Last Saturday riders from 13 teams were tested for cortisol levels on the morning of Stage 7 of the Dauphiné. It’s part of their membership of the MPCC, the Movement for Credible Cycling. The group’s become laughing stock for some recently and teams are pulling out fast at the moment too. But the guarantees it brings riders and their health is no joke. In fact it’s so good the UCI needs to adopt its rules to the leter.
Medical primer: Cortisol is a hormone produced by the adrenal glands which sit on top of your kidneys. When confronted with a shock these glands produce adrenalin but also cortisol in response to the stress. Skimming the medicine it has two effects, one is anti-inflammatory and the other is to help the body access more energy. When someone starts taking big doses of cortisone the adrenal gland stops producing the natural cortisol. So low cortisol levels can be indicative of cortisone use, whether doping or approved cortisone use by a Therapeutic Use Exemption (TUE). It can also signal a health problem, perhaps a disease or a concern with the adrenal glands so it’s good to stop them in any case. If the rider were to, say, crash then the body would respond by producing cortisol for the inflammation but a rider with low levels would not and therefore the body’s natural ability to recover is endangered. This is particularly worrying in the case of a head injury where the body cannot produce its own anti-inflammation response to a cranial injury. The MPCC also has a rule that anyone needing a local injection of cortisone for medical reasons has to take eight days of rest, ie there’s no chance of a TUE.
All together this test is a great idea, it flags up health concerns and comes in handy for anyone taking a knock to the head. It acts as deterrent for those looking to dabble with cortisone and also ensures those who need it for medical reasons get the rest they need to rather than racing on. It’s exactly what the UCI should be incorporating.
Exodus
Still, the test is not for everyone. Bardiani-CSF walked out after one of their riders was tested with low cortisol levels and told to rest but the team started him nevertheless. In a weasel-word open letter they blamed a mix-up over the rules but the MPCC says they made the rules clear to them by email. So the team has quit in a huff, one of those “you’re fired“, “no you can’t fire me, I’m resigning moments“.
Lotto-Jumbo walked out on the MPCC recently citing disagreements with cortisol testing in their press release, in part saying the test wasn’t accurate but also that the obligation to withdraw a rider was damaging from an image point of view. Certainly it places a question mark over the rider but this can be answered with further tests and having a replacement rider on stand-by could help solve the 11th hour problem of losing a rider. If anything Lotto-Jumbo quit because they wanted a series of cortisol tests to measure a rider’s levels rather than depend on one datapoint and the team say they “will continue to disperse the MPCC’s standpoints” which presumably translates as support the ideas in general.
Another idea from the MPCC is the Tramadol ban, all member teams say this powerful opiate is for medical use and should not be given to riders for racing. There’s more on Tramadol in this past piece: Tramdol, April 2014 but the MPCC want it banned outright in the sport. It’s on WADA’s monitor list so it is testing for stats purposes and apparently quite a few cyclists come back positive. Like cortisone if there is a clinical need for this medicine then take it but don’t race; just as people on Tramadol are not allowed to operate machinery.
There’s precedent here with the MPCC policy of no-needles being adopted by the UCI. The MPCC had a rule saying teams should not use injections or infusions, even for vitamins and the UCI has copied it too. There’s more too with the UCI anti-doping code for 2015 allowing collective punishment against entire teams if they have multiple doping offences. It’s not the copy of the MPCC “auto suspension ” but it is close.
The Problem
The problem with the MPCC is that it is a voluntary, self-regulatory body. It has rules which are set by member teams but there’s no law behind it nor a governing body with its legitimacy and rulebook as backup. It means it’s only as strong as its members want it to be and with some teams bailing out when the going gets tough like Lampre-Merida, Bardiani-CSF and Lotto-Jumbo and others stay like Astana but mock everyone over their self-suspension and the Iglinskiy brothers. With members like this it’s going to look weak. But all this is problematic because of the teams, the joke is on them when they try to game the rules. Mock the MPCC for its lame ability to herd the teams and you’re probably mocking the teams.
A Solution
The answer is for the UCI to put the MPCC out of business. Not by a new rule nor a back room deal. Instead it could openly adopt the MPCC stance on cortisone use, cortisol testing and the Tramadol ban. This means going beyond the WADA Code but that’s ok. As mentioned above the UCI has already done this with its no needle policy.
