would take a lot of stuff off the list. Blood doping for example, if you can do it in a proper way and not with smuggled bags in a hotel bath room. Masking agents. And how do you define ‘significant health risk’? If it has to be more risky that riding into the Trouee d’Arenberg with 100 riders all doing 60 kmh you can take almost anything off the list.

Gary April 8, 2014 at 3:21 pm

Very surprising as I can’t see how it’s NOT been banned. There are far more minor drugs one the list. Nearly all opiates are banned now. Time will tell but it won’t be long I suspect.

Dave April 8, 2014 at 3:21 pm

Just read someone is having a ‘rich vein of form’. Really?

The Inner Ring April 8, 2014 at 4:33 pm

I’ve seen that too. A normal phrase… or is someone having fun with it?

Gareth April 9, 2014 at 12:48 pm

Ironic use of the word ‘vein’…………….

Wataboutya April 8, 2014 at 4:01 pm

Decent journalism…..missing the sensationalism yet getting the point across.

It is a storm in a tea cup, but a fairly addictive one and unsporting at that.

Be happy to see the end of these drugs being used, however, I can only feel the pressure will be heightened when the WTour teams reduce rider sizes under the newer UCI rules…..teams will need riders to do less races, but be guaranteed to race in more overall – possibly – equals rehabilitation through therapeutic recovery. This is where pro sports like the Premiership Rugby/Football, abuse these drugs widely. If you dont have depth, you need strength.

GeorgeY April 8, 2014 at 4:40 pm

FWIW: As a cyclist you need to embrace pain, even at an amateur level. Pain is your friend not your enemy, if pain becomes so unbearable that you need to ingest painkillers to keep going you are causing damage to your body (possibly irreparable).

Leif April 8, 2014 at 4:43 pm

I’ve was given this recovering from a motor accident but had to stop. Too strong for the head and the addiction was obvious. If it is making riders crash they should stop using it too, they seem to have no gains.

The Inner Ring April 8, 2014 at 8:20 pm

When I mentioned the subject on Twitter others said similar things, it’s very powerful and imagine someone mixing an extra “one for the road” into their bottle, it’s a worry.

Sam April 8, 2014 at 5:12 pm

Thanks INRNG. Calm, rational and non-sensational writing on this subject…more than a few professional journalists could learn a thing or two about that.

BC April 8, 2014 at 5:30 pm

Interesting stuff inrng, although been in the public domain for some time.

The obvious conclusion one can draw is that the corrupt culture many assumed had disappeared, is still alive and well. Until such times as the UCI takes serious steps to remove some of the undesirable characters closely associated with teams at all levels, the problems will continue.

Pedallerofcharm April 8, 2014 at 5:32 pm

I was prescribed T after a bike smash – just a few days of it and I felt like my head was encased in a sack of cotton wool – pleasant dreamy distance from reality – not what you need on a bike and absolutely not whilst racing.

Gingerflash April 9, 2014 at 2:34 pm

I concur. I was prescribed it for a slipped vertebral disc. There seemed to be a 3 or 4 second delay between my eyes and my brain. I could barely make sense of TV, let alone drive or race a bike. I stopped after about 3 days.

Steven L April 14, 2014 at 2:20 pm

I got given that stuff after breaking my neck participating in one of life’s other extreme sports – serving in Afghanistan. Horrible stuff, lost a week of my life to it.

Dave April 8, 2014 at 5:38 pm

Finishing bottles, sounds like the old days of butterfly’s fluttering above the peloton!

Sad to say we will always be fighting drug war. As I see it new rules should be brought in that are draconian and can be summed up so:

1) Every elite level athlete who tests positive should be given a 2 year ban.
2) An elite level athlete returning to sport (any sport) after the ban should be subjected two extra years of enhanced drug testing, namely once or twice a week when not competing and in every event, regardless of finishing position or DNF/DNS (on top of the standard testing). This testing is to paid for by the athlete.
3) Every rider on a team that hires a convicted doper on their return to the sport must be subjected to testing at every event regardless of finishing position, or DNF/DNS, on top of the standard testing to be paid for by the team.
4) Any non-elite level athlete, especially those under the age of 21 caught doping should banned for life from all competition in any sport.

I know this is draconian, but sports people can be their own worst enemy! I think rules like this would make it unpleasant for those considering doping. It would make it difficult for those who welcome dopers back to justify their stances, and most importantly it would hopefully make those in amateur and junior level sport think more than twice.

Maybe it is time to put dopers on the same level as thieves.
Think of it like this, it could be argued that an elite level athlete who dopes and wins prise money has stolen the results and prise money from those who do not cheat.
In the same way that it could be argued that a person who dopes to stay in elite level sport are stealing the livelihood of the non-doper who gets dropped from a team.
And it could also be argued that a person or junior who dopes to get into elite level sport have stolen from those who want to get in clean.

dhue April 8, 2014 at 5:54 pm

i think the use of this drug (and any other that is ‘legal’) in the peloton is a reflection of our current society. prescription abuse is a lot worst than we think.

Dave April 8, 2014 at 5:58 pm

Too true!

The Inner Ring April 8, 2014 at 8:24 pm

That’s true but several related drugs, eg oxycodone, are banned by WADA. I think Tramadol is likely to be banned, with TUE allowed.

Dave April 9, 2014 at 9:52 am

Inner;
The main issues is as you stated in your article, if you are ill or injured enough to take any prescription drugs, then you should be off work.
The key word is ‘prescription’ this means you are under a doctors ‘care’ for an illness or injury. And for athletes this mean no competition or systematic training.
Once you are off the ‘prescription’ then you can come back to training and completion.