Conclusion
It’s easy to mock the politics but health, whether it’s low cortisol levels and the risk of head injury or the pledge to scrap Tramadol is good stuff and we should praise and support it rather than mock it. Of course it would be easier if the MPCC had more authority rather than being the reflection of its often inconsistent membership.
The best of both worlds is possible. Closer regulation and health monitoring when it comes to cortisone and cortisol and a Tramadol ban is all good. Couple this with the UCI as the governing body and therefore the authority to impose rules rather than arbitrate between volunteer members and you have the grounds for a healthier sport, especially as it could apply to all teams rather than just a few. Once the MPCC rules are folded into the UCI the job is done and the MPCC can be abolished.
How is the no-needle policy allowed when it isn’t in the WADA code? If a rider was found to be in breach of the policy, and subsequently sanctioned, wouldn’t they just appeal to CAS on the grounds that they haven’t broken the code, a la Dwain Chambers versus the BOA?
Good question. WADA supports the policy. Some other Olympic sports have since adopted this too.
(1) Because the WADA code is a kind of “minimum standard” that sports organizations must uphold. They are welcome to go further by their own means, as is the case in cycling.
Anonymous, if that were the case, then surely the British Olympic Association would have been successful in their attempt to prevent Dwain Chambers and David Millar from competing in the 2012 Olympics, which they weren’t. I’m sure I also recall Cookson responding to calls for harsher penalties by saying if it’s not in the WADA code then it won’t stand up at CAS. So surely it will take WADA to adopt the rules rather than just the UCI?
I think that the difference lies between making new rules and enforcing them consistently (i.e. no-needles) and changing the goal posts for existing offences. The BOA lost their case on the grounds that they were effectively banning Millar and Chambers for life when the offence carries a 2yr ban under WADA who have jurisdiction on this issue. By contrast I’m not sure that the ‘non-needles’ policy is couched as a doping issue, simply one of the rules of cycling (like not holding onto a team car for example), therefore the UCI has jurisdiction and can set whatever terms it likes.
The start of the BOA having to reverse their policy was LaShawn Merritt’s successful appeal to CAS against his ban against selection for the US Olympic squad. The basis for it being over-turned was ‘double jeopardy’ i.e. that he was being punished twice for the same office.
The BOA then went to CAS to get a decision on their policy ahead of London, and of course the earlier decision has created a precedent.
As a result of the above decisions, Italy ‘quietly’ dropped their ban on dopers being eligible for the Worlds selection – hence the reappearance of the likes of Pippo and Scarponi in the squad since then.
Although I don’t disagree with idea that if you’re too ill/sick/injured to compete without medication, you shouldn’t be competing, I can also understand that it’s a difficult sell for all. In many sports, players partaking whilst requiring a pain killing injection for example, aren’t just allowed, they’re lauded, even celebrated.
Changing the cultural perception that it’s not somehow ‘herioc’ to continue on with the help of medication is going to be a long and tough race to win.
Agreed, though I might go further and say that the “heroic” athlete is foundational to elite sport (at least to the way it unfolds today). Isn’t sport about demonstrating the extraordinary capacity of the “pure” body? The interesting role of culture, as you seem to allude, is to sort out what is acceptable and what is not.
“Isn’t sport about demonstrating the extraordinary capacity of the “pure” body?” No.
It’s about a great variety of things that people find interesting in sport, one of which is the capacity of the human body. I, for one, am primarily interested in the agon, the contest, between human beings, and all of what that entails.
Wouldn’t the athlete be more “heroic” to perform without the painkillers and other ‘to be’ banned medications?
I had a look but can’t find anything specific – are the testing guidelines published anywhere? Cortisol levels fluctuate significantly across the day and establishing just what constitutes a ‘normal’ value is difficult even for endocrinologists.
Shotgun testing a bunch of riders before/after a race might legitimately produce divergent results based on how much he/she has slept, eaten during the day etc – Lotto-Jumbo’s criticisms are reasonable from a medical point of view. Granted, without specific criteria it’s hard to know the upper and lower limits of the test – daily fluctuations may not be significant enough to produce a suspiciously low level.
Surely the best approach would be to incorporate this metric into the longitudinal biological passport program.
Disclosure: I’m a medical student, not a doctor, so I’ve only had limited exposure to this stuff.
There is a protocol and as you say the levels change. I don’t have it to hand but the test are done after waking and before a meal.
9 AM cortisol would be the standard measurement when investigating adrenal insufficiency.
Effectively self-regulation.
I cannot think, off the top of my head, of any instance where this arrangement is satisfactory and correct in the long-term.
Agreed, but it is very easy to look back now and pick holes in this organisation – however, at least someone has made a stand, put the suggestions out there and hopefully shifted the ‘centre’ of the debate. You always need an out-rider to start shifting public opinion.
If your point is that the MPCC should not be in the regulation business long-term, I completely agree. I do think it can continue to play an advocacy role, even after these rules are adopted by the UCI. For the teams that truly want to advocate clean cycling (and that may not be all members), they will know what questionable practices are being engaged in and can be on the vanguard by setting standards and rules internal to the group, at least for the short term. The UCI adopting these particular rules now may not alleviate the value/need of a group like the MPCC for the longer term health of the sport.
I like your idea that the MPCC could, if the UCI adopted their standards, continue to improve the standards in the name of healthy rideing and a cleaner sport.
the team physicians should be reviewed by their national medical board on an annual basis for ethical prescribing. That would provide an ethical pversight to the types of prescribing, especially the opiates. What is interesting with opiate usage for pain is that outside the US, Canada and Aus/NZ, there is very little usage of opioids for pain beyond cancer and other very severe usages. In the EU, it’s usage by the general populace is de minimis (I’ve done market assessments for pain meds globally). An ethics review by the guideline setters at the national physicians association on meds purchased and dispensed would be an interesting step if the teams want to open their books on meds.
I was involved in another sport at a very high level; sport physicians are like weeds on a vacant lot. It would be almost impossible to monitor ethical prescribing. I’m just guessing, but my thought is that worldwide, unethical prescriptions are the largest percentage overall.
Teams already have two sets of books, the set accounting for cash purchases will never be opened voluntarily.
Considering the increase in race speeds, IMO, the MPCC process is not resulting in “credible cycling”.
Interesting the a number of retired International rugby players have talked about living and training on Cortisone to overcome all the pain. The biggest, single problem facing rugby at the moment is concussion. You could see the same thing happening in cycling with the number of head impacts that seem to occur now
Concussion, as serious as the potential consequences can be, is an acute condition.
There are other much longer-term chronic health problems associated with rugby and magnified by the power and size of the rugby players now – many older ex-rugby players will require joint replacements ,arthritis problems etc etc. Cortisone will only mask the pain, it does absolutely nothing to alleviate these chronic future problems. Incidentally this is not confined to international standard players but even county-standard amateurs.
I do not know how older cyclists fare – possibly back, and knee problems may be common in later life. We mustn’t forget also that the pro cyclists are dealing with falls at speed regularly with road rash injury as a minimum consequence. Factor in things like loss of sleep if part of their body has abrasions, and with the huge physical stress required of their efforts, it is no wonder that cortisone is required.
It is important however, I feel also, that the professional teams do set the goals and standards for all – I have read many articles where foul practices are being taken up by amateurs, almost as part of the accepted game. Cycling after all is supposed to be fun and healthy ! Keep it that way.
Professional cycling was never fun nor healthy.
Here’s an excerpt from an interview with the Pelissier brothers and Maurice Ville back from 1924 after they abandoned the Tour de France in protest of the conditions:
“We suffer on the road. But do you want to see how we keep going? wait…”
From his bag he takes a phial.
“That, that’s cocaine for our eyes and chloroform for our gums…”
“Here”, said Ville, tipping out the contents of his bag, “horse liniment to keep my knees warm. And pills? You want to see the pills?” They got out three boxes apiece.
“In short”, said Francis, “we run on dynamite”.
Or take the beginning of six day racing in the US. Excerpt taken from Wiki:
Quickly, riders began competing 24 hours a day, limited only by their ability to stay awake. Riders became desperately tired. The condition included delusions and hallucinations. Riders wobbled and fell. But they were often well paid, especially since more people came to watch as their condition worsened. Promoters in New York paid Teddy Hale $5,000 when he won in 1896 and he won “like a ghost, his face as white as a corpse, his eyes no longer visible because they’d retreated into his skull,” according to one report.
And finaly one quote from Jean de Gribaldy
“Cycling isn’t a game, it’s a sport. Tough, hard and unpitying, and it requires great sacrifices. One plays football, or tennis, or hockey. One doesn’t play at cycling.”