Dave April 9, 2014 at 9:55 am
Larry T. April 9, 2014 at 11:33 am

I wonder what the reasoning is behind allowing opiates of any type? As noted above, if you’re in so much pain that they are needed, you probably shouldn’t be racing anyway.

Sam April 8, 2014 at 5:54 pm

A good amount of that is outside the WADA Code, and IF any sport signed up to the code tried to impose them (e.g. life-time bans outside of the WADA code parameters) it would fail as soon as the first athlete subjected to it, appealed to CAS.

Sam April 8, 2014 at 5:56 pm

that last post is in response to Dave’s, 2 posts up

Dave April 8, 2014 at 5:58 pm

Agreed Sam, but the idea would be to get the WADA code changed.
I put my ideas out for all sport, not just cycling.
If anything along those lines were agreed I would suggest a two to three year period between agrement and enforcement.

noel April 8, 2014 at 6:23 pm

the only thing I would change on that Dave, is to make it 4yrs not 2, to take any athlete out of one complete Olympic cycle.
the only concern I would have on under 21s is that they might be influenced by a coach/mentor etc at that age, so a 4yr ban would suffice to get it out of their system.

Sam April 8, 2014 at 6:31 pm

And the problem is agreement across all of the sports federations signed up to WADA, as well as what is deemed to be able to stand up in court if challenged legally.

Take for example the new maximum ban of 4 years for a first offence that forms part of the new version of the WADA Code operational Jan 2015. The IAAF wanted/wants lifetime bans. But this was seen as too hardline by some other sports, no second chance or opportunity for reformation. Also WADA took a deal of legal advice, and were warned of a high likeliood of lifetime bans for first offences failing to be upheld if challenged in the courts.

The Inner Ring April 8, 2014 at 9:03 pm

The WADA Code for 2015 onwards is a lot tougher. The rules are severe, the next thing is to increase the chances of detection, to test more riders more often. But that’s for another day.

Mo Rothar Beag Dubh April 8, 2014 at 7:33 pm

Great article (again).
What has happened to Velonation?

The Inner Ring April 8, 2014 at 8:18 pm

Journalist Shane Stokes mentioned something like the owner was thinking of selling. I don’t know any more but it won’t be worth much if it’s just old news.

James April 9, 2014 at 6:01 am

Wow, such surprising rallying support for banning a substance that is commonly prescribed to treat chronic back pain, among other conditions that weren’t mentioned here.

Sam April 9, 2014 at 10:29 am

Knee-jerk reaction

Sam April 9, 2014 at 10:30 am

Sorry, not yours! But some of the responses are on the knee-jerk side.

Anonymous April 9, 2014 at 9:46 am

I agree with the comments, depressing stuff. It’s a worry when you think that some people have died unintentionally through Paracetamol intake. If a blanket 2 year ban came in for this type of thing then it should also the Olympics subsequently following that 2 year period.

Gareth April 9, 2014 at 12:45 pm

is it not too simple a solution to stop a rider racing whilst taking anything needing a TUE? Teams may not be ‘running’ doping programmes as they (allegedly) once were, but the pressure on riders to perform and get results, even when injured, is nearly as bad

Robin April 10, 2014 at 1:58 am

Does that mean a diabetic that has to take insulin couldn’t race? What about an asthmatic?

Gareth April 10, 2014 at 2:44 pm

Apply some common sense Robin…….. people are not going to abuse insulin are they!!!

andy w April 9, 2014 at 1:22 pm

I’m just amused at the list of teams which have signed-up to MPCC
- Astana and Katyusha are ‘credible’ are they…hmm

Whereas some like Sky haven’t signed-up yet have a very public anti-doping stance

The Inner Ring April 9, 2014 at 1:29 pm

I think some teams need credibility. It’s easy to sign up to the MPCC but the test comes in upholding the values. It does mean all teams, Astana and Katusha included, can be tested for cortisol and Tramadol which is to be applauded.

LM April 9, 2014 at 9:02 pm

Great article about a great subject.

VeloRick April 10, 2014 at 2:39 pm

Some interesting points raised and I’m still not sure how I feel about it. I don’t like the idea of riders abusing it to help them through a race as opposed to taking it to help enter the race with (for example) a sore knee, but if they did ban it you would have TUE’s coming from all angles as I am sure — especially in the grand tours — many riders are requiring a little pain relief by the third week.

These drugs certainly are abused in other sports, but then those sports almost come with the guarantee of physical contact and how often do we admire the athlete who shows up to play through an injury as bad as it could be for him? But then, this isn’t a drug to help him recover from an injury – something I more than support them taking – but rather to hide the pain of an injury that still exists.

And I suppose that is where the addiction risks come in. Though that exists with alcohol and cigarettes too and at some point with these sort of things you have to let the athlete police themselves – or at least their teams doctor.

The Inner Ring April 10, 2014 at 2:43 pm

I think the MPCC Cortisol example is the right model: if you need to take cortisone then you need to rest. So anyone asking for a TUE to use Tramadol should also be at home rather than in a race. This doesn’t fix everything, like training on it but it can distance it from racing.

VeloRick April 10, 2014 at 3:31 pm

I know what you mean but if you bang up your knee in the 2nd week of the Tour de France should you have to withdraw if there’s a painkiller that can help you through? I’m not saying it’s good for your health to ride through an injury, but plenty of athletes through plenty of sports are willing to play/race hurt. I agree on the cortisone point and staying home to use it to recover from an injury.

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