Must admit I enjoyed reading those.
I also did, when I first bumped into it.
And there is nothing to be ashamed about it.
It (was) the reality of this gruelling sport.
They were heroes, champions.
It is the attitude of the society that has changed since.
and, really, only society
Low cortisol levels can be the consequence of using asthma (aerosol) or antiallergic medications (nasal spray) which are fully permitted and don’t need TUE. Even the medical scientists said several years ago that those medicines hadn’t systemic effects, which was false. For me, the basic problem is that the use of corticoids has been made easier by WADA, and Cookson recently declared that UCI follow its rules. So what to do with MPCC? To avoid a no-start, a solution is perhaps to do several tests (2 or 3) in the morning (6 to 8 am) to see if the cortisol level is growing and not just one. Cortisol level is bigger in the morning then decrease toward the evening.
The cortisol issue is far more complicated than Inrng makes out and there even appears to be a vigorous debate within MPCC as to how to deal with it if the press releases consequent to the Bennett case are anything to go by.
Ban it and you’ll run into problems with asthma medications, TUEs, WADA and, inevitably, CAS when the first athlete who falls foul of the policy and refuses to suck it up goes to appeal.
I’m not surprised that the UCI currently doesn’t think that game is worth the candle.
Right, the many accepted legitmate uses of corticosteroids make them to hard regulate precisely enough to foreclose advantage seekers, given the available tools for tracking their use. The MPCC seems to exist to call attention to that fact, but fails to play any constructive role beyond casting (commendably unflattering) sunlight on the practices of its own riders and teams. A lot of the stuff that goes on in this area is fundamentally a matter professional ethics for the medical people who “care for” the riders. Based on history we can expect them to reliably do the wrong thing, but at some point the UCI does need to be able to defer to (higher) medical experts when it comes to rider health, so you can understand how they see the cortisone/inhaler game as not “worth the candle.” Given the number of TUEs for this stuff, regulation currently hinges on whether there is a cortisol test that is an adequate basis for stopping riders. This seems to be an open question but I think it is important to try to avoid, for instance, following Inrng’s suggestion only to see the cortisol test challenged and overturned. I don’t know the odds, but I’d want to be confident the new rules were not going to be attacked in court in the immediate future.
I quite agree with everything you say. The UCi should take it up and we should stop laughing about it. This said, let’s not disregard the considerable need people have of hilarity, especially with regard to their favourite hobbies and associated conversations, when the number of opportunities for hilarity on offer these days is shrinking. And people need to laugh about serious things, for laughing about frivolous things feels more meaningless than liberative.
The no needle policy, how is that proven or dis-proven? I can’t really grasp how the UCI can handle this, other than hoping teams self regulate. Without a detailed CSI type investigation, who is to know if a needle is utilized at all? Also, does this apply to IV fluids after particularly hot stages (I assume it does)? I personally witnessed a female pro refuse IV fluids, against medical advise, after a long and hot breakaway effort due to being worried she’d break the rules. With IV fluids, she’d have gotten the hydration she needed pretty quickly, without, it took her multiple days to recover and she had to quit the stage race as a result. Is the no needle policy really best for the sport? Does the presence of a needle necessarily mean that doping is or might be involved? Maybe I’m crazy, but I do not see a problem with re-infusing fluids for endurance athletes after hard efforts, yet the no needle policy seems to apply logic that could be extended to things like a “no pill form” ingestion policy. The historical mis-use of needles does not necessarily mean that needles are the crux of the problem. How is this rule actually enforced? Has anybody been banned for breaking this rule? Under what proof?
They cant regulate it. But if someone blows the whistle on usage (I mean, outside of a hospital when the medical need is clear, for example), then there can be consequences.
Look at it another way: the WADA Code has cover-all clauses covering performancing enhancing drugs. At any time, there can be a PED for which a test hasnt yet been devised – but that doesnt mean the athlete who’s in a sport covered by the Code can use it anyway.
As for why needles are banned, to put it simplistically the idea is that athletes get used to the idea of injecting/having something injected into them, and from there it’s an ‘easier’ step mentally to move from vitamins etc to something banned being taken into their body in that way.
No one claimed IVs were the crux of the doping issue. No one thing is the crux. But the idea is that its one less thing that can facilitate the path to doping.
“This medical practice is prohibited at all times without prior TUE approval. WADA has justified the inclusion of IV infusions on the Prohibited List given the intent of some athletes to manipulate their plasma volume levels in order to mask the use of a prohibited substance and/or to distort the values in the Athlete Biological Passport. Further, it must be clearly stated that the use of IV fluid replacement following exercise to correct mild rehydration or help speed recovery is not clinically indicated nor substantiated by the medical literature.”
http://www.usada.org/is-it-prohibited-or-dangerous-for-athletes-using-iv-infusions-for-re-hydration-and-recovery/
I believe that the reasoning is also such that if an athlete collapses or suffers from a case of heat exhaustion that is severe enough to warrant IV fluid replacement, she is in no fit state to continue the competition the following day.
She probably should retire from the race. But It can still be argued that she could suffer less with the IV infusion. Would it warrant extra damage to an innocent athlete just so that others would’t use it for masking purpose or messing up with passport control.
The USADA’s argument on the other hand is that there aren’t enough medical literature to prove that IV infusion indeed helps re-hydration.
“The USADA’s argument on the other hand is that there aren’t enough medical literature to prove that IV infusion indeed helps re-hydration.”
That’s what they say, but it’s ridiculous. IV infusions are THE way to correct for dehydration. Our intestinal system can only process so much liquid per hour. It definitely makes sense to use this capacity but it undoubtly helps to put some liquid into the system on the most direct way.
Concerning the lack of studies. I suppose they can also claim that they could not find enough scientific proof that drinking water helps re-hydrating. Why would someone come up with a study to research something which is self-evident or has already been proven decades ago?
Firstly IV infusions are a way to correct for massive dehydration (having just come off the drip from my second operation this week I can support that) but that will never occur during a sporting event. Once the fluid levels had gone above life threatening IV infusions are not necessarily the best – I am doing the shares in bottled water companies a power of good.
There’s a lot of woow science arround here.
http://www.sportsci.org/news/compeat/iv.html
“Further, it must be clearly stated that the use of IV fluid replacement following exercise to correct mild rehydration or help speed recovery is not clinically indicated nor substantiated by the medical literature. There is a well-established body of scientific opinion to confirm that oral rehydration is the preferred therapeutic choice. Legitimate medical indications for IV infusions are well documented and are most commonly associated with medical emergencies (emergency TUE), in-patient care, surgery, or clinical investigations for diagnostic purposes.”
The USADA argument is not that there is a lack of studies, it is that there is a well-establieshe body of scientific opinion The USADA argument sees a clear difference between mild dehydration and severe dehydration.
In caases of the former, oral rehydration (i.e. drinking water or other liquids, as the case may be) is, for all purposes here, just as good as IV influsion – which, of course, is superior to oral rehydration in cases of the latter, but then it is a case of an emergency TUE.
PS In cross-country skiing, more specifically in 50 km races, it is not terribly uncommon that a severely dehydrated athlete receives an IV infusion after finishing or DNFing – but (a) it is not administered by the team doctor, but by the event medical personnel, and (b) the 50 km race is the last race on the program and an athlete receiving the infusion cannot thus gain an advantage over those who do not receive a similar infusion.
PPS Cross-country skiing has, let’s say, historical reasons for being particularly strict about the no needle poilicy (and it is the one where AFAIK the push for such a policy started).
It seems the UCI is, for several reasons, moving far too slowly in both changing its policy or addressing the problems facing the sport. The day when the MPCC can happily say ‘job done’ is still unfortunately in the distant future.
I take an extremely dim view of those teams, who for their own self interest, have jumped off the MPCC ship. It seems the sport continues to accept this double standard attitude with a similar complacency to that of the past. Look where that got us !
You talk so much sense. I don’t always agree with your conclusions, but you set out the issues so clearly. Keep at it. Cycling needs clear heads.
If you are short of things to do…
http://www.verbruggen.ch/
I’m sure our esteemed host will have his/her own take soon.
You know the Cookie monster, Mak and their UCI cohorts are screwing it up royally when HV has a rational point…
You found one?
Yeah… You have to read it in order to do so…
Cookson, having won his presidency through a smear campaign that was heavy with lies and inuendo rather than solid qualifications and a vision, is doomed. Everything he has said publicly has been mooted, the CIRCus was a joke and now those who he tried neutralize are going to haunt him.
What a buffoon.